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

ROLL 



1 




«'•. 






-' ul 



fc' 



«:?• 



,^ ■■ >*• 



rOCAL I TY 



RECORD S 



'v 



S A N 



COUNTY 




[SCO 



S AN FRANCISCO 
CALIFORNIA^ 



-t 



R E CORD 



CERTIFI 




Ml CROP I LMED 



FOR 



THE GENEALOGICAL SOCIETY 



■1 ' 



OF SALT LAKE 



UTAH 



CA L I FORNIA 



iipBBaiininHiiipiiiHM 



DATE 




APRIL 



1975 



PH OTOGRAPHER 



MAX J OHN SON 



CAMERA 




NO 



26831 



RED 



VOLUME 



339 



695 



o 



.-^ 



EGIN 




»•.- 




^. 



^^JL^ 




r:^ 




•eWi^y. 



I, 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

,.„...nl,.fn..„l.,-.S-o.,.*.^,.^HCo «FERT08ACK or C«T.r.C*TC FOR .NSTRUCTIONS 



Date Filed, 



1 




lb 



190^ 



Registered JVo. 



839 



^H-vu) (UAHi Deputy Health Officer 

DEPARTMENT OFPUBLIC HEALTB-City and County of San Francisco 



Certiffcatc of Death 

( Xa. S. standard ) 



(^ 



PLACE OF DEATH:— County of Oo./vu J -vix-^vcv^t 



4 n 

^- City of ^''CX.^vu A^4X^vvCA^^<Ld^:C 



rNa OCr\t \n\cLu 



St^ 



Dist; bet. 



and 



(I w^»»» x^Aai,*^ u^i« ana 

" .VSrlTM*'irru.V!lV.L''°** "®^*'- «CSI DENCE GIVE FACTS CALLED FOR UNDER ".PECAL INFORMATION' A 
IF DEATH Occurred in a hospital or institution give its NAME instead of street and number ) 

FULL NAME .iU.'JLu^JjQl CLtL^wnrtk 



) 



PERSONAL AND STATISTICAL PARTICULARS 




SKX 



DATK «»l- niKTII 



A<.K 






MEDICAL CERTIFICATE OF DEATH 



DATE OF DHATH Qf\ 



•MoiitlJ) 



lo 



J ifi I 



(Day) 



M.ml/i^ 



fVcar) 



Da vs 




(Month) 



H 

(Day) 



(Year) 



SINr.l.K MARKIKD 
\Vri><>\VKI> OK niVOKtKl) 
(Write in MKJal <1» <-i!/iiati<»fi) 



i 



lURTIfl'I.ACK 
(SUitf or Country) 



NAMI-: Ol- 
FATIIKR 



nfRTHPl.ACK 
OF KATHHR 

(State or Coniitry) 



MAJDKN NAMK 
OF MOTHER 



niRTiii'T.Aci-: 

<U- MOTHER 
(State or Country > 



OCCI PATION 



OS? 



C3x/vvcyLi 



01' 



I HEREBY CERTIFY, That I attemlcd «lcccased from 

- '90 ~~~to 190— r-r- 

tliat I last saw h -^^—^ alive on jqq : 

and that death occurred, on the date stated above, at t? '6 
^^ ^t The CAUSE OF DEATH was as follows: 



/vu^-vvnv 



DIRATION Yeats Months 

CONTRIBUTORY 



Days 



Hours 



•i 




DURATION Years Months Days 

(Signed) U ^ U)<xt]Luvu> 



Hours 
M.D. 



(Address) CJXcvcyMrw 



f ^9'ftK "^f ^'"^^"'■•ON •"'y '•^ Hospitals, Institutioos, TranskRts, 
or Recent Residents, and persons dying ^vi from Home. 



Resiiifit ill Sdn /'mihi ,'o 



) 'fit I 



\f.„if/t- 



/ill 1 



*^"',k^J-r'^'''' ^'''^'''ED PKRSONAI. I'ARTICII.ARS ARE TRIE TO THE 
HHsr OF MV KNOWI.EIX.E AND mil.flCF 



Former or 
Usual Residence 

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



How Ion) at 

Plafeof Death? Days 



(Inf<innant 






r,V*4^«s 



«CU\|-M> 



I-Ij-^CE OF BIRIAI, OR REMOVAL I DATE of ntRMi. or REMOVAI 







INDERTAKER 

(Addrcsn 






Ttate cIu^E Ap nTrTS . . carsfuily .upplled. AGB should bs .t.Ud EXACTLY. PHYSICIANS .he«ld 

state CAUSE OF DEATH In plain terms, that it may be properly classified. The "Special information'* for asr- 
•ons dying away from horns should be ftlven In svary Instance. 'ormation Tor per- 






WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

Hntird of Health— K N'o. k ^"^^^J H&P Co 



Dnfc Filed, 




REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



c^cMAA^ cM/\v 



190^ 



Registered •A^'o. 



340 



u Deputy Health Officer 



DEPARTMENT OF PUBLIC HEALTB=City and County of San Francisco 



Certificate of ©eatb 

4 



A 



^ 



PLACE OF DEATH: — County of "'a "^v 1 V a >x c^«, c , Qty of '^'a>vJ Vavvc;^ cc 



'^^ ^'' - ' Sua Dist; bet. Xca.V YVH.. and m 

C .VnrlT'L*'^'""' *'*'*'' '^''*"" USUAL RESIDENCE GIVE FACTS CALLED FOR UNDER ■sPrfclAL INFORM 

V IF DtATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD " STReJI AND NUM 



^:\ 



lATION' 
IBER. 



) 



FULL NAME 



lx^.A l> ^ ^l^vU^. 



y\ ' 



SIX 



PERSONAL AND STATISTICAL PARTICULARS 

^-S,. 1 COLOR ^ , ,^ 



MEDICAL CERTIFICATE OF DEATH 



DATE OF DKATH 



DAIl-; nl lilKTU 



A'.i-; 



I Month) 



n ,,.„, 



<I>av) 



A/,iitf/n 



11 ai I 



/),l\s 



fKl(inth) 1 



(Day) 



(Year) 



\vri>o\y»:n or i)ivt»Kri.:r> 

'Wiittiii -H-t:i! (it sit.»nati(iii) 



lURTin'i.xri-: 

^t.iti ' .r ' "oil lit I \ 



.i 



,<^V\w 



A 



>n- 






I- AT J n Ik 



niKTm'i.ACK 

OP I ATIIKK 

'Siatr ,,r Couiifrv) 



MAIIiKN NAM}- 
*»I MuTlIKK 



lUKTMI'l.Ari-: 
<»F MOTHKK 
(Slate* «r Country) 



OCCrpATlOK 

h'rsiiird III Siiii /'i tin, rri* 



1 



'^ o^wLw 



I IIHKi:nV CI-RTIFY, That I attended deceased from 

^KN..ui.i90. to .|vvlu 1.5: L3:...L-i9oH 



^ 



that I last saw h - alive on /^vwU. 1 5 i ' iqqH 

and that death occurred, on the date stated above, at f 15 
M.. The C\ArSH OF DKATH was as follows: 







.1. 



I' 

DTK AT ION Years 

CONTRIBUTORY 



Mont /is 



Days 



I /ours 



^ ^^^i-^^^'^l^^^^ 









L 



Uv 



nrRATION '^^ Years ' Mo>iihs ' Day, 



(SIGNED 

^ IQO 



lO. 



i±^ 



-JH <^ TQoS (Address) %^\X ^K.^,OA^x^ 



Hours 

M.D. 

1< 



) I'l?/ ' 



Mniitin 



//,M 



?^^9'f!'-. "^f^'^'^^T'O'^ ""'y '«^ Hospitals, Institutions. Transients, 
or Recent Residents, and persons dying away from home. 

Former or '\ ^ ^ l \ How lonq at 

Usual Residence CV CA-CL > n vx. >\v ft v > * pj^^^ (,f p^^ji, 7 ' 



""iL^J^J-^^'^' "^rvt'-'D I'KUSOWI. l'AKTUri,\KS AKI-: TKIK TO TIIH 

iihsroi- Mv kn«>wij:i)<;k AND mw.wA- 



A 



(itif.Hiiiant...... ... Jwt 



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



Days 



> N W O 



■?s 



f\<l.lr». 



V'n 



4 



DATHof nrKiAi. or REMOVAL 



PLACE OF BURL\L OR RKMOVA 

INDKRTAKKR U OX^^^Xc 'I ' UXA-A. %^.4 

ft 

15.^H '^t^xMl^, 




\\.k1 4,11. 

'1 






(.\iMi fss 



N. *'-— ^;;;«;y '«^;" "*^^^^^^ -hould be carcfuHy supplied. AGE .hould be stated EXACTLY. PHYSICIANS .hould 

!l ^. . DEATH in plain term., that It may be propeHy classified. The •Special Infoi-matlon'* for D«r- 

•Ofis dyin4 away from home should be ftlven In every instance. 



^ 



II 



a 



,^ 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

Hoard of Health— F No. 15 ':^^^^>B&FCo 



RCFgR TO BACK OF CERTIFiCATC FOR INSTRUCTIONS 



Date FiJed, 




lb 190\ 

Deputy Health Officer 



Registered J^o. 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



(No. 



Certificate of Death 

( "CJ. S. StanOarD ) 
PLACE OF DEATH: — County of 'XVaaj -J \,<X/lVCvl CiCity of C) Ctrvj ACX v\CA.4.£ 

O.J. OHwvuIIl^O lUulu ,. «. D;st.;bet : and r 



Q)l^ 



St4 



"^ ^yjJ^^SV"^!'*"''' '^"OwUiSUAL RESIDENCE GIVt FACTS C*LLCO roN UNOCR "SPCCIAL I NrORMATION- \ 
ir DEATH OCCUK^RCO IN A NJOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF 8TRCCT AND NUM«I» ) 

:.d..a: . .: D.:a.L-4.' 



FULL NAME 




<y\j^\ 



SHX -^ 



PERSONAL AND STATISTICAL PARTICULARS 



DATK <)l- ItlKTH 



AT.K 



kJi, 



COI,OR \ 



au\. 



MEDICAL CERTIFICATE OF DEATH 



'U- 



t\foiUli» 



,11. 

(Day) 




O 



C..^ 

(Year) 



J 'ra t : 



\ Months 



l\i\ 



SIN'*;i,K, MARKIKI>. 
WnxJWKF* OK DIVoRt'Hn 

(NVritf in social dcsii^naliou) 



HIKMIPI.ACH 
(Stale or Coimtrj-) 



NAMK OF 

fathi:r 



RIRTHPI.AOH 
OK FATHKK 

(Slate or Cinintry) 



MAIDKN NAMK 
OF MOTHFIR 



HIRTFfPI.ACF: 

OF mothf:r 

(State or Country) 







-^ I IIKREBY CERTIFY, That I attended deceased from 

^ ^t" I A. TonH fr. H/»^JL. II IQO H 





■'^■^ '■ »- I90.H to 

that I last saw h .•* ': alive on ^|vww.hl. vx \^'\ 

and that death occurred, on the date stated al)ove, at 1 

^■'■^' The CAUSK OF DEATH was as follows: 



,...l.X. 
•H- \X 



VOLA^cLuaUS. r^./ 



^i 



'\JL.\X A V.C.C 



t" 



D I RATION 
CONTRIBUTORY 



Years Months 



Days 



Hours 



«)CCUPATION 

(Informant KIK . 3 ^(HoUvUx^t 



DURATION rear^^:^\y/ont/,s 

(Signed) .i]}\ d,AI 




kti. 



^ '^ 



/Mys 



Hours 



M.D. 



TQO 



Hip p ■ 
(Address) 3>S D. ."^^siJ^.-k > v./^Xi^ 



i.rf^59Jft*-J'^!r^^'^?''''ON only for Hospitals, institutioRS, TrMsients 
or Recent ResMents, and persons dying away from home. "-"Mrnis, 



Former or 
Usual Residence 

When was disease contracted, 
If not at place of death 7 



How long at 

Plafe of Death? Days 



(AcMress 



3v5 ^ 



3'Jl 



»X^\,i. 



4'. 



PI^CF: ok BFRIAI. or RK>n,VA,, jnA^Kof^^m-H.A. orRKMOVAl, 
l-NDFRTAKER fvt CUX^^W %. "^UXiu 

?..5i.kia.^ ^ isSTl. i 



(Add 



resu. 






should 
for psp- 



M 



I! 



'f: 



^1' 



■\h 




I 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

noiinl of Hc.-iltli— I-' No. !<; "SJ^^^^a) hk V Co 



REFER TO BACK OP CERTIFICATE FOR INSTRUCTIONS 



Da 1 Filed, Vlu U 



1 



(I 



19 0\ 



Registered JVo. 



O^u^o Xji/v-a Deputy HeaJth G "-er 

DEPARTMENT OFTUBLIC HE ALTH=City and County of San Francisco 

Certificate of Death 

( tJ. S. Stan6at& ) 

PLACE OF DEATH: — County ofO/CL/yv ^A-^JL^^vc-ui^c. City of O/O/vu ^UX/>v<! c4 C 
rNo. in I Liau, st4 X Dist.; bet. J a JU\; and \lsy\Ji^ 

( *' .Vtl'*^**'^''!''^ ***'' ^''°** "SUAL RESIDENCE GIVE r*CTB CALLED ron uAoCR 'SI^CCIAL I NFORMATIc/ «• \ 
V .F DEATH OCCURRED IN A HO.PITAL OR INSTITUTION GIVE ITS NAME INSTE/d) OF STREET AND NuJ^eI^ ) 



FULL NAME 



PERSONAL AND STATISTICAL PARTICULARS 

DATK 0|- niKTII 



\I.)1<:l>v^- b- yj^itJhJL\t(r 






■■"" k) iv^ 



MEDICAL CERTIFICATE OF DEATH 




a<;h 



SS 



M »iith) 



)'iiii 



(Day) 



M»ntf,s 



ai 



(Year) 



Da \s 



DATE OK DEATH 




IH 

(Day) 



(Year) 



SINT.I.K. MAHKIKD 

(Writf in social tksitfjiatii>ii) I I \ ■ 



HIRTFIPr.AOK 

'Sl.-itr r)r Ci)Ulltr\ 



NAMK OF 
I ATHER 



lo 



I HEREBY CERTIFY, That I attended deceased from 

^ 190 X to HjvJL..lH 190 H 

that I last saw h XSj alive on W!3^ 190 H 

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






iiiil that 
i M 



.. The CAl'SE OE DI-ATH was as follows: 



rA-O 



HIRTIIPI.ArH 
OK I ATHKR 

(St.'itcnr Country) 



MAinj'N NAME 
OK MOTHKK 



HIKTfllM.ACE 
«»l MOTHER 

'St:it«.- 01 (.'onntrv) 



OCCri'ATlON 



^1 






* 

DIRATIUN - Years i:^ Mofiths ^ i9a,'j * Hours 
CONTRIHUTORY DJL^^rs.UL^ 



1)1' RATION 



f© 



)Vr7rj Mouths 



Davs 



Hours 



(SIGNED) Uum^LL V\ . U) ^V^vdL M.D. 



Rr%i<leii in Satr PiMitrisro o j Yrais • 



srpEci^ 



iQoS (Ad<lress) 



QvtcttxK; 



or^er^nl p;.M;;»c*'^„r?"'^?7'°'^ ?^^ '**' ""^'^"*'^' '"st^uHons, Transients, 
or KWfnt Residents, and persons dying away from home. 



yr,)„ihs 



iht\ 



'^"HKJTVu-'iTv'yii' r.!';1^"^'^'- »'A«n.M LARS ARE TRIE T.) THE 
HhhT Of- MN KNuWI.EDr.E AND nil.IEF 



Former or 
Usual Residence 

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



flow long at 
Place of Death? 



Days 



(X'Ulic 



1Mb <Lt<VAM^^vvvAj-t^iJK, 



190 H 



ri,ACE OE ni-RIALOR REMoVAI, I IMTE of^ m k,a,, or REMOVAI, 
INDERTAKKR IbcXA^Xdl *Nc C<5 

(Address S4b ^^^HvMuMrn. J^l 



N. B.— -Bvei*y Item of Information sifouid be carafuliv .••»»ii.^ Afc •! , . . ^^"^"""""^"""^"■"■""■"■■'■''"^ 

..... CAU8E 01= DEATH .n pu," ':;j:::'.c "X bi p;op^.r';'i"'.''..Tf..T'*Th^'^*«"V; . ^"^«"t'*^'» ••»-- 

•on. dyint •«••» from hom. .hould be ftlven In ,v.ry In.r.nM. '^'"••'"«''' Th. 8p«cl.l loform.llon" for p.r. 



u J 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



ISonnl of llealtli— F No. n **:'Si^«j H&p Co 



Date Filed, 

1 




REFER TO BACK OP CERTIFICATE FOR INSTRUCTIONS 



Registered JSfo, 



343 



M^^v^ 



A>Vl 



190\ 
^puty Health OflPlcer 

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

Cettiffcate of H»eatb 

( la. S. standard ) 



1 >0p 

PLACE OF DEATH:— County of '"a>V i'UXWCU (City ofCJavv OAaivC 

(^ .a\>^\0.v u>^ J r St.; Distjbet. and 

( ir DOTH OCCUKS •»• V mOM USUAL RESIDENCE OlVe »«CT» C«llID rO» UNDrR ■SPICI.L INFO>IM<TIOI«" \ 
V IF Ot.TH OCeURIteO IN . HO.PIT.L OK INSTITUTION GIVt ITS NAME INSTOO It n'mlcTiNO K'Hilm ) 



ev4 C 



) 



FULL NAME 



SKX 



PERSONAL AND STATISTICAL PARTICULARS 
"^ - ' COLOR 



^^xy\ 



1 



•-1 



■4^ 



MEDICAL CERTIFICATE OF DEATH 



Wla L 




Ky • 



DAT!-: «)| niKTM 



AT.H 



\ 




Mr>Jlth) 



t ^ r H 



(Day) 



yf,>uffix 



/ u. 1 ;. . 
fVenr) 



Pars 



DATE OF DKATH 




,.LL. 

(Day) 



IQO \ 
(Year) 



I HHRHBY CHRTIFY, That I attended deceased from 



'^ IN*. I.E. NfARKIHIl. 
WIlMiWED <»K IHVMKri:i> 

iWritt-iii '.(K-ial di >.iv<itatinii) 



niKTHPI.ACK 
s State f>r Country i 



111 



A 



N \MK Of- 
FATHER 



RIRTHFM.ACE 
Of FATHER 
tSt.itr or Country) 



MMOEN NAME 
OF MOTHER 



lUkTHI'LACE 
Ol" MOTHER 

fHt;it»- til (■|>nntr^ 



(HClPATloN 



G 



A 



4 



^i-YV-w ..'.A 1 90 V t 

that'' I last saw h alive on 



iAl<LtA...iL 

and that death occurred, on the date stated alxive, at 





U 



190 H 
190 



^ M. The CAt'Sr- OF DIUTH was as follows: 



vO- 



4,V 




rWu Wc 




>v 



Dr RATION Years 

CONTRini TORY 



Vears 



Months 



Days 



/lours 






-^ 



h'f^ldfil in S,j>! / I i;n, lu-i} 









DIRATION ^ ^anr .ifofiths Pays //our, 

(Signed) C,3^/a. "\)JLuxAcr>\j M.D, 

y^l<^ 1 1 icjoH (Add rcss) ^4^u\\x.a vu K ^^ i\Jtai 



^?^9'ft^."^f^''^^''"IDN only lor Hosplldls. Institutions. TrMsicots 
•r iKtit RttldMts. ami pfrs«ns tfyins away from koine. ••-■^iciws, 



thiy 



'"V;,^"I.*^''*-'^''"^''*^■'^ ''»'«'''>NAI. FARTirrt,\RSARETRt-E To THK 

ni-.sroF Mv K;\u\vi,i:i)r,K and hi-uff 



fomiff or *vn 

lISNal RfsMencr i 

When *as disease contracted, 
Ifootatplareofdeatli? 



^A ^^^ Flare of Death? 



Days 



(Infnrniiint 






fA'l<lrr«is 







t-NDERTAKER A^JUt^6^^\f 3j.^^MK.^^ 



'*• ^* Every Item of Information should be c«i^f«l|y ■Mnnll^rf Aff? -w- u •_ ^ "TTTT''''"''"'"'"'"''""""'''''*'''**'''"'''"" 

.t.te CAUSE OF DEATH In pl.tr. tcrmrth-T W «. J* ! . *" '^ •*■*•** EXACTLY. PHYSICIAN* ^«,|d 

-«!. dying .w., f«H. hon.; Should r;iv..,VU";j; i;.r.X^ -«—«»«-. -n.. -Sp^d.! I„forn..tion- for ^I! 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

«o..H<>f n..l,„-FNo „*^^H&,.Co WEFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



Drffr Filed, 




Registered JSTo, 



344 



lb VJO'\ 

cUamx Deputy Health Officer 

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

Ccrtiffcate of S»eatb 

( la. S. StanDarO ) 



PLACE OF DEATH:— County of ~ 



City of M ULUJ- VLvUk 



rNo. 



St.; 





Dist.; bet. ■-- - a nd 







/ ir DKATH OCCURS *W*V FROM USUAL R E S I DE NCE Gl Vr r*CTS CALLCD rO« UNDEB *'SprCl*L ,N'^0«M*Tlft«..- \ 
V .r DC*TH OCCUR«CD .N * HOSPITAL OR INSTITUTION GIVE ITS NAME .NSTtAO " STRCcI iND NUMiJl, ) 



-) 



FULL NAME 



JL\!LMj^ Af 11 , oLliiLrU^ 



PERSONAL AND STATISTICAL PARTICULARS 



boi . ■ 



DAT!-: <)I- lUKTII 



AC.K 




iMojith) 



I>av) 



(Vfar) 



MEDICAL CERTIFICATE OF DEATH 

DATE OF DKATH f\ ^ 

-.3^\J^.^ R..._ 



<% V } Vc/ 1 V 



M.'HtflS 



15- 



Da V. 




SINC.I.K, MARKIKI). 

\viiH>\vKi) OR niV(»KrKf> 

(Writt* in scK-ial (U'siimation) 



IUKTHJM,\CK 
(Statf or Couiitrv) 



NAMK OF 

fathi:r 



HiRTfn'i.Ari-: 

0».* lATIIKR 

(Htati- or Country 



MAntj;N NAMi-; 

OF MOTIIFR 



IMK rHP!.A("F: 
<>l MoTIfJ'tR 

'State or Countrv) 




TpoH 

(Year) 

I HKREBY CKRTIFV, That I attcn.lc.l dcccasedTr^ 

■■ 190 — — to - 

that I last saw h alive on 



190 

190 



anil that death occurred, on the date stated above, at 
M. The CAISIC ()F4)KATII was r<; follows: 



^ 



ou^al^^l,.l: 



fi.^. 





Cv- I ► V r w«a_ I 



oicri'ATloN' 



Mltur 



DI'RATION Years 
CONTRIIU'TORY 



Months 



Days 



Hours 



(Signed 



Davs 



A^<r\v 



V 



« r\ 



DURATION Years Mo>uhs 

190 (Address) l^y,avAtA.<v^ ] 



or Rfcent Resldfnts, and persons dying away from home 



Hours 
M.D. 



%_ 

.^^59J.<5LJNfORMATION only for hospitals. Institutions, rransients, 



hospitals. Instil 



II 



R^'^iit^if in Siiti /'lanr/sm I Yfiii 



Mottttn 



/hn 



SRSdence^ia(j^aJ.^[L< SS^Tlkltli? 



HhsT OF- .\1\ KN«»\\ I.i;4J(,K AND HFIJFK 

\\\ 

( In forma nt \JsJ ' V>"x» 



rv ^' '•> -M, \'.\ K I 11 I I, 

JU^'-K AND HFIJI-: 



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



.. Days 



"'•t^'-- "■'"•^■- T '<':«"v.u, |,.Ar,.:„f,„»„, ,„KKMovAi. 



(AihlrcHs 




l^ , 



-r" 



4- v% 

,1 



. iLA; (>^iXa..,v>x 



i 

wV.A.H^ 






190 



'^' *• Every Item of Infopmatlon ■hould be citfafully «u»nli««i Arc -u u .. ■"*""■"■'■■■'■■■■"'— ■——»—i 

state CAUSE OF DEATH l„ plain term^ th-t Tt mJl t .^„!h . i«*i'**i.^'^?*^"^*-^* P"V8ICIA(V8 .hould 
-on. dying away from horn, should he ^I'v.n fn .v^l? I«t^ce '^ '^'— "'•^- ^"^ * •»^-«-' '"^o-matlon" for pr- 






WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



Board of Ik-riUli- I* No. i<; "^^S*^ H&P Co 




REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



Date File,], \juJLu lb WO'i 



345 



rNo. 



Registered JVo, 
H^, Deputy Health Officer 

DEPARTMENT OFfUBLIC HE ALTH=City and County of San Francisco 

Cectfficate ot Seatb 

( "a. S. StanDarO ) 
PLACE OF DEATH: — County ofliO^YvdiUXvvC^^^^^City ofCJA^V OA.<X/Vv<i\.v - 
iW i J\^a St.; I Dist.; bet. Ll/rUwtr"y\i and ^A.1 'it 

( "" .V!ll*l.°*'''"''^ *^*^ "'°** USUAL RESIDENCE Give FACTS CALLED rOR UNDER "SPECIAL I N FORMATIO N- \ 
V IF DEATH OCCURRED .N A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREeI AND NUM«R ) 



) 



FULL NAME 




SKX 



PERSONAL AND STATISTICAL PARTICULARS 

1 coi, 




O.. ' 



DATi: ni IlIK IH 



.\«.K 






u 



MEDICAL CERTIFICATE OF DEATH 



t 



DATE OF i)i:ath 



(Month) 



«^ •-T 



J :■<, 



■in * 



u 

(Day) 



M, in His 



M\ f 



{ Vear) 



(iMonth) 



,^ 



J- 



IS. 

(Day) 



(Vear) 



Davs 



WIIMIWKI) Ok I)1V»»K(KI> 



lUkTIU'U \i'K 

'St;it< or (.'Diiiitry) 



NAMK o|. 

KA rni;R 



niKTMI'I.ACK 

Ol- I ATHKK 

' St;iii or Cotiiitrv) 



MMDKN XWll 
Mf. M()THI;R 



IlIK Til IM.ACH 
Ml- MoTHKK 
'Si.'itc or Count rv) 



t) 







I HEREBY CERTIFY, That I attended deceased fronT 

j^i.^. i9oi to .U:U ^ 

that I last saw h -L^yy^ alive on 4lyA.4.vi IS ^^o H 

atnl that death occurre<l, on the date stated above, at 
-^M. The C\Vl\SE OF DlvATI! was as follows: 



DIRATION X Years 
CONTRIIUTORY 



A/oftihs ^ D(n's * Hours 





...«.i..^ 



U 







diration 
(Signed) 



)'cars 




MoHl/iS 



IqO 



(Address) foX^ I 



Day 



(HCri'AJK) 



••^- >^ 



h'r<iitf,f ni Sun /'i,inift,i 



Hours 
M.D. 

;^i 

orf rTflSliShfc' '^-J'^^'^^T'O'^ ""'^ ^""^ ""^P"^'^' InstltHtjins, Transients, 
or Kfcent Rfsldfnls, and persons dying away from home. 



.u,. 



)V,/; 



^ f, 1,1th - 



/l,f' 



(Itifominnt 'J-^ A V'WO^A-^ i O' 



Former or 
Usual Residence 

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



Now lonq at 
Place ol Death? 



tays 



(AddreHH h51 J\X<XXaaA4 




-ti 



r N I » i: R T A K E R C > ^X-t^C luUv4 



^ ^ il ' KKhMo\AI. I DA rh of IIiRiAL or REMOVAL 
(Addrc-ss ia.l^ yb* 



■ 



'^^ "• '^^"•y ^*«'»» o' Information should be cat*«fullir nuDiilUri Ari» -v« u w ^ ^ 

.on. <l^..,g ,«,, Iron, hon.. .hauld be «lv.n In .«,r, ln...7«. ■""'"'• ^*" »P«cl.l Information" for p.r. 



WRfTE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

nonnl f.f lU-altli — l* No. 15 '<^^^t:i) H& F' Co 







Bale Filed. r%^xXx. lb igo'\ 

V4^v<i (LiA>u Deputy Hearth Offlcar 



REFER TO BACK OF CERTIFICATE FOR INST RUCTIONS 

Ee^istered JSTo. 



346 



DEPARTMENT OF PUBLIC BEALTH-City and Coitnty of San Francisco 



(NoS^\^ C 



PLACE OF DEATH:— County ofC 



Certificate of Beatb 

( la. S. StanDar& ) 



^\l)AA.^b 



i\^ it; 



St. 



A.a , . ■ • ■ :: City 
Dist.; bet. 



iiy of^ \<Xy\) vl \a/>v 



-.Tu «;.;..;» --V ^"^"^ ««w«u ntoiutnwt give facts CAl 
LATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NA 

?1 



and 



■\NIE. INSTEAD OF STREET AND NUMBER. J 



) 



FULL NAME 



<3f I 



PERSONAL AND STATISTICAL PARTICULARS 



si;\ 



-J' 

DATl-: «)F niKTH (>^ ^ 



--- [^ I 



+ 



I Month) 



<Dny) 



M.K 



O L> 



J 'tUI I 



Moutfis 



\ ^ 



(Year) 



Da vs 



(Writtiti sjicial «lr^i>.'uatioii I 



'Stall- or Country 



(hv 




KhJU. 



'D 






% 



NAM|- or 
I- A THICK 



niKTin'I.AlK 
01 lATHKK 
'Male or Country) 



>fAII>K\ N'AMK 
01 .M<)TIII:k 



lilKTIIIM.ACl.: 
n|. MOTIIKR 
(Staff or Countrvi 



< HCri'A rioN 

AV.f /,//•,/ ,,7 SV;»/ /'i ,111, iu;i 



\JVt^ 



MEDICAL CERTIFICATE OF DEATH 

DATK OF DHATH A h ~ ~ 

%^H - ^90^ 

I HEREBY ClNRTlFyTThat I attended dec^;:a;;;j7ron7 

-^"^ ^-^ '90: to^ |^All^ A.S: 190H 

thflt I last saw h .; alive on 'K^^-M ' i >-. 190 

aii.l that death occurred, on the date stated above, at 
j^--^ M. pie CAISI^ OF DIvATfl was as follows: 






r 




I 



\ 



II, 



UURATION )V:^„ .V.„.O.s Days Hours 

CONTRIBUTORY ^ t.^.ftic^^vA^ . |v?^Jt:^^JJ^<ft.U 

DURATION Ycais Months .1 Days Hours 

(SIGNED) Ha»-^clO ll • M.D. 



i 



Y^u I \ 



fqo 



(Address) b Q b QA^fctjtA., . J-( 



.^f.r«^^i3^»u:l"°rf,;'?w~SL;•;:°'^•''^• '-«'""«-• •"-''•^^ 



) I'll I 



M.nff,'^ 



fhtv. 



r 1 1 !•: A fiov f: s r \r i: i > p ».; k sdvai p^KTuti \w< lui- ,-.>,. 

(hifofiuaiil WV AM V v) -A. • 



Formfr or 
L'sudI Residence 

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



How long at 
Mace of Oeatli? 



. Days 



p . ^ -^ '^ ^'' I '»-^^^<'i »' RIAL or REMOVAI^ 



(A«1«lrps« 






INDHRTAKKR 



Aj d^OLL: 



•■r\,V^. i. 



m1 "vVOLvt \C 

(Address ,, 35 1 ta.i 



190 






41 






WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

Honnl of lU-altli — !•' No. 15 ^^^^k) Jl&p Co 



RtFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



Date Filed, \jJLu I Id IDO^ 



^<^fW^ l^JU\s\A Deputy Heal ti^r>i?ieer 



Registered •A^o. 



347 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of H)eatb 

( "CI. S. StanDard ) 



n 



^ 



PLACE OF DEATH : — County of a->\ A. Ol >\ CL<i cc City of 
(No. l^LcU^V tl.OU' I AV I; St.,— ^Dist.;be t — and 



^a'^\.e\.^-: 



) 







FULL NAME 



! 



4' 



PERSONAL AND STATISTICAL PARTICULARS 



L 



COI.OR 



DATK (»!• HIRTH 



AC.K 




DATE OF D ATH 



WEDICAL CERTIFICATE OF DEATH 




I Month) 



S!N<.I.K. MARKIKI) 
WiDnWKl) OR niVdRt'KI) 

(Writt- il) KiH'ial <irsiKniiti.in) 



nrRTur'i.ACK 

fSt;it«- iir Country) 






(Day) 



Mftitfis 



L 



\ 



.\.i.l.u 



(Jfonth) r 



(Day) 



(Year) 



(Year) 



n,j I , 



NAM1-: ol' 
FATIIKR 



RrRTHPI.ACK 
01- I ATHKR 
(.Slate or Country) 



MAIDHN NAMK 
OF .MOTHER 



niRTir PLACE 

OF M(»THER 
(Statt or iNiutUrv) 



\ 






I HRRHBV CI.RTirY, That I a ttemlcd deceased from 

■ »90 — to .-.-. ^ 190-— 

that I last saw h -^r— alive on - - j - ^ 

and that death occurred, on the date stated alK)ve, at — — ~-:n- 
■^- M.^ The CAUSR OF DICATH was as follows: 

.d,A.A^wc.v<CiL 






,.q. 



F + ? 



DrRATIOX Years 

CONTRIBUTORY 



Months 



Days 



Hours 



H 



DURATION Years Months 

(SlGNED)....U^Vc>^Jl^. J (6.U) IAa. 



Days 



y>-^!Ui..)> 



190 \ 



( A d d ress ) Cfc\<r> AjL^ ^ j. , . 

rr" T~. — :: — ^— — 



Hours 
M.D. 



OCCri'ATlON 



' ' -^\ "i \v a 



) t'tl 1 s 



.^/"ftf/K 



A; 15 



^^^^^'fi^-.^^fOR'^ATION only for Hospitals, Institutions IransifnK 
or Rwent Residents, and persons dying away from home. ''"'""""s, iranslents. 



Former or q « 

Usual Residence ^.\% 

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




1 i How lond at 
^"^^^"^ Place of Death? 



Days 



THE ABOVE STATi:n PKRSONAI, p\KTK-lt :xHs xui.-ruiiv r.. -,',,.> 1"^ ~" ^-' 

BEST OF MY KN.m-,.EI,<;E Am/^hJ^.M^;^'**^ ^"^^^ "*^ "' '" ^"'^ ^^^ACyv niRIAI. OR REMOVAL I IMTE of HrK... or REMOVAI, 



BEST OF MY KNOWI,EI)«;k AM) ItFI.IEF 



(Iiifortnant 



(Address 



lis 



,CL>v-a^t ^ ^ 



Vl 



l-NDERTAKER JviUwi<frS; 3U,.wUsJi^ 
f^ddres, '^■^'^i^'^Vu^a^^ 



T90H 



-on. dying .way from horn, .hould be ^I'ven f„ .v"ri In-fncT •^'•••"'•*'- '*'''* "«P^'«' i"»orm.llon- for p^I.: 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

""""^"' "" '••>-'" '^^^^^^^>-^ t- Co RCFER TO BACK OF CCRTIFICATC FOR INSTRUCTIONS 



D((lc Filed, 




ilp 19 0\ 



Registered J^o, 



348 



i 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of H)eatb 



Ji 



( in. S. StanDarD ) 






m 



% 



PLACE OF DEATH: — County of C -tX-vv "^ \ aivx:v^ ccCity of C O^V \a->vecAe< 

rRe. ^w'^Wu.vdtu Lit 



t , ^^^^^^^H- vV<w>-vv4,lVft'U.4..i.St.; — Dist>;bet> and — = 

f /- ir Ot.TM OCCUR^ AWAV FROM USUAL R E S I DE NCE CI Vt facts CAtLtO roR UNDER -SRCCIAL INrORMATIOf- \ 
J \. .r PCATH OCCURRED IN A HO.RITAt OR .NSTITUT.ON GIVE ITS NAME INSTEAD o" STREET J^ND NUMBER ) 



FULL NAME 







.Il 



SKX 



PERSONAL AND STATISTICAL PARTICULARS 

COI.OR 



DATh; OK IUKTH 



A<.H 






\i.^, 



MEDICAL CERTIFICATE OF DEATH 



DATK OF DEATH 



[Month] 



I Month* 



} ra I 



(Day) 
M„ut/i 



fVear) 



i ...... . 

(Day) 



(Year) 



Pa 



r.v 



iri 



SfK«-.I.K. MARKIHI) 
WrpnWKD OR fXVoKCKD 
1 Write in social «lf-.ijtnati«in) 



Ql\. .. . 



\ 




I HRRKBY Cr':RTIFY, That I attei^,l decc^^^dli^ni 

a^jv)^-. ..a.5....iQo '' to Wi-H-.-U ,90'^ 



that I last saw \\ ■*. 



[90 
alive on 



190 



HIKTUl'l.ArK 

(Stat) or (■(miitrv) 



»athi:r 



nrKTiiiM.ArK 

<'l I ATMKR 
(Slatr or Count ryi 



MAIDHN NAMK 
OF MoTHKk 



HIRTHl'I.ArH 
<»l- MoTHKR 
(State or Country) 



\ 









an.l that death occurred, on the date stated above, at H 15 
\^^- The CArS^? OF DRATII was as follows 




"^-^^ B &riKLi.li\A..vvQ 



I 









H) 



DIRATION Years " Mout/is \\ Days 

CONTRIIUITORY 

DI'RATION Years ^Months Days 



Hours 



(SIGNED) 



i\ * 



-I 



190 



(Address 



)-aL- 



Hours 
M.D. 



^. 



^^^^\\^SA.k^,. 



oCCrj'ATlON "\ I 1 . 



«rf.^59'fi*-J'^r^'"^^"'"IDN only for Hospitals, Institutioiis, Transients 
or Rfccnt ResMeiils. and persons dying dway from home. '"nsients, 



Ft rmf r tr 

Usual Residence L 



lu 



>%^Li ...N 




Rf^uird III San /'inn, 



isri) 



X-i 



) 'Ul I 



Afi'iifAs 



fhtV: 






THK AHOVKSTATi:r> PHRSONAI, I'AK ri»ri \Rs ARi. TWf>? Tr* rill- 
imST OF MY KSiAVLKDC.E AnI) HHUFK ' ^ '^'"' 

(Infominnt -^ .Vt3u-v^K ^^ <^ ck, vV\jC^ v 7] ' 



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



How long at 
Place of Oeatli? 



Days 



f Address 



-Ufc^Ct.di 



r^ACK OK n, K,.M. „R RKMOV.A.. I D.V,^:„f ,„..„, „KEMOVAI, 

'"'-l-^'Vii^iAi—kLSULi, I '41.A..U., I'. tgo'i 



INDKRTAKER 

*! Address 






N, B.— -Every Item of Information should bs carsfulfy nunntUrf Arrr u trT"""'"'"'"!""""""'""'"""**"'""'*"'"^""'"""'''''" 
.f»e CAUSE OF DEATH In p|«|„ t;rmr th"t U mal t J^ 1 ". *^.*!"**i EXACTLY. PHYSICIANS ahould 
•o*. dying .w.y from horns Should iT^UafnUry 1^.^^. "^ '^'•••^'^''- ^'^^ •'»»-*^»-' information- for pTr! 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

Bonnl of H...lth-F Xo. 15 ^^^^H&P Co REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



Date Filed 




lb 



lOO'i 



Registered J^o. 



349 



X>\vu> XiAMj Deputy Health Ofncer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Certificate of E>eatb 

( Xa. S. StanDarO ) 
PLACE OF DEATH: — County ofC'O^^rV JA^^OL^VL/CUACoCity of ^^'<X/>v o A^a^-. c ..^ a/ 



rNo 



,.^H 




I 



1 




ff^ St.: ^^^ 

. ilOENCECIVe TACTS wi^i. 

ATM OCCURRCD IN A HOSPITAL OR INSTITUTION GIVE ITS NA 



DisUbct. Is^ 



±L 



and 



/ ir DEATH OCCURS AWAY FROM USUAL R E S I D E NC E Gl VC TACTS CALLED roR UNDER "SPECIAL INTORMATION \ 
\ IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD Of STREET AND NUMBER. / 



L.i.; 



FULL NAME 



"" ^ 



PERSONAL AND STATISTICAL PARTICULARS 

I COI. 



L'Ll/yxJLiIJ 




£.£l. 






(1 



J^>^\CL 

DATK 1>F HI R Til 



m:\{ 



SfVr.I.K. MARKIKI) 
\Vin»>\V}*F» OR I>fV<>Rii:D 

( Wlil, ill V 



"lu ! 




% 

(Dav) 



MEDICAL CERTIFICATE OF DEATH 



D.\TE OF DE.\TH 



fMonlh) 



(Vear) 



M,;,Ur 



n, 



t\y 



lURTHI'I.Ai'K 
(Stalf rir Cuiintrvl 



N \MK OK 

1'Athj:r 



niRTnpi.\(K 

or I ATHKR 
(Slate or Country) 



MAIDKN NAMl- 
<)I" MOTHKR 



HIKTHIM.AIH 
t)I" MOTIIHR 
I >^tatc or 0<»\intrvl 



nCCri'ATlON ^ 



i»R DfVoRiKD \ 

ial il<-si^Miatiu!i) 1 I \ 

il 1 M ( 




-*f^ 



^ 



\\t>. 

(Hay) 



A 

that I last saw h 



TOO 
alive oil 4v\-<.< 



(Yrar) 

EREBY CERTIFY, That I aUcmlt«l .k< vasc-.l from 

'^ to ....|AAJU^...iW! ,90 S 

and that «leath occurreil, on the date slated alM»vv, at ^ 
M. The CAlSi: OP IH^ATII was hs follows: 






DURATION 3 y^ars ' Months - Days 



Hours 



CONTRini'TORY 

A\JXj^\.^K.%^\ 



f^fsiiffit ill Siiti Fi (till t'sf-i) 




f uU^r \UirdK 



DURATION - rears Mouths ^ :i Days 

(SIGNED) Q I^Xc-^a 




^ ^ Hours 

U.pK^a M.D. 

1^ iQoH (Address) 1H> L^UAvCg. 11 



iCIAL IN 



•r RfcMl Rfsldcnls, and persons dying away from home. 



) I'll I s 



A/fHif^s 



/hi 1 



*''"l■•.^'!?^■'' ^'' '^■|"'-I» PHRSriNAI. I'ARTIi'lI.ARS ARK TRIF Tu TIIF 



Former or 
Usual Residence 

When was disease ronfracted, 

If no! at place of death ? 



How long at 
Plareof Death? 



Days 




'''a'''^"^'^"/'*''* KKMoVAI, J DAJ-Kof BrRiAU or REMOVAI, 




(Address ^"llS. 



^4-4,ur^ 



'1% 



^' ^•'■""Bvery Item of tn?nrmallon should be cat*afullv aunMit.^ kck _u TjZ I . ^„ ^■"■^^^■^■"■■'^■^■ii^"^* 

....e CAUSE OF DEATH l„ p,.,„ UrZ^ti^^ U r." t pi^rt;7l...Vfi;5" Tht^^.IcU; . '?*''^'?:^'^,% '"'"'^ 
.01,. dylnft away from hom. .hould be tl«<n In .v,r, la.timc,. ""•"""'• ^'•« •»««'■" Information" for p.r- 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANEN-* RECORD 






I 



nnmd of IlL-.'ilth- I" No. !<; '^^^^^-^ USiV Co 



REFER TO BACK OP CERTIFICATE FOR INSTRUCTIONS 



Dafp Ff'/ed, fJU^u 




lb 100^ 

Deputy HeaJth Officer 



Registered JVo. 



350 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



% 



Certificate of Beatb 

( Ta. S. StanDar^ ) 
PLACE OF DEATH: — County of C CL^ru "i \ajy)JUA^^ City of ^'<X/>v vJa^CIavcx^^^ 
(No. klT k.L' ' , St.; t Dist.;bct 't CcUIirro and \I K LLLuul 

/ ir Ot^TM OCCURS *WAV FROM USUAL RESIDENCE Give FACTS CALLCO FOR UNDER "SRCCIAL INFORMATION" 'V 
V IF ftCATH OCCURRCD IN A HOSPITAL OR INSTITUTION GIVC ITS NAME INSTEAD OF STREET AND NUMBER. J 



■v) 



FULL NAME 



h 



hJX/lL. dU .aL\mi.:vv.o 



\Ax 






PERSONAL AND STATISTICAL PARTICULARS 

DATK or- HIKTH A 

/jMoiith) (Day) 

AC.K 

?)0 



MEDICAL CERTIFICATE OF DEATH 

DATE OF DICATII 




rllH 

(Year) 



J 'ra t 



Moiilh' 



^ - 



n>i y. 



WIDOWKI) OR niVoKCKI) 
(Write ill s«MMa! rksij^^tiatioy) 



HiurmM.Ai'j-: 

(Statf ur (.loiintrs') 



^ 



OLVu\^JxL 



NAMK OI 
FAT HICK 



niK IIIl'I.A^H 
OI- I ATIIKR 
(.Statr ur Cmiiilry) 



MAIDKN NAMF: 
t)F .M()Tin:R 



HIRTiriM.ACF: 
ni MoTIIFK 
(Stalf or Coiuitry) 



OCCIPATION 




I 1U^:RKBY CI-RTIFV, That I atlcmled (leccasedlronr 

^^5-^ U 190S to |^.\JLu.lH 190H 

that I last saw h .^Ou alive on VLajLu. V^ 190 H 

and that death occurred, on the date stated above, at 5^ H S'. 
iX M. The CAISH OF DFATH was as follows: 



DTRATION 



}ears Mouths .>*^ Days 



Hours 



^j^^^ljJkX) 



DLRATION -Years Afofz/As — Days -^ Hours 

(SIGNED) dlx^ "^.^Xirn^^ 



^ 



M.D. 



rooH 



( 



JA^-itm 



«r D«..-7 D.Vi;-J'^f°"'^?7'0'^ ""'^ '^^ Hospitals, InslituUons, Transients, 
or Recent Residents, and persons dying away from home. 






)V(M.« •■ M^ntilhs •■ Ptt 



TUF AHOVF STATFD , .^KSONAI. PAKTUTI.ARS ARl- TRIK To TIIF 
HHST OI- MV jvNOWIJ'IDC.K AM) HFUn-:F 



(Infonnaiit 



OL^. 






(Address 



\ 



Former or 
Isual Residence 

Wiien was disease contracted. 
If not at place of deatfj ? 



How long at 
Place of Oeatli? 



Days 



I'l^^CK OF niRIAI, OR RKMOVAI. I DATK of BrHiAi. or RKMOVAI, 



INDKRTAKFIR 

(Address 



^\] 









"■ "■~«-.7c'ru" e'oF DEa"th".„''LT'.'' ^' '""'"J" r""""'*"- "'^^ """"' •" "■»••' EXACTLY. PHYSICIANS .h„.ld 





WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

Boanl of liLi.lth-i No i s ^S-g^g^) n& I' Co REFER TO BACK OP CERTIFICATE FOR INSTRUCTIONS 



l)(ff(> FilCil, 



Registered J^o, 



351 



lb 190^ 

\jj\Ha D^P^^y Health Off? 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



\^.AJs 



cer 



Certificate of 2)eatb 

( "Cl. S. StanDarD ) 
PLACE OF DEATH: — County of ^O.^X) JXaT\Ck.i City of^^ 






t^^c^a 



rNo, 



jllfc it WW' 



\^ 



,^uV^<. \ St.; — ~ Dist,: bctr 



" and 



(ir DC^TH OCcjlRS AWAY FltOM \j8UAL RESIDENCE Give rACT<S CALLCD FOR UNDER "SRCCiAL I NFOR MATION" N 
IF dEATH OCCURRCO IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / 



FULL NAME 



V 




<xx!r. 



A, 



kt::\xjU.. 



i 




SHX 



DATH. 4)1- r.IRTII 



M'.V, 



PERSONAL AND STATISTICAL PARTICULARS 

COI.OR ^ 



ex.' 



vrtVu 



L 



L 



iMontli) 



) 't'li > . 



(Day) 



Motiifis 



MEDICAL CERTIFICATE OF DEATH 



DATE OF DKATH 



(Ilfonth) ,|" 



i.l... 

(Day) 



(Year) 



1% 



(Year) 



Pa V, 



SIN«;i,K, MARUli;i). 
WnxiWKI) OR I)I\«tKiHI) 
'U'rilcin social ihsijj'nation) 






mRTnPi.AOH 

(State or Coiintrs-) 



NAM1-: ()!•• 
FATHKH 



RIRTFiri,AOK 
Ol" ! ATIIKR 

(Stale or I'oiiiitrv) 



maii)i:n NAMi-; 

<)l' MilTUHR 



HIRTin'I.ACK 
oi- MOTHKR 
(Slate or Country) 



A 1 



I HRRFiBY CHRTIFV, That I attended deceased from 

..iv.k.^.^wA^-.. .1 looh. to Uvs^Lmu.-.I.^. 



that I last saw h 3. alive on Mva»Xa^^ \'h. 



I90H 



190H 



and that death occurreil, on the date stated al)ove, at I 
^'^ M. The CAlSlv OF DHATIl was as follows: 



l.\..<X^..\^.V..i.. \„x.. X 



^VfrVv 



DURATION Vtars 

CONTRIBUTORY 



Mout/is ' Days Hours 



DURATION 

(Signed) 



) 'ears 
\V,A^.|V. iQo' (Address) blO 




^fonths 



Davs 



Hou 



rs 



^'•.wU.ll 



^'i a^.., ^ 



M.D. 



oCCn'ATION 

A'rshfrtf ill Sat/ /'i iini tsrn 



Vfais 1 A/,>iif//s I o Havs 



TUV. AHOVK STATI'I) t'HRSoNAI, I'A RTICT I.ARS ARK TRt'F TO TIIK 
IU:ST OI' MY KViiWl I.IH'K ANI> MHIJKP 

(ttiformant ^^ "< <\.' ' ^f)\ 



^''^^'^'-J'^^^^'^'^'^'ON only for Hospitals, Institutions, Transients, 
or Recent Residents, and persons dying away from fiome. 



Former or 
Usual Residence 

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



How long at 
Place of Death? 



• Days 



f Address 



Cnui 



^ 



^< 




190 



VhM^pV m-RlAI, OR KHMOVAI, DATK of H. r,at, or RHMr»VAT. 
UNDHRTAKKR JUOCaCUVw ^^ JVcttu 



(Address ^ Skl,:^ '....l.a..,ttx ' .... ll 



"• ^•~r:r/JlT«^Un 'kTrl'r.'*!"."^^^^ h.cnr^u^^y .upplled. AGB .hould bo •tatecl EXACTLY. PHYSICIANS .ho«ld 



ri^l'/f'i^^ OF DEATH In pl„|„ term., that It may be p.opeHy cl...Iflcd. The ''Sp;:!.! InVormatloa" fo' 
•«ii» dying away from home should be given in every instance. information for 



par- 






WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

REFER TO BACK OP CERTIFICATE FOR INSTRUCTIONS 



IJoiiKl ..f IU;(llli-|- No. !«; *^i^^H&P Co 



])((fc Filed, 

1 



>Vt\XJ 




\b 100'\ 

Deputy Health O^iccr 



Registered JYo, 



35! 



DEPARTMENT OFTUBLIC HEALTH=City and County of San Francisco 



Ccttiffcate of Beatb 

( H. S. StanDarD ) 
PLACE OF DEATH: — County of a^\ ''XCL\\.<:A-acr City of^Ov J 



.\.(\ ^ Vt. A,^ ? 



No, V\ 



X 



L ^ i 



tA. V-»^ A. St.; . Dist.; bet. 

(IF DEATH OCCURS AW*V FROM USUAL R E S I D E NC E C I VE FACTS CALLCD FOR UNDER SP 
IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STR 



5iwi.^:a\..CL and ^' 

ECIAL INFORMATION" 'X 
EET AND NUMBER. / 



FULL NAME 



\\,rsx.\Aj V-\-cL>\..\,c 



.-V-.i.s. 



PERSONAL AND STATISTICAL PARTICULARS 
SH\ V\ ^ j COI, 



'^ 



DATI-: OI- lURTfl 



I.OR \ 



vVCtu 



MEDICAL CERTIFICATE OF DEATH 



DATE OF DEATH 



fonth) 1 



(Day) 



(Year) 



A<-.K 



> t'a I 



(Day) 



M..,i/f,' 



\W-Ar) 



I tax 



S1N<.1.K MARklKD 
U'II)i»\VKD <»R PIVoRCKD 
(Wiitc in social fltsivMiatiini) 



niKTHPl.AOK 

I St.Mtf or <"<>niitrv) 



\ \Mi: OI- 
HA TMHR 



HIKTMIM.AjK 
ni I ArUKK 

f Statf nr Cuimtt v) 



MAIl)}:\- VXMI' 
«H' MoTllKK 



HIKTHlM.At^K 
Ol- MOTHKR 
(State cir Country) 



r\' 



'^ 1 



I HEREBY CERTIFY, That I atten.kMl .Icccased from 

^vdlu . 1*^ 190 H. to '^iLS.Lu-.l-'X igo'i 

that I last saw h alive on igo 

and that «leath occurred, on the date stated above, at 
^M. The CArSH OP DEATH was as follows: 



i 



'■ t< 







Dl- RATION Yt^ars Months 



p^^n^M^Lxl. 



Dav 



Hours 



CONTRIBUTORY 



.Ci-i in i r 



ll 



occri'ATlON 

fKfsnff'ii in Siiti /'i ll III isr(} 



DURATION 

(Signed) 







1 



TQO i 



Years j. Months Days 

(Address) 3S b * H 



Hours 
M.D. 



Special information only for Hospitals, Institutions, Transients, 
or Recent Residents, and persons dying away fro.-n liome. 



) V'/? I . 



Minith> 



I hi 



TH1-. \IU>V1-: STATI-.D PHRSOXAI. I'ARTlOri.ARS A R !■: TRfK To THF 

iiKsr or MS' KvouiKiMiK Avr» phi. iff 



(Informant 



(Aflrlre»!S 






k 



i 



Hffmwt 

Usual Residence 

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



How lonq at 

Place of OeaMi? Days 



ri,ACE OF m RlAl, OK KK%f<»V\l 



i^w. 



^ 






DATHof JUKiAt or RHMOVAI, 



INDFRTAKKR 

(Address 







90H 



N. »•— ^;Ye''cAr8F'Ap n^^^ ^^ cflrefully supplied. AGE should be stated EXACTLY. PHYSICIANS should 

!l;l dtw r ? f I ''l* .iY""' **'"* '' '""*' ^"^ properly classified. The "Special information- for per- 

sons dying away from homo should be given In svsry Instance. 



I 






't 



^^ 





WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

REFER TO BACK OP CERTIFICATE FOR INSTRUCTIONS 



Hoftnl r)f lIt:iUh I" Sn. \k. "B*^*2«) Hit I' Co 



Registered J^o, 



353 



Date Filed, |vJLu lip 7.9^S 

dL^vcvo Ixovu Deputy Health Offlcer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Certificate of Beatb 







( m. S. Stan^arD ) 



^No. 



PLACE OF DEATH : — 

i -L f? 



County of*"-'<X>V'l^^(X^vCt^-. City of -<^-'Vu 



\ ^ -\ '01) 



VC^C-^ 



St 






Dist.; bet. 



and 



(IP OCATM OCCURS AWAY FROM USUAL R E S I DC NCE 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 a.»^J. 




?U:>:\/ 




^ 



Li— 



m.' 



si;\- 



PERSONAL AND STATISTICAL PARTICULARS 

COI.OR I 



DATl': tH' ISIU III A * 



'Monlh) 



A<,K 



fs ^ 






W' 



(Day) 



M.,>ifh^ 



\ '-' 



(Year) 



Dii 1 . 



s!N«.i.i-: M\RKn:i) 



w ii»»ui:i> (»K i)iv(»K»Kr> p 

(Wiitrin •-(Ktal ilf^iKnulion) "^ 

H 



C^v< 



HIKTinM.AOl-: 
(State or Country I 



NAMK OF 
FATMl-R 



TUKTFIIM.AiK 
0|- I AT Hi: K 
(State or Couiitrv) 



M\It»i;N WMH 
<>l- MOTIIKR 



lUKTHPr.ACK 

OF mothi:k 

(State or Connlrv) 



4' <3r^ 1 



n 



MEDICAL CERTIFICATE OF DEATH 

DATK OF I)F:ATIi 

(Day) 



[Month) ] 



(Year) 






r HPtRHBY CICRTIFY, That I attende.l dcceasetl from 

..-■..■.---■■:•:.:. IgO — — ■ to . ■ ■ ■.:^ r^r t - ^.-— T? ; ■-.-" • " IQO "^ 

that I last saw h rr— - alive on - .— — v--— — — ■ -t.:-: _ _ jyo 

and that death occurred, on the date stated above, at 
. M. The CATSH OI' OKATlf nv;is as follows: 

ry-juwrrvx^A-iu^X' .,wy.^" 

or RATION Years Months Days Hours 
CONTRIBUTORY 







CcCtI 



^JJ^u^^y^^i) 



M. 



Ut'W 



occri'ATioN C<.q<iX. ^ ■ ' ■ 

Rfsidfd HI San /mm im'o t3 v^ )t'iii> 



DURATION }'i'ars 

( Signed ) L&'ur^AJDv 



Mouths 



Days 



X kiJ^Ak.. - TQO 

ECIAL INI 



(Add ress ) Wx rvVw^ \ V \ 



Hours 
M.D. 



FECIAL INFORMATION only for Hospitals, Instituflons, Translfnts, 
or Recent Residents, and persons dying away from home. 



Mn„th< 



A/ 1 



THK AROVF. STATF';f> PKRSONAT, PAKTrCFr,AKS AKF: TRCK To TIIF: 



(Itifonnatit 






(A.i.l 



ress 



\v\\ 



U/cUULtv© 



Former or 
Usual Residence 



\a L>^e. A I 



How long at 
Plareof Deatli? 



Days 



When was disease confracted, 
If not at plareof death? 



ri,^I| OH IHRIAI, OR RKMOVAI, 

I'NDKRTAKKR ^1 I V 

(Address I X'^'\ 



DA'i;}-: of Hi KCAi- or RKMoVAI, 







190 



^CX*wkAt.,..:il 



N. B. Every Item of Infopmntlon should bs carefully supplied. AGE should b* stated EXACTLY. PHYSICIANS should 

•tiite CAUSE OF DEATH In pfnin terms, that ft may he properly classified. The ''Special Information** for per- 
sons dyln^ away from home should be ^'^^n in •\^vy instance. 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



iu.iii.1 of llt;.ltli-l* No. I"; •^•??aS^) !<& I 



•Co 



REFER TO BACK OP CERTIFICATE FOR INSTRUCTIONS 



i 





Registered J\^o, 



354 



o-tcco 



:i If 



lb 100^ 

Ix^u Deputy Health Officer 

DEPARTMENT OF PUBLIC liEALTH-City and County of San Francisco 

Certificate of Death 



( Ta. S. StanDarD ) 



I 



:ity of ' ^ 



No, 



PLACE OF DEATH: — County of ^<X >x.'^t^a.Q i City of '^tfrckl<r> 



.^^< 



( 



St. 



Dist.; bet. 



ir DtATM OCCURS *W*Y TBOM USUAL R E S I DE NC E Gl VE r*CT8 CALLED rOR UNDER 'SPECIAL I 
ir DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AN 



and 



NFORMATION" \ 
D NUMBER. / 



FULL NAME 




iL- 



PERSONAL AND STATISTICAL PARTICULARS 



I \ 



Cnl.ok 



Nil t>l lilRTII 



MEDICAL CERTIFICATE OF DEATH 



DATE OF DKATI! /> 



'M.lnthi 



iDsiy) 



\'.i; 



I . 



M.nith' 



• Vt-jf 



lhl\: 



-!N.;|.K. MARKIHI*. 

v\ n»»»wKi) nk ntvuRt'KD 

■V;;!. ill »iH i:il '!• "iiMiationl 



• I i.nnH\ 



^ 1 



^ s 




9 



N SMI III 
1 \ I lll-K 



HIk 111 PI. \t K 

'»! I N ihi:k 

■^t:it< ..r riiuiitrv* 



"1 MH'illKk 



lilHIfUM.ACK 

Stalf (M f.,ui\ti \ 



'•' ' ri-ATIoN 







f^tollth) j 



(Day) 



rgo 

(Year) 




I HIvRliHY CI-RTIFV, That F atteii.kMl aeccased from 

— to .rrTT-:rr--rtrrnrrr:r-:rr:— 



■ ■ ■- ^-190— - lo -^ V i QO 

that I last saw h . alive on - ^— T90 

am! that death occurred, on the date stated above, at 
M. The ('AI'SK OK I) i; AT II was as fojlows : 



> 






LK^ 



nr RAT I ON Years 


Mouths 


(.ONTRini'TORV 




IHRATION Years 

(SIGNED) U' UJ 


Months 

4-1. 



Days 



Hours 



<^ 



p 

UP 

i 

r 



Days 



Hours 
M.D. 



'i;.v.A„i. 



L 



190 



f, 



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



O' 



r 
r 

7 



/\fi,ff,f It! Siiii f I iitti isi'o 



I J, )V<n 



Months 



fhi V 



(I 



Hj.^r <)i- MA I. 

\ 



I III-' MJovi: Sj" \ ri,'|) I'KW s( >\- 4 I piurirrr iw«^ \uv vu\\.- r, » i'mi.' 
»»i.^r<M- M^ KNn\VI,KlJC.K AM) JIHI.U:!-' 



f 



fAdcl 



re«« 



i 



Former or 
Usual Residence 

When was disease contracted, 
If not at plareof death? 



How long at 
Plareof Death? 



Days 



ft v., 



V ^. . T90 . 



(Address 



N. B. Every item olT information should be CHPofully supplied. AGB should bo stated EXACTLY. PHYSICIANS should 

•late CAUSE OF DEATH In plain terms, that It may be properly classified. The "Special Information" for per- 
sona dyin^ away fi*om home should he ^iven in every instance. 



i 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

Bo:n.l nf u, ;,nh I No is TS-^^jH&I' Co REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



Ihffr Filed, 



lb 100^ 

Deputy Health Offioer 



Registered JVo. 



nn 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of Beatb 



^ 



{ la. S. Stan&ar{> ) 



-? % 



PLACE OF DEATH: — County of "^ CI. > v t\<X vvOw^.^<:ity of ^^ vu \XX/Vl^a.^ 



all 



X) 



^\. 



No. ^^ Llc^CtcLs, . .\.*.i St; I Dist.;bct. H\-La\jLMJ and SJ ! lUL4.t 

(IF DEATH OCCURS iwAV mOM USUAL R E S I DE N C C Gl VE FACTS CALLED FOR UNDER "SPEdlAL INFORMATION" > 
IF DEATH OCCURPCD IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / 



^1 ) 



FULL NAME 




SK\ 



PERSONAL AND STATISTICAL PARTICULARS 

I COLOR 






)!■, 



DATH or- lilKTll 



M.K 



I M.. 11th) 



] %«i » 



iD.tv 



M.mfh' 



' » « a I 



na^ 



SIN.. I, I- MAKKIKII. 
WriHiUKI* OR IMVORfHt* 

iWrittiii "-.ix'ial 'U»iij.'nat 'i.n) 




niRTiiri.AOK 

I St.'itt iir Coiiiiiry ' 



N \M1 ol 

I \ III IK 



MlkTHI'I.KfK 
o|- I \riIKR 
iStat*' or i'liiintrv 



MAIl>HN XAM1-; 
(II MOTHKK 



lUKTHri.ACK 
«»l MorilKR 
(Slati I'l Cmintrv 













^^L<:Lqdj ..Lt^Va 



MEDICAL CERTIFICATE OF DEATH 



DATE OF DEATH 



tMonth) 




1^ 

(Uay) 



(Year) 



I IJKREBY CKRTIFY, That I atttn.lcrl deceased from 

wU^ X 190H to.. |vvw IS- 190 S 

190 H 



that I last saw h ..rC\? alive on 



V\J 



and that ilcath occurred, on the «late stated above, at 
i M. The CAISIC Ol/ DHATII was as follov^^: 



iv 



DIRATION 



ICt^VU 







VrUrvLtrrv 



OCCri'A TION 



"^r 



VLlav.d 



) 'ears 



Mouths ^i. Davs 







Hours 



DURATION ' Years " Mouths 1 I\ns * Hours 
(SIGNED) L- VJ ^n\^^!v4wV M.D. 

IQO 



N|^..U^|(l.tqoH (Address) S5i Ua.^>V.uU.C4 ^1 
SPEClii^L INFORMATION on!> for Hospitals, Insmutlons Translfiits. 



or Recent Residents, and persons dying vnvi from home. 



h'f-lilfil in SilU J I iliii I .,•,) 13^ ) /■(/ 



M.„ilh, 



J hi 



THK ABOVE STATED PFRSOSAI. I»AKTiri' ! ARS ARK TRt E To THE 
HEST OF MY KN'OWIJ'IX'.K AND majl'.I* 



flnfiinnam 



Ot.>X' 



A<Mi«->i- 



\ ^ 



Former or 
Usual Residence 

Wlieii was disease contracted. 
If not at place of deatli ? 



Now tonq at 
Place of Death? 



Days 



I'l.ACE OF m KIAI, OR kEMo\ AI. | D\TEof BtRtAL or REMOVAL 

n T90H 



t^^ft^M^ k VV4^^ 



INDER TAKER 

(Addn «-*. 



|cw.^>>\'Q^ 



t^ 






N. B.— Every item of Informntlnn should bs carefully Kuppfied. AGE should be stated EXACTLY. PHYSICIANS should 
state CAUSE OF DEATH In plain terms, that it may be properly classified. The "Special Information'* fsr per- 
sons dying away fnHti home should be given in every instance. 



I 






WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

nonnl of iKalth- 1 No i^ T*^^^H&I'Co REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



Registered J^o, 



356 



Dale Filed, lldLu- lb 190^ 

i J (1 

A/O-UA^ <M^\>^ Deputy Health OMcer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Certificate of H)eatb 



( "a. S. StanDarD ) 



4' 'l^ ^ ^ 

PLACE OF DEATH: — County of ^aiv iXa^xCA^ tC City of 'a>XJv3A.a^ 



t^O 



'A:thacL^ 



<^No. % I ^ ^ I^ a L Lts .u . St.; \ Dist.; bct3i^HX<Vtu^ and ^ 

ir DCATH OCCURS AW»V FROM USUAL R E S I D E NCE Gl VC FACTS CALLCD FOR UNDER "SPCCmL INFORMATIO 
IF DCATH 6ICCURRCD IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET? AND NUMBER. 



( 



a.L' 

- ) 5 



FULL NAME 



'IL 



Cw 



Ax. 



.^d.^„L^J 



SKX 



PERSONAL AND STATISTICAL PARTICULARS 

COI,OR 



0)\ al. 



DATl-: OI' niKTII 



A(.H 



(McMith) 



) Vi/ 1 



( iJa y I 



¥ 



r'\ 



(Year) 



/hi r. 



winnu i;i) OR r>iv<iRtHi) 

i\Vrit« ill vdiifil ilt>-i>^naliiui) 



i 



^^^q 



BIRTrnM.ACK 

(Statf or ("Dniilry) 



NAMK OI. 
1 A rill-.R 



niRTMI'I.ACK 
OI » \IHKR 
'st;it< or Country) 



MAHJKN NAMl- 
«)H MOTIIHR 



HIRTIIIM.ACH 
OI MoTHKR 
(Slate or Country) 



nccrpATiuN 



D 



ll 



/I 






MEDICAL CERTIFICATE OF DEATH 
DATK OF UKATH 






IS 

(Day) 



rpoH 

(Year) 



ll|iRKBV CHRTIFY, That I at^tended deceased from 






190 H 



to 




isr. 190.H 



that 1 last saw h . > alive on )p^>-<Nf^ i .^ j(p 

and that <leath occurred, on the date stated above, at I *. ok 
'.' . M The CAISP: OF I)I':AT1I was as follows: 



C^^^ V^. 



4.C Ww I s^o 

1 



^} 



iwV^aL^,^ 



DTRATIOX )Vrt;-.v I\/onths ' t) Days 

CONTRinrTORY ^„.C L :" „ 



Hours 



DIRATION 

(Signed) 



Years 



Mouths Days 

it 



v-wJUU ^ii<iA^ <^ w^K. 



fV W^^^- 1 S^ TQ0'1 (Address) M (\^>:vt<:yA^ V i C : ': 



/lours 



M.D. 



in San Frantisei} O Yrtxis 



M.niiU 



/'■;i . 



TH1% AHOVK STATKn PFRSrjv.M, J'A K lirf I.A RS ARK TRfK To TIIK 
in«:sT <)!•■ ?.JV KNi>\VI,KI>C.K AND l\\'.\,\VA' " 



(Iiifotnuint 



(A<Wre«s C I fc 



! WX^vl.'v 



( 




ax\j. 




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



Former or 
Usual Residence 

W^^n was disease contracted. 
If not at place of death? 



Now lonq at 
Place of Death? 



Days 



PI.ACK f)I' IllKIAI, OR KKMOVAI. 



I)Al>:of ,4lrRiAL or RICMOVAI, 



l>i of JIlRIAL 



I 



tw^u 1 . 190 



(Address 



W. B. Every Item of Information ahould be carefully supplied. AGE ahouid b« stated EXACTLY. PHYSICIANS should 

•tate CAUSE OF DEATH in plain terms, that It may be properly classified. The "Special Information'* for psr- 
•ons dying away from horns ahould be ftlvsn In svsry Instance. 



,41^' 




4 






iKl 



WRITE PLAINLY WITH UNFADING INHl— THIS IS A PERMANENT RECORD 

noarclof lltnlth-i No i.^^^H«tPCo RCPEN TO BACK OF CCRTIFICATC FOR INSTRUCTIONS 



RegLstered jVo. 



357 



Dtttc Filen, %kIu \\c 190'\ 

<Mrvu^ cU.A>u Deputy Heaith Offlcer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Certificate of S)eatb 



( Vk* S. StanDarJ> ) 



PLACE OF DEATH: — County 



(No. 



WV\tx€L\) 



( 




of vJ/(X/w Ox^cc^Yvc.ui.c^.Gty of C'^X^yv o A.<Xavc,c^<i o 



Dist.: bet. and 



ir OCATN occu 
ir DEATH OCCU 



USUALl RESIDENCE Give facts CALLCD worn UNOCM "SPCCIAL INrORMATION" \ 
HOSPITAL on INSTITUTION GIVC ITS NAME INSTEAD OF STREET AND NUMBER. / 



) 



rULL NAME 



SKX 



PERSONAL AND STATISTICAL PARTICULARS 

COI,OR 



4 



O^/YYXJiA 



f 




*50\JL 



llM.vtt 



MEDICAL CERTIFICATE OF DEATH 



DATE OF DEATH 



DATK OF BIRTH 



A(iK 



rtX/Ys.J 

[Month) 






t 



(Day 



.l/.*»////A 



r%S.%... 

(Year) 



M 



Davs 



S INC. I.E. MARKIKD. 
WinnWKI) OR niVORiKO 

(Write ill stK-ial iksiKiuitioii) 



niR rm'i.ACE 

iStati- or Country^ 



NAME OF 
FATHER 



BIRTH PI. Al'E 
OF FATHER 
(State or Country) 



MAn)i:N NAME 
OF MOTHER 



BIRTHPLACE 
OF MOrHF:R 
(StJUe or Country) 



^'^' -c >vcJLli 

M I UX^^<X/CVU-^w4JXL^ 

\ i 




13 

(Day) 



r9o\ 

(Year) 



I HKREBY CRRTIFY, That I attended deceased from 

••• I90 — — to 190 —"".. 

that I last saw h alive on • — 190. " 



and that death occurred, on the date stated al)Ove, at 
~rr-M. The CAUSE OF DKATI! was as follows 






'>V <Xc^;.e^.. ...J..\JL^x.^:v>a.... 




<^^ 




ji O vc^ .. 

J.DwrLv, OrTV,..^<XA^ 

DURATION Years Months Days Hours 

CONTRIBUTORY 



Hours 
M.D. 



OCCrPATION 



f?fi.iiifii in San I'l niu ix-o jSO ^'rais 



^/onf/ia 



Pa IS 



THE ABOVE STATKn PHRSONAU PARTIOir.ARS ARi: TRl E TO THE 
BEST Of' MY KNOWI.EDC.E AN!) lu:i.IEF 



(Itifotniant 



N.l.lirss 3 C) S X' O'WU^ Ui 



DURATION Vears Mout/is Days 

( SIGNED ).... Wur>^.i^) ilB. UO. XuLcx.>vdL 

»H iQoH (Address) L^\X^^i^X) U I V.;i..l 

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




Former or 
Usual Residence 



A/>'V'W<\, 



Now jonq at 
Plareof Death? 



I 



Days 



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



''^'^^'«"**' BIRIAI. OR REMOVAL f DATE of Hi KiAi. or REMOVAL 

(]5V D r> I (\ ft . 

^itLuJj\..ft-^^ I l^-v^ ite 190H 



INDERTAKER ^ VJ . U Lfr^WCVV 

(Address"^ !(? 1 mTWa.'Ql^.^^x ^5t 



N. B.— Every item of Information should be carefully supplied. AGB should b« stated EXACTLY. PHYSICIANS should 
state CAUSE OF DEATH in plain terms, that it may be properly classified. The "Special information** far per- 
sons dying away from home should be given in 9\9rv instance. 



'/M 



'i '! 





''1 



I 



1/ 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

REFER TO BACK OP CERTIFICATE FOR INSTRUCTIONS 



Roar.l of lUalth-l" N'o. i^ ^^ag^H&PCo 



Begisteved JVo, 



358 



Date Filed, VvLu. Ilt> 1^0^ 

cUvcca L/vvu D«P"*y Health Officer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of 2)eatb 

( m. S. StanDatO ) 

A ^ 



f 



PLACE OF DEATH:— County of CL"»v JACL^vccidc City of ' 'a^v >JXaixa> c 



W: 



I 



(ir OEAT 
ir DC 



su 



Dist; bet. 



and 



M OCCURS wWav rnoMi USUAL RESIDENCE give facts called row under "special information" "\ 

EAD or STREET AND NUMBER. / 



eath occurhcd in a Mospital or institution give its name insti 



FULL NAME 




Ctccn->v.\N* 



J s 



PERSONAL AND STATISTICAL PARTICULARS 

SKX -^ 



DATK Ol JUKTII 



Af.K 



A. 



COI,OR ^ 



H 



lu. 



■ > 1 



MEDICAL CERTIFICATE OF DEATH 



DATE OF I>1 



ATH A A 

\vS 



(Month) 




(Day) 



(Year) 



) 'I'li I . 



(Day) 



Motilhs 



I Vear) 



Da r>- 



SINT.i.K MARKIKP. 
WinoWKH OK I)!VnKCK[) 
IWritt in siK-ia! (It^i^iiatiuii) 



i 



lUK THI'I.Ai'H 
'Slate <»r Country 



NAMK III 
FATHKR 



niKTMIM.ACK 
OF I ATUKR 
(State or Conntry) 



MAIDKN NAMK 
<>I' MOTHKR 



niKTUri.ACK 
(•I' MOTHKR 
'Slate or Country) 



OCCri'ATiON 

Rt'siilrti lit Siiii /'i mil isi'i) 



^"^ 



wOlw^ OA^X^xcu^eo 



LUv! 



I HRREBV LIvRTirV, That, I attended deceased from 



4\A.^V\JL k iQoH 



to 



that I last saw h ■'^*^ ahve on 4V\X< 



IyH 






190 s 

-U.- i^a 190 H 

and that death occurred, on the date stated above, at I i 
iL M. The CAUSE DF DHATII was as follows: 



DfRATION years 

CONTRIBUTORY 



Months 



Days 



Hours 



Yfatu \ Moittli- 



I hiss 



THK ABOVK STATi:n FHRSONM, PARTICrLAKS AKK TRl'K TO THE 
HKHT O!" MV KNO\VI,i:i)<,K AND HKUKK 



(Infoiniant 



(Afltl 






DURATION Years Mouths Pays Hours 

(SIGNED) \!fl "J Mf\<XA4.kaL' M.D. 

H^^W^^ iQoH (Address) 3.S '^^ll'AV\.ru> J' 



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



Former or 
Usual Residence 

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



How lonq at 
Place of Death ? 



Days 



PI.^CK OK niRlAI, OR RKMOVAI, 






INDKRTAKKR 

(AtldiC'SH 



DATKQf Hi RIAL or REMOVAI^ 




N. B,— Every Item of Information should bs carefully supplied. AGE should b« stated EXACTLY. PHYSICIANS should 
state CAUSE OF DEATH in plain terms, that it may be properly classified. The *'8pectal Information" for |>ep- 
sons dying away from home should be given In ny^ry Instance. 









4 




WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

Hoanl of lUaltlv-i No i^t^^^MSiVCo RCFCR TO BACK OF CERTIFICATt FOR INSTRUCTIONS 




Ihffe Filed, \^jJLu I b 190 S 



Deputy Health Officer 






Registered J^o, 



359 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of Death 

( m. S. StanDarD ) 



i 



No. 5 4 I u /tXo^v./dvt/v 



on 

St; S Dist.;bct* 1^ 



4 % 



PLACE OF DEATH: — County of C' /CVvu .V^/yvCAJl^ii City of Ooao) ^K<X^xkiui^-^ 



hJ^ 



and I 



'^l tJv 



( 



IF DCATH OCCURS AttAV mOM USUAL R C 8 1 OE NC C Gl VC PACTS CALLCO FOR UNDER "SPECIAL INFORMATION" 
ir DEATH OCCURfUO IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. 



) 



FULL NAME 




^.-d/VVM 



v 




-WJjb 




PERSONAL AND STATISTICAL PARTICULARS 

I COI. 






DATK OF lUKTII 



'■""lOlA 




15- 

(Day) 



(Year) 



AC.H 



SINi.I.K. MARKIKI) 



^LJLliU 



JV.7», 



M.ntlfiS 



Pa v: 



WIDOW HI) UK DIVoKVKD H a. 

(Write iti stuial «U-sit^t>ati<tii) — \ 11 



lUKTMI'I.ACK 
(State i)r Comitrj 



NAMK Of 
FATHKR 



HIKTHPI.AiK 
OF I-ATHKK 

(Stall or I'ountryl 



MAIDHN NAMF 
OF MOTIIKK 



niKTMIM.ACF: 
OF MOTHKR 
(Slate tir Country^ 



CLKcvU.^ 






MEDICAL CERTIFICATE OF DEATH 



llULLL. 



DATE OF DKATIl 




oiith) 



15- 

(Day) 



(Year) 



1 rtlil 

Hi 



I HEREBY CERTIFY, That I attended deceased from 

liS 190 '■j to -^ IQO '— : 

that I last saw h -t—— alive on ■ ■ ^ ■ • ■■- ~ ■ ..-.:. ' :.-- . j^ — 

and that death occurred, on the date stated al>ove, at I >j 
CI M. The CAUSE OF DEATH was as follows: 



La^I^vIvvc-^v/Oj y\x^->v<x:L' 



frVVv^' 



J 



DIRATION 
CONTRIHl'TORV 



) 'ears Months Days 



Hours 



\.!i'Sj:r%j.. 



nr RATION 
(Signed) 



Years 



Mouths 



1% IXv^U 



Days 



Hours 



^ "» 



KV^^UL-CcLu 



<X , U X<X>x^«wsL C.<j 



OCCrPATlON 

Rrliffif III Siin /'i iiiii I Mil 



J 'nt t « 



.\r,n,thf 



/hn 



THF, AH<»VK STATf:D I'KKSONAI. I'A KTKT I,A KS AKF; TKIK TO THK 

iif:st OF' MY knowijjx.f: AM) »f:i.if:h 



l.S' iQoH (Address) Ota^^? UvWvOL U) kA 

AL INFORMATION only for Hos|^ 
or Recent ResMents, and perMns dying dwdy from home. 



M.D. 




, Inslituiions, 



Former w 
Usual Residence 

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



Now tonq at 
Place of Death ? 



Transients, 



Bays 



(infiiTinant 



) 



/Addri-Ks 



5 Hi 9 a.^x/cJxx.v. 3 1 



I'l.ACK OF lURlAI, OR RKMOYAI, 



% 




I>ATKof IltrRtAl, or REMOVAI^ 



INDHRTAK 



CFR ovD g. d>wwl\A)%*c 




(Address 



II3T Qrvu:4^<^% Jt 



N. B.— Every Item of Information shoulfl be CRPefully supplied. AGB nhould b« stated EXACTLY. PHYSICIANS should 
state CAUSE OF DEATH In piiiin terms, that It may be properly classlftsd. The "Spsctal Information" for ar- 
sons dying away from home should be (Ivcn In svsry instance* 



h' 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

Boar.l of TlcMlth-l No i^ <<^^^n&I' Co RCPCR TO BACK OF CCRTIPICATC fOW INSTRUCTIONS 





Dafr Filed, 



\k> 



190 "i 



Registered JVo. 



360 



,{^V^C0 It^u. Deputy Hostth O^-er 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of Beatb 



PLACE OF DEATH:— County 



of a 



( Ta. S. Stan&arO ) 



tty ofO/ 



^ 



/CX/YU AX3L/>AX:. CA- c c 



rNo. 




St4 ■ Dist^ bet. 



and 



M USUAL RCSIOCNCe GIVE pacts CALLED roM UNOCn "SPCCIAL INFORMATION" \ 
CUNRCO IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OW STREET AND NUMSER. / 



FULL NAME 




/yyyo 




SHX 



PERSONAL AND STATISTICAL PARTICULARS 

I COI,(>R 



DATK OF HIRTH 



Af.K 






U)lvt^ 



(Month) 




bS 



J>|/#.V 



3 



n 

<Dav) 



Mitutfif' *v 



rl^S 

(Year) 



Da V. 



SINr.I.E. MARKIKIJ. 
WIDOWKI) OK DiyoKiKI) 
<Writ«' in s«itMal rksiviiation) 




(State or Country' 



NAMK OJ- T) 
FATIIHR 



BIRTH I'l.ACK 
OK lATIIKR 
(State or Coniitry) 



f 

H 



1 







rwi.u. 



MEDICAL CCRTIFICATC OF DEATH 



DATE OK DKATH 




Month)/ 



IS 

(Day) 



(Ye«r) 



I HEREBY CERTIFY, That I attended deceased from 

U.^ 1 190.^ to ....|\U^.LH ,.190 H 

that I last saw h.A.^>^v alive oil N^ 190 H 

and that death occurred, on the date stated alKJve, at l '^^ 
U M. The CAUSE OF DEATH was as follows: 



MAinHN NAMK 
OF MOTIIKK 



lURTHI'UACK 
OF MOTHF^R 
(Statf or Country) 



wwru 



Dr RATION Years 

CONTRIBUTORY 



■t 



Man I /is Days 

rORY LAw^vUkVa.Na^>vw Qj^^ 

DURATION ^'^''^ s^fonths Pays 

3 'X. %/OLAt 



(Signed) 



Hours 
Hours 

M.D. 



Rfsideii in Sit it /'t n iii ist'n 3 I ) '*((i > •" \fiint/ts 



Ihi I 



THF: \B0VK STATFI) PKR^OXXI. PARTim.AKS AKF: TRl'H TO TflK 

hf;st o!- my knowi.i-ix.f: and in:i,tF:F 

(Tnf..tmant LU <VW M I V <VOCVArC^^J 



(\ 



chirrs. LdXjT^ M^ dtO 0-^^.Ajt<xi 



Lt n ley 
:iAL INI 



_iPEClAL INFORMATION 

or Recent Residents, and pers«ns dying away from home. 



\TION «nly for lil)$pitals, Institutions, Transients, 



Former or 
Usual Residence 



) XtAM^vvMrYV 



1 llayi 



When was disease fonfracte<, 
If not at place of death? 



T90<< 



PLACE OF BIRIAU OR RKMoVAI. I DATK of IH rial or REMOVM. 



it: o: iit-RiAt. I 



I ni»f:rtakkr 



P^' 8* Every Item of Information should be carsffully supplied. AGE should bs statsd BXACTLY. PHYSICIANS should 

state CAUSE OF DEATH In plain terms, that It may be properly classified. Th« ^'Special Information** for psp* 
•ons dying Mway from home should be given in svsry Instance. 







f 




WRITE PLAINLY WITH UNFADING INK — 



Hojinl nf II.!.ltli-J"No. 1^ ■*'^«f^H&PCo 



190H 



THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 

361 



Begisterecl JSTo, 



Date Filed, H^^vX^u. lb 

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



Certificate of Beatb 

( "CI. S. StanOarD ) 



PLACE OF DEATH: — County of 



City of 




\ 



rNo. 



St.; 



Dist.; bet. 



OU^^XKAJX, 



and 



/ IF DEATH OCCURS *WAV FROM USUAL R E S I D E NCE Ol Vt FACTS CALLED FOR UNDER "SPECIAL INFORMATION" \ 
V ir DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. J 



FULL NAME 




^>.x.clL l\ 



PERSONAL AND STATISTICAL PARTICULARS 

DATH Ol- HIKTI! 



s,. ^ 



\ . 



/ 



iMoiitli) 



Ai'.H 



^J W JV,/»A 



(Dav) 



Miivlhs 



fYear) 



At 1 : 



SINc.M-:. MARKIHI). 

\vn»>H KD OK nix'okri-D 

(Wiitfiii social (Itsijf tiatinn) 



lUKTHPI.AOK 

(State or Country^ 



^ 



OAA^^wCcL 



\l Ur^c 



J 



NAMl" OF" 
I A in J R 



HIKTHl'l.AiK 

Ol" I \i'iii;k 



M MltF.N N AMI' 
nl' MoTHKK 



lUKTHIM.ArH 

<t| MoTHKK 

I '^■tati (H (.'iiiinlrvi 



/-O 



.OsA 




^W ^' 



cnxaX<xi 



MEDICAL CERTIFICATE OF DEATH 



DATE OF DKATH 



(llonth) 



(Day) 



I go 

(Year) 



I HRRHBV CRRTIFV, That I attemleil ilcccascd fruni 

I90 to 190 

that I last saw h alive on 190 

and that tlcath occurred, on the date stated above, at 
M. The CATSFv 1)11 1)1-: ATll was as follows: 

A^Ol^^cLv^-O^^ J CX^^LwUj^.*.. 



Dr RAT ION Years 
CONTRIHUTORY 



Months 



Days 



Hours 



\ \ 



I • t V 






R'fiLv 



t 

1 



occri'A rioN 






'^ 



) V'<7 / S 



.^/olltfls 



Da I ; 



rHI" AHOVK STATHH t'KRSONAl, PA RTIOf l,AKS A R l-! TKIK To Till-: 
Hi:>.T Ol" MY KNo\Vl,i:i)<',H AND HHIJIlK 



(Iiifotmant 



1^ L^ \t)V D^^voc-. .•- 



(A<1«lress 



DURATION 



f^y 



Years 



Mouths 



Days 



( Signed )..:.1.ac.'a . M\^ 

4-U^ 11 n^S (Address) AlflaL>\A.la 



Hours 
M.D. 



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



Former or 
Usual Residence 

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



Row lonq at 
Place of Death? 



Days 



ri,A«;_K OF BIRIAU OR RKMt»VAI, 






INDKRTAKER 



DATKof lU RIAL or RKMOVAI. 

\ I . . y I '^ I, 



M. B.—— Every item o? in?ormiition should be carefully Hupplled. AGE nhould be stated EXACTLY. PHYSICIANS should 
state CAUSE OF DEATH in plain terms, that It may be properly classified. The "Special Information** for psr- 
sons dying away from home should be given in every instance. 




1 1 I 





WRITE PLAINLY WITH UNFADING INK — 



noar.l of IUr.Uh-I- No. 15 "H^^J^^P^PCo 



THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTION^ 

362 



Registered JVo. 



Da/r Filed, Wiu lip J90^ 

H (J 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 




Certificate of Beatb 



( xa. S. StanOarD ) 



PLACE OF DEATH: — County of^ O. ^\ ' 



-? 



m 



n 



^No. 



1 ! 



^1 



K 



^4 



St 



( 



♦t 



5 Dist.; bet. 



City ofCja^vvJ KO 



>\C1 



.F DEATH OCCURS *WAV FROM USUAL R E S I DE NCE G I VC FACTS CALLED FOR UNDER "SPECIAL INFORMAT 
IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD Of STREET AND NUMBE 



and y ^ 

ION" "S 
R. J 



I 



FULL NAME 



PERSONAL AND STATISTICAL PARTICULARS 

SKX A * I COLOR \ ^ 11 



m 



1 ^ I 



i)\ri; oi' HiKTii 



a<;k 





iMfliitli) 



! Ill I 



Dav) 



\f,.„fh^ 



IV car) 



Davt 



SINr.l.F MAKHIHD 
\VII»»\\i:!) nk DIVMKri-.ll 

tW'rilt ill viiiia! 'Usit'iiat imi ) 



iStatt* <ii I innitiv 



% 



La\ 



NAMH (IF 

I AT 1 1 i:k 



iiiRTm'i.ArH 

(»!• I AIMKK 
(Stall iir Cfuintty) 



MAIIH.N NAMK 
Ml MnrnilR 



ItlKI'HlM.ACK 
Ml- MoTHKR 

(Slat) i)t I'olllUl vl 



i)la)i 



4.JC>V 



^) 



"v w w 



' "^ ' I 




:)t'cri'ATi()N ^% y 



Kr^iiifil III Siin /'iiiiii 



) , ,t> 



.\r„Kths 



ih, 



Till*, AHnVH sr \ ri'l) l'Kks(»N M, I»ii RTUTLAKS A R I-, IRTK TO THH 

ililsT OI- :.v^ Kvnwti: 1)1.1-; and hi:i,ii"j- 



(J 



,.r.,M„ant -XiXcI%jUu L' La^C-vx.^ 



(A(1c1re««H 



ab 



« A 



» '« ' 



i — 



MEDICAL CERTIFICATE OF DEATH 



DATK Ol- DKATIl ,| H 



^s 



iMonlh) ^ (Dav) 



(Year) 



1 HKKKBV CnRTII'V, That I attendt-.l (k( cased from 

^S,*Xi^ iS 190 ^ to •.■.\\.'. ^'.:. 1904 

that I last saw h alive on ' I90 . 

ami that death occurred, on the date stated a!)ove, at 
J M. The CAISP: KW J>I':ATI1 was as follows: 

11 



DT RAT ION Years 

CONTRIHUTORY 



Mouths 



Days 



DT RAT ION ^ Years 



Months 



Pavs 



(SIGNED) * i\^JUH 



iqo 



(Address) iO ♦ ^j w >.. 



Hours 
Hours 

M.D. 



SPECIAL INFORMATION only for Hospitals, Institutions, Transknts, 
or Recent Residents, and persons dyiiii) d^cty from home. 



Former or 
Usual Residence 

When was disease rontrartetf, 
If not at place ol death ? 



How tonq at 
Place of Death? 



Days 



I'l.ACI-: ni inKlAI. (m RHMnVAI. 



I'NDKRTAKKR 

(AddrinH 



"TS^ 



l»ATI- ..f »i KiAi. «)r KKMOVAI, 



J.'^ W- »-%4 



I go 



0, i ^cJ[\A' ^Hc Le 



N. B.— — r.very Item of Informntloti ahould bs cat*«fully nupplletl. AGC «houtd be utated EXACTLY. PHYSICIANS should 
Mtate CAUSE OF DHATH tn pliiln terms, that it ma> be properly alaaslfled. The "Special Information" for p«r- 
Kons dying away frcun home whould be given in 9\%r^ instance. 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

H .;,r.l . f ii.nlth J No l^ '^^^■^- !»& I' Co REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 









Begistered JSTo. 



363 



J)(,l(' I'lh-d, %^Ji^\\c, 190 H 

A^vvco Xia-u Deputy Health Officer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of S)eatb 

( tl. S. StanC>arC> ) 

Ity 



J? ^ JP ^ 

PLACE OF DEATH: — County of O-Ct^vClA.cuwCUCcCity of CJ/CWv JA.Oyvu:^4,ti 



^^<^ Ul,'v>vux^\; 




i awaV from usual 



Su 



Dist.; bet. 



and 



(ir DEATH OCCURS AWaV FROM USUAL 
ir DEATH OCCURRED IN A HOSPITAL 



RESIDENCE Give FACTS 
OR INSTITUTION GIVE ITS 



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



FULL NAME 



'tx-cr 



t(E 



JLtt\^i 



t/W 



>^i;\ 



PERSONAL AND STATISTICAL PARTICULARS 



i>atj: Ml iiiKin 






{xaXjL 



%f..iith 



!);ivi 



/ts- 






■M'.H 



.^ 



Jr,|. 



I 



M.,uth' 



b 



> « ai 



/'(/I 



wni. .u lit MK tJ- I f> 

iWntt-ni -.lit in; <|r -.j^ ii.it i. iii ) 






' ■ • 1 1 1 K 



'H 1 \ ! UFR 

"' ' ■ nitr\ 






fnRTHIM.Ai'K 

'^'.it' '.I < ■ iintrvi 



• It t 1 !■ 









d 




MEDICAL CERTIFICATE OF DEATH 
DATE <•}• DHATH 

(Day) 



(Year) 
I II1';RI-;I;V Ci;RTll''V, That I attcudcl .lectascd from 

' — ■■ I9O to ■■— — ~~* IQO 

that I last saw li :^ alive on Dp 

ami that ileath occurred, on the date staletl above, at 



— M. The CAISIC Ol- DIvATII was as follows: 




Xrsxjyy>JOJ\^ 



I 



^vt^w^^^ 



k, 






DL' RAT ION Years 

CONTRIIUTORV 



Motith^ 



Davs 



Hours 



Ihn 



Tin. MM»VHST\ri Ij I'l-'KsoNAI, FAR TM'tM.AKS ARK TKIK T« » TDK 

1*1, **^'f^ #%*»♦,-***, *,_= _. 



nufijfiurnil 



Xd.lrc 



^ix-a J ^wLe^^Sj "it 



DT RATION }V<7rjf AfoHths Pays 

i SIGNED ) Ui^^-ruUv 'J AD. U). dLuLa^x-dw 

15 iqoH (Address) UrV^-rc£h^ Wile 




Hoitrs 

M.D. 



rj ij V 

^PEcilAL Information only *or Hospitals, InstUuilons, Transients, 
or Recent Residents, and persons dying away from home. 



Former or <^ ^ #n « ^r I ^ 
Usual Residence A li^ J ^XkAf^^^ 

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



How long at 
Place of Death? 



Days 



TLACK OF BIRIAI, OR RKMoVAI. 



fNDHRTAKKR 






IMTHof in MiAi, or RKMOVAI, 

^KaJUo, n 190H 



nfformation ahould be cnrefully supplied. AGB sfiould li« atated EXACTLY. PHYSICIANS should 
►F DEATH in plnln terms, that It may be properly classified. The "Special Information" for per- 

.__*^^.ft. * BBS -■ m •_._.*„_^^_ 



W. S.— Every Item of I 

state CAUSE OP .^ 

soils dying away from horns should be Iti^^n in svery Instance. 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



IJcinl ..f If.Mltli- »•' N'o. It 



Ufa V Co 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



I I' 



li' 




Registered J^o. 



364 



l)nt(> Fil<'<l, %jsXu\\> 190'\ 

Xo-vx^ "Ixamj Deputy Health Officer 

DEPARTMENT OFPUBLIC HEALTH=City and County of San Francisco 

Certificate of Beatb 

( "CI. S. Stan&arD ) 
PLACE OF DEATH:— County of ^ a >^^. J \a City of ' a>v 'Xa ^xcv^a c 

i^vCtcL ^^ \.^i^.^\Ul, vlU>Vv i St.; Dist.;bct, and 

f / ir ot»TH occvns »w*v from USUAL RESIDENCE civr facts callcd for undcr "spcciau information" \ 

' V •' DEATH OtCURRCD IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / 

>7s 



) 



FULL NAME 



<X x\W^ 



\ s. 



PERSONAL AND STATISTICAL PARTICULARS 

i. I »I < 'K 



"" 'lUc 



a ' . 



II 



!)H ri: Ml MIRTH 



\«.K 



i 






} itit 






i|Jhv) 



M„nlh^ 



i'»'>iiri 



l\i 



Wiitriti >-iH-i;ii iU'^ivtiatii>n > 



lUR riu'i.x*"!-: 



A 



eel '. • 



MEDICAL CERTIFICATE OF DEATH 



DATE 01- nilATH 



4 tutu 

(Wunth) 1 



(Dav) 



(Year) 



I HRRRBV CI:RTIFV, That I attendeil .kceasetl from 

.' Z' ,^ IgO ;^ to H^^sXct I'l 190 H 



til at I last saw li 



alive on 



1-' » .' t J 



-^ 190 

and that lUath occurred, on the date stated above, at 1 
' M. The CAl'SH OF DKATII was as follows: 




N \M1- ul' 
»• A I II J-.K 



niK IIII'I.Ai'K 
•»l I AIHHR 

"-it. Ill ,,' c.iinilrv 



<•! MoTIIICR 



inRTHI'KACK 
^t.ii. ,,i Country) 



• MCri'ATKJN 

h'f'uifil III S,ni /•liiihi III ^ 



Lx 



Ww 



M I UX\^Ct\^ ^ 5-tvn 



I )r RATION )'t'ars 

CONTRIIUTORY 



Monlhs 



Days 



Hours 



DURATION 



Years 



Pays 



vwi^ 



. ■«^» 



} I- it ) 



Miiiif/n 



n,i\. 



TIIK AHO\"F. ST \|).- ji |.KH<5Snv*r p^ttTirff *«•« ARK TRl"K To TIIK 

HKST oi- MY K. VOW m: I Mil.: AND ni:i.n-:F 




Afofit/is 

, . 1 1 I 

HA-^JIM I V iQo (Address) A.\A > \V< i 



(Signed 

* ' ' '-^^^ 1 ■ IQO 



Hours 
M.D. 



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



Former or , 1 . 

Usual Residence v,vt , > . 

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



How lonq at 
Hare of Death ? 



Days 



PLACH or niRIAL OR RHMOVAl. 
INUHRTAKER 



DATKof BiRiAi. or RKMOVAI, 





^, 



:t 



it 



190S 



^^ 



(Address 






^ f\f> , 



N. B. Every it«m of Information should be carefully Aupplled. AGE should be stated EXACTLY, PHYSICIANS nhould 

Rtnte CAUSE OF DEATH In plain terms, that It may be properly classified. The ''Special Information" for pei- 
iions dying away from home should be given in every instance. 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

HoMr.l.f H< all). I No i . ^^!^fe H^^ 1' Oo REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 




I If 




lb lOO'i 

Deputy Health Officer 



Begistcred J\^o, 



365 



lhif,> Filed, 

DEPARTMENT Of PUBLIC HEALTH=City and County of San Francisco 

Ccttificatc of Bcatb 

( Xl. S. StanOarC* ) 

\(X ^ iCC4C() City of ^;^/Vv v' * .r> 






PLACE OF DEATH: — County of 

^ H f 

No. St; Dist,; bet. C^ 0-i\A) and '^ 

(ir Dt*TM occuMs *w*v r»ioM USUAL RESIDENCE give facts called roR UNDER "special information \ 
ir DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / 

FULL NAME LlK -v 



~.! \ 



I>ATK ttl lllK 111 



PERSONAL AND STATISTICAL PARTICULARS 

ft 11)1 I iR i 






^r,»^//t^ 



a! » 



^iNi.ij: \t\RNti n 






niKTin-i. \('»- 



riti \ 



■^ 






L>v 



MEDICAL CERTIFICATE OF DEATH 

1)\TK «>F DKATJI \ 



4M(>tith1 



Dav) 



IQO 
(Year) 



I in-iKIiHY CF.RTIFV. Tliat^ I aUen. led deceased from 

j'\ 190^ to iVi^rVi^y; igo \ 

that 1 last saw h alive on 190 

and that death occurred, on the dale slated aVxn'e, at 
' M. The CAISI- y^)V Dl-ATII was as follows: 



NXMi; .1! 
I ATI II R 






MXIUHN NAMH 
ot MOTHKR 



HKIHl'LA* )■ 
'I MoTlIHR 
■-l.tic m v.'<<uult V 



j"ttxM^%v M fUx%^it4 









1 1 . 



Di; RAT ION 
CONTRilU'TORV 



J 'ecus 



Mouths 






I2ay^ 



r 






Hours 



DTRATION 



(SIGNED) 



)'tors 



uccirA rioN 



),•,!> 



^r. iitli' 



/).n 



rill" A l!<»\F «^ r \ r t' t» I'K wv, «\ * t i'\k>rj(-tr \ w s, \KKTKrK T«» THK 
lUvSr JH MY KN<»\V1,HIK^. AM) HFI.IKK 



[Inf.i-mant 



(1 



KJ^^ 



h 



\il<lrc' 



%\\b 



il- 



iv^Xcr II IqoH (Address) 



Months Days Hours 

M.D. 






Special information only for Hospitals, Institutions, Transirnts, 
Of Recent Residents, and persons dying away from liome. 



Former or 
Usual Residence 

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



H«w I«ii9 at 
IHaf e of Death ? 



Days 



PI,.^CK n|- ni KIAI, «>R HKMoVAI, 



US^ (v-^c. 



V 



^^. 



I ) A T \'. of U r K I A I. or R M M n\- A I, 

' 190^ 



A 



(Adtirefts .. . ^. 



u^ 



i 



\ 



N. B. Every ttem of Informatloo should bs carefully •upplled. AGB •houM b* stated EXACTLY. PHYSICIANS mhomXd 

•tate CAUSE OF DEATH in plain terms, that It may be properly classified. The '^Special Information'* far psr- 
a«Mis dying away from home should be given In every instance. 






WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



H.-iii.! of Hcnlth- I" Vo, t.^ 



•• H&l'Cr> 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



1)f(/i' Filed. \l\A.lu lb 




i 



^ 



190\ 



Registered •N'o. 



366 



^ _ I 4. L ^^i t*f j-» 



.ft^vvo Vwv.i Deputy H. 

DEPARTMENT OF i^UBLIC HEALTH=City and County of San Francisco 



Cevtificate oi 2)catb 

( Ta. S. StanDarC> ) 



PLACE OF DEATH : —County of a > v \. a ^ c^^co City of ' O 



Ul 



No. 



( 



St.; 



Dist.; bet. 



\ \ ^\ ' ^„ I * . 



^ , 



and 



Iito,. 



IF DtATH OCCURS AW»V r«OM USUAL RESIDENCE GIVE fact 



IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE 



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



FULL NAME 



^':-X 



^i:\ 



PERSONAL AND STATISTICAL PARTICULARS 

ft I i'OI.tiK 



IiAlI, til lUKTIl 



xt.i'; 






M'.ntht 



J 



lUivi 



M.oi'ln 



I I 



:(i 



Da 1 



-IN'. IK M\KkIi:i> 

u iiiiiw i:r> nR niviiRcKn 

Uiiii in ".tK-iHl elciiifnalitm) 



i;ikTin'i.\i"i- 



("'.oxcr^ 



C 



a 



\ Sill J,R 



<' I vrin-,k 

"»! it( lit riiiiiitrv^ 



MAini \- NAMK 
<>l MtiTHKK 



•>t;iu III l"i>unlf% 



ns_ 






r\ 



MEDICAL CERTIFICATE OF DEATH 

DATi-; «.} i)i;\Tn a 

!(M()nth>1 (Day) 



(Year) 



I lJf':RI':nV CI;RTIFV, Tliat I atten.UMl dervased from 
..! 190 . til < '^.SfS,)^ 190 

that I last saw h .'- • • alive on I90 

and that cUath occurred, on the date stated above, at *" 

' M. The CAl'SI-: OI' Dl-ATII was as follows: 



DTRATION Yeats Mouths Days, 



Hours 



CCINTRIBI'TORY 



I)i; RATION 
(SIGNED) 



if 



yy^KX'^o^ 



A 



f!^ 



^ 'n 



••V vTI'A rn>N 

I 

Kf.'ulfit in S,ni / I ,! in , .t ,1 



) I ii I « 



.^r,»ifiii 



Ihr 



I'll I" A U( i\" I" »i'r t T |.* 1 1 »• w I.? »;. IX- > I 1' i 1,1 I- ii ■ I ■ ! \ I,' < \ M I* TH r K 'I'l t I'lf l«! 

iu;sT oi- Mv KNo\\i,»;i)i,|.; wn iii-i.n.t' 



--^ 



(Iiifi)!iiiant 



'^ 4 



( Nddrc-- 



l1 



W » :„ \ 



Years Mouths 

JuXqJb i,pH (Addrt-ss)^^CA^^ ^^' 



Days 



,K a \ to i()o' 
ECIAL INF 



gacl^ " 



Hours 
M.D. 

1 



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



Former or 
Usual Residence 

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



How long at 
Place of Death? 



Days 



IM.ACH OI* lUKIAL OK KKM(»VAI. 



I»\;ri': fiT HrKiAi, or KI'.MOVAI, 

I90H 






Q 



iwOLu i^ 






!N. B. Bvery Item of Information should be carefully nupplled. AGB should be •tated EXACTLY. PHYSICIANS should 

state CAUSE OP DEATH In plain terms, that It may be properly clossifled. The "Special Information" for per- 
sons dying away from homo should be given In every Instance. 










WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



I.,,,,.l..f ll.altli VSn i.^'f^g^TK'tPCo 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



I)f(/r Filed, HvaJLu lb 



loo'i 



Registered J\^o, 



367 



> i\ 

DEPARTMENT 01^ PUBLIC nEALTH=City and County of San Francisco 



PLACE OF DEATH: — County of JCV^\ bVCV 



(Tertificate of 2)eatb 

( in. S. 5tan^at^ ) 



, V^ 



City of^'<X^ 



x- ' 



vCX sx.Z,^^ 



K^ 



No. HL ll'k L^Vw^l > 



(?. 



St.J . x-'.oi., 

DtATH OCCURRCO IN A HOSPITAL OR INSTITUTION GIVE 



1 DisUbct. ^J.H.A>^ 



and 



\]\ n , 



(ir DCATH OCCURS AWAY FROM USUAL R E S I D E NC E Gl VE FACTS CALLED roR UNDER "SPECIAL INFORMATION" \ 
ir nr.T« nrruMRrn im a mospital OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / 



FULL NAME 



U- 



PERSONAL AND STATISTICAL PARTICULARS 



4 



c'ol.oR ' 



i>\ri; (ti luKTii 



\'.i-; 



^ 



Mnlltht 



\ I'll t 



Montti- 



I V<ai ) 



Iht 



->s\'.i,i" M\kKii;n 

\\ iiMiu i:i» <iK i>iv«»Rvi-;t> 



IIKTHPI.AOH 
>t:itt' or Cuinitrv' 






i 



f A'^!11^K 



HIKTMI'I.ACK 
<»r l-ATHKR 



M A 1 1 > } . N N A M H 
(»!• MUTIIHK 



niRTIIlM.ACK 
OV MtnilHR 
(State or Connttvi 



^ 



a.>v^» A,c 



^a.>\cxAc<: 



^\ 



t*^ 



I , I 



MEDICAL CERTIFICATE OF DEATH 

DATH OF nivXTII > 



lu 



fM<"itli) I 



(Day) 



ipoH 

(Year) 



I ni:Ui;HN' CIvRTII'V, Tliat I atteiuUMl (Icceascil from 



, \ 



tli.il I last saw h » alive on 



to 



^.^sA 



n- 



..lb. 



190 H 
190'. 



aritl lliat iliatli ( icrvirrfd, nii the <lati' stated above, at 
M. The CAISI-; 01 in: ATI I was as follows 



I 1\,W ^VS. NVaviv-S CwWS,^ 



■^ » 



IHHXrinN }r«i/f I Mouths " Days 'Hours 



I oNTkir.l ToUV 



w.&>vcI\-LL^x...C<^,.U. 



'% 

' 



I) etc 



CK.LcL 



t 



CUL 



« K'Cl I'ATION 

Kfsiiini hi Soti f'l (itii isi't} 



);-,t, 



Mmitli^ 



I his 






(Informant 



.^-YX^w^i 



(A«lilres«4 






f 



DTK AT ION * Yi'ars O Months * Days 

KXts-^jkjKXXk^ ^^..Ax'.. 

1 (Address) H '^XM]\<nvt:^'.^ 



(SIGNED) 

^\.J.. \. I<)0 



Hours 
M.D. 



Special information only for Hospitals, Institutions, Transienls, 
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 



DA^i: -it m KiAr, or RKMOVAI, 



lM.ACK,OK niRIAI, (1K RKMnVAI, 

QtaXx<x>x 

(Address... I S..1..H a-Lft'S-*^^L.4.Xl. 1.' 



190 



N. B. Every Item of Information .hould be carefully Rupplted. AGE should be stated EXACTLY. PHYSICIANS should 

state CAUSE OF DEATH In pinin terms, that It may be properly classified. The * Special Information for psr- 
•ons dying away from home should be given In svory Instance. 



'",W 








WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



l!,,,r,l .,f ll.-nUl. I- N'.. '-- ■^T,:^^^U18^\' rn 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 






lOO'i 



UeilLslci^iul vVo. 



368 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Ccttiffcate of S)eatb 

( "U. S. Stan^arO ) 



PLACE OF DEATH: — County of Ctv\ 



^ 



City of ^Cl>^ 



) A.<X vx e 



t,4 



■ Us I 



L<^ vx \x\\ 



'^> 



and 



I^. V^CWv "^ V<^vx\\Xu '•. St; Dist.;bct. 

/ ir Dt*TM OCCUI»^*W*V fROM USUAL RESIDENCE give FACTS CALLED FOR UNDER " SPECIAL INroRMATION" N 
V \f DEATH OCCUHRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / 



FULL NAME 



-^,,1 



I 



^i:\ 



n \ I I. « >i i'.iK III 



PERSONAL AND STATISTICAL PARTICULARS 




(X 



\}.U 



b'1 



Mititli 



)'ni» 



iDiiv> 



M.nifh' 



I Year I 



/J, 



-.{Mil M \K \< ii:i> \ 

Wf In .U i- l> <U< I»I\t>Kt|-I> » 

'i\'!t' ill viHi.il ill •■ii'TKit i'lii I 



HlkTMI-r. M'K 

**!..;< I ,T 'NiUIlt \\ 



^ XMI; ill 

V \thi;k 



i'.iKTiirM,\rK 

<>' I \1!IKR 
-^t.i!. iir I'uiitury' 



MMI.1:N NAM1-. 
<»l MoTHKK 



Htk rill'f.Aij.: 

'H Mi>Tni.:H 

■ Slat, .It ((uiiitiy^ 



'HCri'ATloN 



\1 Live*' 



ft 






MEDICAL CERTIFICATE OF DEATH 

DATK i)V DKATH 



Ic 









(Day) 



(Ye:ir) 



A 



1 H1';R1';HV LICRTII'V, That I attendcil deceased from 



I 



111 at 1 last saw h 



u/3 t 

alive on 



to .......i\.vW.....l.S. 



190 H 
190 I 



and lliat "Uath occurred, on the date stated above, at 
i M. The CAISI-: OF DI'ATII was as follows: 

% 



a-w^^^ 



I) r RAT I ON )V<?r.? 

CONTRIRLTORY 



Months 



Days 



Hours 



■^ 



\[ 



Rf'llfftf lit Siltl /'l illh / 11) 






> III I 






Month < 



Ih 



Tin-: xHt»\i.: siATi-rj I'KksovAi, PAR rn'ii, \Ks \ki: rRCK Tt> Tin 



(Ai1<lrri«s 



DURATION Yiars 

(Signed) uj.>yv 

.11 TOO 



1 c II ' a 



Mouths 



Pays 



/fours 

M.D. 



t 



(Address) Lctu ^ ^' 



Special information only for H»spitals, Institutions, Transients, 
or Recent Residents, and persons dying awdy from home. 

Former or I u 1 ^ ^1 r ,, 

Usual Residence iTl^ ) tu , 

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



How lonq at 
Plat e of Death ? 



Days 



DATi: of IlPRlAL or KEMOVAI, 



Hi.^ 



.,..1. 



PI,ACK OV lU'KIAI, OR RHMOVAI, 

mil V J.- - ' , , , 

(Address iH^'i .M^\^.A^^. C ^ . 



T9O 



IN. B._Rvery Item of Information .houid be carefully supplied. AGE .hould «^««»*«i EXACTLY. PHYSICIANS should 
•tate CAUSE OF DEATH In plain term., that It may be properly cla..lflcd. The Special Information for per- 
son* dytn4 away from home should be given In av«ry Instance. 





1 1 




WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



BO! 



nr.l of HeMlth-F Nn. n "^-^^^ l»&P Co 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



Dafc Filed, 

1 



M.vc^ 




lOO^S 



Registered J\/*o, 



369 



DEPARTMENT OFPUBLIC HEALTH=City and County of San Francisco 



Certificate of Beatb 

( "CI. S. Stan^arD ) 



-^^ 1 



^ 



PLACE OF DEATH: — County of (X^V -Ja.<X-ivcvAc.c City of ' <X^v ^ Vcv\vCLi.C' 
^No. I I LV^ ^U ^vU.\v'v.^ v^ L4'-.i.'. ; ..St; :Dist.;bct. -~^:r-. - — - and -— ^ ) 



(ir ocAitH occuis awav from USfJAL RESIDENCE Give tacts called for under "srcciai. information" '\ 
IF D^ATH OCCURRED IN A HOSPJITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. J 

LULfruA-'waj '■j^'tvvvLL 



FULL NAME 



si'x 



PERSONAL AND STATISTICAL PARTICULARS 

j COJ.UR 






lO.kd. 



\<.l". 



CU4 
Moiilh) ' 



) Vi/ 1 



(Day) 



1/,.;////^ 



(Year) 



Pit 1 



I 



MEDICAL CERTIFICATE OF DEATH 

DATK Ul- DKATH 

\S 

(Day) 




(Year) 



I III':R[':nV CI:RTIFV, That I atton(le<l aeccascl from 



x/ 



Ih i^. 



I90H 



to 



that I last saw h -i- alive on 







B.. 



siM.r.l-t MARKIKD 
\VID«i\Vi:t) OR DtVnkCHn 

iWtili- in siK'ia! «1<».tKiiatiuii) 



' '^tiitc or Ci III ntt \ 



J- A I'll i;k 



BIRTH !•!, \t H 
0|- l-ATHKK 
(SUile or I'otintrv 



MAIDHN NAMK 
<)l- MOTIIKR 



HIRTm»t,At'H 
HI' MOTIIKR 

(St;iU- or <."oiintrvi 




-V '-^ 190'' 

and that <U'ath occurred, on the «late stated above, at M 
U. M. The CAUSH Ol' DI^ATII was as follows: 

Q^-\aJL4.XaJ\^5w-j. 



1)1' RATION ^ Years " Afoulhs ^ Days ^ Hours 
CONTRIBUTORY * 



ocrri'ATioN 



DURATION 

(Signed) 




}'ears 



Afoiiths Days 



Hours 







M.D. 



I()0 



(A.Mrrss) ^lOlK. .KlI-V^4. ^ 



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



Till' M^OVJ": ^TATHD l'H*RS(»NAI, P \ RTiri* 1,A RS A R K TRfK To TIIK 

Ml'*-'!' (»i" »l\' (.♦v»»\t't l*f»/" I," 1 v»i Hf.'f fi*t.- 






( \(Mt.ss 




r 



-•• V- ^^ 



W w4AJr' *.4,4„ V * 



#■ 



Former or 
Usual Residence 

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



How long at 
Place of Death? 



Days 



•.■ \ \ 



I'I,ACK|>1- niRIAI, OR RKMoVAl, I DA '^K of lit hiai. or RHMoVAI. 
I NDHRTAKKR nAjXajU, ^^ AD<X^<3l>\j 



(Addrt-ss ^ b i.^ - l^ A,Ia. 



N* B. Bvcry Item of Information should be cai*«fuily supplied. AGB sfiould b« stated BXACTLY. PHYSICIANS should 

state CAUSE OF DEATH in plain terms, that It may he properly classified. The ^'Special information*' for psr- 
sons dying away from home Rhould be given In ms^ry instance. 



« 



',i 





WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

l?n;.r<1 ut HcMlth — FNo. \\ *^^fe n& 1' Co 



REFER TO BACK OP CERTIFICATE FOR INSTRUCTIONS 



MB 



/>^//f^ Filed , 




lb Li^6^H 

Deputy Health Officer 



Registered JVo. 




DEPARTMENT OF'PUBLIC HEALTn=City and County of San Francisco 







Ccrtmcate of Death 

( "Q. S. StanOarD ) 






% 



PLACE OF DEATH: — County of UO^rru OAXV-ivC' ^T'City of v'<X/>v J 'VQ./w/t.^uL ^ c 



No. 



o^s 



dfll 



\^^^v 



St 



. I) 
.; H Dist.!bct. ^l::' t( 



\' 



and 



T t.k 



f "• "•"[." OCCURS AWAY rROM USUAL RESIDENCE GIVE FACTS CALLED roR UNDER "SPECIAL I N FORMATION' \ 
V .r DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF «T.rr/.J« °.?^*IL°'' } 



FULL NAME 



GIVE ITS NAME INSTEAD OF STREET AND NUMBER. 



^^h^ImX/vlI^ 



+ 



PERSONAL AND STATISTICAL PARTICULARS 

COI.oK 



Qf)\ccL 



!>\ ri: Of niRTH 



\^,v. 



J -4. 



' M<imh t 



^.'^ 



5 'tit I 



u 



u 






^r.H'f, 



MEDICAL CERTIFICATE OF DEATH 

DATE OF I)1;aTII 

LH. 

ilkky) 




I f ;i 



Pa V 



r) 



^1 



WFiK tw I ri «iK i)r\ «»K( J, r) 

|\\'iit« in vcH-i.il i|««.ii.'!i;it!i)ti I 



fpil 




MIKl'IH'l. \*'K 

'*t;ttt <ir '.'•iiintrvi 



I Ail! J, R 



lUKTHlM.At'F 
«•" » ATHKR 

S!.)t( .,r rnunii^ 



M MDKN NAMF 
<•! MOTHKR 



HIKTHI'I.AlI-: 
"I MoTHKR 
'-i.iU I If Cotiiitry 






^ 



(Year) 

r irnRrCnV CIIRTIFv' That r attemled (leceasUiTfr^iir 

190 4 

190 4 



ill 1 aiic 

^vUj li ,^M to.|^lH ,^H 

that I last saw h -WKalive on yWL^ I H 

ami that death occurred, mi the «late state.l above, at H O.b 



M. The CAI'SK OF DJ-ATII wa^ as follows: 



\ 






\x^v^ 



AX*wlHX^v H 



^ 



t" «ri-Ari(iN 





1 



U4A^^vr>i^ 



-U 



Df RATION - )Varj * .mwt/is S" /;rt;.5 ^ Hours 
CONTRIBt'TORV \J^^^n^\^^ a<y<Lusjik^ 

nrRATION a. rears - Mouths - Hav^ - Hours 

(A.l(lress) bCi b 6-tctl^ 



(Signed) 



M.D. 

J 
Mv c)t 






igo 






M fith 



/ ht\ 



. ... s /».^Mn ,, J j Ji , h. AM/ Hll.il (. 
'A.Mn-s. bob U-*MV^^J.hj * 



Former or 
Usual RrsMf ncf 

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



How long at 
Place of Death? 



Days 



*•-**** • 



•J^'^'^'i n^n.tAL,%Ji\ KhAHnAJ 




^'^y^-^f B» RIAi- or Rf:MOVAI, 
>^^^^ t"l T90H 



f NUHRTAKHR 

(AtMresji ...... 



oX^JjLd. "^VL Co 



RSb 




-^. 



.-. -yl-» .«, fr„™ h„„.. Should b.»iv.nf„..":j !:r.r;:c.. ' ""•'"•••• ^'^ •'•«-"•' •■.»orm.,lo," f«. p.,. 



m 



.■ lid 




H 



ir 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

H.,:ir.! of Htnlth — K No i^ ^.^^^cwXj, U^V Co 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 






\\q 19 OH 

Deputy Health Officer 



Registered J\^o. 



371 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of Death 

( m. S. StanOatO ) 



PLACE OF DEATH 



No. 



11 






A 

X — County oi '^ 



11 4 '% 
zc Gty of ^'^ >^' '-^ 



Cl/>\i V XCL^vC^.-! 



<x>\j u ^^<x Yvec4^^ 



St 



; ^ Dist,: bet V\-^ cLcvcc^lk 



and 



'n a ' 



/ ir OE*T»« OCCURS *w«v rROM USUAL RESIDENCE give facts callco for under "special information- \ 

\ IF DEAT-M OCCURRED IN A MOSPITAU OR INSTITUTION CIVC ITS NAME INSTEAD OF STREET AND NUMBER ) 

FULL NAME Ifk -n.' /^'a Cr^,a.A„ 



I \ 



PERSONAL AND STATISTICAL PARTICULARS 

I COI.OR ^ 



I'ATi; Ml- UIKill 



u 






MEDICAL CERTIFICATE OF DEATH 

DATK OF DKATH A 



r,i I 



'^ 



'-IN'.l.K MAKKIKIJ 

U IDMUHI) «>K DIVORfKl) 

'Wiitt'iii s<K'ial ilr'*i^ijation) 




tUKTIIIM. AOK 



NX Ml* OF 
FATHKk 



MIKTIIPI.ACK 
Of- I ATIIKK 

'St.itr «)r roiititry) 



MAIJ»I.:n- NAM)- 



»!RTHPI,A( K 
«»K MnrHKk 



(I)av) 



M.,)il/, > 



CVX\ ' . '^ 



9'^ ™ 

( Vf'iir) 



ith) \ 



(Won 



11 

n)ay 



IQO , 

(Venr) 



\ 



I I|HRl{nV CI'RTn-V, That I attemlcMl deceased from 



iVVU* 10 IgoH to 

that I last saw h 'A,»\ alisc on 



V'-^'i ^ 



1- 



L. 



.i - 



190 U 
190 






if 



C 



OCCrK\TH)N 




I 

w 

W r ' * ' 






and that death occurred, on the date stated above, at ^l 't C 
M. '1 



w^ .^r. The CAl'SH UP DJ-ATII was as follows: 



^^A-^^^A-AwO. 



Dr RATION Yeai-s Months K Days 

^ -L-tL lLo^. 



/Jours 



CONTRIIJITORV 



^xJLs. 



)'rars 



DURATION 

(Signed) 

H^cLi^ 1 . ygpS (Address) I 1 /^ 



bJ.^.f^ 



Mitfiihs 



Days 



^^^ 



Hours 
M.D. 






«rf.''^?^M^J'^f^'''^?''"'0'^ *"''y ^<^^ Hospitals, Institutions. Translfnts. 
or Rffent Residents, and persons dying away from home. 



v..;////. 



Ihty 






former or 
Usual Residence 

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



Row lonq at 

Wife of Death? Qays 



'Infinnianl 



r^'filrews 



I 



ilaUj 



0-.4^K'W> vct^t > 



4 



w. 



PLACK Ol" Hl'RfAr. riH Kf.-M«»V4T | »i%'»-i» -*• «. 

•y ^ "'I •'•^'f^"' J^i HiAj. Of KHAK^XAJ, 



rNDHRTAKER 

(Acldresu 




\^3U.4 "^^WL 






^ 



^^ X 

N. "•-«;;;''j;- ^^;«--;'on .H„uW ^^ --'-'^^ .-PP".-. *0B .H„„,d b. .....d BXACTLV. PHV8.C.AN8 .hcu.d 



. I 



M$ 



i if 



J 



«i. 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

ll..ar.l ..f Ik.illh -1- No n »'^^aiutl-Co REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 




0-ccco 






Registered JSTo, 



372 



•}■ 



Deputy Health Officer 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of S>eatb 

( 13. S. StanOatO ) 



PLACE OF DEATH : — County of ^^C >v ^ VO. a\ i<,4. Qty of '^^ OJr\j A<X > v auL r 






No. 



^'n. 



ft 



vC^%cLLi. 



A.. 



St.; 



Dist.: bet. 



and 



/ it OCATM OCCURS AWaV mOM UbUAL RCSIDENCE Give facts called for under "special INFORMATION • \ 
\ IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. J 



FULL NAME 



\ 



a\e 



d -^.w 



.•\..V< W 



s I : \ 



PERSONAL AND STATISTICAL PARTICULARS 

m 



clL^ 



ll^Jv^ 



1>\ 1 1 <•! lilKTU 



^<.K 



<\Wntht 



J V 



UHiy) 



Mottth% 



a^ 



t'Vear) 



Ihi 



MEDICAL CERTIFICATE OF DEATH 
DATK OF DHATII 



(Month) J 



(Day) 



(Ye«r^ 



^ 



I HI:RI:HV CI:rTIFV, That I attended deceased from 



If 



WjiM>\vj;i) OK i>ivoKt;Hl» 
iWrHe ill v.KJal ili.*ttii;nnti(iu) 



,1 




(X")x 



%- s 





HIK TM J'f,\ri-: 

>t;i!( or I'lnutlt \- 



NAMK Ol 
J- ATI IK R 



niKTIII'I. \t K 
«>l lArilKR 
>»t:»l« or Cotifitrv* 



MxrKKN NWtH 
'•I MoTfflCK 



hikthfi.aok 

<M. MoTIIHR 

'Statr or i'ontitr%- 



OCtTl'ATlDN 



^^^Qj 



M 



4WV>\^ Al I90H to .. ^V^W. lil Tgo4 

that I last !mw h * alive on ^^ vwLjul. A .» iqq i 

and that death rx-curred, on the date stated above, at I C 



M. The CAl'SH OF DHATII was as follows: 



V4.A.4J^V -L C-AXo. vec*. 



DrRATION 
CONTRIBITORY 



Years Moittfh Days 

jN-w.\a.\.,a.L'„.:..\_H„J.ia.\^.Li.,. 



Hours 



u 



DrRATION 

(Signed 



^.sX^, 



t 



Years Months Days 

(Address) ^5 00 ^-cLUi\/rXv 



Hours 
M.D. 



TQO 



^^^^'^i^J'^f O'^'^ATION only for Hospitals, Institutions, Transjfnts, 
or Recent Residents, and persons dying away from home. 



yfonths X,% JhtS 






flnfoi j)i:int 



1.^ Qi\o . 



(Addrrwn 



'4' i 



V 



Former or 
Usual RrsMence 

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



How fonq at 
Hare of Death? 



Days 



IM.ACi; or BVRIAI. K,K RHM«AAI. I I*ATh oJ KfHiAL or REMOVAL 
INDKRTAKKR 



T90H 



^\ru\A 



^^c\- 




(Addremi 






"■ "■ ^"V/Jiw^i;* °d'e;tS"i: o7-U V '""X.** V'"t ^"^ •*•"■'"• •* •••'«" ^'^♦CTLV. PHV«ICIAN8 .h.uld 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



}l,)ar.1 of Iltalth-I" No. !«, 



H& F Co 



RCrCR TO BACK OP CERTIPICATC FOR INSTRUCTIONS 






I)(t/r Filed , 




lb 



190\ 



Registered JVo. 



373 



JLtrv-.U) tibv-^u Deputy Health o<n 



er 



DEPARTMENT OFPUBLIC HEALTH=City and County of San Francisco 



Certificate of Death 

( XI. S. StanOar& ) 



.'^ 



PLACE OF DEATH:— County 



unty of I ' wClXw^ 



v 



o^Avll b AL, C r. . 



No. 



St. 



>ist.: bet* r and 



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



is 



FULL NAME 



LCrV'^'V' 



t Lliv.J.: 



PERSONAL AND STATISTICAL PARTICULARS 



II \ 11". oj- HIRTII 



COl.oK \ 



n 



II 



lLu 






\<.i-: 



J V(/ » 



*I>av) 



M,mlh< 



War I 



Par 



••iV.I.K M.\kKn:i» 
Wlliowili nk I»I\i •KTKIJ 
iWrit«iii v,„i;,| (l"!-ii'iiiUii>n> 



lUK THI'f.At'K 
sintt- or Coll III I % 



^li 



c e . 



iXHH 



MEDICAL CERTIFICATE OF DEATH 
DATE OF DKATH ^ 

'Day) 



IMonth) n 



ipo . 
(Yesir) 



I HRRIUJV CI:RT1FV, That I attemled cleceasetl from 

--■• ^~~ 190 : to 190 "~~ 

that I last saw h alive on — .--.-— —: —r -^-. — - . -t— - igo 

ami that death occurred, on the <late stated a1>ove, at I 
M. The CAISK OF Dl-iATIl was as follows: 

CA-^aJLrvoJ..J^^^ ,. 




N'\MI iM 

> \ rni:R 



fURTIII'I.ACK 
iW KATHKR 
--tit I of <"ountrv' 



MAIKHN NAMl 
or MOTIIKR 



TUK rui'i, \CH 

'»i \iMriri.:R 

I Slat I or Couiitrj^ 






I> r R A r 1 N ) 'ears Months 
CONTRIBUTORY 



Davs 



Hours 



OCCri'ATKJN ^\a 

Resided m San /> aui i.'^fD 






DURATION years 

1 . 



Months 




Days 



X^C.' 



) itii 



.^r, tilths 



ihi\. 



HhhT 0|. MV KNo\Vm:I)<.k A\[) iiKi.n:!- 



(Signed). U- ^ IllUwyxc 

A,vL^.l5^ IQOH (Address) mTIcUI I'cJIuj .C< 



flours 
M.D. 



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



Former or 
Usual Residence 

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



How long at 

Place of Death? Days 



(\tlcl 



rt's>i 




u -cxJLUuj V 



PI.A^K OF Bl'RIAU OR RKMOVAI. 



^1 



INDKRTAKER 'I vV^.<^J* '^ 



I)ATJ:of in-RfAl. or REMOVAI, 

^xJi.u il ,90^ 



N. B. Bv«''y »«*"! of Information should be cai>efuliy nupplied. AGB should b« stated EXACTLY, PHYSICIANS should 
i!"*"^ . DEATH in plHin term., that It may he properly classified. The '^Special Information'* for mp- 

•ons dying away from home should be given In svsry Instance. 



I 

% 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

Hn;inl of Htalth— »•■ No. n t4j.|fat> H& P Cn 



REFER TO BACK OP CERTIPrCATE FOR INSTRUCTIONS 



Dffff Filed, 



(X.-«-VCU5 




lb 



190\ 



Registered vVo. 



373 



A>U 



Deputy Hear ow% 



DEPARTMENT OF PUBLIC HEALTH-City and Connfy of San Francisco 



Cettiffcate of H)eatb 

( la. S. StanOarD ) 



PLACE OF DEATH: — County of M fla 



City of 




\J 



oJLiu 



Wo. 



•C 



St.; 



1)ist.; bet. 



-rn^ and 






FULL NAME 



wfrlsL'v 



tLL.i 



si:\ 



PERSONAL AND STATISTICAL PARTICULARS 

1 COl.oR \ 




•I 



DXTIC 0|. lURTIl 



\<'.K 



:l 



iMoiith) r 



^"^ »v.,. 



1 1 



(Day) 



Months 



MEDICAL CERTIFICATE OF DEATH 

DATK OF DKATH A . 

% f 

(iMonth) I 



(Day) 



(Year) 



(Vear) 



Da 1. 




wrnnw i:i> »>k DivciRCKn 

(VVritiiti sficial iUsj^.|i;,t j,,n) 



IHKTHIM.ACK 

•Statf iir Cimntrvi 



^■\ 



la\N, 



^^ . . 



I IIKRr-BV CI.:RTIFV. ri.at I attended decease.l fro.n 

■■ ^ "90 to rgo — 

that I last saw h alive on —rTfTr:7— j^q 

and that death occurred, on the .late statc<l above, at I 

^^- Tlie CAISH (>F DlvATII was as follows: 



^^.J^i^-^^ llk(-< 



^athi.:r 



niKTIII'I.At'H 
01 l-ATHHK 

I stati 1,1 (.'(iimtrj*) 



^TAI^)1^N NAM I' 
01 MOTHKR 



HIKTHPl.Al-K 
Ol- MnrHKK 
(Slatt' or Coutitrv) 



o 






^k 




«HCrpATU)lyj 



Ttu-v ... 






at 



XvYva "5 



Dl'RATION }V'a;., 

CONTRIBUTORY 

DURATION Years 

(Signed) X 



Months 



fhtys 



Hours 



A/onths 



Days 



1 



Hours 
M.D. 



A'rsiitfif in Salt /'nui, ism 



) ',;, , 



St„iilh<. 



I>,i\ 



\d^j^ 1 S^ iQoH ( Ad.ircss) nKdl I a.iUu U ■ 

nrf^r.lF^'S'", ''^f ^^'^^■'''O'^ ""'y ***^ "«^P"«'S' Insliluflons. Transients 
or Recent Residents, and persons dying away from home. "-"i'mis. 






(liifotniatii 



Former or 
Usual Residence 

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



Now long at 
Plareof Death? 



Days 






(\«l.!r,ss 




k 'C 



rr.ACK CK Bl-RIAL OR kHMoVAI, j DAT>: of |,rH,A,. or RRMOVAl, 

i 

lNni:RTAKKR 



\rS,^ 



o^c 



■M 



(Adilress 






"■ "■ .^.r/cA^Se'of DPrVS",:''",",'' !:° ""'"J" f"-"'""- *•"' """"" "• ■-"•' exactly. PHV«ICIANS .hould 



fe. 






WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

n,.a.l..f lU:.itl.-HVo. .^»^g»>H&PCo ' RCpcR TO BACK OP CERTIFICATE FOR INSTRUCTIONS 







190H 



Registej'ed JV*o, 



374 



\*-u. 



pytv r 



*,F 



^ 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Certificate of Beatb 

( tl. S. StandarD ) 
PLACE OF DEATH: — County of Ow->V J AXtwC-tttiGty ofC a-Yv.! vIx^axC ^ ' 

it« "SPCCIAL INrORMATION" \ 
OF STREET AND NUMBER. J 



_.., - Dist*;bet. 

/ ir DEATH OCCURS AWAY FROM USUAL R CS I DE NCE Gl VE FACTS CALLED Vo 
\ IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME lU S 





FULL NAME 



iLtclfi dxavL'*^ 



'v<-....au4.,<x 



.UA\4ih. 



My\j. 



k 



SKX 



PERSONAL AND STATISTICAL PARTICULARS 

COl.oR 



% 



DATi: n|- niKTH 



Af.H 



lu i.vtt 



fttfonth) 




) I'lr I 



(Da VI 



M mtfis 



i«c-ar) 



Davs 



MEDICAL CERTIFICATE OF DEATH 

DATK OF DKATH f\ ,^ 



GMonth) ' 



(Day) 



jgo 

(Year) 



*^IN«".I.K. MARK 11 I> 
WIDOWHI) (>K IHVoKCKO 

'U' itriii sfKial tlfsiKiuitidn) 



HlkTMIM.AOK 
(State or Countrv) 



N\MI-; t»i- 
I ATHHR 



niKTin»i,Arr 

Of FATHKK 
(State or Couutrj-l 



MAn>i:N NAMF 
OF MOTHKR 



HIKTHPI.ACK 
•n- MOTHKR 

(Siatt or (.Niuntrv) 






I IIHKI'BV CIvRTIFY, That I atteiuU.! deceased from 

190— — ■ to 



that I last saw h -"? 



alive on 



190 
'I90 



aii<l that death occurred, on the ilate stated alK)ve, at 
. M. Th« 



^ M. The CAISI.; OF DliATII was as follows: 






11! 







DURATION Yeats 

CONTRIIJUTORV 



Months 



Days 



Hours 



DURATION 



) 'ears 



Mouths 



Days 



Hours 



^ W^XLCL^ 



OCCUPATION 

Rtsiflni iti San f'raMtfsrn 



( SIGNED ) M j'U^^^^ Wcuvx4. M.D. 

(Address) 4 i'^ CcH^iioi.^M^ l' 



Mi^ 



Ite T 



90 



Special information only for Hospitals, InstitutUns, Translcnls 
m Recent Residents, and persons dying away from home. ' 



) 'r,l i 



Mmtths 



fh!\ 



' " Mt^?U'^'''- '^T^TKr) i'RRSONAI. PARTIcr!.AK>. AKi: TKIK To TMK 

nh'.T 01 MY KNowi.Hnc.T and hhi.imk 



Ustfal Residence 

Wken was disease contracts. 
If not at place of death? 



Now long at 
Place of Death? 



Days 






(A.l.lre^M 



IM.A^CK OF ni'KIAT. OR RRMoYAl. I IJATH of Bcriai. or RFMOVAI 




t9o4 



(Adflress 



MI^^Hml^M;^ 



^ 



••'~"Bv«Fy Item of tntofmation should be carsfully supplied. AGE should Im statsd BXACTLY. PHYSICIANS •hould 
state CAUSE OF DEATH lo plain terms, that It may be properly ela«alflc4l. The ''Special Information** for psr- 
•ons dying away from home should be given in svsry Instance, 



m 




Il^" 



i r 




WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

n. ,.■„,] nf Hcalth-^i- No. .^ i^^g^H&l' Co REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



I)(f/r FfJefl, 




Deputy Health Officer 



Regisfered JSTo, 



375 



DEPARTMENT OF PUBLIC HEALTff=City and County of San Francisco 



Certificate of H)eatb 

( Xa. S. StanC»arD ) 



11 . ^ m 

PLACE OF DEATH: — County of '<X^w ' AxXAAXA^A^Gty of ^'CtYU 1 >vCL\u:«.x» cr 



Wo. 






Ll'Vt>L^(rVkVA 



y^X[ J Cri^ tr>\\) St.; b Dist; bet. H Lt4.LM.tr>\, and U'Vt>t^(n\U\Mbfl 

/ ir Ot»TM OCCURS *WAV FROM USUAL RESIDENCE Give facts CALLCD/fOR^irOtR "SPECIAL INFORMATION" \ 
\ IF DtATM OCCURRED IN A HOSPITAL OR INSTITUTION Gl\/t ITS NAME (NSTtAt OF STREET AND NUMBER. ) 



FULL NAME 



ti-ir\ 



PERSONAL AND STATISTICAL PARTICULARS 

DAI j: oi I'.IKTII 

10 rll^ 



'iDJLu 



S ' . V. 



Muiitlti 



MEDICAL CERTIFICATE OF DEATH 
DATK OF DHATII 

(Day) 




(fWonth) 



(Venr) 



J Vi/ 1 



ilJav) 



Mi>»it/is 



fYear) 



n,i V 



SFNJ.l.K. MARKIKIJ 

wiDouKi) OK njviiRt f:r> 

(Writf in «.(Kifi) ilt"sj|.riijitiim) 



nikTupi.AOK 

(HtMtc c»r Coiinlrv* 



NAMK OF 
> \THFR 



HIKTllpi.At'K 
OF FATHKK 
'Static or Countrv) 



MA 11) FN NAMf.; 
0|. MOTIIKR 



HfkTHPl.ACH 
OF" MOTHKR 
<Siate or Connti> 



OCA- r PAT ION %0 






I HKRl'HV CI':rTIFV, Tluit I attemlcd deceased froiii 

W^^wj.^ XH tk 190 H to . 1^^ ,90 »i 

that I last saw h /^Ai alive on liA.lLc4. J fc igo H 

an<l that death occurred, on the date stated above, at vS \t 
iL >r The CAl'SJi UF DIvATII was as follows: 





DURATION ' Years- A/ouths %LDays 
CONTRIIRTTORY OllA.^.,1V;aw>W.^ ' ; 



Ho HP 



■.v 






DURATION Years 



Afnuths 



(Signed^ 



'^ 



Days 



^^SJ\J^^ 



I/ours 

M.D. 



ib iQoH (Address) HlH U^MAJi^^.^ 






M.oifhs 



Iht 1. 



or Recenl RcsMfnls, and persons dying away from home. 



"l:,^'***^'^^ sTATKn phrsonai, pARTrcTf.Aks arf: tri k to 
iiF.sr OF MY kno\vi,f;i)<,f: and hf: i,n;F 

,0" 



TIIK 



(Itifortnntu 




<kK 




'Address 






Nnner or 
Usual Residence 

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



How ionf %X 
Place of Oeafli? 



Days 



PI,ACF: of m-RFAT. OR RKMOVAI. I r>ATF <.f llrKrAl, or RF^fOVAf 



rNl»F:RTAK 



(Address 



N. B.- 



-Every Item of tnfopmatton should be capsffully supplied. AGB should bs stated EXACTLY. PHYSICIANS should 
state CAUSE OF DEATH In plain terms, that It may be properly classified. The ''Special Information** fop par- 
sons dying away from home should be given In evspy Instance. 



n 



1 1 





WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

REFER TO BACK OP CERTIFICATE FOR INSTRUCTIONS 



]t.>;.i.] (.f lUnlth-l- N'o. !<. -^Fi^^ll&l'Co 



Ditic File<l, wL, n 




loo'i 

Deputy Health Officer 



Registered J^o, 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of Death 



( "d. S. StauDarO ) 



4 



^ 



PLACE OF DEATH:— County of "^' Ct>v \avLCUlt* City of 'aW) JX-a vvCv<j.co 
v^'V, J h Va.JLui,: ^CVwCtot'UStVVW Dist.;bet. and — r-r 

(ir ocAtii occuns iwAv rnoM USUAL RESIDENCE give facts called won under "special iNroRMATioN" N 
ir DVATH OCCUnflEO IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD Or STREET AND NUMBER. / 



FULL NAME 



AAl OUYVCC *^ iu /Cl.lk)LuiA> 




si-:\ 



PERSONAL AND STATISTICAL PARTICULARS 

I COI.oR' 



vJXVvxCLAJl 



X»\CL 

liATl.: OI-' lURTIl 



III 



X&jL 



X 



(Month) 



A<.K 



JV 



i 
( Day) 



M,n,th^ 



(Year) 



Mj 



MEDICAL CERTIFICATE OF DEATH 

DATK OF HKATH 



f \ 



(month) 




n>ay) 



(Year) 



siM.i.H, MAKKIHir 
(X^'rittiii xK'ial lU-sivnution) 



^ 



lURTHIM.ACK 
<St;tfi- or Country! 



NAMH OF 
FATIIKR 



HIRTIIIM.ACK 
Of FATIIKR 
(Statt or Country) 



MAIDKN NAMK 
Ol- MOTHHR 



in KTH FLACK 
OF MOTHKR 
(Stall' ur Coutitr^-) 









I H[':ki:HV CIvRTIFV, That I attviFk-a deceased from 

^UVViC a i9oi to |l.^^ 1&: tgo*< 

that I last saw h 4J\> alive on Y^^'^^i- ^^ 190 H 

ami that ileath occurred, on the date stated al»nve, at I 5C 

M. The CAISH 1)F DI-ATII was as follows: 




DTRATION 
CONTRIBUTORY 

DURATION 



•^ } 'ears 

•I, 



' Months %'\ Day$ * Hours 

ydiuLL. :...'. 



Years 



WvuX'CWv'C**^ ' 



x-^jiL Jjc.V'Cu 



'\kUu 



(Signed) t)x<i 



^l 



Mtniths Days 



\JXr^^KOjOsM^ 



<>i CFFATION 

Rf Slit fit in San Ftanii'sftt 



^JH ii^ Uio\ (Address) %$ cA ibo^UJ-CXA^ 



"special in 




Hours 

M.D. 



J FO R M AT I O N only lor Hospitals, Institutions. Transients, 

or Recent Residents, and persons dying away from home. 



)'rai 



I 



Montfn 



!>it\. 



TIIK ABOVK STATKI) F»KRSOXAI, PARTICFLARS AKK TRFK To THK 
«KHT OF .MY KNOVVl.KDC.K AM) HKI.IKF 



(Infn 



tniant 



(Address . Cj '(X'>\J 



iff 



Usual Residence 

When was disease contract^ 
If not at place of death ? 



How loif it 
nice«f Deatli? 



Days 



PI.ACK OF niRIAr. OR RKM«)VAI, I I>.\TK o^ lliKlAl. or RKMOVAI, 



INDHRTAKKR J ^HullAV ^ U /CUJL lUVutq ^ C 

Uddre.«. IHla^JsftlMA^C^ y^ 



N. B.— -Bvery Item of Information •hould be cafefully aupplled. AGB stiouM Iw •tatod EXACTLY. PHYSICIANS ahoulil 
state CAUSE OF DEATH In plain terms, that It may be properly claaalfled. The ''Special Information** for pai^. 
aona dying away from homa should be given In avary inatanca* 



•'I 







f» > 



I 



i 




i ; 




WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

RCFER TO BACK OP CERTiFICATC FOR INSTRUCTIONS 



Boanl <•{ Mciiltli -!•■ No. i", ^-^^S^ "^"tf Co 




Registered J^o, 



37? 



Datf riled, VJLu IT 190\ 

^M-vvo (^aAvuDeputyHeafth Officer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of H)eatb 



PLACE OF DEATH: — County of '^'CC^yv J\a>\CUCC City of'^Vct 



( Vi. S. StanOacO ) 






No. 



M 



(ir OCATH occu 
IF DCATH OC 



St.; H Dist.;bct.n tW '' 



<X,h. h, v*-«^ x^ 



and 



nS AWAY FROM USUAL R E S I DE NC E Gl VC FACTS CALLCD FOR UNOCR "SPCCIAL INFORMATION 
CURREO IN A HOSPITAL OR I 



ilDENCE Give FACTS CALLCD FOR UNDCR "SPCCIAL INFORMATION" \ 
NSTITUTION Give ITS NAME INSTEAD OF STRCCT AND NUMBER. ) 



FULL NAME 



i\ 



fD 



lLLcol/>'>\ 



H 



f-\ 



PERSONAL AND STATISTICAL PARTICULARS 

! C(H,oK 



vfric^L, 



ii 



DATI-: OI ItlKTII 



A»,K 



iMhnth) 



) ,„ 



• Dav) 



M.mlhs 






MEDICAL CERTIFICATE OF DEATH 
DATE OF OK ATM 



(jMonlh) 



1? 



(Day) 



rgo' 

(Year) 



Da I J 



^IM.I.K. MAKKn:i<. 
WinoWKl) OK niVnKc HI) 
IWritt* in <»fHi:il cUsivrnalion) 




HIKTHPI.ACK 

'Stat*- (ir ^*(lIlIlt^^■' 



NANJH ni 
lATHKR 



BTRTHPI.ArH 
«>K lATHKk 
(Stnlf or Conntrv^ 



MAn)i:N NAM I-; 
<>I- MOTHKK 



niRTHFLACH 
«>|.' MDTIIKR 
(State or Country 






Vl{.^.Jl\. 



I HKRFiBY CKRTIFY, That I attcmlcd ilcccasc«l from 



that I last saw h i'>>\ alive on 



190 N 



and that death cx:curred, on the date stated aljovc, at © ' O 
A- M. The CAl'Si: OF DI-ATIf was as follows: 



o. 



.OTLxalvt l\^ 



■^ 



Dr RATION 
C0NTRIIU:T()R\ 



,.t 



) 'cars 



' Mouths 



Days 



Hours 







J 1 



I ' ' 



A 




VOL >xtu 



\\. 



. ^ 



1)1' RATION 

(Signed) 



Years Months 

..■^JAaidLlfava^ 

^ m 



Days 



Hours 

M.D. 



lU^^lL TQo'i (Address) X\ U6-A.i>< * V U 



OCCII'ATION J I 

kfsidfd i»t San I'ranrhrn I I C. V^'ats I 



?^^9*fiK''^fO^'^'^TION only for Hospitals, iBsmyHons, Transients, 
or Recent Residents, and persons dying away from home. 



^tanlln 



Da » , 



THK AHOVK STATFI) I'HKSONAI, I'AKTim.AKS ARK TRIK TO THK 
BKST OF MY KNt>\Vl,KI)C.K AND BKl.IKK 



(Informant 



Li:%V-kXA^C ^ i ■ ^ - 



(AddresH 



l^ 



:u 



Former or 
Usual Residence 

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



How tonq at 
Ware of Death? 



Days 



P'"^^pP ^V.\\\, OR RKMOVAI, j DAI-Kof B. rial or REMOVAI, 



-lu Z^ 



•^j-^.-Cb 



%vi^ !l 



UNDKRTAKKR \i f V O Cuk^JUW) \| Tl lD\la»' ^ * - 



190 



(Address llH 



4,^4. Cir^ 



\. 



N* B«—-Bvepy Item of Infopmatlon should be carsfully supplied. AGE should be stated EXACTLY. PHYSICIANS should 
state CAUSE OF DEATH In plain terms, that !t may be properly classified. The **Spectal Information** for psr- 
mtmrn dylag away from horns should be given in svsry Instance. 



i 



? w 






WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

" "^ of Hc.»1tlr-I- No. !^ l^^^^H&PCo REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



Dale Filed, 



\.{ 




n 190 "{ 

De&^^tv Health Officer 



Registered J^o, 



378 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of H)eatb 

( Til. S. StanDarD ) 

0^ 



<^No. 



PLACE OF DEATHS — Cpunty of "'/a>v o Ka v\ Ci4 CcCity of^'<X^v OAXtmc^^^ -' 

"j St*; Qv Dist.; bet. itVcluLft YV and UlaMVL vvot t r) 

T DtATH OCdUBS AWAV FROM USUAL R E S I D E NC C CI VC FACTS CALLED FliR UNDER "SPECIAL INFORMATION" "\ A 

IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME il^STEAD OF STREET AND NUMBER. J U 



( 



FULL NAME 




A..Cllv.>\j 



PERSONAL AND STATISTICAL PARTICULARS 



DATi: nl MIRTH 



COI.OR 



11 






M.V. 



M 1-1 



L 

(Day) 



A/inif/n 



MEDICAL CERTIFICATE OF DEATH 

DATK OF DHATH 



\f*nth) 1 



(Day) 



(Year) 



(Vear) 



Pa VI 



SIS<.I,K. MAKKIHI) 

winn\vi.:i> OK nivoRcKr) 



i\ ii)n\\ |.:i> OK nivoRcKr) * 

Writf in sin-ial fUsiifnjitiuu) 1 l \ 



lUKTHIM.AOK 
I Stall- HT Cfjuntry) 



I UI<:KI:BV CKRTIFV. That I attendc.l deceased from 

^'-^M ^H ,9oM to Iv-^H-'-J-^ 190^' 

that I last saw h -'>-'. alive on J v,Vr!*r:i,i, ' iqq 

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



M. The CAISI-: UV D I! AT IF was as follows 



Oi^Juc 



'V.A-^ 



A' 



NAMK «»l- 
FATllKR 



RTRTMPI.AOK 
<>l' lATIIKR 
IStatf «)r fountrv) 



MAIDKN NAMF 
<)1- M()TH1:k 



HIKTHPI.ACK 
•M- MnTHHK 
(Stall- (,r Country) 



4 P 



4jt/\ru v^rUJ^t^'v 



Dl' RATION 

CONTRIBUTORY CcUv..dUucui 



lu 



) 'ears 



A/on //is 



Days Hours 







DURATK^N Years Mouths 

^ MA 



Days 



OCCII'ATION 



%< 



f\f'iifrd in Situ I'l inn in'o »> 0''«I' 



(SIGNED) 



iwlu lb iQO 
SPECIAL INF 



ft \ 



flours 

M.D. 



H (Address) b 5 n %XKA ^ H 



%^^^^^^,^^^OHNi^T\OU only for Hospitals, lisHtuIloiis, Trjnsleiits. 
or RecfBt ResMents, and persons dying away from home. 



Fonier cr 
Usual Rrsklrncf 



Mntlthf 



n,is 



THlv AnoVK STAT!:i) PKRSONAI, I' \KTiri I,A KS A K i; I'K! K T<> TMH 
BKST OF MY KNOWI.i:i)C.H AND HJIJKF 






When was disease rontracted. 
If Hl^plareof deatli? . 



itW loitf at 
Place of Death 7 



liyi 



' \<hlrc<<!^ 



vhkcn OF irrkiAi, or rkm(»vai. I datho! m hiai. or rf:movai, 

fAil.lress ^J^ 5 M'^\^wt<^t, 



rNI)F:RTAKF:R 



1 



N, B.-— Bvcry ttcm of tnffoiinBtton should be cnrefully supplied. AGO should bs stated RXACTLV. PHYSICIANS shoiild 
state CAUSE OF DEATH in plain terms, that It mn^ be properly classified. The "Speclaf rnformatlon" for psp- 
•ons dying away ffiNHn hom« should M glvsn In svspy Instance. 



1 1 



I 



|| ' 



i' 



I' I 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

lininlMf n.iith 1 No K*^^^K&PCo REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 




Dafe Filed, 




(^.^D^CirA^ 






100 H 



Registered J^o, 



379 



DEPARTMENT OFPUBLIC HEALTH=City and County of San Francisco 



Certificate of H)eatb 

( Ta. S. StanDarO ) 



ip 




Wo. 



PLACE OF DEATH: — County of U€UTuOA.(X>xcc<^t< City ofOoL^X) o;v<X^Cmlcc 



Dist.: bet. n X]\) 



and tAJl^ 



(ir orATH occuns hwav rnoM USUAL RESIDENCE civt r*CT8 callco roH UNOcn "special information-- \ 
IF OCATH OCCURRCO IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. J 



FULL NAME 



PERSONAL AND STATISTICAL PARTICULARS 



i 



SKX 



'S 



1>A 1 !•: nj- ItlKTH 

♦ Month) 



COI.OR ^ A 

a 



a<;k 



O O )Vi/#.< 



Moiilhs 



\\ 



I't', ;ir^ 



/).? V 



'd\:OL/vv/>xa^. 






Lx.u.. 



MEDICAL CERTIFICATE OF DEATH 

1>ATK HK DHATH 

l.fc 

(Day) 




(Year) 



SIN<.1.K MARRIKI) 

wimnvKii OR nivoRrKO 

♦Write in *t«K"inl «!i-!%i^nal»tml 




HrkTHHI,A<'K 

'St:it« or Oountrv) 



N' \MI- iiF 
1 ATIIHR 



RtRTHI'I.ACK 
Ol I ATMKR 
|^^tilt< or Country) 



MAIDKN NAMK 
ni MorilHR 



BIRIHFM.ACK 
nf McniIKR 
'Slat* ur Countrv I 



I 



1 



I J 






I HKREBV CKRTIFV, That I atternkMl deceased from 

Itx-wil 190 S to |sU4^ lb 190 H 

that^r last saw h J^ alive on \^^i^ '^ 
and that death occurred, on the date stated above, at 
- M.^ The CAISU OK DEATH was aR follows 



190H 



c 



<XA, O-v^^x-^rwA^au 



It 

1 



v.;j 



DIRATION % Years Mouths Days /Jours 



CONTRinrTORV 



\\ , 



DURATION 



) 'ears 



AfouiAs 



Days 



Hours 



(SIGNED) iX.vJ ^a.^-vrL<v.hJL M.D. 

^.U^ I V iqoH (Address) SSMxXjX/y^ t^i^..Q 



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



, Traiisients, 



OCClfATION , 

Kf sided in San /'taHttsra a v )'eaii •■ ^/"nfhs " 



/la r: 



Tin: ABOVF. STA TJ- I) PKRSONAI, I' \K IICI I.ARS AR H TR IK H » TIIK 
JIKST OF MY RNo\VI,Kl)(,K ANIJ HKMHK 



Clnfottiuint 



f ^clflrrn* 



Ion %rsM m 



Former or 
Usual Residence 

Wlei was disease contracted 
If not at plare of death ? 



Mw long at 
Pfareof Oeatti? 



Dai's 



»*'-^K "*" ni-RJAI, <m RKM.iVAI. I DApJCof j^It KIAK or REMOYAI, 

%&4a, ^ft^t^ I W^ *^ 190H 



t 



I NUKRTAKKR 

{A«J«Ire«f« 






,A^ v\ 



N. B.— Bvvfjp Item of Information •iiould be cnpcfully sailed. A6B shoald b« stated EXACTLY. PHYSICIANS should 
state CAUSE OF DEATH In plain tcrme, that It mmy he properly classtfted. TIm ''Special Information** for per- 
■MIS dying away fro«n ^ms should he given in every Instance. 



i 



',ji|' 





WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



I!,.:.r.l oi IIt:ilfh- »• N'o. is *t^a^B&P Co 



Dale Filed , 

■ 1 



5-^w4.A^ 




100 "i 



Registered J\^o. 



380 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Certiffcate of 2)eatb 

( la. S. StanOarO ) 

J( «i) Jj ^ 

PLACE OF DEATH: — County ofvl<X>vOAa>\CccL ( City of Clo^vuO^a >v ac^ 

^^ } f] f 

rW©.^^ v1 OHv^vcLl».A\a LL4,^,Ul i St.;— Dist.;bct, and 

(ir DCATH OCCURS M"*^ FROM WSUAL R C S I OE NCE Gl VC FACTS CALLED FOR UNDER "SPECIAL INFORMATION" \ 
IF DEATH OCCURRED IN A HOpplTAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / 






FULL NAME 




-CTYVCUucL , <:Lol\4_4„ > 



'^KX 



DATK OF HIKTH 



A«.I-; 



PERSONAL AND STATISTICAL PARTICULARS 

I COl.OR ^ 




a. 



(Moulh) 



n i^ I 



a4 



)V,n 



(Dav) 



Months 



MEDICAL CERTIFICATE OF DEATH 



DATE OF DKATH 




lb /poS 

(Day) (Yenr) 



fVearl 



Da \s 



SIN'<;i,K. MAKUIKO. 
WirxnVHI) OK DIVORCKD 
(Write ill social rlesij^jialiun) 



niRTIIPJ.AOH 
(Statt- or Cotintrv> 



N'AMK OF 
J-ATUHR 



niKTUTM.AiK 
OF FATHKK 
(Stale or C<>untr%-) 



maiim:n NAMK -v 
OI- MOTIIKK 




that I last saw h 



I WKRKBV CHRTIFY. That I attended deceased from 

i9oH to .^|^^4u. iS: ...190H 

• alive on \\^Xkjl \^ 190*^^ 

and that death occurred, on the date 'Stated alwve, at ^ 
^- M^^^The CAUSR OF pICATII was as follows: 



U(x<x^L 



XJs \U ^OuM-t-^xj 



DIRATION Years Mouths \ ^ Days 

CONTRIIUJTORY 



Hours 



\^K 



\ 



y A 



FUKTIIIM.ACK 
OF MOTHKR 
(Slate or roiititrv) 



A 



DURATION 



Years 



OCCFPATION 

Rf sided in Son Fi am iM'o 



5'Vc\^a.u 



(T 



J V(i $ .< 



Months t^ Daw 



Mouths Davs 

SIGNED) y)\i ()>lcUvJvJI 
UaIu lip iQo H (Addre ss) %^^^ ^ 




«\A 



Hours 
M.D. 



-- -^ INFORMATION wly far Hospitals, Institutions, Transients, 
fir Recent Reswents, and persons dying away from home. 



THF: ABOVE STATHD PKRSOVAI, T' XRTICfT.ARS ARK TRFK TO THK 

BEST OF Mv i^No\vi,F:D«',F: AM) iu:un:F 



(Informant 



UkoAJl 



•5 



(Address 







LcL ^ak- 



i^ 



racted, \ , 
If not at plareof deatk? sh^\J^^^\^s^^j-s%, 



Wlien was disease contracted, \. ■ 



Days 



::E OF BIRIALOR RKM< 



PI.ACj^ OF BIRIAI^OR RKMOVAI. | DAT^ of ^tRiAi. or REMOVAL 

n rgoH 



rNDKRTAKKR WVO^VCL C^<L t 



(Addrcsn 






^v*-C 



N. B.—- Bvepy Item off information shoyld be carefully supplied. AG6 ahouid b« stated EXACTLY. PHYSICIANS ahould 
state CAUSE OP DEATH In plain terms, that It may be properly classified. The "Special Information'* for per- 
sons dying sway from home should be given in svsry Instance* 






\] 



4 



tl 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



)!..ai.I nf Hialth- I* No. 15 



H&l'Co 



RCFER TO BACK OP CERTIFICATC FOR INSTRUCTIONS 



Ddlc Filed J 

1 



^-VM^ 



X4/N>u Deputy Health Officer 



Registered J^o. 



38i 






4I» 



'*f 



ii: 



DEPARTMENT 0F1>UBL1C llEALTH=City and County of San Francisco 

Ccitlffcate of H)eatb 

( la. S. StanC^arD ) 

J I . J? j (^ 

: — County of ^ cute >v(X6 City of CVoJ.C^x<XA; v ^' 



PLACE OF DEATH 



(No. 



St 






Dist.:bct. 



and 



(ir DCATH OCCURS AWAY FROM USUAL R C S I DC NCE CI VC rACTS CALLED FOR UNDER "SRCCiAL I N FOR MATION" N 
IF DCATH OCCURRCD IN A HOSPITAL OR INSTITUTION QIVC ITS NAME INSTEAD Or STREET AND NUMBER. / 



-) 



FULL NAME 



1" 

VOLA.i'Wi'X 



"" ^\ 



PERSONAL AND STATISTICAL PARTICULARS 



ll 



ImU 



MEDICAL CERTIFICATE OF DEATH 



HXTK UI MIRTH 



Ar.K 



iMotithl 



51 



J Vrl J 



aiayl 



lA.»////t 



(Year I 



An. 



SINC.I.K, MARKIKH 

wjDowKn OR nivoRiKn 

(Write ill siH'i.nl (h-ivjiatiiin) 



mRTHrr..ACH 

(Statt or CouiUrj-i 



NAM1-: Ol- 
HATHKR 



niRTHPI.AOK 
OK l-ATMKR 
'StMle or Conntrv) 



i 



O A^-W 



JLvmA ^ 




UATK OK nKATH A 

id 



(Month) 



( Day) 



I r 
IQO 

(Year) 




I HERKBY CERTIFY, That I atteiiaed deceased from 

• ■• I9O ~~ to — .......... — .„ .....IgO "" 

that I last saw h ~ alive on "~ ^~" — — ~:~— — r— jqo ~~ — 

and that death occurred, on the date stated alx>ve, at ~ 

^^^ M. The CAl'SI-: OF Dl-ATH was as follows: 



,\., 



^ 



cvva . 



V.S. 



>VC'i^AJ--V%i 



MAIDKN NAMK 
OK- .MOTHER 



lUKTHPUACK 
<>l- MOTHER 
(State or Country) 



OCCrpATlON J A 






I)rR.\TION Years 

CONTRimTORY 



Moulhs 



Days 



Hours 



I 



t 



Dr RATION 

(Signed) 



Years 



c 



Months 



Days 



Hours 
M.D. 



^wlu Ki 190 A (Address) 



JPECIAL INFORMATION only lor Hospitals, liistltiiHoRS, Transients, 
•r RfCfRt Residents, and persons dying away from hone. 



Resided in Sati f'tamiseo ' )>(?» 



.\r,.iitii> 



Pars 



ftmer or 
Usual Residence 

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



Now lonq at 

Flare of Death? Bays 



THE ABOVE .STATED PRRSONAI, I'ARTIi II.ARS ARK TRIE TO THE 
BEST OF MY KNoWI,ED<;E AND HEMKF 



(Infr>rt«a«t 






(A<1(lress 




4^A.\.<rrK 



c1 



Clt 



•"'aACB Ol- m^RIAL OR RKMOVAl, I lUTJ! of BllllAl. or REMOVAI, 



INDERTAKKR i 

(Address 



UBlOVtuMteUD 



N. B.^HBvery Item of Information should be car«futty supplied. AGB should tm Stated EXACTLY. PHYSICIANS should 
state CAUSE OF DEATH In plain terms, that It may be properly classHlsd. Th« "Special Information** for per- 
sons dying away from home should be given in mvmry Instance. 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 




#• 



1 





Hrntrd of Health- I' No. is '«*: 



H&PCo 



REFER TO BACK OP CERTIFICATE FOR INSTRUCTIONS 



J)((fo Filed, \xAm n lOO'i 

dL^-u,^^ cMyvM^^Deputy Health Officer 



Registered J^o, 



382 



DEPARTMENT OFPUBLIC liEALTH=City and County of San Francisco 



Certfffcate of H)eatb 



( Ta. S. StanDarC> ) 



PLACE OF DEATH: — County of C'avu \aA\.CUlC^ City of f^' <X'W A^CWUM^CO 



No. 



n.sci 



dk. 



14 



AJro 



St 



(ir DEATH 
%r OCA 



I; . Dist;bct*Uo^hJLn^.il;\^ii and \litr\iN ) 



OCCURS AWAV rnoM USUAL RES 

ATH OCCURRED IN A HOSPITAL OR 



FULL NAME 



SIDENCEgive facts called for under "special INFORMATION'MN 
INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. '/ 



J\A,'CLc)U^v 









SKX 



PERSONAL AND STATISTICAL PARTICULARS 

I COI.OR 



Q^ 






DATK or HIKTII 



iD.Lu 



Month) 



ACK 



V I I t'it I ,^ 



.15 

<Dav) 



yroulhs 



/..fc..l...i 

(Vear) 



Pa V 



MEDICAL CERTIFICATE OF DEATH 



DATE OF DKATH 



/|( Month |] 




lb 

(Day) 



(Year) 



SISr.l.K. MARKIHl). 

wrnowKD OR nivoRiHi) 



(Write in si)oi:i! (U <.it'nation) | . 



lURTHIM.ACK 
'State or Coimtryi 



NAMK OF 
FATHKR 



BIRTH PI. ACF: 
OF I-ATHKR 
(State or Country) 






I HRRHBV ClvRTIFY, That I attended deceased from 

*Wio iX 190*^ to ..^^\^L-L.J te 190^ 

that I last saw h -UV alive on N11k\Xa^ 1 fe i^o H 

and that death occurred, on the <latc stated above, at 
1^ M. The CAUSK OP DliATH was as follows: 

iLv^vt Jt^....aJt^v^-iJ^ . 



(>XJtl<x/-^vdL 



Dr RATION ^ Ytars ^ Months \ Days ^ Hours 
CONTRIBUTORY }\fr:yU. 



MAIDKN NAMK 
UF MOTHER 



BTRTHPtACK 
OF MOTHER 
(State or Country^ 



OCCUPATION 



k 



i) 



>VfL^\4-u. , 



(^ 



^vUUx^^xdw 



Kfsitlfd in San FttlMtisftt i 



DURATION J^'^"''^ Months Days Hours 

(SIGNED) n)\XXiM}AjC^ M.D. 

Up iQoH (Address) J^L?5b M)>^<><t\4^ ut 




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



)>-(?/ 5 I U yfnnfhs 



/hn 



THE ABOVE STATED PRRSONAI. PARTICII.ARS ARE TRUE TO THE 
BEST OF MY K.NOWI.EDi.E AND HEI,IF:F 



( Informant 



(Afldre»<<« 



ais-o van 



t L. at 



Former or 
Usual Residence 

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



How long at 
Place of Death? 



Itap 



PI'A^ OF BIRIAI, OR KEMOVAI, j DATE of HfRIAL of REMOVAI, 
UNDERTAKER V cULt\\AX V J^OAA-^^ 



(.Address. 



^(> B. Bvcry Item oV Information should bs capsfully itupplied. AGE should b« atatsd EXACTLY. PHYSICIANS should 

state CAUSE OF DEATH In plain terms, that It may be properly classified* TIm *'Speclal Information** for par- 
sons dylnft away from home should be i|iven In every Instance* 



> 



•■ r 



II 



f 



«ti» 



^ f 




r i 




WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

Hoar.! of HLaltl. I No. is f-^J^ H&l' Co REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



Date Filed, 



0-^UJ^ 




woH 



Registered JSTo, 



383 



Deputy Health Officer 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of H)eatb 



PLACE OF DEATH:— County of '<X^vv]A<X^ Vtc* 'City 



( 13. S. Stan^at^ ) 






! \ 



X 



St. 



Dist.; bet. 



(X'"vv vJAxX/>v<u^.c^ 



and 



(ir DEATH occuns 
ir DCATM OCCUKMCO IN A HOSPITAk OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER 



H OCCURS AWAV rROM USUAL RESIOCNCe GIVE facts CALLED roR UNDER "SPECIAL INFORMATION' "\ 



FULL NAME 



\isA. 




A^axX^LC 



PERSONAL AND STATISTICAL PARTICULARS 

Sl,\ A- j Cni.oR 




V 



Ol 



1 1 



MEDICAL CERTIFICATE OF DEATH 

IJATK OF 1)1-:ATH 



DATH OF BIRTH 



ACK 



f^i. 



iM..iit1i« 



iIJmv) 



) «■.»/.* 



Miiulfn 



( Vi art 



/)<;i. 



SINl'.I.H. MARKIHIl. 

\vri)<>wF:i) OK r>iv«»K*F-i» 

'Write- in swxrial ilt-MiKimtiuii) 



niK THIM.AOK 

^Slatf or Countrvl 



NAM}-. lU 
FATUHR 



BIRTH IM.ACK 
OF I ATHKR 
(Htati- or Coiintrj-) 



MAIDKN NAMK 
OF MOTHKR 



niRTlIPr.At'F: 
o|. MOTHKR 
(Staff or cViuntrv) 







(Month) 



It 

(I My) 



igo I 

(Vear) 



I Iji;Ri:nY CICRTIFV, That I attenikMl deceased from 
Iv^L. IH T90H to ..|v\lu,lia itfiH 

that I last saw h '.. » - alive on ^^^'^^ ' ^ '9° *^ 

ami that death occurred, on the date staled above, at X JO 



K.K. M. The CAUSK OK DKATII was as follows: 



KaJX 






DIRATION 
CONTRIIU'TORV 

DURATION 

(Signed) 



Years 



Mouths " Days ~ Hours 

"^A^iX.'iXN.. '„x. ^ 



occrrATiON 



cm 



U^A^Utt 



^.A^CL' 




Years Mouths Pays 

\b iqoS (Address) 1.13» UaiU_^ 



Hours 

M.D. 



Hesidfd in Sitfi I'ianii>f'<> " \'iuns 



^/oH(Hs A thi vs 



VWV. ABOVE STATFU* l»HRSONAl, PARTiri T.ARS ARK TRIK TO TH K 

hf;st of my KNaw'i.F:i><*.K anh hklikf 



(Informant 



sJ/VO» . 



(Addresd 



\k\ 



^l 



\ 



Special INFORMATI ')N only for Hospitals, Institutions, Trdnslents, 
or Recrnt Resldfnts, and persons dyinq away from liomr. 

Forwer tr H , /^ | How \w% al 

Usual ResMeiKfw^->^va. tt oH . V a I, pi^^ ^f p^^tfi ? Q, .,.. Days 

Wfipn was disfisr contracM, 
If not at plaff of dfath ? 



I'l.ACK OF BCRIAI, OR RHYtoVAL I DATK of BiRiAL or RFMOVAI, 
INIIHRTAKKR N HV a,<i<iA/VV \ W l^ ^U^X^ 

.It!., 



"♦^ 



(Addremi \X3,X 



^urv\*. 



N. B. Every Item of Irtformntlon should he cnrsfvlly stipplted. ACB •hould be stated EXACTLY. PHYSICIANS should 

•tate CAUSE OF DEATH In plain terms, that It may be pi^pcrly classified. The "Special Information** foi* psr- 
•ons dying away fi*om home should be given In svsry Instance. 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



::l* 



i.,in.l (.f Health — F N'o. i<; "^ 



!l.,in 



H8:PCo 



RtFCR TO BACK OF CERTIFICATE FOR INSTRUCTIONS 




Registered JSTo, 



384 



r 



^KxvA Xt-v-u, Deputv Health Officer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of H)eatb 



( ta. S. Stan^ar^ ) 



PLACE OF DEATH?— County 



of d,a.>^0; 



m 



,0L>^ Jxct >VsI.Cn 'City of ^'OLlv ^ KCK 



No. H()H^ 
( 



- iH.tl 



V 



St.; !C Dist.:bct. 



^., 






and 



\r DCATH OCCUMS AW«V FROM USUAL R E S I D E NC E Gl VC FACTS CAtLCD FOR UNDER "SPECIAL INroRMAT 
IF OCATM OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBE 



ON" \ 



FULL NAME 



I!" 




>i:x 



DATK «)I- JUKTIl 



\<.l- 



PERSONAL AND STATISTICAL PARTICULARS 

Cni.nR \ . A 




t 



'?" c It 



V 



iMinith) 






^ 



Pi 

(Day) 



Mtnilli^ 



'■>iar' 



Ai 1 . 



srM.I.K. MAKKllvU. 

WFixiWKi) OK I)I^•^)R^K^ 

(Write in stniaJ iU>.i^iiatii>n) 



UIKTIII'I.AOK 

Stall or O'Hiiitrv' 



^ 



SAMi: «)l 
FATHER 



W 



m 



\Anyx<xjs 



(XhJyjO-^ 



to 






A, 



MEDICAL CERTIFICATE OF DEATH 
DATE OF DKATH 

"u I Id 

(J^^oiith) f (Day) 

I IIKRHHV CI'IRTH'V, That I attciickMl deceased from 

^^^^»^' l^ 190*1 to^....|^JL:.iL IqoS 



(Year) 



UL 



that I last saw h ' ■ alive on '*^v\.l.i. igo 

and that death occurred, on the date state<l above, at i 

M. The CAUSE OF DEATH was as follows: 



H 




'1 



niRTIIPl.ACK 

ni- I ATHHR rt . 

(State or Co«ntrv> \\ (1 



MAIUKN NAMK 
OF MOTIIKR 



HI K TUP LACK 
OF MOTIIKR 
{St«t»- or <V.»i«i»rfi 



OCCri'ATlON 



\kX<x • 
C\ ft 



DURATION i 
CONTRIBUTORY 



} 'cars 



a 



Months 



Days 



Hours 



DURATION 



Years 



Months 



(SIGNED) UL.J Xx^nXCUx-^ 



Days 




C1AL IN 



iqoH (Address) J>cULa >v ^ 



Hours 
M.D. 



i-i 



JPEClAL INFORMATION only for Hospitals, Institullons, Transknls, 
or Recent Residents, and persons dying away from home. 



Kfsidfif in San Fiann'stu> ! t ),-aif 



Af,»/t/is 



navs 



Tin-: ABOVE STATF:I) PHRSONAI, PAKIH II,AKS AKK TRFK TO THE 
DEST OF MY KNONVI.HlXip: AM) HJ:MI;F 



(Infurtnant 



LWv>%aJ- u l 



f^fMrcsH 



SClHl . IH tk 3i 



Hmtfwt 
Usual Residence 

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



How long at 

PJareof Oeatli? Days 



PI,Aj;^E OF nURIAI, OR RKM<>\ AI. I DATE of Hikiai, or RKMoVAI, 



INDERTAKKR III a dLiij^Tu ^Tf V' ^'i) A^^ 

lQ.L.^lflc4.4.^v.:: { 



(Adtlre»» 



N. B. Every item of lnfoi*matloii •hould be carefully sapplled. AGB sliould be stated EXACTLY. PHY8ICIANS ahould 

•tate CAUSE OP DEATH In plain terms, that It may He properly classified. The **8pectal Information*' for per- 
•ons dying mvfm^ from home should be given in rnvry instance. 



k 



J) 



1 



( 



•I 1; 




WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

r..,anl..f li.MlHi- r.vo. i^'i^^^]\9i\'Cn REFER TO BACK OF CERTIFICATC FOR INSTRUCTIONS 



wo'i 



Date Filed, LvL 11 

<^^Hx^ ILta^^u Deputy Hftaff^^ rsm^^r 



Registered JVo, 



384 



II 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of 2)eatb 

( la. S. StanJ>arC> ) 

of ^^a. -^X' JXa ^\^'.< ^City of -^'Ow'">v I AXX/1\C< 



lA c <: 



(^ 



^No 



i'.^ 



•^ 



IM 



PLACE OF DEATH t — County of ' a. ^x J X a ^ 

. HCH'l ^ IH t'\) Sn; 10 Dist.;bct. \/W^ and lasLbtx: 

f \r Oe*TM OCCURS •*•¥ from USUAL RESIDENCE give facts called FOU under "special tNFORMATlOW N 
V, if DEATH OCCUnnEO IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. • 

rvf; fi! 



FULL NAME 



si:x 



PERSONAL AND STATISTICAL PARTICULARS 

I COI.UR \ 




HMK i)V HIKTII 



At.H 






U ;•>'. 



(Miuitb) 



) <•(/ i 



1*1 
(Day) 



M,.„tli- 



I L', . 

(Vt-ar) 



/>a l'.t 



MEDICAL CERTIFICATE OF DEATH 

DATH OF DKATH 

" " , Ik /p«M 

(;Month) 1 (Day) (Year) 



■^INi.I.K. MAKKIKI). 
WIDOXVKI) OR I)IV«>RCHn 
(Write in »i«»cial clf>.i^r„;,tiijn) 



FURTflPI.ACK 
'St.Mtf or Cuiintrv^ 



NAMK OF 
FATHKR 



m 






I HEREBY CERTIFY, That I attcMidtMl dccxascd from 

^^OJX' U 190 't tO^....|v^i.U:..ll 



190 s 

that I last saw h alive on ' ' ^ ix.\ \ I i^q \ 

and that death occurred, on the date stated above, at I 



■ M. The CAl'SE OF DEATH was as follows 



k'v©--vx :x* 



a . 



m 



l^'f^ 



niRTHPl.ACK 
Of lATIIKR 
••Stall- or Country) 



MAinivN NAMK 
01 MOTIIKR 



HIRTHI'UACK 
OI- MOTIIKR 
'Stall- i.r Country) 



a, 



Dr RAT ION I 
CONTRIBUTORY 



) 'cars 



rs 



Months 



Days 



Hours 




a-. 

e 



OCCUPATION (^ , .. 

W<r") V<1Ljw^ tXcrX' 

Ke:^idfd in Satt f'tatniseo I ^ )V*ii;.« 



DURATION 

(Signed) 



Years 



Mouths 



a.^1 



Days 



Mmiltti 



r\} 1 




190 i (Address) 




\ 



KXjy% 



(Bid. 



Hours 

M.D. 



«r dL!!^ D ft*-, "^!r^'"^^''''ON only for HosMtals, InstitotlMS. Translfnts, 
or Recent Residents, and persons dying away from fiene. 



I 



). 



THK ABOVE STATKH PKRSONAI. PA RTfCI'I^A RS ARK TRIK TO THK 
HHST OK MY KN0\V1J;D<;K AM) ItKI,li:K 

fl'>r""nant LvYVTV-M-A V Co-Vv^x.' ' ' 



(Aclclrcss 



HOHi vll .blv ai 



Fomer or 
Usual Residence 

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



Now long at 
Hare of Deatli ? 



Days 



'''''^^^^"'■'ft"^''*'-V' '*•* KKMOVAI. J DATKof in-RiAL or RKMOVAI. 



INDKRTAKR 



in I 



{AddreSH 



AA.K. 



N. B.. 



-Every Item of Infopination should be carsfully supplied. AGB should bs stated EXACTLY. PHYSICIANS shoald 
state CAUSE OF DEATH In plain terms, that It may be properly classltlsd. The "Special Information'* for par- 
dons dying away from home should be ilvcn In wr^ Instance. 











#^l 





WRITE PLAINLY WITH UNFADING INK — 



h' Filed, X^JUi n 



THIS IS A PERMANENT RECORCT" 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 




1)((. 



190 H 



Registered JVo. 






DEPARTMENT OFPUBLIC HEALTH=City and County of San Francisco 



Certificate of H)eatb 

( •©. S. StanDarD ) 
PLACE OF DEATH; — County of Oa^^' J n^O/YuCMiCc Gty of ^ ^>^' ^' ^^CL > vC<.<^ 
rNal lU\xJUdfv 'ta- St.:- Dist-jbet "^Acl-'V 1 U. M«jr 



m...,^) 



) 



FULL NAME 



^, 






PERSONAL AND STATISTICAL PARTICULARS 






COI.Ok 



!) 



iJATK <)l ItlRTII 



A(.K 



iMitnth 



lly 



) V<7 t : 



.Day" 



M, oil In 



r w 



(Year) 



Daxi 



HfN<.i.i.:. MARK inn 

WIIMJ\VKI> OR IHV<lR('KI> 

(Wrilf in MKrial (iVsivmitiou) 



lilKTmM.Ai'K 

•^t.-itt III •*<nii)trv) 




N\Mi: <u 
I ATHHk 



niKTun.Ai-K 

<M I AIHKR 
'State or Crmtitrv) 



MAIDHN NAMK 
<»1 MOTUHR 



MIK rilPI.ACK 
OH M<»THKR 
(State (»r {'ruintrv^ 



ns \ 
an 






MEDICAL CERTIFICATE OF DEATH 

HATE OF DHATH A ft 



f|W<.nth) , 



<Da>0 



(Ycrir^ 



\ 



1 UHRHBY CI':RTIFV, That I attended (k-ceased from 



Xm 



ivctL4 190H to j^ ;jjr*Mij-.l> 190 H 

that I hist saw h alive on tT^^H ^^ ^90 '^ 

and that death occurred, on the date stated a1>o%'e, at » 

M. The CAUSE i)F DIIATH was as follows: 



y.kii 



\JsA.\A Vr^A-fi 



r V-fe 



Dr RAT ION \ Years 
CONTRIBUTORY 



Moil 'ha 



Days 



Hours 





) \ 



Month h 



Da \s 



OCCIPATION Q\ , 

Resided in San Fmnrisru ' v Yfttt^ 

THK AROVK STATl'J) PKKSONM. I'AKTHrLAKS ARK TRIK T«> THK 
BKST OF MY KNOWI.KDC.K AM> BHUnCF 



(Itifiirinant 



fAddres* 



n 



tL 



XL 



DURATION 
(SIGNED) 



Vears 



Mouths 



Days 



y U].%. 



Hours 
M.D. 



kclu lb iQoH (Address) 5 Q 1>. QA.vfct«.>v ' 

SPECIAL INFORMATION only for Hospttih, Inslltutloiis, TrMslwils, 
tr lllKMt Residents, mi pcrsoiis dying away from lionie. 



Former or 
Usual Itesidence 

Wliei w« Mea% cMtractcdf 
If RotitpliretfdeaHi? 



ftactff Intti? 



kys 



PI^ACE OF BIRIAI. OR KF:M0VAI, I IJATK o( ni'MIAI. or REMO%'AI. 



UACE OF Bl 






TQO'i 



• HX<MCfcj..>^ U?LU^ 



(Address 



ni,^ 



\,C4,^u<s>\ 



J ,+ 



N. B.— B^«ry Item of Information .hoald be cp^fuliy •uppHed. AQB .Hoyld b. .t.ted EXACTLY. PHYSICIANS should 
state CAUSE OF DEATH In plain term., that It may be properly elasaltisd. The Special Information for per- 
sons dying mmm9 from home should be ^\yn In m\9r9 Instance. 



'.f 



A 



m 



\'h 



t' I 



. I 



m 



.* 



•«! 



f 




1^ I I' 






I 



Ho: 1 1. 1 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

, n. nlth^F NO ,. *C^fc H&l' CO REFER TO BACK OF CERTIFICATE FOR I NSTRUCTIONS 

386 




n 



190H 



Registered JSTo, 



I)((/e Filefl , 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



H^Mi Deputy Health Officer 



PLACE OF DEATH:— County 



Certificate of H)eatb 

( "a. S. Stan^arD ) 

itv of 1 1 



of M L<xlv' 



(No. 



SX 



<X) 



Dist.; bet. 



City 



a 



vco 



and 



UxjL 



/ .r or.TH occu.,, aw.y r«OM USUAL RESIDENCE C'vr J*", cM.LtD ^o" "ndcj ,;%7^;*i„'~^„'»;;;j';"" ) 

V ir DEATH OCCOHPltD IN A HOS^ITAt OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. J 



) 



FULL NAME 




iLJii 



\Ajsj\\JihJ D.rJLccLLL^ 



PERSONAL AND STATISTICAL PARTICULARS 

COI.OR 



■" ^\oL 



DATK ni HIK III 



A<;K 



I 



iMonlh) 



%% JV.n. '^ 



lUl 

IS- 

(I)HV) 



xdjL 



r%k{D 

(Vear) 



.\/.,Mf/l} 



Pay 



siN<.I.K. MARKIKI) 
WIIMJWKI) nk DIVoKiKIJ 

tWritfin HfM-ifil di xit/iuitiou) 



HIKTHPI.ACK 
'SUitf or CfHiiitryi 



NAMK uf- 
I AT Hi: R 



RIRTHl'I.XCK 
')!• FATIIHR 
'St.itf ur rf)untry) 



MAIDKN NAMK 
OF MOTHER 



HIRTHPUACK 
<»1' MoTIIHR 
(Stair i^r Count rv) 






C^ kt<.Lt^ 






^» f 



^rUr\An^ 



OCCUPATION 



Resided in San I'l an, I wn *' )>ais * U.»ifh' 



rhi 1 



THK ABOVK ST^THT) PKKSONAI. P^KTim.A RS AR I- TRIK To Till- 



(informant 



CAd«lrc*« 



ant mV^ 



i.frYU 



rit 



MEDICAL CERTIFICATE OF DEATH 

DATE OF I)1;aTII 

"m I.S.. 

(Day) 






/90 

kMonth! (I)ay^ (Vear) 

I UURHBY CERTIFY, That I attentlcMl «lcccasea from 

to 



■I90" 



190- 



that I last saw h "rr— alive on 



— - — ic;o - 

ami that death occurred, on the date statcil above, at — — rrr 
M. The CAUSE OF Dl-ATII was as follows: 



Loa-cLmvc- ^ ^,laLcxtct;i\. 



DURATION Years 

CONTRIBUTORY 



Mouths 



Days 



Hours 



Vcars Months 



Days 



Hours 
M.D. 



DURATION 
(SIGNED) Lk 

\jjuc^ 11 iQoH (Address) rla|-^ 

^PECilAL Information ow'y tor Hospitals, InstltuHons, TransJeiils, 
or Recent Residents, and persons dying away from hMie. 



uXi va 



Ferner M" 
Usual Residence 

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



niretf Deatli? 



Days 



PI.ACK OF BrRIA!< OR RKMOVAI, j IlATl" af IliRML or RRMOVAI. 
l-NDERTAKKR CaUCtiA "^'^ tC 

(Addre.«. ...... ^tb ^l^MMU.ir:>% S.i 



M. B,— Ever,. It.m of Information should be c«..f«ily -PpH.d. AGB should "^ •«-»•- ^'^.^CT^,^! jri^Jnlt-U^'^Ii 
•Mt« CAUSE OF DEATH In plain terms, th.t It may be properly classified. The Spsctol laform.tlon for psr- 
W»ns dyinft away from horns should be given !n svsry instance. 




f 



i 



\ 



Y 



1. 





H' 




J 



#^ 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

„ ,,, ., ,u a,th F NO .. l^t ^4>H^.»Co REFER TO BACK OF CERT IFICATE FOR INSTRUCTIONS 

387 



Dale Filed, WU H ^^0\ 

dL^WL^ \x^^^ Deputy Health Ofriccr 



Registered J^'*o, 



DEPARTMENT OF VUBLIC HEALTH=City and County of San Francisco 



Certificate of Beatb 

{ Ta. S, StanDarD ) 



A 



^ 



i 'nil 

City of C'/<X-(v -i.>V'a'>\<i^.;i,ct 



PLACE OF DEATH:— County of Va-rv/oXaA " v - 

No. IHUor'.-. -., St.; -S Dist.;bet. 1^^.:^- and 

^ ••oiiAi tsr e mr Mr P r- iwr rACTS CALLED ton UNDCft SPECIAL INrOWM*TION" 1 

/ ir DEATH OCCURS *w<»v rnOM USUAL RESIDENCE GIVE '^•cts "^J/" "" "'l" .tiiect and NUMBER J 

V ir DEATH OCCUHHEO IN * HOSPITAL OB INSTITUTION GIVE ITS NAME INSTEAD Of STREET AND NUMBER. / 



4 i^ 
11 - 1 



/D 



FULL NAME 



I !■ 



"* toLkK. 



>i-;x 



PERSONAL AND STATISTICAL PARTICULARS 

I COI.iJR 



^oL 



bolj 



IiAll. <t|- IMRTH 



\ 1 . 1^ 




iM.m'th 




HS r.„,. \ 



Drivt 



M,.n!li 



ri 



I Viar' 



An 



HINT.I.K MARkIKI> 
\Vll>M\VKI» OR l>lVoHri'r> 

'Wiitt in •MH'i;i! iU-*'ik'fi.it ■" lU) 



niKTuri.xri'. 

'Stat* (»r C<»iiiiti \ i 




a\x^xtl 



AX.^^^<X^"v<- 



I \Tin:R 



niRTiipi.xrK 

«)|- I ATHKR 

'siatr or Cmjiitry) 



MAIIU'N NAMK 
<»!• MOTHKR 



HlKTm'f.Afl-: 
<»l MOTIIKK 
(State- or Country^ 



ll , ! 



1, 1 jJ\ns w Ot'^xu 



AV 



I 



\ 



'-\ - 



•HCri'ATION 






\ % ) lit t s 



Af.iiif/r 



Ihi 1 , 



THK ABOVE STATHI) I'KR'^ONAI, I'ARTrctT.ARs ARI-; TRlK TO TIf K 
HKST OI* MV KN< tU i.I'D'.H AND I'.HI.IHK 

(Informant vJvO^ Q ^<-VC..k.A_' » 



i \.l<lr«-ss 



MEDICAL CERTIFICATE OF DEATH 
DATE OF UKATII > 

h 

(Day) 
I IIh:Ki:HV CI-yKTIFY, That I attcmletl tleccased from 

to ...-^aJm; 1 5. iQoH 




vvjL i X 



that I last saw h 



190 



alive on 



to ^¥f^ 






190 

190 



ami that death occurred, on the date stated above, at 1 I J 
V M The CA I S !•: ( ) 1* I ) i: X T 1 1 wa^ as follows : 



Dl* RATION Years flfonihs Days Hours 

DURATION D Vtars " .Uont/is " Days *" Hours 
Ik) T90H (Address) lObS m^^Oy\^ 



(SIGNED) 




U.l\o 1 
DfAL ll 



^PECfAL INFORMATION wly for HosplUls, NstltlMMS, Twiisteiits, 
or Recent Residents, and persons dying away frtm ' 



101 HMC W 

Usual Residence 

Vfliei was iiseasf cMtractN* 
If not at place of deatli ? 



flan If DeaH? 



Days 



PLACE OF BIRIAI, OR RHMOVAI, I DA'CK of BtfRlAt. Of RKMoVAl, 

Ma^ Cvvvvvfi*^ I ft '^ -90H 



UNnKRTAKER 



(AdtlredH 



Wh^ Ql\MM^^un\ % 



N. B.— Bver^ Item of l„form.,lo« .ho«ld b. a...f«llr -PPHeJ. AGE .hould »-•«-»•- f.^^TL^ ,„ToTJttn^'"fof :;I1 
state CAUSE OF DEATH In plain tei-ms. that It may be properly claastfled. The Special Information for per- 
•wis dying away from home should be given In m^mrv Instance. 





M 




N > 

HI 






WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

,,,ar.1..f ikai.h-i No , . 1^^^^ HS: P Co WEFER TO BACK OF CCRTIFICATE FOR INSTRUCTIONS 




l)((le Filed, 




u 11 



Registered JVo. 



388 



190^ 

Deputy Health Officer 

DEPARTMENT Of PUBLIC HEALTH=City and County of San Francisco 



PLACE OF DEATH:— County 



Certificate of Beatb 

( 'CI. S. Stan2)ar& ) 

of "^.a-kf.. 



City of 




,'\ 



Cat 



No. 



St.; 



Dist4 bet. 



^nd 



) 



(ir Of ATM occurs »W*V rnOM USUAL RESIDENCE give tacts called tor UNOEB "•fecial INrORMATlOW \ 
,r rtlxH OcJIrREO IN A HO.F.TAL OR .N8T.TUT.ON GIVE ITS NAME INSTEAD OF STREET AND NUMBER. J 



FULL NAME 



111, 



»i.X<X/^\<X.^-V 



<L< 



I I 



-'liX 



PERSONAL AND STATISTICAL PARTICULARS 



UATi; i>F niRTII 



a i.^t 






A«.K 



IV ,.„,. it 



iJavl 



M.ifilh 



t »ai 



/'./I 



sisr.l.K. MARKIHI). 

wiD<n%'Hi» «»R i>ivoKri:i) 




a^VA^<^ 



HI HT HIM. An-; 

(Slftt*- or Ctiiintry" 



NAMK Ml 

I A I iii:r 



HIKTHIM.At'K 
'»! I ATIIKR 



MAIHKN NAMK 
<»F MOTHKR 



niKTflfr.ACK 
<»|< MOTHKR 
Olatf. ur Couiilry 



'^ 






k^\ 



^ 



^^^X^^l-S.<HwAwt V\. LaxC 



^ 



1 



MEDICAL CERTIFICATE OF DEATH 

I>ATK OF DKATH "\ 



'! (Montn) 



igo 

(Year) 



I IIICKMHV C1':RTII'V, That I attended deceased from 

--.-- 190—* to ' ...:rrrr-..icp 

that I last saw h tt— alive on t— - igo 

and that death (Xrcurred, on the date stated above, at 
M. The CAl SR OF I) I! ATI! was as follows: 



.CyCL^VXA/t 



.fe-V*-\? v. 



W ft 



J 



xy^' 



li 



Ol% '*m 






occri'ATioN 



c. 



Sl.<nth^ 



IhV 



Rf^iit^d III S,i>i / I lUii iffit tU )»*iT'' 

THK AIIOVEHTA TFT) I'KKHnNAI, l» \ KTI« t f, \ K^ A K I- TKIK r«» THK 
BKlsT OF MV KNUWI.KIH.H AND nit.tl.F 



niif.irmnnt 



a 






(Add re!!* 



as n vA 



.a^n^v 



^4 



Dl RATION Years 

CONTRIBUTORY 



DURATION Years 

(SIGNED) 

kvi^. IS igoH (A 



Months 



Days 



Hours 



Months Days 

ddrtss) "XcvkxIvtSl 




Hours 
M.D. 



n I 



^FECIAL INFORMATION «nly for Hospltils, Institutions, Transients, 
«r RKett l^idents, and persons dying away from lionie* 



ti 



i-^ n ID'tl 



Usual Residence 

When was disease contracted, 
If Mt at place of death ? 



H .Now loi^ Ik 
<Sa}-\/K imatt of Deatli? 



IC... 



Days 



190 



I'LACK OF BfRlAI, OR KF:MoVAI, I UATF: of Wvhiau or RKMOVAL 



(Addreiiii 



•t«t/cAU9E W DEATH In pl«ifi term., that It mmw b* properly clarified. The •Specl.l Inform.tloii for por- 
•ofi« dying sway trow homo •liould be given In ovopy Instance. 



I 



1 



|v 



.l, 



fr 



Ill 



Hw;n 



IW 




WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

1 ,,f lie alth-F So. IS <<^^}{&l>Co REFER TO BACK OF CERTIFICATE POR INSTRUCTIONS 

389 




Jtc4 Vl 190 H Registered JSTo, 

^ Oflficer 

DEPARTMENT OF fUBLIC HEALTH=City and County of San Francisco 



Ihtfe FiletJ , 

\ H ^ D' 

;Vfr\-VU) <iJlA>U^ •-''-^'-'■» 



Certificate of Beatb 

{ "Cl. S. StanDarD ) 

:ity of ^'/Ct'^ > J 



PLACE OF DEATH: — County of ^^a>v MX'Vvauit^ City 



.\XtA\^t 



(h 



No. 111^ \l 1 V.^.>^A.trvc ( v\v Kr^^t ffi) S S Dist.;bct. 



Ul 



and ^ 



± 



f ir DC4TH occu«« »wXv FRoL USUAL JlESIOENCECivc r*CT8 CALLCD roR unocb 'spcci*!. INFOHMATION- \ 
( ,r rclxN OCcI/lTcO IN Jto.^.T.l. Jr .H.T1TUT.ON GIVC ITS NAME .N8T«0 OF STRtCT AND NUM.CR. ^ 



FULL NAME 



rt^vu 




-^i^x 



PERSONAL AND STATISTICAL PARTICULARS 




lulou 



n.\TK nr IlIKTII 



\c;k 






^ 



1 ViJ » . 



II 



it 

(Dny) 



, !/,.»////< 



/10„0. 

(Year) 



AO 



Da V5 



SIN<.I,F,. MARKIKH 
\VII)«»\VKI) OK IMVoKil-:il 

i'A'rif' in "-'K-iiil di -tvii.'itiou) 



HlKTHPf.ACK 
(Stall- or CcMuiiry* 



N WW. Ill- 

I A Tni;R 



HIRTIII'I.ACK 
Ol FATHKR 

(St.-itf or Cduiitrv' 



MAIDKN NAMK 
Ol- MOTllKR 



lURTHIM.ArK 
OF MoTHKR 
(stall* iir t'oiintrvl 



^3 iA vcyli 




MEDICAL CERTIFICATE OF DEATH 

DATE OF DKATII A A 

Ytviu lb r9o\ 

mMontJr n>«y) (Year) 

I lIRRIUiV ClvRTIFY, That I attetnled (k-rcascd from 

-- . — — 190 to •■ - 190—-"" 

that I last saw h ■-. Hlive on — T90 ~ 

and that death occurred, 011 the date stated above, at — — r-rr- 
M. The CArSI*: OK DIvATlI was as follows: 

UlRATION Yeajcs Months Days Hours 

CONTRIBUTORY kLs^^'^ ecihXfv. Jmjl..^^ 



^ 



c<XA 



.4, 



w^ ^» 






/t^t4rvu 



■A /D 

occrPAT.ON Ch^tr,^^ 



TIIK ABOVE STATK.I) PRRSONAI. rARTIOff.ARS ARM TRl K TO THE 
BHHT OF MY KN*)WI.KI)«;K AND MltLUlK 



(^f 11 forma tit 




f A«l«lre««» 






KvvtoCrv^* 



DURATION Years Months Pays Hours 

( SIGNED )...Wu:>UAj 1 i^ lU. luUttX/wx^L 
^UJLu.. ll iqoS (Address) LsW^jUU W^jt. 



M.D. 



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

rormertr t^uXW ! Jr ^ How long at 

Usual Resldence<^H wAA^VV-Vvx^^w Death? Days 

Wtieii was disease contracted. 
If not at plictff tfntli? 



PLACE OF m'RIAI,OR REMoVAI, 



J^J-UiAJ^ . 



OMX 



AA^Wj 



DATEof mniAL or REMOVAI, 



INDKRTAKER vj ((XVvX/VXJthj ^J3K/6-^ 



N. S._Bv..y Item of Information .hould be c«r,f«lly •upplUd. AGB .hould ^•'•^•^L^^'J^^l':^' ,^,^^J^!!So^.%:!:Zt 
•tatc CAUSE OF DEATH In plain term., that It mny be properly cl..iilfled. Th« Special Information for paP- 
aona dying away from homa shouid be given In •vmry Inatawce. 






I 



k| 



i 



I- ( 



'III 



I'i 




'i 




II 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

, ., ,,„,,„„ , N„ „*3;^rt.HS:.>C„ REFER TO B«CK OF CERTIFICA Tt FOR INSTRUCTIONa 

390 



I )((/(' Filed 



, V^^^^- '^ 



IDO'i 



Be^isteved J^o. 



DC 



DEPARTMENT OF PUBLIC HEALTH^City and County of San Francisco 



Ccttificate of Death 

( Ta. S. StanC>arC> ) 



Wo. 



PLACE OF DEATH 



: — County of ^ ^ 

I 



Q^ 



<X^\^ -)Xcxi\c.<.a.ccCity 



cCity of'^'<XAV ^' 



(!K\ 



St.; 



Dist.;bct. 



<Xaaj J Ka,>\x^c4.ct 



and 



L 



FULL NAME 



.wo-W^ 




PERSONAL AND STATISTICAL PARTICULARS 



^i:\ 



(n\c.L 



C01,t>R \ 






IJATI-: oi- lURTH 



\i.K 




\1 ! 1<X(.4 

■ Month) \ 



1^ 

tl»av) 



r../i 



'^ t 

Mntllhs K, \ 



\ <;u 



/ht ). 



'^1\<.1,K. MARKIKIV 
WItMnVKfJ OR niVoKi Kl» 
(Write in scx'inl tli'-i^'iuit mn) 



i ! 



^^--T 






wL^v^Kv 



^t.i'r . it roiint I V 



N\MF nl 
JATHHR 



lUKTHri.ACK 

ni- J- vrUHR 

' M:itt ur rimtitry) 



(>l- MOTflKK 



<>t- MoTHKK 

'<»l'(l. Hi «•. ,11 tit r«>l 



• HCri'ATlON 

Kfsitlftt ill Siltl f'i illh I I'll ' 

Tin: AUoVlsHTXTII) I'FRSONAl. I'XKTUri.XK^ \K1. TRfK T«) THK 
niCsT OF MY KN«»WLi:i>r.K AND HKMl.l- 



Y,;,,^ I ^r..,lf>l^ X\ /'.'I 



(Infonnant 



{'. 



(Addrr«* 5* 5" Q D 



^ W -I. 



MEDICAL CERTIFICATE OF DEATH 



DATE Ol- DKATH !'\ A 

4l.,tith) 1 (Day) (Year^ 



rpo-i 



I HHRICHY CIIRTIFV, That I attended <leceascil from 
|U.VUL id igol tn , 1^^^^^ ^90*^ 

that I last saw h -l^-'v^v alive on ''^|vwtL^ ^ ^ I90 'x 

and that death occurred, on the date stated above, at I 
tL.M.. The CAl'SK OF Oi: A TIT was as follows: 



I>r RATION * Years 
CONTRIin TORY 



Months 1 Days ' Hours 



DT RATION Years Months Pays flours 

(SIGNED) M^ 6 MTla\.4.!vav' M.D. 

I<K)H (Address) 3.^60 Jxlu-JVcM '^i 



SPECIAL INI 



Special information (»nly for Hospitals, listitMtioRS Transienh, 
•r Iccent Residents, and arsons dying away from home. 



FMVieror 
Usual Residence 

mien was disease rontrarted, 
If Mt at plafe of deatli ? 



Htir lonq at 
nut at Oeatk? 



Days 



PJ^ACK OF BIRIAI, *»R KKMnVAI. | DAJ^K of ^i hiai. or RKMOVAI, 



P1,A- 

rSDKRTAKKR ^fU^Llu. ^ ^\P A A f^. ^V 




(Address 



N. B. 



. * . * .1 -i.„..irf h- <-«K«ffull>F suDolted. AGE should be •t.ted EXACTLY. PHYSICIANS ^lOttM 

■Every Item erf Information •hould be carafuiiy •uppiiea. f^^ ••j|«-ei-| InroniiBtlon** tor D«r- 

•t«te CAUSE OF DEATH In pi«l« term., that It m»> be properly 6l...lfled. The Sp«ci«l inform.tlon for p«r 
•ORS dying away from horn, nhowld be given In .v.ry Instance. 



1*1 



Ml 



V\^ 



ii 



\f 






WRITE PLAINLY WITH UNFADING INK 



li„M,<1 of !!■ alth~F No. IS t'^^^ M&PCo 



THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 

391 



Jtegisteved JVo, 



Datr Filed, Wiu 1^ ^^^^ 

DEPARTMENT OF PUBLIC HEALTlI=City and County of San Francisco 

Certificate of Beatb 

( XX. S. StanOarO ) 
: — County of^a^ 1 VavtCU-CC City of ^^/CL'YU \XXyVVCA^tU) 



PLACE OF DEATH 







IcN^kvtcU) St.; 



N©. KKku V WtvvJlu 'k^ N, kvtoi) St.; ^-^^ Dist.; bet. *''^,.«... x 

1 / .r OC.TH occjii .w.v r.oJ USUAL RESIDENCE o.v. r*CTS c*tLCo -" "««, ."CU^^^-JMJT'OH.- ) 

1) t IF OtATM OCCi)l«RCO IN * HOSPITAL OK INSTITUTION CIVC ITS NAME INSTEAD Or STBCET AND NUKIBtR. ^ 



FULL NAME 




IWH^Vl 



^ 



SK.N 



PERSONAL AND STATISTICAL PARTICULARS 

COI. 



^YiaU 



■■""lo I 



xaXi 



DATK i»F niKTll 



a<;k 



iMotUli) 



b I jvi»»v 



<l)ay) 



.1 /,»!////' 






Pf/ w 



^IN'.I.K. MAKKIHI* 
WI1M)\VKI» OR niVoKiKD 

(Writf ill Micial tlesi|fjiatii)ii) 



MikrmM.AOK 

( state or Countrv* 



4 






NAMH OF 
FATHKR 



rUKTHPI.ACK 
or l-ATHKR 
(Statf f)r Country) 



MAIDKN NAMR 
OK MOTITKR 



niRTlIPLACK 
oi- MOTHKR 
(Slate or Country 




\^^vCjI 



OCCrPATION 

Kfsidfd hi Sati Ft uni rsri) IW )>ir» < 



\f,mth% 



Ihi 1 



THK AROVK ST\TKn t'KRSONAl. I'ARTICtLARS ARK IRt H TO THE 

HKST OF My kni)\vi.i;i)<".f: and HHMJ'I" 



niifottnani 



r^dilresH 



ZL<L ** 



4 



%lCo ""i^DCK^Kctat 



MEDICAL CERTIFICATE OF DEATH 



DATE OF DKATH 



1 



/iMonth) 



I 



(Day) 



9o\ 

(Year) 



igo 



I HEREBY CKRTIFY, That I attctulcMl deceased from 

Lllvva H... 190H to ^-V^- "i 190 H 

that I last saw h ^ ' • alive on 1 v^U^ H I90 S 

ami that death occurred, on the date stated above, at » 
M. The CAl'SK 1)1' DIvATH was as follows: 



DTRATION Years 

CONTRIBl'TORV 



Months 



Days 



Houfs 



DURATION Years Mouths Days 

(Signed) .LL'Vw mT\ d^(xv^<^^J 

^ciu II igoi (Address) AltiJM.\l^ 



Hours 
M.D. 



■ess)_^^M__^__ 
>N only for l^spitais, 



institutions, Transleits, 



_. L INFORIVIATIO 

or Recent Residents, ^nd persons dying away from fiome. 

Forrarr or / 1 n ( V U W ^•^ ^^ ^ > t 

Usual Residence \o I H \JXX<U^\^ t U plare of Deatli? . u. „„ (toys 

Wlien was disease contracM, 
If not at plare of deatli ? 



D 



n.ACE OF BIRIAI. OR RF:Mt»VAI, I DATK of III KIAI- or R8MOVAI« 

(Adctre.« J 3tl:X - laji.lil . 



„ - - ,^ - i«L-«-ti„„ .hould he capsfully supplied. AGE should bs stated EXACTLY. PHYSICIANS should 

N, S«'-*«Evepy Item of infoMnstlon should oe carsruiiy ■uppii»« i«.j «.|.. •«««^^i-i i«tiLwiM«tlnn** ki> naii- 

state CAU8B OF DEATH In plain terms, that It may he properly classtftsd. Ths Special Infciwatloa for par- 
sons dying away from home should be gWsn In svsry Instance. 



^i 

41 




■| 




WRITE PLAINLY WITH UNFADING INK — 



,,,,.1 nf IKaltll I- No. It *'^!^ PA- 1' Co 




i 






190^ 



THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 

392 



Registered JVo, 



Dfffe Filed, 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of Death 

( la. S. StanDarD ) 

1^ >f 



PLACE OF DEATH: — County of ^'OAV l\a>vC,u4a City of ^'O.^^' ^<^'WCuaac 
(No. I'Xl'^ JUUVv^v^i, «^*- ^ r,:.*.wUniL^ and "^ 



/ .r oc*TH occu».sVrw*Y r«oi- USUAL RESIDENCE Give r.CTS "i""" ;«»" "/'''"l'?"^^ ) 

\ ir OC*TM OCCUlTnCO IN A HOSPITAL OR INSTITUTION GIVE ITS NAME IN8TCA0 OF 'STREET AND NUMBER. • 



and ^KUL/y\) ) 



FULL NAME 



^<'\.V.^CJy\;X. 




II 



II ^ 



SHX 



DATIC OF lURTII 



At.K 



PERSONAL AND STATISTICAL PARTICULARS 

COI.OR 




luixvic 



(Month 




J 'j'fi * 



II 

(Day) 



.1 A ;«///< 



(Vetir) 



An. 



S1N(.1.J-.. M.ARKIH!) 
\V!I)<»\VlvI) OK niVoROKO 
IWritf in «sucial ilt>.iK>»ati<»n) 



BIRTinM,.AOK 



,4 



C^Vi 




RTinM,.AOK I *¥> 

ateur Cimiitryi -d ll 

NAMK or n 
lATllKR Jfi 



CL>v "1 VOywcUJ-CO 



ed 



lURTIIIM.ACK 
OF l-ATHKR 

(Stair or Comilt V' 



MAIhKN NAMK 
0| MOTIIKR 



niRTIIl'UACF: 
OF MOTHKR 
(State oT Country) 



if 





CxLcuLm 



OCCl'PATION 

Rrsidfit in Sati Ft mui ■•••,> 



Yrttvi * \f,>nths 



/hi y. 



TIIF AUOVK HTATFn I'KKSOSAl, !'AR T ICF I.ARS ARK TRlK TO THH 
BEST OF MV^kNO\VI.F;i>C,H AND lUU.n%J*' 



n 



(lufommnt 




(.\«UIre»t« . 







X 

(Day) 



(Year) 




MEDICAL CERTIFICATE OF DEATH 

DATE OF DKATH A Ij 

W 

flMonth) j 

FRHBY Cf':RTIFV, That I atJtemkMl deceased from 

^ I90H t^ iH^^W^^^^'^^^ '*^^ 

tliat 1 last jmw h .^^VHalive on HmJLu i X I90H 

and that death occurred, on the date stated above, at \ 
'J M. The CAl'SR OF I)l':ATn was as follows: 

'^iMs.Jjdi^ 

DIR.^TION - )'fars - .^font/is % Days * Hours 

coNTRinrTORV ii.!-^l^UL\X^iXurvx. 



DURATION 
(SIPNED) 



Years 



Months Days 

1^ TQo H (Address) ' mtrvdtivY -h.b.g.^ 



Hours 
M.D. 



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



Nnner 9r 
Usual Residence 

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



Now loRf at 
Flare of Death? 



Days 



Pl,ACE OF BFRIAI. OR RKMoVAI, I DATK «^ nt'RlAr. or REMO%'Af, 



A 



L^awxM w <L^ 



t 



\^ 



tgoH 



t NDKRTAKKR ^^ CUXO^'Y^j ^<^ AXtXu 




(Address 






i^i 



N. B.— Bv..^ Iten, of Inform.tlon .hould be ca.JfuM. .applied. ACB f -'^ *- •^-^'-^'^.^C^^^^^^^ irrL^.uLt" Vr'^I-l 
•t«te CAUSE OF DEATH lit plain terms, that It mi.y be properly clMs1ffl«d. Ths Special Inforiti.tloii for p^r- 
Hon* dying pway from horns should be glv«n In svsry Instance. 



'!■' 



1 



/^ 



«! 



411 f 




r 



i 

i 



WRITE PLAINLY WITH UNFADING INK — THlS '.5 A PERMANENT RECORD 

,„,,„1 .flhalth-FNo .^-J^^^H&PCo REFER TO BACK OF CERTIFICATt ?^y.J.t?t^T RUCTIONS 



393 



IXitoFiJcd, VJlu.i1 190\ Registered J^To. 

ds^^-vAA^ S<Mj\>^{. Deputy Health OfTiccr 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of Beatb 



( XX, S. StaiiDarD ) 



i m 



PLACE OF DEATH: 



County of -Ojy\) J AXXAM^UecCity of ^'<XAV 3 AXWv^^^A/C^ 



(No. 



^ 



i. h. 



\%^ MU-i. St.; S Dist.;bct 

/ ir otATM OCCURS *w»v rnoM USUAL RESIDENCE civt rACTS callco for undcr -r-iu., 

V IF OCATH OCCURRCO IN A MOSRItAI. OR INSTITUTION CIVC IT» NAME INSTEAD OF St^ECT 




PCCI 



and 1 J 

AL INFORMATION" '\ 
AND NUMBER. / 



tl 



FULL NAME 




OA^' 



tytJt^jLtr L 




<.KX 



PERSONAL AND STATISTICAL PARTICULARS 

I COI.OK 



^ f 



lAjAdjl 



n^TK OF IIIKTH 



hV.V. 



iMiiiilh* 



1<) b y,ais 



a>ay» 



M.tHilii 



(Year) 



An A 



'>IN<'.M.:. MARKIHU, 
WrnoWKI) OR l)TV<»Kii:i> 

'Wtittiti sfK'ial •h'iU'natif'n) 



1URTH>'I,ACH 
(Slate or Country) 



NAMK OV 
KA IIIHR 



lUKTHPI.XCK 
|>I I AIUKR 

' Slate >ir roiintrv) 



MAIDHN NAM1-: 
<)»' MOTHKR 



IlIR'ruI'LACK 
oi- MOTHKR 



(f 






vn 






r 






MEDICAL CERTIFICATE OF DEATH 

DATK ()!• DKATH 





II 

(Day) 



Year) 



Tgo 



,EREBY CHRTIFI', That I attended deceased from 

.1.1 190H to . |^|iu,... 1.1 190 H 

that' I last saw h -^^ alive on H^aX^ I b 190^ 

and that death occurred, on the date stated above, at 
iQk M. The CAUSK Ul' DIvATII was as follows: 

*! .cv^..<:L..../C3d:Lob'tA ^ 



nr RATION - Years ^Months 5 Days 



Hours 



CONTRIBUTORY 




DURATION 
(SIGNED) 



Years 



Mouths 



\^J\^% y. v"t,4jt .; 

Davs Hours 



m.^ 



Q^Ct-^W 



M.D. 



r 



OCCVI'ATION Q^Vf j) 

Rfsi(if-<i in Sn» Fiamhtn wyi )><?/.< 

THH AnoVK STATFI) I'KR^ONAI, PARTlOl I-AKS AKlv TRIE TO TJlH 
lli:ST OF MY KNOWl, F:n<'.F: .^NI) lUrUFtK 



^fnnt/n 



/hi 1 .' 



{Informant 




L^^ru 



^\<l«1ress 



.A> 



^, 



^u vn 



^\..< 



[uXu ii 190H (Address) in U]lah„|-L.tli 



.•FECIAL INFORMATION only for Hospitals, Institutions, TransieRts, 
or Recent Residents, and persons dying away from home. 



Former or 
Usual Residence 

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



How long at 
inaceof Death? 



Days 



ri,ACK OF niRIAT, OR REMOVAI, I IJAIti: of J«i lUAl- or RRMOVAI. 



UHDERl 



u^mLucIoJu.' 






M. B.— Bvcy Item of Inform.tlon .ho-ld be carefully .upplled. AGE .hould «^„-'«*«4 "^X^^STLY. PHl^^^^^^^ 

state CAUSE OP DEATH In plain terms, that It may be piH>periy classiflsd. The Special Information for per- 
sons dying away from home should be given In mvmrjf instance. 



'. • 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

,. ,,„n,..„l.1-|-N,....*^H'^l-C" RtFER TO BAC^ OP CERTIFICATE FOR IN8TBUCTION8 

394 





1^ 



190^ 



Daft' Filed, 

JU-uc^ ii/iMi. Deputy Health Offloer 



Be^isteTed JVo, 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of Death 

( m. S. StanOar? ) 
PLACE OF DEATH:-County of ^a^v ^ Va^vt^^.tc City of ^''a>V a,\a^vCc4. Cc 



IJi 



m 



fNo. I'^OO 



^ 



IruracC v*^ 



5t 



and I Id 



^lVcX^.ln..radL WV • SU '■■ Dist.;bct. 1^ ^^^ and i^A 



JL^vv Li^'-c 



FULL NAME 




H^ 



^;V^^UXJ.^'-CiL^C-1fV^ :> L.a..^.x^^. 






PERSONAL AND STATISTICAL PARTICULARS 



HATH ni- lUK III 



L 



lc.i> ' 



'1 



M-.mln \ 



M.K 






ll>ay) 



%r.-itffn 



/111. 

(Vt-ail 



An-. 



SINT.I.r.. MARklKl). 

\vinc»\vKi) OR DfVtmrKi) 

tWritriii •>'K-iaI <!« sii-tiation) 



lUKTHl'I, \CK 
(Hlatf or Country) 




\<xv 



h^wL 



a. 






1 



1 1 



NAMH Ol' 
FATIIKR 



niRTHIM.ArK 
OP I-ATIIKR 
IHtjile or Country' 



MM1»I-:N NAMH 
<»! MnTllHR 



mRTHI'I.ACE 
Ol M<»THKR 



■'^ '^ 



L 1 



'"^^XOw^-VW 



Lt^-wk'^v&'V 



\ 







JXhjwvOL'^xt 



ttCCl'l'ATION I 




} 



Prsfd^<{ w Sat, Frnmfsrn ?,D )>,;>.- - -V"»//^' ' ^^'^' 



THR ABOVK ST^THH PRRSONAl, PARTirf LARS ARK TRIH TO THK 
BEST Ol MV KNOWl,En<;H AND niM.l HK 



(Informrdii 



(Address .. 






(Yenri 



MEDICAL CERTIFICATE OF DEATH 
DATE OF DEATH C\ ft 

VL IS 

(ftonth) fT <«)ay> 

I HI'IHI'HV C1':RTIFY, That I atteiuled tUHcasctl from 

AAV*.. 4 I90H to ^VaJUjL l.^ I90H 

that'llastsawh •' alive on t'v^^H ^ '' ^9^ • 

an<l that tlcath occurrc*!, on the «lati- stated above, at ♦ "^ - ^^ 
! M. The CATSR OF DlCATII was as follows: 

LcU'vcLs.lXc i\aA.||^J-^wVve \ ■ ^'i 



DT RATION IX yeat;s ^ Mont 
CONTRini'TORY J\:. -iO-h^t ^1 ^A ' 



/?ffV.? 



Hours 



DURATION " )Vf7;'5 " ^Tonths, * /?<iv.? 1 Hours 

) U). a-%oA.-..u' 



(SIGNED 



M.D. 



NkAjLu lb TQoH (Ad.lress) \%S. U^<.CVVi.^ 
SPECIAL INFORMATION only for Hospitals, Institull 



^PE<ilAL Information only for Hospitals, Institulions, Transients, 
or Recent Residents, and persons dying away from fiome. 



former or 
Usual Residence 

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



Now lonq at 
Hare of Death? 



Days 



PLACE OE ni'RIAI, OR RHMOVAI. 



.KJ\>^' 



INDERTAKER 

(AddrcM 



DATE of nt'RiAl, or RBMOVAl* 

^v\,iL\j 1 1 T 90H 

ll'^n ^^\AjL^.fir>x3t 



N, B, 



- . . .1 i.^..M K. .-«ra?iillv KUDDlled. AGE BHould iMi Stated EXACTLY. PHYSICIANS should 

Every Item of Information should be tnrofuily «uppiiea. «« ....i.i.h ti.* *«Sf»ct«l Information** for Dsr- 

state CAUSE OF DEATH In plain term., that It may be properly classified. The Special Information for par 
sons dying away from home should be given in svsry Instanca. 




11^' 



w 



i 



fit 




l.,.,:ir.1 <>f !k:iltlJ-l- Nn. i 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

. iOfHS^lffS^mvco REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 

395 



1% 



190'i 



Date Filed, Jp-V^l 



Be^istered JVo. 



DEPARTMENT OF PUBLIC HEALTH-City and County of San Francisco 



Certificate of 2)eatb 

( TU. S. StanOarD ) 



PLACE OF DEATH:— County 



i f 



CuecCity of 






Dist.:bct. 



— — — ~ and 



•) 



FULL NAME 




{X^^.A. >\' 



'il.X 



PERSONAL AND STATISTICAL PARTICULARS 

COL 



OOwl 



■■■■'loLi.-. 



DXTH nl- IlIRTIl 



At.K 






\ Jfc y.ai' I 



sisr.i.K MARKIKU, 

\\ iiM»wKn OR nivt)Rfi:r> 

Write hi »«r»ciaJ ck-M^natiuti) 



HIRTIiri.AfK 



n 



L >V 



(Davl 



M.itiUi^ 



I 



,\i> 



n n 



I Vt:ir) 



Pa 



NAMK <>1 
FATHKR 



RtKTHPI.ACK 
O) fATlIKR 
iSlnif or Cenintrj) 



MAII)1-:n NAMK 
ni MOTIIKR 



lUKTHPl.Al K 
<U- M*>THKR 
iMaif <ir Country) 



occrrATioN 







V 



<X.JLAX^\) 



\Xy\K' 







Resided h, Sav r,a,n,^r,y ?)0 Vrars *' ^r.»>fft< ^ ^'M < 



TIIF. \no\h: sTXTl-It I'KRHONAI, VAKTHMLARH ARK THr K T« » THH 
IlKST til- MV KN(»\VI.i;i)t.K AND HJ'.I.Il.K 



f ^ddreMM 




vC 







MEDICAL CERTIFICATE OF DEATH 
DATE OV DKATH 



(Month) 



! I 

(Day) 



lYeari 



I IM'lKliBV Ci:RTirV, That I attendeil deceased from 

Vv^VJw I 190 'I to ...^kJLu...l.b i<pH 

A (j ft 4 
that I last saw h alive oti ^»-UjL i te 190't 

and that death occurred, on the date stated al)Ove, at » ^ H U 
S.L M. The CAISH OF DICATII was as follows: 



-A..*>-w 



^M 



DURATION Vears fl/otiths Days Hours 



CONTRIBI'TORY 



XV 



DU RATION 
(SIGNED), 



Years Months Pavs 



tU^li^ lb 190 H (Address) 

SPEblAL INFORMATION on'y 

or Recent Residents, and persMS dying away from tiome. 



1y for fftspltals, Institutions, Trai 



Hours 
M.D. 



Former or 
Usual ResMrnce 

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



tV<^VV^>%' 



How long at 
Place of Death? 



TransieRts, 



>it Itays 



PI.ACK Ol' m RIAf. OR HKNfOVAI. 




Xi^ vLLlvn<x 



DATi%of JpiKtAL or RKMtJVAl, 

W^K^i l-^ 190H 




1 



CAddre«« 






O^CA/VWA,' 



,^L 



A.i 



^ -. ^ ,. . , , ^ .,«« .h«„lii be cai.«fttHy •upplled. AGB .hould b« stated EXACTLY. PHYSICIANS shoald 

•9it« dylnft away fro« Horn, nhould be given In every Inetpnce. 




I* 
I 



I ' 








WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

,„,,„, .,r „,.:, Ul,-|-s-o...^^€g»."'^>-Co REFtR TO B ACK Of CtRT.FICATt FOR IN»TRUCTION» 

396 



Registered JVo. 



X«^vv4 cUv^. Deputy Health Offii 

DEPARTMENT OF PUBLIC !IEALTH=City and County of San Francisco 



icer 



Certificate of Death 

{ "Cl. S. StanOarC* ) 



St 



PLACE OF DEATH: — County of ^ <^^ ^ >uaA^eA.4C City ofVlOAV ^ K^Xj^sj^la.^^^ 



o"'^'^ Lum^JL/>Otv%x^ St.; v^ Dist.;bct. i t4i and S tJhu 

V ir death occurred in a hospital or INSTITUTION Give ITS NAME INSTEAD Of STREET AND NUHUBKR. J 

ru V . n crviJLdu 



FULL NAME 




PERSONAL AND STATISTICAL PARTICULARS 




JhjCtx 



UATK t>F niRTll 



A«".K 



^W 



i Month » 



v^H r..,. 



^ 



ICl 



M.mlln 



Ahh 



'^ 



(Venr) 



Pff V.V 



^.ISr.I.K. MARKIKD. 
WIDOWKI* OR DIVoKv KD 

iWritf ill siK'ial lU— itfiialioti) 




^T 



ION fh n 

Resided h, San r,.u„i.u'n AjL^V'"'-^ " ^^'"^'^^^ ^"''•' 



1UKTMIM,A«'H 
(Statt- or I'ouiitry^ 



NAMK OI- 
FATHKR 



FURTHPI.AOK 
(U* 1 AT UK R 
IStatf or Country) 



MAII>1{N NAME i\ 
OF MOTHKR i ^ 



niRTIIPUACK 
OH MOTHKR 
(State nr Coutitryi 




THK ^noVK ST\Ti:n PKRSONAK rARTIi-fl.ARS AKH TRt K T() TIIK 

hkst of m\vknc>\vi,f:i><;k and mcMHi" 



(Infoiniatit 



(AfUlre^s . .4 9l O 




^xi/W»-^^-^^v^-A. 



MEDICAL CERTIFICATE OF DEATH 



DATE OF I)F:aTH A jj 

mA^U^ 

f](Monthj( 



n 

(Day) 



190 H 

(Year) 



J HKKlUiY C1:RTIFY, That I atU-inkd deceased from 
^JL^ JK^ 190 X to, Jifl-4^^^^ *^^ 190 H 



that I last 55aw h .*^vrv alive on 




n 



^UK I I 190 ^^ 

and that death occurred, on the <1ate stated above, at 
M. The CATSR OF DIIATFI was as follows: 




DURATION 0^ Years Months Days Hours 

CONTRIBUTORY 



DURATION^ Vcars Months Days 

(SIGNED) UA-^rt^^y^AVD UxiAiAitrvVi 



^aIuIV iqoH (Address) 5 IH^ITUxA^-Aj 
S-PECIAL INFORMATION only for Hospitals, Institutions, T 



Hours 
M.D. 

it 



Sl>ECli^L INFORMATION only for Hospitals, Institutions, Transients, 
or Recent Resi<ients, and persons dying away from home. 



Former or 
Usudl Residence 

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



How lonq at 
Ptareof Death? 



■• Days 



IM^ACE OF BURIAI, OR RKMOVAI. 



ini)f:rtaker 




Ud.l 



ress 



DATj^of ly-RlAl. or RKMOVAI. 



M • = . a . <i .« - -i.«..i<i h* c«rafully suoplled. AGE should b« stated EXACTLY. PHYSICIANS shonld 

N. B.— Every Item of Infopmstlon should be carovuiiy suppnew. .«««.^t«i i«ff^-«,>tlafi** ffai* nar. 

.t«teCAU8EOFDEATHI«plalnterm., that It maybe properly cLsslfled. The Special Information for per 

•ons dylnft away from horns should be given In svsry Instance. 




►' 





Jl,,;!T.1 .if lll.'lUh 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

- .. No .s *.?S3^»&I'C., REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



])(itr Filed J 




1 



ii 



IVO'i 



Re^i^itcved JVo. 



397 



LvJ ij^ Deputy Health Officer 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate ot 2)eatb 

( la. S. StanOarD ) 
PLACE OF DEATH:-County of ^ a^ ^J AXX.^vCU.'W City of Oav^^ OxavxCCACC 



i % 



rK\ 'y'\% "^t>-\.<.^<y\^ St.: ^ Dist.;bet. I -■J-V and .l.a\. ' 

(INC. ^ ^ V VV V> ,,.,,., BEBIDENCE Give r«CTS CALLED FOR ONDCll "SPtCIAL INFOKM.TION- -V 

( '^ rr^or.T^^o^Ju'.rcV.rrHO^.^"*.^ o"?^ST'.?u"o';"o.vr.T. NAME .nstc*o or .t.ccT ..o HUMBC«. ; 



) 



FULL NAME 



> xtx^^ \1 1 1 0L"> V >x\/> 



Xi 



PERSONAL AND STATISTICAL PARTICULARS 



si;x 



(^at. 



Ct)I.iJR \ . , 



i»\ 1 !■; oi niRTii 



ACIC 



ll.vkv 



(Month* 



O ^ ) ''(1 > 



iDav) 



Mnflths 



i Ve:ir) 



Ar 1 . 



SINCl.lv MARKlKt* 
WIIMtWin OK I>!VttKi'KI> 

W'titf in vii.i.il il( — is.Miati'in) 



niRTHIM, \*K 

iSt.ilt or l■olltlt^^ 



VAMl-: Ol 
l-ATHKR 



niRTinM.ACE 

Of- lATIlKR 
(SlaU or Country) 






«» 



MAIDKN NAMK 
t)J- MOTHKR 



lUKTHri.ACK 
ni- MoTHKR 
istaif tir Coniitryi 



OCCUPATION (^ 



Rr.sidfff iti Sail f'latnhi-o ) i ,n 



Months 



Ihis 



THK ABOVE ST \TT'I) rKRSONAI, I'ARTKMT .^RS ARlv TRV K To THK 
BEST Ol- MV KN<»'AI,i;i)«".K \M> Hl'ljll 



(Informant 




^V 



VOL >VCt-i.»i 



Address 53% % C^^.<.HX^.<A. 



MEDICAL CERTIFICATE OF DEATH 

DATK «>!• UKATH A \ 

I Hi: RUBY C1:RTIFV, That I attended dcccasea from 



(Yf.irl 



igo 



to 



that I last saw h 



-alive oti 



190 



and that <k'ath occurred, on the date statetl above, at 
— M. The CAl'SB OF DUATII %\^s as follows: 



DlkATK'JN Vi-ars 

CONTRinUTORY 



Mouths 



Davs 



Hours 



Jloulhs Ihivs 



Hours 
M.D. 



nr RAT ION Years Months Pass 

(SIGNED ) .L«Vfi>XJlV 

Vv^lc^ IS TQoH (Address) UT'UTtlIA^ I V> ^4. 

Special information only Icr Hospitals, Insti^tWs, 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 ^ 
Place tf Death? 



Days 



DAT^: of Ht-KiAi. or ri:m<>vai. 
1 T90 , 



rH 



I'LACH OK niRIAI. <»R RKMnVAI. 

l-NDKRTAKl-R Jv O^O^SJy\^ ^^ 'JUrit 

(Addre.. ...Sbh^- »H tkit 



- . <. , i. ij K- ^«—fulIir nuonlled. AGB •Hould b« •tated EXACTLY. PHYSICIANS •hiwlfl 

•«« dylut .way Iron, hom. -hould be «lv«. I« ...r» l».l.n«. 



I r 1 1 




li 



I-. 



i 



! 






!,,;.nl nf nu.!lh-l- No I^ ^-r.r 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

B EFER TO BACK OF CERTIFICATE FOR IN3TRUCTI0N9 

398 



nScv Co 



Dfffc Filed f 



Registered JSTo, 



Xi^.vti Deputy Health Officer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Ccttificate of Bcatb 

( "a. S. StanOarO ) 






vcaa ': 



PLACE OF DEATH:— County of CVa>Vi 

rffe.UNWvCLl) K.^^\XKQJL's\.^U ^^\\Km' Dist.;bct. 



City of ^' ^^>v U Aa 



^\ 



^ 



'^ t L^A\L'U3 i-vw-Cu ^ ^ i\ ^.m Dist.; bet.— — ^nd 

...VA) ^'^^-^^H^*-^^;H ,,-uAL RCsTdENCEGIVE facts CALLED FOR UNDER "SPCCAL . N FORMATION" \ 
( " ^F"o;:TH"oCC^fc^"t--'-' ^'T^St'^u'tU'o.VE ,TS name .NSTEAD of STREET AND NUMBER. ) 

i 1 (\A,^ 



) 



FULL NAME 



/yx^'wJu 



T" 



PERSONAL AND STATISTICAL PARTICULARS 



ii\ri; «)i' niKrn 



COI.(.K \ , i\ 



LL^vk^v'^^. • 



(Mf>ntlO 



At.K 



) til i 



l):iV» 



Mo'itlr 



I Vt-nrt 



n.i\> 



-IN*. 1.1*. MARHIKI>. 
WIDOW 1-1» OR I>IVnK».'Kn 
(Wilt! in -.'irirtl flt-Hij'nali'Jii) 



RikTirpi.ArK 

Stnti iir Con tit ry 



ll 



rwrw^vc - 



» 



VAMl- Ol 
I ATHHR 



Ml 1 ATHHR 
St;itf or Country^ 



MAIDHN N'AMK 
Ol- MOTIIKR 



niKTHl'I.ACl". 
<iF MOTHKK 
i?!iaif iir Country 



OCC? TATION 

Rfsidrd in San ri<i>ni'r<t 



«. 4 



*« 



IV, 



\f,H,fll' 



Do 



TUT* \^M^\■U ST\TKD PKK^ONAI. PAKTICl-I.AKS ARK TRl K To THK 
lUiST OF MY KNOWI,j:D<.H AND HKMKH 



MEDICAL CERTIFICATE OF DEATH 

DATH Ol- I>KATIl A 

ivvlu, I*' 

JM.nith* I 'I>"V' 

I III<:K1':BV CI-KTIFV, That I attctukMl (Icccasca fruiu 







(Year) 



I90 to 190 

lb at I last saw h alive on 19° 

and that death occurred, on the dale stated ahove, at 
\r. The CAl'Sfv (>!• DI'^ATII was as follows: 



I )r RATION years 

CONTRIBUTORY 



Afofiihs 



Davs 



Hours 



Afoul h; 



/)avs 



Hours 
M.D. 



DT RATION yr<ns 

(SIGNED) L#\^ry%JlK' u.Mj U^ AjlI^ 

- ^ 

%.JU\. \n iQoH (AddreHs) L^ryUA;^ ^^^ 

3P£^IA|, Information only for Hospttah, InstltatAlib, lr4Misleiils, 
or Recent Residents, and persons dying amy from home. 



4^ 



..»- 



Lcfcu 'i' 



Former or i r v 1 >^ 

Ijsual Residence vAAU, Ja^.4,t >\. 

Wlien was disease contracted 
If not at place of deatli ? 



NtwtMfat 
i^eof Deatli? 



Da^rs 



I'LA^K OF Bl'RlAL OR RHM<»VAI. 



H 



INDKRTAKKR 



% 



DATKof IltRiAL or RKMOVAl, 



T90*1 



<x 



^^ i(.du 



\< 



(Adilre<«? 



Sfclx - it^tk ■ll 



\ 



- * , K ij L L-^fttllv RUDolled. AGB .liould b« .t.ted BX4CTLY. PHYSICIANS .hould 

N. B. ^Bvery Item of Information .hould be carefully ««P»»"^?- ^^^^^^ cl.«»lfl«d. The "Special information" for p«r- 

•tate CAUSE OF DEATH In plain term., that It may be property cl.«.lfiea. ne op 
•on* dying away from home ahould be given In every Instance. 



r 



1* 




■'I 



I 



(' 



I 



if 




WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

,„„„ ,, ,„„„„ ... s„ ,„ ^■^>,K>.|.Co REFER TO BACK OF CERT IFICATE FOR INSTRUCTIONS 




\l 



190 '\ 



Me^istered JVo. 



399 



!)(f/r Filed , 

i(KXA^ "It/v^. DeP"*y Health Officer 

DEPARTMENT OFrUBLIC HEALTH=City and County of San Francisco 

Certificate of Beatb 

( "Q. S. Stan&atO ) 

SI % i ^ 

PLACE OF DEATH:-County of ^ a >V ^K a ^vCv^cChy of^lct-vv Ox<V>xc^ e 

( " r^or-ricc^RTcVi^r-o.^.r--*' r- ?»"?u" "'a.vc ,ts name ,n.t»o ». .t-.«t .»o «u«.c.. ; 







tHo, 



FULL NAME 



\\.U>JUlO^' 



XKX.^\. 



Km 



»1 ^L 



PERSONAL AND STATISTICAL PARTICULARS 

C<Jl,oR \ 



IiA I i: III HIKTll 



L 



L 



I 



♦ 



\<.l- 



1 o y.>n 



lb 

I Day) 



V, .»//// f 



III 



A? I 



stNr.t.i- M NKUii'.n 

W II » I V,\ J. 1 1 OK I > I \ « » k ( • I J) 

(Wtite in ^orial (U "ij-'iiiiti'Mi i 




lUK I iiri,\**i-: 

suiii oi iNiiniti V 



HATH J- K i i) J « y 



niK riii'i. \4i<: 



mmui;n n\mi 



flk I tll'LAi'H 
>t MnrillvK 

•■1 itr III i (iHlJtl > ' 



«•( I I 1' \ IIUN 







KrsiitftI nt Situ /'inrni >•> 



^fnllUl- 



l',,\ 



Tin- AHOVRST^T»-t) PKHsONAI. P KKTUT 1, \KS AHH »K» H H • TIIH 
HKHT r>l'* MV KNi»\VI,i;i".l'. AND HI I, HI' 



'Itifi.iiii-nil 



(j)vouuJL>- OXwvfL 



(\cl.lti« 



■T ■?, 5 



« 1 J. . \ 



\ 



MEDICAL CERTIFICATE OF DEATH 

DATK 0\- I)1:aTU \\ J 

,'VAjt 



(Ytar) 



Month), J <!>'»>•) 

1 HHKlvHY ci-RTII'V, That 1 altcn<U'<l deceased from 



\ >X- I igo'i to .^Y*-*|^ . 190 S 

that I la^t saw h alive- 011 ' ^ '^ '' ^ I9O ' 

aii<l that <Uath ocrurred, on the date state<l above, at 
- M. Tlie CArSI-; (»!• DI'ATII was as follows: 



\ 



DIKATION )\ars ^ Months Pay^ I/flurs 



Hours 

M.D. 






1)1 "RATION Years 

( SIGNED ) LI) ^i t > 



Minilhs 






WIm it IcKiH (Address) Iklld-u ^ ' W 



Special information ""ly '"f Hospitals, institutions. Transients, 
Of Rfccnt Resident;, and persons dying away from home. 



former or t a ir III ^ ^i ^ "®* '""" ** , 

Usual RfsMenw o ^ 5 KJ O.H " Hare of Deatli? 



Days 



When was disease roiitracted, 
If not at plareof death? 



I'I,Ae"K HI- m*RlAI, C)R R|;M<»\ Al, I DATK of HeHlAI, Of RKMoVAl, 
I NDKRTAKKR l^Wvtx^ iX^^^UUsXO- tViH^ 



t i. i I H. .nrofully •upplled. AGB .houW b« .tat.d EXACTLY. PHYSICIAtNS •hould 
N. B,_Bvery It.m of «"»»«-"«i,^"" •^'^^'^ tL«r»h»t H m„y be properly cl«.lfled. The "Specl.i l„foP«,.tlon- for per- 
state CAUSE OF DEATH In plali* terms, ti»»t it mn> J' » 
;»;; dytni .way from home should be Alv.« I" -.ry In.tanc.. 





f 



I • f i 





WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

RE FER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 

400 



Hi.-.Uh I-' N'-v I'' '^ 



hlUSil'O.) 



1)1 



,/eFiM, Liu ll 190H 



Registered JVo. 
XtAMJ. Deputy 3lth Of?l":. 

DEPARTMENT OFPUBLIC HEALTH=City and County of San Francisco 



PLACE OF DEATH:— County of 0(X>v J Vex 



Certificate of Beatb 

( m. S. StanC»arD ) 



.. V- 



No. 



cu 




U 



Rll UA\>a^.adL St.: U Dist.;bet. 

/ ,r oc*TH occurs .w.y rROM USUAL RESIDENCE give facts calleo ro« u 

( IF OC.TH OCCURRED IN * HOSPITAL OR INSTITUTION GIVE ITS NAME INSTCi 



,lv. 



^^x,\x.^v and L'^^wXl^ 

lyiiCR "SPCCIAL INFORMATION'" '\ 
j£or STREET AND NUMBER. / 



Av. ) 



FULL NAME 




WlJLv)!' 



* 



X-CtkT 



PERSONAL AND STATISTICAL PARTICULARS 



1)\ i i: i •! BIRTH 



COI.UR ^ 



\(,K 



-Null? 



JV.i 



ll 



n 

(Day) 



M.nilfl' 



( Vfar 



/)(/!, 



<!Ni.I,I'.. MARKrKI). 

U Il)o\\ KI» «»R DlVMKt'HIl 

■Wtiti'iii -MiciHl (Icit'iiatiiiiil 



!ni<Tin'l,\OK 

>t;it' i.r i'liinit ! V 



I ATHKR 



HlKTIIIM.Av'K 
<>l I ATHKR 
>l;it«- or Coinitry' 



<•! MUTHUR 



lUKTHlM.ArK 

Ml m«)ThI':r 

->UlM l»I k.Ollllil J I 



01 



I A 



^VWO 



o ^ ())1 



(^ a >v ^ 



U V 



w(XAXC\.fl,C^ 



Re^itlfii in San Fitiniist'it 



Yi si I 



^r.Hith' 



I hi 1 



Tin \n.)VK HTXTl-.n PKR'^ONAU I'ARTiril.XKS AKK TKlK To THK 
HHST <)1 MY KNi^WUHIXUC ANI) nHI.n',|' 



(Infoiniant 






MEDICAL CERTIFICATE OF DEATH 

DATE t»F DKATIl 

VI 

fDnv) 






I 



(Year) 



I II1:R1:1?V CI:RTII'V, Tluit I altcn.lt-l «kcca^ca from 

tbat4U*<t«llw hiv^w4f\jrK3ii0^txNj cL- ^ 190 

ami that dtath f)ccurretl, on the <laU- <tatcjl at)nvc, at b 

LLm. The CArSP; Ol' I)I:ATII was as follows: 



0'-V^-»^va.W\^ 'h.s^' 



- 0' 



Dl' RATION 
CONTRIIUTORV 



Yiars 



nr RATION 
(SIGNED) 



Years 



^louths 



AfoHths 



Davs 



Hours 



Pays 



C.i^! 



fVM 



t lours 



M.D. 



tqO 



( 



Address) WhS VCAlVt U. 



wPE^IAL INFORMATION »nly f«r Hospitals, Institutions, Transients, 
er iccent Residents, and persons dying away from home. 



Former or 
Usual Residence 

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



How lonq at 
Place of Death? 



Days 



ri.ACK oi- nr RiAt or rkmovai. 



u 



(Addresx 



^11 




V^CXX^ 



T 

tNDKRTAKER 



DA'/K of Bt «iAi, or REMOVAI, 



IVV4 



nV 



T90 



•* 




f^ 



.'1 



<Adclreis 






. , . u iJ K, ««follir •woolled. AGB should be stated EXACTLY. PHYSICIANS should 

"* ""S^t^Crul^of dTa't^I; P^^^^^^ ^;::r th?t U !;,t he p^ope... cf...f»ed. The 'Specl.. i„fon..tlo„'' »o. .•.- 
sons dylBA -way from home should be given In every Instance. 



. 



*i 



f 




r. 


1 


1 ' 


■ -^ 








IU( 



I 





^ 




i\\M 





WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



,„ ,:, r.1 uf n. alth !•• No. .^ -^^JSS^ »^'' ^'" 

l>al.'F!h:l, ^vvL|| ll 100^ 

vJ^ iiL/v'-tt'^®P"*y Health Officer 




Re^iatered J\''o. 



401 



DEPARTMENT OF I^llBLIC HEALTH=City and County of San Francisco 



Certificate of Beatb 

( "a. S. StanDarO ) 
PLACE OF DEATH:-Coonty of'^^OAV^.^^UVwCV^^O City of Clo^v^AawCi^ 



-D 



V. 



No. w^ y<\xo^ 



t XOX) U\\ 



cun« iw*v rnoA USUAL rtESIDENi 



Dist.; bet. 



and 



s ^ iieiiAl arSIDENCE GIVE r*CTS C*LLCD rOB UNDER "S»»tCI*L INrORMATION- 



) 



FULL NAME 



•1. 



PERSONAL AND STATISTICAL PARTICULARS 

.;kv a . I COI.oK 



" ^ 



WCXJ 

DATl-; nf- niRTII 



lJU^J^^ 



i M.-ntli 



\«,K 



gu' 



kXi 



5V.f» 



(Day) 



M.oilh- 



(Vtar^ 



Ai 1 .^ 



■^ISr.l.K. MAKkll',1) 
Wll>u\VHI> OR lHVOKiKU 
(Write ill stKMal clf.siffnatiuii) 



niRTHlM.AOK 

Si.itf or Country) 



NAMK OF 
FATHHR 



HlKTHI'l.ACH 
<)I- l-ATIIHR 
(State or Cotintry) 



MAIUHN NAMK 



mRTlllM.ACK 
OH NfoTHKR 

istatt' iJT CotiJitiy 



OCCl PATION A I 







) ,ai . 



\f,„ill>^ 



I hn 



THK ABOVR ST\TK n PKR^ONAI, !• \RTIi-T'I,ARS ARK TRfK To TlIK 
imST Oh MY KNOW 1.1.;U«-.H AND HKMl.H 



Informant \J/>vt^^>£tv V% 



p^xJlMS^^-^^*^ 



1 



>^4,V^^ 



Xajl 



MEDICAL CERTIFICATE OF DEATH 

I>ATK Ol* I>HATH A y 

(Month) i <I>«y) 

1 HHRliBV CICRTII'V, That I atte!nk'<l tlcceased from 

— to 



(Year) 



I9O 



that I last saw h 



alive on ' "•■^-•"•■'■"•■"" 



TT90 
190 



and that death occurre<l, oti the date stated above, at 
M. The CArSK OF DIvATII was as follows: 

nr RATION Years Months Pays Hours 

CONTRIIU'TORY 'OXt 



w'\^i-v,.C 




^U,^« 



:„o..' 



1)1 RATION 



1 

IpecI/ 



3- , 



Yf'ars 



AfontAs 



Pays 



Hours 



(Signed) ^ 'D lU dLcLou^i^uL LtfU^UA^ M.D. 



(Aildress) 



wu 






wiPEC'IaL Information on'y '*r Hospitals, InsUtNtlclns, Transients, 
or Recent Residents^ and persons dying wijf from home. 



,, t. r a, ", *0 



Former tff ,- „ 

Usual Residence vn^^o.^ 

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



How lti|ri 

Ptareof Death? 



Days 



fAfUl 



ress 



ri^^CK OK BlRIAr, OR RKMOVAI, I DAlJJ-: of IHRIAI. or RKMOVAI^ 

i \]Ao ^ %^^Lji.n T90H 

L-NDKRTAKKR TAXULu ^< '6\D<k%0^^\J 
(Address 3b.m-R m 3 



N. B. 



u iA K. «,.«fuilv suoolletl. AGE should be stated EXACTLY. PHYSICIANS should 
•Every Item of Inform.tlon •houtd h« -«;«»«'^y ft ««y be P-operly cl.sslfled. The -Special infowtlon" for psr- 
state CAUSE OP DEATH In plain terms, that it may oe v v>^ 
•oa« dylnA away from home should be ItJven In svsry Instance. 



U 



i 



4i 



II 



il 






•I 



ri|! 




Hoanl ..f Hc.tltlv 



-1-' N'o. It T?" 



U&PCo 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

WEFER TO BACK OF CERTIFICATE FOR INSTHUCTIONa 

,>al. FiM, Y^ '^ ^''^ ^ Registered A^o. 402 

X^r^-cus dU/v-M Deputy Healih Officer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Certificate of Beatb 

( Xi. S. StanDat6 ) 



J* <^i) 



Q 



PLACE OF DEATH:-County of ^ a^- ^Ix^-x c U '^ . City of n<X^ ^Kc^x^ 



n^ 






Dist.; bet. 



^^ and 



) 



( "/^;3S3:iii^^t''^H?;f4r.^^ .'«" .-r^p ..%%%Ti»"r:.Tr- ) 



FULL NAME 






^1 



PERSONAL AND STATISTICAL PARTICULARS 



^ ^icL 



n| lUKTH 



Ql\. 






\<.i-: 



Id 



)V,fi 



1 



(Day) 



Mritifh 



f 

r t 



1 1 a r 



/'.; 



^IN«.|.K MARKIKfi 
WHmWHU OR IMVoKi Kl) 

•Writfjii siK-ial clts»j^n;itii.n I 



iStiitr I.I ' 'untryl 



NAMK Ol* 

I' A r m; R 



OK lAIMIKR 
tStatt ur Counlry) 



MAIIU N NXMK 

«»i m<»iiii:r 



ul MiiTJlHR 

' M'M.K or t outitry ' 




h 







MEDICAL CERTIFICATE OF DEATH 

DATK i>l DlvXTH 

(I)ay^ (Yftu) 

I HI:R1:BV CI;RTIFV, TIuiI I atu-u.lca ac(xaMMl fr<»in 

— — — — ^go to ■ "~ »90 

that 1 last saw h ^ — alive on ^ '""' '9© 

an<l that .k-atli «.ccurre<l, on tlit- -lati- statc.l ahnvc. at - 
M. The CM SP: Ol- Dl^ATll was as follows 



A-^^ 



ot'cri'ATioN fy !| 



M.iiilhs 



lui 



THI-: ABOVE HTATiai I'KRSOVM, I'AKTItM'I.AKS AKH rKli: To TH K 
BKST OF MY KNOWI.ljx'.K ANP llhMHl' 



fliiforninnt 



(AddrcM . 









0\! 



At 



DIRATION years 

CoNTKinrTORV 



Months 



Days 



Hours 



DURATION ^ Years Mouths 

(SIGNED) . LcrXcvO^J 3 **Mu A»w.\ 



Days 



I/ours 
M.D. 



BPEOli 



I*- 



^•-.^w.r^.. INFORMATION only f»f ilospHah, Instil 
or Rfcent Residents, and persons dying away fr«iii tote. 



tibns. 



Former or 
Usual Residence 

Wken was disease contracted, 
If not at iilare of death ? 



Ntw lonq at 
Hare of Deatli? 



Transients, 



Days 



I LACK <»1 HIRIAI, OH KKMOVAI. 

- W 



C 



A'JxXAAj 




DA^'HoC Rt KtAi, or RKMoVAI. 

4 il T90' 



A^ a 




(Add res* 



^1 \'<x%v cvuA i-i. ^^ 



. .. .J h, .»«»«ll. MPOll.a. ACB .hould b. .«.t.d BXACTtV. PHYSICIAN* riw«ld 
"• "•-r.r/cr8E'0F°DE a"tS" : pt'n U.™: .HM U :."., H. prop.H, cl...lll.-. Th. "•p.c... l.f.r«....o-" ^ P-r- 
«:. d" » .«« .rom hon.. .hould b. tl » '-"•»«• 






1^ « 

« 



■I'li 



l)>l 



(>l 



I tf 



I i 



'*•" 



WRITE PLAINLY WITH UNFADING INK-THIS IS A PERMANENT RECORD 

^r~> „<L.PC„ ""•> -^^ ""^"^ "" CE BTIFICATE FOR INSTR UCTIONS 



190^ 



-MA^US 



njj^^^^^^^ Deputy Health Officer 



JRe^isfeved J\'^o, 



403 



l)((fr Filed. WK\ 

1 

DEPARTMENT OF? UBLIC HEALTH=City and County of San Francisco 

Certificate of Beatb 

PLACE OF DEATH:-County ofC)a^O;^.xC^Gty of ^-vx; 3 AXX..vC.A,CC 

Mo. \\ k *' Wi „.... oreinrNCr GIVE rACTS CALLED roR UNDER 'SPECIAL INrOBMAT^ON•^ ^ 



FULL NAME 







si:x 



PERSONAL AND STATISTICAL PARTICULARS 

COLOR \ , i 



ftl ' 



au^ 



liA I K <H" BIRTH 



X*.l% 




) ■#■(/ » * 



I 



11 



M,, II I In 



\ », 



fS'ear) 



1 1 /'" 



l.s 



HIXC.l.R. MARKIKt) 
Wir>c>\VI-*!> OR DIVOKfHI) 

\\ii!< in <«iu'ia! d<'-i^Miat ion • 



niR rui'i.ACK 

'•^I'lTi fir Country I 



At ^ 



MEDICAL CERTIFICATE OF DEATH 



DATK ol- DKATH A jj 



i 

-^-/ 



Month), 



(Day) 



(Year) 



I4II':RI':BV CHRTIFV, That I at^e!i(U-«l (Urtascd from 

i^^Lu 15 loo'i to HrvJUtil ^ooM 



alive on ^"^^"^H 

U 



that I last saw h ^ ' 

and that .U-ath occurred, on the d'ate stated a!)Ove, at 
U M. The CAl'SI': OF J)I':ATII was as folL.ws 



190 1 

H 




V^'SxS^K '^ . ,: 



VVMI-: Ol- 
I A iin:R 



O! ixruHK 

■>i.it c or Country) 



MMUhV NAMH 
01 .M«»THI%R 



lilKTlll'I.Ai K 
01 MOTHFR 

' •'litii III i ontitrv' 



l^^J 



v\.ukxKaa, 




(I 



/7) 



td'U^^'vVCL^v^CL 



),■,/; 



\ri,iitfi- 



n,i 



01 ( tl'ATlOM 

Rfu'dfd III San /ntm/n'i^ 

THHAnoVKSTVn-nPKUSnNAl.rXKTirrKAHS A K 1^ T R r I- T. > I" HI- 
nKST OF MY KSOWIJUX^H AND HUIJlvl' 



(Informant 



( \(Mn'HK 






I >r RAT ION }'<ars 

CONTRIBUTORY 



M(>tt//is I ^ /)ays Hour 



Dl'RATION 
(SIGNED) 

It iqoH 










Moulin i^ /An'.v 



^. 



(Address) ^Hb 



OvW^ttca^ 



Hours 

M.D. 

I 



SPECIAL INFORMATION only for Hospitals, Institutions, Iransients, 
or Rccfnl Residents, and persons dying a<*ay from fioi»e. 



Former or 
Usual Residence 

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



How tonq at 
Place of Death? 



Days 



^ • n J- r 



IM.ACK qi' BIRIAU OR RKMoVAI. 



a^Kj 






DATI^of ntHIAl- or KKMOVAI, 

" .L 1 1 190H 



V-i 



(AdKlrt"*" 



^ b 1 \/ rlA.^.A^.HrY' 



u 



^■^^■■^— — ^ "^""^^^^ . „ . 7rH .hnuld Im fltated EXACTLY. PHYSICIANS shottld 

N.I..— Bvery U.m „f .n.o.n...lon .hou... b. c„«»-n, .-PP".-- ^^^^.'X^^,,:;!* Th. "Ilp.cl.l ln»orm..l.»" fo, p.r. 
■talc CAUSE OF DEATH In plain term., th.t II mp» ne P™P«'- » 
:". dy.»i -w., from hom, .h..ld b. ».«. .» .v.ry I»...»«. 




it! 



I 



I 






WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOB INSTRUCTIONS 




Hii:irit 



I hit 






y X 



190% 



Bc^islci'od JS^o, 



404 



-LtrM.^^ .<v'i.-M 



Dcr 



^i^t. ,*^*<^„^^ 



DEPARTMENT OF I^UBLIC HE ALTn=City and County of San Francisco 



PLACE OF DEATH: — County of 



^Ne.UVJ-x^ w\^^ 



Certificate of ©eatb 

i "0. S. standard ) 

a^\ 'n<^ -\ev4ceCity of a^vuA^ 



m 



-^ I "^-,. ^ St»: Dist.;bct. ^^^ . 

^-^ ^^ - w^ - ' • «i.«,Ar*irr r.vr r.cTS callco roR uNorR special information \ 



FULL NAME 



-r\ 



PERSONAL AND STATISTICAL PARTICULARS 

."I .1 1 »K 



ri"\-, 



KTH \ 



VV >V K N ^ 



iN! 



.\^^" 






lUKI'in'! \<v 



» ATlll R 



lUK rnn. \\ v. 
i>l I \ ruKK 



<«1 MnillJ.tH 



niKTIIlM.ArK 
••I MnJHHH 

14. li • t .1 I 1 III Hi I 



MEDICAL CERTIFICATE OF DEATH 






\ 



s% 



1^ to 

Ihnt llaM -nn It Mive on 

nti-1 thn< .Wath rMMMirr.Ml. .-n the .Inti stati-! :i1...ve. n1 
M The C M ^l'. m IMATIl u fnll..\ss 



iVr:ir^ 

IQO 






M^'tiihs 



Pavs 



Hours 



>)< f ri 



\ri()N / 



ff'tntrif nt Snti /tiin.mti 



}V,n 



V.o'ffi 



Ih 



i'.i:m- <»i my KN<>\vi,i:i»<.r \ni» t-> i." ' 



I 



\f1f1fr ,«* 



(SIGNED ) L0^(^V'%X^ 



^ror/fAs 



/>:n 



^^UiU.- ' 



M.D. 



U n^H (AfMnsH) 



I ^'1 >■ , V f 



itecF 



Special information on'y '"^ Ho^puti^ iiismttHtHi^. Traitsifnts, 

or RfffBl RfsMenl'*. ind persons iyliif twiy frwi iMwe. 

UsatllleiMwee"^^ ^ '' 

HHfd wts dHfa^f fontraftrt, 
If ii#titMaferf<f^? 



iHttw ionq i\ 
^reri fteitli? 



Diys 



pi^ACK OK nf Ri\r. MR Rr%f<.v\i, 



C!>^t, 



190 



H 



I NIiHRTAKKR vJ 




fi 



t^SVi'n' HrMi,%r ."f Ri:Mn\AI, 



A,^A. v%vO 

V- 



r\.-. v4 



V* 



■■"'■''^■■■''■'■''''^■■'''''■■^■■■■'■''^■''''"'''■'■■'''^"■"'"'^^ .H^,«lfl Im atAtetf BX4CTLY. PMY«ICI4N«I ahould 

N. ^~llv.r, ...». of .nfo,».«..o» .H.u.H he c.,..ul., .upph.- ,:^X7.,..Vf.:i? Thf •Rp.cl.. ,n.„.n.,.l»n" for p.r. 
.t.1. CAUSE OF DKATH In <"/^'';;:'l\:^:'J'S^l ^.',Z. 
Mil* dyllit ■»•» f'O" hom. otKMtd he »l»»n •" •»• ' 




'W 




WRITE PLAINLY WITH UNFADING INK 

n.,ar.l of lUulth-F No n ^^^^pH&PCo _^_^«, 




WO'i 



THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 

Registered JVo, 4Uo 



])(tfr Filed , 

DEPARTMENT OF ^BUC HEALTH=City and County of San Francisco 

Certificate of 2)eatb 

PLACE OF DEATH:-County of ^^ O.^V Xa^vCUtcCity of '^' O^ J VOA^C^A/tX 
■vAxWWs ilM^lvvXav St4 — • — Dist.;t)et. and , 

1 J „ ••eitAi DremrMrr riwr rACTS CALLCO rOR UNDER «^tC««L IWroRMATION 1 




) 



FULL NAME 



.C ell 




VOLWV 



\\.K, 



<L 




SKX 



l»ATi: Ol HlKTll 



M,K 



PERSONAL AND STATISTICAL PARTICULARS 
\ I COI,OR 



CL 



L 



\)ikdu 






% 






),,ti 



It 



1/.I///I/. 



AIL 



XL 



I Year) 



An 



•«fN<.I,r. MARKIKtV 

u irH»\vi:i» OR i»fvi»Rti:ri » 

W titc ill »i<HiHl clf»!$r»i:»t'"''' 1 I ^ 



Hlk TlltM.^OH 



V«.MH OF 

1 ATHKR 



niRTHI'I.ACK 
ni lATIIKH 
(Stiitfor C«»utilry) 



MAIHKN NAMH 
<tl MmTHKR 



lilK I IIIM.ACK 
»>l M<>rHKR 
- »UM iiT * •itiiiir) 






ll 



1 



\ 



Rfstilfit HI Situ /mm If.' 3L I )'" 



1- 



^/,,nf/l' 



lhl\. 



THK ABClVK STATKD PKRSONAI, I'AKTirT I,AR*4 AKH TKli: Hi THH 
BEST OF MY KNiJWI.l In.K AMi lU Ijrj- 



( ItifftfTiiaiit 



ft 



(AiWres* 



1L%S 



I 



1 " n 



MEDICAL CERTIFICATE OF DEATH 
DATE OF DKATH 

lMonth)i fDay' 




(Year) 



that 



I JII:ri:HV CI:RTIFV, Tbat I attended deceased from 
I^Jki I T90H to ^^V^. lip 190H 

saw \iX/yY\ alive on 1 t^MJ ' ^ 19° ^ 



and that death occurred, on the date stated alwve, at 
M. The CAt'SK OV DICATII was as follows: 



J Cv^^VWT'W.O^ 



n 



rs 



IH RATION - Years 
CONTRIinToRV 



^ tvb-CVCL4. U-4A^ 



L Months ^ Days * I/ours 



nr RATION )V<7r5 Mouths 

(SIGNED) lLLUju^ 



Pays 



//ours 

M.D. 



ImXu n iQoi (Address) J I' l X MjUaAa^^ 



«v,-^^IAL INFORMATION only t«r HosplUls, Institutioas, TrM^Ol^ 
tr limrt tesMeits, ind persons ^yin^ i«»»y from Nne. 



TmWIn 9f 

Usual i^sMfflce 



XLa.ft-^^C*.' 



narcff l»e«tt? 



Days 



Hiea VMS IhoM CMlractd, 
If iiMatplire«f4eitti? 



PI.ACH OF Bl'RIAl, OR RKMoVAI. | IIATK of IltHiAL or RBM<JVAI, 

'^ -^ ' Wh ''^ 190H 



W 



\?yL4^ 



<Xt^rru 



A ^ 



t) 



I'.NUKRTAKF.R \1 /Q.^\t^l^lJAj . _ 



<Atldre«« 



^- .. - . u 1^ !.• «...f«llv .uoDllcd. ACE •houM b« .tated EXACTLY. PHYSICIANS .hoiiW 

■«» drlnt away Iron, hem. .hould b. »lv.» In .v.rr l-.tanM. 




♦ 



II f 



!i. 



I|» 



I 




• ■■ -I 



i 



■« 




. i 




WRITE PLAINLY WITH UNFADING INK — 



1 i It ., 1 1 h - F Vo 1 1. •tS"^^^r^) H&. 1' Co 



/>r^/r Filed, 





\% 



190H 



THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 

Registered ^''o, 4UO 



J^^^h^KA ijU>U. 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of S)eatb 



( Vi. S. StanDarD } 



-P 



(Ji^ 



PLACE OF DEATH:— County 



of d -CU-»-V J X a ^ \ C*.4.cc City of '^' ^^^yy^ ^ K<V'\x.<l V4 C c 



^o. 



't 



xct^t4 



lb H^ k ci ^ 



St 



Dist.; bet. 



and 



( 



''^;:fi^::r;; -- i^^t ^^^±^^^^^- ^if^^^" -i^ri^-::^^r; ) 



FULL NAME 




<x\X4'va; 




,CC'VV ^) Cw"^-^"^ 



PERSONAL AND STATISTICAL PARTICULARS 



-•i;\ 



^ri 



V f 



C<>1,«»K 




Vt' 



iiATK <•» lUKTII 



'.<.l- 



M. mill I I 



*.IN«.l.l' M KKK III). 
WllmU KH OK niVoRfKH 



) ■.„ , 



n.iv) 



M'utti 



(■j'l-.ii 



Pii 



^\ 



\\\V KWVX.WV. 

-1 !. (if c'iiuilll V 1 



NAMK Oi- 
1-ATHKR 



lilHTm'I.Ai'K 

<M I \ rnKK 

■^l.ii* i.f Ccnintryi 



MMKIN NAMH 
Ml Mi»rill%R 



lUK 1 Hi'r.Aij': 



,n 



Co 






. 4 



'^ 



0.vt 



CXXC6 



La^ 



vO. J 




/^ urn 



MEDICAL CERTIFICATE OF DEATH 

DATK <»»* UlvVl'U 



u. 



fMotltljl 



lie, 

!l)av' 



I go \ 

(Yc-art 



,1 m-RI-HV ClvRTlFV, That I utjjcn.le<l acivasca from 
^kAA'Nj^ 190 H to. 

tliat I last sa%v h -^^-^ alive Oil ^^^-^-^^i ''P 



X 



t 



lb 



iqO H 



an.l that death occurred, on the date stated above, at I A 
M. The CAr^SI-: C)F DICATII was as follows 



:'^ 






I '^« 



> \\_0^ 



« I 



CI. NVC 



.^ 



nr RATION I Ycar^ ^- Miyut/is Days 

CONTRIIU'TORV v^L-iA- i\..i- v^'>^ <Xj 

DT RATION )'rars Afonf/is Days 

r SIGNED). Hlnv^w Uj<xa>\JL?w 



* I louts 



/fours 



\/ZAjCL 



M.D. 



urctl'ATIoN 

fCrsiifz-if III Situ f'tmi, If* I J ^ •'"' 



%/,„tt/i> 



/hlV 



TIIK Am.VKSTATKf.l'KKSoNAI.IXKTI'TI.XK-AKKTKrF Vn TlIK 
IlKHT Ol- MA! KS«tSVlj;iM,K \M> '*' '''^^ 

(t.,f.,„„„„. ^.vcuAAJk U-a-vv -I cv.'iA.t 



rAdilrc<m 



S^ECtALINF^RIVIATION flnly 'o^ Hospitals, Institutions, Iransients, 
or Recent Residents, and persons dying away froai home. 

Former er ai <5l . |i 4 ^ %h !?*' '•? V* .. , ^ n 

UsMal Residence 3 Wb 1 1 AJ'Aj OAj WareofOeatli? Oiyi 

When WW disease contracted, 

If no! at place of death ? - - 



IM.ACK Ol' lU KIAI, (IK KKMfiVAI, 



tJATKof UvHlAi. nt KKMOVAI, 

HvaXu t'\ 190H 



H 







■""■""""'"^ ATP .Hnultl ha «tateil EXACTLY. PHYSICIANS aliould 
N. B.— B..r, l..m ol In.ormMlon .ho„ld b. c.r.fuHx .uppl .d ^^"p^:;'?;.''..^!.."? Th. •■.,« for™....o»" for p-P- 

.MM CAUSE OF DEATH t» pl.I" «""«.. •""'«"•"» ,„„"L°^.. '^ 

«m< dyt.t »r.y Jrom homo "hould b. ftlvn ll. .v.ry lo.t.nc. 



II 



11 



11 












|!,..,!.l • r ll'-ll'l' I-NO. !«. 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



. Hit I' Co 




\\ 



190^ 



mirFiM, -■' - '•"- Begistered ^0. 407 

Xcr^cC^ Xix^-u Deputy Health Offlosr 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of 2)eatb 

( Ta. S. StanOatO ) 
PLACE OF DEATH:— £o«rt,=trf , ! ' ^ ^ ^ty °f 




.d 



V^vO'-CL'^aa 



No. 



St.; 



Dist; bet. 



and 



,.-,,., or«:iDCNCE Give facts culled roR under "special information- ^ 

( " r/r»T°H"c"u%*."V,'""„o""p"*t o"T«""o -"vt ,T. NAME ,N,X»= C, .T„CT .NO NU-.C >» 



FULL NAME 



i:\ 



PERSONAL AND STATISTICAL PARTICULARS 



I>AI K OF HlKTIl 



\<'.l' 






\ • 



iM.>iith> 



J 'ra I 



IU.1 



I Day 



M.iiiHi 



\ 



\ 



( Vt-art 



Ihr 



WIHc)\Vi:i» OK UI\'MKrKt» 

iWritt in mkuiI «U'sif imlion) 



lUKTitn.Aoi-: 



1 A iin;R 



niRTHPl.AiH 
Ml- I- A I'll KK 
Stall nr C«)»uitryi 



MAinKN NAMK 

t)i M(iTni:R 



HIRTHIM^ACH / 

OF MOTIIFtK / 

(Hiatf (jf Ctnintry 




MEDICAL CERTIFICATE^ OF DEATH 

DATK OF I)F:aT11 \ 



(Year) 



(Molith) •l>:*y^ 

TTiSkHV C1';RTIFY, That I atttnilcd ilcceased from 

190 to ^90 

that I last saw h alive on '9^ 

antl that death occurrca, on the date stated above, at 
M. The CATSIv OF DIvATH was as follows: 




ov cr FAT luN 



7 



Re„d,',t h, Sa„ l-,.u,.f>r,> " Jn?/^ '^ M,n,1h> 



I his 



THH ABOVE STATF.n I'KRSoN^I. rAKTrcT LARS ARK TRFK To TIIK 
IlKST OF MY KNOWJ.IJX.K AND HFMF.F 

(Inf'.rmam \ J fV(Xytr\j ^ ■ Uw D ' 

1^ a •. 



Dr RAT ION Ytars 

CONTRIBITORV 



Months 



Days 



Hours 



DT RATION >V(//5 



Months 



/ftjvs 



(SIGNED) 'i ^ "^ MU 

"^U^A-iw'X !t)oH (Addre ss) MHa.%\A-L< 



Naurs 
M.D. 



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



Former or 
Usual Res' I'-e 

When WIS disease contracted. 
If not at plar c of death? 



How Itnf tf 
Plareof Death? 



I^s 



;U,ACK <>F BIRIAI, OR KKMoVAI, 



(\Mratm 




1 



J-u 



Q 



s \ . >n 



t* ni)i:rtaker 

( Add r CSV 






MATKof m-RIAL or RKMoVAI, 



tQO' 



. . ». 8 ii„ »„„,»lted AGE .HouW b« .tated EXACTLY. PHYSICIANS should 

N. B.— Every Item of lnform«tlo« .hould be c.pef-Hy •"^PJ'^J* ono,^rtr"l. Jwted. The 'Specl.l inform«tlo«" for p.r- 
•tate CAUSE OF DEATH In pl«l« term., tha It mmy »- property ci.-im^l. 
•Of., dying aw.y from home should be given In .vry In.fnce. 





I 

I 

ll 




WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



nn;ir« 



„nUnUU- FNn. i=-f-^^vH&I'Co 




w 



\% 



190^ 



p/t/r FiJcd . 



Registered J^o, 



408 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of 2)eatb 

( tl. S. StanDarD ) 



PLACE OF DEATH; — County of 



"VJlty Of 




^tV 



No.- 



St.; 



-Distjbct. 



- and 



-) 




„ ^„^». lieilAI RrSIDENCC GIVE FACTS C*UUCD FOR Uf 



UNDER "special INFORMATION" 'X 
D OF STREET AND NUMBER. / 



FULL NAME 



1 1 V^v 



XJJJ 



.44- 



SK\ 



PERSONAL AND STATISTICAL PARTICULARS 







i-ATi: t)i- niKTU 



\<.K 



I I 



Month' 



Kfifi 



I Day) 



Miiulh.^ 



/ 



'Vciir) 



/)</! 



'-INr.I.l-, MAKHII-.n 
iWiitciii <^i>oial dt «.it' 'i:it i< iti) 



MiKruiM.xoi-; 

'St;iti' or Country' 



NAMK OF 
1 ATHHR 



niKTHri.ArK 
t»i- ivrnHK 

' St.it ( III Ciniiitry) 



MAIDKN NAMl 
n|. MOTHKK 



liiK ini'i.ArK 

(It M< »'I"M %'U 

I state iir tNmntiyl 



(UCr I' AT ION ^ 




MEDICAL CERTIFICATE OF DEATH 

DATK Ol- DKATH (" 




(Motilh) 



(Dns-) 



I go 

(Year) 



J 1H':KI*:HV CI';RTII'V, That I ntton.kMl <leceased from 
tgo to 190 

that I last saw h ■ alive on ^9° 

ami that death occurred, on the <late stated above, at 
M. JThe CAl'SI': Ol* l)l*;AriI was as follows: 



Rffidci ni ■><"' / 1,111, nrn 



)'ini 



M„iitln 



fhi 1 



THKAnovr. sT\Ti.:n i-hhsosai, I'XRTicti.xKs ark trih to niH 

IIKHT 111- Mvi KN«»\VIj;i><.l'; AM> JUJ,n> 




\ 



DTR-ATION Years 

CONTRIIUTORV 



Dl'RATION _ Years 

7i i^ 



■\fon(hs 



Pays 



Hours 




Mouths 



l^avs 



(Address) \1 l\(XAV^'la. 



Hours 
M.D. 



(SIGNED)' 

V '^ 

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



iqO 



former or 
Usual Residence 

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



How long at 
f»lafeof Death? 



Days 



ri.ACK OF niRiAr. hk khmov.ai. 



■V 



A 



T90 i 



« i 




I NDKR TAKF:R 

(AddreKS 



DATK <'f "'"'*'- *''■ KHMi»VAI, 



\L 






. u .IK „.-fullv «uoolUd. AGE should Iw stated BXACTLY. PHYSICIANS should 

N. B. Every Item of Information should be cHrefully ""PP"*^' „CooeH«. classified. The "Special information" for psr- 

state CAUSE OP DEATH In pinin terms, that It may ^e properly classified, 
sons dyl«4 away from home should be given l« every Instance. 





I ^^f 






I t 



l« 





WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

REFE R TO BACH OF CERTIFICATE FOR INSTHUCTIONS 

409 



,f U...I1I. I'N'" ! ^ -^-t^S^- »■""' <-■'■> 



.iwviu 1 1 



190\ 



Dale Fih'il, sj^wvu. 

itrV^vA \ju\^^ Deputy Health Officsr 



Registered JVo. 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of Beatb 



( Vi. 5. StanDatD ) 



PLACE OF DEATH: — County of 



-City of 



\ lu 1^ d voA^xcx H cv l\ -a. > 



No. 




A) ^CHilfV^taA: 



St.; 



Dist.: bet. 



and 



C FACTS CALLED TOR UNDER "SPECIAL INFORMATION" \ 
.--. KiAMr iMC-rrAn or STREET AND NUMBER. • 



"( ™^.^l^;!R;:^rJ:^^t ?^?^?^?^^;^';;i ^- .^^- S^^EE^ZNONUMeE. 



FULL NAME 



PERSONAL AND STATISTICAL PARTICULARS 



•^IvX 



lUo^U 



COI.'tK 



I 



\>\\K 01 lUKIH 



A(,H 



H)xc 



(Month* 



1% JV,,/< I 



(Diiv) 



}f,>itt/{^ 



I ■« t-ai I 



A/i.* 



-INt.l.K MARKIKI). 

\\ l!Hi\\ 1 I> (>K Il'^■<»K^'K^ 

(Wiittin MKial (U">i).'iiali<in) 



'>x a 



UIR rUPl.ACK 
stall itr (".iiiiitt y 



FA I'm: R 



nrKTni'i.ACH 
ni- I \rnKK 

(Statf ..! i".)iintry) 



NfAlUKN NAMF, 
<•! MoTIIKK 






HlKTm'I.Ai'H 
(Stall i.r voutiliN 



<H cri'A rioN 






MEDICAL CERTIFICATE OF DEATH 

DATK OF I>KATH A 



I Monlh) 



fJ 

I go \ 

(Year) 



(Day) 
\ m{Ki:r»V CT-RTIFV, That I atteiKkMl dectasoi from 

.— ■ 190—— to -rr-^^rr-^^-- :^.I90 — 

that I last saw h •■ alive on — ^^^^^ 190 

mill that death occurred, on the <late stated above, at -^ 
M. The CAl'SF. OF' Dl^ATH was as follows: 



I )r RAT ION Years 

CoNTRII^L-TORY 



Mouths 



Days 



Hours 



I ft 

Addrt-ss) VlytrKH 



Hours 

M.D. 



DURATION Years Months Days 

(Signed) v- '^. yv 

^i v^VK. 1 iQo'i ( 

SPECIAL Inform ATI ON «nly f«^ Hospitals, Institutions, Tfansleots, 
or Recent Residents, and persons dying away from home. 



\cv^>\a- ^ 



J . 



t4v\^ 



/', 



THl', \n<>VHST\Tl-,n l.KK^<»NM.l'^«'l""' ''^"^^ ^'^'■■''■"^"''* '^'* ' ' *"' 
nivhT OF MV KN«>\Vl,i:iH-,l--, \M» Hl•,IJ^-^■ 



'Iiifijtmant 




Oju^ C.LL • • -^^ 



f AlllllL SS 



AHi 



CLV- "? 



Former or 
Usual Residence 

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



Now lonq at 
Place of Death? 



Days 



I'l ACK OF lURIAIy OR KFMoVAl, 



t NDFRTAKK 



IJATH<J!' UlRlAi. or K KMCIV.^I, 

il 190S 



1^ %x\X 



■tatc CAUSE OF DEATH In pl.ln term., that It m», h" n^P""' """""<'• 
■on. dylnt away Irom hom. .hould b« ftlv.n In ..ery Instance. 





II 




III 







i 




WRITE PLAINLY WITH UNFADING INK 



,,,,.nl ..f H. nllh-F Sn. ,. IS-gg^. P.M' Co 






Dfffe Filpfl , 



<wLii \\ 



:| 



lOO'i 



THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 

Registered J\'o. 4x0 



l,.c^"^ia^cuDeputy Health- or 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of Death 

( -Q. S. StanDarC» ) 



PLACE OF DEATH:— Cotmtr- 






€itr-trf^5l'0^^ 



I % I 



a 



v%d 



St.; 



Dist.: bet. 



and 



loll 



FULL NAME 



r^X 



C^^xjU. 



sKX 



PERSONAL AND STATISTICAL PARTICULARS 
A - ' COU>K 



ll 



I 



( 



i»\ri «>i lUkTii 



M.V. 



Vl 



>x 



r 



Day 



Moulfi^ 



i Vt-al I 



Pit 1 . 



'^IM.l.K MARKIKIV 
\VIIM»WI*1» i»R IMy«»K»"KI> 

Writf in ^•■tiai <U *ii'iialioii) 



vt nt .,r C*»unli > 



MEDICAL CERTIFICATE OF DEATH 

DATK OJ I>i:aTII A 



(Day) 



(Year) 



I IIHRKBV CI-RTIl'^V, That I attciulcl <k-(HascMl fruni 

— — — — — — " ri ^o ~~~ — to ■•• ^*P 

that I last saw h-^TT-— Tilive on — — 190 

an. I that ckath occurreil, on the .late ^^tatt-.l .ibove, at - 
M. Tile CArSI* (M" I)1;ATH wa-s as foll.nvs: 



X 



VS.'^M^'v^^W.vv 



N\M! Ill 

J-A III !;r 



niH TinM.Ai'K 
«>l 1 ATIIHk 

istatt or Cotiiitry 



MMDJ N- NAMK 
.tl' MDTIIKR 



/ 



/ 



/ 



inUTlllM.Al'K /' 

i . w ^ m . ^ *r* ****** ^ 

f*»t;i\t )r Countryt / 



/ 



A'ftiiifif til S,ui /iinh I,,' i,a>f 



occri'ATioK r\ 



THKAnoVKSTATKDI'HKSCNAI. I-AKiri-r LARS ARK TKrK T< » THK 
nKST Oj- MY KN.iWI.HlM'.K ANI> HllJI-.f 



tnft.nnaiit \| rXCXvIl^ W ■ U^ '^' 



r\ 



I )r RAT I ON yc'J'S 

CONTRiniTORY 



Montfi.i 



Pays 



Hours 



DIRATION 



Years 



Mouths 



Day 



(SIGNED) A Xl S K^^^4- 

(AiMrcss) \l i la^XXUX ' O 



I /ours 
M.D. 



tqo 



SPECIAL INFORMATION «n'y <or Hospitals, Institutions, Transients, 
Of Recent Resident*;, and persons dying away from home. - 



Former cr 
Usual Residence 

Wlien was disease contracted. 
If not at place ol death ? 



How lonq at 
Place ol Death? 



^s 



PLACF. .>l lURIAl, OR KHMOVAI. 



DATK of ill RiAi, or RRMt»VAn 

xxvu 1^ 190 



(AddreHu 



N. B.— Bver^ Item of Information .hould he c.r-fuH^ ««^P"*^; ^^^^"^ ,,„.,f|ed. Tl« -Specl-I l«for«.llo«- for pr- 
•tate CAUSE OF DEATH In plain term., «*»«'*"';* |„.t.«ce. 
son. dying away from home .hould be g.ven In .v.rjr In.taac.. 



VI 



. I: 



i 



1 




n 



WRITE PLAINLY WITH UNFADING INK 



H„a,.l..rH.a!lh r No is^^^^jS^PCw 



Dn 



fr Filed. %^tu \% 

A^vtVO ^vtAMi De 



IDO^ 



THIS IS A PERMANENT RECORD 

Hg FER TO BACK OF CeRTIPICATE FOR INSTRUCTIONS 

Be^istered JVo. 41.1 






DEPARTMENT OFPUBLIC HEALTH=City and County of San Francisco 



Certificate of Beatb 

( •Q. S. StanDarD ) 



PLACE OF DEATHt — Cuuulf of V.XL^^^^ 



}^^ 



% 



\lflL>Vcl 



vO-lvuA, City of M lU->va.<x>vxo 



No. 



St.; Dist.; bet. 



and 



(ir OCATH occurs AW*V FROM USUAL RES 
ir DCATM OCCURRED IN A HOSPITAL OR I' 

FULL NAME 



iTdENCE GIVE rACTS*CALLED rOR UNDER "SPECIAL INFORMATION" \ 
NST.?ut!oN 0%E ITS NAME INSTEAD OF STREET AND NUMBER. J 



L rvt^ tx'x' 



i 



Lsj^^^^xy\M 



PERSONAL AND STATISTICAL PARTICULARS 



•-HX 



C«iI,<»K \ 



DATK Ml IllKTII S f, 

Ll^>^K ^'VC-V' 



M.>^lth^ 



Ar.H 



) til > ' 



il)ay> 



M.niUi 



/ 



\ \ rar) 



l><t I 



>>TNt.l.K. MARKn:i> 
UIlMiWKIi OK niVMKfHn 
tWrilf ill ".m'ial «l«'-«i'.'ii;iti'iii) 



HIRTHlM.Ai'l-: 

•Slate tiT Cotiiili % 



MEDICAL CERTIFICATE OF DEATH 

DATK nl I)1:ATH 



(Mi'iith) 



e 

<I):iy> 



TQO 

(Vt'ar> 



NAMIC <»!• 
lATHKR 



HIRTHPt.ACK 
1)1 I ^THKR 

I si:i! . ur ruinlt V 



MAIDF.S NAMF 
nl MoTHKR 



nfKTHPf.ArK 

I U' \T« >TII |,"U 

tStat*' .Jt Coutitry> 
UCCri'ATUIN 



^ 




ffrsiiinl ill Situ fiiiniiu- 



)>,n 



}r,',irh 



ih 



1 IIi:Ri:nV CI^RTIFV, That I attenaed .K-ivaso.l from 

-r--t-rr — ■ — I90 —to • ."I9O 

that T last saw h " alive on -—— — — — ^ 190 ~ 
an.l that .Uath occurred, ott the date stated above, at 
M. The CAT SI*: ()!• DIIATH was as folk ws : 



1)1 RATION Years 

CONTRIIU TORY 



Mouths 



PiUS 



//ours 



DURATION 
(SIGNED) 



)'C(ir.s 



A/ont/is 



^XlAjJb^K^ 



/yavs 



//our 



M.D. 



Uk^U,^ IQOS (Address) A\\(X^XkX^. ^ i 



x% 



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 lonq at 
Place of Death? 



Days 



I 



FWLCK OK niRIA!, OK KKMi»VAI, 



^y 



% 



U)k 



nATKof llrRiAL or HKMOVAI, 



Kv.t,, ft 



rNl>l<:RTAKKR 

(A(liSnss 






\ 



THK \noVE STATHI) PKKSONAI. rXRTKri ARS AKH TKIK T« » TI!K 
BHST OF^Y KNnWMU><;K \NI) HJ I,!!-.!- 

(Aa«rr.J^ 1 % g^ V? ^ 

■M— *— ,« j A#*K afinultl ba •tafccil EXACTLY. PHYSICIANS slimild 

IS. B.— Ever, Item of Information •houW be cn^.f-Hy •"^P"'f; p^operlrd-^in-. Th. "Specl-I Inform.tloi,- for p.r. 
.tate CAUSE OP DEATH In pl«ln term., thn It m«> ^^JJ^^;;*'' 
•on« dylnl away from home -hould be given In evry In.tance. 



190'i 



wV. 



I 






' \ 



fl 



i 



a 



i\ 




I!r,;,t.l .,f Hinllh- 1" No > 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

*»-5!>-,.^,.c„ REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 

412 



na/r Filed, ^vvL \\ l^O'i 



Registei-ecl JVo. 



H 
jLyJL ixANu Deputy Health Officer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Cevtificate of ©eatb 

( XX. S. Stan&at? ) 
PLACE OF DEATH:— €o»«tT«*^CV>v.kAj I la\a Grtr-trf 






fNo* 



—St 



-Dist.: bet. 



and 



- ) 



T^v:^vi^::^ :::v\^^^ --^^^;^^;i^- ^^" ;?;ii-N;-:::ir • ) 



FULL NAME 




A 



XXJL 



\ 



a.\A i\..a. 



I I 



HHX 



ii.vri: Di' 



PERSONAL AND STATISTICAL PARTICULARS 

J. j COI.UR \ 




liLt. 



I1..I 



k 



t Mi. nth I 



«lJav 



AT.H 



SlNi.l.I' , 

\\\\n i\\Y 

U T!t« in 



J V.I 



M„„t/i 



Vt-aT) 



n>i I 



MARKir.I> 

I> OK I>IVi»HrKt) 

Hoiial <!t >-is.'nat mnl 



/ 



MEDICAL CERTIFICATE OF DEATH 

DATK Ol^ DKATH \ ^ ^ 



w 



ll 



\.v^^ 



I 



(M.^ith> 



I Day) 



(Year) 



niK'nn'i.Ai") 

<.; '. , f Cirtiiitry 



S'\MI' Ol* 
I A 111 I. K 



niRIIll'l.AOK 
OF lATIlKK 
(State or Country) 



MAIDKN" NAMK 
01 MoTlIKR 



H1RTHI»I,ACK 
(State or Country 






/ 






5 lit I 



\h»ifli' 



I hi \ 



Tin- \HOVRHTATKnPKKSONA!. rAKTlClLAKsAKK TKt K T<. TIIH 

iu>T OF MV kno\vi.f:i)<.k and in;i,ihi- 



fTnformnnl 




( A 4tIr g W !« 






ThEReFv CI'IRTII'V. That I attemltMl aeceased from 

■ -190- to ■ :tr r-:n- 190 

that I last saw h^^r— aUvc on — — - 190 — 

ami that .Ualh occurrea, on the tlate stated ahnvc, at 
M. The CArSr: OI* DICATH was as follows: 



Dr RATION Vtars 

CONTRIIU'TORY 



nrRATION Years 



Moiilhs 



Days 



Hours 



i^fonths 



IhlYS 



( SIGNED )-,:.AL '- I •. ''<\>V4. 



Hours 

M.D. 



SPECIAL INF< 



\ (Aililress) 



bwir^b ..JFORMATION w^ ^of Hospitals, InstilutJons, Transients, 
or^ltteS'RfsMfnls' 'and persons dylnn away from home. ^— 



Former or 
Usual Residence 

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



How long at 
Plartol Oeath? 



Oays 



PLACR OH BtRIAI. <)K KK.MoVAI. 



K-aJnx^ 



f»\l'j:«>f lltHiAl. or RHMoVAl, 



'■-! 



Ht '' 



I90H 



I NUURTAKF.R 

(Additsfs 






■■■■'''■■■"•^■■^ ItB should b« stated EXACTLY. PHYSICIANS shottld 
N. B._Bvery Item of Information .hould be cnrefully «"PP»«J- properly cl«..lfled. Th« -Sp«li^ Inform.tlon" for p.r. 

•t«te CAUSE OF DEATH In plain term., that It ma> »* J'^^P*'' ^ 

•on. dying away from hom« should be given In -vry Instance. 



»4 






t 






ill' 



^1 !• 

i (.1 



fl 





WRITE PLAINLY WITH UNFADING INK-THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 




Dale File(f , 






kXu 

u 1 



,^^ Deputy Health Officer 



Registered JVo. 



413 



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

Ccvtificatc of S)eatb 

( U S. StanPatO ) 

PLACE OF DEATH: — County of Cvl r. ^ity oi 

and ■" J 



Na 



St 



-Bist.; bet.- 



( " -v^vi^:^:^"-^^ o^^-^^^'^4r.',;-,;uvM^.° r.-r^: -:it^i:-:^r- ) 



FULL NAME 



lOJlcvCcll ' 



PERSONAL AND STATISTICAL PARTICULARS 



DAIi: Ml- r.lKTH 



At.K 



Month > 



VC^-^ 



5 I'll > 



l>:iy 



Mntllh^ 



\ ea 



r) 



Pn \ : 



WEDICAL CERTIFICATE OF DEATH 

DATE OF DKATH Q^ 




/go \ 



(Month) 'I ♦='>•• 

rTnTRl^iv^C'l'RTIFV, That I attcMuUd acrcase.l from 

190 ~— 
n;o 



190— — to 
that I last saw h Trr— - aUvc on — 



(Writf in MH-iMl (lt«-ivnation) 



lUK rillM, \<')' 
iSttitv <>i I .I'.tiili % 



N\M1 <)1- 

I- A'lH j:k 



/ 



/ 



/ 



an.l that .leath occtirre.l, 011 the .late state.l above, at 
-— — M. Thei^AlSI-: Ol- DI'ATH was as follows 



nr RAT I ON IVrtf-y 

CONTRIBUTORY 



Months 



Pays 



J /ours 



lUKTHl'I.ArH 
Of- l-ATHHK 
isialf or Country) 



MAIDHN NAMi: 
«»F MtyrilKK 



lUR I'llTI.ACK 

1 ir M I < I 1 1 I-. 1% 

(State or Country) 



^/ 



duration 
(Signed) 



Years 



Mouth^ 



^^ I tun i>n",,'>' 



Pays 



f fours 

IM.D. 



t\ y ij /. 11 . ,\ M |X(\ >"^A, vA, J ' 

%\. K "VXX. H tqo 1 (Aihlnss) I ' ^ '^ ^ 



uCCri'ATIoN ^ \ 1. 



Rfsidfd in SiUi /'i ,111. i.'->'ii 



1 



)'tU!l 



Month' 



! his. 



KfSHlflt in r\tni t i mn i^i^ • 

THHAHOVKSTATKDPKKSOSAI.I'AKTICt-l.ARsARKTKrHTO ^W. 
BEST in- MV KNoWI.i.ni'.H AND Hhl.n.»' 

(Informant ^1 UXVy^^ W ^%' ^ 



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

Days 



Former or 
Usual Residence 

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



How lonq at 
Hare of Death? 



PI \CH OF BIRIAI, OK KHMOVAI, 




(AIMCWM 



L.a.iS)cL. 



rNDliRTAKF:R 



( Aililrt"*^ 



DATE of HfKIAl- or KI':MoVAI, 

\J^ 1^ '90S 

U -^ 0. • 



(AlWlMiiH, 'W^ v^' ^- «^ "-' • „^^— — »■— ^— — ■ 

N. B._Bve..y Item of Information .houW be «»"««««•'; f"^**"^^. Jl^o^Jxl'^'lxLlm^d^'^^^ Information" for p-r- 

state CAUSE OF DEATH In plain term., that It may P* J » ' 
wn.%yl«i .wy from home -hottld b* given t» .vry Instance. 



't 




ii 




* 



. r 



i| 



WRITE PLAINLY WITH UNFADING INK-THIS IS A PERMANENT RECORD 

^«^ REFER TO «Ar. K OF CERTIFICATE FOR INS TRUCTIONS 

..,.,,■ ,n:.l»h ■■■NO i.»1J g5^Hy.l'C,o "• ^^_^— -^— — 








7^(94 



Re^l.stcrcrl J\,''o. 



414 



"^ .. . . A "1 lAVii Deputy Health Officer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Cevtificate of ©eatb 

( "U. S. StanDarD ) 






No. ^ 



PLACE OF DEATHi— Cuuiity of 



. "^ > \. 



Xfr-V*.. 



Oil 1 ^^% 

City of x' I^CXYvaa I. 3 



> \ ^ I 



Su ~" Dist.;bct. 



and 



-) 



r w %. ■ ** 1^ F<«B iikinrM "BPCCIAL IN rOBM*TION" N 

\ (F DC/ 



ns 



FULL NAME 



!S\a.^\^Jt ^'^ecri-'^ 



PERSONAL AND STATISTICAL PARTICULARS 



\i I ^(X\^*.. 



;i\ IK ()J- HIKTU 



A^K 



\ 






J iUl I 



Day 



A/nnf/i- 



/Veur) 



Pa 1 A 



•^IVc'.UK. MARK !1" l> 
\\II>(»WK1) OK niVoKii: I) 

Wtiit ill v<H<i;il (Usivnatii'ii) 



niKTi!i'i.\rK 

(Statt i»r CnniUry* 



MEDICAL CERTIFICATE OF DEATH 

DATK OF DICATH \ 



) 



n 



(Vcar) 



N SMI' iU 
1 ATHKR 



lus; riiiM, \i'K 
si.it. tir i"<i\uilrv) 



MMDJ.N NAMK 
til- Mt»Tin-;R 



T'.IR rmM,ACK 



istnlc or Country) 



^- C . - 

(Month! " j' 'I^^y^ 

^I IIKRKBV C1<:RTI!'V, That I MttencU-a (U-ceascl from 

^., , _ ~ 190 to ' - -.:-----rr-T:r..i90 - 

that I last saw h aluc on ^'^^ 

an.l that <Uath occurred, on the .late stated above, at 
M 'Ihe CXrSJ*: Ol" l)|iATIl was as follnsvs: 

* " "^ 1 ' J V 



I )r RATION JVrtri 

CONTRIHCTORV 



Months 



Davs 



Hours 



/ 



oc 



Yt at 



•^ \h<,ith 



7 

Cl- 1' AT ION A % X 

AV-\v,V,/ /;/ Sail I't ani irn 

THl- AHOVE STATKl) PRR^ONAI, l')«'i;|r/;|'.X'*^ ^'^'' 
I5KST OF MY KNn\VI,Kn<.K AND in IJli- 

(hifonnant \ I f ViXA^^^ \) Sk 



/)tn. 



TKrK T<» THH 



I) r R A T U ) N ) '<''? '■« Mouths 



(SIGNED) 

MKau ■ ■ 1 TQoH ( Address) iAoU 



Pavs 



^ ^ 



I fours 
M.D. 



SPECIAL INFORMATION only for Hospitals, Institutions, Transients, 
ftf Recent Residents, and persons dying dway Irom home. 



Former or 
Usual Residence 

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



Now l9R9 at 
Place of Death? 



Days 









P1.ACK OF niRTAI. OR RKM«>.AI, 



DATK uf HI RIAL or KEMOVAI. 



inI)f:rtakhr 

( Address 



.♦-»• CAiisn OF DEATH In plom term., that »«"'"> ,_:..«. 



•tate CAUSE OF DE« ... - ""•,.. .. ^- |„ .^.py Instance, 
•on* dying .w.y from home «hould be given 



(I 




Ml A 



* I 



f4 



^^i 



i 



1 




I t 





"I 




4 



mU 



||i|B^' 



ft 




^'i 



WRITE PLAINLY WITH UNFADING INK-THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



11. ...1 



! ..: II. 



!,h FNo, ..-^^^r^^HSil'Co 












Deput 



190^ 

alth Officer 



Registered J^o, 



4i5 



DEPARTMENT OF PUBLIC HEAUTWity and County of San Francisco 

Certificate of ©eatb 

( "Q. S. Stan^ar^ ) , ^ . 

^ \ i +■ (? ^ 

PLACE OF DEATH:-e>nntr-l^^^^M^^' ^'^^' i ^'*^ °' T' 



No. 



St.; 



( 



3,. Dist.;bet. »"<* ,,. 

IF Dt*TH OCCURRED IN * HOSPITAL OR INSt.iu 



FULL NAME 



L \ vavLift 



t^a 



1 



-1 \ 



PERSONAL AND STATISTICAL PARTICULARS 

Col.OR \ 



V 1a 



HAT I. Ml HIKTH 



I Ml. nth' 



a«;k 



) VcM 



l):iy> 



M,„ilh- 



I Ve.-ir* 



Pii 1 



\\ n»i i'.\ 1 i» <»K invoRvi-". n 

NVrstt in ^im iai ilt si^iiati'in) 



niKTinM.Ai'K 
stair or Couiuryi 



MEDICAL CERTIFICATE OF DEATH 

DATE OF DJCATH ' \ 



(Muiith) 



(Day 



IQO 

(Vcart 



I HHRIUiY CURTIFV. That I atten<U(l aeccascd from 

IqO 

.... . .. u 190 



- ,_,. — —————— T90 

that I last saw h T.r^— «live on 



to 



»j^»4 4.t.irMJiiH'l-^t 



aii.l that acath occiirred, on the dati- statcl alx.vc, at 
■M The CArSE.DF DICATH was as follows: 






/ 



/ 



N \M1- <)I 
I \ TUHR 



HIKTH PI. ACK 
ni 1 ATHKK 

S!,it.' iir i'outitrv 



M \ir»HN NAM1-, 
(•I MOTHKK 



niKTIHM.Ai-K 

. .1 \»i .111 i.-u 

Slat I or Ciiunlry 



/ 



/ 



-jUtU<L...l^v 



t 



nr RAT ION years 

CoNTRIBrTORV 



Mouths 



Days 



Hours 



nr RATION 
(SIGNED) 



Yiiirs M out In 

^1 ^P 4,^|\xcc^^^^. 



Davx 



Hour's 
M.D. 



HI 



sJpEC^AL INFORMATION only lor llosplUls, Inslitutlons, Translcnls, 
or Recent Residents, and persons dying away Irom home. 



/ 



ULCll'ATlON , 



Kesidfii iti SiJfi t'tini, i:,n 



)V,rr 



^rn^ltf^s 



fhl ' 



rHF.AnoVESTATKni'HRS(»N\I, «' ^»< '"'V;!' ^'^" \RK TRIK l«> 
BKST OF MY KN<)\VI,i;i)' H AND lU-.l-ni* 

(Informant Qr^\0.y^\> ^ d^ 1',^-*^ 



fA#*i^«s 



i^ai^i^ 



Former or 
Usual Residence 

When was disease contracted. 
If not at plar e of death ? 



Now lonQ at 
nareof Death? 



Days 



-PI^ACK OF BFRIAU <>H KKM«»VAI. 

m .it ! J '^ ■ 



rSDF.RTAKF'.R 

(A<lclr<'^< 



k : J, 




* * /•Aiicp nts nFATH In plain tepm», tnnt 11 mwy y^ h f * 
mtmU CAUSE OF OtLM in in pi- *iv#ii In «v«ry Instance, 

•tms dying away from horn* i.hoiild Ims tlv«« m « • y 



'I ■■I 






^1 > 



'I 



I 

I! 






,,f Ihalth-KNo. 1 



WRITE PLAINLY WITH UNFADING INK-THIS IS A PERMANENT RECORD 

.*^„^.C0 n.PER TO BACK »^ r.r„.,p,CATE FOR INSTRUCTIONS 

416 



l)(ifi- Fifed, 





Registered J^''o. 



io^J!^ Hanu Deputy Health Officer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of H)eatb 

( Vi. S. StaneatO ) 



0/ 



PLACE OF DEATH:— County of ' CV-^\' VCL >\wv,-i oty oi 

FULL NAME fcoAX^^I— ^--^^XA.tA^lL^xA^u^U 



) 



PERSONAL AND STATISTICAL PARTICULARS 



-l.\ 



OOloL 



coi.oR 








1»\T1, til- lUKTH 



S«.H 




(Month) 



Hi 



) 'ra I <■ 



1>0 

I):iv) 



M.mffr 



(Vean 



a 



A/1 



-•iN^.i.K, MARK n-.n, 

WIlliiVVKI* nR I)lVORi'KI» 



\\J. 



MEDICAL CERTIFICATE OF DEATH 

DATE OF DKATH i \ y j 



IQOH 

(Year^ 



FniFti^iYT^RTIFV; That I atten.k-1 .kccasd fm.u 
%%.sl-<JL I'^i-- I90H to^l^^i^ I'l 



that T last saw h 






up H 



\; 



190 I 

ana that (U-ath occurre.l, 011 the date stated alK>ve. at 



,0." 



nikTniM.KOK 

^itti lit t'linTid %■ 



I A Till. K 



I'.iK riiiM.ArK 

nl I \ IHKR 

I ^ta!' Ml i*(Hiiitry) 



MXIDI'IN NAMK 
• II Mf)TIIKR 



niRTliri.ACK 
4 11 MiiTllh'R 
(Siatt ur Country) 



0\ 



H 




^ 



fif fitted in S<tri rmn, isf'o \ J^ ) rui 



<.\ M:, The CAl'SIC Oi- DliATII was as follows 



Dl* RAT ION ^ J''<"'-y *^ Motitfis ^ Oays 
CONTRIin'TORY 



" Hours 



OrRATION ^ >V^'^ ^ Months ' Days ' /fours 



(SIGNED) 

c 



*- Months 
fl\D/OL\t' 



M.D. 



'' ^ ' Hospitals, 



FECIAL INFORMATION only for Hospitals, Institutions, Translfnts, 
or^ccent Residents, and persons dying away from Ijome. 



jht\ 



run MKWH ST XTKin.KKSnNAM'ARTn;r;,AR^^'*'' '■'''■'■ "* '"'*' 



,„„„„„:„„ Ijo^>v.Ooi. "It^wVv 



(Atldrewi 



,\ 



PL 



0-4,4^^v 



^i 



former tr 
Usual Residence 



When was disease contracted. 
If not at ^lare of death ? 



How long at 
Place of Death? 



Days 



rLACK 01 lURIAt. OR RKMoVAI, 





1 .NUKRTAKH 



i)\'n; <»f Hi KiAL ur ri:movai, 
%^ T90H 



G 



X.4M^' 



< Address 



\\i\ QfViA.^vt--^ "^^ ^ 



AkC'VX 



^ .fte CAU8E OF DEATH l« pU,tn f*^""; V^jJ^^^J In.LnL 
.on* dylnt away from homo -hould be tlv.i. «n .v.Py i« 




I' 




r A 





WRITE PLAINLY WITH UNFADING INK-THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



Da 



■^ ^ '^ Deputy Health Officer 



Re^Lstered JSl'o, 



417 






DEPARTMENT OFTUBLIC HEALTH=City and County of San Francisco 



Ccvtificate of Beatb 

( "a. S. StaiiDarD ) 

n^ ^..OXlX/>va^<l^CoCity of Ooav 0.^.<^ 



No. 



PLACE OF DEATH: — County of 0.>\; 

. S Dist.; bct.^ij 



1 



St 



ItcJr'UX^a.a.^* and 



U)x^* ^- 



J. t ». I 



( " r.r.^"oc.";.-,""- o"r,*.t :.^?^?f,?J=^^";";j «v^^ .■^»-" ,;%%--i»o'pr ■ ) 



FULL NAME 



"^ .[ill 



PERSONAL AND STATISTICAL PARTICULARS 



IjATK of niRTIl 



oJjb 



I i 






\i,\'\ 



y.;n 



I 1 ):!\ ' 



M,}Vth': 



'» eai » 



/'(?). 



MEDICAL CERTIFICATE OF DEATH 



DATK <>l- 1)1:aTH 



Month) S 



Ik.. 



(Year) 



A ii»i f A j;ii Ok nivoRi'KD 

WiUfiit HfHinl <U sis.'iiMtinn) 



-t .t> .ir I'ouiitrv' 






Xj 



\'\MF oi- 

1- \ I iii:r 



BIRTH I'l.XrK 

OF fathf:r 

iHtaie or CtmiitryJ 



M "kllH'.N N,\MF: 
ol- MoTllKK 



BlRTHPf.ACK 

= * = * » * * fc * ± I , i^ 

^^tat' nr rounlryi 



b 



!\ 






y\j^ 



'^OJ\.Oj<M ^*- 






'%'n 



t>CCri'ATION 



.\ 1- , 



Kfffitft in Sail l'iitn>i>r< 



■> \ 



)'iii I . 



M,>ti(hs 



,4 /'f^ ' ■ 



-- pHERFnY Clckl'IFV, That I aUcn.lcMl deceased from 

that t hist saw h alive on f^^ ^ - ^'^ ^ 

an.l that death occurred, on the Lu- stated al>ove. at ; ^ 
^' M. The CAl'SK Ol- DKATII was as follows: 



nr RATION )V«r.? Months Pays J fours 

CONTIum'TORY S^.^i! v- ■- ^^ '^^ 

DURATION " Years ^ Months b Days 
(SIGNED) \D-lA.-Ci 



1 90 



(Address) HOb 



* /fours 
M.D. 



r . vM 



^Special information only for NospUaU, Instltullons, Iranslents, 
or Recent Residents, and poo.ons dying away from liome. ^— 



Former or 
Usuat Residence 

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



Htw ItRf at 
nirt^ Death? 



... Days 



n^cK OF" nrkiAi. OK HF:Mov\f. 



(I lift mil an! 




SodL^tU-v. 



.Vtik- 



THK AWOVK STXTKI) VHR^OXAI. rAKTICri^ARS ARK TRlK T. » THK 
BKST 01 MV KX<>\VI,F:rH'.K AND HFl.Il.H 

(ArUlrcss A V 

NA— Bv.r, ...m of l„Wn,..lo« .hould be cr.^uHy .uppll.d^ p;^p"rt!;7l«S'n:i?*'Thf *»^W l»tol«T<.*"Vr plr- 

/^ ..... CAUSE OF DEATH I. '•^■''•.'Vrf, •;.'';„''.,"; J ,„««.. 
f nan. dyint .w.y from hom. .hould b* «lv.n in . . » 



ii\rj.:i>f itfRiAi. or KE^'^>v.Al, 
l^udu 0.0 190H 

ni.krtakfr' tolvyv^^ W^ 



(AtMitsft 



il 



II 



i 



M 



r 



ill I 
II 



I 



4 



^«— ^ 



it 

i 



I I 







-;- ■->, )i}i r Co 




Ite^istered ^fo. 



WRITE PLAINLY WITH UNFADING INK-THIS IS A PERMANENT RECORD 

H EFER TO BACK OF CERTIFICATg FOR INSTRUCTIONS 

418 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



! itvM Deputy Health Officer 



Certificate of S)eatb 

XX, S. StanC>arD ) 



PLACE OF DEATH: — County of O^^v J Xa 



^rL^V 1 \a>vCC^^Gty ofO<VYvOXa^^<^^t 



U'l 



No*^^ 



J ^W-kvcLu >va ^Uvyl 



( " .V*o;rH"oCCU%TeV.'N"rHlVp7T*:OR .NST.TUT.ON O.VE ITS 



Dlst.;bct. 



^- and 



) 



X.. ..oM^usu^L ---NCEa.vE;.cTs call;o ^ und.j :^:ii---::^r- ) 



FULL NAME <^ A.^ 




A^Lc^voX^ > 




SKS 



PERSONAL AND STATISTICAL PARTICULARS 

COI.OR 

DATK nl' HIRTH 



^^ctL 



l^X 



^^ 



(Month) 



A'.K 



r,</i 



Z 



It 

II>MVt 



^t,•^nll• 



%% 



(Ytari 



tht V 



"v!N<,|,l' MAKKIKI> 
Writt ill -iK-ial ihsii'iiuliuii) 



a 




lUR rillM.At'K 
'M:(tf iir (.'"nmlry) 



TA I II KR 



lURTHPI.ACK 
nv V.W'WVM 
'Statf or Coutilrv) 



MAIDKN NAMK 
OI MOTHER 



lURTHl'LAOK 
1 ?»1 i •Til i%K 
( suiif or Country^ 



<»CCri'AT10N 

Ren'iM in Sitft FuDi.nrn 






MEDICAL CERTIFICATE OF DEATH 

DATK OF DHATH {A | 



I go 



fkfonlJi) f) 'i'=\>:' 

I 1IHR1:HV CI-RTIl'^V, That I attemlea deceased from 



O^v %.V 190 'i 






that I last saw h !- > ' * alive on N 
and that death occurred, oti the date- statc<l above, at 
CL M. The CArSP: Ol' I)I':ATI1 was as follows 



190 



% 




^V^A-^^""^^ 



ii 



«4 



«* 



I )r RATION -Years - A/on/As - Davsl^JAmrs 

coNTRiiuTORV U^xA'^v^rs-.r^x. 



nr RATION Yrars ^fontJis Pays 



- JVrtr. 3 V..»M-'3Jb ^>'"" 



TH,.: AHOVK STATKn TKR.nNAL '•^HTjrr.XK. xRK TR.K TO THH 
BKST OH MHLKNOWMADtU-: AND HI.MI.i 



(SIGNED) 
BPEOIAL IN 



.<v\,4.4wxx»-*. 



Hours 
M.D. 



(Address) QL550 J^LLwv^u. J 



wir,- ..4 FORMATION only ^«^ Hospitals, Institutions, Iransients, 
or^Mcnt^esWenlsVand persons dying away from home. 



Former or 
Usual Residence 

Wlien was disease contracted. 
If flotat (rfi^^eof deatti? 



How I0R9 at 
Plareef Death? 



Days 



flnfotniant 



AcUlress 






UI.ACK OV nrRIAl, OR RKMnVAI, 



1 

rNDKRTAKKR 



I)ATJ-:<if lii KlAf. or KI-'MoVAK 

\\ igo'i 







(A«l<lr..-x« 






H 



state CAUSt ui- uc:« ' * • • i.„ *\^.»m In «very Instance, 

•on* dytfliA .^-y t«Hn home »hould b« ft.>en In evry in 



■J 



f 




n 



11 



I' 



I 






I*^>1 




k'l* 






WRITE PLAINLY WITH UNrADING INK-THIS IS A PERMANENT RECORD 

HCFER TO «rK OF CERTIFICATE FOR INSTRUCTIONS 




Ditic Filed, 



dJ^ 



I 



% 



\\ 



wo'i 



Registered JVo. 



419 



(K^ V. ^ VO. <?vi.^%H.\ 




Deputy Healt? 



DEPARTMENT OF PUBLIC HEALTH-City and Coanty of San Francisco 



Certificate of ffieatb 

( Xl. S. StanDatO ) 



PLACE OF DEATH:— County of ^ ^tnvcn-^xa 



:ity of LI Uxh^oi!/^^ Wl 



City 



No. 



St.r 



-Dist.;bct. 



and 



) 



( •' ^;u;::^i^:!R;;:v.n"ti^^t -^S^i^^H'^^ ^^" ;?;i^n^:'?::«r' ) 



FULL NAME 



« 



4 



^ 



J^-Ui\iv ^D \^U^ 



SKX 



I»\l !•: «>l- lUKTIi 



\<*.H 



PERSONAL AND STATISTICAL PARTICULARS 




<x 



u 



K ' t 



lv^>Ub 



(Mortth^ 



Iv jvri>.f n 



I I 

(Day) 



M.tHlIn 



(Year) 



Da V. 



MEDICAL CERTIFICATE OF DEATH 



190 1 

(Year) 



DATE OF DEATH A ^ , 

TiTeRHBY CKRl'IFV, That I attenacd deceased from 

— to 



190 



sI\(.l.E MARKIKI>. 
WIDOWKH <»K UIVORCKD 



lURTHn.ACK 
Mate 111 <'(niiilry 



NAM I", «U- 
I ATHHR 



mklM PLAt'E 
iH" I ATIIHR 
stall iir Contitry) 



MAtDHN NANfK 
nF MOTHER 



niRTIlI'LArK 

'Stale or Coiintiy) 




that I last saw h-^r—r- alive on - ^— ::...-. - 

and that death occurred, on the date state.l above, at - 
M. The CAl'SR OF DHATH was as follows: 



Tgo 
190 



1 x^ 



it 



,1 ' 




Cal 



DT RATION years 

CONTRIIUTORY 



IMouths 



Pays 



Hours 







_ kl 



\xLo^ 



DTRATION 
(SIGNED) 

\1 



Months 



ruin d'lf'f" 

iqo'x (Addn--->) )<X^^Aa; JV. 



Hours 
M.D. 



" d'PECIAL INFORMATION only lor Hos^itils, Institutions. Transients, 
or Recent Residents, and persons dylngjway Uom home. 



tK Cri'ATloN 

Rfsidfil t,i S.ju /'itimhrn It' ) r,n s 



.\ronth: 



Ihivs 



,„KM„.VRS-,^TK..rKKSONA.rAKTU-rj.AK>AKhTKrR TO TIIK 
UKST OF MV K^-oWI.KI>«'E AND J?HM»-»* 

(III forma til 



(Addrc^Fl 



former or 
Usual Residence 

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



Now lon^ at 
Place of Death? 



^$ 



ri.ACK OF BIRIAI, OR REMOVAL 
IN DF. RT A K E R ^ I ' I O /(XCMXl, 



(AddreHs 



n\ Q1*Ua-< 



DATE of niRiAi. or RKMOVAI, 

^Wwi4 V' T90H 



V^-rs %^ 



* \ 






V 



i» 



:? 



' i 





It 





i 



WRITE PLAINLY WITH UNFADING INK-THIS IS A PERMANENT RECORD 

»rrrH TO BACK OF CERTIF -r-ATE FOR INSTBUCTIONS 

420 



,..s-„. „»^^^i)&rco 



100^ 



Dale Fih''L "^^^W ^^ 

l^vvv!Ll- Deputy Health Pfflcer 



Redisterecl J{o, 



Xrs>^\ 



DEPARTMENT OFPUBLIC HE ALTH=City and County of San Francisco 

Certificate of Beatb 

( ■a. S. StanOatO ) 
PLACE OF DEATH:-Co„ntv of^V.. J ^a.^CV. . . Cty of ^ O.^ ^^C..vC.. 



No. 



.d^ 



(^L 








at.? l^'lSt., l^l» „„1eo "special INFORMATION" \ 

RESIDENCE GIVE FACTS CALLED ^OR "N^ACR SPEC^ ^^^ DUMBER. ^ 



.<j-cKU^ 



) 



RESIDENCE GIVE FACTS CAUL.u — — OF STREET AND NUMBER 
OR INSTITUTION GIVE ITS NAME IN8TEAU « 



FULL NAME 



4 I ^ 



^ 



^La.^-v.dAA.' 



T t 



•-i;\ 



PERSONAL AND STATISTICAL PARTICULARS 

CO I. OR 



^J. 



KXi K ui juK rn 



\(.K 



i ' 1 « -^ 
V ^^ vv. wA - 

I Month n 



J *ri? t 



(Day) 
^ M.wths 



•1 



Year) 



A/v 



MEDICAL CERTIFICATE OF DEATH 



DATK Ol- I » HATH ^ | 

iMonth) 1 



It 

(Day) 



(Year) 



S!N(,I,K, MARKIKI). 
WIDUWKI) OK niVOKtHI) 
iWiittiii wK-ial cU-HiKt»iit>"'>' 



HIRTfnM.Ari-: 
stall 111 i.otnitryl 



n oxci' 




,b 






NAMF Ol 
FATHKR 



BIKT IIP LACK 
OI- lATIlKK 
fHtalc or Country) 



MAIDl-.N NAMl-; 
<)|- MoTlIHR 



HIKTHPt.ACK 
(Slate or Country) 



oCCrPATION '^ 






4v 



^iujUU-HV CKRTIFV, Thai I ajtenat-.l .Icccasca from 

'^xllui B 190H to I^^Xy l"^ '"^"^ 

that llastLh.V-^ alive on ^ti^ . li 190^^ 

a„a that <k.ath occtirre.l, on the date stated above, at 
Jj, M. The CMSI- UF DHATIl was as folUnvs: 



DURATION years 

CONTUIBl'TORY 



Months 



/)a 



I'V 



Naurs 




tvCCO/VXX 



hX<x^^ "^ ^ 



Dl'RATION 

(Signed) 



Vears 



i\fotilJis 



Days 



\ 



I tut A i'l ^■■' 

00 H (.Vl.lross)^lI^t. Al<X,y 



Hours 

M.D. 



(^tcul 






\^. 



Kesidfd ni San Finn'i' 



) 'fUl I 



i^ 



\r„nfli' 



Pitrs 



THK ABOVE HTATlU>PKKS<>NAirAKTICr LARS AKKTRrHT<) THK 
HKST OK MV KNOWI.KDOK AND Jn^Ml-^* 



(Informnnt 



(D.vtx^v^ ^ 



i«u I INFORM ATI ON only for Hospitals. Instltuflons, Transients, 
^^eceS^esMentsVand persons dying away from home. 



Former or 
Usual Residence 

When was disease contracte*, 
If not at place of death? 



Nmt ionq at 
mreof Death? 



.. Days 



PI.ACK Ol; BIRIAI, OR RKM^VAI. 




(Address 



'h% 






i 



INDERTAKKR V V?^^^^ > ^-'^-^ r ' ' >, 

15 %H at..fr^Jkt^ 



(Addt 



iiii,^^^_^_i^ii^^^^^^^^^^^ii»^i^M— i^— ■-■— '^'^■'^■'■■"■^^^^ ij i« ft * d BXACTLY. PHYSICIANS •hould 

state CAUSE ui- ut« • " ^ ^Iven In •v«ry l«»t«i»c«. 

iifHit dylnft Bw.y from homo -hould be glv«« i« .v.ry 



fff! 



'r-. 




I 













!'f 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



Boanl nf !I .riih- I- N... i =; "^'X.^^^V" HN:!' C> 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



Da 



h- Fihil, |tJ^ IS 



t<,cco 



Deputy Health Officer 



Registered J\^o, 



42± 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of H)eatb 

( H. S. StanDar? ) 
PLACE OF DEATH: — County of^'CX^V I>UX.^\C\.4,C() City of-aA\' \a > 

(No. I^IS Hxa>w>%u ' 



(ir oe*TM occun/k awav rnoM USUAL 
ir DCATH OCCURRCD IN A HOSPITAL 



St.; 



Dist;bct. flXLi/^^' 



and 



X^LAxit 



\x\xxj: > 



RESIDENCE GIVE facts called roR UNDER "special information 

OR INSTITUTION GIVE ITS NAME INSTEAD OF STREE 





lAL INFORMATION" A 
T AND NUMBER. / 



) 



FULL NAME 



PERSONAL AND STATISTICAL PARTICULARS 

^ A I C*H,ok 




i) 



\ ri-: ' 'I luKTM 



L 



Ic 



I 



MEDICAL CERTIFICATE OF DEATH 

DATH OF DKATH 






)>.,, 



I):iv> 



^f,iHf//> 



(W-ar) 



An 



I. 



L 



(Day) 



(Vt-ar) 



'iN« i.K, MARi<n:i» 

■' -'" I'll '!■ -i'."iiili.ii!) 



line rifji.Jn'H 



1 M lll.K 



f.IKTHlM.AfK 
'" JAIHI.-.k 
'-t.i!. HI t'oinitr' 



m\ii»i.:n' nami. 



inRTni»r,\ri.* 
tstatf »»r Couiitrvl 



«Hd I'ATHiN 

^'^Mifrif iti Sijfi J'l ,111, !>ti> *" J**'(7(» 




. I HI'RICnV CI-:RTIFV. That I atten.kd deceased from 

^^*-*^i. I'l t90S to ....|lL.JLu. \% igo^ 

that I last saw h . alive on igo 

an<l that <loath occurred, on the datr staled ahove, at 
M. The CAl'SJv ()!■ |)1<;aTII was as follows: 




nrRATION )'tars 

CONTRIISUTORY 



Mouths 



Days 



Hottt 



s 



rVSA^U 



I )r RAT ION 
(SIGNED) 

^^wV-Aa-^_ I V TQO 



y'ears 



Mouths 



^ovu^lv^l 



Days 






I lours 

M.D. 



tlU l1 loo'i (Address) %^ 5^ ^aA.Kii:^VA^»ir\.tK 



:]al ini 



«, B^^^^ftL Information only for Hospitals, Inslltullons, Transients, 
Of Recent Residents, and persons dying away from home. 



\\ 



M.ttiths 



Ihi r 



' " «i^'-.V^''*" '^'I'^'IJ- n I-KKSOSAI, I'ARTrt'lI ARS AKH TRf H TO THK 
HhSI op MY KNOWM-.nc; H AS!) Wr.X^WA- 



'Inf, 



Hiimijt 



I' 



A^a^'CjU^V 



% Ccx^ 



'VV^^. 



N-l.hrHM 



I'iR . 




^VYV 



%- 



1) 



f 



r&riJitT or 
Usual Residence 

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



How Ion) at 
Place of Death 




Days 



I'l.ACKOF m-RIAI.Ok RHM-iVAI. | n.vri: of HrRiAL or REMoVA!, 



TNI) V. R T A K K R ' VO <XJX^K'>(\} ^H. "^K^ C \ Li 



A. -/ 



I90N 



(Address 3b^lQ^' I 



N. »•— R-Y/c*l^im2Up''nTriM". ^^""ft **' '="'••*"•'»' »"PP««^«I- AGB .hould b. .t.Ud EXACTLY. PHYSICIANS .houid 
~ CAUSE OF DHATM in plain terms, thnt It may be properly classified. The "Special Information'* for pei*. 
•one dying away from home nhould be given in 9swy instance. 




I 



K 





I 



J > 



I 






UnilT. 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

, ,1, 1 No s i*^?a?^nS:iCo REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



I)(ifi' Filed , 



Hi 



IS 

(1 -VO 



I 



Deputy Health Officer 



Registered JS'^o. 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of Beatb 



N 



a 1 vj 



( tl. S. StanDarD ) 
PLACE OF DEATH; — County of ^^^\J ^^0.>\^CC^ccCity of )<X/"iV 1/va^vCA^C.t 

St.; \ Dist.;bct. 1 NJLX^V and l^ - ' ^ 

(ir OCATM OCCUMSUWAV r»»OI» USUAL RESIDENCE CIVr mCTS C*ttCD rOH UNDCR "SPCCIAL INrORM*TION • \ 
ir oc»TM occui^ncD in a hospital or institution give its name instead or street and number. / 
> r 



ol4 A^avv.v 



FULL NAME 



(X'V\.'CA_^ 




PERSONAL AND STATISTICAL PARTICULARS 



A 



y)l 



Qj 



<<il,. iR % 



<i niHiH 




\«.K 



" I r M \kkJKl» 

\\ Mm i\\ 111 J IK f»'^ 






\% 



I»;iv 



%l,>ntks 



/'l^'^ 



A. 



^ 1 



MEDICAL CERTIFICATE OF DEATH 

DATK <n- I)i;ath 



H 



fl»ay) 



/go . 

(Year I 



I ,in:ki:HV CI:kTJI-V. That I a^temlc.l .Uceascil from 
K^Ia^ 11 190 H tn WdUjL li 190 S 

that I last saw h alive on 190 

afi«l that <li:it1i orfurred, cm the ilatt- stated ahove, at 



M. The CATSI-: Ol' 1>I:ATH was as follr,%vs 



'1 OF 

in.k 



l?fRTlIfI,\t }. 
\ I IIKR 
• '! C«imitrv 



MM IMS N\M1 



HIKTHfl, MI* 

' ' ' . U t , t I \ 



' ' ' )' \ 1 ri >N 






^^C^\A^CL 




nr RAT ION )V«/rr 

CONTKIIU'TORV 



Months 



Days 



Hours 



VvLSjj 



K'r'iffif in San /'lain 



w \^^ ^ W , 



S>(M t 



DIRATION 
(SIGNED) 



> 'ears 




^fonths 



/7a vs 




flours 
M.D. 






'SPECIAL INFORMATION w»y ««r H^s^tafs. Itsttotlws, Tw*its, 
•r Iwiit leMJwrts, »n4 ^yon |y|ii| may frwii home. 



%f,>,ith 



fhi 



nV SW)\y <x\-XVAs PKRSONAI, I' \ KTI«'ri. ^ Rs AKK TRIK To rilK 
I:K>»'1 «il- MV KNo\VJ.HI>GK ANH HHI.IKF 

'l!if ,-n,r,,il I 'i.^-1 f* fi,-i,A_tr WC5UVwt:^U 



>V^ 



f \<iare 



\'h\-,l 



VC<X'\.>X«. 



I 



former or 
Usual Residence 

When ivas disease tontrar W. 
If Mtatplireffdettti? 



RM' Im^ it 
PtoiVff Deatli? 



Days 



ri.^K or nrkiAf. OR i<km.iv\i, | ha ti .,: h. imaj. m Kv.ynw \\, 



fAUfJrcwii 



N* S.*- -B^^ery 1t«m of Inrofmattofi •hould bs caf^fully Rupplled. AOB •Hould be statcil EXACTLY. PHYSICIANS clMttM 
state CAUSE OF DEATH tn plain term*, that It mny be properly vlaaalfled. Tli« ''Special lafoifnatloa** for p«r- 
aona dying away frmn lMm« ahoutd Nr given In «v«ry Instaacv* 



II 



If 

i 




WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



nnnni ..f H. iltli- »• No. !<; **::?*:r*> HM* ^" 



?!' 



Dft/e Filed , 




looH. 



X,frvcv» dUL/v><. Deputy Heaft*- 



Registered JVo. 



423 



rs^^ r^ 



er 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



(Tcrtiffcate of Beatb 



( la. S. StanOarD ) 



4 



PLACE OF DEATH: — County of "'CL^v LVO^vtu^;:^ City of ^CUru ^a n/'' c. ac 



No. ^.1 0^"^^ 



\ 



d 



"^ >\q. 



, lUu 1 



St. 



" Dist.:bct. 



and 



(ir DC*TM occurs «A»AV rHOIwilSUAL RESIDENCE OIVC r*CTS CALLCD rOR UNOIH "•^eCI*L INroRMATION" '\ 
ir DtHTH OCCUnnko in a MiliBPITAL OR INSTITUTION GIVE ITS NAME INSTEAD Or STREET AND NUMBER. / 



FULL NAME 



Ql 



\ 



cx^w^vju wa 



I 



PERSONAL AND STATISTICAL PARTICULARS 



fi»i,< >k , 



V 



IJA I 1. Ml- lilKTH 



M.K 



Vl)\ax(. 



Mt.iiihi 



IV..- 



iDav* 



I /..»/'//< 



< I 



/J./1 



\Vn!i in Hociiil <l»'sii,'n;ilinu) 



li 




niK riiiM. \rK 



N'Wtl- lit 



n!KTHI'I,.\rK 
OK I AT IIK K 
<Hlate#>r Coimlrv) 



M^IIiKN NAMI- 



niRTIIIM..%CR 

Mr Mill HKK 



' I'ATION 






-^KX^v t.va 



MEDICAL CERTIFICATE OF DEATH 

ij\Ti: ni- nivv'iii 



\\xL 



Month) I 



li 

(Day) 



IQO 



I UKRI-:HV CICRTIFV, That-I atttMHUd .Umcu.so.I fruni 



,\xk^ 



(ivJL 



190S 
190 i 



thai I Inst saw h ' alive on '*C^^VA-i It 

J rt 

ami that lUath *K"(urre<l, on the <latc statetl above, at w 

^A. M. ,The CAISI-: Ol" I)I':.\TII was as folUws: 



\ 



UUJi^ 



-uO-vOnv 



nr RATION Ytars 

CONTRIIH'TORY 



Moulin 



Ihiys 



flours 



Kflitfil ul Sittt t'tatti l<^fn * )V'r»/« (t, Sfiiiifh', i htt\ 



THI-: \HoVf.' '^TXriJi f'HRsnwi, I-\KT|il'I.AkS ARI-: TKI K To Till' 

iu;sTtji Mv KNitwi.i i)(,i: AND iu;i.n;i- 



Hi 



nt 




\.llll. ss 



1^0 i^Li>AVfr\X 



II 



4 



>V<7/'J Mouths Days 



Dr RATION 
^SIGNED) 



>A\.**\ 



/fours 

M.D. 

\i 



PEClAL iNrORMATION mIv f«r Hasritah. l««tif«»lA««. fr«HjMN, 
r IlKcit ^MeMs, mk fmm tf^ini away frni toM. 



formfr w 
llMal RfsMencf 

IMtot was Mmmc contractd* 
IfMlMplaretflealft? 



Htw loRQ at 
Wareal leatli? 



Days 



TQOH 



l*LA<'K oi" niRIAI, OK RHMOVAI. I I»a;^ H of ^lli hiai, or RUMCiVAl, 

» i<: R r A K V. R ^ V <\, CytJuw ^ 



t VI 




Acl«!t«'«i» 



ff. B*— *Rvcry Item of Infopiiiatloti should ht cafafully nupplied. AGB iiHould b* •t«t«d BXACTLY. PHYSICIANS ahould 
•tatc CAUSE OP DEATH In piMtn terms, that It ma<r he pi*opsrly clusstffled. The **Sp«cl«l Inropmattoii** fM> psr* 
ii<ms d}'tn^ away fiH»m homs should b« ftlvsn In svsry Instance* 



Ml 



^ 



I- 




> 



I( 



w\ 




WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

I, .r ! r il.alth F N o . . T^^^^^ Itf^I' Co REFER TQ BACK OF CERTIFICATg FOR INSTRUCTIONS 

J)afi' Filed, %jJLm l^ 



190H 


■ if^ Offi ^ • 


A 1 Til riA, 


ALTH-Cit^ 

• 



Registered J\''o, 



484 



DEPARTMENT OFPUBLIC HEALTH=City and County of San Francisco 



Certificate of H)eatb 

( TH. S. StanDarD ) 



'V-CL YV-t-Li. 



PLACE OF DEATH:— County of U/a>v JACb>\.CUM:.£)City of'^'^W '^ 
No. 2.SC) VrU-O St.; S Dist.;t)et. IS" tL and MrUvJ"t 

/ ir Ot«TH OCCUH8 «WAV FROM USUAL RESIDENCE GIVr r*CTS called roH UNOtn "SI»CCI*L INro«M*TIOIll" \ 
V ir DCATM OCCUBREO IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD Or STREET AND NUMBER. J 



FULL NAME 



PERSONAL AND STATISTICAL PARTICULARS 

COl.OR \ . . A 



■■" (^\JL. 



U'Jv.l 



DATH Oh HIKTH 



\».H 



^\ 



<X\) 



iMoiithI 



(Day) 



A'bX 



1 fl^ ) till » 



,1/ .»////« 



(Year) 



Mn 



-'1N<.I,1'., MARHIKU 

wriMiWHi* OR nrviiRCi-!!> 

•Write in •Mxial •If««iKnatioti) 



HtRTHI'I.Ki'J-: 
•<\A\< 'iv 'i.iintrv 



NAMK nr 

FATIIKR 



FUKTMIM.ACK 
n|- FAIUKR 
istiiti or Coinitryl 



MAIDKN NAMH 
OF MoTMHK 



BIkTIflM.ACK 
(»F %f«)rHKR 
fstatr iir Counlrv) 



nCCri'ATlON 



^ ^vcuJl VOX 



IT. 



DATE OF DKATH 



MEDICAL CERTIFICATE OF DEATH 

ll 



rt 



\ 



month) 



I 



(Day) 



I go . 

(Year) 




\ HERKBV CI-RTIFY, That I atteiuUMl lU ( i ased from 

'' iaCl.^i9oi to . 1^.^.1 L icp'i 

tliat I last saw h »"* alive on N^^lcy ' igo H 

and that death occurred, on the date state«l above, at ill 
wL M. The CAlSfv Ol" DJ^ATJI was as follows: 



A?<\' 



\j\^rVtIv lt/CX/v<m. M 1^ 



^a >\x 




c3 ^ VVV V^lU,./Vw4*Vi 



ftv 



Dr RATION Years 

CONTRint;TORV 



Months Days 

I- 



Hours 



bJUv^r^:%:%„k3u. 



DC RATION 

(Signed) 



. Vmt'S Months Days 



Hours 



M.D. 



%<vU^ r^ IQO- (Address) VXXKKehtt & idq,.. 



'V*. 



Kf>idfii It) Saft /'t ttMt isf'ft* \U 1V*f», 



Af„tt/h< 



/hn. 



THH \UnVH STXTF.!* f'HRSONAI, I>\R ricMl.AKS ARK TRIK TO THH 
lUvST Ul .MV KN'nWLHIHiK ANI> nF:i,n:F 



i.\<lilri'>*M 



ano 




^^-c 



J 



Special information wiy fc»r Htspie^, iwiitiHw, t 

or Recent Residents, and persMs tfyli| away from home 




former or 
Usual ResMeRce 

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



Now ttiHi tk 
nactif Death? 



Days 



-9cH 



Pn.4CK OF nrRIAT, UR REMciVAi, | r>ATi* of BeRwr. or REMOVAI, 

, ^51 0S,cvfciA^.,.-a.5(: 



t'NDKRTAKER 

i.hfitlrenm 



N. B. Every Item of Information should b@ cttrefttlly (SMpplled. AGS should b« statad BXACTLY. PHYSICIANS should 

state CAUSE OF DEATH In pinin terms, that It mny be properly classified. The **8pcctal Informatioa** for f>ar- 
sons dy tn^ away from homs should be given In svsry Instance. 



i\ 



i» 



.( 






!:'. 




WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

RgFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 

4' 



I I , I'S ll I "^^o !•■ 



HN !■ Co 



Jhffr tiled , 




Deputy Health Officer 



Jfrdfsfr/'pfl A'^o. 



DEPARTMENT OF PUBLIC IlEALTH=City and County of San Francisco 



Certificate of ©eatb 

i •©. S. Stan^a^C» ) 
PLACE OF DEATH: — County of^a^^ ^ 



A 



N 



D. 



X:ity of^^^^ 
St.: ?* D^st.j bet. - *^ ^ and "^ ^ 

/ .r ot»TN OCCURS nwav rwew USUAL «ES IDENCC Give racTS c^LUCO roR uNOtP special iNroSMATiON \ 
K ir OtATN OCeu*»«ltO IN » MOSPlTfct 0»» IWSTITUTION GIVE (TS NAME tNSTt»0 Or STUttT »NO NUMBtPI. ^ 

/^ I 



) 



FULL NAME 



-a. 



PERSONAL AND STATISTICAL PARTICULARS 



^^ 



h 



t't »1.< »R 



-^ 



K . ii 






%i-K 



•^•N" t 1* M \KK f1- p 




\\ liM i\\ in i iK n;\i >k. 


•< i . 


\\ ■ iii • 11 s, ., ■ , ■ ,], vy nn»i 


m ' 


lUK I'MIM. \i*l' 




"^l.ili .1' • *, .1! tit ; \ 




v\^t^ oi. 




1 M iii;r 




niK 1 n II. \, ). 




<>i i N riii-.K 




still III I imiiti vi 




MAini N S'SMl 




•>J Mt>Tin,K 




l»r p r • » f.r 4 , ». 




«»H M'.THI'K 




■' ""' '" ' 'Hlflf I % 




• I-AT|f»S* 





A 



b 



lla- 



vX'w 



. A 



v\ 1 



•( 



ux 



t VUtOx 






MEDICAL CERTIFICATE OF DEATH 



>t 



'1 






n ! Hi•f<i^H^ v Ik I UN, T!i:H l^ i'i,.|i 1. ,1 .Iimh a'^eil ironi 
"l^ 'A ^ ^ lb iqnH 



\:" 



thnt 1 Inst sn\v 1i -t '^ alivion ■, ' 190 % 

mill llml <linth 'U'nirrr'fl. 'mi ''i»- iVi'i -iitiil al'i\f, al I 



IMP \ IH'N lV<t; f 



i nNTUinr roRV 



!M f ATfnN jtv;rt 

( SIGNED ) 



Mtyuh'> 



/>rfV 



t tours 



M 



/'r71 



M i 



^v .,',,/ 



/ Jf Wi I fil I A I ^f'' 



/,,,/A 






nt 




n 



■44. 



I »;' .1 



(Afldrtss) 






M.D. 



or Iteeeiif ResMwN, »w# ^wff< <fvf«^ ^av fron hnmf . 



|^,IU,,U„_^ f . 



f ifPflff . W 

WhfB wti «fHf«f f«nff8f fed, 
If m\ »f ^l»f f ftf deaf* \ 



How lom a! 
Hart ftf Ofatli .» 



Dav^ 



ft Af r f.f nt Ri\i, fjR RR\f«iv\f, I fiVTf^.i' fn Mi\f or RKMnvAi, 



T VIiKKT AKRR 




f 



n, B.— Bvefy lt«m of Info^'mwf }«m» aliouM be c«f«fylly winpll-d. AGB nhmild he stnterf RlCACTI.Y. PHYIIfCIANR vfiould 
•tate C4tJ9R OF DEATH In pinin tef*m«, that It mny Ke ppr»perl|r clacttlffed. The "Rpeclpl Infopmatlon" for p#r- 
«««« dying iHfirsir fi-^m fiomo ithmild h» Alv«n In »vei«y inMtiince. 



M 



I(i 





WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



noan! of Health- I- Vo. .^ 'i^^J^^ "^^t'Co 



REFER TO BACK OP CERTIFICATE FOR INSTRUCTIONS 



Registered J\^o, 



4S6 



Ihilo Filed, 'ikvOu IS I'-fO^ 

ifrvJo tLu Deputy Health Officer 

DEPARTMENT OFPUBLIC HEALTH=City and County of San Francisco 



Certificate of Death 

( "CI. S. StanDatD ) 



PLACE OF DEATH:— County of U<X->V JXa>vCi4': C 



i ^ 



-3' 



tX'-w uXa>v^^4-^c 



(?^P 



4, W W^ : ' 



St 



'^ 



Dist.: bet* 



/ IF OCATM OCCUHS *W»Y FROM USUAL R E S I D E NCE CI VC r*CT8 CALLCO FOR UNDER "SPIf 
V if Ot*TM OCCURRCO IN A HOSRIT»L OR INSTITUTION CIVC ITS NAME INSTEAD OF STRB 



njL.cw>\\.i, and 

(piAL INFORMATION" N 
i-CT AND NUMBER. / 



1 



FULL NAME 




0Xy\J\M.O.yy\Al 




1... 



PERSONAL AND STATISTICAL PARTICULARS 



UATK Ol- lURTII A 

r Vlontli) 



,.„. , . 



i 



) V.r » 



:'! 



^1 

(Day) 



Mnvt/li 



1.31 



MEDICAL CERTIFICATE OF DEATH 

DATK OF 1)1:ATH 



(Aonth) \ 



A.. 

(Day) 



rpoH 

(Year) 



.Aw. 
Vtar' 



n,i 



'^INt'.I.K. MARKIi:!), 
\VII)()\V1-1> OR I»I\nRrHl> 

Writ' ill sorial ■Ifsij.niation) 



HIRTHPKACK 
(State i>r Comitrv' 



NAMK UK 
I A IMICR 



HtRTIin.ACK 
Of I \THKR 
(Stii, 1,1 C(nnUry) 



MAIDKN NAMK 
t)H MOTHKR 



HIkTMPi \rv 
OF MOTHKR 
(Slate or Countrv) 



1; I * 



^wf 



.Ctl 



I HEREBY C1:rT1EV, Tbat I attemlecl deceased from 



Avl. 






.1.1. 



IqoH 



lCLm I90S to 

that I last saw h ■. alive on ';^Cs-<La.^.' it 190 i 

and that death occurred, on the date stated above, at i H5 
M. The CAUSE OF Dl^ATII was as follows: 



DURATION Years^ Mouths Days 

.L^dda.^5. 



Hours 



CONTRIBUTORY 
DURATION 



...Si 



}\(irs 



\.o^ 



Ji font As 



Days 



Hours 



occip 



"'""O^v^-U^ 



Rfsiifnf in Stjtt J'niiii i.^ra O \ JVif/ 



^r<^,lfh^ 



/),/v. 



THF: ABOVK STATKD f'KR^^^*A^ PARTirtl.ARS ARF: TRFK To THK 
lUvST OF MV K\o\VI,f;DC,K AM) HKI.nCF 



(liifoimnnt 






(\. Mi CSS 



JAK.^ )\) 



n 



( Signed )....yiiwA»H>A^ i . y A tx^^ih. M.D. 

i^ tqoH (Address) ils^ a^4^tU\< ol 




SPECIAL Information ««»•* 'w H«%#it»it, insMirttetf, Triisiwh, 

•r lecnt ResMents, ani persons dying away from Nme. 



Fornifr or 
Usual Residence 

When was disease contracted. 
If not at place of death 7 



How If flf at 
Placed Death? 



Days 



PI.ACK of BVRIAI. or RKMOVAI, I DATKof IHrial or RKMOVAI, 



!'NnF:RTAKKR 



(Addrew "^^LbC 



r%-ffMUA,tft-V.\. 



^. 



N, B..^Bvef.y Item of Information should be carefully supplied. AGE should bs stated EXACTLY. PHYSICIANS lAouM 
state CAUSE OF DEATH in plain terms, that It may be properly classified. The "Special Informathm** •m' par- 
sons dying away from horns should be ftlven In svsry Instance* 



% 




111 



It 




u 



fl 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

,„„r,l„n,.,l,h-. NO. K*?^*l.&VCo REFER TO BACK OF CERTIFIOTg FOR IN»TRUCTIOWa 

427 



(■ t 





190H 



lUilc Filed, NllA,iu IS 

'L^^.vc* dU/v^ Deputy Health Officer 



Registered JVo. 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



PLACE OF DEATH: — County 



Certificate of Beatb 

( "a. S. Stan&arD ) . 



No. 



y U'*-^^^ '^ ^'V (tLI '^^<^ St.; ^ Dist.;bct. ^A^-^rr^ and J^-^^A^LV^. 

/ ir DCATM OCCURS AWAV rRofcKjSUAl. RESIDENCE GIVE facts called for under -special INFORMATION- \ 
( "iEATH OCCURRED IN AUbsPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. J 



FULL NAME 




"UX/tAxXi 



i)Jxt 



PERSONAL AND STATISTICAL PARTICULARS 



^} \ 



t) \tj: t>i- mu'ni 



ACiR 






co>.oR I . p 



Moiithn 



1^ 

(Day) 



(Vear) 



^t.iuHis 



SINi'.l,K MARKIKH. 



H^ ,...,„, !f 

I. 
(Write ill ■«<KMal lit >j|^iiatiou) I VyN 

lUkTin-I.AOK 

'hUUi iir «.'>>utUryi _V 



Pays 



N\M»-: d:- 

lATHKK 



H 'V C fi 

niRTHIM.ACK ll 

OF I ATHKK *^ ^ 

(Slate «>r Country) (jl ' 



MEDICAL CERTIFICATE OF DEATH 



DATE OF DEATH 




It 

(Day) 



(Year) 



intry 
MAIIU.N NAMK 



OF MOTII-H^^'TU I I q\ 



itlK I HPI,ACE 

HF MOTHER /W 

•State or Country) v(jn 



on 

fKCri-ATlON (^ , i_i. 

t?f}^ided in San Fratniseo H\ )>ars y .\f,iHffis %. /7<7. 



t5 



THE ABOVE STATKD PKRSOVAI, PARTUfT.ARS ARE TRIE TO THE 
HEHT OF MY KNOWLEDGE AND BELHCF 



(Informant 



xXvy^jL ^rixt 



' \»!ilres» 



l%'\) 



'\\^<X. 



(fi. 



n r 



1 HEREBY CERTIFY, That I attended deceased from 

%^Su IH 190H to V-*^-^*« 190 H 

that I last«aw h t . : alive on K-JUj. Ite igo H 

and that death occurred, on the date stated a!)ove, at w l^ 

M^ The CAUSEC)F DI^ATH was as follows: 



nr RAT ION "" y't'iirs *^ Months "X^ Days "^ Hours 
C()N'i;^iBUTORY UwtJkx^N^r:vv\.au cir 




Di; RATION ycats Mouths Days 

(Signed) ^dk^v^^ \- <3\a^^wvcl^-a>4JUL 

u.... ID ^ 



Hours 
M.D. 



%b 



lb 



190 



H ( A.ldress) 1 6H ^ Jhi4Hk->-r%. f^t 



.•FECIAL INFORMATION »«'•> fw Nas^als. toditnHMS, TrMMMl», 
or Recent Residents, ani pcrsMs tfyinf away frM Imk. 



Former or 
Usual Residence 

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



N«WlMf ^ 

Hare ff Death? Days 



PI,ACE OK niRIAL OR REM<»VAI. 




INDERTAKER 

(Adclresfi .. 



DATEof BfRiAL or REMOVAL 

\A^ '"^ T90H 




W, B.— Bvcry Item o» tnfformatton should be cnrefully nupplled. AGB should b« stated EXACTLY. PHYSICIANS should 
•tato CAUSE OF DEATH In plain terms, that It may be properly classified. The "Special Intormatlon** for psr- 
•4ns dying away from home should be given In svery Instance. 




Ill 



/* 



,1^ 



I ^ 



n 




?' 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

,,,„,,r,Kmh , NO ,.i^'ti?S>HS:»'Oo WCFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 

4S8 



Pu/r /'V/f'</, AkvLi H 



O-Cvv^) 




V-M* 



Deputy Neaif^-' nF^'^^r 



Registered J\^o, 



DEPARTMENT OF PUBLIC IIEALTH=City and County of San Francisco 

Certificate of Death 

( TH. S. StanC>ar^ ) 
PLACE OF DEATH:— County of Ha^vOXCU^iCuiet City of ^Om; KSXa^vx^^^t> 



rNa 



^ 



lb ^] kcvc^ St.; ^ Dist.;bct. 1^0-U><X)UL and ^ J ^^ 

/ .r oc.TH OCCUi.8 .v.*y rpoM USUAL RESIDENCE c.vc r*CT8 C*tLCO ;o« 7«>" .■5;";*i '^N Jm^'iI* '*'* ) 
V ir o«*TH occunnco in a mo»pit»l or institution oivc it» NAME instead or stbcct and NuMatn. • 




A..0^^\. ) 



FULL NAME 



.CLVV^Lu^VAjU 



cUa. 



M 



PERSONAL AND STATISTICAL PARTICULARS 



I»\Ti: n| lURTII 




COI.OR 



;) 



iMniitli) 



lot. 






<% 



(Vcat) 



ai;k 



1% 



I Vj» # . 



Mnnth^ 



^ % 



S Pa r. 



«'!N«.I.K. MARKIHf>. 
WIlMiWKI* «»R IMVORCKI) 

(Writi'in •ifx-inl <hsijj'!ialiiin) 



i, 



3 



lUKTIIPl.ACK 
isiiiltor CoiHitrji 



NAMH ri|. 
FATHKR 



niRTHPI.AC'K 
nr lATflHR 
(State nr Cfintitrvi 



MAII>KN NAMK 
OF MOTIIKR 



•>l MoTiiKK 
(hlatf ar Cutintry) 



'31^ 






VjVa 0^4 ' 1. 



MEDICAL CERTIFICATE OF DEATH 
DATE OF DEATH 

lonth) K 



I go , 

(Ycnr) 



<Day) 
I HHRUBV CIVRTII'Y, That I attciuhMl ilcccascd from 

-^— ■ — "Tgo ■ to — 190 ^ 

that I last saw h — alive on "^ :-— -: 190 — 



and that death occurred, oil the date stated above, at 
31. Th? CAT SI-: OF DKATH was as follows: 



^lidih^l) 



...A 



I) r RATION Years 

CONTRIBUTORY 




Months 



, 9), 



Days 



Hours 



-\ 



l^U 











OCCrPATlON 



f^rstfffif lit Sini /'i ,11/, nil) JV«T».< 



Months 



Ihu 



THK AMOVE STATHH PKRSONAI. I'ARTUTI.ARS ARK TRIK TO THH 

BEST OF Mv Iv^owm:i)«;e and nicijKF 



(Infonnnnt \l TvOwUJ. J 



^A%.C' 



kV^^VN^ 



^U'' 



1. 



nr RATION 



(SIGNED) 



y'rars 



^fofif/is 



Days 



Hours 



Ur\.CrvaAj J.'O.U) Xi^^ M.D. 



SPCCTAL INFO 



P 
(Address) UTw^n^^^^ 



or Recent Residents, and persons dyiflf mvi from home. 




W* !Vt ' 



rvllMi •• 
Usual Residence 

H^ WIS disease contracted, 
If not at place of deatti ? 



N«w lonf rt 
Hire*! Deatli? 






• Days 



ri,ACE OF niRIAI, OR RKMOVAI. 



mt m^^ 



nATF:of BiHtAL or REMOVAI, 



JLu A^ 



T90M 



INUERT 



AKKR lL>XA^AX<i. U.A^<Li/ut.cJ(MAA 



(Address 



A il A J A-V» "^T 



I kt \0\v4.^w«'>%. 



N. B.—- «v«|.y Item of Infopmattofi •hould ht cAfeftilly •upplled. AGE should b« .tated BXACTLY. PHYSICIANS should 
•tttte CAUSE OF DEATH In plsln terms, that It may be properly classlflsd. Ths "Special laformatlon" for psr- 
•ons dying away from lioms shoald be given In %yry Instance. 



1 





,j ■ 



i 

HI 






' ll> 



Board nf H< 




l<f 



If 



*|r 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

mh F NO ,. 1^^?*^ nScV Co REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 

429 



loo'i 



Registefed JVo, 



It * -^ l«.t^ ^u f^^ 



1)1,/ r Fih'l, W^U\ \^ 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of 2>eatb 

{ 'd. S. StanOarO ) 



PLACE OF DEATH:— County of ^ <X^A) -1 .r^<X-^xc<JL<U, City of '^CV>v J.'ua.'wautCc 



% 



( ir et.TH OCCUHS AW.Y fro., usual RESIDENCE give r.CTS C*LLC0 ^O" "•, " .""J.AL INrojiJATION- ) 
V %W OCATH OCCUnneO in a M0«PIT*I. oh IWBTITUTION GIVt ITS NAME INSTCAO or •T«eCT AND NUMBtH. / 



fNo. R UxlL^^u- LU-^^ 



3«*« 



Dist.; bet. 




'^-v^ 



and 



FULL NAME 




K 



CL^\Xjl<i^ 




CL^Tw>^\.i^i^A. 



'1 \ 



PERSONAL AND STATISTICAL PARTICULARS 

COM»R 



DAli: nr HIKTH 



A'iH 






VlVL: 



iMomli) 



1 >;i \ ' 



(Year) 



MEDICAL CERTIFICATE OF DEATH 






Pars 



WllHiWKii OR I>fVnRCKD 



niR Ifll'I.Ai'K 
i!>t;itt or Cmiutry) 






"TC^-^^ 



N\M|.- OF 

I '. THHR 



RIRTHPI.ACR 
<M' FATHHR 
JWateor Country) 



MA!I>RN NAME 
OK MOTHER 



• ' >• > ill \.J\K H 

"1 MoTUHR 
"^lit< or Country) 



ll I 



>ATK OF DKATH ^i Ji 

(JMonth) A <Day) 

1 IIHRi:UY C1:RTIFY, That I attciKlcMl Ueocascd from 

— in ■■■■..,„...„„.,. 



(Ye«r) 



190 



that I last saw h tt— alive on 
and that death occurred, on the date stated above, at 
M. The CAl'SK OF DIvATII was as follows: 



7190 
190 






■\ 



nrRATION Veats 

CONTRIia'TORV 



Months 



Days 



Hours 



f^avs 



tKCll'ATION (^ 4_ 



Rfsfdeti iM San f'tamisfo <a5 JVir;.* 



M.nith^ 



* /»<n. 



Tin. AROVE STATKI> HRRSONA!. I'ARTTCfl.ARrt ARE TRIE TO THH 

in-.sT (n- Mv knowi.eix'.f: and h»:iji:k 



(Iiifoniifint 



(AiUlress .... 






DrRATION Viars Mouths 

( SIGNED ) Lo^(n\XK; J ^n Lu laL(x-rwd. 

kA Xl4 Ik^ Tqo 4 (Address) WoXffrU^ 

SPECIAL iNfORWIATfON w'y ^w ^^Ws, I 
or Recett Resists, aid persons dying away from Niie. 



Hours 
M.D. 




IStt 



rorwfr or 
Usual Residence 

Wlien was disease contracted. 
If notalMweof dfath? 



NowIni^ 
PliMtf Ml? 



^^itetb* 



Bays 



TMCE OF III RIAI.i)R RKM<»VAI 



r 1 i 



DA'^Kof^IliitiAl, or RBMOYAI« 

i^ T90H 



F:»f Ilii 
t NDHKTAKKR J fr\]wV ^<V \A U ^ U 



N. B. Every ttem of Informatloti •hould be c«f«fully suited. AQB slMraM b* •tated EXACTLY. PHYSICIANS s^miM 

•tate CAUSE OF DEATH In plain term«. that It nmy k» pi*^>«i*r el^tfl««l. Th« ''Special Infomnatlon** for p«i^ 
•o«« dylnS away from home should be glvea ta m^mrv Instance. 



I I 




/Hi 



\ 



!■ 



I" 






I » 



I 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

R EFER TO BACK OF CERTIPICATC FOR IIM3TRUCTION3 

430 



Jta.r.1 ..f Ihnith - K No. i^ T^^^^^r^v H&l' Co 



h> Filed, NLvJLi. l^ 



Be^istered J\/*o. 



190 H 
Deputy Health Officer 

DEPARTMENT OF I^IIBLIC HEALTH=City and County of San Francisco 



dL/fe-wUi ^M-A^H- 



Certificate of Beatb 

( H. S. StanDarD ) 

, .Th 



PLACE OF DEATH:— County of '^Va^X' T,fvaA\CC4rt City of HO^-A. >v<V>^Ca^<1c 



rNo. jt ^'i-^^ 




St. 



Dist.; bet. 



and 



) 



/ .r nrUTH occu.. .w.» rk-oM USUAL RESIDENCE o.»t ..cTS c.LiEO ">" 7°" ^ccI'InTn OMir'n""" ) 

t ir Dt«TM OCCURHID IN « HOSPlT»L OR INSTITUTION GIVE ITS NAME INSTE.O OF STREET INO NUMBER. y 



FULL NAME 



fila^ci x-o. 



PERSONAL AND STATISTICAL PARTICULARS 

;tx>^^<xU u I 



VJLA.A 






A(,l'; 



■IN< I.l". MARK IK I) 



) '''It I .* 



(Day) 



.!/,'»////' 



,^v... 



« Vrarl 



/^(M 



\\ II). r.\ 1- 1> ( iR m\-()Hri-:f> D h 

t^\nt( 111 soviitl i|isi^tiiili<iii) "^ Ij 



HIKfHI'I.M'K 

'*^t;l!( or I'-Mltltl V' 



NAMI-: OJ. 

!■ m-iii.:r 



niRTlHM.ACK 
fti- I-ATHKR 
'Stall- or Coutitryl 



MMUHN NAMH 
nl MOTHKR 



HIK I HI'I.ACK 
01 MoTllHK 
"-t.tU 111 Cotuitrv) 







MEDICAL CERTIFICATE OF DEATH 



DATH OI- DHA'I'H A ft 

kwLu 



I'l 

(Day) 



(Year) 



-^I 1II:RI:HV CI-:RTirV, That I atteiKled deccastMl from 

J .j<Xt X 190 '\ to ^ ^wU-^ .1.1 190 H 




that I last saw h^'**' alive on NjvvXcu ib 190 H 

and that death occurred, on the rlate stated above, at 2k O ij 
M. The CAi;SK C)l DI^ATII was as follows: 





.v.. 



Hours 



.^ . ^ 



}f,.)ith; 



!),i\ 



OCCIJ'ATION 

Rrsidfii in San Fra misfit %i U )'ttii ^ __^__^__^^.— 

Tin-. MiOVH ST\T}"I» I'FK^oN \1, 1' \ KTICfLAKS AKi: TRTK TO TIllC 

niChT ui- MY KNowi.i'ix.j-; ANii, hj:mj:f 



( A<l<lfes« 









DT RATIOS * )'iars 5 Months 15 /M;/^ 
CONTRIIK'TORY _ 

DURATION Years Months Days 

(Signed) vV'^^v jS o.a^v'-vva.q.oaxju . ^ .-..^. 

^wlu It iQoH (Address) Bt I^MJ^^viJ:^ m^-^ 
^eiAL Information »»•> 'or Haipftals. IwWatlJBS, Tra»sl«als. 



Hours 
t^v M.D. 



iSPE^IAL INFORMAT 

or Recent Residents, and persons dying away from home. 

Former or d4^(\ * * a L ^ . %^* *1 **®^ '•"« ** 
Usnal Residence Or NpU. ^^\« J' l5 (SAfv pjaf e of Oeatlj ? 

When was disease conttlcted. 
If not at place of deatk ? 



X^xa'u. Btys 




l)ATH«»f Hi'RiAi. or RKMOVAI, 



1^, 



niKIAr. OR RKMnYAI, 

LcXXJtMT^^ . 

9^ \)a.^v Qu^ DU:^ 




190H 



(Add 



rcss 



N. B. Every Item of InfoPfti.tlon .hould be cwi^fttlly nup^tad. AGB .hould to stated EXACTLY. PHYSICIANS should 

state CAUSE OF DEATH In plain terms, that It m«y he properly classified. The "Special Information** for psr- 
sfwis dying away from horns should be itiven In svsry Instance. 



' li 



i\ 



i 



\ 



r t. 



file 



II 



),o 



f' 



^1 

i 



Tloiird <.f !Ii:iUJi » 




/)<//(' Filed , 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

vo „iS;?^SS!fe;»&PCo REFER TO BACK OP CERTIFICATE FOR INST RUCTIONS 

431 




IH 



WO'^ 



Registered JVo. 



^fyU^ cLt^vj, Deputy Health Officer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Cei'tificate of Death 

( "a. S. Standard ) 



of ^ <X^' ' 



m 



PLACE OF DEATH:— County of^Ct^' TV<V^<:x«.CO Gty of 'OAvO^avvc^C^ 



•i 1, 






rnand 



) 



/ ,r Dt.T»'oCeU.» .WKY f.OK USUAL RESIDENCE O.VI F.CTS C.LltD '<>•< ""•'" .'?.'";" J "."jMiJ',"" " ) 

V ir ot«TM occumicD in • MO»Pit«L on institution give its name instead Of STStiT <N0 Nunsin. y 



FULL NAME 




4 



,OJx.u ^IWhJXXX^JJO 



■1 




-»:n >^ 



PERSONAL AND STATISTICAL PARTICULARS 

I COI,OR \ 



V A 



LL JvCtjL 



nxiK <ii lURTU 



\>V. 



Qu, 



(M.mth) ] 



1% 

(Day) 






J V<f I 



M,»itfis 



(Vfar) 



Pa vs 



-iN'.I.i;, MAHKIKI) 

W IDuUKn OR niVORCKI) 

iWiifi in '.nriiil (U-<ij?iialion) 



C)K^y\,<x 




lURTHJ'I.ACK 
M.itt (.1 Country) 



N ■ Ml-: OK 

! \ rm-K 






mRTin»i,ACR 

fH' lATHKR 

'M;it< or Con ti try) 



MAIDKN NAMK 
<)l- MOTHKR 



itlK riJIM.ACK 
')!• MOTHKR 
(Slate or Cuuiitryl 



OCCll'A'l 



Mfl CUU4 n I vn^xxx]^ 



Till* SHOVK STATI'.n PHRSONAI. I'ARTICri.ARS ARE TRIK T<> TIIK 
MKST OF MY KN'0\VI.l%r)«/.K AND HKIJHH 



Uiiforniant 



^^lulJ 



(Address 



( 




rx) 



^ 



U( 



MEDICAL CERTIFICATE OF DEATH 



DATE OF DHATH 





AaXv, 



I 



Month 



(Day) 



(Year) 



:HRKBY Cr^RTIFV, That I attended deceased from 

1 190H to . I ^W- .1.1 190 S 

that I last saw h -tiAJ alive on ^wUii- : \\ T90 H 

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

M. The CAISH OF DKATH was as follows: 







DL' RATION ^ }'ears 3 Months^ Days 
CONTRIBUTORY ■l.^rXSr^.^iA^S^^f^A 



Hours 



DIRATION ^ Years ^ Mouihs ki Pays "Hours 

(SIGNED) Jo. -J. UwcJj^>UJl 



SPEC! 



f^ 



rqo 




H (Address) LKAJ^^il/y^^, JOM- 



M.D. 




_. Information w!> fw ttes^s, lastiMtoBs, ii^fcrts. 

or Recent Residents, and persons dying away from home. 

former or fk, 3 1 i' y HowlonfM ,, 

Usual Residence »)-tnJ5wiAXu VaX piare«f Death? ' Days 

When was disease contracted, i 

If not at place of death? 



I'LACR OF RIRIAI, OR RF:M<)VAI. | DATK of BiKiAL or RRMOVAI, 




y9oH 



(AddreM 



XbisAo 0^\A^4..ur^ dt 



N, B. Every Item of Information sltoulil be carefully supplUd. ACE sHould hm stated EXACTLY. PHYSICIANS shMiM 

•tate CAUSE OF DEATH In plula terme, that It may be properly claaalfled. The **8p«ctai Infoinnatlon** for per- 
aone dying msvmy from home should be given In msmrw Instance. 




^'^Mi 



; • 







4lir 



W» 



4 




WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

, ..,„f,u.itl.^.-No...^^^^H.^>'Co REFER TO BACK OF CERTIF.CATC FOR INSTRUCTIONS 



\c^ 290 S Registered JVo. 

3s^tCU5 dsXAHu Deputy Health Officer 

DEPARTMENT OPPUBLIC HEALTH=City and County of San Francisco 



Certificate of Beatb 

( XX, S. StanDarC* ) n ^-- 

m i ^ 

PLACE OF DEATH:-County of ^ ^ 1 ^ - . - -City of Ua^X) J.)U^>V^C^eo 
rNo.HR Lcl14o\a%.c<U St4 X Dist; bet. ^ ^ O^^v^ <r>VU.f , and I T ^- 1 W I fi • - 

I ir OcHtM OCCUHHCO in « MOBflTHL OP INSTITUTION OiVE ITS NAME INSTCAO OF STUtET ANO NUMBEH. • 



FULL NAME 



,L^Lf».W' 



c^ u Mil. Lc.iwLu 



Y 



^i;\ 



PERSONAL AND STATISTICAL PARTICULARS 

I COl.OR 



^ 




ok.t 



Ii\T!' "! iURTH 



\!.K 



II 

1 H j>.j»< 



^vfr 



Drtyt 



M,t»ihf 



\ < a I I 



A#' 



ufiMnvKU UK nivoKCKn 

i\^'ritr ill M)i-i:i] (lisii'nalioiiJ 



HIRTMl'I.ACK 
hUiu- »)r Country* 



NX Ml- ni 
! \ III i;r 



"IRTH J'I.A<-K 
<>l 1 APHHR 
>i ii. or c"(niiitry) 



maii>i<:n namk 
•>i MornKR 



"i Kill I l.Ai h 
<>l' MOTIIKK 
'Stall i.r Country) 




• >rrri'ATION J 



f^f.'itlrif in .Sint I'l aiii I'lo 



y 



MEDICAL CERTIFICATE OF DEATH 

DATH OF DHATH A ,, 

Hi.clu iv. 

(Month) X (Day) 



(Year) 



^I HEREBY CURTU^Y, That I attended deceased from 

— ■ ■ TI90 — ~ to \qO~ ■ 

that I last saw h -- • alive on - - 190 ~ ~ 

atnl that <loath occurred, on the <latc' stated above, at — - — -- 
- M. The CAISI: OI- DIvATH was as folU.ws: 



)'i n I s 



Mniltll^ 



J>tl\.- 



THK AnoVKSTATK.n PKRsONJ^I, I'ARTKC t.ARH ARIC TRIH To TIIH 
IJKST OF M)i KN0\VI.F;IM".H AND \U%\A\:V 



(Informnnt 



fA'Mrt- 



i 






Dr RATION Years 

CONTRIBUTORY 



Months 



Days 



Hours 



DURATION ^ Years Months Pays 

( SIGNED ) .,L^\^rraK^ 1 ^b UJ.. AaX^/w^k 



mciu I '. 190 . (Adi 

Special inforwati 



iress) vevrvvi\.^ 



Hours 

M.D. 



or Rtcent Residf nts, and pfrsons dying away from hmne. 



Former m 
Usual Residence 

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



H«w JMf at 
nacetf Oeatli? 



• Days 



PI^CK OF BIRIAI. <>R RHMUVAI. I DATK of BtJRlAI. or RSMOVAt, 

VN1»F:R lAKHR 



fAdf1rc««. 





0-v^M-AX ot 




N. B. Bv.ry Item of Informstloti should b« earsfully supplied. ACB should bs stated EXACTLY. PHYSICIANS should 

state CAUSE OF DEATH In plain terms, that It may be ppopeHy classified. The "Spsclal Information'* for ■-— 
s©ns dying away from horns should be 4ivs» In svsry Instance. 



¥i III 

W 



t> 



T 





1 



^< 



^' 



I 



. 7 



11 



t 




WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

,„, ,r n..l.h-F NO ,. ^> ^^..«^.-Co REFER TO BACK O F CgRTIflCATt FOR INSTRUCTIONS 

433 



i«\ 



190H 



Dale Hied , 

i M d Deputy Health OF 



Registered JVo. 



' '- rr 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Certificate of Death 

( H. S. StanOarO ) 
PLACE OF DEATH:— County ofUOm; ^hAX^rsJUAZLOij of HOa^; 0X<X.mx^4 tXi 



(Na I 



HS lbt)-wixNA 



St4 ^ Dist.;bct. 



^AXt 



and I 



lIv 



/ ,r DEATH OCCUR. AWAY FROM USUAL R C S I DCNCC C. VE FACTS CALLED ^OR "NOCR .'»;";*i '!; ^^^"JJJ ',*»•*■ ) 
V IF DEATH OCCURRED IN A MOSPITAt OR INSTITUTION GIVt ITS NAME INSTEAD OF STREET AND NUMBER. / 



) 



FULL NAME 




■vu 



(]0'^ 



hJJUy>i 



PERSONAL AND STATISTICAL PARTICULARS 

DATl. tH !5IRTIl 

n M 



(Month) \ 



\' .)■■. 



I Day 



M,mf/f 



^INC.I.K. MARKIKI), 
\V|TiM%yHn OR DIVoKtHI) 

•Wiit' iti <ifKMal (It'si^iiatioii) 



lUK rifPI.AOK 
iSi.iu or Country) 



FAi HHR 



BIKTHI'KACE 
')!• lATIIKR 
iStatr «)r CDunlrv) 



MAIhKN NAMK 
<»F MOTIIKR 



HtKTHPr.ACK 
<)l- MOTHKR 
(Slate or Country^ 



OCCUPATION 



Oj^tAUxxL U m K^ 



iVt-ar) 



Ai 1 



MEDICAL CERTIFICATE OF DEATH 



DATE OP DKATH 




n.. . 

(Day) 



(Yeari 



I II1:REBY certify, That I atteniletl deceased from 
|lX^V 10 190H to |\JLl..I'1 190 S 

that I last saw h A./Y>\ alive oa W It 190 H 

u J '3> M A 

and that death occurred, on the date stated above, at O. \ w 

} ^. The CAUSE UE DUATIl was as follows: 



^<>^ x^rrv^wCU; 



Ls^... 



Dl' RATION ^ years 
CONTRIBUTORY 



Moni/is ' Days 



Hours 







Kh. 



Kfsidfit i„ S,i» liatidsfo %%ytats I \ .\fnMfh,^ Pavs 



THK AnoVR STATKn PKRSONAI, PARTICt'LARS ARH TRt^' To THK 
HKST OF MYJKNQWI.KDC.K AND HKIJHK 



(AddreM... I 



^% 









DURATION Years Months Days Hours 

(Signed) LI. J- Xx-rvx^cxn-^s, M.D. 

11 looH (Address) 'LnjJuX/v^^y^jU" 




a 




^PEcHaL information wA) foi n^Ws,l»dnilfoi$,TrMinrtr 
or Recent Residents, and persons dying away from liome. 

Former or Now lonf tf 

Usual Residence Place of Death ? Days 

When was disease contracted* 

If not at pire of death ? 



pi..%5^in nrRiALOR rkmovai. 




T>AT^:of H;|'RiAL or REMOVAL, 
■ia 190' i 



INDKKTAKKR > 

(Address^.. 



J.vJ L^'WVX.Cr^V . 



N. n, Every Item of Information should be carefulljf supplied. AOB should bs stated EXACTLY. PHYSICIANS should 

•tate CAUSE OF DEATH In plain terms, that it may be property classified. The "Special Information** for — — 
dying away from home should be given In myfry instanes. 



r»t 




I 



WRITE PLAINLY WITH UNFADING INK 



Biirir-l i>r II. ill 



h V No. 15 "^jS^ H&H Co 




1 ' 

• \ i 

I 



'.' 



t 




THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATC FOR INSTRUCTIONS 



\'\ 



190H 



Registered JVo. 



434 



])ff/r Filed, 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of Death 

( U, S. StanOarD ) 

: ^ ■:. Gty of tX/Vu K<X' % \ c v-a C o 

ft^ i n ^ }h (ft "^ i^ 

rNo. i^l ^JCtN„^tK- U\M. St.; Dist.; bet. v) ^wLA.<r>\' and - v 



PLACE OF DEATH:— County of^<^"^v Vi \a^ 



/?) 



(I 



) 



/ ir oc.TM occuns .WAY rRO^i USUAL RESIDCNCE Give r.CTS CM.tto ^OR ^^CR "'""'•i 'J'^";;:'°~" ) 
C ir DEATH OCCURHCO IN A MOSPITAt OR IWSTITWTION OIVC ITS NAME 1W8TCAO OF STREET AND NUMBER. J 



FULL NAME 






mNi\^^v<Lv 



ij 



\ 



PERSONAL AND STATISTICAL PARTICULARS 

COl.oK \ 




1 < i' I" I 



\r.K 






L 



lVf»».» 



n 

(I>:«v) 



M.inftn 



I "« car) 



/)»l I .V 



SIM.I.H. MARHIKH 



|%\>!t» in "-III i;il ilcsi^iiaiiiiii) -ni u 

niRTHPl.ACK li r^ ft 

(Htate or Country) -A Mjl I U 






^ ■C' , 



FATHKR 



HIRTHn.ACK 
nr I ATHHR 
Stat.- (»r Countrv' 



<»|. MOTHKR 



ink iHi'LACK 
Of- MnTJIHR 
JStau- or Country) 



W 






\^ 



MEDICAL CERTIFICATE OF DEATH 

DATl-: iM" i)i:ath 



,1 



lonlh) I 



ll 



i 

(Day) 



(Year) 



I JI Iv R i-: BY C i: RT 1 1^ Y, Tbat^ I atj^ciuled deceased from 
I90H to 






igoH 



that I last saw h 



alive on 




ami that death occurred, on the date stated above, at 
M. The CAISJ-: UF I>I:ATII was^as follows: 



1> 



§1' 



J cJtx/>veiu, V 



;J\a^ 



fi 



nr RAT ION Years 

CONTRinrTORV 



Hfouths 



Days 



Hours 



I 



^ 



a 






11 



XN.'v^^<X>^U 



Rfsid^ii itt Situ Fiiinfh^ti 



y,-i 



M,niffts 



/ht I .« 



TIIH \H<)VKHTATKI> I'HRSONAI. PARTK'f ^AR^i. ARP. TRl K n> THK 
in%ST <»I MV K^'OWI.IJX'.K ANI> HKMHF 

J y 4 



ntifrMmant 




Adclrc*^ 



1)1* RAT ION 

(Signed) 



it 







Days 






Hours 
M.D. 



^^ 190 H (Address) 3^3> Ltvvv^ t i 



^PCeiAL iNrORMATION m for Hm^h, InWrtiMS, TnNmcirts, 

or ftetrnt Residents, and (persons dying away from home. 



Former ir 
Usual Residence 

Wkei was disease contracted. 
If not at plareof deitk? 



Hmt lonq at 
Bare of Deatli? 



%9S% 



PI,ACR 01* BIRIAI, OR RKMUVAI, I HATK of IH'RiAi, or REMOVAI, 



INDHRTAKKR 

(AddrcsB 




^- 



(o.(?.(?-. 



N. B. Every Item off Informiitlon should bs careffally Rupplted. AGB should b« •ttttcd BXACTLY. PHYSICIANS should 

state CAUSE OF DEATH In pisin tei«m«, that It may be pPO|i«Hy classlffsd. The '*Sp«cial laformstlon" for psi^ 
sons dying away from homo should Im given In svsry Instance. 



H 






M 



I 



^U 



Ul 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



H.,;.,n1 of llt-alth F No. is T^^^^^H&PCo 




I)a/r Filed y 



Registered J^o, 



435 



\°[ 190'\ 

"Xjuy,,.^ Deputy Health OflfJcer 

DEPARTMENT OFPUBLIC HEALTH=City and County of San Francisco 



Certificate of Beatb 

( TH. S. StatiOarO ) 

i ^ A '"V 

PLACE OF DEATH:— County ofC'a-i\;^)AXXoA.Cx.^Coaty of ^ J 'O^a; ^vap^va c t 
,No niol >1^LLv .d!v St.; ^ DUt;tet-Ux3uL^a/i^a. and*^'; • VL'Lt ) 

( ir Dt.TH Sccu.. .w.y r.o. OSU.L RESIDENCE G,«t r.cT. e.Li" '•""»''" """;*i;?'«°„";iJ',°" ) 
t. ir 0l«tB oceumito in • Me»piT«i. or institution oiyt 1T» NAME in»ti«o or «T«ctT tNO NuMain. j 



FULL NAME 



U, 



I. a 



K.~x 



^Cl\. 




SKX 



ii\ ri-: Of- lUKi'H 



PERSONAL AND STATISTICAL PARTICULARS 

C01.< )R \ 



A< . H 




II 



> 



! 






(Vear) 



O b iVrt#» 



Month <• 



nu\. 



^tvr.i.K. MARRIHI). 

uinnwKi) OR ntVt>RrHi> 
'Write in social dt-siif nation) 



lUKTMlM.AOK 
'State or Country 




^ 



N \M1- or 
HATIIHR 



lUkTllPl.AiK 
')|- I ATIIKR 
(Ht.it. or Country) 



maii)i:n namk 

ni- MoTHKR 



HIKTHPI.ACK 
OF MOTHKR 
(Stflte or Country) 



Ol>^\ 






A 



I 



y^ 



,x^^'. 



1 



Lt>\£4-^-^VU* 



AVn^VCft^C 



<Hv ri'ATloN 



Mlc 



u 



.^lMj^ 



xL 



%f„uths 



Ihi 1 



Itesidfd in Satr Fiami.<ro ■ > ^ ? I't t > ' 

THK AHOVH STATl -n PFR^ONAI. rARTlCf LARS ARK TRt'K T< > TlIK 
BK8T OF MX KNn\VI,i;DC.K AND Hl-MUK 

fitlfof Mtflllt 






(Adtlress . 






MEDICAL CERTIFICATE OF DEATH 

DATK OF DKATH 

11 
(Day) 




fpO \ 
lYear) 



I III'KICBV Ci'RTll-V, Tlial I altcmk-il deceased from 



IX 



«^ 190^ to HAAAluL I i 190 H 

that I last saw li V"» ' alive on %^-Mj, l» 190 H 

and that deatli cK:currcd, on tlie dat^- >.tated above, at » %i 
d M. The CAl SIC ()1* DliATlI mvbh as follows: 



<r7<'^\jM*-A^Luc.A-4»^"r^ tu..i^ 



I>r RATION 3» )>ars 



Afopilhs . Days 
CONTRIIUTORY LL\L4,?^.^weoJL UjSl'' * 



Hours 



nr RATION 
(SIGNED) 



Years 



Months 



SPECIAL In 



Days 



90H (Address) HCl ^ CM^a kt 



Hours 
M.D. 



or Recent Residents, and persons dying away from liome. 



Former tr 
Usual Residence 

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



Flireof Deatii? 



Days 



PI^ACE OK BIRIAI, OR RKMfJVAI, j DATK of, niRiAt. or REMOVAI, 

klAJUi IH 




I90H 



rNDKRTAKKR 

(AddfeM 



uJ\Mu4.Mn.j 



N. B. Every Item of lnffoi*m«tlon •houlil be carafully •iipplled. AGB •hoMM b« stated BXACTLY. PHYSICIANS •bovld 

•tattt CAUSE OF DEATH In plain terms, that It miiy be properly claestned. The ^'Special Information** for per- 
sons dylnt wmmw fwHW home should be ftlven In svsi»|r Instance. 



H 






't 



n 



T' 





1 



lir- 







;f 






WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

RCFER TO BACK OF CERTIFICATC FOR INSTRUCTIONS 



,,,,,,.1 t n .:.ith 1-No.i's g^?Sgy^H&''C^ 



Registered JVo. 



436 



icer 



Ihi/r riled, NLlA-Ui. I'i I'^O'i 

iWo ittu Deputy Health Offl 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Certificate of 2)eatb 

( la. S. StandarD ) 
PLACE OF DEATH:-County of ^'a^ ^^a^XCUvlCity of '^ ,w -.ACV>vtvA,5U) 



(ir ot*TH OCCURS *w«W rR 
ir DEATH OCCURHCP IN 



im^.ff^SFtiura 



w^wwww. St.; Dist.;bct and 

AM uiuAL RESIDENCE GIVE rACTS CALLED FOR UNDER "SPECIAL I N FOR MATIO N" ^ 
A MOiJ.TaI: or institution give its name instead or STREET AND NUMBER. J 



FULL NAME 



vLt\Ai\ca 




-i:\ 



PERSONAL AND STATISTICAL PARTICULARS 

Cnl.oR 



^l>\.alt 



\X^i>h 



iiAIlC ()!'• niRTIl 



\*.v. 







11 

'Hay) 



/ k 



a t U 



) '*■(/ / 



M.nillr 



\ I :H I 



I >it 1 



•>tX<;!.K, MARRIH!) 
(W'nttin »<n'i;il c|« sii'iiiit i'Hi) 



lukrm'i.At'H 

(Stnli III roiniti V I 



X XMI ()!■ 
I-ATIIHR 



HIRTHIM.ACK 
«H I \THKK 



maiih.;n namk 

<>I' MOTH MR 



i5IRTIflM,ACK 
•>l- M(»THKR 
(St;iic or Cuunlry) 



(H rii'ATioX 




^VVwTL>V^'VV^*1a 



tl 



\.\ 



«» 



i\tl I'l It ll( i^Ci) 



)'lltl 



H ^r>•^^fflf I 



Pa \s 



THK ABOVKHT\TI-n PKRSOXAl, J'AkTKT f. XRS AR K TRIH TO THK 
HKST OH MY KNOWMinr.K AND HIUJHF 



(I 






(Address 



9.5 00 




'VeXJ 



MEDICAL CERTIFICATE OF DEATH 

1)ATH OF i)i:ath , , „ 



fMonth) 




'Day) 



(Year) 



I IIHRHBY CI':rTII-V, That I attciKkd deccascil fn^n 

hJ. .11 igoM to .^Ha^JLl i% : 




\uKjOJ\J \:X i9o'1 

tbnt I last saw h W » i .alive on 



T90H 

A^ A L 190 H 

and that death occurred, on the elate stated alK»ve, at ^ 
WV-M. The CAlSIv OT DMATII was as folU.ws: 



I )r RATION -- }'('ars ^ Months 3 Days * Hours 
C ( ) N T R r R i; T (3 R Y ^T FXaXw,uX^.4XA^4 



Dl'RATION * Vvars i AfofiiJis " Days 

(SIGNED). \m\ ^ ATy\xx;v4JLoJX 



Hours 
M.D. 



^vliU- 

pecIal Information ^ for Hospiws, instittttitis, TraasfeBts, 



KkLu \% iQoH (Address) ^5^0 



g 



V^MT^UCit 



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 

Ware of Death? Days 



ri,ACK OF ntRlAt. OR RKMOVAU 

(JvD X3L/<V0UW 



DATKof lUKlAi. or REMOVAI, 



INDHRTAKKR 

(Address 




N. B.^ ^Bvcry Item of Information should be carefully supplied. AGB should bs stated EXACTLY. PHYSICIANS should 

state CAUSE OF DEATH In plain terms, that Jt may he properly classified. The ' Special Information' for per- 
sons dying away from home should be given In mvry Instance. 



I 



i 




f 



V 



II 



w 



-I 



i» 



I 



J!,,:i!.l Mt 




'I; 




WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

neFCR T O BACK OF CtBTIFICATt FOR IN8TWUCTI0W8 

"" 437 



lte:.1th- I' No, i^ "^5:. 



t> USi. 1' Co 



!)((/(' Filed t 

1 



\^ 19 OH, 

Deputy Health Officer 



Registered JSTo, 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of Death 



{ xa. S. StanDard ) 



PLACE OF DEATH:— County ofO/a^v ^ Xo^x'^isjl 



City of ''^"vx» XXX/^yA.^CAA/<U. 



1 \ r- 

No. O 1 . 



X 



1.1 



St 



Dist.; bet. 



and 



--.^ ••eilAI Br««IDENCE GIVE FACTS CALLED FOR UNDER "SPEOIaL INFORMATION" \ 

( " r,'r»TH"c";-.;"v,"°"»o.*-"*t :.'?«n?u" «"». ,« n.me ,».,.« o. .,«.j .no hums... ; 



mTU^xIam ) 



11 



FULL NAME 




siA 






:. 



PERSONAL AND STATISTICAL PARTICULARS 

I COI.UR ^ 



i)\Tl- t)l' lURTII 



A».K 




UjJ-v^lx 



vlWvOb 



(MoiUhl 



H 

(Uay) 



{ Veav ) 



b 6 )V,J<A O 



yt.itit/is 



IH 



/'</ ) A 



^IVi.i.j* MAKKIKH, 
WI!)(>\Vi:i> nR l>IV(»KCKn 
iWrilciii social cU'sij;natioti) 



niRTUPI.AOK 
' stall i>r rutjutrj*^ 



Qf)w 




N'AMF Ol" 
KAIIIHR 



HIRTHI'I.ACK 
ni- KATHKR 
(State or Oouutry) 



MAIDHN NAMK 
nl' MoTHKR 



1-1 K ( II I l.ACh 
iSiatf (M- Country) 



<>v:cri'ATlON 



K/Uud^ 



(J XVwvcX/>"^u 



UJIXAVUX^ 




KfsMfif in San Frnnr/.wy I ^ ?>,?>.< * ^f.>nt^^s 



/hn 



THK AnoVESTATi:!) J'HRSoNAl, rARTlOr I. KR>^ AR 1% TRTK Ti> THH 
UHST OF MY KNU\VJ,i:i)C.H AND HHI.n.F 



JC'W 



(Itifornmnt XTnA^ ^ a4x^-i^^-^U 

cAddreM 3r; xjAAxo^ ot 



MEDICAL CERTIFICATE OF DEATH 



DATK of- nKATH 




(Day) 



(Year) 



I IJHRIvHV ClCRTIl'A, That I attenrlcd <leceascd from 

..m^-W looH to ...HM-W )^ 190 H 

that* I last saw h '• alive on ^\AA^ I t> 190 

and that death occurred, on the tlato 'Stated above, at \ 

M. The CArSR OF DHATII was as follows: 



n 



DURATION }Vv7;g 

CONTRIBUTORY 



}V<7rj Months ^ Days ' Hours 

sLhsJ\Jry:),.sj!Z..^^^ 

C!\V{nvv/^A-M^M-^XA^ Q-C^'wiAA:S.i. 

DURATION "^ Years ' Months * Days " Hours 

(Address) lOloS" dto ^WHDwhA.al 



(SIGNED) 



fek 




w. ^^.«.- INFORMATION onlv for H«$pitils« lasHhittoM, TrMdfaN, 
9r RecfBl ResMeits, aN pfrsans dying away from home. 



Former or 
Usual ResMence 

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



How I9119 at 

Plife of Deatli? |^s 



PLACE OH BTRIAI, OR RKMOVAI, I DATK of BURIAL of REMOVAl, 



,« 



^L«-tJct^x., ja.i 



(Address 



N. ft. ^Bvery Item of Information .hould be ca-efully .upplled. AGB .hould be .tated EXACTLY. PHYSICIANS should 

•tate CAUSE OF DEATH In plain term., that It may he property claaatficd. The Special Inrormatlon for p«i>- 
•ona dytaft away f«»« boma should be given In ^yrv Instaace. 



'! 



HI 
■4 







f, 



oRill; 



I 



U- 



1 



m 



k 



H,.av! -f I! 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

RCFCR TO BACK OF CEBTIFIOTg FOB INSTRUCTIONS 



i.,lHi-l--No. 1= *Se^'>'"'^"'' 



Registered JVo. 



Dale Filed, VkA^Lu iH -?^^'^ . 

%<S'V^'^^ Itv t. Deputy H .h omcer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of 2)eatb 

( Ta. S. StanDarD ) 

City of ''<X>vO 



of UXX^^V 



\XWw^^A.CC 



PLACE OF DEATHS— County c^^f^ ^ .^a->\<:^v 
M^ ^?i\ ^ULk St.; 2, Dist.;bct. LLl^ and 

INO. V ">■' ^ . W w 1 ■% .,-,,., BrcinrMCE riwr rACTS CALLED rOB UNDER "special INFORMATION" \ 

( '^ rF^DrATt^oL^u'R^EVirrHO^.^PrAt o'r" ?,;;t%"u^tU' V./e 7tI SlAilE INSTEAD OF STREET AND NUMBER. ) 



U d^<VMjJUL ) 



FULL NAME 




xs^ 




^ ^■ '% 



'-liX 






j'c 



PERSONAL AND STATISTICAL PARTICULARS 

COl.OR \ , ft 



ii\ n-: OF lUKTH 



.1 



u 



,-t., 



\'.K 



I ^ «^ 



iMcHlth) 



)>(?», 



I Da y I 



.!//;;////( 



^Ibl 

(Year) 



Pa 



SINC.I.K, MARklKl). 



\vri)«)\VHi> OR nivoRrKi) ^ 

(Writf in stKinl «!fsijfnalioiO 1 \ \ i i 



lURTIflM.AOK 
'^t.iti .ir I'niintry 



NAM!' Ol' 
lATUKR 



>X.^"MJ^%; 



HIRTHPI.AOK 
oi" lA'IMKR 
' stall or Country 



MAIDHN NAMK 
OK MOTHKR 



• « 



niHTHI'i iff? 
OF-' MoTHKR 
< State or CouiUry^ 



nCClPATlON 

Kestdi'd ill San r'tatins,viA}i )'^aif .\r,>irtfi> 

TIIK ABOVE STATHD PHR«;ONAI, I'ARTICfl.ARH, ARH TRVK TO THK 
BEST OF MY KNOSVl.KDC.K AND BKMltK 



I hi V. 



fli 



' ijl 1 IN .>« »%^ 1,1". l'»i r, .-».-••» #.»,.<«» J. 



(Ad«lr€»« 



ii.4^LLitH^<^^ 



MEDICAL CERTIFICATE OF DEATH 



DATE OF DEATH 



lonth) / 



li. 

(Day) 



(Year) 



I UERKBY CKRTIFv, Tliat^ attended deceased from 
,S 190H to ., .^ArJLi, li iQO H 



kVAjLu, l.i 

tha^ I lastHiaw hXhj alive on H^-XJU^ 11 i«)'. 

and that death occurred, on the date stated above, at C> 



\? M. 



The CAUSK OF Hi: AT 1 1 was as follows: 



C<XA. c.^ -i vcrs^^.<x^ . 



^aE 



i 



Dl'RATION ' )V<7;vf 
CONTRIBUTORY 



.yotithft 



Pays 



Hours 



Dl'RATION )'t'ars sMotiihs I 

(SIGNED) J4. ob <x>w<i.A %vA vnia. 

N|\.A.lu it iQoH (Address) ^ lb M/l 



Pays 



Hours 
M.D. 



A 



-,\ « 



^PEcI/al information only lor Hospitals, Instltotlons, Traislwts, 
•r Recent Kesidents, amt persMS tfytng dwdy irom home. 



Former or 
UsNal ResideRce 

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



Haw ^ at 
naeeof Deatli? 



... Days 



PI,ACR OF Jll'RIAt, OR RKMoVAI, I DATKof BfRlAL or REMOVAl, 




wl f^ *'* »<>oH 



^ 



INDHRTAKKR C^.^.^^^%^K-4>V ^^^ i^V^yvt ^ 

(Address... .....3%.!lfi.kb.. \F rL4^4-4,4,fir>^.. :'i. 



N. B. Every Item of Information •hould be c«r«fMlly .applied. AGB should b« stated BXACTLV. PHYSICIANS .tioald 

state CAUSE OF DEATH In plain terms, that It may be properly clasalfted. The Special laformatlon for psr- 
•ona dying away from home should be given In mvmrw Instance. 



I 



M 




f 



m\ 




I 




H 



^■^\ I 



\m 



u 




f H 



P' 



!i 



-"iA 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 






7.90 H 



Be^isteved A^o, 



439 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of Beatb 

( U. 5. StanDarD ) 



PLACE OF DEATH:-County of ^a>^ ka>vec4.cc Gty of^Om, ^ Va^e^^t 



A 



No. 






uX'd.s.^nx; Li 



' '^ ».»j 



St.; H Dist.;bct. H„ a\.M.4. 



/ ir M.TH oecuM .w.Y moil u«o»i. ?5«j?.«;N,f,^„'i'«,'.j,*";;; i»„E ,»,ti.o or .TiiitT •NO >.u>oc>. y 



,^„.. and 

"o;".T°-"o?c"u%*.".V.'»":"-.".":t O-r^T-.TJVV.V.vr.Tt i.»«C .-.T»0 O, .T.«T .« 

FULL NAME LcUuv>v Ll>^d^X«.--r. 







U^ 



PERSONAL AND STATISTICAL PARTICULARS 



• i;x 



^\X 



COI,UR 



II 



I'K [ \ > '! IIIK 111 




1% rl^^ 



O b )V4?»* • I 



I>;iv> 



\f.„ff/i 



I V«-ari 



Par. 



-■•--• 1.1" MARRIKU. 



hiuthpi. \.*k 




OJiJvAwVci 



VSMI oi 
FATHl.R 



k 



n 



L^ 



jLi.i^a^\x w. ^^axi.L 



niRTHPI.ACK 



"I McrilKR 



fIfRTHI'I.ACF. 
«»F MfiTHKK 

•^1 i»i ■ II Voiuitrvi 



" 1 VXTinN Jl 






it 



aw 



J 



0, 



f^fuilfd iM Sat' i mill i^ri> 



) rit I 



Af,>Mt/l . 



/h!\ 



THK 4BOVP. ^T1 r|-|> PKRWINAI. I'ARTHMURs ARK TRTK TO TIIK 
HKST O! MV KN«»WI,Km".K ANU HKl.IKI" 



< Addrt«« 



•XI ^'TnxuL 



MEDICAL CERTIFICATE OF DEATH 
DATE OF DEATH 



(Month] 



1 L 

(Day) 



fpoi 

(Yenr> 



1 HI:R1:IJY CI:rTIFV, That I attemled <lecease<l from 

— —190 to — — — IQO^ 

that I last sawh .. alive on - ■ >90 

and that death ocrurred. nii the dnU- dialed above, at ~ 
M. The CAT SI-: (H DIATJI w-as M followa: 



1)1 K AT ION years 

CONTRinrTORV 



MottlJis 



Days 



Hours 



Dl RATION 



Years 



(SIGNED) Ub^^vOA; 

* 

■i 



Months 



Days 




<jjLcL' 



Hours 



)•■#• 



ti\ 



Uw L^ : I 190 t { AddrcHH) SJ^\Jt ^ v.wV^ ^' 4 



iPECIAL iNPtmMATION ^ tar ^km/U^ li^tiiUtns, TrMSkits, 
m ^nm In^Kis, «NI ^enim lyiffg tm^ IrMi **— ^ 



•r 
If NtMNirtili^i? 



nrerf 1^1? 



N« 



I'l^ACE ni in RIAL <»R RKMoVAI. j IIATK of BrRiAL or REMOVAL, 

ill I \jfVW'luVv<-»v . JL 



(A4dre«« 



W. 



■«very Item of lnfor«i«tlo« .hould he ear.fMlly iiypplled. ACB •Hould b« •**t«j[BX^TMr. .^^^•^f *f,* 

•t«tc CAUSE OF DEATH In plain tei^s, that It way be pi*o|»ertjr vlaMlfffod. Tfc« ^se^ IMBrmatioM for p«p- 

•rnic dying away fiHwii home vhould he 4lv«n la avary Inataiicc. 



I 



••IT 



f 




• I 




B.n.iU ..f Health- I- No 15^^ 



WRITE PLAINLY WITH UNFADING INK-THIS IS A PERMANENT RECORD 

REFCB TO BACK OF CERTIFICATE FOR IN8TBUCTI0NS 



11& I' Ci 



Be^istered JVo. 



I)„lr Filed, Vvlu "^^ ■'^^'^ 

\ Nvcl 1^ D«l>"ty Health Officer. 

DEPARTMENT OP PUBLIC HEALTH=City and County of San Francisco 



PLACE OF DEATH: — County of 



Certificate of Beatb 

{ Ta. S. StanOarD ) 

City of LvrUAU/ 




^"W^ 



%As/>. 




I a 



No. 



-St 






-and 



^»., Dist.;bct. — -"' . 

.••iiAi or«ilOCNCE Give r*CT8 CALLED rOR UNDER ' SPECIAL INroRMATlOW \ 



) 



FULL NAME 



t 



>xv<rw 



L,-' Q 



^\cLc\4r^\ 



-rs 



PERSONAL AND STATISTICAL PARTICULARS 

I I' 'I.I »R \ , 




oJut 



1 Ml lUKTII 



OOw 



M'.nthi 



H- 



Ai.K 



ob jv</.^ I 






M.itidi-. 



9.H 



■» «;lf ) 



/>.fr 



^!N<.I.F, MAKRIKH 
WIlMtWKI) tiK niVnKfKtl 

U;i!. in ^iH i.il fit *it»nati«»ii) 



(Stnleor Cmintry 






F ATI IKK 



BIHTIII'I.Al'K 
<^H. FATHHR 

' •! C'.iuilrv 



'H .Mi»THKR 



?UK! lift, \VV\ 

•'II i'ATlUN 

Rf<iiifd in San l'i,iii,i ••> 




ll 



(vdUiAA 



\^ 



\>o 







A^'-O.U 



\ I ai 



St.nilhi 



Dn 



THK AWJVK»T*THI» I'KKSOSAI, P \KTI* T f A Rh AK I" TK I K T< » THH 
IlKHT OF MY KNOWI.KIX.H \SU nHI.IIlH 



'lnf«,-munt 




(AdclreM 







MEDICAL CERTIFICATE OF DEATH 



DA TK OF I)I:aTII 



[\ 



Month) 1 



(May) 



1 1 
IQO \ 
(Year) 



^ I HKKi:i'.V 11:RT1I'V, That I attcn<UMl <U-oca'ie«l from 

— — — ' —190 to . •-■ -■•■ 190—— 

that I last saw h ' alive on Kp ~ 



an.l that «Uath occurred, on the date stated alKJve, at 
^I. The CAI SI'! (U I>f:ATII was as follows: 



I) r R A I" I ( ) N > i'arK Mouths 

CONTRimroRV 

D!" RAT ION Yiiirs flf,niths 

(Signed) vtWrvM 



Days 



I Jours 



/hn 



cLwA^' 



■v 



Hours 



'\\j >%» 



^V4,U^ ll I (|0 ' ' f A dd ress) 



iy^kXa>%H la* 



^PE.6l/kL INFORMATION •■»? fw Ros|itals. IrMHiMns, TrM$ie«ls, 

m ^»l fcilfcrts, i^ m^ <yN ***y ^'^ " 



i , 



MMfcucf "^ I C k^\aA%Av.. . . rStTirti? 



Iq« 



When w« 4l!»ise fwlriclH, 
|(iiotatplirc«f<e«tli? 



PI.ACB OP niRlAI, OR KKMnVAf. 




I NliJCRTAKKR 



OA^ri'o^' Bi MlAl. or RSHo\'AI« 
'XO f90H 

Hi (^ 







WC5WVQ L^^Jv^UX/VU 



•tate CAUSE OP DEATH In pl»ln term., th.t It may h« proptrly elassHWil. TIw •p«;1»l l«toi««tloii for pvr. 
•9fi« dytnft away from homo alimild b« 4*v«« l« ovary loataaca. 



'I 

V 



f ■ I J' 



% 



I 



•f 



toi 



I I 



I . 




WRITE PLAINLY WITH UNFADING INK 



I. lltll I" N'd. !^ "*^L* 



H&rco 



J)((/r Fi1c<L 



ac> 



i^OM 



THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 

Regisf creel J^o, 44:1 



lfrvw>tLu Deputy Health Officer 

DEPARTMENT OFf UBLIC HEALTH^City and County of San Francisco 



Certificate of Beatb 

{ la. S. Stan&atO ) 
of Clav^ a>va^yvc^<:x City of '^Va>v aAa>vc^.c :■: 






<i5i^ 



I'No 



PLACE OF DEATH:— County 

T>4 'icia^trrvu St^ ^ Dist.ibet. <SaA and "^ MV 

^ I O A \J » (^^r^YV rEsTdENCE give r.CTS C.ILIO rO« UHO.B ••.►tCl.t INfO.M.TION- ■) 



FULL NAME 





A 



x(Xk<>^ 



flli 



PERSONAL AND STATISTICAL PARTICULARS 



-i.K 






COI^OR 



lOiv^^ 



in II'. nl- IUKT1I 



X'.K 







6v )>.;» 



It 






M.nilh^ 



iV<:ir) 



Pit vs 



^IN'.l.K MAKKIKD 

U llMiU )-,l» OK 1»1\< >m'i:i) 



Vnla^^oui 



'Slatr in CmuitryJ 



N XMI- (H 
I'ATHl'R 







niRTMPt.ArK 
ni* I ATIIKR 
'Stall- or Country) 



MAI1>KN NAMK 
OF MOTHER 



HlRTIUM.Ari: 
i^latf t^r Country^ 



AXL^vv 



I 1 



1- 



;! 



MEDICAL CERTIFICATE OF DEATH 

DATE OI' DKATH 

loiith) 1 



1^ 

iDay^ 



(Year) 



l|_ 



I iTiuTkh V CI-RTII'V, That I attcivkMl acceased from 

,, _ , 1 90 " to ■■ ' 190 "^~ 

that I last saw h "^— alive on ^ = I9O •■ ■ 

and that death <x rurred, on the date stated above, at 
M. The CAUSIv i)\' DICATH was as follows: 



.-yvcaam. a cctW^4A^^^*^ 







l*^:r,j[S)M':X 



DIRATKJN }\af'S 

CONTRIBrTORY 



DURATION ytutrs 

(SIGNED) V<^V0-N\UV 



Mouths 



~'\\Axm 

Days Hours 



Months /}ays Hours 



ft 



vs U »Ku iqo 



(Address) CyUTVUX'^ U, 



M.D. 

At 



OCill-ATlON 1r\p '1 

Hft'idett in Sail /'i mu i^iit », a )'lM^ 



LI 



.'i/nUfhs 



n,i 1 > 



THK ABOVE STAT |-,U I'KRSONAI. I'AKTU! LARS ARK TRII-: in Till-: 

nRST oi' Mv KNo\vij%i><".K ANi» Bi:i,n K 

15 H Oo-Ll' 



(Inffjtmnnt 



f \(t<lro«^ 



.tr>vv 



SPECIAL INFORMATION only for Hos|Htal$, InstititiMs, Traisinits, 
w i^XRt flrsi^ttN, Mtf frn«R<k dying away fron bone. 



Former or 
Itsval ResMence 



*'ow If 1^ at 
Piarert OcM? 



Iiys 



When was itamt ctntractH, 
If iiotatpNreitlMMi? 



l»I,ACE,oK nt* RIAL OR RKM«)VAI. 



k 



^ I < 



DATKofHiRiAf, or RKMOVAr. 



i\A.tc 



'^ t 



r 





(Address 



' ;■ 



190 






n^tr^T.. 



N. B.— Ever. It.n, of lnfor«.tIo« .hould I.. ...•fuH. -PplUC AOB .ha«ld *»- -i-^'f^^^.^.^j;^.^ XI1Il1lt-*i^" 
•tate CAUSE OF DEATH In pMn term., that It may he properly clarified. The Special Inform.tloa ffpf par- 
aofia dying away from lioma alMMtld ba given In avary Inatance. 



1 









i t 



I 



l( 



I: 



t ' 



I. 




.1 > 



i 



■ \ 




M 



i 



li 



'I 



WRITE PLAINLY WITH UNFADING INK-THIS IS A PERMANENT RECORD 

REFEH TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



|i 1 






i^KxJ iiUNU Deputy Health Officer 



Registered J^''o. 



442 



DEPARTMENT OFPUBLIC HEALTH=City and County of San Francisco 



Certificate of ©eatb 

( XX. S. StanDarD ) ^ 

:ity of O/CUYvfcou 



PLACE OF DEATH:-County of C) (nrV^r^^TUXi Gty 



of n 



UVm^oj 



nV. 



No. 



SU 



-lDist.;bct.-^ 



~ and 



FULL NAME --^— ^^ VO^-^^- 




PERSONAL AND STATISTICAL PARTICULARS 



^ i ^-^ VOL 

n\ i I. <>r lUR IH 



u 



•oI.dR N 



lli.^.L 



lMo!lt1ll 



'.'■.i: 



IK MAKKIKn 



(I);«v1 



Months 



/ I'l'i. 

(Years 



/),/ V.v 






MEDICAL CERTIFICATE OF DEATH 

DATK OF I)1:ATH i i „ „ 

!l 



rgo \ 

(Year) 



I IIIIRKHV CERTIFY, Tliat I attemle*! deceased from 

— to 



190 



"^90 
—190 



^ 



trMJ- 



HlRTIilM.XOK 
(Stall- or C'umti v 



FA IHHR 



niHTUI'I.ArK 

fii- » \rni-:K 

-^\^^< .1! ("oiuitry'i 



MAIDUN NAMK 
OF MOTHKR 



1'! k' I'll pt sr\' 

»U MoTMKR 
(Mntc or Country) 




I 






vev^*->v 



1 1 



that I iMst saw h r—^live on- — ^-~-r— — 
and that death occurred, on the date stated atiove, at 
M. The CAT SI-: Ol* UIIATII was as follows: 



nr RATION years 

CONTRIBUTORY 



Afonths 



Days 



Hours 






n 






Da vs 



DURATION y'tars 

(SIGNED) "^^ . . „ 



Hours 

M.D. 



^ TQON 



*H CrPATION 

fif't'itrif in Safi Finn, nfo 



)'i'a> 



^r„n^hi 



PtlVf 



Tin-. AHOVl- SIX III. PKR-^<»NAI. i'A KTUT t.A RS ARK TRf E TO THK 
IJHST OF MY KNiJWIJUX.K AND »KIJF:f 

(li'.f.injuinl 



tJ-wiu, AJt>"VV«%'-tLjk 4%A-^./VL^«X 



Af1<lres!» 



Ipccial Information wiy t«r H«s»itais, institatiMs. TrM^Mis* 

kcMl ^^Mts. Ml ^rsi»s tf)i«i away frw fc^. 

« Ikqrs 



NrmerM' 
tlsval i^sMeiKe 

WiM wm 0anu CMtrartH, 



Now l9i^ at 
Plareof Death? 



PLACE OF Bl RIAU OR REMOVAL 



rNDKRTAKKR Njl J ^<^ \^ ^ 



DATK of HiRiAi- or RKMOVAI, 



rgoH 



(Ad<ltcSK 



mt 



•t.te CAUSE OF DEATH In plain termn, th.t It may be properly cl-wlfted. TU. Special Information W par 
•on* drlng away fiHWi home ahoald be 4iven In every Instance. 



I ■; 



.1" 



(» 



f 





ni..ri!.vnh- i-No. i^-n^^^ 



n&r Co 



WRITE PLA.NLY W.TH UNFADING .NK-TH.S .S A PERMANENT RECORD 

HEFER TO BACK OF CeRTIFlCATE rOR IN 3TBUCTION8 

443 




Deputy Health Officer 



Begisterecl JV^o. 



DEPARTMENT OJ^ PUBLIC HBALTH-City and County of San Francisco 



Na 



PLACE OF DEATH:— County 



Certificate of Bcatb 

( Ta. S. StanDarD ) 

J ^ 

ofV 






^ 



St 



.11 






^ 



tj 



V IF DEATH OCCURRED IN A HOSPITAL OR "^^^y " y^ 



Q^ 



FULL NAME 



\J 



[xKT-^^YSJOJS vljJtc\.^MU^ 



PERSONAL AND STATISTICAL PARTICULARS 

IS A « ft I COI.OR 





^\\^Lt 



.b 



t| lURTH 






. 1 15-. 

(V.-ar) 



AOI- 



,1 /,.»////.' 



-INi.t.l' MAklvIKH. 

U 11 M I \\ i; 1 1 I » k 1 ) t \*« > K (' !•: H 

IWt't- Ml v(,ci,(i ilc^i'^Mlati'ilO 






N WU oj* 
1 \ I'll l-.R 



ISIk THI'UAf'H 
'»! rXTIlHR 
'st.it. .ir Country! 



>!An)l-N NAMH 
Ol- MUTIIKK 



5S »''-"^ i 



/),/ 1 



MEDICAL CERTIFICATE OF DEATH 

DATE OF DKATII , , „ 



/90 ; 

(Year) 



Moiith)J' 'I^«>'^ 

rHBRRlirY ctfRTll'V, That I attetulea deceased from 

l^^.,^ 1 innH to H:V^-W^^^ ^9oH 



that I last saw h 



190 



((5? I] /15 



..alive on H^V^J^ 1 i 
aii.l that death occurred, on the date stated above, at ^^ 
(? M. The CAUSP: OF '''^'•"^'l^V^'"'' ^^ follows: 

^..AjkX,' 



/>:Y%.'0U CTk 



fcr Q!wk.w^^a ;i 



nrRVriON ' )Vvz;-^ % ^/oulhs ^ Days -Hours 



CONTRIBUTORY 



,u^ 



t > T , . ■ I I f f . f I , « 1 • 

"1 MoTl'lKR 

I Stall (It Country^ 



'JC:Cll'ATU)N 



aAjXo.^» 



A 



Krsitfrd ill Siitt /i tim rm 



)%',ii^ * M"n>li^ 



/>-/ 



THK AUOVKHTATKI) l»K.RS< »N A I. J'AkTH' T I.AKs AKi: TRt'H TO Till- 
BKST <)]. MV KNOWMUit.l-: AND HHIJIJ- 



DURATION years Afouths Pays I/oins 

(SIGNED) \jH.Vy IXm-^v\v M.D. 

\KkMjl%^ n)0 ' (Address) 3^'b%b - \'\ *U\^ ot 



opEC^IAL INFORMATION only ^^^ Hospitals, Institutions, Transleiits, 
ir iecwl lei'»4e«lSt M ^rsttis tfytas «riy ffw *««. 



Former or 
UsHil Residence 

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



How long at 
Place •! Deatk? 



Bajfs 



I'l ^CH 01 HI RIALtiR RKMOVAI, 



(Iiifonnant 







V\^-^4> 



ISIiHUTAKKR 



[Address 



DATE of BrRiAL or REMOVAI* 
JLA XI 1903 



•tate CAUSE OP DEATH In plain term., thot it may b« pi-opeHy cl...Iflea. nc op* 
fltm« dying away from home ahoald be given In every Inetance. 



W 



4l 



i : 



ii 



WRITE PLAINLY WITH UNFADING .N..-THIS IS A PERMANENT RECORD 



f 



Dair Fih'<l, W-W "^^ 

•Lv^lt^H^ Deputy f 



REFER TO BACK OF CERTIFICATE FOB INSTRUCTIONS 



100^ 



Be^istered JVo. 



444 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of S)eatb 

( Ta. S. StanOacD ) 






K 



. nn ^. ^thO-a L^ « ■ City of 6t(Kiufct! >v C CVx 
PLACE OF DEATH:— County of U^Lorx. |0-lv.i^l. v-.ty oi 



1 

., 1 



^No. 



SU 



-Dist.;bct. 



—and 



— ) 



OiA -L/ISI., DCU UNDCR -SPECIAL INFORMATION" \ 

V. ir OC«TM OCCURKtO 1» • HOIPlT«L 0« lH»TlTUTlo™ ^_^ ^ 



FULL NAME 



'JLaA.V'5/ 







':\\ 



I 






^ 



• IK 



P»ERSONAL AND STATISTICAL PARTICULARS 

I COI.t»R 



t\TH til lilRTII 



Ul.k-- 




ittonth) 



At.l; 



Q 

)v«/» 






V. '»/'//' 



Vi-ar'i 



I go i 

(Yenrl 



MEDICAL CERTIFICATE OF DEATH 

DATK in- DKATll A 

"TllHRlCHV Cl'RTirV, That I atten.Ud deceased from 

— — 190 tu -:- ■ >90 

that I last saw li «livc on - ' *^ 



" .1 



It > 



t 



uiijmwki) UK nivokvKn 

'Wtittiu mjcitil ilc^i if nation) 



'A^'^Xt 



HIKTIUM.X'J-, 



t ATllHR 



mKTHIM.MK 
n|- I ATHKH 
'HttUf iir Country) 



'u MirruKR 



<H \I(»tiii-;r 

iMiitt or I'ritmlry) 



oi'tri'ATION 






L 



and that death ..centred, on the date stated above, at ^ ...-...■ 
-M. The CAUSK Ol* DHATII was as follows: 



.CVCL 



cJrXU 




ur RATION years 

CONTRinrTORV 



Months 



Days 



Hours 



DIRATION Years Mouths Days 



1<)0 



( 



Address) 0*ttr^^^tfr>v 



Hours 
M.D. 

n 






SPECIAL INFORMATION o«ly *or Hespltals, Institutions, Transients, 
tr RetMl ttsMcats, 1^ W^m m% ^=>^ '^*" ^^ 

ftiys 






/',( 



THi: ^BOVRSTATIM* I'HRSONM, r\K rUtl \R^ AKi: TRl K fi > Tl h 
IJKST OH MV KNMWIj;n<.K AND H^:M1,^ 



\-1.11 ••<*«« 



M^ 



-I I » 



^ t 



Former tr 
Usual Residence 

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



How long at 
naretf Dealb? 



rU.^CK OI" BI RtAI. OR KKMnVAI. 






DATIvof m-RlAl. or RKMOVAl, 

yLAX^U '.^X 190'. 



:ri. 



■■■■^^■■■'"■■^'^■^"■^^'■'■^■^■^"" „ . -«R .»,„.,irf h. atated EXACTLY. PHYSICIANS slimilfi 

N. B.— Every Item of lnform.tlo« .hould b. c«r«f«Ily "«PP"«?- „i?^Hrc,„Sfted! The "SpecW Information- for pr- 
.t«t/cAUSE OF DEATH In pinio Urm., th.t It mmy be proi^rly vlawWled. p- 

•on* dylnA «w«y from Mme .hoyld be ftW.n In evory In.tnnce, 



h 



I 









M 



I« 





t 



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

,^ ,.,„ .» B.rK OP CEWTIPICATt FO R IN9TRUCTI0NS 

Uc^ '14 Oeput, Health omce, 

DEPARTMENT OF PUBLIC BEALTH-City and County of San Francisco 



Ccrtiticate of IDcatb 

{ la. S. StanDarO ) 



PLACE OF DEATH:-County of CVa^v ^ \a/.vc^^'Chy 



.^ 



^? 



(3^ 



cvi^'-City of^''<XAvO 



A^Xao/C^-^ '■-c 



PLACE UP UtAin: — v-oumy v.. 



) 



FULL NAME 



^<X. 



<^ 



XAV 



Dx> 'Jvt'UvU 



■^i \ 



PERSONAL AND STATISTICAL PARTICULARS 

COI,OR \ 



W\\aXx 



a 






HATK »H- lUKTII 



\i.K 



, n ^"' 



(>!finth> 



^S 



) "f't/ 1 



(Day) 



Mnntlis 



(Vc;»rl 



/!</ v.< 



MEDICAL CERTIFICATE OF DEATH 

HA IK <>|- DHATH 1 I L ^, 



(Month) n 



<I)ay) 



190 

(Ye.tr) 




W IDnWK.n OR niVORiK.n 
•Wiitt ill «»f>cinl <Usit'iiatic>il) 



luK rinM.xcK 

isi.iti (if i"oi\iitry) 



N \M1. i)».' 
t'ATHKR 



RIRTHI'I.At'K 
Ol- I AIIIKR 
iHtate fir Cmmti v) 



MAIUKN NAMK 
<•!■ MuTllKR 



Iff r» *ftf ♦»» , , » , . 

«»!■ MnVuKK 
(stntf or Country) 




-y\i 



I lIliKlCBY CKRTIFV. That I atteuilcMl <krcasca fnmi 

\ lb 190H to.||lY^^: '90 H 

that I last saw h '-- alive on T ^^^ ' ' ^^O^^ 

and that death cKCurred. <.., the date stated alxne. at ^^^ 
UL M The CAl'Slv OF i>HA'l'»» ^a-s as follows 



^jclvA^vv^x X»U.'»^^> ■. 



I)^RATI()N JVtf'-^ 

CONTRiBrTORV 



Mofilhs 



Days 



't' Cl I'ATION 



Q o^-vcLa 



Rfsidfd in San f'lanchfn 



^ )>a>s - .^/""^*^ " '^" 



TIIK \BOVF. ST\TKI) PKRHONAI. l-ARTtrr 1,ARS ARK TRTK TO TIIK 
DKST OF MV KN<)\Vl.KD<iK AM> HHI.IU* 

(Infornmnt \X ■ ^ SX 



DrRATION 
(SIGNED) 




Viuirs A font As Days 



Hours 

Hours 
M.D. 



M 



C^ll TQO' 



(Address) 



s 



^wW^ V 



. .4 . ^ 



gp^QI^^^ INFORMATION onJy ^0^ Hospitals, Institutions. Transients, 
or R«e«l feasts. Mi ptrsflns <y!fl5 a*ay ?tw ^m. 



Former w 
Usual Residence 

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



Hew toiif at 
Plareof Death? 



Days 



(AtldreiMi 







^.a4%aX<X,a. 



PLACE OF nt'RlAl, OR RRMoVAI, 



DATKof BfRiAi. or RKMOVAI^ 

AiM..^V . ,9oH 



INDHRTAKHR 

(AthlreSH ... 










— ^'■^ '"^*"'^* ., . .^p -K«..iH h> tttated EXACTLY. PHYSICIANS shovlcl 

N. B._Bvery Item of Information .hofW be car.fully •"PP»^*J; „^„5;Hr",-..lfted. The "Specl.! Inform.tlon- for psr- 
•ftc CAUSE OF DEATH In plnl« term.. th« It may >»* P^"^*''*^ .l...lfl«d. 
nous dylnft away from home •hould b« given In every Inetunce. 



il 



I7 



^ 




I ' 



I 



(1 






(IPI! 



1 1 

/ 



> 



lA 






• » 




WRITE PLAINLY WITH UNFADING INK 




Ihi/i- I'ilc'l , 




•w 



VJO'A 



THIS IS A PERMANENT RECORD 

REFER TO B ACK OF CERTIFi r.«Tt FOB INSTRUCTIONS 

lie^ialered JVo. 4-4D 



X^.^ ^taK. Deputy Health Officer 

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

Certificate of Death 

( H. S. StanDarD ) p /?pi 

PLACE OF DEATH:-County ofC^a^v OAXX > .C> . Oty 
.U it 1 St. 5 Disfbet. J^U^^>^' and il;^V^.^O■-l^ 

V ir DCATM OCCURW^P IN * MOSPIT-u wn ,^ 






FULL NAME 




^DOva-o-'^'-^ ^frV^ 



4- 



1 



PERSONAL AND STATISTICAL PARTICULARS 



«HK C^ 






IjA I 1 . .1 lUK I'll 



Coi.uR ^ 



iM..ntlO 



\(,1' 






)V.f. 



u 



<I):«v 



,1/,.w,'A.v 



1^ A» ,», 

, L C . - 

( Vi-nr) 



Da 1 J 



MEDICAL CERTIFICATE OF DEATH 

DAiH oi i.i:atii ^ ' i) ^^^ 



/po t 



''iM I I" M \RU1KI>. 



.HKii «ir*.ij?nalic»n) 



lu 



niRTIUM.XOK 

citric m! "■■.llUtl V' 



SAM1- OV 
1 ATIIHR 



niRTHI'l.ACH 
OP FATHKR 
iSlolf nr Cmintry) 



iWAn»i,N NAMK 
tt] MoTllKR 



<>i m<»t'hV:r' 

'^tatr ni Country^ 






^^TllBKlCHV CHKTIFV. That I .lun.lc.l acccasea from 

i...A^ 190^ to^W^ it I90't 

that Ilast saw h alive on ' ' M ■ »^ ^ 

a„a that .Uath occurre.l, o„ the .latr stated alKive, at <^ 
M tbe C\rSK l)F 1)I':ATII was as follows: 



0^*.rV< 



CONTRIIU'TORV 



1 Mouths I H /^avjr - Hours 



|\0 -4"\'%A„ia.Ll-:>:*^^«A.'*. 



'»■«. 




iXv 



Rt<.i,ifil in S,iti riattnffo ^^S V"?'j^ 






DERATION ^ >V<ir* 1 J/owM.? IS /?«W //ours 

(SIGNED) wL^v 'kjX^tk • M.D. 




I /T 



^/.ntff 



/h,\ 



THK ABOVE STATltn PKR^ONAl. PARTUl-t.ARH ARH TRt R TO 
HKST OK MY KrioWI.KIX.K ANl> lOI.n.l 



(infonnnnt 




'Afltlrcss . 






oPECIAL INFORMATION •««> lor Ho^P"*"^- Instimtions, Translfih. 
Of Retert terftots. irt fersws <yli| «^ km taM. 



Former w 
Usial ResMeiKt 

Wlie« W4$ disease cenlracted, 
If not at place of death? 



How 10119 ^ 
m^9H BetM? 



•WJ 



rUAC£^Or nf RIAI^OR RKMnVAI. 




HATKof BiKiAi. or KEMOVAl, 

wlu ai 190H 






N. B.— Every Item of Information .houici h. c«ref«lfy •«wrf»edU J^^^^/^^^^^l^^ ^he "Special Inform-tlon" for p.r- 
•tate CAUSE OP DEATH In plain term., thot It may ^ J^^*"'' 
;«. drtag aw., from home •ho«Id b* *lv.n «« ^vry !««*• »ce. 



^ 



I'M 



W 



.( 



* ' I 



1? 



'i'\ 



m 




m 



\ 



WRITE PLAINLY W.TH UNFADING INK-THIS IS A PERMANENT RECORD 

REFER TO BA CK OF CERTIF. r-ATt FOR INSTRUCTIONa 

„„„,.„fn,.i.i. i-N ,....>Sga»""^'-^" . _— — — M/ti^ 




Kegistered JVo. 



.^^.rwv^' .wv^ Deputy He-'t^ ^P'-^r 

DEPARTMENT OfIiBLIC HEALTH-City and County of San Francisco 



Certificate of S)eatb 

( *Cl. S. StanDarD ) ^ 

f?t^ -J( 



f'No. 



PLACE OF DEATH: — County of va^v J \a-» 



1 



x'tu^ct City of ^' O^yv V^S-^w^ix-^/c^ 
Di-t.! bet. ::-:.::::.., ..,^. 






') 



FULL NAME 



t)crv^A-CcL4) 



SK\ 



PERSONAL AND STATISTICAL PARTICULARS 

I COLOR \ A 



J rLcJu^ 



vvctc 



DATK tt! ItlRTIl 




KK^ 



I 



\<.K 



J 't'li > > 



I 

IDiiv) 



Mntilfn 



(Year) 



n 



/?f? 1 5 






>^lN<.l,i:, MARKIKn. 
WIl»u\VKl> OR n!V<»Ri.KI> 

(Write in sm'ial tlfsiynalion) 



^,c>vaU; 



MEDICAL CERTIFICATE OF DEATH 

DATE OK DEATH {\ \] , -^ . 

ll t9o\ 

(Day) (Year ) 

i^RlCBY CrTRTIF^TTliat I attejidctl aecoased from 

lb 190 H to Ww...l4 190 H 

that 'l last ^^ss h ..L^malive on J^*^ ^'^ '^ ^ 

ana that death occurreti. on the .hite stated above, at ^ 
CLm. The^CAl'SK OF DHATII was as fo!lo>*-s: 



d 



"■^ ' jj* ; 1 



HIKTHPI.ArK 
'*^t u> or CountryJ 



NAMK «»I- 
HATHKR 



BIR'DII'I.AOR 
OF I ATHKR 
IState or Coutitry* 



MAIUKN NAMK 
Ol- MOTHKR 



TURTIfPT *f*P 
OF MOTHKR* 
(Slate or Country^ 



nccrPATlON 

Resided ill San /■'iaui/si-» 







L ft^X^V^^^- VVA->fr>v. 



Afoiiths 



Day 



CONTRIBUTORY (:^ ,-1^vdw44|i^^^ 



.six 



Hours 



sL.ia 



Hours 




t5^^\\uQ. 



r, 



V.ir.c ^ ,V, 



»(////' 



/)<;) 



THK ABOVR ST^TKD PKRHONAI. PARTU't'LARS ARK TRlK TO TIIK 
HRHT OF MY KNt)Wl,lvr)(;K AND lUU.lKF ^ 



DURATION .^'^'^''^ ^^.^''"''" ^f 

(SIGNED) iTl lyIla^A.I;^,J€^ M.D. 

\% IQOH (A ddress) X5 'J Ji/WV(>^X.5l 



sWcwL INFORMATION •«•) 'of Hospitals. InstltBtloiis, Tra«slf«ts, 
•r tecert tesMtnts, iirf pefsw? ^yl"! «wy fr«» *~~ ™^~ 



Former tr 
Usual ResMence 

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



How lonf at 

pliceof Deatk? - 1^ 



PI^\CK OF HI HJAI. OK KKMoVAI, 



(Itifomtant 



Addre- 






liArj-:of j^iRiAi. or REMOVAL 

HA,^.t^i 15 190N 






INDHRTAKKR 

(AddrcJiii 



I 



N. B— Bv«Py Item of l«form«tlo« .hould be Carefully ""PP"* J' ^^^H^^l^liiTfui'^'^h^''''^^^ fnforw.tlon- f«^ p^P- 
state CAUSE OF DEATH In pNl« term., that it may »»« j;^'"*' ulM.imii. 
•an* dylnt aw.y from horn. «ho«ld be ftlven In •v.ry ln«t««c«. 




(1 



< 



I 



it 







^ 




• i 



i 



■i 




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

""" „FER TO » r.K or C.:RT.P.CATr rOR ,N8TRUCTI0N3 

H&l' Co 




/)rf/r FiJrd, 



i "iju^Li. Deputy Health Of^-^r 

DEPARTMENTOf'pUBLIC HEALTH=City and County of San Francisco 



Ccvtificate of Bcatb 






ipfo. 



Dist;bet.- 



"and 



PLACE OF DEATH:— County of^'CV.AV 

V ir OtATM OCCURRCD IN A HOSPITAL OR INSTi ^ ^ 



) 



FULL NAME '^^^^ OC-aM/vwa. 




PERSONAL AND STATISTICAL PARTICULARS 



I) s i r^ t.i luK rn 



A'!-: 




a 



y,-in 



(Day) 



Mutilln 



I - 



(Vt-ai ) 



/).r 



MEDICAL CERTIFICATE OF DEATH 

DATH OK DHATH U ^ 

1 IIHRHBV CliuTIFV, TliatTattendea <lc.vasc.l from 

- to .^rrzzr:.:. .:" 



190 



'Xq/Q 



siNi 1 1- M AKKIKH. 
\\ 1 iM >\\ 111 < tU I>iV<»R»"KI> 
Wsii' iu -.,Hi;il (U^i^'tiatioii) 



I'.jK niri.M"!-'; 



ill ' ' _ ti _ 



N 'Ml (H- 

1 \ riii-R 



FUR IHI'I.XrH 
'H I \ IIIKR 
si;i!i (It i"niintt y) 



MM|i1-,N NAMH 



"1 Mo'liniR 
iS!;tl- <i! I'.iuiUry) 




that I last saw h alive on ^^^ ^U C\ ts 

,„a that .U-ath occurred. o„ the <late statcl above, at «£) ■ U U 
Q M. The CArSH.C)F niiATII was asj^follows: 



^^ 



-^ 4 

xA-<*-'*VVA^ 



^, 



I '^ 



^x^crvox It) a\t/vvxxx ^vv\j 









"^ 



nrRATION >Vv7r5 

CONTKIin'TORV 



J\Ionths 



Days 



or RAT ION 
(SIGNED) 

A 



Years 



Months 



Pavs 



Wvrv^ 



\ 






Address) V 



.rLCi/%iiM w,Us ^ 



— m- 



Hours 

Hours 
M.D. 






/ >,t\ 



\0 O^C^.'^vv^c*. 



SPECIAL INFORMATION on«y «or Hospitals. Ins!ltutl6ns. Transients, 
or Recent RtsWenh. t«# ferwiw dvinq awav from homf. 



Former or ^ \ I 

Usual Residence ' ^ ' 

i^^ tvM disease contracted, 
II not at place of death? 



1 ^ 



How ioni} at 
Plareof Death? 



r"t 



toys 



I'l \CK <>1' IH KlAI, OR K)M«tVAI 

lU 



tiATI."! H'lUAf. or RHMOVAI, 

UiuwLu O.t 190', 



I'HK AllOVK STXTKH PHHSoNAI, f XRTIc'r !. ARH ARH THrK TO TIIH 
HHST t)|- ?.iy KNo\Vl.i:i)<,l% A^'^ lU'.IJll- 

N. B.— Bvery Item of lnform«t1on .hould bt ..-.t-lly ";»^»»"'J; „^op^.rtr"l«-^«*d^^^^ l«^o",^.tlo«" for ^r- 

•tate CAUSE OF DEATH In pl»l« term.. th.t It mmj, ^^^^^^^ 
.<m« dying aw.jr from hom« should be ftlv.n l« .vry l«.f»ce. 






(AcWres* 



I I 



f 



1^1 



i 




u 

• t 



..■i; 



' . Ill 



ri 



WR.TE PLAINLY W.TH UNFAD.NG .NK-TH.S .S A PERMANENT RECORD 

..^ REFER TO BAC K OF CERTIFI CATE FOR INSTRUCTIONS 

Board of .„■.,.- r NO ..-^Cg^H^^'^" 



Begistered JVo. 



449 



Dull i lied , \tUXU *U 

DEPARTMENT OF <>UBL1C HEALTH=City and County of San Francisco 

Certificate of 2)eatb 

PLACEOFDEATH:-Countyof6a-ixa>vc...GtvofO^JKa^^ ^^ 






) 



No. 



FULL NAME 



LL;>X'^v 



^ 



^•\ 



u, 1 



PERSONAL AND STATISTICAL PARTICULARS 

COI, 






■■"" u 



DAIH or lURTIl 



iMi.nthi 



\'.j: 



i 



},,n 



I I):tv) 



M.vtlr 



\ «ar' 



At 15 



MEDICAL CERTIFICATE OF DEATH 

i»ATK Ob Ul-.ATH J, „ 

(Month)J 'I>=^y^ ^^'^'»^^ 

I HKRl'BV UvRTIFY, That I attenaed .leccased fnun 
.W>>JL Xb looH to... I^^^-K ^^"^ '^ "^ 



w n » I w J-: I ) • > K n : VM K f K i> 

'Urit« ill >.<H iiil <U»-ivri'iitiiJii) 



llfV: I'Hl'l. \rK 

*-t • •.lnltr^■' 



SAMK «>I 
H ATHKK 



niHTHTI. VCl., 

" 1 \ 11! 1 K 
-.' i' . 1 It i fiuut r % 



Mxim-iN NAMK 
'•I MoTUHR 



"1 \t.>'r!!i':i< 

' Mat! ■ .; rulilltrv 



niiTpAiioN 







-VW V 



G-ajlUx . -^ ^ 




J LI, -^^ 

that I last saw h -^ alive on V^^ ^^^ '^o |i 

aii.l that <lcath occurre.l, on the <lal.- .tatcl above, at I ^ 
; M. The CAl'SH <)F DKATII wa^ as follows: 



1)( RATION JVarj 

CONTRIHl TORY 



-.. Mouths 



Pays 



Hours 



I ( 



Years ^ Mouths 



-VX-^VU^TU 



/"> 



I ^^ 



Rffiitfit in Snti /tni"' ''■ 



)'iii I 



yf. iiifi 



THI: AHOVT- HT\Tl-ri I'HHSuN^I, l' XHTFt' f 1. \ KS A K I- TKll-: JO IHh 
!ii:sT Ol- MV KNi>\VI,l.l)<.K AM> MJJ.Il.l- 



DIRATION 

(SIGNED. - 

kvlu J.Ci iQo'i (Achlrcss) HC] U 



/)ays 



du 



., Qu^ 



Hours 
M.D. 



4LAI. w' 



'SPECIAL Information on'y '©^ Hospitals, institutions. Transients, 
w Reteiit tesMrots. art ftnw^ ^yfflf a»*«y »rii« hwif . 



former or 
Usual ResMence 

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



Hew leiif at 
Plareof Death? 



0ays 



(tnforninnt 



,vi.i..s nib sM^ 



DATjKof liiKiAL or REMOVAt, 






I'l.AiH 01 lU RIAJ^ OR RKM<>\ AI. 

l-NDHRTAKKR LCUULW '^ ^ ^^ 



'•'■'■'■■■■■"■■■'■'''■■■■'''■■■■'''''''■^^ h Irf ha stated BXACTLY. PHYSICIANS shoald 

«. B._Bvery Item of Inform.tlon .ho«ld be w«ref«lly -«'»n"«f^ „!^ooep1rcl«..lfle«l. The -Special Information- for pr- 

•tate CAUSE OF DEATH In plain term., tha It m«3. ^ f;°^;-»* cl...lfie« 

•M« dying away from home •hould be ftlven In •^•ry Instance. 



i 



iv II 






11 ^ 



WRITE PLAINLY WITH UNFADING INK 

Dafr Filed, V^^ ^t) 




i t 



i&OH 



THIS IS A PERMANENT RECORD 

REFER TO BA CK OF CE RTIFICATE FO R INSTRUCTIONS 

Ee^isfered JV*o, 



450 




x^^^ vUx^u Deputy Health Officer 

DEPARTMENT OFPUBUC HE ALTH-City and County of San Francisco 



Certificate of 2»eatb 

( Ta. S. Stan&arC» ) 



% 



iHn VA, J Kn '^^ <-' 4 ■ City of 'O'OAVi ^Aa w/t^i tt 
PLACE OF DEATH:— County ofO/0^>V ^' ^a^ c.ty oi 



(No. HlH LcLA. 



St.; 5^ 



Dist * bet 



:. \yXA> y '^ UWr'vl l^and ^^ t 



\! 



) 



V ir oc*Tl 



FULL NAME 




<X4. 



PERSONAL AND STATISTICAL PARTICULARS 



SHX 



i^ 



l^ 



LCX 



COl.OK \ , ft , 



li \ rs ' 'I lUKTII 



OfWr 



I M..iith» 



\*.H 




53, 



J '<*ir » .» 



% 



in»y) 



M.<nths 



r> i:ir i 




MEDICAL CERTIFICATE OF DEATH 



(Day) 



I go 

(Year) 



\ O />" '> 




MN« l.H MAKKM'.n 

\\n»" 'Ai:n ok ntvoKfKU 



tUK rill'I.ArK 

"Stilt, or v'ouiitryi 



g). 



f '* 



1 xin iR 



A 



BIRTH PI,ACK 

np IAT!IKR 

IStali or Ciituitjy) 



M XIDHN' NAMK 
ni MUTilHR 



"1 motiVkr* 

(Siait or Country^ 






LL\x4V^" " 




JWotith) j ^ 

THERT<i\' CimTU'V. That I ^ttciuknl deceased from 

^^^^ -9oH to M^.. 1-1 i9oH 

that I lastLw h .*. > . alive of. H^^^ *^ ^^'^ , 

and that death occurretl, on the dale 'stated above, at AO V»--. 

■-. M. The CAl'Sh: Ol- DI'.ATII was as follows: 

DURATION 5^ >Var5 
CONTRIIUTORV 



" .Vofilhs " Pays ' Hours 



Years 



^fonth^ 



1)1 RATION 

(SIGNED) (\ a '^ 

^ ,U,q ,cps f Addre ss) H^Hi5cuv^.^t i^^M:^ 



illiaHt 



/^fl>'5 Hours 

M.D. 



iv^ 



'H'CrHATlOK 



' e. 



hir^idftl ill San /'i nihi.^iif 



)V<f rf 



M,>„rhf -^ /'«'»•, 



»1: 



UK AHOVK ST\TK,H PHR'^f^NAI. I'AKTICrLARS ARK THIK To THK 
BHsr OK MY, KNoWl.KIX.H ANI> HlCl.lKh 



SPECIAL INFORMATION only lor Hospitals, Institutions, Transients, 
tr feccrt feiMcBts, M penws iytas awiy \^m hwi*. 



Ftrmerw 
Usyal Re$MeR€« 

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



How lonq at 
Place of Deatti? 



.. Bays 



n \CH OK niRKM. OR KHM«>VAI, 



Or)u iD-Lv^t 



VNI>KRTAKKK 

(Address 




^a.1^1.'^ *"''' 



DATE nf IJfRiAL or REMOVAI, 



i9oH 






N. B._Every Item of Information .hould be cnraf-Jljr JiupplUd. *^^ •^^^^^.^j^j. The -SpecW Inform.Hoii" for |»«r- 
•t«te CAUSE OP OEATH In plain term., that It may be PJ^^^^ Ua..ifie«. p- 

«on« dying away from home .hould he given In every Inat.nce. 



I, 



I 



» ■ 



'f 



i 



f. 



i 



:!i!i 



■ t 



WRITE PLAINLY WITH UNFADING INK 

T)((fr Fifed, MaaXu 2. C 




190 "{ 



THIS IS A PERMANENT RECORD 

,.. cn TO BACK OF CERTIFICATE FOR INSTRUCTIONS 

Begistcrecl J^^o. 'iOX 



^^Vc>u^"L^^vv Deputy Health Ofr.-.er ^ 

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

Certificate of Death 

^ "a. S. StanOacD ) 



PLACE OF DEATH.-C.., o.6<X.. 1^...C....C.. o.^O^ i^--c.. 



".i 



(K>r 



— Dist.;bet. 



) 



I \ *> * I (A (lV)&-^'l"' St.;"""^ "*^*^^** '^'t^ ,«..,«otR-SPCCt*L INFORMATION- \ 



FULL NAME 




S i . V 



PERSONAL AND STATISTICAL PARTICULARS 

COI.oR 



I*'' i \: <ii niKTu 



S' v. 




U)JLtc 



"vx, vV^"^'^^^* > 



iMonth^ 



H^l .,... 



(T>ay) 



Months 



IV car) 



Ai I f 



MEDICAL CERTIFICATE OF DEATH 

DATK Ol- DHATH ,, „ 

Ix. 



I go . 

(Ycar^ 



"l HPREBY CRRTIpf^ That I atteii.ua iUvcascl from 



la 



I90H 



u tin (U 111 UK i>ivoKi iin 

Uiilt ill •«)* ial iU-><it'it,uiiin) 



I i 



UK nii'i, \ri-; 



I \T11HK 



ni- KATIIKH 

• Statr iir rouiitryl 



M\!I»KN NAM1-: 
OH MdTHKR 



li i K I HI' I.AC K 
"1- MnrilKR 
<Slfttf or Country') 









that I last saw h ' alive on |^^ — T^ 

a„a that death occurre.l, o„ the Hat. stat.-.l above, at t- U 
U^M. The CAUSE OV DICATII was as follows: 



,:\.wO^ 



Vtars 



Months 



Pays 



Hours 



Dl RATION >^ , ^.v,nn.^ !'«,- 



%\ 



%k 



in' RATION ' Years ^ if^'!^'^ ' 
( SIGNED ) LtvwIvvW s) \1 H 



Days 




4. U iQoH f Address) dl Qlla^^ '- '" 

PECIAL INFORMATION oirty for Hospitals 



Hours 
M.D. 



! V(?/ 



%f.,iif/i' 



/'..• 



THH ABOVF ^T \TKI> I'KRSnNAI, PAHTlOr I.ARS ARK TKl K T< • THK 
BKHT »>1 MV KiioWUKIx.i: AND »KIJ1-.I' 



(Infotninnt 



^f"^"^'oIt 



I 



'xaar.ss g rw<v>\<i- H 



ft 

t I 



or Recent 1^^. ^ ^«««» *^ ^ ^'•* **^ 

former or ^V^^ ^i 
Usual ResMewe OoVfrj 

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



s, Institutions, Tr 



Transients, 

J[V% How lon^ at , « 

V MUaT piaretf Deitk? i^r^il.»iy$ 



l'UA£.K,01* lU'RtAl, •)K KKMoVAl. 



HM"! .it III KiAi. or RKMOVAI, 






**^^"""~^^'"^*'"^"^"**'''"^^"'"'"^^"""*^"''^*^^*'"^'^^ ^P H Id b« stated EXACTLY. PHYSICIANS •tHMld 

N. B. ^Rvepy Item of Information .houM b? carefwlly MPpHed. j"^ •^**V ,« j, ^he "Special Informntlon- for pr- 

iitate CAUSE OF DEATH In plain term., that It may be properly wlaa.lfiea. 
89n« dylRA away from home should be ftlven In svsry Instaiwe. 



h 



'I m 



t>i 



1/ 

1^ 






^- I 



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

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS ^ 



Ho; 



,inl..f II> 'Uh I'Nu. I< 



U&l»Co 




I'JO'i 



Registered JVo. 



452 



"ifrvvL iL-i Deputy HealtH Officer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of IDeatb 

( Vi. S. StanDatO ) 



PLACE OF DEATH:— County of ^ f^ >^ 

(No. ~ 1 1 ^ 



n 



'■i •. o. -V- Cid cc City of n.cuy^ • va ^^ C^^-6 



"f 



EOFDEAIH: — coumy oi .- . - • ^ 

I'' i «:» 1 ni.fbet*^*-a\A^-H and ^'•<^'l^<^">'^'fc ) 

l^YVVY^^Jl^C'<.<Vll ^^Jnce a,.e ^cts'c^Icd ro. uno.- ■ .lite,.. .Nro.M.T.o-" ) I 



FULL NAME 



"L^u, A 



i^^t 



SK\ 



PERSONAL AND STATISTICAL PARTICULARS 

I COI, 



^ " 






i>' rr: ••! uikth / iX y 



(M.>i)lli> 



\i.i-; 



JVrn 






.1 /,/«///.' 



( Vcart 



ATI 



IQO 

(Yf 



1,:^ 



sfM.I.K MXRKlKt). 
WIlHiWIH nR IHV(»KrKt> 

(Wiittiii N(Ht;i1 (U ■.is.'n.(ti"ii> 



i-A 



It: 



.,.1 



■:H 



(Stall iir I'.iiiiitiyl 



XAMl- <»!■• 
I'ATH1;R 



niKTHPI.ACK 
Of" IXTHKR 
(stall <>t riMintry^ 



MAIUKN NAMl- 
OF MOTHKR 



oi? M(itiii-:r 

(S-iati- or Country) 



t>CCrPATION 

Rrsidrd in S 






A^VOU 




MEDICAL CERTIFICATE OF DEATH 

DATH OF DHATH (\ « 

(^onth) I '"»y^ ^ 

I In-KICT'A- clTirril'Y, That I attcn.kMl deceasea from 

190 to ■ '90 

tlint I last saw h -. alive on '9° 

a„.l that .Icath occurrea, on the date stated above, at 
M. TlK- CAt'SI-: OF DlvATII was as follows: 




O 



P 

1 



DURATION y^ars 

CONTRIBUTORY 



Months 



Days 



Hours 






•I n I I a Hi I 'I'll 




THK AHoVESTi^TKl) I'KRSONAJ, P AKTUT 1. XRH ARK TRT K T<» THK 
KHHT OF MV KNl)\VI.ia)C.K AND llHl.U'.K 



«f 



Uiifiirnmnt 



:^ 



I in*. 1,11-. 1- f| 



fAtUlress 






DURATION 
(SIGNED) 



m 



)Vari 



Afonths 



Days 



/four. 




JAiublXM^w 



^vvUu lyi.D. 



I 






PEcIaL information on'y 'or Hospitals, InstiluHons, Translfnts, 
or Recent RcsMents, and perionb 4)ii»a ***> frftJR »»mc. 



P 
J., 



Former or 
Usual Residence 

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



How loHf at 
Place of Death? 



Days 



I>.\TRnf, ntRiAl. or RKMOVAl, 

^ I 1 90 H 



PI.ACK Ol- n^RIAI, OR RKNfoVAT. 

(Address Ic^ ) accj^c^ at^ 



^ 
^ 



'"■■■~^~ ^^^'*'^"''!r"*^"Ti J AfR .knultl h* stated EXACTLY. PHYSICIANS nhould 

N. B.— Every Item of Information .hould be carefully f-PP"*"- *„^ Hrria.sWIed. The -Special Information- for per- 
state CAUSE OF DEATH In plain term., that It may be properly Uaaeifiea. p- 

aon« dying away from home ehould be ftiven In every Inatance. 



t^ 



i[ 



>l 






I 






t N I 





\ 



i, 



I 



'4 



WRITE PLAINLY WITH UNFADING INK 

Dah' Fih'<J, VvUl ^t ^'^^"^ 

DEPARTMENT OF PUBLIC HEALTH 



THIS IS A PERMANENT RECORD 

REFER TO B ACK OF CERTIFIC ATE FOR INSTRUCTIONS 

Begistevcd J^'^o. 453 

=City and County of San Francisco 



*^ 



I 



! 



Ccttiflcate of 2)eatb 

( "d. S. StanDarO ) 



PLACE OF death-Co.* o.?(c.^v.Kc. cpfl^'V«^p:. 

I ir DEATH OCCURRED IN A HOSPITAL OB INSTITUTIU 

1 ! t\ i U 



) 



FULL NAME 



AjL<j \].lU^ 



V 



% 



Lt; 



It 



s!:\ 



PERSONAL AND STATISTICAL PARTICULARS 

COl.OR '^ 5 



l*ATl.. ul- UIRTU 



Ai. M 












(p )'</' 



a>ay) 



M, nit In 



(Vcar) 



MEDICAL CERTIFICATE OF DEATH 



DATE t>l- DHATH (\ () 






(YearJ 



I go 



10 



A? » -f 



•^IVi.i.K. MARUIKP. 

\vn)»»\VKi) t)R nivtmcKn 

lUtitciii social ilcsitf tuition) 



HIKTHPl.AOK 
' si;,ti or Country^ 



N'AMl- ot' 
FA rillCR 



BIRTH IM, AC K 

Ol- lAPHKR 

( State or Country) 



MAIDKN NAMK 
<)1 MOTHKR 



lURTlUM.ACE 
OF MOTHKR 
(State or Country) 




HTkRCBY CKRTIFV, That I atten.kMl (leceased from 
190 to J90 

that I last saw h alive on "^^ 

an.l that .leath occurre.l, oti the .late stated above, at 
M. The CAUSE OE^DHATII was as follows: 







/^>A,fr^nuOL^^ 1 j.4^^>vSXuU^^. 




or RATION years 

CONTRIBUTORY 



Months 



Days 



Hours 



^ 



DURATION 



^ 



Years 



Months 



Days 



Hours 




OCCUPATION 



RTIOri.KRS AR 

..) Bi-:i,n;i' p 



Ihtvs 



THH AnoVR ST\Tl-,n PKR^ONAU PARTHT I. ARS AR»' TRlK TO THK 
UKST Ol- MY KNi)Wl.Kl)<".K ANl)Bi:i,n.l' ^ 

(Informnnt ». -..-w-*,^ » • 1 - r 



( Signed ) IXxAx^k^jM 

|u.lu^^i"^H (Address) It^ ^ 






PEC^AL INTORMATION only for Hospitals, Institutions, Translfnls, 
or^ccent Residents, and persons dying away frwn iMwe. 



Former or 
Isual Residence 

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



How lonq at 
nareirf Qeatti? 



Days 



< \jMress 



"Ifcb .'CtCclrV^ 



p, .cK Ol- niRIAU OR RKMOVA!. UATK of IUr.ai, or RKMOVAT, 




•V»i 



t NI>i;kTAKKR 

(Address 



y 



N, B. Bvei.y Item of lnform«tton .liould be carefully .uiipiled. JJ*^^ •^^^I'f^^^'J*^^^ Information" for mf- 

•tate CAUSE OF DEATH In plain terms, that It may be properly claaaifiea. p- 

•nna dytnft away from home should be ftlven In every Instance. 




''i;' 



WRITE PLAINLY WITH UNFADING INK 




THIS IS A PERMANENT RECORD 

REFER TO BACK OF CEWTIFICATE FOR IN STRUCTIONS 

Registered JSTo, 4D4: 



DEPARTWENTOfViBLIC HEALTH-City and County of San Francisco 



Certificate of ®eatb 

( Til. S. StanDarD ) 



PLACE OF DEATH:— County of v ci.^\ 



■i 



III 



(No. k^ 



FULL NAME ^i^^^''^^^'''^^-^^^'*^-^-^*^ 



) 



-d 




^ 



SIX 



PERSONAL AND STATISTICAL PARTICULARS 

COI.OR 



)M 




* J< i| 



J 



I)\TK <»|. lilKTU 



A(.K 





^T )V.i.v O 



?^0 

(Day) 



Movlhs 



(Vt:ir) 



MEDICAL CERTIFICATE OF DEATH 

DATE OF DKATH , , „ 

In- 

(Day) 




i9o\ 
lYeur) 



IS 



Pa \-s 



HINT.UK. MARKIKD. 
WinoWKD OK DIVOROKD 
(Write in stx-ial iieH»je«mtii)n) 




niRTHPl.AOK 
fstati' ur Country) 



VAMK OF 
FATHKR 



BIRTHPLACE 
OF FATHKR 
(State or Country) 









Thereby certify, That I atteiuUMl dcccasea from 

^\vt J^l 190H *«\ IV'^t ^"^ '^"^ 

that I last saw h .V»% alive on f^ ^ ^9° J 

ana that death occurred, on the date stated al>ove, at I H "^ 
Am. The CAUSE OF DIvATll was as follows: 



MAIDKN NAME 
OI" MOTHER 



IMRTHPI.ACK 
•»F MJlTHRR 
(State or Contitry) 



n 




,UAKXtH 



DURATION ^ ^^^'^H ^font|s -^ f><^y^^ ^iours 
CONTRIBUTORY ^ J^^^^-^^h^S^A^^ 



oeci 



A 



Rf$idf(t in San FiaHcis^n 4^ >>'>' 



.^UWJU 



M,>iif/is 



IK 



THE AftOVE ST\TED PRRSONAl, PARTTCFI.AKS ARE TRIE TO THE 
BEST OF MY KNOWl.ED'.E AND lU-t.HvF 



(Iiifnnnant 



(A<1.1 






DURATION ^ years I ^^cjwMj ^ Days ^ Horn 
(SIGNED) 



% y. ^iUJU/>vL*l M.D 



1-5 




T-twIAL INFORMATION •«!> !•' Hospitals, Institutions, Transients, 
or^weS'SesMents, and persons dylnf iway Irom home. 



former or /^ /^ ^ h 
Usual Residence \J OJ>rJ 

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



ly Iron 



Diys 



ri.ACK OF BIRIAI. OR REMOVAI, 



DATEof.nrRiAl. or REMOVAL 



I NDERTAKER 

(Adtlress 





1p i 0A.<-^^^V^ jt 



... >GB iihould hm •!■ Ud EXACTLY. PHYSICIANS .hovld 

N. B, Every Item of Information .hould be carefully .ttpplled. J'^° " cl«.«lflcd. The "Special Inforiti.tlon" for p^r- 

•f te CAUSE OF DEATH In plain term., that It mar ^ fr^^*'"'' cla..mca 
MM dying away from home should be given In every Instance. 






':; 



n 



!t 



tV 






!t 



r I; 




III 



\< 



t . ' 



> • 



I 



.h 



Mf 



WRITE PLA.NLV WITH UNFADING .NK-TH.S .S A PERMANENT RECORD 

* ^_ - »> e»Tir.CATC FOR IN STRUCTIONa 

290^ Registered JVo. 



455 



/;,,/,■ riled, "4^-^^-^ '^^ 

•LvJ.li^/:u..- Deputy Health Ofnner ^ 

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

Certificate of Beatb 

( m. S. StanDatO ) 



(fj 



^.i 



1. ^ 

KvLixi' St.;— Dist.;t«t- 



-and """ 



FULL NAME 1^^-^ ^^^^ 



= ) 



^i.\ 



PERSONAL AND STATISTICAL PARTICULARS 

COLOR ^ ^ |, 



^A 



DA I 1-. !>!• BIRTH 



A(.K 




(Month) 



-1 



Ik) 

(Day) 



5"^ yr.u. % ^f<"<"'-' ^ 



(Vear) 



/!(/ 1 .< 



MEDICAL CERTIFICATE OF DEATH 
DATE OP DKATW \\ \\ - 



KATH A ft 



.f 



(Year) 



I go 



^ 



I IIKREBY CHRTIFV 



That I attemlc«l <lccfase«l from 



sIS.i.K. MARKIKI). 
WnxtWKI) OR DIVORCKI) 
(Wrilfiu social <U'siKtml><»ti) 



HIK rill'LAOK 
(l»t«li or Ouuntry 



SAMK OF 
FATHKR 



niRTni'i.Ac'K 

OF I ATHKR 

tSlnli- iir Country) 



MMDKN NAMK 
"I M»)THKR 



BlRTIlPtACK 
OF MOTHER 

(Stall- or Country) 




that I last saw h ...i/Wsalive on f^^ ^ ]y 

and that death occurred, on the date stated above, at 'i '1 



T M The CAUSE UF^DHATII >jas as follows: 



M. TheCAUSEUF DEATH jas as follows: 



i/UVVV<V\Vu 




tl I 



DURATION •^ ytars i^ Months ' Days 
CONTRIBUTORY S^''i\jOJ:UXJ^^^ 



Hours 



DURATION •" >V<i»'^ -^ Months " Days 
(SIGNED) %- ^JM^U^dU^ 

' Address) ii?i U.kJO^ 



SPECIAL INFORM/ 



"Hours 
M.D. 

,i^- d..l 



occrpATiON 



THK ABOVE STATKI) PRRSONAl, FARTICtM.ARS ARK TRlK TO THK 
HKST OF MY KNOWl.KIX.K AND »KMKF 



(Ijiforinuiit 



( Address 



1 .KrK^N^ 3 Vcx/«-4L 




Willi. ..^FORMATION o«ly tw Hospitals, Instltutlois, Traiisle«t$, 
w teceiit ResMcdls, #•< H'^RS iyliis ^^ hwi lw«. 

utXM..ce*l lUlLu (!Wt Mfc.«.? I H Itays 

When was disease contracted, 

If Mt at place of death? ^^_^^ 



I'l \CE OE BIRIAI, OR REMnVAI, 



(.^dtlreHs 



DATE of niRiAi. or UKMOVAI, 



I 



XX A AGE .hould te stuUd EXACTLY. PHYSICIANS •hould 

N. B. Every Item of Informntloii .hould be cnrefully .yppHed. ^UD •" , ,|^^, ^^ •'SpecLI information" for p^P- 

•tattt CAUSE OF DEATH In plain term., that it may be properly cl...lW«. ■•« P- 
MRtt tfyliiA away from home abould be given In .vary ln.t««c«. 




^ 1 



I 



J. 1 



! " 



1 



If 





_.».^ .Mtf THIS IS A PERMANENT RECORD 
WRITE PLAINLY WITH UNFADING INK — THIS IS A i-tn 

WRITE PLAIIM ^^^ ^^ „..K O. C.RTIF.CATr rOR .NaTRUCT.ON^ 

„ ,, H .'. ,s.,.,.»^'rgg^"'^''^" _ ■ \ZZ 



/)«/(' fifed. 




0.C) 



Registered J\''o. 



Deputy Health Officer 



DEPARTMENT OF POBLIC HEALTIl=City and County of San Francisco 



Certificate ot 2)eatb 

( XX, S. StanDarD ) 



PLACE OF DEATH:— County of 



\^ 



n 






City of 



"^t^c-k^^^-'^ 



p 



m.to 



(No, 



——^ — - St4 Dist.;bet. ^ .,„otR •special INrORMAtlON • \ 



) 



FULL NAME 



UJcLtfv^c ^Ir 



SI 



PERSONAL AND STATISTICAL PARTICULARS 

I COI,«»R 



vnuU 



nl ISIKTII 




iMnllthJ 



\i 



a 



iN(,M' markikh 

I nk IMVnRCKt* 
Ilia! !• -iiftialion) 



Ix- 



10 

I |)a% 



M.i>t//n 



I 



i ■»■( ai I 



/>f/ r.^ 



MEDICAL CERTIFICATE OF DEATH 

1)ATI% nl- DHATH ft „ . ,^ 

1 IIHKKHV CiWtIFV. That I attciiaea .leccascl fmm 



/po 

(Yt-arl 



igo — " to 
alive oti 



Tg5 

tgo 






^^VC" 



'1 nt I \ 



I ATlil.H 



UlHTlH'I.ArK 
<tl I \ I HI",K 
''>i:tl- 'i\ I'dtititry 



"•1 Mtri'Hl-.K 



Ilf W 'fit IM » 1* ^ 

"I- ^t<>•r!^^R" 






tliat I last saw h 
a„.l that .Uath occurred, c,„ the .late stated above, at ^ 
M. The CATSH (>!• Ul'lATU was as follows: 



(^ 



^ 







CcuU V 



I 



^Lm^4u 



nr RAT ION y>ars 

CONTRIIU TORY 



Afoiiths 



Pays 



Hours 



niRATlnN 

signed) 



Years 

(0 



Days 



-i -i 



K/O 



rA.hiress) U^.fr-^^.>i>^^ V U 



Hours 
M.D. 



n 



i 



M.iiitfn 



Dm 



rHKAHOVKsTXTI'IM'KRsnNU. fXHTirrt SKSAKKTKIH T< • THH 
IlKHT «>1- MV KN'tiWLJUx.K AND in.LMI 



IlKHT «>1- MV KN<i\VLi:i)<.K AND 



CL C C- t^iA,AJ 



d 



SPeeiAL INFORMATION 

Fwiwf w' 
Usual RrsMeace 

Hfteii was disease contracted. 
If not it place rt death ? 



only lor Hospitals, Institutions, transients. 



Iron 



How loR| at 
naretl OciUi? 



Days 



I'l.ACK 0|.- lUKIAI, OK KKMoVSI, 



DKTLlof IJt HiAr. f>r KHMoVAI, 

,kX,kjl %i 190 



rNDi;K I AKHK 



4^ 



.'CA.^^'i ■' 



^ 



U.,dre.. ^ X«\ ^ h^tXii^-CM|^ Ji 



fAiMrt'HH 



b'^H ^hN{ya<^ 



A 



N. B.— Bverj. Item of Information .hould he ^-•••»»««y •"^ " f e onopeHy cli...lfUd. Tli» "Spccl.! i«for«i.tlon- for p«P- 
•tatc CAUSE OF DEATH In plain term., that It may »e propc y 
n-m. dylai away from hom« .hould be ftlv.n In .v.ry Instance. 



b 






II 



1 



if 



^ l> 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

B.v,ni.,f iiciih-PNo. n*^^wtpco wcrew TO back of ctHTiriCATt row instructions 



Dale Filed, HiaJuu ^0 WO'i Registered JVo. 457 

JUA>^5 ilAhu, Deputy Health Officer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certiffcate of Death 

( tn. S. Standard ) 






PLACE OF DEATH: — County of ^'XX^v A<XA\CC4C^ity oi^^CL^X) ^KCvyK^KA^^ 



oA 



(Ne.Cc 








vc 



^vc 



y<kK.i K> 



Ml IvAXa 



I 



St.; 



Dist.;bet. 



"and 



ir DEATH OCCURSfAWAV FROmI USUAL R E S I DC NCE filVC FACTS CALLED FOR UNDER "SPECIAL INFORMATION' 
IF DEATH OCCuilRCD IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. 



) 



-) 



FULL NAME 



"^r:x 



PERSONAL AND STATISTICAL PARTICULARS 

COL 





UA IK i>h HIRTH 



A<.K 



a 



■'"" lOldi 



(Month) 



SI 



J Vr/ » 



V.1 



(Day) 



JA»w/;/< 



<Year) 



Da vs 



>>IN<il.E. MARKIKI) 
WIDoWK!) <»R DIVORCKD 
(Write in ptocist ilfsit^iiiitiou) 



HIRTHPl.ACK 
fHtatr«)i CuuntryJ 



c1 



NAMK Of 
FATHKR 



BIRTH fl.ACK 
Ol* I ATIIKR 
(4l«te or CMiitiii vi 



MAIUKN NAMK 
OK MOTHHR 



BIRTH PLAlK 

•'» MiiJ II HK 
Estate or Counlrvl 



ovCll'ATiON J 



^^x<Ax 




MEDICAL CERTIFICATE OF DEATH 
DATE OK DKATH 



ivt 

/jMoiilh 



"•H 



IS" 

(Day) 



(Year) 



I HEREBY CERTIFY, That I atteiKk-d .lecoascd from 



d^^AX.-H 190 a, to...Wtu...l5 190H 

that I last saw h X-'\ys alt%'e on 4 Vclu I 5 

and that death occurred, on the date statetl alK>ve, at i ^ ^ 



190 H 



LL. M. The CAt SE OF pl^ATH was as follows: 








\,a.aaXxXam 

I>r R AT ION Years Months 

CONTRIBUTORY 



u '\<v\,^wLl-''\ \X 



Davs 



Hours 



DURATION Years 

(SIGNED) LUn^V 

lb 190 M (Address) 



Ke^idet 



/ Sail J't\lU,l:,i) 1 ^ )'i-,it 



.y/.inf/r^ 



/),ns 



'"Vl.^ni.^^'*^''^^^''*'''^* PF.RSONAI. PARTkl'I.AR.H ark: TRfK Tu TJIK 
HKhfOK MY KNOW!. KIH.K AND IIKMK'K 



'Iiifutmanl 



Du 



rvw 




( ^«UlreHm 



t 



-"» I 




Months 



Hours 
M.D. 



^S^ifclAL INFORMATION ^ ™ ^ 
•r leccit iesMMto, mM perMis <yfii| iwty Nm Nm. 



Days 



Whei Wis 4israsf CMtracM, 
If RttatplaretfleaUi? 




4> U HawlMiat 



PlaretfleM? 



1^3^,„aiys 



I»I,ACK OF BIRIAI, OR RKMOVAl. I DATR of niKIAi. or REMOVAL 






190^ 



(AdtlrcHs 



N. B.«-— Every Item of informntton should be cnpsfully supplied. AGB vtiould b« •tatcd BXACTLV. PMYMaiANS ^ttsM 
state CAUSE OF DEATH In plain terms, that it mai' be pM0«Nr clasalfled. The "Special lnfonii«tlo««* for par* 
•««• dying awair from heme should be ftlvan In every instance. 



f^ I 



i 



^ i-' 





'i :^ ' 



.Ill 

It: „ 



III 




r 



• ♦ 



^ ' 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



MoaPl -f lU^'lth !■■ Xo. IS I^^Sg^MScl^ 



REFER TO BACK OF CERTIFtCATE FOR INSTRUCTIOIMS 



Dale Filoil, 



1 




atj 



V)0'\ 



RcSisteved J^o. 



458 



-f 



fr^^ .Uam. DeputvHr^a.thOm:.er 



'No 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Certificate of 2)eatb 

{ m. S. StanDarD ) 
PLACE OF DEATH:— County of C'<X^»V OAOL/vvCUlCO City of n<X->T-- OAA/vvCV^CO 
, iH'^ulViitoN. St.; ^ Dist.;bet. L'J^lAUlf) and "^XiUUJ 



FULL NAME 



cr\ 



a\xcL 




i 



LloX^ 



>KX 



PERSONAL AND STATISTICAL PARTICULARS 




'laU 



COI.OR 



UAli; nl- lURTH 



\<.K 



( Month > K 



\Q Js 5V</>> 



.1 



(DaV> 



}/.»i//n 



rl'iX 



i 



(Veavl 



/'.n- 



^INi.1,1 MAKklKn. 
WllM.\yi.:i) OK IHVOKi'Kn 

'Writi ill siKJal il< ><uMiat ion) 



nik rin'i. 


\CK 


' >t,(! 1 1 .! ( 


■ mntry) 


X\MI «i| 
FA'ni KH 


• 


BrRTin'l.ACK 
OF lATHKK 

S!strit» or Country) 


mmi>i;n namk 
<>i* M«rnn;R 


HIRTIIIM, 
(IF %T<irt 


ACK 
1 1.- p 


(Slnt. ,.r (. 


oiuitrvi 



I 






vet 



U).nji<d:trvv 






MEDICAL CERTIFICATE OF DEATH 

DATE t>F DJ'ATH 




month) 




may) (Year) 



1 HI;UI:BV C!;RTII'V, Tli.it I atUMKUtl »Uh cased from 

^1\ff\r H 190.^ to |t^lu.i^ 190I 

that I last saw h A/Vv\ alive 011 ^V.Vt4 ' i^ I90H 

and that death occurred, oti the d:itr stated above, at X\ v 
c\ M. The CAISIC OV DllATH was as follows^ 



> ^4 ■ K-A^aM ^ •. :^ I t , 



DIRATION y't^ars . A/on/As 



CONTRIIUITORV 



r lL^yv.CLM.^dXI^r%\ 



Days 



//ours 



Hours 



ix 



'H<M J'A rioN 



dvO.-^^ 



r\C<i 



Rfhiihd itt Smi /'lanf/sfii \ i'tun % * ^fl^nths ' Pay 



IHK AnoVR STATKH J'KRSON \I, I'ARTirf f. A R-^ A R 1% TRti: To TIIH 
HhST OF MY KNoWI.i:i)<,K AND HHI.IICI- 



I \(lclie*i'« 



DURATION Vtars A/oNths Days 

(SIGNED) .mM dUKi tj.lL Lft-^ M.D. 

^UlLla 190H (Address) iH0l'lHlii^.4.ttV jl 



^ 



:ci 



FECIAL INFORMATION on'* '»'' HosplUls, institutions, Transieiits, 
w bccti RtsMcnts, and pcrioBs tfiini may trsa 1^. 



Former M^ 
Usual I^Mfiice 

Wfirn was diseasr rontracM, 
If not at piare of ikatli ? 



N«w lon^ at 
nwtri Oeitli? 



- toys 



PLACK OF nrRiAi, OR ri;m«»vai. 



I MH-,RTAKHH 

(Addrefts 




IJ.VrKof Hi KiAl. or RKM*»VAf, 



N, B. 



Kvery item of 1n?ormiitlon should be cnreffully sttpplted. AGE should b« stated EXACTLY. PHYSICIANS should 
state CAUSE OF DEATH In plnln ter<m*. that It may be properly classified. The '^Special laformstlon*' foi» psp- 
•4MIS dyln^ away from home nhould be Alven In svsry Instance. 



I 



\ 






li 



« 



^1 ^ 




1 



m, I 



4» 



• 



WRITE PLAINLY WITH UNFADING INK 



I)(Uc Filed f 




loo'i 



THIS IS A PERMANENT RECORD 

REF ER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 

Registered J^o. ^^9 



Dep«* 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of 2)eatb 

{ 13. S. StanDarD ) 



PLACE OF DEATH:-Co«nty of^a>vdKaAV(^C^Gty ofOa'^v JXXXAV^*-! -^ . 
1VJ l^C^~l Llau St.: 1 Dist.;bet. >*AAA.AA^.*Vl. andU.. 

( " °/r»T4"-%*-"o ."° »0"" - ?.-="-"" -V= ." N.ME ,«ST»0 O, ST.E.T .NO NUM.t.. ^ 






FULL NAME 




,<l ^K,::-^ Vl 



ft 



V. 



PERSONAL AND STATISTICAL PARTICULARS 

COI.OR ^ 

a ■■ ■ 



"" (DioL- 



1- 



A'.K 



vl 



Ml UIKTII 



v)>\. 



M. mill 



I l)av> 



yj.,„ih 



' Year' 



/>,?• 



MEDICAL CERTIFICATE OF DEATH 



DATE OF DKATH 



iMii)nth) ) 



(Da J') 



(Year) 




'. 1 I> < >k I>!VnRCKJ> 
■ - .. 1.,: lU'slKnaticin) 




Hii- ' tM'i ^I'l-; 



N ^MK OF 

1 A i u j-;r 



BtHTHfKACK 



"I M'iTiii-;r 



^'' ' ' t ■ .unt 1 \ 



( M i r i' \\ \( ix 









1 



^.1 CUvOU 




,Vi^ 



(^ 



t V 



A'f h/f'lf in S,ltl I I, I Hi ist'lt O 0* 



1 ,U-^ 



/Jl?l 



THK ».Hcn'K ST\Ti:r) T'KK'^ONAl, 1'AK Till I.\KS ARK THIK T« » TIIH 
JJKST OJ-- MV KN'UWlJ-.lM.H AM) Fn'I.HI* 



i \Ax\\V<S 






i 



U 



I,riRRi:HV C1:RTIFV, That lattciidca deceased from 

15 190 H to .. |:W:vL^.K 1904 

that I last saw h V>n alive on ^JUa, 190 

an<l that cleath occurred, on the date stated afjove, at » O ii 
J^l. The CArSI*: Ul- I)!':ATII was as follows: 



DTK AT ION Years 

CONTKlHlTOkV 



^/on^flS 



Days 



Hour 



DIRATION y't-ars 



DavK 



(SIGNED) 



4 



Mouths 
%^ iQoH (Address) loll )lO\ K J 



SAM 



Hours 

M.D. 



SPECIAL Information only f«r HospUdls, institutions, Irdnsifflts. 
or Recent ResWerti, «« pniws dying *way trtm hww. 



FMiff tr 

Wke* was disease ctntrarted, 
If Rotaf piire^tfeitli? 



How lORf^ 

nveof Beath? 



Days 



I'I,ACK 01* IIIRIAI, t>K KKM<'\ M, 




DATi;-! HiKiAi, or RKMoVAl, 

190 . 



in!>i:ktaki:r 

(A.Mt>->.H 









N. B— Bve.^ It«« of Information .ha«ld b. ^«.«f«llr -ppl-d. AGB .hould •-^••f ^X^TI^. ,^^^^^!!«j;!*^;:l 
•tatc CAUSE OF DEATH in plain term., that It majr be prcn.«rty cl.».lfl«il. Th« «p*cliil Information for p.r- 
«on« d^'lnft away fr^ homo s^Mild be ftUen In avary Inatance. 




i' I 






i| 



I 



1 


II 

1 


1 

1 



WRITE PLAINLY WITH UNFADING INK-THIS IS A PERMANENT RECORD 




REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 




Dff/c FiJpd, "I^W ^^ 



Registered J^o. 



460 



cU-^cvo 1^-u Depu*y ♦*e«lth Officer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of Bcatb 

( xa. S. StanDarD ) 
PLACE OF DEATH: — County of U<^Tc'vJ/va.AX^w <-ity oi 



MipHi 



rl%. -mu^^ou UAjita»Cja.TLal 



1 1 ' 



St,; 



Dist.; bet. 



and 



-) 



lA.<X;WaX »\(X.V,C l- ■- - • 3Ut ^ .itoV^, m for under "SPtCIAt INrOHM*TION • \ 



FULL NAME 



Ovs^aX 



(Xa^r^cU^ 



\OAxU^ 



ll 




si;n. 



PERSONAL AND STATISTICAL PARTICULARS 

j COI.uK 



DAli i>! lUKTU 



\i .I'. 









lol.i. 



(Dayt 



.\r,>t,i/i> 



Vcar) 



Ihi 



MEDICAL CERTIFICATE OF DEATH 

DATE OH 1)H ATH 



I()0 

(Year) 



'•IN'. IK, M\RHIKI> 

Willi >\VHI» «>R I)IV<>Kl"HI> 

'\\!tt>- 111 --iHMal <lfsi>^nati<>n) 



I'.nrrmM.AOK 



VAM!- ni- 

i-ATii i:k 



RIHTIIIM.M'K 
r>|- 1 AIHKR 
■^i lit (ir Country^ 









L<xl 



M M 1 1 r \ N \ M V. 
<'l MnTilhR 



OH MoTHKR 



OCCl I'ATION 



«H 



UX^UWV<X^V%4JL 

Rr.idfd ni San I'loii, :'^r., \% }Wr>.< * I/..;////- 



I JIKRirBY cV:RTIFV, That I attemUMl <Ut rased from 

^vUh.. ^1 190 'i to ^ |ui^.ai up '1 

that I last saw h :. "~ alive on pJLA^..a.i 190 i 

and that death occurred, on the <late stated above, at i 
' M. The CAl'SIC Oh' DI'-ATII was as follows: 



\C.i -•- -■ 



L^^^Jv^;^v 



a.. 



.A^^fl^.i. 



DIRATION - J'''^;^.^ ^ro,ltflS H. Days- Hour 
CONTRIIU'TORY Llv^\.tr-rs.eS^...L^^ . 



DFRATION 
(SIGNED) 



Years 



i^^ 



Months 



Days 




ds^^sr^\^ 



I fours 
M.D. 



" f J 4 

LXI iqoH (Addres.) 1^5'^J^^VH^^ 
>e6iAL Information <"«'y *w Hospitals, InstUullons. Translenh, 

•>•* Uaciil*al<: .afMl ArfUIIIX dviltll ^Mrft iffttll ROM. 



^peCi-- V . I. 

«r Recent ResWeRts, and ^CMini oyiifj anii) if»m wiw 



/>.n 



Tin- MIOVH STATJ-.I) I'HRSOSAI. I'A R III' f I.AK S A RK TR T K I'* Till- 
HKsT c)l- ^.tV KN<)\V1,HI)<*.1-;AN!) HHIJKH 

'!.if..;„unl \l l\^^ Ai 



XM^ A^ vr> > 



fAddrcM 



(I 



i\)c 



^ OJUU^-v 3t 



former or 
Usual Residence 

When m% dlseas 
If not at place ol 



3L^D- 'hK^ d:t l^ellOeatli? H 
onlracted, <$ A^,.. {^A^sj^ ^ , 



Days 



PI ACl' <»|- lUklM. OR KKMoVAI, 



DATKof niKiAi, or REMOVAI, 



VNUHRTAKKK 






160S 



fi ^^^ 



m 



■t«U CAU8E OF DEATH in pluln term., th.t It may be property cl«.«lfled. TIm» Special Inform.tion .or per 
•one dying away from home ehouN be given In every Instance. 



i J 



I 



i^B, 








n<,:ir.l .1 lUaHlv-J 



4 



WRITE PLAINLY WITH UNFADING INK-THIS IS A PERMANENT RECORD 

RtFER TO BACK OF CEBTIFICATE FOR INSTRUCTI0W9 

461 



Xo. , ^ ^^^^^ BSlI' Co 






Registered J\''o, 



JLc/xMi Deputy Health Officer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



I 



PLACE OF DEATH: — County 



Certificate of ©eatb 

( "a. S. StanDarD ) 
of Q/CUVM J AXc-^vcx^Oi City of CVa-,\. va 



No. 



s^a'la J 



s 



. ^ 1 ^■ 



( 



IF DC 
IF 



Dist.; bet. 

rclT*i^^OC:u%rcV.;"rHo"."p^T*At rR^?:^"^.?JVTo^rO.;r.;i ?.AmV .nVtC-AD-OF street and number 



and 0.'^ -^ 



KUJ\KXK^ .. „r.;^NCE O.VE^^S*c^L;DroR under -SPECAL INFORMATION-) 

ATM OCCURS AWAY FROM USUAL RfSIDENCE GIVE FACTS C A^Lj^ ^ .^stEAO OF STRrET AND NUMBER. J 




FULL NAME 








4^^>\. MOAiA 



.tt^\i 



*-( \ 



\ IM- 



PERSONAL AND STATISTICAL PARTICULARS 

a ' . ' 

/ 



1)1 lllKfH 



iMo^ilhl 



I 



5V<( 



i ■» I'ai 



Ihi 



fi 



>IN« !.i: MARklKI) 

Willi i\VKI> OK I)tX«»KrKH 

iW'titi ill Hociiil »h "-ir"'''li()ii) 



nil'. nuM.Ari". 
SI, lit i! Ciiiiuiiy 




1- X 111 IK 



niKTniM.AOK 
•>' 1 \ riiKR 

St.ci" or I'oiuitry 



MAIDMN NAMK 
UF MOTHKR 



'•1 motukk' 
(Statt i,r Country 



^ 






MEDICAL CERTIFICATE OF DEATH 

DATK t>l" DICATH 






n is 



IQO 

(Yeart 



I IJI:K1:BV CI:RTIFV, Thai l attfn«Ua .lc( rased from 



VH 



I igoa to HtvCu, XD 



ir\. 









xcXXrvu 



f 



^^.^ 



•KUl I'ATloN 



^Xm^-^w^ 



j^uwjOl o> V- 




^ 




Kff^idfd in San Fuinitsro 



) 'r'll I * 



M.int/i^ 



I hi % 



Tlir \n(i\ 1- sTXTKH PKK^nNAl. J' ^KTUT I, A R S AKKTKtH Tt > TIIH 
i'.HsT i»i. MV KNnWMUx.K AND !U:i,n: F 



(Infunnata 



iD'l (^. 



U.WrrsH 



4, 



k- 



R ^1 kTj-VUA 



IQO 

that I last saw h A/V>% alive on ^^-^^j^ ^ t> 190 

an.l that .leath nccurre.l, on the <late stateil above, at t 
M. The CAISK ()!• DI-ATII was as follows: 

DTRATION )V'<7r5 Months Pays 



Hours 



DV RATION 
(SIGNED) 

SPECIAL IN 



I lours 

M.D. 



0% 






L 



.^i. ..JPORWIATION only f»r Hospitals, Institutfons, Transleiils, 
or^ccnt'Kslients' 'and perstns #ywi a»»d) irwiii h»««. 



rormer or 
Usual Residence 

Wlieii was disease rontrarted. 
If m( at i^m of death ? 



Nmr lonq at 
Rare ol Death? 



iteys 



IT.ACK Ml* IirKtAI. nH KHMnVAL 



UATKof ntkiAt. or KKMOVAI, 



tooH 



INIU-RTAKKR 



(A-1.1t. H-i 






. ... I. 1 AfP .hnuld ha Mtflted EXACTLY. PHYSICIAN* sImmiIiI 

N. B.— Every Item of Info.m.llon .houid be c.ref«ll,r •-PPl-^. ^^^^^ •^74^,^„;i'* The "^^^^ l«for.«.llon" for p*P. 

■tate CAUSE OF DEATH In plain terms, th.t It mny be property classifiea. tie <»p« 

•«n« dying away from home nhould b« %\smn In msmry Instniice. 





ftf 




■ 


^^^H * 




^^H| t 








^■f *' 




1 


f r 


4 



•Hi 





WR.TE PLAINLY WITH UNFADING INK-THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



Dafr Filcil y \vcL 



li&l'Co 



1 



ai 



190\ 



Registered JVo. 



462 



.(rcvA^ 



^„ JUavu Deputy Health Offlcer 

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

Cevtiffcate of Death 

PLACE OF DEATH:-County of C^^. .W>vCc..C<City of C^O^ .U<V>.^.^C 



No. 



aia.. ■^: 



I 






) 



FULL NAME 



M 



si: 



PERSONAL AND STATISTICAL PARTICULARS 



''^<.L 



lo*> 



ti.xri: Ml- I'.iRTii 



At.H 



inth> 



) '••!! t s 




U 

I Day) 



Movtlis 



(Vearl 



/>(»!.< 



(Ytar» 




sfN..I,K. MARHIKU. 
WllKiWKt) OK I>!VOKCFr) 

tWrttf ill social tit sit'iiatioii) 



niRTlU'l.ACK 
(State or Count i s 



^ 




1 ati!i:r 



RIRTllJM.Vi'K 
or lAIHHR 
•"^t.itt or CfHiiitry) 



MAIIil'.N- XAMH 



«>i MMrin-:R 

(Stale nr C(niutry1 







MEDICAL CERTIFICATE OF DEATH 

DATK <il- DKATH ^^ 

rTll-KlTirv' CI'RTIFV, That I attcn.U-.l .Ut rasc.l from 

il I90H *"(% It^H "^^ "^"^ 

that I last saw h -<^a alive on |^^^ ^ '^ I90 H 

an.] that death occurred, on the date statiMl above, at H 
CX M. The CArSI<: OF ni<:ATIf was as follows: 



UlRATION * Years ^ '^^'"'^^'^ (S^ '^'"'^ * Hours 



I ) r R \ r H ) N * J Vrt rs ' .'^fon ths % Pays ^ /fours 



(Signed) 



/'W^y%.A,''v%^ 



M.D. 



O/CCA'XJ UK<VAa/C 



OCCl I'ATluK 

fCt sided in Sapt Fia»i iffo 



J 'I'ti I 



.\ronths 



1 1 



Pit 1 



till \1!()VK ST\TKH PKRSONAI, I'AK rut I AKS AKK TRIK Ti> THK 
HHsr OH MV KN<>SV1,HI)«',K AND IIKIJHK 



(Iii-"'iuafit 



f AdilresR 



9,0 4 0* lb tlvLL 



^ 



"»^ TQO f 



Address) 110 W,avl/-.^o^,il 



PECIAL INFORMATION only for Hos|>ilals, Institutions. Transients, 
or^Reccfl! ResMents, and persons dying away from home. 



Formf r or 
Usual ResMence 

When *is disease contracted, 
If not it place of death? 



HoH lonq at 
Place oi Deatk? 



Diys 



PI^ACK OH nrRlAL OR KKMoVAl, 



math: of Ui'KiAL or RKMOVAI, 



indh:htakhr Ow o U-VV^-x/x 

11 'in VnVMu4^^u 3^ 



90H 



(AcMi. 



^ ikfti .k»t.irf ha mtaft^d EXACTLY. PMY8ICIAN8 •houlil 
N. B— Bv.r, 1..™ «. .„l„r™..Ion .hould b. c.r.fully .upplt.d. ^^^^'^^.'.''..'S,:;:*'^,^ ..,"c..l Inform.tl.n" f.P pr- 

■tote CAUSE OF DEATH In pliiln term*, that it m«» be properly clPMilwa. ■"« "I 

•<m« dylnt away from home should be tlvca In every Inelance. 




I' 



■■ i 



m 



11 



i 




\ 




m 



III 



m 



i 



^111 



ir? 



kl m 



! 



WRITE PLAINLY WITH 

j)(,/r Filed, 





UNFADING INK-THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRU CTIONS 

463 



t^wc^o ^^^M D«P"^y>'e^'th Officer 



Registered JV^o. 



DEPARTMENT OF WBLIC HEALTH=City and County of San Francisco 



Certificate of 2>eatb 

4 «J i ^ 



PLACE OF DEATH:-County of^a>. ) X^>vCv^-^ City of ^^a.v 1 xavv- - 



) 



FULL NAME 



PERSONAL AND STATISTICAL PARTICULARS 



a 






I t»l,«»K 



:\ 



I Month) 



.\<.|- 






.1 



H 

(iJav) 



M„mUis 



Year) 



/></ v.^ 



>.IN-.1 I MARHIKIJ 



MEDICAL CERTIFICATE OF DEATH 

DATE OK ni%A'ni 




«^IN< .1 1 M AKKlh.n. » 

Wn»< . V. I |i OK 11IV»»Kt*KI> \ 

'V. T 'i 111 -,Ki;il .1. «.;i'iiati«n) 1 I ^, 1 



I IIKRI'HV cV:RTIFV, That I atteiuk-a deccasea from 

%^s^ . 190H to L^^ 190 H 

that I last saw h-. alive on f^-^^ '^* ^^ 

aii.l that ilcath occurred, on the date ';tatcd al)ovc, at A D t^ 
iX^I. The CArSI-: or DICATII \%as as follows: 



mKTUI'UACH 
(SlaU'nr Cnmitry' 






\\M1 c»| 
HA rilKR 






lilKTllI'lArH 

01 I \ rnKK 

(st.it. f.i Tnutitry) 



MAfUKN NAM!-: 
01 MnrilHR 



IltHTIIPl \('K 
OF MfiTHf.tH 

(Stall .>r voimtryi 




THi; MioVKSTATHl) PKk^oNAI.I' X K T HI t-A K> A«»'' ^K IK TO THK 
BF.ST 01 MY KN(L\VM:ih'.K AND M-AJVA- 



Pa 



YXJ^^ QfyUA^irtL.<MW4A^t 



UrRATION yrars 

CONTRimTORV 




Mouths Oays^ Hours 

1)1' RAT ION ^ • >V<rr5 Motit/is Pays 

(SIGNED) IU^V\V Nfl XoA^A^lc 



Hours 

M.D. 






^i 



INFORMATION Miy <or H(Kpitals, Institutloiis, Transicets, 



^,-t^lAL iNrORMATu-., 

w ^crt R«Me»U, *«« ^T^s ^tef mm ^m hasw 



Hew lo«f at 



Kl^iice I^WUjWw^vv*^ ' J^T^t*? IH.. ^ 



Wlieii was dlsfasf contracted, 
If iwt at place of deatli ? 



Ut 



I I'll* ma nt 



(A. 



^ I /^ (^0 



aX 



V\ \CK OF m-RlAI, OR RKMoVAI. 






DAIU: nf inniAi. or RBMOVAI* 
^|vJLu V\ T9O ■ 



f Ad.lK^s 



^""""""^ Itf .hnulfl ha atated EXACTLY. PHYSICIANS ^«mld 
N. B._Bvery Item of Information .ho»ld be c«raf«lfy jiupplUd, ^Jtl^l^^tt^^t^^^^tp^^Sm^ l«formatlo«" Im* p^r- 
state CAUSE OF DEATH In plain term., that It may be properly claaalfiea. •"« «P« 
•«»n« dylnA away from Noma should be given In every Inatanee. 



I 



\ 



\ 






■ \ 
. ■! 



M 







i' 





'i^'i in 




1 



WRITE PLAINLY WITH 

lU,u.1uf lUuUlv- KNo- !^ 



■^ggS^li&l'Co 



V(tle FilcjU ^^-^'•'^^ ^^ 



UNFADING INK-THIS IS A PERMANENT RECORD 

REFER TO HACK OF CERTIFICATE FOR I NSTRUCTIONS 

463 



lOO'i 



Registered J\''o, 



dLUx^\i 



4^^^..^^ cCcx^M Deputy Health OfHcer 

DEPARTMENT OF MIBLIC HEALTH=City and County of San Francisco 



Certificate of 2)eatb 

( •a. S. StanDarD ) 

i.'? ...„J * 






PLACE OF DEATH;-County of^V>v^ 'U^.^X^ Gty of ^'^^X. 



) 



FULL NAME 



/yfV^vwx- 




PCRSONAL AND STATISTICAL PARTICULARS 



4 

ii \ ; 1 ' ii niRTll 




COI.OR 



L 



I 



\ 



311 
iMonlti) 



A<.H 



St 



H 

il):iv) 



M„tiths 



/I 



Vcarl 



Am 



S1N(,1,1.\ MARklKl>. 
Wnti.WI'D t>R DlVnKt'KI) 




,cL 



CO-^^<-^ 



luk rifi'i.Ai'K 



NAMK <>!■ 
FATIIl.R 






HiR nii'i.Ari-: 

OF J ATHKR 
(Statt or Couiilry 



NfAIl)|.:N NAMH 
'II MOTUHR 



ii 



MEDICAL CERTIFICATE OF DEATH 

DATE OF DKATIl 

% . . jgo \ 

ThERUHV Cl-RTIFV, That I attcndcl <lcccasea fruiii 
..k.^./^:a.^^^a^ 190H to ^..-|Mi^...XA 190 H 

that I last saw h ' alive on p^^'^^ '^^ ^^^^ 

and that death occnrred, on the date stated above, at 3. D b. 
tl 



Cl M. The CAl'SR^OF DKATIl was as follows 





DIRATION 



}'ears iVonths ^^a)% Hours 

. w .> i K I n . . - R V L/^J^^i-LolA^^A.^. J^ 



niHTHMf hCU 
OF MOTIIKR 

'stat( or fmintryl 






M,„illi 



IhlVS 



nrRATION n Years Mofiths Days 

( SIGNED). ID A^%'. nK Xoo.V'-i^'U 
^l iQoH (Addres! 




Lull 

ilv for hAi 



SJS^KX 

%L...U. 




Hours 
M.D. 



s, Instit utions, Transients, 



^pe6ial INFORMATIO-- ,__ 

or Recent ResMenb, dii4 perwis iyteg aw^' fftm fc^ 



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



I 



<H'cri'Ari«)N Q\ 4^ 

RffitUd in San /'tnttn's^n ' ^ ^ '*'<? ' '^ 

THK ABOVE HTATKH f^F.RSONA!, I'A RTiri' r.ARH ARK TRlK T<> i IIH 
nKsT Ol- MY KN(L\VI.H1)«.K AM) HlCLIllK 

''*'"""*"^'™^"'''''''''''''^'*'**''^^'''~"'~""''^'*'''"'^ .k»..irf hm «t8tecl EXACTLY. PHYSICIANS stiOMld 

N. B._Bvery Item of Information .hould be .Tof-II^ f^ ^ t „ron.rir"l.«.r«^^^ Info.m.tlon- for pr- 

•tale CAUSE OF DEATH In plain term*, that It may be properly ciaasitiea. ■ nc »» 

•©«• dying away from home should be given In mvmry Inatance. 



Days 



(Infuf 



innnt 



(A. 1.1 



rcsH 



PI.ACK OF^IURIAI. OR RKMOVAl, 



, ., i- lU Kl- 



•Uj 




(Ad<lre.« ll'M mYUAA^ , - Jl 



.1 I 




ll 



I 




n 



•I' 



I 



t M 



4 



B 



„;,..] -t" !K:i!tli '' 



WR.TE PLAINLY WITH UNFADING INK-THIS IS A PERMANENT RECORD 

BgFER TO BACK OF CCRTIFICAT E FOR IN9TRUCTI0NS 

464 



>;o ,^ t-?['ar>?^ UScV Co 



lOO'i 



Registered J^^o, 



I)((fr Filed, -^^^ ^^ 

Icrw.^ ii^^v^ Deputy Health Officer ^ 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of H)eatb 

( Ta. S. StanCatD ) 



PLACE OF DEATH:-Countr of^a.^ .ka V.Cv4C' City of ^W^^'^XCr^Z.^ ' 




^N«, 



'^^ 



,dLl.k,vxq\^-44' 



a= 



St.; 



Dist.; bet. 



— and 



-) 



^U>Xa-\.l.\Xa VWMU\.U > ;,;^^fi-? ._,,, tAcVs^^LtO rOR UNDER •SPCC.At , NFOR M AT.ON ■ N 

( - r."o;':Tricc^%;r/.rrHte o%^?^?x^"u"4^n^o.;eTtI ^name .nstead o. street and nu.scr. ; 



FULL NAME 




PERSONAL AND STATISTICAL PARTICULARS 



*-! 



>, 



^1\C 



COI.OR \ 



U. 



I 



1^ "1 lilK I'H 



L 






(I):iy) 



A(.l- 



)',;i 



.\ft»rf/t^ 



1 « J 



I Vfiir) 



n,i V 




SIN. I.I- M\Kkn:i> 

\\ lilt ,\\ i:i» OK i)iv«»krKn 

'W-' in Miiial il'.'-ii.'Hiitiou) 







MEDICAL CERTIFICATE OF DEATH 




(M<inth) Q 



(Day) 



igo H 

(Year) 



II-:R1':RY CHRTIFY, That I atteiKled (kccasea from 



1 



i^ 



to 



'\.^X' 



that I last saw hN'"*^^ alive on 



^^^sXv,-, 



-n 



•X.O.. 



IqoH 
igo'* 



lL>Ok/ 



III 



niH riin. Ai'i-: 

■ iinmtry) 



N\MI nl 
I- ATI IKK 



OF 1 ATIIKR 
tStati- or Country) 



MAIDl'.N NAMH 
<»l MOTIIKR 



'<i i» 1 i i I i ,.\s. \; 

OF McnilF.R 
'st;n, or Countryl 



hVsidfd in San h'l aitfisro 



'>Xfr-^wA>^%. 



»i 



It 



and that death occurred, on the <late stated alx.ve, at 
M. The CAl'SK OV DI-IATII was as follows: 



C^.:^csJL.^r\^:yJf^ ' 



pr RATION ' years 
CONTRIIU TORY 



^ Months I H Days '^ Hours 



DTRATION 
(SIGNED) 



Years 



Mouths 



Days 



^\jOJ\J< 



\jXu^%X IQO i ( 



'W 



Hours 
M.D. 



Address) ^S O .AXL^yWt^U. 



SPECIAL INFORMATION only for Hos|>ltals, Institutions, Transients, 
tf iRClrt ^sldents, and persons dying away from home. 



> itX I 



yf.,nths\ I Ihirs 



THF: AHoV H STATl'I) PRRSONAI, I'ARTICrf^ARS ARK TRl'K To THH 

HKsT oi MY k;^<»\vi,i:i)<.h AM» nivlJHH 



(infuTmrnit 



\<l<lrfs>i 






as DO 



^\ 



Ml 



Former or 
Usual Residence 

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



How lonq at 
Place of Death? 



Days 



Pl.^^CK ni" UrRIAl. OR RHMOVAI. 



^v-^v 




( 



I NDHRTAKHR 

(Addresis 




nxTI. of H« RtAt, or REMOVAL 

^^ 190 H 

3^h%' \^Xk.M.. 



N. B.-BV.., ,te„, of InfcmMlon .hould be ca.-fu.l. .applied. AGB -hnuUI »»• •i-**i.f .^fj^^^^^ .ri^ll^i-V.'';:!.! 
•tate CAUSE OF DKATH In plain term., th.t It may be properly cl«.»lfle^. The Special Information for p«r 
•on« dyinft away from home Mhoiild be ftlven In •vrw Inntanc*. 



«# 




■t r; 



WRITE PLAINLY WITH UNFADING INIl-THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



Biwnl 1)1 111 111 11 I >". 1 . fc,^^ - 




Redistered JVo, 



465 



Dale Filed, HiAjLu ai -^^^"^ 

A ' \ Deouty Health Officer 

DEPARTMENT flfr PUBLIC HEALTH=City and County of San Francisco 



(Tcrtificate of 2)eatb 

( la. S. StanOate ) 

PLACE OF DEATH:-County ofOa^X-l'vO^^^^C^ City of <^^ J AAyw^^^.1^'. 



I e ^ 

M"^ 



( " ^'rc".Tt,"c^^%i"."r4'.-" o%'?«n?u"o';"o',;r.;'. name ,«st»o », .t«et «o »u-.«. ; 

J . lA-Ovk 



) 



FULL NAME 




-1 M 



PERSONAL AND STATISTICAL PARTICULARS 

I COl.t)R 1 



mo.U 



a 



!>A1F •>! r.lKTH 




Midilh) 



A«.K 



} V<7 I 



iDav 



M.nilfr 



I Veil r) 



Da V, 



"^IN' ! 1 MAKKIKI). 

w 11m . < in OR nivoRCHi) 

'\\ . i' -1. - vnatitui) 



BIRTH I'LACH 

'Stat'- iir i.'onnlrv) 



XXZ'- 






NAMi: or 

FATHl.R 



I''IHTHI'I,A(*K 

<>'■■ I X nil- R 



ISt 



itmt ! V 



MA III FN NAMK 
<»I- MOTMKR 



'"X I H IM.Al'K 
"I NtnTllKR 
(Slatr iir Country ( 



'H:ri PATioN /'U 



MEDICAL CERTIFICATE OF DEATH^ 

DATK Ul- I)1;ATH f\ A 

.lu n.- 

(Day) 



(4foiith) T 



(Year) 






1 HHRIUiV CI':RTirV, That I aUeiulc<l deceased from 

.— 190—— to ■ 190-—^.. 

that I last saw h^r— alive on '9° ~ 

and that death occurred, on the date stated above, at—rrTrrr 
^M. The CAUSE i)F DHATII was as follows: 



A-Ow^cto^^->vt 



T 




11 was as toi 

crt a A.*.^ 



Dr RATION Years 

CONTRIBl'TORY 



1^ ^"^l 



Months 



Cf >"vvvt>wi 



Days 



Hours 



I )r RATION Years 



flfonths 



Pavs 



Hours 



(SIGNED) 









M.D. 



li IQO i (Address) WwrOXA VJ^^ Civ^ 



0-- 



R^^idfil ni S,i„ /,,/;/,/ v.> ' )/-,/!» *" M<<nih^ * /'■?," 



IK \H(>\ K sIATKH I'KKmiNAI. PARTUMI.ARS AH H TRTK 
I'KsT OF MY KNOWMUH.F. AND HKMKF 



T*» THH 



Miniit 



f\.1c1re 



4H05 



^m 



nysjstsX 



*^PEdAL INFORMATION •?Hy hr ««^tih, IsititaHens. T^^ts, 
•f Recent Residents, and persons dying away from home. 



&%.„5iio(E-Jv.it rr.i',., 



Usual Residence 

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



Days 



PI,ACK OF m RIAI. OR KKMoVAI. 



190 



IJATF. of HiKiAt. or RKMc.VAl^ 

H^aJUj xi 

(Address ^HbNjfV\A,^%-4A,irY\^^ 



N. ».^Bv«ry Item of Information .hould he c«ref«lly .upplUd. AGE should ^•^^^^t^^^r^V, . ^"^^ n'^-^t^'^'j* 
•t«te CAUSE OF DEATH In plain term., that It mw.y he propeHy cl«««lfled. The 8pecl«l Inform.tlon for per- 
•««• dying away from home nhould be gklv«ii In every Instance. 



k 




( 



!■■! 

it 





f 



'r 



I 



WRITE PLAINLY WITH UNFADING INK-THIS IS A PERMANENT RECORD 

R EFER TO BACK OF CERTinCATE FOR INSTRUCTIONS 

466 




lOO'i 



Registered JVo. 



J^^^,v-\( Deputy Health Officer 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



\i\ 



V > 



PLACE OF DEATH 



Cevtiflcate of Bcatb 

( 'd. S. StanDarD ) 
mty 



9 <^ rS '^ 

:— County of O-O/^v JAXX,>vC^'i-CtGty of 0,00^ aAxX/>v<M^X^ 



■^ 



(No. iH'i'i dxoM/r^' 



.^LMj vl^NA. 



. k 



Disubct Mrvj 



i«< 



FULL NAME 



Si.; i-riai., 

nwsilDENCE CIVC fACTS 

OR INSTITUTION OIVC ITS NAME INSTEAD OF STREE 



and 



/ IF DEATH OCCURS AWAY FROM USUAL RES.DENCEO.VE FACTS;C^A^LLED ron^^-OZ^ sT%"E;*iN ^N U^rilR"""' ) 
V. IF DEATH OCCURRED IN A HOSPITAL 



i iu i. ) 








^/:^;x.CL 



l..».. 



'•IS 



PERSONAL AND STATISTICAL PARTICULARS 

i COLOR 



ma 



u 



V 



•! HlkTH 



iD.t 



<M..ntlit 



J* 

to 

(Uav» 



4 



/ '- 



A«;i' 









I 



I } lilts ' 



Mntifh} 



I Vi-nt 



l),i\. 



' ^ •ttuilrv* 



A 



w 



\ 



L 



41 



«i 



FATIIKR 



BJRTHI'l.Ai'K 
'If- KATIIKR 

^t.i!< ..r rontitry) 



MMUKN NAMK 



*»t-" MoTHKK 
•State !ir i«j«inrv) 



"^<^1 I'ATIUN 









Qin 









^W^YU^ 



f^f-^ldtil in Siifi / I iltiil-^t'ti H )>(/<•; I .^fiinlfl: 



I hi 1, 



T J 1 1' A n< n- K ^T a r j •, i > i» k r son a i, i» a r r i c r i , a r s a k i: T R t • K t » > r 1 1 1-: 

IJKST ni- Mv KNoWMUx'.K AM) BKMKF 




|| 



'Iiif,,. 



in 






f \"MrcHS 




MEDICAL CERTIFICATE OF DEATH 

DATH OF DKATIl [\ h 



lotith) 



1 



(Day) 



I go \ 
(Year) 



1 UEREBY Cl'IRTlFV, Tha^ I atteiuk'tl deceased from 

190 H 
igo H 



T-C^ X 190 H to ...JkAi^ 



that I last saw h <^^^^ alive on yN-JU^. %6 



and that .loath occurred, on the «latc- stated above, at /O'A 
CX M. The CArSI*: OF DIlATIl was as follows: 



CU^li^^^u^ \M.v.i 



"N^-Wfr^V«W,J 



rlU^. 



DURATION 
CONTRIIU'TORV 



years 



Mofiths Days 



Hours 




Di; RATION ^ Years %, Mouths "" Days 

(SlGNED)...iXA-i\x4^ Vnl .<LcU-v<%i:\.A 

^\^LuJ^O I QO H (Address) UxiR^ ViiJkiLM^ 



Hours 
M.D. 



Special Information »»t> tw tt»s^uis, issmHtiaBs, TraRsicBts, 

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 
nare of Death? 



Days 



I'l.ACK OJ- mUlAI. OK KKMOVAI, 







UAT^:of nt KtAl. or RKMOVAI, 

3.x 190H 



I NOKKTAKl'R 

(AddrewJi 



«. B.-.Bv.ry Item of Information •hould be c.r.fuliy .applied. AGB should •^^•*»*«il EXACTLY. . P"^««|!«^!t*, J?^!.** 
•t«te CAUSE OP DEATH In plain terms, that It mf^y He properly cl.s.lfted. The "Spscial iwform.tlon for psr- 
•«i« dying away from home should h« given In svsry Instance. 




' I 



w 



I 



lii 




WRITE PLAINLY WITH UNFADING INK-THIS IS A PERMANENT RECORD 

^^ , . orrrR TO BACK O F CERTIFICATE FOR INSTRUCTIONS 



fl 



^uJLk,{ 



WO'i 



, , M . o I rju-i Registered JSTo, 

icviollv^u Deputy Health Officer 

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

Cettiticate of Death 

PLACE OF DEATH:-County ofO.^ ^>va.vvcu aCy ofOam. J^<V>v^.^c 



A r .roT.^>; occuiqr.w.v r«oJ USUAL R".DENCE_ o-vj: .*cts C...J 
U V ir ocATM occilhnco in * hospital 



— ) 



»re.r.rn.r^.L ciivt r«»..» O ro»» UNOCB 'SPCCiaL IWrOW 

rp"NSn?u"oNV.;r.;; name .n8TC*o or st.cct *no hum 



FULL NAME 




<XK^ 





ftl%\ 



PERSONAL AND STATISTICAL PARTICULARS 

1)\ ri: nf HIKTU Aft ' 






\i 



'^^^ m 



■> t 



)'iii) 



.\t,inf/i' 



/hi\. 



^iN« IT- %f,\RKlK!>. 
\V!l)n\\ ID OR niVOKCKO 



--i",*- — -nr-m Tiwr*=wii-.ro»'^'ir 



tUK nil'I.Ai'l', 
'si;('. ,,r t'.iimlry) 



NAM I' ni- 
I- \TnUR 



BIKTHFM.ACK 
«'l" IM'UKR 



<>I- MOTIIHR 



ItTRTHPI.ArR 
"I- MoTHKR 
(State ur Country^ 






MEDICAL CERTIFICATE OF DEATH 

DA IK 01- ih:atii 



(/Wonthl 




1^ 

fl)ay) 



(Ywr) 



I HERUHV CI^KTIFN, TlisU I attcmlea deceased from 
l<n * ^ 190 ^ to .-l-uJ^...!.^ 



]"h 



to . l-VM^U,. ...l-.-l. IQOI 

that I last saw h ■'• ' alive on H V^l^^.U I90 : 

and that death nccurred. rMi the date stated above, at 1 0- *i 
(? M. The CArSI':jJI' ni«:ATII was as follows: 







X"^ 



I 



\J|\a>\ai nta\J>n^ 



Oeci I'ATION 

/\f>idri1 in Sijn liiiihi^ii' 




^ I A 



* 






nr RATION ^ )Vtfrj •" Mouths - Days 
eONTRIIUTORY 



I /ours 



m'RATION 
(SIGNED) 



5 'h % 



JlfouiAs 



Days 







Hours 
M.D. 



IvvLlwD ic^H (Addr.-.s) Cd^ut^.% 
^opE^IAL INFORMATION wlHw Ho^Uls, lislltatteis, TraBSfests, 



or Recent Residents, and persons dying away from home. 



) '-a I 



\/,>iif/r 



I Pars 



I'Hi: \lu>VK HTATKI) I'KRSOV^M, f XRT lOfl.AR?^ AR K TRl'H T<> THK 
KKST OH MY KMgWl,i;i)(.K AND IIKI.II'F 



(Infurmant 



"^ju vJ.l^xt.^ 



(Afldres!* 



Utu/"^'' Lo m CHt^v^.tft.i 



I Residence ^'^v?- Jipe^v^fcd mt^^mklSSmMM^^ 



Form 
Usual 

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



I'LACK OF Bl RIM. <>R RKMOVAI. 






DATKol Hrm*r, or KEMUVAI« 

Hiuwvu^ '^X. 190'; 



(A(lUri'<is 









•tate CAUSE OF DEATH tn ptatn term., that It may be pro|i«rt|r «l.«slfle«l, Th« Specl.I I«fo«««tioii p. 

•Ofi» dying away from home should he given In every Instance, 






1^ 




!■ 



k 







«l 






L^ 



WR.TE PLAINLY WITH UNFADING INK-THIS IS A PERMANENT RECORD 

BEFEH TO B»r.l C OF CERTIFICATE FOR INSTRUCTIONS 

468 



mnt..nh:.Hb 1-N'n i^_';^^ 



H&rco 



Ih,fr Fi/rff, >4.V. 




Deputy Health Officer 



Be^istered JSTo. 



DEPARTMENT OfVuBLIC HEALTH=City and County of San Francisco 



(No. 



PLACE OF DEATH: — County 

a., a,.. 



Cectiflcate of Death 

( la. S. StanDatD ) 

% 



ofC^ 






and V'clo 



rH 



St 



.; ^ Dist.; bet. 




^ 



j/(Wv OAXuwa^vct 



If) 



A 



FULL NAME 




- 1 \ 



PERSONAL AND STATISTICAL PARTICULARS 



*^ ft 



r^ .+ 



DA IS. < il llIKTlI 



\<.H 






/ 12, t 



1H 



J V'rt t 



( 1 )a V 



Month' 



(Year) 



fhns 



MEDICAL CERTIFICATE OF DEATH 

DATE 1)1' I)i:ath /^ ft 



(M4nth) 



I 



a 



I 



(Day) 



(Year) 



1 HHRHBY CP:RTIFY, That I nttemlcMl deceased from 

Qfk:t5^. JX5 ,90a to .Wi^^^^^^^^^ ^9oH 

that 1 last saw h.:*' alive on J^^. '^ 

anil that death occurred, on the .late stated above, at I 



190 H 



'^IN.,1.1* MAKKIKH 



\VIiHi\\ 1 I) <»K ntVnKt'KI) \ 



BlRTHPJ,\rK 
(Stat* 1)1 Country) 



NAM I- nl 

HATHKR 



Rlkl'llPl.ArH 

Of- I \T1IKH 

i State or C(iinilry) 



M A ! 1 1 1 : S N \ M i-: 



niRTHI'LACK 
OF MoTHKR 

(State iir Cu\intry 






(ijt*V'WvCU\ 






nil that « 
i M. 



The CAT SB C)F DICATIl was as follows 





N^vJLl»0 I 



i 



occri'A rioN 



Rfsided i» San Piamisro % % Ynits .MoiiHn 



/hn 



THK AlluVK STATF.n PKRSONAl. PARTU'ri.ARS ARK TRVK T«) THH 
HHST 01- MY K^()Wi,KD<*.E AND HHMKK 



DIRATION 3 >'eW5 • A/oNi/is ^ Days - Hours 
CONTRIIUTORV Vm^^O^A/VVXA.^. 

DI'RATIOS ^ Years \ Months " Days ^I/ours 

(SIGNED) % "^Ua^J^^ ,WI-D. 



qO 



or Recent Residents, and persons dying away from home. 



Fomiff w 
Isual Residence 

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



H«w liit at 
dire of Death? 



Days 



< K'lilress . 



SO d^nj^LLxr 



PLACE Ol- m RIAI^nR kKM«>VAI, 




rS'DKRT 






( Address 



..„. o. ln.„,.m.t..» .•.Jld b. carefully .uppll.d. ACB .hould *;• ""'^f *"^,^.; .r/nfJuLn-'lo;";:!.''- 
AU8E OF DEATH In pl.ln t.rm.. .h,« It may be properly cla..t»led. The Special Informa P- 



•tau- CAUSE OF DEATH In plaii 

wm% dying away from homo should be j|5v«n In •vry Instance. 



\ 



I- 1 



< 



i!' 



> 



^^^W 



I 




■ 'i 



! i 



) 



1 1' 





h 



I I 




"*'■ 



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

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 

■ '^ " 469 

XOOH Registered J\ro. 







Vi ^u Deputy Health Qflflcer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



J? % 



Certificate of Death 

( 13. S. StanDarC» ) 
PLACE OF DEATH:-Count. JJ^J^^^^^^-C^^ „, O^ Xa.X^C. tC 

V ir OtATM OCCURRCO IN A HOSPITAL OR INSTITUTION Oiv ^ /%* '^ 



FULL NAME 



kx/VYSJ^ 




\Q AJULA..t.l A 



sl-\ 



PERSONAL AND STATISTICAL PARTICULARS 

COM>R \ 



DA ! ) ul HIK I'll 






tM.iiilh) 



A«.K 












3)^ 


5V< 


>--I\. 1 


1 MAKUIKI). 




u r ' ■ 


It i»R 


DIVOKC 


K.n 


u 


'n.iul 


cit'sii.Miati«>ii) 



.•^ 



b 

(I>ay) 



M.niHn 



A 



/111 



1^ 



(W-ar) 



Pit v« 



RIKTIHM,\('K 

(Hl.it. ..» r,.iintivi 



VAMI' Hi. 
FATHKR 



RlkTHri.ACH 
fil I xrnKK 

•stall .,r Country^ 



MAIDI.N NAMK 
OF MoTllKK 



niRTHPI.ACK 
OF MOTHKR 

fStriti or Country') 



D-V^xt 



ClvAVClU, 



MEDICAL CERTIFICATE OF DEATH 

UATH OF i)F:A'rn »' y I 




Olltll) 




(Day) 



I go » 

(Yrar^ 



V 



YWtC 



JUXLCTTV 




AA^4,frV\X^« 






' rHi:Ri:HV CKRTIFY, That I attcnaea aiHtasc-a from 

Wvi' t 190H H lp4^^ ''^ ^ 

that I last saw h alive on |^ ^^ '^^ 

an.l that death occurred, on the date stateil above, al HaO 
Q. M. The CAUSE UF DKATH was as folU.ws : 



.-vv^va.^^ 



Dr RATION 4 >Vflr5 ' -Vt;//M^ 
CONTRIHUTORY LLd.O.^^T^ 




Days 
CONTRIHUTUKY wvw^.--^ J -j^-^^ 

nrRATION H )V<7r^ JMonth 



Hours 



Days 



Hours 



(SIGNED) 



M.D. 



Xt IQOH (A(l 






aress)nSl dx^tti.>t. Ol 



aPEblAL INFORMATION only tor Hwpftds, InsUlMltoiii, Twnsleits, 
or Recent Residents, and persons dying away from home. 



oecipxTioN ^ 

Rfsiilrii it! San /'rant if/'o 



)■/'((/ 



Mnnths 



<Hl 



Da V. 



PUACK OV lUKlAI, OR RF:M<»VAI, 



THK AROVR STATKt) PKRSOVAI, r XRTHMI.ARS ARK TRUE TO THE 

bf:ht of mv kno\vi,f;i)<;k and hkuifU' 

fAdclrefl« IIdO LLLIHn^^^ AXa' ^ , 

N. B. Every Item of Informatlofi •hould be carefully supplied. AGB "^"" '***•"•'" '\,^ •'Special Information*' for psr- 

•tate CAUSE OF DEATH In plain terms, that It may be properly classified. The »P 
sons dying away from homo should be given In svory Instance. 



Former or 
Usual Residence 

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



(jtU^OAvA; WV. 



How I0114 at I , . 

Place of Oeatfi? A a pays 



( 

rSDHRTAKHR 

(Addreufi . 



DATFtof m-KlAi, or REMOVAI., 






I 



^ 



•J 

i 

t 









V . 



• .«- I 



M 





im 





I' 



Hoar.lnf H.aUl. F V., i 



WB.TE PLAINLY WITH UNFADING .NK-TH.S IS A PERMANENT RECORD 

RE FER TO BACK OF CERTIFICATE FOR INST RUCTIONS 

470 



.^f'^^Siy^.nSiVCo 



Ihilr FiJnl, )i^^W ^ 







Deputy Health Officer 



Registered JSfo. 



DEPARTMENT OF PUBLIC nEALTH=City and County of San Francisco 



PLACE OF DEATH: — County 



fNo. I'i^^Tlrvxlatri 



>\iAJU 



I 



Ceitificate of Beatb 

( "d. S. StanDar^ ) 
of OOm^tAXX/Yv^i^tLO City of OO/^v Q K/Xfy^. 






m 



St.; 3. Dist.;bct. 




and 



/ IF DEATH A;CURS AWAY hnot* USUAL 
\ IF DCATM occurred \it A HOSPITAL 

FULL NAME 



M USUAL RESIDENCE GIVE facts 
OR INSTITUTION GIV- "•'" 



■»CTS**CALLED 4« UNDER 'SPECIAL INFORMATION" \ 
e ,tI name INSTEAD OF STREET AND NUMBER. J 




I 



si;\ 



PERSONAL AND STATISTICAL PARTICULARS 

COI.oR 



^f»vL 



IiA 1 i < -I iUK \\\ 



\i . K 



iM.mth* r 



t^ p% 



),•</ 









^/nuf/r 



(V<'ar) 



PiJ V 



HlM.i 1 M \KUn"I). 

uiiH.u J n OK nivoRCKii 

lUlitf in >^.H!iil cU'si^tltltiuu) 



BIK riiri \c\f 



NAM!' m 
I- AT 11 IK 



HIKTIiri,\CK 
OF l-ATMKR 
(State or 0<niti(iy^ 



MAIin-.N NAMK 



HlkTH1M,Ai'lv 
J>1' MnTHKK 
(State or Count r\ 



I. 1 



.lAjudb 



y 






MEDICAL CERTIFICATE OF DEATH 

DATE ol' DHATU ,\ ^ , . , 

! HICKI'i'.V CICRTIFV, That I attcmkMl .leccascd from 

____— — 1 90 to v-igo— " 

tliat I last saw h ^T"— alive on " " "~ ^'^ ' 

an.l that death occurred, 01, the daU- statc-d above, at 
M. The CAl'SR OF DI-ATIl was as follows: 



'sty.:-.- ?.. 

1)1' RATION Vi'^rs 

CONTRIIU'TORV 



Afonihs 



Days 



J lours 



\ 



Ww^ I '•^ 






Mouth 



/h! 



THK AUOVK HTATKD PKRSONAl. 1' Xk'r ICf I.ARS ARK TRIE Ti> JHE 



r, AisuvK STATED PKRSC1NA1. I'AR I FCtl 
HF.ST 01. MY KXoWl.EDt'.K AND BEI.H 



(Itifortnntit 



NOW I, 







AddresH %i^. % 



(^ 



O^Ms" 



-?, 



I )r RATION 



Vears 



3fon//fS 



Pays 



luJL^ IH looH ( Addr,.ss) UrXAntxXhM ^M-- 



Hours 
M.D. 

X-^ 



^ S P E^ I A L IN ro R M AT I O N only '"^ Hu!»|nWi» InsUlMlwiw, Traaslcftts, 
or Recent ResMenls, and persons dying away from home. 



Former or 
Usual Residence 

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



Ntiv Itiif at 
Place of Death? 



Diys 



PLACE OI- nrRlAl, OR REMOVAI. 



QQi^J.W^ 



DVrE"f. lURiAi. or RKMOVAt^ 



% 



(AddrcH?: 






190 



M. B Every Item of Information •hould be cai-efully nuppHed. -^^^^ •^**"*f^'l«.j ^he •'Special Information" for p«r- 

•tate CAUSE OF DEATH In plain term., thnt It may be properly cl.MWed. ne ope 
«9n» dying away from home Hhould be given In evary instance. 



I 



It 




lU 



i 



ilto 



I i 



I 



►! 



I. 



U 



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

.^^ REFER TO BACK O P CERTIFICATE FOR HM9TRUCTIONS 






Registered J^o, 






Dff 






190'i 
vvus •'-^ Deputy Health Officer 

DEPARTMENT OfIuBLIC HE ALTH-City and County of San Francisco 

Certificate of 2)eatb 

( TO. S. Stan^at9 ) -^ 

i on -^ ^ 

PLACE OF DEATH:— County of ^C'tV^ VO-^V^v*.^. v-.ty oi 



nj lit* /^ V tKA/vxtAi vO M^ 1 xvlcLSt; — Dist.; bet 

(No. V\.tH ^^^^^^^^Hr.„„.2 ..«U. prS.DENCE GIVE FACTS CALLC 



and 



u'^ UrU.^^<tu vO M^ IxvloSt; — ^j^'^^DroR under ••spccal .nformat.on- N 
l( - I^^Jli-n-ii^t :^?:S^?U^^^ -s|ir^ ^^o OF street and nu.ser. ; 



) 



FULL NAME 



.^^a 1 



PERSONAL AND STATISTICAL PARTICULARS 



<i 



1>\ 



ll 



:ui,uR \ 



lu^^ 



UK in 







lUv? 






\<.l 



>V.7 



,1/,»W///' 



I Viar) 



A/ V 



MEDICAL CERTIFICATE OF DEATH 

DATK OF DKATH 




(Month) 



I 

(Day) 



/go i 

(Year) 



^ 



FjIHRKBVcI^RTIFV, Tliat I atten.U-.l .leccased from 



^vU 



H. 



190 



to « 



I 



WliXiU ID itK niVoKClUJ 






V 



NAMl 111 
FATin:K 



HIKTllIM, \rH 



ft/ 




iStal. 



I ■ 'M nl I 



MA1!»1:N NAMl-- 
OF MiiTHKR 



J'lK rui'LAiK 
OH MnTHHR 
(SUtti or iNmntry) 




tHat I lasf saw h ^' ' alive on pS-'^^ 

an.l that death occiirre<l, on the date state<l above, at 

'\ M The CAl'SlvC)!' DICATII was as follows 



190H 
190 
U 



DIRATION >V'?''^ 

CONTRIBUTORY 



Mouths 



Days 



Hours 



W 




OCCll'ATiuN 

Rr'suifil ill Silt) /'i itiu iff'ii 



) '/•(! 1 



M,>iilli> 



!hi\. 



THK AROVK STATKn PKR«^OVi^!, rARTIiMl.AKf^ ARK TRtE 

m:sr of my knowi.fjxvk and HF;i.n:F 

(Informant uJ f'^'W^ \TH dwOUW^M^^O^ 



TO THK 



(SIGNED) '.I %'%0..^-^ ,^ M-D. 

lAL INFORMATION only for Hdlpltals, Institutions, Transients, 
or^ertS^csMents, and persons dying away from home. 

When was disease contraclei. 

If not at place of death ? 




I I How long at , ^ 

iA*k.piafeol Death? < -* 



Days 



(A.ld 



ress 



LcLj^Vw w ' 




^ t - 



PI ^CK OF BIRIAI. OR RKMoVAI, 



DATK of IJfKtAf- or REMOVAU 



I NDERTAKKR 



CUVOUW 



^\<JLu ^^ T90H 



(Address 



mir- i^-.tL 



N. B. Ever, item of tntopmatton .houW be cBPe«uMy .upplled. *•*" •^°''. „,„.j. The "8p«cl«l Infopmallon" lor per- 

.t.,e C*U8E OF DEATH In plain term., that It may be properly ci.a..tle«. f 

•one <1ylng away »Pom home ahould be »l»«n In every loatonce. 



I 



V 



.J 



i 



V^'\ 





^'.\ 



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

,^,,,„ "e«R TO « ACK OP CERTIF.C«T t FOR .N9TRUCTI0NS 





Dad' i'Hcfl , 



-V 1 



lOO'i 



Registered J^fo. 



472 



X^^ oUv^ D^P"*" "^^^'''^ °"'*'*'' 



'' i ' 



■ 






DEPARTMENT OF PIIBLIC HE ALTH^City and County of San Francisco 

Certificate of S)eatb 

( Ta. S. StaneatO ) 
PLACE OF DEATH : - County of ^^ ^ ;UWV^<ACC Qty of -^V.^ ^^ 






St.; ^ Dist.; bet. 



?),\d 



and 1^ A. 



) 



\1 I IaAjH-ITTV St.; ^ UlSt., cei. _ „„„,, ••,,tci«i mronM.TiON- x 



(% 



FULL NAME 



iVCrVyVO.^ 



PERSONAL AND STATISTICAL PARTICULARS 

^|.>, « . CliI.OK 



OUcu 




^ 



1 



ii,i.'-wt 



DA 11 't! niKTII 



^\ 



Month' 



,\'.!- 



\\ )V,/'v 






M,mth> 



/15(o 



I f 



I'j'tai 



Af 'V 



MEDICAL CERTIFICATE OF DEATH 

DATE OF DKATH /\ ft 



(Year) 



k,nth)| '''''^'•\ 

I III'KUUV CKRTIFY, That I atten.lc.l tleceased from 



Tgo 



to 



that I last saw hnr— alive on 

a„a that death occurred, cm the <latc stated above, at 



190 
190 



^1%' ; i M xKklKt). 
WliH.A I I» oK 1»!V«)RCFI> 
(Wntv ,11 -iKi.il lU Hiifiiatinii) 



lURTHrixri". 



'St;i!i 



I A nil- k 



m i t ! \ 




1!IUTH!'I.\<-K 

"I 1 \ ni 1- k 



MAlt))". s N \MH 

"1 M'tiin-u 









— M. The CArSK UF I>f:ATII was as follows: 

dp Si.^<-^;>"^ 



I 'i.^l^iw :. .-w^ i^wv^w^t^ hs.^ 



HiK run. mi-: 
'•> M'lTlIKR 
'stutf or Ciiunlrvi 





*. . . . ^ 11 ,. ... 



y 



or RAT ION ><•«'-* 

CONTUmrToRV 



Months 



Pay.^ 



Hours 



DIRATION 
(SIGNED) 



Afouths 



Days 



IHIoIlUwcl 

1^ 



Hours 
M.D. 



Sfioiths 



Davs 



Rfsiiird 111 Salt Fi itiu /vr> A k J fiiis 

THHABOVI- ST\TJ'I» I'KRm >NXI, 1' VRTim' !.ARS ARK TRVK n> TUT, 




II-; ABOVI- ST\TJ,I) I'KRmiNAI, l'\RTirri,Al 
BKST 01 MV KNOWI.I'.IX'.K AND KHMHF 

T5S mJ» 



niimit 



aAJ^'^ 



.k 



SPECIAL INFUMIVIMI IWII ""■/ 7^' 

or Recent Residents, and persons dying awiy frwi mm. 



Former or 
Usual Residence 

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



Itowtotf It 
Plareof Death? 



Transients, 



Days 



PLACK OH m'Rl^M. «>»* Kl-MoVAl, 



I \flilrt*)« 



(A.l.tn-ft "tic 



I)\Ti:of m-KiAl. or REMOVAl, 



1.^ I I'. I'j »•» 



'X 



a^ 



IQOM 



r.VliKRTAKl- 



1 uVWt-4,v.rvT. 



" " « ^ APR «hould If »f t.d EXACTLY. PHY8ICIAWS •N^-W 

N. B. Bverjr Hem of Inform-tlofi .hoHld be c«r«fully .upplUd. ^„„^ •^^ ,--,,f|,j, Th« ''Sped.! Inform.tlon'* for p^r- 

•fte CAUSE OP DEATH In plain term., th-t It m»y ^fJJZl 

•on. dying away from how. nlHHild be ttv.n In ov.ry In.tnnce. 



:i 






t 

I 







I 

I 

■i 



i 



1 1 



r I 



■%: 




t4 



I 







WRT 




Boru-lnfll. -n, FNo . 



T. PLAINLY WITH UNPAD.NG .NK-TH.S .S A PERMANENT RECORD 

^^ , rrER TO BACK OF r.rPTT.CATE FOR IN STRUCTIONS 

-»—————— 4*73 

■ (\ ^, jPt'H Registered ^o. 

ill- t'ilcil , r-*-^-H '^ 

1 ixi-M, Deputy Health Officer 

DEPARTMENT OF PUBLIC HEAITH-City and County of San Francisco 



Certificate of ©catb 

( XX, S. StanOarD ) 



PLACE OF DEATH: — County 






Dist.; bet. 



and ""^"^ 



) 



X f ^'S dVi 5-4- ' ' St.; J^lSI., ^^'^^^^ ^^_^„ 'SPECIAL INrORMATION" ^ 

.r DCATM OCCUHHCD IN A HOSPITAL OR IHSTITU 

: MiULL- 



(>r DEATI 
ir OE 



FULL NAME 




PERSONAL AND STATISTICAL PARTICULARS 



si.\ 



llA 



\r.i.; 



^ 



IKTH 



UOJvvU 



■ Months 



I 



SIX' ,! r M \RU H*!> 

WII 

l\Vi , • 



ll>;iv) 



M.nitin 



i\,::v.) 



fhl V 



MEDICAL CERTIFICATE OF DEATH 

DATE Ol- DKATIi 




(Day) 



/go 

(Year) 



alion) 



HIK IM 



Mi(tr\ 



N\M1 1(1 
I- Mlll.K 



nikl'Ht'I.XiH; 

f" V \ II! !• !■; 



I- <ir I 'ill lit ry 



M^IDl S- N\M|-: 

<ii' Niftrui.K 



• I I- \tl 1 1 11 J. J< 



1 I UX^VA^<i- 



TjIFKI-P-V CHRTIFV, •rh.t I attcn.k-.l .Icci-ase.! from 

i.vtu rv .90': to W^-li^ >9oH 

that I last Haw h alive on ^^^-'^ 9^^ ^ 

ana that death occurred, on the date stated above, at I v w 



M. The CAl'SK OV DJjiATlI was as follows 






-i. . . t , 



t-'S- . 






Hours 



1 



"^ <:i I'A I ION 

Rfhlfi! in Situ /'i nin ist'o 



y\^ 



y\JK,yx^ 



J>,rrc ^Ti'iitfi^ 



IRRATION 
(SIGNED) 



Davs 



Special IN 



TooH (AddreH^) 



Hours 
M.D. 



^ 

^ 



^ 






, ,^ FO R M ATI O N only lor Hospitals, Institutions, Translf Bts, 
or^twrtfe'^eiits, «* persons kim *w> •'•» ^• 



fomtrw 
Usval lesMeiice 



<i^ 



?o^i^^...,.• ^ 



THH AHOVK STA TKn PKRsCiNM. I' AKTHT I.ARS ARK TRIK T 

HKsT oj. MY kn«)wi.»:i><;k and hki.ihk 



(> THK 



•ttttani 



When was disease contracted, ^ ^ \y ^^J|^, 
If not at place of death ? • 



How long at 1 li ^ 

Hare of M»l ' ''^^ ft»y5 



%l <>^t« %1?>V 



(J.1 



PLACE OI- niRIAU OR RKMnVAI, 




f ^f1»1re<«« 



%15C^ 



'yXKM. 



UNDERTAKHK 

(AtMi''*^*^ 



I)\TK«if Ilt'KiAi- or REMOVAI, 

^%aXwl %i 

isn B'L.XtjL\, "at 






^ „ ^ >" .h„„,d ^ ,t,ted EXACTLY. PHYSICIANS shottld 

N. B Every Item ol Inform.tton .hould be c«p«f«lly MPpH*^ !.„„eHy c!.««lfl«4. The -SiMrcl.l l«forii.«tloB" for p«r- 

•»«te CAUSE OF DEATH In pl»ln term., that It m«y n€ prop 
•«!• dying away from hmmm •ho»ld be ftW«" «" •^•^^ In.tnnce. 



f-'i 



H •! 



f 1 

I) 





4 



(i:i 



f 



ill 




iih 




r I 1 




l! 





WRITE PLAINLY WITH UNFADING INK-THIS IS A PERMANENT RECORD 

, ,„ ,„ . .„ „..^,,...Co ».P.R TO BACK or CeRT.r.CATC rOR ,N3TRUCT.ON3 

V. w ... ,,.,. Registered JV'o. 474 



X\ 100^ 

jl^j^/v-u Deputy Health Officer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



thwVA^ 



Certificate of Beatb 

( "Q. S. StanSatO ) 



J <^ 



PLACE OF DEATH:-County of 5<V>V ^ K<Vy^^^U^ Gty of OxXAV I'va^vCA C 



tTw. ^"^ 1 ,icsii*i nrsiDC 



Dist.; bet 



and 



-) 



1 C'—S^h^^^^^ ^^^---'" ) 



FULL NAME 



>KX 



PERSONAL AND STATISTICAL PARTICULARS 

I CUl.OR \ 




vkoU 



ll'v.-t 



DA 11 Mt IMHIH 



M(i4lthi 



\|.i 



O A, )'(/»> 



u 

'l):iv) 



Motil/i' 



r%?\ 



1 



(Viari 



I his. 



WI!)( lU 1 ii MR T>n'«iKCKI> 



niRrMiM.\>i* 

iHlati OT < . ill ills y) 



\'\M1 Ml 
I'ATHl.K 



ntkT!iP',,Ai-F 

''I I ^^lI^.k 



MAiltlN NAMK 
OH .MiiTHKK 



"• ^t")iii:R' 

'''tilt. .It ( , ,,,,(, yi 



C).<.w 



q/u 



1 

d 



•H'CI l-AiiMN 



( 



Hi ^ 



MEDICAL CERTIFICATE OF DEATH 

DATH Ol- I)1;aTII 

(Day) 




(Year) 




l^EBY CHRTIFY, That I atteii'lcl <k'icasc(l from 

Ik) 190H % W^ ^^ '90H 

that I last saw h V»v alive on |1JM^ l^ 190 1 

an^that death occurred. 011 the date stated above, at I O 
The CAl SI-: Ol' DlvATlI was as follows: 



lid that < 
(?, M. 



Uct>%c4^ 



.\f,>iiflr 



Ihis. 



h 'fMiini iti Son I'l (uu i-fit lO )V(f; .^_^— i^— »— — 

THK MUJVKHTATKTJ PKRS«»\-AI. r\RTHM*I.AKS AHKTKIK To TIIK 

in.M- 01 \\\ KN-«»\vi.!:i)<',H ANf) hi:mi*.k 



'\'1(lr.-sH 



^ 








,aJi' 



Dl' RAT ION 
CONTRIBUTORY 



Years 




DURATION 
(SIGNED) 

SPCaAL INF 



Months Pays J /ours 



Hours 
M.D. 



fars . Months Days 

H (Addres.) UtH%. U. h 



i^ 



..^FORMATION m'^ '*' H&pitaK. laUUutiois. Traasleits, 
orleceSlffslJfntsVand persons dying way from home. 



5nH 



Former or 
Usnal Residence 

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



%,-LHowloiS8l 
HAHXn^OA Place of Death? 



,X ftays 



PLACK *)l' nrklAt, OK KKMOVAI. 




f NDKRTAKKR 

(Ad'lrew 







..n.L 



Ntt^ Tan afintild ba atated EXACTLY. PHYSICIANS ahould 
N. B Every Item of Information ahoalH be carafufly aupplled. AGB aboald "^ """"^ .7^ ' . , i„for«atlon'» for par- 

•t«te CAUSE OP OEATH in plain term., tliat it may b« properly claa.lfled. The Special Information tor par 

•on* dying away from homa ahould be givan In mvrw Instance. 



m 



V 



li 






ii .1. 



I 



iV 



:.f 



r 



m 




^ 



r 



t 



\ 






If 



!• 



I 



m 



III! 



WRITE PLAINLY WITH UNFADING INK-THIS IS A PERMANENT RECORD 

, ,„ „„ , ., ..^l^....o„ P.r.RTOBACKOrCeRT.r.C*T.rOR...STBUCT,ONS 

1 irv^^o 1«^M Deputy Health Officer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 




PLACE OF DEATH:— County of Oav 



Certificate of 2)eatb 

( TH. S. StanOarD ) 



^a^-r^tA.4/CU) City of ^' O-^^ J ^^"^^ 



Dist.;bct. 



■rrrr-. and 






\/Z c4 t 



FULL NAME 



-r 



PERSONAL AND STATISTICAL PARTICULARS 



SI A 



I)\ 



At.l. 



•I :,.Kiii 



COI^OR \ . \ (| 



+ 



Miiiuhl 



} , 



n).iv> 



M..„fhs 



(Yrar) 



Jhrr 



' MEDICAL CERTIFICATE OF DEATH 



Month)] 



4 

(Day) 



igo 

(Year) 



t, .V I \ ' ■ I 

I UKRECBY^HRTIFY, That I atteiuled .kocasca from 






s!\. I I Nt \K1<1K1> 

Willi ■•' . ' . . ,)• II M', 
iWl;!. 



niKTiii'i ■' i 

1st *. 






-Yvo-v^rw 



ii. 




N'AMl.- (11 
FATIIIR 



nikTiiiM.\r|.- 
f^'' I AlilKk 
ist;itc or ilfiuiUiy 



MMiU.N N\MJ.' 
01- MOTHKK 



RIKTHI'I.ACH 
'»»• MnTHKk 



••'ITI-XTION 






'"VXd^Aj'^Xi 



II 



190^ 

that I last saw h ■ alive on 

an.l that death occurred, on the date stated above, at 
Am. The CAlSf' t)F DHATH %|is as follows: 



T90 



\ '\ 



DURATION >Vv7;.? 

CONTRIBrTORY 



Months Days 



or RATION 



Yrars 



Jfonf/is 



Days 



(SIGNED) Wy ^. Vr>VY^-^>^ 

^^^ix4lCi iqoH (Address) Uj^>A> 



Hours 

Hours 
M.D. 



Special information ^ ^ Hospitals, IwtlteHitt, Tfwsteits, 
or Recent Residents, and persons dying away from home. 



IHi: ABOVE STXTKD l»KR^O^•A1. T'\HTKM-I,ARS ARK TRlK Tt> THK 
I5RST OF \1Y KNOWI.HDck AM) lU'.I.IHI" n 



'Inf,„,„. 






'Afld 



rc!^«8 




]. 



'Mv4,1i VCrA.WH„* 




Former or 
Usual Residence 

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



How loni at 
rsy\AAXJ^^*^JLX, Ptoft of Death? 



Days 



PLACE OF BIRIAI, UR RKMOVAI, 

INiniRTAKKR J\D 0-<3^0.n^ ^ ^^SM^- 




Mb - .. -i . A np .kAiild ha Stated EXACTLY. PHYSICIANS «hoMld 

N.B.— Every item of Information .hould be CBrafuIly •applied. ' ^f^^^ •^^^/.^^f ^he •'SpUl-l Information- for p.r. 

•tate CAUSE OF DEATH In plain term*, that ft may he properly ci^am— • »~ 

«ion« dying away from hom« should be given in mvry instance. 



6 I 




« . 



1 



1^ 



l! 



< 



T 



I ( 
I 



f. 



I II 







WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



H„:.!.l ..f lIcilMi- I- No. I', "^x:*);^ H& I' Co 






Deputy Health Officer 



Registered Jsto, 




DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Certificate of Beatb 

( Ta. S. StanDarD ) 
unty of 0/CX/YV JXKXA^XLV^/tO City of ^/CX/W ;UX/\vC4=4,^^ 



PLACE OF DEATH: — County 



rplo. 



UkJUOu 




t/ru v^ M. 



kvt 





/a A.) 



St. 



Dist.; bct.- 



and 



(ir orATH OCCUns away »-R0M USUAL RESIDENCC GIVr rACTS CALLCD rOR UNOCR "•RCCIAL INrOftMATION" \ 
ir OCATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVC ITS NAME INSTEAD Of STRCCT AND NUMBER. / 



FULL NAME 



I I 






PERSONAL AND STATISTICAL PARTICULARS 




COI 



.OR .\ . 

10 



A 



\<.i-; 




(Day) 



)''iM 



Mimlhs 



/a.o,*i 

rVcar) 



A; V.' 



"IN' I.I" MXRKIKI), 

N\n>. i\\ III » iK HIVOKCKI> 

lUiitciii H,)(i,i! (lr>iU'nntioii) 



I'-lkTtH'I.Ai'K 
M.iti or Countrv* 



I- A I' 1 1 J.; R 



HiKTH!M,\t'K 

'>i' 1 AT in: R 

'State (ir riMuitrv) 



UX/VXOAJi 






c Ca^' 



M^EDICAL CERTIFICATE OF DEATH 
DATE OF DHATIl 

at, 

(Day) 




(Year) 



HRRHBY CI':RTIFY, T1 

aO UilMlgO I to 

that I last saw h A\.' alive on 




[at J atteii<le<l deceased from 

ao. i.iKyK ,9oH 



|\,»lu XO l(?Of)l., igo'i 



and that death occurred, on the date stated abcn-e at li 
VJ >L The CAl'Sr: <)!• DI-ATII was as follows: 



MAII»1-:n NAMK fTl ^ 

\JL^A/t\ AM I M> I Ai I /v-f JL-k ♦. 






..yA,'(^WJi^L^ 

DURATION ' }Vrrrj * Months 
CONTRIBUTORY 



V 1 ry^-v «-©-> 



Days 



\ Hours 



inKTHlM.ACK 

"I M<'TIII-:r 
^'^lat. ur Cuntrv) 



DURATION 



Vt'ars 



^font/is 



t\'fu'df,l i» Satt /'in II, I SCO 



<3J 



LcJt' 



) III I 



Months j /iays 



(SIGNED). Kp J. C>UC^t 



Days 



Hours 
M.D. 



jflonsT 



' *' BKST nK'l[s''y'J\i;f-'*:^'^^^'- rARTICn.AKS ARK TRfK TO TMH 



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

Former or , . .^ CyV^ 1^ ^ i No* Io»« at 

Usual Residence »5v v v rlrwvavjL J C piare of Oeatti? t v .... Oays 

Wlien was disease contrarted. 
If not at piar c of death ? 



I'lUACR OF Bl'RlAr. OR RKMOVAI. I 1>A TK of rirRiAI. or RKMOVAI 

M)u OL^*^ I vlu. 13^ 



r.N'DKRTAKKR U /Q^WVVAJl V fXOJ 




A^WU^ 



(.4d<Ires«i 



^.t^^cJktrvw 



t 



190 



tlin a^uJ^ iaHl'ZTV^'*'' •*'**"''* *** c«i»«fully supplied. AGB Rhould h* stated EXACTLY. PHYSICIANS ahould 
mfwn^At^ DEATH !n plain terms, that It may be |»MH»«ply clasalfflcd. The "Special laformatlon'' for per- 

■<»• dying awajr from home should be given in every liMtenee. 



\ 



I ■ 



1 



* 



IB 



HoiiKi if li 1' 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

1 N I ^ ^t^^ J'S^P Co REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



Registered J^o, 



477 



iL-vvv4 ixAVM Deputy Health Officer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of 2)eatb 

( la. S. StanDarO ) 



PLACE OF DEATH: — County of 




City of 




^VCt' 



LcLJ 



fNa 



St.; 
ill 





"Dist.; bet* 



and 



(ir Ot»TM OCCURS *W*V PROM USUAL RESIDENCE GIVE tacts called roR UNOCR "SPCCIAt INFORMATION" "\ 
\f OCATH OCCURRCO IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD Of STREET AND NUMBER. / 



FULL NAME 



ux^.1 WxXmxX^y^ \ijXv^ 



lyCK. 



SIA 



PERSONAL AND STATISTICAL PARTICULARS 

I coi.ok 



D\JL 



Uii. 



I)AI I n! lURTH 



A< . l'. 







i%n)iith) 



1% 



<? ■.. 



bi 



J Vf J t f 



■^I ' 5 1 MAKKIKH 
U Ih ruFH OK DIVMRC};!) 
U<;!, Ml ■.fii-i.il ilf'.i'Miatioii) 






I 



(Djiy) 




(Year' 


M.iiiHis 


ai 


An^ 


OlV'Va. 


xA 





N\M| (ij 
l-ATIIl.K 



HiKTill'I.ACK 
<>l' I APIIKR 

(State ..r I'niiiitry) 



MMI'KN xamk 

<'i m"Thi-:r 



• M- M(rrin.:K' 

isi;it.- or Countrv) 



ra 



(K 



7h 1 ^s ^ L 



MEDICAL CERTIFICATE OF DEATH 
DATIC OP DKATII 

It). 

( Day) 




(Ytrar) 



I HEREBY CERTIFY, That I attemlcd deceased from 

~ to T90 """* 



that I last saw h 



190 
"alive on 



190 



and that death occurred, on the date staled ahove, at 
The I 



M. The CAISE OF UliATII was as follows: 



1)1" RATION Years 

CONTRIHITORY 



Mo>ii/is 



Days 



"^'^'' rATION 



ihtM 



^"lipjTy.r ^J.^ ''''' ''HKSnNKl, I'ARTICf I.AKS ARKTR t*K T<» TII|.; 
tU.sriM M\ KNnWMUH-.K AND ni'.l.IHF 



DURATION 



}'ears 



^ ,t..,.. Months Days 

( SIGNED ) nA - M n J\4ujA4A<Xn^^^ V 

^1.4X441.1 TOO i rAddrt^H) Vrux^iCu ^^^ • 



Hours 
Hours 



f 



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



(A'lilress 



151 



U J <O^AMXi 



t 




Former or , . , 

Usual Residence I VI 

When was disease contracted. 
If not at pMrrof deatli? 



aKKi \ y 



How long at 
Place of Deatli? 



.• Days 



ri,4C»S *^l" HIRIAU t)R KKMoVAI. 



I NDKRTAKKR 



I>ATKof III HiAi. or REMOVAI, 

V^-Lm a^a 



^'^A^Kl 



190 t 



(AddresK 



UM j;t^u«.4,.w^^ it. 



. B.>-i.Bvei>y Item of information should bs cafafutly supplied. AGB should b* stated EXACTLY. PHYSICIANS should 
•tate CAUSE OF DEATH In plain tei^s, that It mmy he ppopeHy classified. The "Special Information" for per- 
•«•• dying «way from home should be given In mypv instance. 






r 

Ji 



H 



' I 



I ' 



% » ,- \ r- 




(inat'l -I I' ''' 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

Hsn ..i^-tS^H&PCo WgFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



I)((f(' Fi/efl, 




190% 

Peputy Health OWcer 



Registered JSfo, 



478 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of Beatb 

( la. S. StanOarO ) 






PLACE OF DEATHS— County of O'CV'W' OAjX-rvXU-C 
tU^VQjU'UXaj CJ d/WOXtVlUOYSt^ — Dist.;bet. 



'.City of U/CIAV vJA.<Xa^vcv4.Cc 



-and 



( ir DtATH OCCUHS *W*V FROM USUAL RESIDENCE GIVE facts called for UNOCR **SI»CCt*L INFORMATION" \ 
V IP OtATM OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / 



FULL NAME 



N^rL'^v h<Xm 




icM 



y\ UCC 



PERSONAL AND STATISTICAL PARTICULARS 

COI.OR 



IIXclL 



lui. 



4 



Il\ i 1 «.! I'.IK III 



Aui: 



'S 



-M.itUh) 



(Day) 



(Vear) 



MEDICAL CERTIFICATE OF DEATH 

DATl-; nl- DlvATH 



/Vonth) 




l^\ ... 



igo % 

(Year) 



Sic ,v,M. ^ 



M.nilhf 



Ih( f 



'^I"«'.i.F' MARKIKl). 
WIDnWHIi OK I)lVOR<'Kt) 
iWriu- in «(jcial designation) 






KAMI' or 
PATMl'R 



BikTiiri.ArK 

•^!' I ATHKR 

"'t It. .,,! Couiilrvl 



M\!1»i:n NAMi.- 
<>»■ MOTHKR 



I'lHrnpI.ACi.' 
[H- MoTIIKr' 

(St.lt. ,,! t ,„s„j^^,i 



OCCn"AT|,)s- 



,tHM.. 




lU. n/o^r^ 






EUUJV CI:RTIFV, That I attenckMl decensetl from 
it 190H to ....|>J»M....W 190 H 
aw h .1- • ' alive on ^^vwUhu-.I?,. T90 ' 

ami that «lcath ocmrred, on the daU staU-d ahove, at \ 5 O 
U M. fhe CAISIC OI- Dl-ATIl v%as as follows: 



DU RATION- 
CO 



Years 



Months 



Days 



^\xx^Sj^%^ 






NTR nU'TOR V &) ^tX/Vn^.^ t^^ 

TION *- ^ 

(SIGNED) O J c^w^n^ 

^4 » i( , . 1 r _^ u / , , ,_ ^ I a ^ tI ff /^ », . . 



Hours 



in' RATION *- y^4^^ ^ Mtynlhs *■ DavK ^ Hours 



M.D. 



SPECIAL INFORMATION only for Htspitals. Institutiom^ Transltnts, 
•r Recent Residents, and persons dying away from ' 




<lA4/ 



,&.\ 



Rr^i.hd ni Sat, r,oui,s,;, Ot Vrais 



Pit M. 



^"hkJ^IT.I' 'tT^'"'" fKRm)N-Al. I'ARTICri^ARS ARE TRl'E TO 



\bl Ltac^ 



Formfr or u ha' 

Usual Residence H OS 

When was disease contracted, J 

If not at place of death ? W^sX. 



How Ifiif at H 

Ptore if Death? u ...... |tay$ 




PLACK OF Bl'RIAU OR RKMoVAI. I DATK of «iriai. or REMOVAI, 
INDliRTAKHR vOAJi-^^ ^^ 




• D.— Bvepy Item of information should be csfsfully supplied. AGB should b« stated EXACTLY. PHYSICIANS should 
•tste CAUSE OF DEATH In plain terms, that it may be properly classified. The "Special Information*' for p«r- 
«ons dytnft awajr from home should be given In svsry instance. 




;> 



■ ii 
11 

>■ ^1 



I' \ 



1 

w 




WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

is4^m^mvCo REFER TO BACK OP CERTIFICATE FOR INSTRUCTIONS 



J 3 






Bit: 



lOOH 



Registered JVo. 



479 



^ >" uv\.^ 




iLa^u Deputy Health Officer 

DEPARTMENT OFPUBLIC HEALTH=City and County of San Francisco 

Certificate of Beatb 

( la. S. StanDar{» ) 
of (j^'Vu 0,^JCXAvCX>M^X) Gty of HCXav U A^O^w^m^ ec 



PLACE OF DEATH: — County 



fNo. %101 U<I^\^\!iu^ ll\M; St4 '^ Dist.;bct•^C^M^^<UA^aA^ and O^l 

/ ir OtATM OCCURS *WAV rHOM USUAL RESIDENCE Give facts CALLED FOR UNDER "SPCClA. I N FOR M ATION" \ \, 

\ ir OCATM OCCURRED IN A HOSRITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET'-kNO NUMBER. / 



Dist; bctVD 



d 



FULL NAME 




db /OAfc J .Uw.(ri\M 



PERSONAL AND STATISTICAL PARTICULARS 
-^1 V^ » I COI.OR 



a 



L 



Uii.t 



IK 11 1.1 j;iK m 



A«.K 



(ttonlh> n 



^5 



] Vi? # . 



(I)av) 



Miiul/is 



\S 



1 k L.'ll 



/?./ IV 



•^iN' i I \!M<kii;n 

WriJowit* iiK IMVoKOHD 

(Wr III- ill v,„j;,i .lf*.iKnali»m) 



luK run. x^K 



S'AMI oi 
FATlll.k 



Hrk TH PI, \^- J/ 

'>' I xiiikk' 



MAUU'X namj.- 
"I- MuTHHK 



»JF MnTHHR' 
iSrttc- or Cniititrv' 




KKXd^ 



^\jy\ 



^W<wt 



)ta\ 



I 



4 



mUmt NLtvk 



MEDICAL CERTIFICATE OF DEATH 

DATI- OI* i)i;ath 

(Day) 




(Yenr) 



I in:Ri:HV CIvRTIFY, That I attended deceased from 

v^vUL %%. 190 4 to. ^vULaj^ 3».l igo H 

w 



190 



OCCfl'ATiuN 

ffffi,1r,1 in San f'l ,iii, isfo ^ )'ritrf 



I 



yfiiHifis 



Pa vs 



^"HKs'-r'';*?-^^'',^ ''*'•" '•HKSONAL PA KTI' T I.ARH AR K TRTE TO TIIK 
»".sr «ih MY ^NOUX HOCK AND HKl.lKF 



nnrint 



(Addrew 



i^ 



Vj 6-4:1 a 



t 



til Jit 1 last saw h-thj alive on ^VaXw % I 
and that lUatli occurred, nii the date stated above, at ID 
CL. M. The CAISK Ul' DIvATII was as follows:' 

i 

Dl* RATION * Years Months 1 Days \^ Hours 
CON T R I BUTO R Y f ^^.X^.^^X^.AJL . V. UXf^ 

DURATION Viiirs Months Days Hours 

(Signed) »-^- > Q<x.'^^\AJJ^A4!^^ M.D. 

I I . , '1 i , -1/ f \ i,i_..e.^ ^ I M U ^ *.,\n A » A I I , , r 



3; 



_.PECIAL INFORMATION only for Hospitals, Institutions, Transients^ 
or Recent Residents, an4 persons 4ylng away from hone. 

How long at * ^ 

Hare of Death? J*^..„.. Days 



uJwTReTldeBce vTj^UA. VA.I' 

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




PI,.^K OF nVRIAI. OR RKMOVAI, I DAr>: of BrmAL or RSMOVAI« 

toX I I^J^ Xa igoH 

VNDKRTAKKR TO Cwi4^tccL "^^M. ^^ 

(AdclreM ..^Hb QrV\A.^M^i,rVW "^t 



K B. 



^'^ery Uem of information should be cafafully supplied. AGE should bs Stated EXACTLY. PHYSICIANS should 
state CAUSE OF DEATH in plain terms, that It may be properly etasstfted. The ''Special Information** for psr- 
sons dyinft away from horns should be given In svsry Instance. 



1 

!4 



1^ 




n ■ 

iiii 

ill 



« 



I. 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

H<v.r.l..fM. tU I No ..istS^cHSciro REFER TO BACK OF CERTIFICATg POR INSTRUCTIONS 

480 



r 



Ma 



l)((h' Filled, 

i 




X\ 



lf)OH 



Megislered JVb. 



C-LCvO 



iLtv r Deputy Health om-er 

J 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



4 



PLACE OF DEATH: — County 



Wo. 



"*^ M!\aVuc^ fC'H.* ■' ' ■ 



Ccvtificate of Death 

( "Q. S. StanOar^ ) 

City of U/tX'W u A.O 



ofO/OAx^gAo 



?A4ec 



St.; 



^ist; bet."^ 



and 



/ ir otiiiH occu«« »(*«v rnoM USUAL RESIDENCE oivt r*CT9 callcd won uwof»» "•pccial iNronMATiow \ 

\ ir tAtkTH OCCURRCO IN A MOSRITAL OR IWITITUTION OlVt ITS NAME INSTEAD OF STREET AND NUMBER. y 



— ) 



FULL NAME 



L4.aJvLu 



PERSONAL AND STATISTICAL PARTICULARS 



•! \' 



^Ji. 



l>\. ! "! lUHTH 



(\ 



»nth> 



r r I 



1 

i |)a% 



} >,: I 



1/. . '/; 



( VtMl ) 



An 



-i,'!:;)!;' lilt 



ititr \ 



lOv 



cLmaM-Hj 



V\M(- ... 



in«THP!.\i F 






;,,, 



illltl 



l*4>WWM?^ 



\ 



ILLxv- 



UX\/WMX 






MEDICAL CERTIFICATE OF DEATH 

DATK "I I»1;aTIC A 



U .i 



\ 






<Vf:tr> 



I Hi:Ri:nV CICRTIFV, That I aUtiLU-.l rkn-asfd from 

A A " 

»..>^-^ 'XI 190S to ^vOUi, ,IH 190 S 

tliat I la^^t saw h 1. alivf on ^"^-^a^ it up 

anil that <Uath oicurre*!, on the date slated above, at '^ 
J. M. The CArSI-: (H- DK AT 11 was as folUms: 



I ) r k \ r 1 N ) t-ars Months Day$ Hon is 



DIRATION 



Years 



Months 



^'^Cll'ATHJN \ 



Mb-^I nj MY KN'MWI.KIir.l.: \M, Hl.IJKK 



rt: TO TiiH 



(A.ldresH 



Hoo 



^i)u. 



>% 



i t 



(SIGNED) U.K.tk4X^I J 4a "K'^^*. 



Days 



\ 



\^A\ I I 



V 

'I 



(ft;; 



Hours 
M.D. 



Special information mIv Itr NnpltaK, iRstMitions, Iransieits, 
or Rfteiit ResMeits, m4 perstis 4yla| iway frM Imm. 

1 * , "' < Hw lti| il 



.^ 



Ftnuer k y 

WlM «M 4lfM€ MRtrxtrd. 



n.ACK OF niKIAt. OK kHMo\ AF, 




) V W\n4as 



IM][Kof Bt MiAi. ur KKMoVAI. 



t'NUKRTAKKR JkjUO-nL^^J ^ ^C4A-J^ 



(Add res?* 



qsn (V>U4. 



4^*^% 



N. B 



t-. ! 



•hould be cni-efully sMpplted. AGB should b* stated EXACTLY. PHYSICIANS cImiiM 
n plain terms, that It may he p»K»f»crly classified. Ths "Spsclal Infcirmatton** for pap* 



Kvefy Item of Information 

•tate CAUSE OF DEATH I.. ^_ , .._ „, - ^ 

sons dying away from horns should be given In svspy Instance. 



» . t 



r: 



I- 




L— .^ mI' 




Ill 



Bdiinl "( l( 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

,„„ » No ..tugag^HScPC o REFER TO BACK OF CERTIFICATg FOR INSTRUCTIONS 

480 



100 H 



Dale Fih'il, \-*-^M^ ^> 

1^ iwv. Deputy Health omcer 



Registered A^o, 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of S)eatb 

( Ta. S. StanDarD ) 



PLACE OF DEATH:— County 



of 6 



/CUTuOA"- ' •- City of O/O^TuU A.<XAa^>t4 



Z.L 



St 



Dist.;bet. 



and 



" ) 



/ ir DC«*H occo»»« AWAV rnoM USUAL RESIDENCE oive r*CTS callco ro« under """'f '*^J'|';°""**J'°''" ) 

V ir C^ATM OCCUHRCO IN A MOBPITAt OR INSTITUTION GIVC IT« NAME INSTEAD OF STREET AND NUMBER. / 



FULL NAME 




SIX 



PERSONAL AND STATISTICAL PARTICULARS 



DAT]. Ill lUKTH 



'\r.i: 



I until I 



(4 ,.. 



(I):iv) 



)/n„t/,s 






MEDICAL CERTIFICATE OF DEATH 
DATE OF DIvXTII 

(Day) 




I 



onth) 



4 



(Year) 



(\ r:il I 



/hiv 



WllM .A J I) OK IHVliRCKn 



Htk III I'l x,-}.- 

I'St.iti ..r i'M\nitr\ 



lAlll i.K 



'nKTiii'i,\(}.- 

(Stalf or I'ouiitryi 



MMni:N XAMj.- 
'H- MoTllHK 



BIRTH I'r.AfF 
OF Mmthhr' 

f>tut. nt Cuutitrv) 






Ill 



r\ 






^^vck: 



1, B 



M. 
11 




I IIRRI:BY certify, That I attemlcjl jUncastMl from 

,yU^..%.^l 190 H to |vJLL..Ja 190 H 

tliat I last saw h -^ > > alive on J^^^vi^^. l\. 190 . 

and that <U*ath occurred, on the flatc stated above, at ^J 
U. M. The CAl'SR t)F I)i:ATn was as follows: 



Years Months Days 



I )r RATION 
CUNTRIIJUTORY 



Hours 



Years 



Months 



Days 



" U) ^^A 



OCCfl'ATtON 

K^^isIM ni S,ui Finn, i\,',) %,S^ Vrats 



•■ HfoHthi " />(/.!> 



rUH MunK HTATKI) PKKSONAI. I'AHTICr I, \KS ARK TRIK TO THE 
"'^' "I MY KNOWI.HIK'.K AND IIKUKK 



(Itlfu 



niiant 



Ad.li 



CSS 






nr RATION 
(Signed) 

Special information only for Hospitals, Institutions, 
or ReccRt ResMeuts, and persons dying away from liome. 



Hours 



tgo 



fw4^i, 1 



i; 



Transients, 



Former or uk k 
Usual Residence TuC 

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




I I 

^4 How long %\ 
' ^ Place of OeiUi? aX,... A^ 



tSM Q 



PI,ACK OK Bl'RIAf, OR RKMOVAf, | UATK of BrRIAI. or REMOVAl, 



I'NDKRTAKKR 



190 H 



as 1 Ona^vM.,Vf>%...J..t 



».— Rvery Item of Informatton should b« ciirstully aupplled. AGB stiould Im stated EXACTLY. PHYSICIANS should 
stats 6AU8E OF DEATH In pinin terms, that It moy be property classified. The **6peclat information*' for psr- 
•«•« dying away from homs should be ftlvsn In svsry Instance. 



H 







(, il 



\\ 




I 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



»&rco 



Boar.! <'f ll. ;niii I- V" i-^ "HL'! 

e Fi/rff, WJLu 3.1 



D((f 



Registered JSTo, 



481 



190\ 
ju^u.^ lxA^u. Deputy Health Offln^r 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of H)eatb 



( "a. S. StanDar& ) 



Jl 



^ 



fNo 



PLAC^ OF DEATH:— County 

^ t ^ f 4 ll ! } 



of u O^^^ *3 ,\xx^xciA^^ City of w Ojy\j a-vva^4. 



>^U.Tl1)'tt4.LSt^ 



Dist.: bctr 



and 



I / ir OCATH OCCUMS AWAV 

g \ IF OCATH OcduRMCD 



rnOM USUAL RESIDENCE CIVC FACTS CALtCD ton UNOCH "SPCCIAL INrORMATtOW "V 
lli A MoVilTAL OR INSTITUTION CIVt ITS NAME INSTEAD OF STRCET AND NUMBER. J 



') 



FULL NAME 



M ItcRtrl^^.^^ IJxLlh: 



PERSONAL AND STATISTICAL PARTICULARS 



si;.\ 



UA I 1-; "1 |;iR III 



At,).; 




COI,OR 



bjlcti 



MmitlO 



(Day) 



r w 



WIDoWKD Ilk r»!ViiKCHI> i 

(Write iij miiial .Irsi^MiiUion) 



Months 



Da \. 



\\\\KX\\V\.\c\:, 

(Stutf .,r « ■..II III I V 



NAM I- 111 
FATIIKK 



RiR'i'Hi'i.xrr 

(St;iti .It I'liiinti V 



MAlIii'N NAMK 



f>i- M<>i'in-:k' 

(Slate or Cotintrv* 



(^ 







<rv^^' 



OxUaj 






wco^^v^ 



'>'^ci-i'Arujx u 



Rfsiilftf ,'„ Sail I'liuicisfo QL 5 IVrti.t 



M,ittf/if 



Bar. 



'"uri'r'^ '"• ^'"^THJ) l"HRS<iNAi, l'\K I Ut ! AKS ARK TRfH T 



() THK 



(Infoiman 



(Ariel 



Tv*n 




aJv^^aaJn. 



MEDICAL CERTIFICATE OF DEATH 



DATl-: l)F nivATH 




(Day) 



IpO I 
(Year) 



I HERKBY CI'^RTIFY, That I attended deceased from 

Ol^Vcu^ i*^ 190H to .|^|i4|. ..la 190 4 

that I last saw h Vvy\ alive on ^AAXml »" 190 4 

and that death occurred, on the date stattMl above, at 3- H C) 
(P. M. The CArSl*: t)F DICATII was as follows: 

\) AiAH^i<W $)A.AXd3MLJi. &| ^ti%Jr3fe^^.'.d 



DURATION ^ years 
CONTRIBUTORY 



Months 



Days 



Hours 



DURATION Years Mouths 



Davs 



Hours 
M.D. 



(Signed) WJ. ^ 

wPEClAL INFORMATION wly »or Hospitals, Institutions, Tra»sleiits, 
or Recent Residents, and |>er$9ns dying away from home. 





Former or 
Usual Residence 

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



f 1 t ) How lon9 at 

WUL\^v44 VfrM^4^» Hare tf Dfj 



Death? 



Biys 



PFJ^CK OF lURIAI. OR RKMoVAI, 




I>ATK of Hi'RiAL or REMOVAI* 



INIJKRTAKER 

(Ad«lre«!i 







T90H 






Bui'a* latk it 



> 



N. B Every Item of tnfopmttticMi aliould be co(*«ffully supplied. ACB •houW b« staUil EXACTLY. PHYSICIANS should 

state CAUSE OF DEATH In pinin terms, that It may be properly clasalfled. The ''Special Informatloa** for psr- 
MfiB dying away froM homa should be given In mvmr^ Instance. 



't 

n 



I 



k . 



I 



^m 



•\ 






♦■ 




WRITE PLAINLY WITH UNFADING INK -THIS IS A PERMANENT RECORD 

RE FER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 

482 

Bate I' I J ('(I, NUaAa.l X\ 



„nlufll, V.il, tvo ,,1>>g^^H&PCo 




^^^ 



lOO'i 

Deputy Health Officer 



Registered J^o. 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of Beatb 

( "d. S. Stan&arD ) 



(No 



PLACE OF DEATH:— County 



of aC^>v JXa >vCUlt^ City of ^^^^^ J^a^xc^4 - c 



tVV4.. Su 



Dlst.; bet. 



"and 



\ r^-i^ 



FULL NAME 




.a>L 



PERSONAL AND STATISTICAL PARTICULARS 



ta,a.u. 



/y\A\j 




/CL, 



.W-V. 



>r.\ 



t\ 



\ 



I) Ml. "I HlKTH 






COI.OR ^ ^ (\ 

LI ■• 



ACF 



i.5 )V.,i> 



1! 

(Dav) 



yt.nitfis 



I ■»'f:ir) 



Da \s 



*^iN'.II' MARHIKI). 

WIlM ,u KI> nK I)IVnROKI> 

iWiitt 111 MHial iJcHiKtintion) 



UJ A^cWv^ 



ntRTjn'i.At'H 

(Slnti- (>! I'.nintry) 



I'ATIIKK 



niRTin>i,Ai*K 

OI" ! \ r H K R ' 
(Still. ,)i I'ountry 



<M MiiTHHH 



HlKTHI'UAi'l- 
OH MoTHFR 
i^t;it( itr C(iuniry) 



OCCrj'ATlON 






\X^ kkXjsJX/YS 






*<.''VM 



'V^ <j^ 



Residfit in Siin /'niHffsen 



} 'fa i s 



}/,>,! f/r 



/hi ) . 



THH AROVESTATKD fHRSONAl. PAR T im.ARS ARK TRTK TO TIlK 
BKST OKMY KNOWI^KDCK AND HKl.lKF q 



(Illfo! 



mant 



ox<wJk _ 

i 



MEDICAL CERTIFICATE OF DEATH 
DATK OF DKATH 



iJu 



(Year) 



XT at. 

I III<:RI:HV CI:RTIFV, That I atteiule<l «leccase<l from 

.QILCUU.! i9o'^ to^...|v^ iH ,90M 

that I last saw h-^?^ alive on .•. «wL^ M up 

and that ilcath occurred, on the date stated above, at 10 -O 
wLm. The CAISI;: CM- DKATII was as follows: 



DIRATION •• y^ars 1 Months il Days 
CONTRIBUTORY 



Hours 



Years 



AfoHtJis 



Pavs 



DURATION ....^- ^ 

(SIGNED) LU Xd. \Jrs\Lo^^\j 



I/otU'i 

M.D. 



AwLi^ ^0 TQO'^ (Address) 



aPEt^lAL INFORMATION ©"'y lor Hospfldb, In!>titHtiM$, TfM^iti, 
w Recwt Residents, iml persons dying away from home. 



Former or 
Usual Residence 

When was disease confracW, 
If notat plareof death? 




How lonq at 
4jt Place of Deatk? 



Days 



ca«m 




^vsaJ^^saa^ 



D^TKof Bi'HiAL or KEMOVAI, 

XX 190^ 



PLACE OF nVRlAI, OK RKMoVAI, 

(AUdrt-is oL l3» * I i L^ 



•t«t« CAUSE OF DEATH In plain term., thnt It m»y be p-operly classified. The «|>eclal InTormation o p« 
•on* d|ftng away from home should be given In every Instance. 



t 



J 



m 



I I 



N 




Boarrlof 1I> .''> I 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

,,, „ ».^^5:s.,*,.Co "EFER TO BACK OF CERTIF.CATe FOR INSTRUCT.ONa 



Vll 



Jhifc Fi/cff, 

1 



Registered J^o. 



483 



"^jirj^u Deputy Health Oflflcer 

DEPARTMENT OFPUBLIC HEALTH=City and County of San Francisco 



^u-vo 



Certificate of 2)eatb 

( "a. S. StanOarO ) 
PLACE OF DEATH.-County of O^t^ ^S ^^ > ■ C. City of O^XavJ^UX^Ca^ 

^^l- St.: 1 Dist.bet.ffHj^ JU^ 



(ir DCATH oVcoKS *w*v 
IF DC 



i.^n 1 1 



ATHj OCCUHRCD 

FULL NAME 



WA^^K-- 



C01,0R 



PERSONAL AND STATISTICAL PARTICULARS 

I)\Tl' i.f lUk I II 



L 



\i\ * . . + . 




V 



A<.i; 







I I Wat 



n 

(Day) 



Mouihy 






/>rt v.< 



SIN". 1.1' MARKll-:f» 

Wlin I ,', i n ( )K lHV()Kri>:i» 

I Will. Hi ».Kial (itsiirtiiition) 



rUKTIHM.\t-K 
iSt:it. .,1 iMiinlrv) 



WMI- (»i 

f-"A'i iii;k 



nik TMPi.ArF 

<>'■ lAllIKR 
'st.it< 11 CoimtTy) 



MAIUIN NWn- 



RIHTlllT.ACR 
<»H MriTHKR 
(Stall- or Country) 









/),? v.< 



oecn-xTiox 

'*'"« AWOVF. STATK I> PKRSONAI, l'ARTlOri,ARS ARK TRlK TO THK 
"hST UJ- MY KrjOWI.KIX.K AND BKMKF 



'rniant 



r\«l dress 



ISHH 



m 



.fr\» BA 




MEDICAL CERTIFICATE OF DEATH 

DATE OF DICATII {\ ft 



(ifonth) j 



(Day) 



(Year) 



1 IIiTrICHY certify, That I attciulol <lcocasc»l from 

lb" 190 *" ^ 1^''^ '^"^ 

that I last saw h J^ alive on l^^-H- " ' ^^o 

and that «leath occurrcl, on the date stated above, at 1 - 
QL M. The CAISK (»F DIvATII was^s follows 






JVtfrjr 



i\fimths 



Hours 



DERATION ^^^*'h\ ''^""''^^^ ^^^^'^ 

CONTRini'TORV i}A.aJ[>4p-d^^. . ^ 

"^XAviA-oX lUIaa-^-^I ^t.l4^^V 

Dl'RATiON Viars Mo?i//js Pays /fours 



(SIGNED) 




(Addre<s) 



h.t^'' M.D. 



SPECIAL INFORMATION ««») for ^os^tjls. iBSUtBtlttiS, Tf 
or Rfcenl Rfsidcnls, and jwrsons dying awiy from home. 




Former or 
Usual Residence 

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



How long at 
Place of Dettli? 



Days 



PLACE OF ntRIAI^OR RKMoVAI, 

INDKRTAKKR ^' ^' ^ 
< Address /^^ 




LiJija^. 



•tate CAUSE OF DEATH In plain term*, that it may be properly cia»»ifi»a. ••»• ''i'^ 
•on« dylnft away fpom horn* should be given In avapy Instance. 



I 



(I ' t 



I I 





I'm 

11 



ka 



Board of U vnUh I- N"- i^ *X; 



WRITE PLAINLY WITH UNFADING INK-THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



llS: V Co 



as. 



Deputy Health Officer 



Registered JSTo. 



484 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Certificate of Beatb 

( Ta. S. StanDarO ) 
PLACE OF DEATH.-County of Q^^v (r;u:^^^^-*'" Gty of Ooav /vC^>^c,v,^^o 



% 






'1 



1^ J \JJVJ:M} u Ch^k^^<x\ 



St.; 



Dist; bet* 



and 



) 



(ir DEATH occults *W«Y FBOW uaw»»l. ntsi"*" — "'1^ lu * u r iHSVrAB O 
"ot.TB OCCURRtO IN » HO.flT.L OR INSTITUTION OlVt ITS NAME INSTI.O O 



; rc.T:^c"^u':t :::;;.;- us«.u «""«."« -«.'„7^;r„vi.7 x."" i: s'TV%%TiN'o"N°u":.':'.°"' ) 

FULL NAME 



>5| 



i.Xcuk 



I. 



• ♦ 



'*f 



PERSONAL AND STATISTICAL PARTICULARS 



> 



DVVV ..!• lUKTJl 



COI.OR 



(Knr 




(M.mthl 



AC.K 



)><„ \ 



a 



IS 

(Day) 



Mtuttln 



(Year) 



% 



Da %s 



Wnx.n ! I) OK DIVoRfKIJ 



nfKTllI'l.Xi-K 



^^^^■: of 

lAl UHR 



RIKTlH'I.ArF 

'St.ili .)t t'ouiiti v) 



OF MOTIIKK 



BlkTHl'l.Xi f: 
OF MnrifH;^ 
(Still, or Country) 




.. ^XoJki' 

Mm I 



/^ 



XX<5.WL 

M 




"\ , 



r If 

occri'ATioN y 

Rfsidfii ill San Ftaiirhfn 



)><nx 



- .\r„iitJn 



Diivs 



THKAmiVESTATF'.I) »'KR^ONAI, I'AKTUTI.AKS ARK TRIE TO THH 
BHST OF MY KNOWl.klW.K ANl)_HF;i,n: I- 



fliifonuanl 



lAtUlreins 







I , 



MEDICAL CERTIFICATE OF DEATH 



DATE OF DEATH 




IMontli) ^ 



'Day) 



190'K 

(Year) 



\\ 



I in:Rl':BV CI^RTIFV, That I atten.kMl .leceased from 



i'wV^Uv 'X. 190^ to^W 

that I last saw h : alive on 




5LX 190 H 

''hi 190 ' 

and that death occurred, on the date stated above, at 
\ M, The CAlSie OF I) K AT 1 1 was as follows: 







DU RATION 'Years^y Months O /Ja>'| * Honfn 

CONTRIBUTORY Q^:k^W:A, U^li^wJ^ L^Ww.4.A.afS.... 



.^..^r*^ 



DURATION 
(SIGNED) 



•^ Months O />av5 



VAVcLt^XJ 



^Vji^,^^ t^^ (Address) nSi 



i^itli.! 



Hours 

M.D. 



'SPECIAL INFORWATION ««y ?9f ««P<Ws, l«ttt«t}#«, IrcBS^Ms, 
•r Jteceft ResMcuts, and persons dying away from heme. 

KntSwence (^oL -dXt^^ U' Jj^'ri^U? A Days 

WlKH was disease cwitracfed, f T ^ K i 1 (K LoX 
If not at Macerfdertli? ^^ y WAw^^U VOA^ 



PLACE OP BI:R!AT. OR RKMOVAI. 



D.VrEo/ BiHiAl. or REMOVAI, 



INDERTAKKR 

(Address 






id 13 



190H 



? 
^ 



■ « w. 



It: 4 



„ . 7^ .H„„id b. atated EXACTLY. PHYSICIANS ^mhiM 
of Information .houW be c»r«f«ll,. f"'»'»"*t ^^^^HrclLI^Tmi! T^^ -sUcl-l I»for«Mlo«" for p.r- 
E OF DEATH In plain term*, that It may be properly Giaaswwo. •« ♦- 



"• ••— Bvepy item 

state CAUSE OF DEATH In plal - 

•on« dying away ffpom hom« should be given In •vrw Inatance. 




I I 



\ I; 



II 



Boardof IU:i'tli- J- No. i> 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

HgreW TO BACK OF CERTIFICATE FOR INSTRUCTIONS 

485 



'TsSi^ HM' Co 



,r\A-. 



L 



%'X 



190H 



T>((fr Filed , 

tfrt.J'L^ Deputy Health Officer 



Registered JSfo. 



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



Certificate of H)eatb 

( in. S. Stan&arD ) 
PLACE OF DEATH:— County of S-CUtva. 



City of 




c)uULu>VU-ru L<Xl 



(No. 



St 



Dist.; bet 



- and 



■) 



/ ,. OEATM OCCUR, AWAY TROM USUAL « " ' ^^S^" ^^.^'TtI NAME .•nVtcTo"" ST^R^E^iN?;":::;"" ' ) 
i, ir DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD 



FULL NAME 



PERSONAL AND STATISTICAL PARTICULARS 




A 



Cl'^\.:iXCV 



DATI i>! lilRTli 






COI.OR \ 



u 



(Month) (l>nv) 



\«.K 



"fli 



^< JV(/> * 



Mnulh> 



/ L L ■ 

(Year) 



Iht r. 



SIN',1,1- MARRIKI* 
wiixiu ID (iR invokri-t) 

t Write 111 -iKial iU'>»«Kii;iliiiii) 



BIK THIM.ACH 
(Strut- nt •'.ituitry) 



NAM). (IF 
FATIIKR 



RlKTHn,ArE 
OT* lArilKR 

(Stfit( or fountry) 



MAIUKN NAMF 

"!• Mother 



MlKlHPI.At'K 
OH MOTHKR 







CL'"vx^>va, 



LL^vck 



>X ^' 



(State 



"r Country) 



'»^'^<i'Ariox 



lA 



4l 



•► )Vr(, 



• ^r»)l^fls -^ /'<'» 



f^'^si dfd in San f'l iim ism - i , ,, , .^ 

"•""^i^^ttpVR ST\TI-I> PKRSOSAl. I'A RTHI" I.A RS ARK TRVK 
»h>iT OF MY KNUWI.HDC.K AND BKMKI*' 



TO THK 



(Illf,, 



inritit 






MEDICAL CERTIFICATE OF DEATH 

DATE <>l- DEATH jA 



(Month) 



(Day) (Year) 



I III':RI:HV CI:RTIFV, TIuU r atten(le<l deceased from 

■— to .- 



190 



that I last saw h^:^ — alive on— -^ 

ami that death occurred, on the date stated above, at 

- M. The CAlSr-: OF DIvATlI was as follows 



-I90 
-190 



DT RATION Years 

CONTRIBUTORY 



Months 



Days 



/fours 



DURATION _ Years Months 

(SlGNED)Ju.0^^t^ 

TQO (Add ress) 



(kct^lJli. 



Days 



Hours 
M.D. 



QpEci&L Information *»"'*' ^"'^ Mo^pitais. iiKtituttoM, Traisteiis. 

Of 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 Deatli? 



Days 



ri,ACE OF BIRIAU OR RHMuVAl. 




D\THof m RIAL or RKMOVAI* 






\»-v 



N. B.^Bv.., ,f„, of l„fo.„..tlo« .hould be c...f«lly .«PP"ech AGB f -'«« .^^^i"*^:^^^^^^ inSiTon-IJI-'^rt 

•t.tc CAUSE OF DEATH In plain term., that It may be properly claaslfled. The »pecia 
•««• dytnt "way from home should be l^lven In •very Instance. 





r*i 



j» 




ff 



Boar.L.f lU-'l'-'' ' 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



so ,,T^a|^K&rCo 



N! 



Bate Filed, \L\. 




la 100^ 

Deputy Health Officer 



Registered J\/*o, 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Certificate of 5)eatb 

( Ta. S. StanDarD ) 

ity of M iXul^Lictc^vu^v Lai 



PLACE OF DEATH:— County 



of d^oJkA^ 



City 



rNo. 



- St4 



Dist.;bct. 



-and 



...... oreTn^Nrr riwr raCTS CALLED rOR UNDER "SPECIAL INrORMATION" \ 

( " .VrElT^H^O^C-u'rcV/NTHO^.^rTrL o"r'?^^'^.?^T^^N^O*^.;e7tI ?.AME INSTEAD O. STREET AND NUMBER. ; 



FULL NAME 




0^y\'yx.o^. 




SEX 



iJATi: >'I lUKTU 



A(,K 



PERSONAL AND STATISTICAL PARTICULARS 

COI.OR 






lOla. 



,^%^?r^ 



(Month) 



it* \ )V./#> 



il>av) 



Months 



(Veail 



n<i 1 .^ 



(Writfiii .....ial (icsi^Miatinii) 



niKTIIl'l.AOK 

(StHtf OI 1'. .illltl \ ' 



I I 



NAM!-; Ml- 
I' ATM J. R 



niKTllI'l.M'K 
<>'■ I ArilliR 
'Stalf or iinuitry) 



MAini'N NAMK 
OH .MuT!1i;r 



"JKl Hi'i.ACK 
<)H MoTHHR 
(State or Country) 



Oecri'ATKXN 






/hi 



I I 
I 



"^"^AnoVESTATKn P^-KSONAU I'AKTICri.ARH ARK TRTH TO THH 
HtST OF MY KNOWI.HIX'.K AND MKI^IHF 

(In for, 



nil a tit 



^■"Vvw .^JL^vvw<r^rC^v ,lxju>v/vwu. 



d 



(Adflress 



III : 

(Year) 



MEDICAL CERTIFICATE OF DEATH 
DATE Ol- DKATH U\ 

(Month) ^I^ay^ 

nrrrRKB\' CHRTIFY, That I attcndtMl (leceased from 

, — 190 - — to -^ 190 

that I last saw li -- — —alive on - — -— 190 — ^ 

aii.l that (k-atli occurred, on the date stated al)Ove, at " 

M. The CAt SI-: OF DIvATII was as follows: 



f ,cai 4^ -^-^^ 



DURATION y^ars 

CONTRIBUTORY 



Months 



Days 



flours 



DURATION 
(SIGNED) 



Years 



Months 



Pays 



TQO 



(Address) 



Hifttr'i 

M.D. 



Special INFORIVIATION ««'* *•' H«splW$« lastitttton. TrM^its, 
or Recent Residents, and persons dylni iwiy from home. 



Former or 
Usual Residence 

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



Now long at 
Place of Dfith? 



Says 



PI^ACE OF Bl-RIAl, OR RKM«»VA1. 



DATKuf HCKlAt' or RKM»>YAI, 



\JL ,.x 



(J^ . . ,4 



(A.Mress A J* ,^ J trv^>*f. » 



•t.t. CAUSE OF DEATH In pl.t. term., that It may b. properly cla..HI.d. The •p.cial lolorm. ^ 



•»B«c ^fj^uoc ut- utA in in piaiii terms, ¥n»» i* t"**^ "- ,-■-»-- 
•WIS dying away 9rom home should be given In •very Instance. 



^ 



i!iH 



M 



ii 



' I 






WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

, ,„ „„ ... „**S^,*.-C,^ BtFER TO BACK O F CERTIFIOTC FOB INSTRUCTIONS 

Board of H'"'"' ' ^ ' ^ ' ^ m.^..^^ _^____— ^^^^m^^— i^— — ^— — ^i^^^^^^^™^^^^^™^^ 



il 



10 0\ Registered JVo. 

i,trVA.Ajs Xxtlvu Deputy Health Officer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Certificate of ©eatb 



( XX, S. StanOarO ) 



PLACE OF DEATH: 



4 t i ^ 

County ofC^OA^^^^^O-^^^'^^'^'^^^ Ci^Y ^^ '^OA^) Jxa->xcv,4 ac 




^^^Jr>^' 



ursAav** fromIusual rcsideni 



Dist.: bet. 



ind 







X ( ,r or.TH occur.Uay rROMlusUAL RESIDENCE c.vcrACTS CALLED •'«'' 7«»J 

) t IF DEATH OCCuCnCO IN A HOSPITAL OR INSTITOTION O'^E «T» NAME INSTEAD O 



R "special INrORMATION" \ 
F STREET AND NUMBER. / 



FULL NAME 





D ^y^Ji'^ 



PERSONAL AND STATISTICAL PARTICULARS 



SKX 



'^^)IclU 



COLOR \ 



lo.r.i 



DA ri: •>! hlKTH 



A(.K 



K 



(Month) 



lb 

( Day) 



fVt'ftr) 



O V )■,•.;/> V 



M.niUi^ 



A; 1 : 



^'IN*.!,!", M\RKIHt>. 

wiDmvjii OR nivoRrHl) 

IWrilt in -<.Miul (lesitirtialiou) 



n K^^a 



MEDICAL CERTIFICATE OF DEATH 

DATE Ol* DKATIl 




k\>' 



(Mbnth) 



I 



(Day) 



igo K 

(Year) 




IIKREBY CI'iRTIFV, That I attended deceased from 



IS.. 



190H 




I90H 

190 'i 



rURTIII'I.Xi'H 

(state nr '",,111111 v> 



2) 



I) ll 



N'AMl' n| 
FATIIKR 



X 






»IRTni'I,Ai'F 
Ol- lAPllKR 
(Stall' or Country) 



MAIDKN NAMH 
OF .MorilKK 



[>H MoThkr' 
(Statf or Count rv) 






XA^U»XO. 






occri-xnoN 




^^''tif;f hi Siin Ftantisfa 'X^ Yiuiis yfnnths 



Da V. 



Ml. ^noxT SI \'ii:n i-hrhonai, partuj-lars ark trth t»> thk 

•"•SI «»l MY KN'OWI.KDf'.K AND nKl.lHH 



(In for 



mant 







tfiat I last saw h ^ •-» alive on Vvvv\^. ^l 
and that death occurred, on the .late stated above, at 1 1 H fc 
QLm. The CAUSR OF DHATH was as follows: 



Dr RATION 



Years Mouths 

contributory uaa^l^>^^>v^!^ 

duration 
Signed) 





vdHfe^lAL INFORMATION wly ««r Ha4^Mf, liKtttiiClMS, Tr^iriwls, 
or Rwenl Rfsldrnts, and persons dyliifl away from home. 



Former or .q. 
Usual ResWfice ' )0 

When was disease contracted, 
If not at place of death 7 



Jo , I -L Mow long at , 
d^^vU^ CP l^reof Oeatli? w Days 



PLACE OK Bl RL\L OR REMOVAL 

(A. A 



DATE of muiAL or REMOVAL 



V 



I 



1 



a 'A 



T90H 



I'NDKRTAKKR 



WvvJtui U^^Vxdul>LteoLWLA4 



(Addresi 



^^^Ckwut 



4* 



A,^iacs,, 



N. B.— Every Iten, of lnfor«,stlon should be car.f«Ily supplied. AGB should »»Vr*4hf •i'sIcW Jol^JtTon^^^^^^^ 

•tate CAUSE OF DEATH In plain terms, that It may bs properly classified. The Special laformatlon for psr 
•WIS dying away from home should be given In svsry Instance. 



lip 

1 





\ 




I 



WRITE PLAINLY WITH UNFADING INK-THIS IS A PERMANENT RECORD 

,*.S^^„o.pen REFER TO BACK OF CE RTIFICATE FO R INSTRUCTIONS 



r 



I 



Begisteved J^o. 



488 



Bale rno'i, Y^kK»^ 2>1 -'^^'^ 

-V -M Deputy Health Officer 

DEPARTMENT OF t»UBLIC HEALTH=City and County of San Francisco 

Certificate of Death 

( U. S. StanOarD ) 

J? ^ i ^ 

PLACE OF DEATH:-County of ^^^ ,1 X<V>^^m:ity of ^'a^ J;va>vt^ C t 



(No. 



Ibb 



St 

/ ir Dt*TM OCCURS AW*V TROM USUAL RESID 
V %f DCATH OCCURRCO IN * HOSPITAL OR INS 

FULL NAME 




4 1 Disubct Ldxxa ^"^..«..x 

ENCE Give FACTS CALLtO rOR UNDlA "SPCCIAL INFORMATION \ 
T,?UTI0N GIVE ITS NAME IN8TCA0 o\ STRCCT AND NUMBER. J 



Kj^ 




Q^MJiXh^ 



SHX 



PERSONAL AND STATISTICAL PARTICULARS 



DATK «»F lURTH 



bio 



10^ 

1 Month) 



Ai'.K 



Ol^ JV.n. % 



(Day) 



M„nl)is 



(Year) 



ao 



/j/f 1 .^ 



•SIN».I,K M \Rkn--,i>. 
winowi-n OR invoKi i:i) 

<\Vrttf in sniitil lii >iitMiati«)H> 



HIRTm-I.XOK 

(St;it( or iiniiitry* 



\i TUuuw 



MEDICAL CERTIFICATE OF DEATH 



DATE OF DKATH 



(3/t<inth) j 



It 

(Day) 



TQO 

(Year I 



\xA, 



It 



NAM J- (11 
I'ATUKR 



RlRTllfl.ACK 
'>'■ IxrUKR 
(State or Cuniitry) 



''»• Mother 

•'•'** )i I I, \l 1^ 

OF MoTHKR 
Otaic or Country 

WCri'AIIUN 




A 







O-M.^M.A.v-'^-M. 



U| K 



Da 



^^t":i,lr,f iti Son Fiatiiisfo It Vfats " yfonfhs' 

"•""^^^rjoVKsTXTl-.n PKRSONM, I'ARTim. \ RS A R 1-. TRIK To THK 
HHST C)l MY KN(AVM:n«',K AND HKI.IKF 



(Infot 



mnnt 



wcLu 



u-v^x 




^^r1,l 



rr«iH 



1 w (JAlk :^t 



I inUU'HV CI':RTII'V, That I attcn.kd cleoeasea from 

(HWa \^ 190H ^"n %^H^'^ '"^^ 

that I last saw h AM alive oti J^"^ ' ' '^ ^ 

and that (Uatli «>ccurred, on the date stated al)Ove, at 3 

? M The C\tSlvt>I- DICATII was as follow: 



vs : 



Avur-vxOAM. 



Ls4A/^'Vw LiHt u.'i 



tu 



DIRATION a IVari ' Months 
CONTRIHUTORY 



Pays 



Hours 



DURATUV , y<'a*'s ^^fonihs Days Hours 

(SIGNED) vk'OU to ^J^*^-^^ , '^•'^• 

.X\ rooH (Address) RllBcCtll^^t 




FECIAL INFORMATION 9Rly f«r Hospitals, Institutions, Transients, 
tr^cenl Residents, and persons dying away frtu Nile. 



Former or 
Usual ResMeRce 

When *vas disease contracted, 
If not at place of death ? 



How iotf at 
nartof DnMi? 



Days 



PLACE OF niRIAJ, OR RHMdVAl, 





Aj^d 



rNDHKTAKF.R 

(Achlt."^ 



n 



IiATKof Bi RIAL or REMOVAI, 
yLctu, A\ T90H 







^Hiw 1 l\uU-Mm. 



^».--BveP, ,t.n. of l„foP„..tlo« .hou.d b. c.P.fu... .«PP»ed. AGB f -" ^„:i-*^:f,f .^^^^^^^^^^ InZl^Juot-lj:?'^^ 
•t«te CAU8E OP DEATH In plain term., that It may He properly cla.«lf1ecl. The »p«ciai 
•wit dyln4 away front homo should be given In avary Inatanca. 





1 







WRITE PLAINLY WITH UNFADING INK-THIS IS A PERMANENT RECORD 

^«-^ BEFER TO BACK OF CERTI FICATE FOR INSTRUCTIONS 

.......vw i.l,.aa l^O'i Registered ^o. 




Iai^uu? ijL^ Deputy Health Officer 

DEPARTMENToIf public HEALTH=City and County of San Francisco 






il! 



Certificate of ©eatb 

( la. S. Stan5arC> ) 
PLACE OF DEATH: -County of "^ a^ T;uV>vtv«.C* City of 

(No. 'iV^TUX'YV Ibft^Vulal St4 

(ir DC 






Dist; bet 



and 



r*TH occuns *4*v rnoM USUAL RCSIDENCE Give 

'icATH Sc"rRCo',« I HO.P.TAL O.I mST.TUt.ON G- 



i.CT8 CALLED rOR UNOCR •'SPECIAL IN FORMATION ■ \ 
,Ve ItI name INSTEAD OF STREET AND NUMBER. J 



FULL NAME 



SEX 



DATl-: •»! lUKTII 



A<-.K 



PERSONAL AND STATISTICAL PARTICULARS 




Xtbc^» 



t- 




U).lkd. 



•M.itith* 



"l V )V,M, 



2. 



y/tiMth* 



,U-1 



IS 



I V«ar I 



/>(/ 1 



HfN<,j,l.: MARHIHII. 
Win<»\VKI» OR DIVORCED 



BlkTHi! 
(State or < 



MEDICAL CERTIFICATE OF DEATH 

DATE Ol- DlvXTH 




(Diiy) 



1 1 
/pO t 

(Vear^ 



I JfKKHBV CI:RTIFV, That I atteii.kMl acoeasea from 
^\*»tf- il 190H to WLm ^^ »9oH 




'^ 



190S 




??AMF. (ii 
HATH IK 



niKTHI'l.ACR 
OF 1 ATHKR 



1 1 ' r \- 1 



MAIUKN NWIF 
OF MOTIIKR 




JLVWUXAAAH 



ti f i> ••• 



pi> mother' 

IStiitt or Countrj-} 
OCCVPATlu.N 






th*i I last saw h^^'^ alive on f^O^ %l 
nuA that death occurred, on the date stated above, at ^ "^ 
Vl M. The CAISK UF IHiATII was as follows: _ 

DURATION >'^'«''^ .1/^«M5 Days Hours 



CONTRIBUTORY 



avu 




M^ 



Hours 
M.D. 




R^fideil in Siiii f'tati, is^ii I t) }>rt*5 



\ 



}/,Hlf/l' 



/hn. 



■^"K AIIOVK ST\THI) I'KRHOSAK I'AKTICtl.ARS ARK TRIE TO THE 
B«»T OF MY KNoWI.EDr.E AND HEI.IEF 






f \<M 



re"*!* 



JLK/W%^i./^ Ibft^^AA^^ 



DURATION ^ )V^'^ .l/t.wM.9 Days 

(SIGNED) C.^/i.'^iM^«^^ 

k du Xi tO^-^ r Address) 'Pi^^-^v 

■ySl»«IAI- INFORMATION •*r^^»tt*b.l«UUrtIiiS. Tr«$kits, 
•r Recfirt Resldwls, ai« pefsws iym w*> f«« "^ 

If iwti! place tKeiffc? __^___ 



PJ.ACE OE HI RIAL oK RE>loVAl, 




DATE of BvniAU or RKMOVAI* 



T90 i 



INI^ERTAKER 



n.^Mluix4^ 






■ . _,, . . «B .hould bs at-Uil EXACTLY. PHYSICiANS rfMMil<i 

•ft. CAUSE OF DEATH l« pl-ln ter«.. that It «.y b« property cl...WI«d. Tta •P^ 
•«»• dying away ffroM horns should he gl^^sw In svsry l«st««cs. 



ii' 



i^b^ 



, ( 




tl 



i 



WRITE PLAINLY WITH UNFADING INK-THIS IS A PERMANENT RECORD 

^.^ prr ra TO B*CK OF CERTIFICATg FOR INSTRUCTIONS 

^^ WO'i Registered JVo. **^^ 



Bate I'ilrd, 




XixNur Deputy Health Officer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of S)eatb 

( la. S. StaneatO ) 



PLACE OF DEATH:— County of Ca^vdA,a^vCc».C 



(No. 



n 



Qflc.xti 




^^ St.; 5 DIst.;bct. 

- iieiiAi or CIDCNCE Give FACTS CALLC 
rAT^H^^O^C^NrEV/NTHO^.^VT^At o%' T^ St^'JV • O N G.VE ITS NAME INST 



ty 

.'DA.- 




and 




^.^cciv ) 



' I V»fc-^ V ' _...r.» rna iiMnrM "SPECIAL INrORMATlOW | 

( „ O..T- occu., .»., .-o« usu.L ?."^?5.?.a^„i"'.'.;.*?,i nam" ,;" "r" .?.%" «,. -u-.... ; 

V IP OCA- 



FULL NAME 



.''.cLl^ U^xmAJU A^^ 



PERSONAL AND STATISTICAL PARTICULARS 



SHX T^ 



DATK III l-IKTH 



ki'.V. 



u 



COl.oR 



lOlvt.. 



^L 






J t'a t ! 



% 



W 

(Day) 



.l/o»////« 



li 



(Vrail 



A/ V. 



MEDICAL CERTIFICATE OF DEATH 
DATE OF DKATH 



rVwLc' 



(Month) 



1 



( Day) 



lYenr) 



' i 



'^IN«.1.K, MARRIKI>. 
WIIM>WHI> «»R nfV<»R<KD 

(Writ'- ill -•rtiul i!i sif iialiitii) 



BIRTH»M,Ai'K 

(stale or C»mntrj-1 



NAMl- (II 
HATJIKR 



RIRTtlPl.AfR 
<»I" I \THHR 



MAIt»KN NAMH 
OH MOTIIKR 



<tF MoTMKR 
'Statf „r Coumrj) 



c) A/>vaLt 



I 1II-:RUBV CI'KTIFV, That I altcn.le<l .leccascd from 

luluj^l igoH to ...WJa^ 190H 

that I last saw h^'- alive on |^*^ '^^^ ''^ 

ati.l that dcatli occurred, on the date stated alK>ve, at 5 

-' M. The CAl'SK OF DI-ATII was an follows: 







C4.41 



ft 



vXrw>^4^w^HX>v^ a. 



Hi I rD 



wwLXmx 



,CC > w^C 






Vs,-sl.«4. 



Dr RAT ION y^'^'-^ 

CONTRIBUTORY 



AfoNlhs 



Days 



Hours 



DURATION Years Months 



Days 



(SIGNED) 



a^ :V;CV >>. 



Hoin<i 



M.D. 



fxjyxux 



AV../,//-rf /w .s-.,» /,„„,/..,■„ * )Vvi»5 t .1A»/M.< I i ^^'" 



THK MtoVK ST^TKt) I'HRSONAI. rARTIClI.ARS AKK TRl K T« > TIIK 
HKsT Ml- MV KNnWI,l*.n«,K AND HKI,tKP 



?Iijf.,r 



luant 



''Aihlreiw 






u tiu a.a. iQoH (Address) ii:^ dAAtbA ^± 

» SpJciAU INFORMATION only for Hospitals, Instltatloiis, Transleiits. 
ir%:eiil Residents, and persons dyinj «»#y fr»» wmc. 



Former tr 
Usual Residence 

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



How lonf •! 

Ware of Oeatli? Days 



PI.ACK OF niRIAU OR RKMOVA1, 




t NDFRTAKHR "^ -O.'^^^ 



DAXK of^BlRiAl, or RKMOVAl, 

a^ T90H 



mi-N 







(Address 



IXC^a Qf>\^4.4^>v 



.i 



N.B, — Bvei-y Item of litfopmatloit shoulcl be ciip«fully supplied. ^^"^ JJ^"" . .-,_j, xiie ''Speel*! Inforwattwi" fw* P»r- 
•tate CAUSE OP DEATH In plain terms, that It may be propeHy vla-sWed. ~ V^ 
•out dylnft away fiNm lionis shoulil be gtvsn In svsry Instance. 



I- Si 





? 



ki 



IP 



:,ar<l<>f ll.ittli 1 



WR.TE PLA.NLY WITH UNFADING .NK-TH.S .S A PERMANENT RECORD 

neFEH TO n^CK OF CERTiriCOTE TOR IN STHUCTIONa 

491 



Nn .^*^^''«ilCO 




oia 



190'i 



Registered JVo. 



|uj| 



'Wc. V^^ Deputy Health Officer ^ 

DEPARTMENT OF PilBUC HEALTH=City and County of San Francisco 



Certificate of S)eatb 

( m. S. StanCarD ) 



J m 



PLACE OF DEATH:— County 



of 0<X^^^O MX^voo^Gty of O^L^^^u:^^^ 



(%). 




/VVV ^^ V^^VWH IV 1 ....... ■r.lOENCECIVC r*CT8 CAULt 



and 



JVV'STM yV ^^tl-V.*^'^^"''*^ ^^^ M^^^^»f *~" ..MorR SPECIAL INrORMATION- \ 



FULL NAME 



LLLa.^. ...':•-'»• v[ nadvoJ.^:<-w 



PERSONAL AND STATISTICAL PARTICULARS 



DATK "] lUK rn 






L 



ACK 



?H 



I V«f # > 



(Day) 



M,>tilfi> 



1 I c 



L-ar^ 



/),/ 1 



SINU.LK MARKIKD. 
WtlXtWKU «»R niVnRiKI) 

(Write- ill -■ i l.^ifnatiDii) 



MEDICAL CERTIFICATE OF DEATH 

DATE t)H DHATH ,^ ,^ 



) Month) j 



il>av^ 



(Yearl 



"TlU^RFBY CHRTIFV, That I a);ten,U-l .kroascd from 

iX la 190^ to..WU:^i .00 H 




BIRTHI'UM'K 

(Slatr nr i"<iiintry > 



NAM I- ttl 
PATH IK 



BlRTMn.AiK 
OF F'AIIIKR 

•Statf or ('<nnitrv! 



MAIDKN N\MK 
OF MOTIIKR 



OF VoTllKH 
(Slate or CtMintryi 

OCCll'ATJON 



fl 






190 H 
ana that .Uath occurred, 011 the date stated alK^ve, at % 
Q M. The CArSI<: Ol' DltATII was as follows: 



tlmt I last saw h .SJ\) alive on ^^^-^ ^^ 



(TKm rCXX^V i S.L s^u 



■\ 




AV 



Df RAT ION- 
CO NT RIIUJTORV 



.1/<j;////5 ^ /^«;'^ " //<?«r5 



1 Years b 

DURATION iVflf^-s ^routln 



%x\ 






flays 



Hours 

M.D. 



(SIGNED) 

■ ApEClAL INFORMATION only tor H»S|Mtals, Institutions, Triisle«U. 
#r Recent Residents, and persons iymi way »«?» Iw»c. 



iqO 



f Address) I^SIO'-^ >^^^^ 



\f,mfh: 



t^fstdfd hi SiUi /'i iJiti isi-i) O **' 5 '''7''' ■ ■ 

THK AntHK ST\T1-,I) I'FRSONAI. PARTICl' I.ARS ARK TR 
BEST OF MY KN<)\VI,3,I)<;K AND IJHIJKF 



/)(n 



IK m THH 



nnant 



Former tr %M i l, » ftt 

Usual ResMewe ^^ * ^ ' ^ ^ 

When was disease contracted. ^ 4 

If not at place of death ? ^ ^^^^ 1 



How loRi at 
Place of Death? 

i 



Days 



PI \CK OK lURIAI, nR RKMoVAl, 




\«l.lrcs« 'iH \b * \% 



VNDKRTAKKR 

(A«Jiln«*» 






DATK o! Hi KiAi, or REMOVAL 



N. B.-— -B 



„ ^ ,^' ,h„„,d b« .t.ted EXACTLY. PHYSICIANS .hoald 
Every ttem of tnfoPmatlon •hould be c8P«fylly •uppHeJ- * _ "^"^ ,,,,|f|ed. The "Special Inform.tlon" f©r psr- 
•tate CAUSE OF DEATH In plain term., that It may be property claaameo. 
•««• dying away tram home aluHild be given In .very Instance. 






WRITE PLAINLY WITH UNFADING INK-THIS IS A PERMANENT RECORD 

«,™^ nercR to back o f ceRTincAT C for instbuctiows 



lOO'i 



492 



Registered JVo, 
ttrvL tL. Deputy Health Officer ^ 

DEPARTMENT OFPUBLIC HEALTH=City and County of San Francisco 



in i 



M 



PLACE OF DEATH:— County 



Certificate of Beatb 

( XX, S. StanDarO ) 
ofJjJixOmvOu City of ^^W^ 






r ■■ 



(No, 



St 



Dist.:bct. 



and 






FULL NAME 




t 



SKX 



t)ATl «H niRTH 



A<.K 



PERSONAL AND STATISTICAL PARTICULARS 

I COI.OR 




ecu 



(Month) 



O ^ } Vrt I 5 



U\i 



(Day) 



M.'ulli^ 



\^ 



(Year) 



/><; 



MEDICAL CERTIFICATE OF DEATH 



igo \ 

(Year) 



I HI-^Rl-nV CI-RTII'V, Tliat I attcn.UMl .kccasea from 

— to -^^^^^ ^ ^ 



19O 



that I last saw h 



alive on 



'igo 
-1 90 



SINi.l I MARkll'.n 
WllxtWj h nR niVoRCKI) 

(Write ill '-II. -a! «li •-ij/niitinii) 



luri 



BIRTm'I.vi'K 
IStatt lit t ttuuiry 



NAMV 01 
FATJll k 



BIRTIII'I.ACK 
<^»' lATHKR 
•M;ttenT Cauistrv 



MAIDKN NAMK 
OF MOTHER 



BlRTHl'UAeK 
OF MOTHKR 
(Stale or Country^ 



nceri'ATio.s- 






an.l that .loath occurred, on the .late stated above, at 
M The CMSH OF DI-ATII was as follows 



c>m 



\ 



ll^rwk/ 



.WA.^r>X<Xh-ML 



I )r RAT ION >V<zrJ 

CONTRIBITORV 



.youths 



Days 



Hours 



DL'RATION 
(SIGNED) 



J/()Uf/lS 







^lu 'Xt iqoH (Address) ■ 
EClAl- iNfORWATION f^ 




or Recent Residents, and persens dylnj away frosn Hmk. 



Hrmttw 
UsH^ Residence 

When was disease contracted, 
If not at placed death? 



H«wiM|M 
Place if 1^1? 



Says 



PLACE OF nrRIAt. OR REMOVAI, 



|>\TH"f nrtiiAt. or KKMOVAl. 



uvvu 



%% 



THE ABOVE STATKI) PHR-^ONAI. PARTlcrT,AR> ARlt TRIK Ti> THK 
RKST OF MY KN(>\Vl,i:nc.K ANP BKIJKH 

(Informant CrV%Xu Aj.^'VVr\K3LAJ 'lfVt>W>VX.*X 

'"*'**"'"'''^*'"''^''*"*''"''''**""^""'^"*'"^"""''^^'"^"^'**'"''"^"'^''^'^"*^^ Id ha t ted EXACTLY. PHYSICIANS should 

N. B, Every Item o« Informntlon shoald be c«f«fully •ttPI>««d- ^*^® •■'°!*,..-,«!/ The •'Special Infopm-tloti" for per- 

•fte CAUSE OF DEATH In plain term., that It may he properly .l—lfl«-. •» P« 

•«»• dying away from home ahcnild be given In every Instance. 






igoH 



(Addre«j» 



t 



m 



m 




I I 



t1! 




M 



lit 

t 

)' 

1^ 



' L 



493 



WR.TE PLA.NUV WITH UNFAD.NG .NK-TH.S .S A PERMANENT RECORD 

\^ ^ RCFCR TO BAC K OF CERTIFICA TE FOR INSTRUCTIONS 

.,. i,.fn-:iHi.- KV i^^% 

,,., ,v/./. ULu a^ ^^^ H ^"^-'^^-'^^ '^'' 

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

Ceitificate of Bcatb 

( la. S. StanC>atC> ) 






PLACE OF DEATHt-County of O^ZKXXyyy^ 



^a,. GtyofCxJ^^^^ ^<^' 



(Na 



. — St.; ^*'**** * r«« UNDER 'SPECIAL INrORMATION \ 



) 



FULL NAME 



Axou. 



M 



Slv\ 



PERSONAL AND STATISTICAL PARTICULARS 

COLOR 



I 



DATK n! UIKrn 



ACIC 






in 



4 



(MotitlO 



5.1 

(Day) 



Vtitr) 



} Vi7 I 



S[N<,1,1- M KRH11U>. 
WIDOWl I) OK niVDkCKD 

(Wrili i'l vcHi'al lU'-iKiiation) 



niKTIUM '.I 
(St;iti- nr I mititi V> 



NAMK oj. 
FATIll K 



HIKTHlM.\rK 

oi' hathi:k 

(Stati. 1)1 rountry) 



MAIiUX NAMK 
OF MOTHKR 



RlRTin't.ACR 
<>;■ MOTHKK 
(Stale nr Cotmtry 



t>Cv:ri'ATiuN 



\ M„ulhf A - 



Pa y: 



MEDICAL CERTIFICATE OF DEATH 

1 lIURiarrCHRTlF\\ That 1 atUinlcl deccasea fnm. 

^. — — — 1 90 to 

tbat I last saw h alive on 



rgn 

(Yr:ii) 



190 
190 



,K) 



a„,l that acath occurrea, o„ the aate statea above, at 
M. The CAIS!': ()!■ DHATH was as follows: 



DrRATION years 

CONTRIBl'TORY 



iVont/is 



Pays 



I fours 




DURATION 
(SIGNED) 



Years 

Q 



Months. 



Pays 



Hours 





M.D. 



tooH (Aaaress) 






) 'ra I ^ 



.\f,>tilh> 



Ihn 



in S(t>i f'l am isro 
THK AnoVF. STATKT) PKRHONAU PARTUTI.^KS ARI% TRVK T* > TUlC 



(Illf< 



I , -^ m I \ fi. >, 1 A I J<. n H K K Sn N A U I' A K I I ^ > la 
HKST OF MY KNoWl.l-.IX'.K ANl> HKI.lllH 



^sJ-iikL INFORMATION (Mily tor HwHtals, Instltatlons, TrMMents, 
Of R«eS Mcnls. and persons dying away from N«e. 



iirmnnt 



Former or 
Usual Residence 

When was disease contracted, 

If not at place of deatli ? 

ri.ACH <)« m-RlAl. «»R RKMnVAl. 



■WW iMf It 



Days 



IlATl'of BtMlAl- or RKXIOVAI, 

INI) V. R r A K »• R U^ CC ^II^^VWW^-^^ _^, 



(A«1<trcsH Vy #» I NJU /Viru.vv%^ ^MA ^ '^ ^^^^ _— — 1 

'"''''''"'''^'"'^'"'■■^^■■■^■"^■^■''■'■■'*'''''*^*'''^'*"^^"*''"*'*^ ft d EXACTLY. PHYSICIAMA should 

N. ».— Every Item of Information •hottW be cnr.fully .Mpptled. ^^;^^^ •^**",',^,^^^^^ Vh. -Specl.l Inform-tloB" for p^p- 

•tate CAUSE OF DEATH In plain term*, that It may »« pr P 

•wi. flirini away from horn, ahould b« glvsn In •vai-y Inatance. 






* 



1 




WRITE PLAINLY WITH UNFADING INK-THIS IS A PERMANENT RECORD 




REFER TO Htf-K OP CERTIFICATE FOR INSTRUCTIOWa 



Valrl'i'r,!, W^ 3.^ ^^^ "^ 

1^^ iL^ D«p"*y "«^'*^ °"'°*'' 



Registered M*o. 



494 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of S)eatb 

( "0. S. StanOarD ) 






-f % 



PLACE OF DEATH:-Countv of ^^- ko^vv^^Gty of ^^ >v ^Ka^^c^cx 



(Na Av^\a'^^'aw.QA^]JA.'^ Iv 



St. 



Dist.; bet 



and 



) 



\ ir DEATH flcCURRtO IN A MOSPITAU 0»l INSTITUTiwn /^ . 



FULL NAME 



.r\_Ou^.v 



A 



SKX 



PERSONAL AND STATISTICAL PARTICULARS 

I COI.OR 



\ 



DAii; CI niRi'ii 



jJtr 




iv^ 



I Month) 



A<.i-: 



k"^ jv,T#^ 



H 



MimUis 



fVcai 



/'.n. 



MEDICAL CERTIFICATE OF DEATH 

DATK OV 1)J:ATM | 



(Moiitli) I 



l>ay) 



I Vert r^ 



I 1|1{RHHY CliRTIF\\ That I lUtenacl acccascd from 

to W^ ^^ 
thia I last saw h J^ >^^alive on HvOm. 1 H 190 H 



iW'titrin ki)<j;il di->-u''i;ilii>t)) 




BIRTHJM.ACK 
iStatt- or (.'iitiiitryl 



NX Ml- til 
J'ATIM R 



niRTHiM.ArK 

OF FATHKR 

iStatt ill fun tit ry) 



MAIDKX NAMK 
OF MOTHliR 



niRTlU'I.ACF 
OH MOTHKR 
(Statf or rtuintryi 







NfTloui^ 







..oJuuwdba n i\ wL^\ 



Iv-^ixl 190H to V^Xm.0.0 190S 

...at I last 'saw h -^ >^^alive on |^^^ 

an.lthat death occurred, 0,1 the date statcl alnn-e, at I 3 
'? M. The CATSK Ol- MlvATH was as follows: 




OCCll'ATioN 





Kt-h)i'il ill San /■') mil isi'o O )V'«f»>" 



.\/,>iitli^ 



}\i 



Till; \1!<(\ !■: STATJ-.n t'KRHONAl. I» SKTICr I.ARS A R I-: TK 
UUsr KtV MY KN()Wl.i:i>r,K AND HICMKF 



f \{Wre«ii 








D I' R A r I O N ^ J 'I'ais Afotiths 

CONTRIBUTORY ^ ^<CVbHL\-i. J 



bURATlON X Vvars Mofiths 

(SIGNED) VU \S dlLvs^^V^, 



Days 



1 1 our Si 



Days 



/fours 

M.D. 



iJ^. g-k ..nH fAddrcss)l46a Ua4^V>^^<^^^t 
0_ _ _L . . . , ., ^« -M ATK^N Mlv for Hosaltals. Ii&tttittois. Tiaaslerts 



^SPECIAL INFORMATION wlv »«r Hospitals, libtttithiis. TfMSlerts. 

or Recent Residents, and persons iylug away from home. 



Former or 
Usual Residence 

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



Now loRf A 
Place of DeaOi? 



Days 



PI,ACK tllLBlKIAI, OR RKMnVAL 



XXh.^^ 






INDKRTAKER ^' 

(AddreHS 






UATKoS III HIAI. Of klvMoVAI, 

%H T90H 



H 



,„„.,. lit" *l>Xv«.^^.l* 



"^^"""""'■■'"■"''''''''''■''■'''■''''''^■^''''^^ I pxACTLY. PHYSICIANS sHoald 

N. B. Every Uem of Information •hould be cRPefially •applied. AGB •*»°"*^ JJjJ ,•*■ %|^ ••Special infopmatlon" for per- 

•t«te CAUSE OF DEATH In plain term., that It may be properly cla.^lfled. Tiie pe 

•«i« dylnt away from homo nhoald hm given In evory ln«t»«ce. 



i 



r rl 



■• I 







V' 




41 



ft 

I' 



WRITE PLAINLY WITH UNFADING INK 



\ 




THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



Dnfc /v/r'r/, 



XX 



lOO^i 



Registered JSTo, 



495 



i^ V 




Jouvvu Deputy Health Offleer 

DEPAiiENT OF PUBLIC HEALTH=City and County of San Francisco 



^^A^A^A^ 



Certificate of 2)eatb 

( "CI. S. StanDarC> ) 



J ^ 



PLACE OF DEATH:-County of ^^O^ ^ ^^VW^^o Gty of 3<VW J VXV.vc. 



(No. 5^ 1 ^^ ' ^ 



St; ^ Dist.;bct. 15 Ui\ 



and It 



ti 



) 



r ■;'£^s^";^v,rj:^t r^T^si^;^^";^":'^^^^ ™ " -ri^n^^-rr^r' ) 



FULL NAME 



iLtQW^bA. ILlvI 



LVl-Y^VCL^V-VAi 



1^ 



PERSONAL AND STATISTICAL PARTICULARS 



I>AT1% «>| lUKTII A^ 



COl.UR 




SINT.l.l.: M\KkIKI> 



)'/'iM 



T> 



30 
iDav) 



Mntilhs 



(Year) 



MEDICAL CERTIFICATE OF DEATH 

DATK OI- DKATH A 



(Ye:ir1 



I HKKl'HV CHRTIFV. That I attemWa dcccasfd from 



Da I . 



I\V; 



BIRTIMM 
(Slatr nr < 



VXM! 1.1- 
J-ATIIl K 



niRTHI'l.Ni'K 
OF I \Tin K 



'natiinO 



tilt VI 



MAllM V N\MF 



RTRTHPI.AOl-: 
W MOTHKR 
tSlate or iNnintrv 






. |vv^*. H 190H to ivJU^ XO 190H 

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

ati.l that .loath occurred, on the <late stated aVH,vc, at ^ i^ 
J M. The CArSK OI' DKATIf ^s^ as follows: 

X^^J,Xv4 .^OX<x<ix^ Ua.<U^-x 



^ \ ^ 



X\AWOLA'VtV 



OCCl I'ATION 



* 1 






M,»)lh- 



/hi\s 






rt T ' ftl r 4i f tt . 'iff n f f H ft I i .-^f t' I - !"V t ' " ■ , 

THF MioVK ^'l\TI' T> »»KRSONAI, PARTICt'l.AKS ARl-t TKlK T 

iiHsr 01 Mv KNowi i:i)(;e and bki.ikp 



1) TIlH 



CONTRIBUTORY UttN^^^^ ^..CVx4A.tv^ 
DURATION y^'Jf'i ' MofUhs /hiys 

(SIGNED). |y.UJx'^vm,lX 



//ours 
M.D. 



"^PeJiAL information «««v '«' H«^»"'^- iBMiwHoiis. iraisteiits, 
or Recent Residents, and persons ^fim way ^'<«n •»'»«• 



Fftrmer or 
Usual ResMence 

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



How Ion) at 
Place oi Deatli? 



Days 



maul 



i\A,) 



tv%s 






j\i 



VI \CK OF BlRIAt, OR RKM«>VAI, 



n\TKof BiHiAr. or KKMOVAI, 






(Address 



Ul>n 



m\ 



AA4,4^^v 



'^*^'™—— — ■■ii»MiiMJii^M^«"ii^»i™'*''*'^^*"*'"'""'**^^ f ted EXACTLY. PHYSICIANS •hould 

N. B Every item of Informntlon should he carefully nuppHed. ^*^® ••'®". .,,|,*a, -fhe "Sp**!*! l«fc>fni«tlon*' for pei- 

•tate CAUSE OF DEATH fa plain term., that It may be properly claa.lfieo. h- 

•one dying away from home ahowld he given In every Instance. 



I 





11 



I < 



i 





r 



III 



\ .1 




WRITE PLAINLY WITH UNFADING INK-THIS IS A PERMANENT RECORD 



Doh'Flh'il, Hvvlu 0.% ^'^^"^ 

i^vliivvu. Deputy Hea.t.Ofn.er 



Registered JV^'o. 



496 



DEPARTMENT OF t^UBLlC HE ALTH=City and County of San Francisco 



Certificate ot S)eatb 

( H. S. StanDarD ) 

^ acs J 






»i 



:ii 



PLACE OF DEATH:-Cou„ty ofAa..1U.vcv..o City of la.. .Ixa v.c< .-. 



(No. '^l vaUk' 

(ir Dk*T[ 
ir OE 



SU 



o 



Dist,; bet* 



15 



vk 



and ^ 



fti ^i 



) 



.' blM ' l-'lSUt DCU .-.Mnri* "SPECIAL I NTORMATIOW '^ 

PULL NAME CLUJ^^^i"-H.a Ad 



A^N.<X/>\.:^r 



4^ 



PERSONAL AND STATISTICAL PARTICULARS 

DATi ' n in Kin 



M'.H 




"'"la.u 



J 'ra r 



•>1N«.I.K MARKIKO. 
WiixnvMi riR niVORCKD 

(Writ* 111 ^iH'i;i! ilc«i5pnatioti) 



i. 






M, ft lily 
ft 






/Ijj 1 .« 



MEDICAL CERTIFICATE OFJ>EATH 

DATK OF DHATK f\ [, 



rU 



ith) 



(I)ay^ 



(Year) 



Tm^R I'BY CKRTIF\% That I attcmkMl .Uncasca from 
that I last saw h ^^ alive on ^^^^^-M 




itti 



HIRTH!M.\rH 

(Statv or Cniiiitry 



f.^ti!i:r 



niRTin'i.xiK 

OJ* l-ATHKK 

(State <ir ruuntry 






it)o i 

-L .' ' I<)0 

ana that acath occurrc<l, on the aalc stated a1>ove. at 
M. The CAT SI-: Ol* Dl^ATII was as follows: 






MAlDltN NAMK 
1»1 



1. ryvcr > ^ "^ 



mRTH!M.^^^: ' 

ft I- MmTJIKK 

'Stat. 1,1 r.nintrvi ^ ^ » » jj 

loo- Vl' tvk 
\ 

Rf^idfif III S,nt Fnnnisrn *■ ) 'm > - * .\f>>nfft 






^V 



DURATION ^'''-y 

CONTRIHI'TORY ^v 






DURATION 



(SIGNED) 







/)^7V.V 



1 Wvv'-wu-^v 



//ours 
M.D. 



ocsjti'A ri.iN 




/)(/! 



"Ill xnnVKSTATHI) PKKSON-AI, rARTICri..\RSARK THl K T<> THK 
nKSTtn- MY KNOWI.HIX'.H AM) BKI,lKP 



(Infc 



orinant 



51 Utjvjx^ 



^kpEtlAL INFORMATION -"Iv f«r Hospitals. InstltuUMS, Trwslcits, 
or R«enl Rfsldents, and persons dying away from home. 

r !•■« at 

Days 



fmmm 
Usual Residence 

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



How lent at 
Place of Death? 



PLACE OF J^-RiAl, OR RKMoVAI, 



JhJ^'>>X<Xt^\^ 



DATHof HiRiAL or REMOVAL 

T90N 




INUHRTAKER 

(A«Mrt.s« 






f Address O I VS-VJ^'V^' -^ ' | 

^""i^mmim^m^mmmi^^m^^^^ammm^^m^i^mmi^mmmmmmm^mmi^^mi^^^^^^''^^ FXACTLY. PHYSICIANS should 

n, B._Bvery Item of Information .hould be carefully auppll.d. ^*V^ !*;*",'^,!jj|^ir%h« ''Spcclai Information- for pmr- 
•fte CAUSE OF DEATH In plain term., that It may be properly cl..«ima. 
"on* dylnft away from home nhottld b« given In every Instance. 




f* 




V\ 



i«. Ill I 

111 



\ I • 




WRITE PLAINLY WITH UNFADING INK-THIS IS A PERMANENT RECORD 

.«^ orrrp TO BACK OF CERTIFICAT E FOR INSTRUCTIONS 

' ^ 1 ^^ ia/m Registered J^o, ^^^ 

Date J'ilr<h W 



JL ^^ I'jo^ 

^^Hm Deputy Hea.t--f^-r ^ 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



.^VCM^ 



Certificate of 2)eatb 

( -Q. S. StanDarD ) ^ 

c] 



i^i^ 



PLACE OF DEATH:-Cou„ty of ^a^ Jx^na^x4^Gty ofOom; ^X^^v 






(No. 1^0^ yoj^^^h.. 



St 



Dist,; bet. 



XC\A.^^^j and 



o 






00 



FULL NAME 



iVL* 



(^, 



cVi) 






-qaJI 



si:\ 



PERSONAL AND STATISTICAL PARTICULARS 

COLOR \ 




n 




Lew 

DATl-: t)I lUkTII £\ 



I 



Uci 



iMmithi 



At'.K 



} Vtr I 



SIN..I,|-, SfARHlKH. 
WlDnwrTi OR niVoKCF.n 

(Writ' , (1 (lisi^Mi:iti«m) 



r^ 



niKTIIi'I.X't' 

'Stat I lit ( .)n!itrj-l 



NAMf <M 
I- \ 111 IK 



BlRTin>I.\(H 
OF FATHKR 
(Statr .IT Cimntry) 



MAIUHN NAM]. 
OF MOTIIHR 



niRTinM,A(.H 
OP MOTHHR 

tstatt' nr Countryi 



^. 



(Day) 



.Untiths 



c t "^ 



(Vear) 



/htvs 



MEDICAL CERTIFICATE OF DEATH 

I)\TH OF DKATH ^ ^^ 

3LL 



(>(j>i«ni> (J 



(Year) 






'^ (Day) 

I ni-KFHV C1:RTIKV, That I attemkMl ac(Hi,sc<l from 
Wk -1 «9oH to |-«'^^^ '<^^ 

that I \J saw h ..V > > alive on VUl^ ^^ '^"^ 

ana that death occurre.l, on the .late state! above, at ^ ^ « 
M. The CATSK OV DKATII wa^ as follows: 




Dl'RATION 



years 



'fi 



Montfis 

...sJ,. 



Pavs 1% Hours 






\J 









occri'Aiius 

Rfsitlfii ill Sail /'i aiii nrn 









I/ours 
r tun -«»* *"y\'"iC 

(SIGNED) J^V\^>vwO^ Ci^ti . .;.- |«-«^- 

Lxu .:/.. u,n r Ad dress) ID i^^ X^^Ax.- .^ 






M i-M '- 



SPeCIAL INFORMATION f'y ff "•'^^'^ '"'=«»"»'«''^- T""^^"*^' 
or Recent Residents, and persons dying way from lioBie. 



yr<>iith$ 



. ,,„ , ,„,, )'i'itif »rf ____. 

rUF. AH()VKST\TKI> PKRSdNAI, J'AR TIOn.ARS ARK TRlK 
HKST OF ^\\ KNO\Vl,KlH-,K»\Nl) JIHM1:H 



nil sf 



TO THK 



(Infonnnnt 






former «■ 
Usual Residence 

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



ll«wl«R4|at 
Plire of Deatk? 



Diys 



I'LACK OF nV/^'v^^' "•* HFMt>VAI. 







I)ATi%of Ij^t RiAr, or REMOVAI, 

,^^axa ^3i 190*1 




,.JSf %lk^ 



fc>v....x 



A 



— — _— —^M^— ii^— — ' ij ^^ ♦ ted EXACTLY. PHYSICIANS shtHild 

N. B Bvery Item of Information ehould be carefully supplied. ^^^ 'I;"" _,,|Jj" fhe **Sp«cl«l informntloii'* for p*r. 

•tote CAUSE OF DEATH In plain term., that It may be properly cla..iw«. 
•««• dyliiA away from home •bould be given In •very Instance. 





Ill 
III 

1 1' 



Ji' 



»H|* 





tiri 




'■ u 



' I 



l<l 



li 



S~/f- <5 



./AfA-^^ 



WRITE PLAINLY WITH UNFADING .NK-TH.S .S A PERMANENT RECORD 

^^^ REFER TO r«Tir.C*TE FOR INSTRUCTIONS 

■ ,.s., ,.*^'"^'-C.' 



Dale Filed , 



\aO 



190^ 



Registered JVo. 



DEPARTiTeNWPIIBLIC BEALTH-City and County of San Francisco 



Certificate of Beatb 

( tl. S. Stan£»arC> ) 






PLACE OF DEATH:— County 



of 0(nx6'^'^^ 



<*i 



City of 




n '■ ^ 



(No. 



St. 



Dist.; bet. 



and 



_ " :— Ol»^' l-'iai** 1^" ^ M,yp,rR "SPECIAL INFORMATION- 



) 



) 



FULL NAME 



a 



.kjJ. ' 



4 



L-^^^ 



SKX 



PERSONAL AND STATISTICAL PARTICULARS 

COI.OR 



^\Ju 




y 



DAT!', nl lURTII 



A'.K 




b 1 )V(7»^ 






5- 

(Day) 



M,,ulli^ 



^ n 



Vtar' 



/)cJl 



MEDICAL CERTIFICATE OF DEATH 

DATK Ol- DlvXTH 






(Year) 



SIN!, 1. 1' M\KKn<:i>, 
\Vin(i\Vi;i) nR TJlVnKi'Kl) 

(Writf ill '■iH-.il (l>-^ii.'natii>n) 



niHTin'i.xi'i-: 

(SUtte or I'liimtty 



VlluXAAXX^ 



J r3lo.. 



N'AMl- MI 
FA Til IK 



RIRTHIM.AOR 
OF FATHl'R 

iStair or riiiititi V 



(IF MOTHKR 



BIRTH FI, AC f: 

OF mhtiif:k 

(Slate or Countrv 



OCCFI'ATIO.N f 




(Day) 

I HKRlUiV CKRTIFV. That I attcn<kMl acccascd from 

— — — r 190 — to ^ ■ ■" '90 

tliat I last saw h ' alive on — — l^ 

a„.l that .Uath occurred, on the .late stated above, at 
M. The CArSrC OF DIIATII was as follows: 




Dr RAT ION J'"'-^' 

CONTRIIUTORV 



Moul/is 



Pays 



Hours 



/y\}fL_/y\,^-\Ay^^ y 




h'fsnlrd n, Sat, r,a,i.,s,-n 5^0 >''"'^ ^ Mon Hn ' />'?' 

tHF: \!t()VF. STAI'F-.I) FKRS<»NA1, rARTlori.AKS \K1. IRFK T 
fiHsT UF MY KN()\VM:D<iF: AND BHI.IHH 



DURATION 



Mouths 



} cars 

n ^^^ 

(Signed) vV ^J 

^wIm a& 100 H (Addi 

SPECIAL INFORWATIC- 
tr Recent Rfsldcnts, and perwns dying away from howe. 

Former w 
Usual Residence 

When was disease rontracted. 

If not at place of death ? ^_ 



Days 



nour% 
M.D. 



JUxiduJl^^ 



How Ion ^ 
Place of DeatI? 



Days 



Tt> TIIK 



(Infui 



mniu 



_ . ^ AJL/VVV^rvrpJU 



ksJJ^ 






! Artdreiwi 



in.ACK OF m-RIAl, OR KKMOVAI. 



DATHof m-HlAi. OT kKMuVAI, 

an T90H 



^_ *3w/<XAArru 




'"""''"^'""■''■"■'■'■^■■''■■"'''''■'^^■'■'■'■"''^^ Id ha t ted EXACTLY. PHYSICIANS ahould 

N. B. Every Item of in»orm«tloti .hould be curafuHy i»uPP»«f- ^^",^!;°",.-.|f|L! The "8$>ecl«l InformnUon" for p«i- 

•tate C4U8E OF DEATH In ploln term., that It may be properly clM.itw 

«iwi» dytiiA •way from horn. i.hottld be ftK«i« »" •*««'y »"«•"«*• 



I ( 




i lif 1 



I i« 





!".. 



WRITE PLAINLY WITH UNFADING INK 




it 1)^ 



Dale Fih'<l, t^^^H "^^ 



i 



^S^^KJsJ^ 



190H 
Deputy Health 



THIS IS A PERMANENT RECORD 

REFER TO — -" ^"^^T.r.CATE FOR INSTRUCTIONS 

Registered J^o, ^^J 



xo.^r 



It 



DEPARTHIENT OfViBLIC HE ALTH-City and County of San Francisco 

Certificate of 2)eatb 

( •a. S. standard ^ a j. ^ ^ ^ 

PLACE OF DEATH: -County of XLV^V^ Uty ot 



(No. — 



Dist; bet. 



- — and 



— St.; - UlSI.t DCU^ ^^ under'spccial information- N 



FULL NAME 



' 1 ^ ^1 



<X 




SKX 



PERSONAL AND STATISTICAL PARTICULARS 

COI.OR 



^UJU 




ix-^^L^ 



DATl", <'l UlKTIl 



AGR 




{ I 



1 Month) 



\'r,ii '• 



H 



(I)ay^ 



M.mths 



^ 



IVfiiri 



A/' 



MEDICAL CERTIFICATE OF DEATH 




DATK ul- DKATH 



0, 



tl>av) 



igo \ 

(Yrar^ 



(Month) ^ 
i IIICRKHV CI^RTIFV! That I atten.lcl .Icronscl from 



SIM, 1,1- MNKKIHIJ. 
WlUnWl 1> (tR DIVORCKI) 

iWiitt u( '»!:i! ik>i^tiatitm) 



% 



\o-wv.-. c^ 



i 



niRTiii'i.xti' 

(^Intr or I MiiiUty' 



NAMK Ol 
FATMKk 



BIRTHI'l.A' K 
OF I-AIUHR 
(State or Cotiutryi 



MXIDKN NAMK 
OF MUTIIKR 



RlRTItn.ArK 
OF MnTHKR 
(State or Coimtry^ 



OCCll»ATU)N ^, 
Kf-uini 



-.^ r— ' 190 — to 

that I last saw h r— alive on 
ana that .leath ocourre<l. o„ the .late statc<l above, at 
M^ The CAISK OL', DI'.ATH was as follows 



190 



f..lv^cL ^i^^ ^ 






DC RATION JV'i''^ 

CONTRIIU'TORY 



Months 



Pa v? 



Hours 



DURATION 



) Varjt 




mA.^.i 



Mouths Pays 

(A<l<lress) - *-^ ' ^ - -^ ^ "^ 



(SIGNED) .^.^^ Uv^KSO~. U*.^. 



IJnurs 

M.D. 



U)0 



1 






)'ttn ,< 



yr,i,tfii^ 



fhU 



THK AUoVH STATl-.n PHRSON-Al. I'ARTUT I.AKS ARK TKlK T«> THK 
HKST OF MY KN<)W1.F",1)(.K AM) HJ'.I.lKF 



SPEC AL INFORMATION f^ ^ ^^^^^^ W^^-*^ ^"•^•«^' 

or RweSt Residents, and persons dyinq away from Iwiie. 



fr or '\Oi'n '^ „ \n T 
Residence^ i ^ -^ ^ ^ " 



Former or 

Usual 

When was disease contracled» 

If not at place ol death? 



4 



How tonq at 

Place ol Death? "^ 



Days 



(Ilifot 



iiiatit 



\ IS .> • > S\ I . I ', M > 1 I*. . \ ^ 1 ' 



t 






ri.ACK <)K lURlAI, t)K KKMOVAI, 



tiATK'if lUKiAL or RKMOVAI. 



INDKKTAKKR 

(Address 






'"'"""'""■■■"^^■'■''''^"■^^^■■'''■^^''■^■'^'■■''■*'"''^''"'"*'*"'"'"""'"^^ lil h t ted EXACTLY. PHYSICIANS •hould 

N. B.^Bvery Item of tn?orm«tton .hould b* carefully .uppned- ^^^ •'j**",...,^,;/ Vhe -Special inform.tloi.- for pel- 

•tate CAUSE OF DEATH In plain term., that it may he P^^J^^ *='* 

•<m« dying awajf from home ahould be given In every Inataace. 



I : 



h 



!l 



I'll i 



'ft) 



I < 



I « 



1. 



WRI 



Dale I'ih'ff, 



TE PLAINLY WITH UNFADING .NK-TH.S IS A PERMANENT RECORD 

^^ BEFER TO «eK or CERTir.CAT t TOR INSTRUCTION. 
^ K^ 



Re^Lstcrcd J^'*o. 



Deputy Health Offlcer 



1 • L 

DEPARTMENT 0?PI]BLIC HEALTH=City and County of San Francisco 

Ccrtiticate of 2)catb 

( TH. S. StanDarD ) 

^.. r ♦v nf ^ Ct^^' ^ fv^xc^^ City of O^CU^v 1xa vxccc 
PLACE OF DEATH: — County of v,v^^ va. 

,*. i i1 i r'H I MJ^^hi ni ^'^^VO.CX.l' St.; - — ^-Dist.; htir • specal .Nrf^AT.oN- \ 



FULL NAME 



loau^Av--' 



SKX 



PERSONAL AND STATISTICAL PARTICULARS 



mcJL 



lOJvd. 



till 



n.\ri; • s .ik i ii 



ACK 



He r, ^ 



(Day! 



Mofilhs 



(Year) 



' MEDICAL CERTIFICATE OF DEATH ^^^^^ 

DATK OF 1>KA"«'>« (\ fi ,» y 

IIIPHl-BV Cl-RTIFV, That I attcn.le.1 clcocascHl from 

1 ..... ..,_.... ^Jie*: ii 190H 



/)(/! 



SlM.l.i- \1 \KU ll-'U 
WlHnU 11. i.K IilVnmi-".f> 
(Write ill .<.(i:('. 1(1 >.ij.'nat!i>ii) 



BIRTm'I.NOIC 

(St;iU fir ri,untt> 



FATIIKR 



BIRTH ri,A>K 
0»- FAI'IIHR 
(Stntcor Country 



MMDl-N NAMl- 
UP MriTHKR 



HIk rilPl.ACK 
OF MOTHER 
(Slate or Country) 



^ 



n.K^TJckk 



that I last saw h A'Vn alive on 



t^ 



,„a that .Icath occttrrca, c, the date stated above, at 
f ^, The CAISK OF IH-ATIl was as follows: 






i'l C 



Months 



Di; RATION >V<"^ 

CONTRIBUTORY 



/Mj.f 



I to lit 



Hi 






DURATION 
(SIGNED) 



Vt'ars 



Mi)ntlis 



/hiv 



Hours 
M.D. 



Transients, 



oCCri'ATloN 



^^^^ Kf sided in San Fmn, isnt i /- ^ >'(?<< 

THK \»(,VK STATK!> PKRHONAI. I'ARTIOri AKS ARK TKlK 
RKST 01 ?.!Y KNoWl.I-.nC.K AND UHMItH 

\ fs. C, « 



(SIGNED). -^^-^^_ p^ 

"Special INFORMATION f v lor hospitals. InstilBtlOBS, 
' or RereSRe^ents. and persons dying away from home. 

Aaa How lonq at , . -. 

Former w nVl lffU^4A^>v Place of Oeatli? lOa hys 

Usual Residence v ti I ^l I wv^»/v» 

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



Unfoimaiit LvWtNJ . M \\ 



I 



fA.Ulrr 



IM^ACl- OH m-RIALOR RKMOVAI. 




^ 



\ 



INDKK lAKH 



L\.OA. 



DATi;<«f IHKIAI, or KEMOVAI, 

f i.^wlOoxlwv. 



,<n.\. - 



u 



,<1 1;| 



'*■'*■■*■'— -■'^^^^^^^t^"*--'*""^''"""^^"''''"''""'''"*"''*"''**'"^^ t d EXACTLY. PHV8ICIAW« sHoiild 

N. B._Bv.ry Uc„ „f l„l„,™«.lon .houl.1 b. c»..lull, .uppH.-- *«^,t7,.„Mkd! Vh. "•p^Ll l»»orn.....»" for p.,- 

•tatc CAUSE OP DEATH In plain tepm., thai It may "« •■ V" 

•on, dyint away Iron. horn, ahould b. «lv.n In .vary Inatanc 



•«l 



I ! 



.11. 



I 



fl*'* 




^ 




r 




,TE PLAINLY WITH UNFADING .NK-TH.S .S A PERMANENT RECORD 

REFER TO BACK O" CERTIFICATE FOR INSTRUCTIONS 



H&l'Co 




Begistercd *N*o. 



^,,... -.^H Deputy Health Officer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 









on 
vLva 



City of 



.i--/^'v, . 



(X^^. ^ 



Certificate of 2)eatb 

( tl. S. Stan^arD ) 

PLACE OF DEATH:— County of CX^x- 

' ^ n J c*. ^ nut •bet. ^ A^^A) . 

.«T ^hl'l l ^VL^tXXO' ^^•^ ^..r« roK UNDCn "SPECIAL INrORMATION' \ 



and 



FULL NAME 



SH\ 



PERSONAL AND STATISTICAL PARTICULARS 

C01,v>R S^ 




Al 



DAT!. t»l 1 ;k i 11 



A(.H 






I 



\' 



f 



I 



d^ 




MEDICAL CERTIFICATE OF DEATH 

DATE <>I'* DHXTH 






il):iv> 



igo 

(Yfar> 



/ Li 



iMimth) 



) Vir I 



(Dav) 



M.mihs 



(Y.-ar' 



Dn vs 



1 lIliRHHY CURTIFY, Tl,.t^IMU-...U4.Uvw.ol from 



190 ^ 



to 



i- 






(Writ' in - » utl lUvu'iuition) 




niRTliri \'-V 
(Slatr 1.1 i Miilrt-'t 



WMI 01 

I- Mil I K 



luk THri.ArH 

<M- lATHHk 
ISlatf (iT I. iituUry) 



m\iiii:n x\m1'" 

OF MuTHHK 



m i 



oUlUJ-V^ U-IX'VYV 



190 ^ 

U„„ I last saw h ■ alive on ^^^ * ' >90 

.„a ,l„.t .Wall, .HH-urre,l, o„ ll.c '.late staU.l ahovc. at 
M. The CAISK IH- UliATII was as follows: 







.)L\rwsJLoA^ 






lU 




1) 



^^1 



niRTlIl'l.XiK 

or m<)tui:h 

(St;Ut- or C.inntryl 

ucci l^v^ION 









Hours 



'm 



V 



-^Xa.' 



)V<t« 



Month: 



Pavs 



DIRATION 
SIGNED) U-AjIu^W 



/ fours 

M.D. 



SPEGIAL INFORMATION f y fjr H^UK l«stU»Uo«s, Transients, 
or R^ent Residents, and persons dylnfl away from Home. 



A^UlX>VVCU 



Montll: 



THK AnnVK ST\TF1> PKRSONAl. PARTICfl.ARS ARK TRVK Tt! 
BKST Ul- MS KN<»N\I,i:i)(',H ANU niU.Il'P 



(In for 



inani 




Former or 
Usual Residence 

Wlien WIS disease contracted. 
If not at place of death? 



How I0119 at 
Place of Death? 



Days 



IM.ACKni- m RIAL OR HHMOVAl. 



(Ai1«lre»s 



\x^x'\ 



)jJXa 
inuhrtakkr 



-\ 



DATKof Ht KIAJ. or RKMOVAl, 








XH 



tooH 



[ Addfe«» 



^51 yiWs-^^w 



io^A. 



^^mmm^mmmm^i^mmmi^^^^mmmm^mm^i^^m^'^i^''^^^'''''''^''^''^'^'^^'^''^^^''^^ , j EXACTLY PHYSICIANS should 

N.B.— Bvery It.n, of InWm.tlon .hould be ca.ofuMy •-PPi'*?' Jl^^J^^^lt^^X %h« "Sl^W l«»orm-tio«- for p.r- 
•tate CAUSE OF DEATH In plain tcrr.t«, that It may ^ P^ J ' 
^i» dying away from homo .honW b« glv«n In ovony l««t»"««. 



K4 



11 




¥ 



\ 



I- 



i 




i I 




i:.i ■ ; 1 1 



* 



t) 




'tf 



wmTE PLA.NUV W.TH UNFAD.NG .NK-TH.S IS A PERMANENT RECORD ^ 
WRITE PLAinu cERTincATE for instruction 




ifrv^ liA^H ^^p"*'' "^""^^ °*"*'* 



REFER TO B ACK OF CERTI 



502 



DEPAmENTOF PUBLIC HEALTH=City and County of San Francisco 



Cevtificate oi ©catb 

( tl. S. StanDar^ ) 



PLACE OF DEATH 



.-County of ^O^^^-- - Cty o.^^- i-'V<X.:vC-.e 



'B 



Lll 



and (iV'a. 



^Tfll^XiAj St.; ^^^*'*.h«\«ll UNDER 'SPECIAL INFORMATION' \ ^ 

t ,r DEATH OCCURRED IN A HOSPITAL OR IN. OOS /V A 1^ I'l 

Add:', lib '^ 



) 






FULL NAME 



D OF STREET ANO i»ui«. 



SKX 



PERSONAL AND STATISTICAL PARTICULARS 

COM>K 



:^ 



OJs^- 



HA IK 111 i ii< III 



W^Lm 



i||cinth 



At . I-: 



}V.n.« 



U', 



(Dav) 



Mntitfi^ 



n 



lll:(Vt 



TOO \ 

(Year^ 



iVf!ir) 



Da \: 



SIM, 1. IV MARHIKH. 
Wlltnu 11. OK I)tV»>Ri'Kf» 

l\Vii!> ill -M i.i! ilcsii'nati'iii) 



BIRTHfLXtl*. 
(Slati- >ir iiimiti y i 



NAMF «il< 
FATin:R 



RIKTH1'I.\( K 
OF lATIlKR 
fStutt or Cuuiitry) 



maii)i:n n\mi- 

'M' MnTHKR 



niHTIIPl.Al-H 
<»F M(»THKR 
(Slat- iir C(nintry> 



0. ub ILrrUU^ 



-^ MEDICAL CERTIFICATE OF DEATH 

VrK OK DKATH ^ » 

(sinnth) (] 
1 H KK I- HV C 1- RTIFY, Th^ I ^tenad .Icccased from 

that I last saw h ^ — -«live on '^ 

a„a that a.-ath occurrea. on the aatc stated a!,ove. at 
M. The CAISI- OF DFATII was as follows: 

-r 



DIRATION >ew^ 

CONTRIBUTORY 



}fotiths 



Par 



Hours 






n I 






4 * 



Mofit/i^ 



Pays 



DURATION )V«« „ •"•'"" ■• "'""■ 

(SIGNED) iXw'bolL^^ "-•°- 



t, ft 



uxi. d 



it 






OCCUPATION 



a^ ^Ko^y^^"^^"^^ 



)'iiH 



M„iillf 



/hn 



rUH MKiVK STSTK!) fKRSONAl, rARTIcr I.ARS ARK TRVK T«' » "H 
Informant vj 



SPECIAL INFORMATION -'v far M^plUls. lnsUt«lto.s, Traflsle«ls. 
or RcTent Resldrnts. and persons <yH.9 av^ay from home. 



Formers 
Usual ResMcncf 

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



How loRf at 
Place of Deatli? 



Days 



,r\TK!> PKRSONAl, TAR rUl UA* 

Hl'.STiil MV KJ^)\VI.l'l)«".K AND IlKUKH 



J 



leC^\ yXt^^^-t' 



JM ACE OK m'RIAI. OR RKM<»VAI, 



I>A'\;i%'.f JU KiAt. or RKMOVAI, 



.d, 



INDKRTAKHR 

(Address 



%<vLUdLV'C« 



.^^^Vfr^V 



''"■^— — ■■-^^■^^^^■■■^^i— i^— ^•^■^''■'■■"'■■■'■■■'■^■'**'"'"*"'"** . RV4CTLY PHYSICIANS •honld 

N.il.^Bve.. Iten, of Information should b. ca.ef-Ur .«PP"--; ^^^^erlfri^SiterVh. ••Sp.cl.l Information^ for psr- 

•f te CAUSE OF DEATH In plain te-ms, that It may ^ f^^jf *' 

•ws dying .wny from home should be given In svery Instance. 



m 



1^ 









<• 



h 

) 1 



H 





11 





1 1 



I 1 » 
• I * 



•vf ff 



.^.iw.^ .MK THIS IS A PERMANENT RECORD 
WRITE PLAINLY WITH UNFADING INK — THIS IS A ft. 

Wn» ' «^ '^'- -,.».^«i.«. una INST 



SI 



REFER TO BA CK OF CERTIFi r^Tr FOR INSTRUCTIONS 

503 



Re^istcvecl JSTo, 



\\ \\ 



Bo.r.1 ot IIO.. IIK I N" '■■ ^'— -Z- 

3v>^vu> ^i'v^M Deputy Health Officer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of Bcatb 



J (3i\ 



^, , ^ ^ ^f n n -vsj n \ <x/w>C^4 CO City 
PLACE OF DEATH : — County of v O.^ ^^ 



rNo. Hll 




X'A 



1 1 






md Mi . v\ 



, . «... ;::^in^, -..- --^ rf ?I^^^" ;;"i ^ifi r,^" -^;-i^o =r ) 

V IF DC«' 



FULL NAME 



ri 1 4 A ^ I kk^yvx^. A^.^A^^^-^'^^ 



.i^^ 



A.cc^.MM^^^^'^^^^ 






PERSONAL AND STATISTICAL PARTICULARS 



MEDICAL CERTIFICATE OF DEATH 



\ 



SKX 



DATl-: 



A(.R 



. 



COl,oR \ 



(Month I 



U 



(Dnyt 



M.niths 



O 



(Vcarl 



A J I « 



Year' 



DATE nl^ DKATH (\ I ^ ^ 

(|onth^ ;\ ^->' ^ 

I UFrThW CKUTIFV,^ That I attcu-Wa aecea^ed from 

' L. Tnn. to >^vta. 



t. 



SlNt.l 1' N'.AKUlKn 

wiixiw I I) «»K i)ivuK(i-"n 

(Write ill '••Hiiil (U-<iii'ii:itii 111 ) 



}, 



BIRTH I'l.Nri-: 

'Stati' ot ("i rlllllt \ 



NAMl* Ml- 

FA'nn;k 



^a^ 






i^S-Li^ .190 

U Jl last saw h.^S^ alive on H^-^^ ^^ ^^^ 

,„.l that .Ualh .>courrea. on the .late stated al>ove, at ^ 
OL M. The CAISI- OV Dl-ATII %va< as follows: 



*c. 



^ 



jlO 



IX 



4. 



r(»H*"Tr»'*j'i^ 



Mil 




■ ^ 

fs- Anh am ic 



BIRTMI'l.x. i-- 

OF »-\iin.:H 

'Slrit. ni I'liiiiitrv 



MAIItl-N v\MH 
OF MdTIIMK 



niKTHlM.ArK 
"»• MOTIIKR 
(Stats- nr I'liuntry) 



tHCri'Ai'lON 

AV^n//- (/ iif S an J,anii.u'(> '^ )%uirs { .'Jf-'"/^' 

THK AUOVH STi^TKn PF.RSONAl. PARTirfUAKS ARJ-: TRlK 
Hl-.ST Ol' ?.tV RN'oWlJ'Di.K AND HKUKF 

(Informant NA/VWVMX; W <kXjLaX^^^^^''^ 

f Address H%*1 \^.!kAAA.">- 



IHRATION 
CONTIUIUTORV 



Vi-a/s 



dW' K 



.l/i7;////<r t) Days * //onr< 



kJL, 



DURATION 
(SIGNED) 



) cars 



Mouths 



Pars 



Hours 
M.D. 



■ ipr^lAL INFORMATION •»»'« l.r H«,lUh. l«slHu«.ls. If.«fc.ls. 
.r toflrt ««M«ls, and ptrsons dying a»ay from !.««. 



+ 



Ftwier or 
Usual Residence 

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



How lonfi at 
IHacc ol »"^'* 



Days 



r%AA 



PI,ACK OF m-RIAI, «)R KHMin-AU 



DATH'Ji' m RIAL or RIlMCiVAl, 

(Address UT t*» A — »-^*' 



:>v 



^^,^„^— ^M^M^^— ■ —— *"*'^^ I EXACTLY PHYSICIANS should 

N. B._Ev.„ ,„„ „, ,„.„.„«„„„ .hould b. c»r.»uM, .uppll.d. *°« '''^.'.^..T,,:" 'rh. ■•8p««.l lnfe™.t.on" lor p.r- 
•l««« CAUSE OH DEATH In plain term., that II may "* f^^ 



•late CAUSE OF DEATH In plain lirma. t"»> — i ....,, 

•■Ml* dyln* away from hom* .hould ba »lvtB la a.ary In.lancc. 





I ! 




y\: 






]{ 




i;i 



til 



W^ 




It 



X 



f 



N 



WRITE PLAINLY WITH UNFADING INK 




Da/ 1' rifcdf V^vu '^^^ 



lOO'i 



THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 

Jle enisle red ^^^^. 504 







DEPARTMENT OF PUBLIC HEALTH 

Ccvtificate of Scatb 

PLACE OF DEATH:-County of ^a>^. ivavvC..^-Gty of 



=City and County of San Francisco 



(No. 



1 

and 



M L ^- ^Ll^^ ^ VUAV'.' ' St.; ^*^***^ho FOR UNOCR "SPCCAU I N fOR MATIO N" ^ 

V ir Ot*TH OCCURRCO IN * HO»f»lt*LOR IN» ^ 



) 



■ 



FULL NAME 



u 



\jja.- 



PERSONAL AND STATISTICAL PARTICULARS 



SKX 






C()I,«>K 



DA'l'J-: til 1,1 R I'M 



A(.K 



J 



onth) 



) ■-•./ 



b 



3 

(Dayt 



r \t 

(Vc:ir» 




syjx^xi.%i-^^ 



w 



MEDICAL CERTIFICATE OF DEATH 



TQO 



iq 



Da v.v 



DATK or DKATIl A 

1 IIFKHBV CKR-nrV, That natemUMl.lcrcase.1 from 
. ,9oH to.4^tH. 3,A ic)oH 



^V\\a;v,. -Xv 



that I Inst saw h A alive on J^^^ '^^ '^O 



ill 






SINC.i,K MAKHIKH, 
WIlHiWMi OR niVoRi'Kn 
(Wrttt ill -1.. lal iU»ii$.'iiali')ii) 



C),<X^v 



Ll 



»i 



'State nr (■ntuiti y 



NAMH nr 
FATIIHR 



HlkTHJ'LAvK 
nr KATJIKK 
(Statf or Ctiutitrj''* 



maii»i;n namk 

<U" MuTHKR 



nfHIHIM.ACK 
"l- MOTHKR 
(Stale nr COuiitry^ 



OCCrrATKJN 

Rfsidfd hi Sav f'lapuhfn *" Vfan 







,„a that .U-ath <.ccurre.l, on the .late- .tatcl ahove. at 
' M. The CAISH t)l< DliATH was as follows 



w 



\J(l'\c\^«r 



Dr RAT ION 
CONTRIIU'TORY 



)Vc?r? Months 



Pars 



I loin 



s 



Yvats 



Monlhs 



.\fnllfh! 



n>i\. 



niK i^nnvH statkd prrsovat, rARTiof i-ar-^ ark TRt'K TO THK 



DIRATION 

(SIGNED) ^l^^lavUvD 
l^^i^. Ci:^ ,^H fA«hlress)3>5 00 



f^avs 



llour^ 

M.D. 



^clt. 



V e^\ « 



SsirliAL INFORMATION o»«v t«r Mt^ti^ l«tHutlo«s, TranslfRls, 
or RefeS Residents, and persons dying away from hoiie. 






Former or 
Usual Residence 

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



How lonq at 
Place of Deatk? 



... Days 



(111 for 



inrint 



^W' 



h^o^ 



J • 



f \»l«!rc!w ,. 



15 C) 



PI ACH OH m-RTAI, OR HHMOVAI, 



l>\TKof HiRiAL or RKMoVAI^, 

f\ 

T9O 



rNDKRT.^KHR 



'0^0-Ct'tW^^ 






(ona ' ^'» ^• 



N.B.— Every item of tnfopmtttlon •hould 

•tate CAUSE OF DEATH In plain »^....-, • •-- i^.t-nce 

•w» dying away ti-om horn* should be given in .v.ry in.tanc. 



■"■■^■'"■■"■■■"■"""'^''**"** . w • * <i RXACTLY. PHYSICIANS atieuld 

be c«.«f«liy •uppiicd. AGB f ''"//.^^Jf The -Special Information- for p.r- 
terrn., that it may He properly claa«ifie«. 




• I 



\\ 



I , 



• t 



i rl 




WRITE PLAINLY WITH UNFADING INR-THIS IS A PERMANENT RECORD 
^„„,,„.,„„.....,^S.H..c„ MPe. T O MC. or c»T.r.c>TC ro. .n.t.uct.on. 



I 



^w^ ix/v-vt Deputy Health Offlcer 



Begistered JVo. 



505 



VO-WVO os^^yv-vA ^^^.--^ -^ ^ 

DEPARTMENT OF PUBLIC HEALTII=City and County of San Francisco 



PLACE OF DEATH 



Certificate of Beatb 

( •a. S. StanDarD ) . 

« 4 






:-County of C^'aA^. i^^ouT^^c^A^^ty of ^a^v vixa licence 



(No. .1 1 1 



(1" 



.ry\? 



'^4 



ix^io 



a- St; 



Dist; bet. 



and 



.^it^ .JiV^i^^t -B^Hc-vcJ^^*^^ ;;;^^j; -JJ^i^S'^Jriir " ) 



i;:xt.^ic:u%rcV.;";"ti'.*.^*.t :;?:sf.?u^4';'^o.v77T; ...i .n.tcao o. .trcet and nu..cr. 

FULL NAME 




Xj mtx. 



PERSONAL AND STATISTICAL PARTICULARS 



si.x 



DATi: r»F UlRTH 



A<.K 




OL 



L 



COI.OR 



lO 1.0 . 



(Month> 



) V<: ' 



(Day) 



Months 



(Year) 



Pit 



MEDICAL CERTIFICATE OF DEATH 



DATE OF DEATH 




rpo 

(Year) 



rTlRR K BY T* K R T I FY, That I attendccl deceased from 

Wu-t iH 190H to .^|.^^^^ ^^ '90^ 

that I last saw h A^a. alive on »90 ' 

and that death occnrred. on the date stated alxjve. at 



SIN«,l,i;, MARRIED. 
WIDOWKD OR DIVORCED 
(Writi- in fscjcial desit^natioii) 



nik rnri.ACH 

(Stati or Cfiuntryl 



NAMK o|- 
FATHER 



Rlk IHJM.ACE 
OK FATHER 
(State or Country) 



m 



t>x 




M. The CALSK UF DliATII was as follows: 











.uj^UvtA^i 



MAIDEN NAME 
OF MOTHER 



BIRTHPUACE 
OF MOTHER 
(State or Country) 







n svr 



OCCUPATION 



ilW^ vli &vk 



DURATION ' >VaiJ * Mouths 
CONTR IIU-TOR Y Llc^wU. 



Days I ^ Hours 



DURATION 
(SIGNED 



* Yiars * Months 



)...Lld^kiuv^'^J dsX- 






/>rti'.? ' ^ Hours 
M.D. 



( Add rt ss ) ^^ o.v. v^wr^.^ v > 

OECIAL INFORMATION «•»* ^^ IN^^ lAi^M, TfMslMh, 



RfsidM /» Sati F) ant ism 



) Vi7 / t 



Mi»itfn 



/kn. 



THE ABOVE STATED PERSONAI, PAHTICF t.ARS ARE TRf E TO THE 
BEST OF MY KN(nvr,ED<".E AND HEUUCF 



( Informant 



j(nvr,ED<".E A> 



C^^W.QJWVsj 



(Afldre»<# 






or ReceBl ResMeiils, and persons dying away lro« 



II9W iMf it ,_ 

Plareof ikatli? i 



hys 



Wliei was disease cMt'f^^'OfyVm n ^O^mi ^-v^^ 

H wot at piaceoNeatN? M K<in.^| avcrti .\.:^%.^^. 



1a 






PLACE OF BlRIAt. OR REMoVAl, 
UNDERTAKER H^'^'^'^^ 




- ' „ . .pi .u«„M b« .tated EXACTLY. PHYSICIAN* ^Myld 

N. B.^ Bvepy Item of Information .hould be car.fully iiupplled. 'J^ '"'V ,„,j, yh, *'8pect«l Information*' for i»F- 

•tate CAUSE OF DEATH In plain term., that It may be property claMifW-. »- 

•ons dying away from home ahould be given In ovory Inatanc.. 




i« 



hi. 





\i\ 






WRITE PLAI 

Board -t ,l.,n Ub---FNo..^^€^^'>-'^>'^'> 



NLY WITH UNFADING INK-THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



lir 



J)(fft> Fi^ed, V^ 



Eeo^isfej'cd JSt^o, 



506 



l(^vci ' . Deputy Health Officer 

DEPARTMENT OF' PUBLIC HE AlTH=City and County of San Francisco 

Cettificate of 2)eatb 

( Xl. S. StanDarD ) 



(No, J ^ 



PLACE OF DEATH: — County of' CV^ 



:* 'a-.\' ova 



4 ^ 

City of CU ^ J 



!\ 



St. 



Dist.; bet. 



'va > 



and "~ 



V IF DCl 



) 



I'l) .1 ft '"^ 



FULL NAME 



/ 



v<X"*VC 



Ih 






PERSONAL AND STATISTICAL PARTICULARS 

..) X >^ ! C01,0R' 






u 



t Month) 



A<.)- 



}'.'<H 



(I>ayt 



L 



Vral 



n,r 



(Nliinth) T 



(Yt-ar) 



Wtli. \ ID «»K I>IVi iRiJ-:!) 
iUiitt in '-.K'ial (U—i^rnalifiu) 









!'1K IlllM.AfK 
"' lAIHKR 
istatr MT C.iutitry'> 



"I M'lTHKR 



<»l MoTHHR 
(Stiitc or Country) 



'►CCri'A'noN 

R^sidfii hi San f'l 










•t 



MEDICAL CERTIFICATE OF DEATH 

DATK OI- DKATH 

(Day) 

TTTrRI-HV CI':RTIFV, That I aHemlci «kHvasecl from 

,. JVw0.v XU 190 ^ UK %^'^ ^i 190 'i 

that I last saw h-t-' alive on —v '9° 

ati.l that «leath occurred, on the «iate state.! above, at 1 
CL M. The CAlSrC ni- DI^ATH was as follows: 



^ L "%•». 



I) r RAT ION Vt'ars .Vonths Days - Hours 

CONTRIBl'TORV \l iXoX-^ v< -^--wvis c - 

DURATION - y^'(^*'S 



(SIGNED) 



-Months % Pay^ * Hours 
Ql\ ^ Qf7lQAA^k<:^U' M.D. 






ail nfo 



Yra 



Mr.iitiv 



1 ! /V' 



Tin- \!!()VK ST^TKrM'KKsON^I. I'XHTICir.AK- Akl% TRIK TO THh 
liHhT 01 MY KNOwi.HlX.K AND ni:i.n;i' 



"'Iiif,,iii,j,nt 



sJTWa.^^-^< 



# 



fArldref»« 






\ 



SPECIAL INFORMATION ot^j »« HospKils, Inititatl^M. Tr«staih. 
or Recent Residents, and persons dying way from home. 



Former or 
Isual Residence 

When was disease contracted, 
If not at >tafe of death ? 



^taif at 
Bare of Death? 



Days 



PI \CK OF BlRIAt, OR RKMoVAI, 

"t*" " K * 



t NDl'RTAKKR 

(Addict*^ 








0\D 






t 



N. B. Every Item of Inform-tlon .houW be carefully .uppned. j ^ B • ^^ "Specl-I Inform.Uon" for p#r- 

•fte CAUSE OF DEATH In plain term., that It may he properly .l...lfl-. ^ 

•on* dylnft away from home .hould be 4lve« In -very liiataace. A 



i! 
If 

J 'I 



I 



^<!. 



I t 



1' i( 



i 




WRITE PLAINLY WITH UNFADING INK-THIS IS A PERMANENT RECORD 

REF ER TO BACK OF CERTIFICATE FOR INSTRUCTIONS ^ 




1 





190 "i 



Deputy Health Officer 



DEPARTMENT OfVuBLIC HEALTH=City and County of San Francisco 



PLACE OF DEATH: — County of O CX^x. JXO . 



Certificate of 2)eatb 

( 13. S. Stan&arO ) 

f ■ (^:^ J? '■■op 



,1 



n 



+ 



ei^ VU<Vii-U--av,^^ 



Tito 
I -r 1 - *, . Q* . 1 nut • bet. 3 X^w '.vw^-vx- and 

INO. V ^ W \:\\XXfn\i SJ JC\ „r=T;V,«rFV.WE r*CTS called roR under -'special .NrORMAT.ON • \ 

^^''* / „ OEATH OCCURS AWAV -OM USUAL J^ f^^^^, J^J^^^J ^1 VE Ts NAME INSTEAD O. STREET AND NUMBER. ) 

\ %f DEATH OCCURRED IN A HOSPITAL OR INSTlTUiu ^^ ^ 



) 



FULL NAME 



VCn"»X(XV 



<£>. ii... 



sKX 



I" * 



Ai.l 



PERSONAL AND STATISTICAL PARTICULARS 



Ifllcdx 



!;iK III 



\ 



L 



V 



) f <(» 



(Day) 



^V.ar) 



Ih: 1 H 



(YfMr) 



'ilNi.I !* MARRIKI*. 
\V!lM> > ! K (>|< l»!VnKri-:i> 

iW'riti- ill -(H'la! <li-^ik'iiati«»il) 



nik riUM, \i-I' 

(Stall ..T t'nuntrvi 



KAMI rtj 
FATin;K 




TUKTUn.Ai'K 
<M lArilKK 



MM|»i:s NAMJ- 
<»l MoTHl.K 



niRTniM.Ai'l", 
«»|. MiiTHKK 
ISUilc i»r CoHiUryi 



IHCITA riuN 




MEDICAL CERTIFICATE OF DEATH 

DATK oK DKATIl A ,| 

1 HKUI:HV CI-KTIFV, riiat, I atun<!ea (U(vasc.l from 

that I last saw h • alive on . »90 

aii.l that .U-ath .KTurred, on the .lati- statcl above, at 
M. The C.XrSl-: Ol- DliATII was as fol1«)Ws: 



a.^\S\^ S 



-^ 






DIRATION JV<7;v 

CONTKlin TORY 



.^foHth: 



fhivs 



I/ottfs 



^SAAJ^^y^'^'^ 









nr RATION >evix ^ JA»;/Mv I Am 

(SIGNED) ^VM^ v^ ^ ' -^ •■ * 



A 



^;,,^,f/^s 



Till- \H()\ F S-|\TI-I) I'KRSf>V^l, I'ARTIi-l'I.AK^i A R l*, TRfK T 
lU.sr OJ MY KNoWMUlC.K AND HHUIKK 



lh1\ 



O TIIH 






Hours 

M.D. 



SPECIAL Information 9") "■ n ?i.- . , 

or Recent Rcsidfnts. and persons dyinq away from home. 



Formfr or 
Usual Residence 

When was disease contracted. 

If not at ^m o f de atti ? ^_____ 

I'l.ACE <>1' m RIAI, <JK RHMOVAI. 



Hon long at 
Place of Deatli? 



Days 



(^^OL-^A. 



W|uguAj^fl^L^^^^' ^^ 



IlJ^rilof Ht'RlAl- or RKM«»VAI, 
V.U 190*1 



D 






INDHRTAKKR 

(Ad«lrf(«* 



VII \i 



vo vt 






4 



r 



■■——*"** * . ij ^ stated EXACTLY. PHYSICIANS riMMld 

N. B. ^Bvery Item of Informntlon .hould He cnr.fttHy RuppHeU. *''^ •^"'",.,,,||gj. Th« •*8pecl«l Information" for |»«i- 

•tpte CAUSE OP DEATH In pl«l« terms, that tt m»> »«^ f^^^"*'' ^'"•"'^^ 

•WIS dying Mway from homo •hould be given m evsry Instance. j 




\ •: 



♦ ' 




'♦I 



( ] 



,^ 




\\ 



n„a..h.l il...ltH »'N"-^ 

l)uh' Filed , 



WRITE PLAINLY WITH UNFADING INK-THIS IS A PERMANENT RECORD 

WCFER TO BACK OP CERTIFICATE FOR INSTRUCTIONS 

508 



e^IbhS^ H& I' Co 




0.5 



190H 



Registered JS'^o, 




'XjJ^sj.^ De^u*"^ Health Officer 

DEPARTMENT OFPUBLIC nEALTH=City and County of San Francisco 



PLACE OF DEATH:— County ofC'<X/v\j 



Certificate of ©eatb 

( la. S. Stan^ar^ ) 



"i 



> ) 



V.' 



City of C^^ '^ '^ '^ 



^ 



(W». 



A, IAa^ ^ 



■ \ 



I LoAx 



' . ' 



St.; 



Dist.; bet. 



and 



) 



^-<^-^^-H^ ^^ ^ . -re^NrrcVC fACTS*CALLCD rOR UNDER "SPtC.AL INroRMATION-\ 

/ ,r O^EATHrtoCCURS *W.y /ROM USUAL «CfjOf.NC^^^<;'^^^,;*';;| ?r;i,E INSTEAD Or STREET AND NU-.CR- J 



rEX-O^CC-uSrcV/N'^rHO^S^VT'lt o%^?^?fi?u%To^N^C^;ETTS NAME INSTEAD O. STREET AND NU-I 



FULL NAME 






0. 



SIA 



PERSONAL AND STATISTICAL PARTICULARS 

C<U,nR ^ i 



yvcci 



l).\i J III lURTII 









\(;i- 



\ < y,;u^ 



<1N<.! I- MARKlKtJ, 

WllH i\\ |;i) OK ntVOKCKI) 

iWntL 111 ^i>ii.il tUsii'naliiin) 



d 



XA-V 



I 

iDayi 



M,,„lli- 



SJU 



111 



/>,» 



MEDICAL CERTIFICATE OF DEATH 

DATK OF nHATIl : \ ll 

01iloiith> I 



(IJay^ (Yenr) 

I III:UI:HV CiVrTII'V, That I atunacd .Uneasca fnmi 



^W^'-r 



ICyO 



to 



1 



^ 




3.3. 



that I last saw h ■ aUve on ^^ ^^P 

ana that acath .Krcurrea, on the date statea alH.vc. at -» 
M The C\rSI': OF DliATII whs n% fo1lm%s: 



MIKTHlM.Ai'H 
fStulf nr Connliy 



fatui;r 



lURTlll'I.ACK 

'M' I \ riii: K 
'Sluu ..r CnHitry"* 



"1 MiiTHKR 



HIR 1 Ilt'LAiK 
'siti- .,r iNiuntiyi 



a 



i * * 



O o^j^^ V , V ct 



» 



g^VvrvvvouA 



\u da- 



.^uw^a ' 



Uw'^X ^x 



\1 I WO^^^ 



uL^-wtx^^v^L 



DIRATION >j^^'^ 

C()NTKIHrT()RV 

^ 

1 i . 



WC.-W^^*Vj ^' 



Months 



-•w 



k 






Hours 



\>Uk^sJ< S^v 



DIRATION 
(SIGNED 



Yt'iirs 



^fonihs Pavx 






Hours 
M.D. 



fAaart-^s) 



Kfsuli'if in .^nn /'i iin, i i •> 



> f if » < 



1 .%/,.Hffn 



I hi 



S^^IAL INFORMATION '•••v !«' "«#^ lirtMrtMS. TrjBslwts. 

or Recent Residrnts, and persons dying away from hMK. 

When was <He«e cwt»r«f ted, 
If not at place of death ? 



THK AHOVF. ST XTl'.n PKKSoXAl, J' \ KTIiT !,ARS ARH TRIK 
UKST oi- MV KNmWUKIx'.H AM) lU l.II'F 



Tt» THH 



vcx^ KX. CX< 



I'LACK nl'- niRlAL «»H KI'M"VAI, 
I NDKRTaLr "I rUnrVO.^ 



DAJl 



^.JU^ 



mitiAt. or RKMnVAI. 

%B 190H 



S.Mr. 



Q 



(Adtlrc*** 






^'"'^"■■■■^■^■■■^^^^HBiMi^^BaHBiBaaHaHiiHaM^^a^*^"!*'^*'^*"^^^^^*'^''^^^^^^ • FVACTLY PHYSICIANS «I|0MI<I 

N. B. Every ttem of Information .hould be tar.fulljr supplied. ^"^ •^°"'f_^'i"*%he 'Specl.i Inform. llo«" for p-r- 

•late CAUSE OF DEATH In plain terms, that It may bs properly wlaaslfied. 

•on. dylnft away from home should b« given In avary Instance. , 






( • 



1' 




II 



m 



I' 



1 



I' 




Ki' 






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

...^^ REFER TO BA CK OF CERTIFt r^ATt FOR INSTRUCTIONS 






jyo4 

d^w, ..^-u. Deputy Health Officer ^ 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 






Ccrtiticate of S^eatb 

( "d. S. Stan^arD ) 



i 1 

PLACE OF DEATH:— County of ^ Ct->v AaX. 



i I 



City of "^O^-^^ ^ ' "^CL vv C c. ^ 



UlSI., DCU ^ -sPCCAL/^NrORMATION- \ I 



,K . kY\^ \ c^ 1 nj^f-t>et '^^U-aCti^^H- and W/tL 



) 



FULL NAME 




M 



f. ' 



"C 



>wKOw..t . '. 



SK\ 



PERSONAL AND STATISTICAL PARTICULARS 

I COl.oR 



:v 



i)\ n 1 .1 I'.iR'rn 



A<,|-. 




11 



i 



5 I'll I * 



si\.,i ] MAKK!l-:i). 

i\Vtn> '11 "^JHMul <!» ssi.'!i;i!ii>n) 



niK i'HI'KACK 



F \TI11-.R 



HIK ruiM.AOK 
<>! lAIUHR 

isi;i),' .ir (.'mintrv") 



M MDl'N N"AMK 
<'l MoTIlKK 



HtRTHPI.ACK 

«t|- MnTHKR 
tSlaltj ur Country) 



«H CI rATlON 



A 






I Day) 



.!/,.»////* 



,AJl» 



(Vturl 



MEDICAL CERTIFICATE OF DEATH 



DATH Ol' DHATIl A ^ 



onth) T 



(Yfur) 



fHonth) 1 ">^'V' 

I UI'KI^HV CKUTIFV. That I attcii.Ua .Icrc asc.l from 



190 i 



^ 



'ki 



that I last saw h :• alive on V --v^ ,^i Icp ', 

a„.l that .Uath occurred, on the .late ^UWd above, at 
M. The CAl'Sh: Ol" in: ATM was as follows: 




S.0 



A 



t 



J 



in- RATION yrars 

CONTRIBL'TORV 



Months 



Days 



I /ours 



A 



Days 






W 



I ' I 



DURATION >''''^''-* Moulhs 

(SIGNED) y y U\l^.qj^_^ 

iLlu IX tcK^H (Address) ^ ^^ U CUv A . 



Hours 

M.D. 



^vclu ax tc^H (. 



mm. 



^■^IciAL mrORWATlON wlv tor H(H|i1U1s. lisUlarisns. Translfiih. 
or toTent Residents, and perwil <yta| «i«y «ro™ »»««• 



Residfi! hi Sntt Fran, />/'/> l> ^ '"^'^ ' ^ 



Mn>itlf 



fhn 



% 



rSUKRTAKKR 



TH1-: \novKST^TKn pkrsonai, pak rufi.ARs ark tkih tc thk 
nnsr m- mv kmowi.iux.k and hkuii.i- ^ 

C^.t.lre*. IDlH Mil* 



■■•^—^i-^^iii^^i— i— — — i— ^-^-■■■■'■'■■■■^^■^■'*''^*'''^*'*"^^"^'*'^^ I I l»- t ted EXACTLY. PHYSICIANS «H<Mld 

N. B.— Rve,.,. Item of Information .houlcl he cnr-fully •»PP»«'^?- ^^f^Hlj^^^iawifled! The •'Specliii Information- for par- 

.t.t« CAUSE OF DEATH In pl.l" term., that It mn^ ^^^^^''"^ * * 

monm dying away from home ahoald be given In every Inetance. 



Former or 
Usual Residence 

When m% disease contrarted, 
II not at place of death? 



Ho«^ lenq at 
n«reof Death? 



Oiys 



l>\TI<<>f III KiAl. i<r RKMOVAI, 



pi.ACK oi- iURiAi* «>H ri:m«»vai. 



190 



11 



* 






f! 










I' 



1 

I 

I- 




•*;■ 



"f 




WR.TE PLAINLY WITH UNrAD.NG IN^-TH.S .S A PERMANENT RECORD 

RCrCR TO Tl,.r«TI rOR IN»TRUCTION» 



^ m 



J)((/r Filed, NLl^: 



B&PCo 




WO'i 



Registered J^o. 



510 



I > 



\ m 



L aa 

i '^ ijilvu. D^P^^y Health Officer 

DEPAmENTol PUBLIC HEALTH=City and County of San Francisco 



(Xertiticate of ©eatb 

( "d. S. 5tan&ar& ) 




A 1 



:ity of Oa/>\^ 



%. -. 



PLACE OF DEATH: -County ofCa.v ^ ^XV>v^ULC. G 

FULL NAME ' k^'i^^^'^--' 



) 



SKX 



PERSONAL AND STATISTICAL PARTICULARS 

COI.OR 



m 



»n -I 



DA IK <>!• lUKTfl 



A<".K 




n ' f 



)VfT».< 



t 



(Day) 
M.tutfis 



(Year) 



Davs 



MEDICAL CERTIFICAT E OF DEA TH 

DATK OK DHATH 




(Day) 



(Year) 






S!\(,!.K„ MAKKIKI). n 

VVIDOWKI) OR DIVORCKD U 

(Wriuiu social <lesi»rnation) -^ 

n 

HIRTMPT.ACH 
(State or Comilry^ 



XAMK <ll- 
FATUKR 



BIRTHPLACE 
or lATHKR 

IStati- or Country) 



MAIDKN NAMK 
OF MOTIIKK 



RIRTHPUACK 
OF MOTHKR 
(State or Country'l 




FllKRHIVYC^rCRTlFV. TbatT^net^ed deceased from 

\X)^sJsi...^^ 190'^ to , |^^i.i|...a.^ 190H 

that I last saw h alive on |%^^ -^ ^- '90 

and that death occurred, on the date stated alK3ve, at I 
M. The CATSR UF DICATU was as follows: 

^ II 

1v^ ^ 






(D 



nr RATION years 

CONTRIBUTORY 



Mont/is 



Days 



/Jours 



OCCVPATION 



C^ 



aJux. 



.Ikl^^^v \0 all 



Months 



Pays 



DURATION years 

(SIGNED) 

l\■^, lt^ ' TQO ^ - ■ — 

■ tpCCIAL INFORMATION only lor Hospilals. Institutions, Transients, 
•r teTent RfsMents, ^ pwsw 4ying away from home. 



U<CL>v 



Hours 

M.D. 

1 



ii..\Ar..<.^ \%^^ \j.cL>^.\]La^A. 



C/ K^nnj^^^r^'^ 

l^esidfd in San riaunsrn 3k"l>>'^'^ '^ ^^"""' 



iHlVf 



Kendfa in >av /mui i sm ^ i 1 , •>■ — 

THK AROVK STATKD PKRSONAI, PARTlCll.AR"^ ARK TRl K 1<> » 
BEST OF MY KNOWI.KDC.K AND nKMKF 

(tt,fmmant "O X^XCUb UXoX^ 



Former or --t u 1 

Usual Residence i ^ ^ 



(;\ ^ 



. . 4 



Now long at 
nare if OetHi? 



I 1. * 



Bays 



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



PLACE OF BrRIAI.OR RKMnVAI. 






DATKof m-KtAi. or REMOVAL 



4 



190 



<S<h\ 



CduV^ ^-^ 



Iv* 



rNI.KRTAKER ^^aCvU^ ll>AjCt^N'* ' 
(Address 






■■^ t d EXACTLY PHYSICIANS shvuld 

N.1I.— Every Item of l„lo.n..tlo« .hould be c.r.fall^ .«PP"«^ J^Z^^'clmJ^i^ Vh« **8i-^«-' •"♦--•"-'-'' '^ •-^■ 
mtmU CAUSE OF DEATH l« pl-ln term., that It ma> »^ f^ J^ "^ 
MR* drini .way from ho— rt»o«ld Ix glv.n In .vry In.t.nc. 



ill' 




,i I 



.;i 




M 



I' » 





H 



WR.TE PLAINLY WITH UNrAD.NG .NK-TH.S IS A PERMANENT RECORD 

BEFEH TO BACK OF CERTirlCATt FOR INSTRUCTIONS 

»^ J 1 

, . „ -f r 1 / I kj #j,f' A' in f I / » ' I' w f >-'. 



Deputy Health Officer 



DEPARTMENT Ot PUBLIC HEALTH=City and County of San Francisco 






Cevtificate of S>catb 

( tl. S. StanC»ar? ) 



rNo. 



PLACE OF DEATH: — County of' 0.^ - ^^ 

St; S 



/ „ 



(ir DEATH OCCURS 
ir OCATM occu 



City of 






and 



M.; I t^lSI., DCU ,,^o-- "SPCCIAL INrORMATION- \ 



) 



FULL NAME 



.■\JjiA 



,Vl 



PERSONAL AND STATISTICAL PARTICULARS 



Nl, 








o 



COl.oR \ 



1 1 



DATK tt! lilKTII 






A'.F. 



tj ^ JV,r»5 



iDavl 



M.nil/i 



(Year) 



Ihiv. 



MEDICAL CERTIFICATE OF DEATH 



[)ATK oi^ I>l^^■^l A I 



11 

(Day) 



(Yt-ar^ 



%\ III. lU l.n Ok I)lVnK*l-'. I> 
'\ ". ill vtK'ial il("ii|,'iiali<>ii) 



I HKKHBV CHRTIFV, That I atten.lcl dercascl from 
^J ., .,A..A. 190 H 19 i vwU^ ^^ ^ 190 H 

that I last saw h - ahvc on V ^ 

a„a that .Uath occurred, cm the .late .tat..l aV»ovc, at 
M. The CAlSr-: <)1' HI'.ATH was as follows: 



iStnti 1,1 r.nintryi 



NAMl* Of- 
\ \ niKK 



(MR rUPI.XOK 
01 IM'IIKR 

'still, i.r Coiiiitryl 



MMIU'X NAMJ: 
<i|- MoTllKK 



lUKTllPl.ACK 
01 NioTllKR 
(Slate or Country^ 



I \j^\J^' 






I 



LCr^v^O. 



"NX 1^ 






u 






T,rRATION - )V.;. Months - /^.n^XH /A.... 



f 



DURATION 
(SIGNED 



Yciirs 



Months 






/hlVS 



Hours 
M.D. 



^ 



<h:ci TATlUN 




" 'Lpri-.a. iNrORMATION only for Hospitals Institutions, Transients 
©r feteSleside~nts and persons dying away trom Home. 



Vi 



Ke$idfii in San 1-^ an, nfo 



) Vr(» 



\rnulfl- 



/hn 



HJ- \1U>VKST\T1<I>1'HRS<.N-A1. rXRTU-tl,\RS ARHTKIK T' > I'Hh 
HKST OF MY KisM)\Vl.KDOK A^n HKI.n.I' 



Former or 
Usual Residence 

When was disease fWtrieW, 
II not at place of deatli ? 



Now long at 
nife»l Oealh? 



Iiys 



(111 fin ma 111 




^ >fr-^^fWVW> 



^ 






ft' 



( \<l(lrp«i<* 



Ui 



?. 



i H 

.' c e Lis 



PI \CK Oh- lit RIAJ. t»K RI:MoVAI. 



ivwtM - ^ T90H 






(AdarcH^ 



I 



■^■•^■^^■^^^^^■■^■■^■■^^iiMi"^^^^"".^"'**''^'"''''"^*'"**'^'"^^*"^^"'*^^ I fXAGTLY. physicians showW 

ft. B.— Every Item of Information .houW ba carefully .uppH.a. ^^^^^;,y"^,*,1,^fi;i!*%^ "Special information" for par- 

•t.te CAUSE OF DEATH In plain term., that .t mny h« pr^*;''' 

•«n« dying away from home «ho«ld be glv*" •" -^W I"***"**' 



II' • 



|i 






J :t 



i-f 



I 



..^ 



WRITE PLAINLY WITH UNFADING INK 

■. „„l„fll.,.M.,-N'o. l^*^^'"^'"--" 

'buI. Filed, UL a^ 1^0\ 



THIS IS A PERMANENT RECORD 

RCFER TO B ACK OF CgWTirtCATC FOR INST RUCTIONS 

Registered JSTo, DXiw 



fc., I "» ^ « ifr «. 



DEPARTMENT OpipUBUC HEALTII=City and County of San Francisco 



Certificate of Beatb 

( TH. S. StanOarD ) 



(Wo. ^W 



PLACE OF DEATH:— County 









cx-^v^ev.: 



»l« U8I 



St.; 



Dist4 bctr 



and 



) 



4 V ^ , w^x. V- M _ ,. .. _ ^Vk ^t.; *^"*** "^.1- .«• UMom "«PCCIAL INrOHMATIOH" \ 



FULL NAME 





.IU.VC 



,i 



I 111. It 



i| 






SKX 



DMK «H HIRTII 



At.i-; 



PERSONAL AND STATISTICAL PA RJMCULARS 

COI,OR ^ 




<X 



LI 



(Month) 



\: 



J 'rn » * 



(Day) 



yfnnlhf 



(Year) 



MEDICAL CERTIFICATE OF DEATH 

DATK OH DKATH A 



(Month) 



11 
(Day) 



(Year) 



Aj > v 



SINC.I.K. MARKIKD 
WIDOWHD OR DIYoKcKD 
(Writ.- in s«»cial desiKiialioii) 



ncv-vali 






0, 



lUKTHPI.ACK 
(Stale or Country) 



NAMK OF 

FATMI-.R 



RIK TMI'l.ACK 
OF FATHKR 
'Stnte or Country) 



MMUKN NAMK 
OF MOTIIKR 



lUKTIIIM.ACK 
OF MOTHER 
(State or Country) 



h 



% 



TO 



JUrlKX.A.\<X' ' ' ■ 



fTnFRHBYTnRT^^ I attendea .leccascd from 

i :— ..190— to - r::^^ ^ ::nr:.nrr^.l90 " 

that I last saw h a live on ■■ "*^ 

an<l that <kath occurred, on the date stated alK>ve, at 
M. The CAT'SR OK DHATH was as follows: 



.\ 

DURATION »<"'^ 

CONTRIBUTORY 



Mdyiths 



Days 



Hours 



OCCl'FATION J I 




DURATION 

(SIGNED) 



Years 



Kw 



L 



Rfsidfd iM San f'lamm-it 



Miinfln 



Davi 



Kfsiara IN .>«?« r tit lit I 'I" -^ ^^■^__^^— —— — ^— ^ 

THK ABOVE STAT KD T>F.R^<»NA1. I'ARTICfT, \RH ARK TRIK TO THK 
MRST OF MY KNO\VI,f:D('.K AND HKI^JKH 



Months Days Hours 

XK.^'^^l'O.ijlLx.vvdL M.D. 

^preiAL INFORMATION only lor Hos^Uls. LstltgUon^. fraslerts, 
•r lecart tesMcuts, M< perstis <yiiu i»*y h«» k^- 

UsMlResMeiice ^^ ^ ..a 
Wkni WIS <!««« ctiifraclii. 



PLACE OF BIRIAUOR RKMoVAI. 



rifclAL INF 



(Informant 






'V 



ft <*»'> 







"V%J 



DATE of BUKiAi, or RKMOVAI, 



190 



rSDKRTAKKR 

(Ad.lresK 



S.1H o.t^^V^iA>x 



_ _ . I EXACTLY. PHYSICIANS sIimiM 

N. S.-.BVC., Iten. of l„form.tlo» .hould be c.n.f«ll. .«PP"ed^ p^o^^H^Tl. jT^a. TKc -Sp-I-I l«»— *«-" to. ^r- 
•tatc CAUSE OF DEATH In pl.t« term., th.t It m.y ^ P^^ ^ 



i 



'!!« 



[I'l 



11 



I l|( 

I 

' 'I 

^' If 



*l 



,1 



I 



I 



^! 



WRITE PLAINLY W.TH UNFADING INK-THIS IS A PERMANENT RECORD 

^^ ,.r rp TO BACK OF CEBTIFICATE FOR INSTRUCTIONa 
.■■.,., in, I- N-.v.^t^^'"^ ■''-•" . — ' KA O I 

^nnu Rpsiifitevecl JVo. 'J J 'J 

])(t!i' Filnf, ^K^Lu 'as 



190 "i 
1^1 vu Deputy Health Officer 




DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 




.LJ^^\ 



^p 



rNo. ^H?5"l (!l)a.V\^ir.\ 



Certificate of 2)eatb 

( m. S. StanOarO ) . 

City of ' ' Ct^v 0XO.>vac<tCc 



PLACE OF DEATH:-County of^V^ ^1 \a>VC^ City 

Dist.; bet. -^ ^ 

vc 

(\ 



and >•* -^ 



) 



^^•» l^'iaW "i^Xr, roR UNDER "SPECIAL I NrOWUdATlOW '\ 



I i 



FULL NAME 



IXr^^J^ ai.cq- ' -' -^ 



4- 



•!*S 



PERSONAL AND STATISTICAL PARTICULARS 

i ctil.«»R 



jTlcvU 



LO' + 



1»A 11 <•! lilK I'll 



7". 



i Month' 



\|.) 



»iIN«.l,H. MAKKIKH. 

WiHi in -..Mia] ill >.ij^ti;iliitni 



luk rin'i.\^*K 
>;,ii. ..T i.nintry) 



(Day 



M.>ti//is 



»'t ai 



/hi 



MEDICAL CERTIFICATE OF DEATH 






J» iA. 



lYt-ari 




.O^UvU-^ 







lit 



ttl 

a 



HM IlKR 



BIK THPl.ACK 
<M I AT1IKR 

•'I ttr .,r rtmntry) 



MMliKN NAMK 

u! mothkr 



niRTHPI.S( H 
OF MiJTHKK 
istnli- nr C<»»unry> 



\ \ v.. 



(>^Htlhl j 'f^"^^ 

7l UKRHHV C1:RTIFY, That lattcmUMl.Urcasc.l fnmi 

that I last saw h :• ^ alive on ^^^^^H " - ^^ 19O ^ 

ana that .loath .occurred, on the aatc statol alK.ve, at 
M. The CAISH OF IH-ATII \v,«s as follows 







i 



Dr RATION • >>«« 
CONTRinrTORV 



Months 



Pars 



Hour^ 



YX/r^X 



^.j 




nr RAT ION 



Years 



yfofUbs 



(SIGNED) K ^'-C^ 



I w 



SPECIAL 



TOO 



H (Athlress) H3ib 



/hivs 






Hours 

M.D. 







(*'% s 



o^'rri'ATioN 



Kf iihii in San I'liti 



JV.n 



* ^r„nflr 



lh< 



T«» THH 



SPECIAL iNrORMATION •«»* »or Hospitals liislMitlMS, Triwleih. 
tr Itwirt ItesMeits, iN perwds <lyN wv ^•w **^- 



f ormfT or 
Usual ResMencc 

Wlien was disease contractei. 
If nol at \^t ol death ? 



rtottcf Death? 



IMys 



/I 

f Af1«lre<*« 



IMACEOH B1R1A..OR KKMOVU. I I.A-|l-..f »,».*.. .. KKMOVM, 



Tin MUJVF. !sT\TFU I'KRsONAI, V \R T U'!' !,ARS ARK «'Rl * 
liK>Ti»I MV KNUSVMax.K AND lUlUlKF 



N. B.— Every Item of Information ••««« be .•.'•f-Hy f««»^»'«t ^^—^^"ll^.Steif 'tI^'^-^S^^ Information" for pr- 
•fte CAUSE OF DEATH In plain term., that It mny »^ ^^^f '^ 



(AiMk-.^.^ 



in I I i\,w*<-r.\ 



i' - 



y ! 



^t« 




ii», 



I ' 



.( 



i »' Ml 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

„...., .f ncalth-l NO u i^^^H&PCo REFER TO BACK OF CERTinCATE FOR INSTRUCTIONS 



h 





11 



'it 



1)((f(' Filed, 



Eegistcved J\'*o, 






a^ 100^ , 

Xaa^u Deputy Health Officer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



C'AA.U) 



Certificate of Death 



( "CI. S. StanOarD ) 



PLACE OF DEATH:— County of 



^ 






St 



R 



Dist.:bct. >J VWK 



and 



Id ^ 



f ir Dr*TH OCCURS *w*v from USUAL RESIDENCE give facts callcd for undcr "special information- "V 

( Tr DEATH occurred IN A HOSPITAL OR INSTITUTION OIVC ITS NAME INSTEAD OF STREET AND NUMBER. J 



FULL NAME 






>i \ 



PERSONAL AND STATISTICAL PARTICULARS 

COI.OR \ ,, ] 



i •.! IIIRTII 



L' I , f . 



/ w 



'MmiHIO 



AOH 



IpS >>./»> 



il»ay^ 



Moulfr 



fVenr) 



Day. 



*ilv<.l,K MARKIKH. 



lUKTHPI.Ai'K 

<l.i!t III (.'iiuiurv) 



f A rUHR 



P.lRTHr>I.A<'K 

•»r I \riiKK 
^.', i!i I)! i'oiiiitr%') 



M^mi.X NAMK 



JHRTHPI.ACK 
<ir MOTHKR 
(Ht:u. ,,r Counliyi 



uJL^-w* 




MEDICAL CERTIFICATE OF DEATH 

DATK i>l' I)1:ATH 



ft 

1 



(Month) 

4+- 



1 



( \)\K\ 



(YfMTt 




I JIERICHV CI;RTIFV, That I .iltemlo.! .kccasoa frutn 
U 190H to WUt. ^-^ i*pH 

that 1 last saw h -^^ alive on i - -^ - -^ 190 

atnl that «U-atli (Kcurreil, on the <late stated mIhivc, at 
M. Thc^CAlSK Ol' l)i:.\TH was as follnws 




't*i't I'ATiox A 



\XX^ 



^r\r% 



Rfshtftf f» San Fi atii isfo 



H t 



) 'I'ii > 



\f,n,lh' 



Ihir 



TUT* MIOVK ST^TKI) PFRmiNAI, I-ARTIi-fLAks ARK TRt K T< > THK 
Hi:sr tu MV KNt)\VI.i:i)<.K A?.I» HHI.IKK 



(a : J. -^ 



fA.icittss i'X'XH ^^-^^^C^rX-0^'VwiX/> 



I)i; RATION " Vear.^ 
CONTRIIU'TORV 



Wcr|V\.,w V 



.youths 1 Davs ' Hours 



DURATION Years .Uonths /)ars 

(SIGNED) Llt|c\X<i^Mfl H^CtuU^k' 
^U^lu ?.% Tcjo (A<hlress) ..vvd^li 



//i>ur<i 

M.D. 



SPECIAL INFORMATION oily for HnMWs, InsmyHods, TrmsleMs, 
•r fieceit i^^eiits, «iid persons dyini iw«> from liMie. 



Formfr or 
VsMil ResMf Me 

IWifn w«« disease contr«te<. 
If not at place of deiHi ? 






Uf% 



PI,4CB OF BT'RIAt, C)R RKMuVAI. 

A , T . 



I)AT>:of IlfKiAL or RKSI<»VAI. 



► VA^4m 



190 



(AU,lr.H^ ^a \) ^^^^ QXjU.^ d 



N. B.-^very Item of Information .ImuM be ci.r,fttllr •upplled. AGB .hould b* .tated BXACTLY. PHVSICIAN8 •boi.M 
state CAUSE OP DEATH In plain terms, that It may be propeply eiaaalflcd. The Special Informatloa ¥«< par- 
«•»«• dylai away fiH>m horn* ahould be tlvcn In mvmry Instance. 










i I 



i 



: I 



i 



1 



II 




t 1 ! 



M 



i\ 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

IS Ml f ircMith-l No i^ ^.^g^H&l'Co REFER TO BACK OF CERTmCATE FOR INSTRUCTIONS 



! 1 




I)afe Filed y 

i 



.^.lu as 



fi 



0-vcc^ 




X>1. 



1 



190'i 

Deputy Health Officer 



Begistered ^^a 



515 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of 2)eatb 

( "a. S. StanOacO ) 



PLACE OF DEATH:— County ofC'a^v ^l\a^xc^.c City of'^^C^v 0.'vct>vc.ci r 



NJi^tk 



<X\,U 






St. 



Dist.:bct. 



and 



/ ir DEATH OCCURS AWAV FROM USUAL RESIDENCE GIVr FACTS CALLED FOR UNDER "SPECIAL INFORMATION" \ 
v. IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER ) 

FULL NAME u..A.a:^\^ JMrh.^v4.c > .. 



PERSONAL AND STATISTICAL PARTICULARS 



si:\ 



DA IK oi I5IKTU 




a 



L 



COI,OR 



N 



\ 



w V 



(Month) 



At'.K 



oJA -5 I y.uu> 



(Dav) 



Months 



/.is 3... 

(Year) 



MEDICAL CERTIFICATE OF DEATH 
DATE OF DKATH 



^Nlonth) r 



K 

<Day) 



(Yt-nr) 



Da vs 



•^INf'.l.l'. MAKRIKI). 
W'lDnUKl) OK IMVORiKr) 
iNViilfiu social ik-sii-iwilioii) 



niRTHl'I.At'K 

!St;it,- or r.iuiili \- 



N\Mj- m." 

HATHKK 



HlkTHIM.ACF, 

OF lATHKR 

I mat. or Couiitrv) 



MAIMIIN NAMi-' 
OF MOTHFR 



IHR rni'LACF 
(Slate or Couiitrv 



UCCfPATioN JP 



LUvk> 



"W^^^vr>Aj 






i IIRRHHY CI-RTIFV, That I alttii.ltMl .K-, i ascl fmiu 

■ —I go - — to ■ ■■ ■ " .iQO 

that I last saw h • alive on — :, -,-—.'■ ~~~— iqo - 

and that death occurred, on the ilate stated abnvc, at - — — — 
•^ M. The CArSI- OF DI-ATII was as follows: 

LLf:.'t:^£L<^.vt.ou.>- ^ 



t . 






or RATION Years 

CONTRIIUTORV 



Months 



lyays 



Hours 






DURATION 

(SIGNED) 

A ' 



^ }'iuirs _ .yfoulhs 




I^avs 



\\ 



Vc 



cL 



(U 



Hours 

M.D. 



i] 



i t/O 



^ 



^''*^?'f!*-.*'^5'°"'^'^^'ON only lor Hospitals, Instltntloiis. Translfnh, 
or Rfcfnt Residents, and persons dying away from home. 



"■ ) Vi7 I S 



- Mitilhs 



- Da vf 



»».M OI' M\ KN'U\VI,HI)(-,K AM) ni:i.ij.;F 



f Inforiiiant 



r*W^-\%X^\,4 



1 1 



fAc1«lre».s 



former or 
Usual Residence 

#hen WIS disease contracted 
If not at plar f of deatti ? 



How ItiKi iH 



Dirs 



Pt^ACK OF lURIAr. OR RHMmVAI, j DA H- of », h,ai. or RKMOVAI, 



'^^-^H ' " 




TooH 






(AtldretiH 



N. B. ^;Y/^J**"» «» «"»^^^^ b« «r,fully •uppllcU. AGB .hould b. .ft«d EXACTLY. PHYSICIAMR .ho«ld 

••^rdvfJi L^r f^«I '*i!!^",JY'"*: *''•! " •"■*' *^ P-«Pcrty classified. Th. "Sp^:!.! |„form.tlo«- for p,r- 

«wis a>ing away from hom« should be given In svafy Instance. 



• 



1^ 




♦I* 



r 



«(>' 



ni 




ui 



J 



ril 

I 
I , 



II 



WRITE PLAINLY WITH UNFADING INK — 



Boat.l ..f llcalth-F No. \^ tb^^H&P Co 




THIS IS A PERMANENT RECORD 

R EFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 

516 



Jtegisfcred JVo. 



TXilp Fih-il, VJLu 3.?> l^OH 

SI (1 41 
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Certificate of 2)eatb 

( TH. S. Stan&ar& ) 
PLACE OF DEATH:— County of ^X/w J Xa>\euccCity of ^ O-^^^ J Va>vCL4.a<i 



No. nol'J.CLeJU^ St.; 1 Dist.;bct. si ac^^' ^"^ 1^ 

/ IF DE*TH OCCURS AWAY FROM USUAL RESIDENCE GIVE FACTS CALLED FOR UN*ER «PtC.»L « « ^O"***^'^ N" ) 
( IF DE*T^ OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAoJor STREET AND NUMBER) J 



FULL NAME 



^^XXXXX. 



ti O "V ^ ■ ^^' <^'^ v^XouXv 



'^I'.X 



PERSONAL AND STATISTICAL PARTICULARS 



IJATK «»|. lUKTU 



/I^H 



Mnnth) 



ACK 



CL 



4 



k '; )',•,! I 



(I):iv) 



M.>t,ll,^ 



\ > ;ir ) 



/)</! 



-iV'.i.K. MAkun;i). 
u rin»\vj:i) OK DivoKrKD 
NVr >. Ml -orial (k-siyn;iti<>n) 



lUKTllI'I.Ai*!-; 

'Sl:itr or I'mnilr yi 



(k 



oj\k.kaA. 



-L 



X' 



'> 



V\M1-: CM- 

1 \ I hi:r 



HIRTHl'l, \(K 
Of- FAT! IKK 
IStati fir Couiitrv) 



M M I ) »■; \ N A M K 
<»I' MorilKR 



HIHTMIM.ACK 

«'! ^^<>rH^:K 



"Ccri'A'riuN- 'V', 



n[ I L^4X4 



^ 



MCOICALCCRTIFICATE OF DEATH 

DATH OI- DKATH A ^ 

(MontlO 



\lULc4 



(Pay) 



(Ytar) 



I HKRiaiV C1':RTIFV. Thai I atteinkMl <k( . M^rd from 

190 H 
190 H 



..>D. . . 'J^'X 190 '1 ^^'/v Tt^^ '^^ 

that I last saw h -.. alive on T^-AXu^ XI 

and that »U'ath orciirred, on the date stated abcn-c, at a,V.»^^l 

.jCj " M. The CATSK OF DHATII was as follows: 



ni* RAT ION 



UXh^WV<3L%Xt 



lO. 



I ^^ H I 



M 



i 



n 



/s'rsiiifii III Siiv f'ltui: 



1 4x^n-x<x.^"wu 



) , „■ ; •• 



l/.'/z/zV 



//iJ !J 



THH AllOVK HT^TKT) l'HKS<»NM. I'ARTH"I-|,ARH ARK rRTK TO TllK 
HKHT OK Hi' KNOW I,»:iK,l-: AND III" t, IK I* 



(inf. 



"unnnt '\,^\.**^*Wv 



4* 



dUv^x C%**^n,^ 



f \.l.Il.-H»« 



(1 



rs A 



M 



4 



■^ 



CONTK IHl'TORV M i AAAJlXvi\JjL' y.«4.?iu^^ 



Years Moni/is 

}'iiifs Afont/is 

(SIGNED) ^K^X^^rs^l^ ^A^.' 



Pavs 



/fonts 



DURATION 



fhiy 



t 



VwIh ^x tqo (A<idress) ^ lb M jla*wk,Jj 



»^\ 



Hours 

M.D. 



SPECIAL Information ••»«y »or Hospit«i$. iRstitatiMs, iriwietts, 

or Recert Residents, and persons dying anay from Nme. 



Ferniff or 
Usual Rrsidence 

II^R was disease contracted. 
If not at place of death? 



How IwMi at 
Ptareef Deatk? 



Days 



ri.ACK OK IMKIAI. <iR KKMoVM. 

♦ 1 



iLlL ^t ^ 



OATH of lit KtAt. or KKMOVAI, 



H^.,u. 



.^H 



T9oH 



,^ 



rNliKKTAKi:R V - K^^CCi^^ < -^^^lA-^W^ 



(Adt!r»«s«» 



^$ 1 I r\w4^.we'Tx 



N, B.«Hlv«py n«„ of infoi^atlon •hould be cBrefully aupplUd. ACB •hould b« stated RXAGTLY. PHYSICIANS should 
•tet« CAUSe OP DEATH In platn t«i*ms. that It m«> he ppoperly claaslfted. The **«pmilal Information'* for |>er- 
•♦»»!« dying away frcNn home nhmild be Atven In every inetance* 




J. 





M 



I 1 







l»*^ 



h 



Pohh! of HcHlth— F No. is 



ZJ/^/Y^ Filed, 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

WtFEW TO BACK OP CgRTiriCATC rOR INSTRUCTIONS 

517 



n&FCo 



Eegistered J^o, 



as i^^H 

Deputy Health Officer 

DEPARTMENT Ot PUBLIC IIEALTH=City and County of San Francisco 



PLACE OF DEATHS— County 



Certificate ot Death 

( Tfl. S. Stan^a^^ ) 
of Lutou^XiL<LDu . Gty of V.' ClI%X' 






^ 



fWo. '\nrvcLL^vcJL, 





L 



XUwCU 



St4 



Dist;bct. 



and 



) 



/ ,» »*ATi« oeeuVm awav tnom USUAL RtSIOtNCC OiVl r»CT8 c»LLCO 90m UMOCW "•#tCUL iNroiiMaTiOM- \ 

( .Vit^THScJ^lTtO .rrMO.'"*!: 0« .N.T.TUT.ON G.Vt .T. NAME .N.TfO Or .TPCrT AND NUM..M. 7 

LLILiAt k:^ ' ' ■ 



FULL NAME 



PERSONAL AND STATISTICAL^ARTICULARS^ 

ir ~ 



DATK OF UlRTH 



COI,OR 



\ 




(Day) 



AOR 



> V<7 ; . 



?> 



ytnuth^ 



/. u.\.. 

(Vear) 



Af vs 



SINOl.R. MARRIED. 
WIDOWRD OR DIVORCKD 
(Write ill social clesiKimtion) 



niRTHFI.ACR 
(State or Coiiijtr>'^ 



NAMH OF 
FATHRR 



BTRTHPI^ACK 
OK T-ATHKR 
(State or Country) 



MAIDRN NAMi: 
OF MOTHKR 



BIRTHPLACE 
OF MOTHER 
(State or Country) 



ux/>xa)U 

h 1 

1 



.f»^ P h 



\<3L/W^a^ 



OCCUPATION 




R fsided itt San Fiamisfo I t> )W; ».« •" y/onths «^ /)<n> 

THE ABOVE STATED FKRHONAI. FAKTICFI.ARH ARE TRIE TO THE 
BEST OF MY K!^0\VI.):d<;E and Hia.lKF 



(Infnrmnnt 



i\M 




rew 



lus Vma^Ltv ^-^ 



MEDICAL CERTIFICATE OF DEATH 



DATE OF DEATH 



i 



I HEREBY C 



[Month) 



(Day) 



790% 

(Year) 



?.RTIFy, That I atteinle«1 deceased from 

I9O to igo;nrnr-- 

that 1 last saw h -alive on -^- ^ 190. ■■:;^^ 



atifl that death occurred, on the date stated above, at -^"-••— --^^ 



M. The CAUSE OF DEATH was as follows 



\.L.fitLJ^.....w.^- 

DURATION Years 

CONTRIBUTORY 



Afflttths 



Pays 



Hours 



Days Hours 



DURATION Years Afonths 

(Signed) . \a 1^x44 J. oo-M^^.x-vk.. ' IW.D. 

l^tJUyaX iQo'i (Address) V Cwk.Lcu\v<L V ' 

^PEdUL INFORMATION ••»> f»r Htspltils, ImOHMms, Tmsteiitsi 
•r Recnt ResMeflts, aii4 ptmn ^\9% away from \wm. 



.cn\ 



U«ialllesM«Kell Vn5 

When was disease c«atractN, 
If Mtatplaceafdeatk? 



Haw tM| ^ 
Plartaf teatk? 



lays 



PI^ACEOF BIRIAI. OR REM(>VAI. 




D.\yEof, Bl-RIAL or REMOVAI, 



"H ^ ^ 



U 



UNDERTAKER 

(AddrcH^ 






i^ 



N, B. Bv.Fy Item off liiffofmntloH .liould Im caraffully aupiMlcd. AOB ttlioyld b* •t«t«d BXACTLY. IWY8IGIANS 9^mm%4 

•tatc CAUSE OF DEATH In pl»lii MMM, that It may be ppofxHy elM^totf. The * Special Information ' for par- 
a«m« dying ai^jr from home ehould be Alven in every Inotanc*. 



. f 



) 



ti 




|if 



,* 




^ ^ 




I 



I 



Bonr.l of Health— F No. \^ 




WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

„apcn mrew to back of cewTiric»Tc row instwuction* 

Registered ^o. 5jLB 



Dale Filed , UaXu, 1 i : ■ • 190'\ 

ifrwJliL, Deputy Health Officer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certiffcate of Death 

( TU. S. Stan&ar& ) 

\ % A 'Oil 



TLACE OF DEATH:— County of ^J<X^^AXXm>C4Ae(iGty of ^Ojy\j 



vC-\-4<: t 



(No.'Jj/CLu CV O/CUYU iMkmjtAJL.ZJ:. SU Dlst>;bct> 



'^od 



') 



.t;';;c^urs .vTaTTrom usual «c8iDtNcco.v.rACT.cA^ti^eo "OT^u^N^o^j i^r^^i^i^TN^rir;"" ) 



A / iIr DEATH OCCURS AWAT FROM WWWi«w n c *»• w«. .-.■«»-.-■- ZTmi^r ..T.vv.n Ar ■▼■rrv AM 

C niVoEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD Of STUECT AN 

"^ ft (V^ I 



FULL NAME ^-^ 




PERSONAL AND STATISTICAL PARTICULARS 

I COI.UR 




DATE OF UIRTH 



Ul.t. 



Vu^Jk 



(Month) 



A<-.K 



C0l>t 11 )V«,5 



(Day) 



.\/,it,f/ts 



(Year) 



/)<! I .s 



NiN'.l.K. MARKIKD. 
WIUOWKn OR DIYOKCF.n 
(Writtf in (mcial ile.<«i|;iiation) 



k 



UlRTHPLACR 
! State or Comitrj-) 






N'AMK OF 
FATHKR 




vvJK.'^ ^ I 



niRTHPl,ACE 
OK FATHKR 
(State or Country) 



»i 



MAIUKN NAME 
OK MOTHKR 



niRTM PLACE 
<U MOTHER 
"^t.iif or Cotintry) 



OCCUPATION 






Resided in Sati I-'i a»i isi'n 



) ><T » .« 



A/fiiifiis 



Pa vf^ 



THF. ABOVE STATKP PFRSONAI. rARTfOt'LARH ARK TRIE TO THE 
BEST OF MY ^NOWI.KDCK ANI> IlKIJKK 



(Arid rex* 



MEDICAL CERTIFICATE OF DEATH 



DATE OF DEATH 



Conth) 



L 



I 



If 
(Day) 



(Ycnr) 



I HEREBY CKRTIFY, That I attencleil deceased from 

„..„■■■ .....■■■.....■ .. .igo— to ~ 190 —r^ 

that I last saw h-^^^^^^alive on -•■ ■•■- - 190 ~^^ 



and that death occurred, on the date stated above, at - 
— — M. The CArSH OF PUATH was as follows: 




.^A.*or>^ 4'v.c • ' 



DURATION Vears A/oh (As Days 

CONTRIBUTORY 



Hours 



DURATION Vi-ars Afonths Days Hours 

( SIGNED )..L^*Vfr>xXh/ y % Vp ^dUUa/^^ -< M.D. 

JUj at iQO '\ (Address) veN,frYy^ ^ ^^V.^ . 



iPECIAL lNFORMATION«i^torVtipMh,iMiMMs,fraiMHft, 
•r Ikccft Residents. iN persans tfyiog away from hr" 



\ 



riWWf if 1 1 , 

WkM m» AiMse ctitracted, 
IfMtitMaceffdeatI? 



ntrttff iNtti? 



9<)fS 



PUACE OF Bl'RlAI. OR REMOVAI, I DATS of IIlRIAI, or RElffOVAt, 
I NliKRTAKER ViXrM* 



^Addrewi 



W^Mi;< 






N. B.— B,^ry Item of Infform.tKm .IkhiM Im c.p^fiillr •i.|»MI««l. ACB .honlil ^•^^t^^^'^^^ \ , ^^*'?^r.lf^'^ 
•tate CAUSE OF DEATH In pliil» tepms. tMt It imy bs fM-oiJtrtjr claMlfl«4. TM Special InTopmatlon for ■•■»- 
■Ofis dyint away Yrotn homo should b« glvsn ta avary Inatanea. 



I ■! 



Ml 



^ I 



1 




^» II 



I ' 



.^ » 



il^f' 



H 



noar.I •>( lliaUh— FNo. l^ 



N 



I 



'i 



II 



J)f(fr Filed y 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 

519 



IJ&PCo 



Registered J^o, 



as 10 0\ 

Deputy Health Officer 

DEPARTMENT 01^ PUBLIC HEALTH=City and County of San Francisco 



Xm-UJ) Awm- 



Certificate of Death 

( Ta. S. StanDar& ) 



PLACE OF DEATH?— County 

(0 {\ ro 



of O/CL'^V ^<X > '- ^- ^- ^- -''City of ^ 'O^'^J 






VCL 



1%. 



lx>v't* 







-) 



FULL NAME 





^\J^^: 



^ ■ 



t\.4.* 



^KX 



PERSONAL AND STATISTICAL PARTICULARS 

COLOR \ j 

1'' \ 




"^IvL 



i>\rr. 1)1- liiKTii 



(Month) 



^^ 



\'.\'. 



(AJC >V</»A \ 



I Ui« y ) 



M„nth^ 



(Year) 



U 



Pa vs 



MNf.i.K. MARKIKl). 

wriMiwKiJ OR i>iv«»RCKn 

iWritrin nociitl tle?«iKn«lJoii) 



HIKIMPLAOK 
"*' ii< or i.'onniry^ 



NAMK OF 
1 ATIIKR 



niRTuri.Ai K 

•" I'ATHKR 
-'t.iij' or Countrv) 



N' M1»i;n NAMK 
<M MOTHER 




C4.\A-/0L/Yy J - C w-u ^ w- ^ 




BIRTH rUACK 
OF MOTHER 
^StiUc or Countrv) 






L 



fOAAxrrsi 



OCCrPATIOK 



Rffidftt in San /'tttttn'sro 



) Vr» » .< 



\rn„fhs 



/hn. 



(InfuTtnani 



THE ABOVE STATED PKRSOXAI. I'ARTHM' I.ARH ARE TRIE TO THE 
BEST OE MM KNOW 1,1 : DC, E AM) HEMEF 



CAddnMs 



MEDICAL CERTIFICATE OF DEATH 



DATE OF HEATH 



iMonth) n 



11 



(Yfar) 



190 



I HERI'-HV ClvRTIFY, TUat I attcmkMl tieccasetl from 

— -^ 90 ^ 

— 190 — — 



-to 



that I last saw h a live on 

am! that death occurred, on the dati- statctl above, at " 
M. The CArSK OV miATII wan as fcrtlows: 

.A 



> vQ . 



DIRATION y^ars 

CONTRIBUTORY 



rA«Mv 



.\fonihx 



Days 



Hours 



DURATION ^ years .1A»//Mv ^ ^/^y^ 

( SIGNED )......Lir\.rraAi^.^ II' lolo v 



Hours 



\^ 



\qo 



(AddresH) L^VC 



Special information o«iy \m iit^Mb, iRstKititis, Tr«MM^ 

or Recent Residents, and ^rs«ns dying away from hoMf* 

Former or ;4^yfi^i.f-f Mwrlti 

Usual ResldenceCl CtC^ ^<XMU U.lu nare el 

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



Deitk? 



Ui% 



LACE OE BIRIAL OR REMOVAL 



DATKo/ BiRIAL or REMllVAL 



ATKo/ Bi 



%^ 



190 



rNDiiRTAKERtvX^Ctv^ArfLww'^^tMrn* u^.t'^^vaA * 



(AcldrciH 



N. B.— Bvery Item of tnform.tlon .hould b^ «p«f«tly «tt|>plt«d. AGB ahould «f •««••:; EXACTLY. PHYSICIANS •hiH.W 
•tate CAUSE OF DEATH In plain terma. that It may b« pp^Mply elaaatftcd. The Special InrormBtloa for par- 
•ona dylnft away frww home ehould he given in evopy Inatanea* 




N 






I 





m 



i 




'ii 



poar.l .if He alth— F No. i^ 

!)((/(' Filed , 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

REFER T O BACK OF CERTIFICATE FOR INSTRUCTIONS 

520 



H&rco' 





a?, 



joo'i 



Begisteved JVo. 



vw) JL^\>u Deputy Hearth Officer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



<?!^ 



Certificate of Death 

( Vi. S. Staii&atO ) 

PLACE OF DEATHt-County of^ CL^^' JjUX^XCLi City of^" a>^ >1x<X^VC^^c 

vv*^ v'WUAXU-'k^^H tADC^.lst.'j.'^ ^ V Dist.;bet.— ;: and - 



I^.M.'>\tA.ojL V 



FULL NAME 






PERSONAL AND STATISTICAL PARTICULARS 



six 



(TioL 



COl.OR 



U" 



I '. 



DATK »>|- BIRTH 



a<;k 



iMujith) 



I , 






.!/,.»////< 



/ I. 



(Vtar) 



P(; 1 A 



uiiH»\yKl» i>K mvoKi KD 
(Write ill swiuJ iltHiitiiatiun) 



HIKTMPI.AOH 

(Stiiti- (ir Cotintry 



/ 



/ 



VAMI-; UF 
l-ATHKR 



HIRTUPI.An-: 
"I- FATMKK 
(Stall or Country) 



MAII»KN XAMK 
«»F MOTHER 



/ 



/' 



• 







ruk riiri.ACK 

;»l- MOTHKR 
iStatf or Cuuntryi / 



/ 



'""■'■"'■'"^ (^^JU> 



R^sldrif in Sitn Pi aitt lu-o 



) fUt I 



M.,».fh' 



Jhn 



THK AROVR STATHD PFR^ONAI, PARTUni, \RS ARl" TRIK Tt) TIIH 
BUST OI' MV KN-<i\Vl,i:i)<'.K AND IU:i.n.l'' 



(tiifnniinnt 



i I 



\.1.1r. v>i 



MEDICAL CERTIFICATE OF DEATH 
UATK OF DKATH 



(kWunth) \ 



<I)iiy) 



lYeiir) 



I IIF.RKBY CI":RTII'V, That I altcinltMl <lt( hmscmI from 

— ' — 1 90 — to 1 90-^ 

that I last saw h alive 011 — — — 190 



and that death occurred, 011 the date staled al>ove, at 



■— M . The C^ S i: ( ) i< I) !•: A T 1 1 was as ^l^>ws : 

(XtA^jt^. ^ Jl aXcCtvc ,..0-1 ' fc Jtcvxt 



nrRATION Years 

CONTRIBUTORY 



Afonths 



Days 



Hours 



DURATION Years 



lifonths 




Days Hours 

ia%\^ M.D. 



(SIGNED 
'kpEc'lAL INFORMATION only lor Hnpltets, li^Hi^s, TrMSieib, 



or Recent Residents, and persons dylnj a*»ay from home. 



Fonnertr 
Usual Residence 

Wken was disease contracted. 
If Mt at place of deatk ? 



NamliNilit 



Days 



PI.ACH Ol- BIRIAU OR RKMOVXI. 
UNUKRTAKKR AD<Mla^A%, ^ 



UATK f,f Mt RIAL or RBMOVAI« 




I90H 



N. B._Bvery Hem of tnform.tlo« .hould be carefully -applied. ACB i.ha«ld «f •'-'•i! B^.^f'^'S^; , ^"^*'f/^^.* •'^"'^ 
State CAUSE OF DEATH In plain term., that It may b« properly claasltWd. The Special Information fOF per- 
•one dying away from home iihould be given In every instance. 






I 



1 




w 



!('< 



|IM< 



K 



in 



II 



I 



I 
I 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



ponr.l of |i..iHh-FNo.i^1^€^S^»f^t^go 






Registered J^i'^o, 



521 



3.3, 100'\ 

Deputy Hftslth Officer 

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

Certificate of Death 

PLACE OF DEATH:-County of^'^a^V ^ 'VO. WCU: -Xity of JOov .lA,a'>xC. ; 



\x^\ 



Q 



iM. 



rNo. 1 HI H '^1.^-u.. • ' „„St4 M Dist., bet. ^ ^J^^ J; ■ ,,^,^^,.^ ,„„and 



ao I 



FULL NAME 



^ l". \ 



PERSONAL AND STATISTICAL PARTICULARS 



*1x^V%"coJLb 






lu.J 



|Mr)nth) 




I'X /t.HO,., 



A".!'! 






(Day) 



M,inlh- 



(Vear) 



/).; 1 .V 



SI\".I.I'. MAKkllCt). 

w iit(»\vi;i> (>K nivoROKn 

Wiiii ill sDcisil (ksijf nation) 



HIkTHPI,ACK 

iSt.iti iir ''oinitry) 



^ 



MXhA^-L<L 



N\MK or 

I- A I'll HR 



BIRTH l'l,ArF 

<>i 1 \riiKR 
(^t.u. .It (.'(nnilry) 



MMKl'.N XAMH 
<'l -Mt>Tin;K 




xiJLo^'v^' 



s .'L 



inkTHPi.ACK 

'>l MnTHKR 
(Hlatc or Country) 



OCCUPATION 







A'.'.v.VfAf f„ S,i,i FrniniMO %% rents A /.>,,/;,- /}<>: 



THK AHOVK STATl-,n PHR'^ONAI, PARTICl'LARH ARK TRIK TO THK 
U ST Oj- MV KNOWI.ICIX'.K, AND HF.IJKF 

J ^ H 



MEDICAL CERTIFICATE OF DEATH 

UATK OF DKATH 



(Monlli) 



(Day) 



(Ycnr) 



ITuHKIUiV CI'RTIFV, That 1 attemkd »leccascd from 

,L^ >\^ ..^i 190't to ^ |^<^ ^^ ^90 H 

that I last saw h alive on 'i^'^^ '9° 

anil that death occurred, on the date stati-d above, at 



' M. The CAl'SR Ol' DlvA^TII was as follows: 



DURATION years 

CONTUir.rTORV 



Monifis 



Days 



I Jours 



DTK AT ION ^ >Var5 

/ ! 

( SIGNED ) ^ J\>^ ClAw. dd. 



Motitfis 

kLch h 



Days 



ll, 



TqO 






Hours 
M.D. 



f -^ >v ^ 

SPEC^IAL INFORMATION only for Hospitals, Institutions, Transients, 
or Rfcent Residents, and persons dying away from l>ome. 



Furmer or 
Usual Residence 

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



Haw lani A 
nareaf Dtath? 



Days 



PIvACK OF in KIAI, OR RKMoVAI. 



DATKof nJHtAi. or KKMoVAI, 

ar 190H 



VYV. of nJHI 



f Aflilress 



VNl.KKTAKKR vl^V^Ajt^^ U.^r%<Luh.t<K k.«^s^ 



« .. it J ARR MfifMild b« Stated EXACTLY. PMY8ICIAN8 •hoald 

N. B—Bvery Item o? inform.tton .hould be c»rcfufly f""*"*t p^l^Hni-.iTfl'r Th. "Special inform.tlon- for p.^ 
•tate CAUSE OF DEATH In pl«ln term., that it may be pfoperiy wiaeein*-. h- 

none dying away from home nhould be given In every Inetance. 








i 




WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

i..,:,nl of Hcriltli-I- N-.>. i^ »^gg^lU^t'Co RtFER TO BACK OP CERTIFICATE FOr'iN^TRUCTIONS 



7)(((e Filed, 

i 



^^cu3 




a^ 



2.9(94 



Begisfered J\^o, 



Of^/^ 



x^u 







DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Cevtificate of 2)eatb 

( "d. S. StanDarD ) 

PLACE OF DEATH; — County ofUa-^x Iva >xc.a„^cc City of^^^\' Vrx >vc^^ 

\u 1.0^^4. St.; Dist.;bct vl Cr\A.<rrrv» and Ut e-lV<X\H ) 

( " r/«rlTM*'^)!r.!/-*'** ^''**** USUAL RESIDENCE G.vr r*CT8 c*llco roR UNOCR •.PtCAL iNroKMATiON- N ■ 

V ir OCATH OCCUnncO in a hospital OB institution CIVC its name INSTCAO of STUtET AND NUMBCn. J 

FULL NAME 



No. IH^'Jll 



^i:\ 



PERSONAL AND STATISTICAL PARTICULARS 

I COLOR 




(jUa 



10 Ju ) 



UATH ()|- HlKTH 



A<.K 






MEDICAL CERTIFICATE OF DEATH 

DATK ol- I>i:.VTll ^ 



1 






(Yrnr) 




) V *ff I 



(Day) 



M»utfts 



'Vcar) 



1 



fhlVs 



\vii)(»\vi:n Ok i)iv»)KrKi> 

iWrit'iii srH-ial <U'.si|.i:iiuliiin) 



J : I' 



IIP ' ' 1' ! 



M 



MIKTUVM.AOK 
'St;iff or Cntiiiti v) 



N'AMK Of 
I ATIUIK 



HIKTHI'I.ACK 
"I lATMKK 
(stritc nr Country) 



NfAIDlCN NAMK 
OK M( THKK 



niK ri?i'i,AcF 

Ol- MoTHKR 
(Slate or Cotintrvl 






(Mjonth) 
I JIKRlvHV CKRTIFV. That I alUMi<le.l .IctH-asol from 

^^^vU Xi 190 H to .^^^^.^ ufi s 

tliat I last saw h . . alive uti H^^H. 3L I t QX joo S 
and that (loath occurred, oti the date stated above, at * 
M. The CAl SIC OF I)I:aTII was as follows: 



C . % A 



O > 



DIRATION }Vv7r.f 

CONTRinrTORY 



Mouths 



Dav!; 



Hours 



P 



!l 



OCCIFATION 

f^fsnird ni San I i mt, i\^n 









DIRATION 



(Signed) 



Vtars Mi^tiths 

1 dX/"' 



Pavs 



Hours 
M.D. 



|l^lu XX uyo'i (Address 

Special information 



.) H ^ 1 ;v Crv^HX^V^. 



only lor Ho$»iUls, InstitHtiois TrMs^sH 

or Rfccnt Rfsldfnis, and persons dying away from home. ""*'"""«• «»■««■». 



) V*(/ ; .« 



Mntithi 



Da 



'"nASr oH'^l^''^v^uM'1M '^'' ''^KnciLARS AKH trck to TIIH 

(fJifoMnant 




f X<1drt'H«s 



IH 



0. 




V it 



former w 
Usval Residence 

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



Wifetf Oealli? 



Da)rs 



nr.ACK Ol- m-RIAf. OR RHNToVAl. j DATK uf H, u.u «r RKMOVAI. 
INIIHRTAKKR A^ <X<X't5^Vu '.C A^XXm 



,a^ 



^H 190H 



fA<l«lre*$» 



^bhj^- m tk it ' 



i«.w a^iti^ awsy from home ghould b« given In every instance. 



I 



' 



^.'ll'i 






!I 




WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

H anlof HtMUii- I- Xo. i^-^^^H&l'Co REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



Daf(^ Filed, 




as 



VJO^ 



(>^-CrWuj c>sJta>ct 



Registered A^o, 






DEPARTMENT OFPUBLIC HEALTH=City and County of San Francisco 



Cevtfffcate of Bcatb 

( "a. S. standard ) 



^ 



PLACE OF DEATH: — County of '"^a^v g A,a i\ t^.^.- City of ^^CLA^ Xcvi 



X c '^^ 



P*©.V.>X'^tU. 



U.dv4 C 



c 



val, v\>vcVaSti{v^u '"^DtktiiH^ 



and 



/ ir DEATH OCCURS AWAV FROM USUAL R E fe I D E NC E*GI Vt r«CTS d*LLCO rOB UNOCR 'SPECIAL INFORMATION" \ 
\ IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / 



FULL NAME 







^i:\ 



PERSONAL AND STATISTICAL PARTICULARS 

I COI,OR^ 



^ah 



U'u,» 



I'AIJ-. «»!• HlkTH 



iMoiitllt 



iDav) 



M'.V. 



jJA 



5><n 



Miitit/i.^ 



I Year) 



/)„ 



SlNi'.I.K. MARKlKn. 

wiiH)\yKr» <)K nrvoKOKn 

(Write in 'im-ial (Itsit'iialJuti) 



BIRTH PI.ACH 

(State nr Ciimitrv^ 



NAMK <)J. 
I ATHKR 



/ 



MEDICAL CERTIFICATE OF DEATH 

DATK OF I)1:aTII A 

^^^.^Im is 

(!\i(oiilh) \ n>av) 

I HRRKHV CHRTIFV, That I atlciulctl ilcccasd fn.tii 

to V - .^ — 



(Year) 



that I last saw h 



190 "— 

alive on 






ati«l that lUath occurred, nii the dale stated above, at 
M. The CAl'SI-: OF I)I:ATII wm «s follows: 



/ 



niKTHPUACF 
fH I ATHKR 
(Si:it( or Country) 



MAn»KN' NAMF 
OF MOTnF:R 



niKTHPi.ACF: 

'»»■ m<»thf:r 

•Stat.- or rnuiitrv 



Dr RAT ION Years 

CONTRinrTORV 



Months 



Days 



//ours 






^, 



DIRATION 



Years 



f^ ^ 



Months 



( Signed ) LtrXrw^V; 

A 



»CCl FATION -^ 



Rfiiilfd in Siin /'i ,i it, :.,',> 



)V.j 



Af'inf/tf 



Pa 



1^^^ Tq 

SPEtlAL IN 



/J,7t? 

90H (Address) v^V^^^X^J^ t i'^, c. 



//ours 
M.D. 



. „ , FORMATION ©My hr H«s^tils, Iwtltit^^, Twnsteits. 

or ^ent Rrsidrnts, and persons dyiog away from liMie. 



Former or 
tISMi Residence 

Wken Wis disease coRtracted, 
If ootrtplareofdeatli? 



Now loiif A 
ftirc^iettfe? 



Days 



'^" nuJ^i'VlV':'"^'''^'^^ PKRSONAI. J'ARTrCff.ARS ARF. TRfF: To THK 
liF.ST OF MV KSUWI.KIX'.F: ANI> HHI.IFF 



(Illfr; 



nnam 



WtX.r^^wW'V^ ^ ^ 



X'MrrsH 



PI,ACK OF BFRtAI, OR RFtMoVAI. 



4 ^1 



r»Ari;,»f ||,R,AL or REMOVAI, 



t ni>f:rtakf.r 

(Ad.lit 







190^ 




. Every Item of tntoraintion should be eiii*«rully su^pited^ ACB should b« stated RXAGTLV, PHVAICIANS skould 
state CAUSE OP DEATH In plain terms, that It ma> he pr^MHy classlffod. The "Spsetal Information** tor psr- 
SMis dying away fiw» home should be ftlvsn in svsry instance. 



ii 



' * 111 



f^ '■' 



I, 




r 



» 



I 



r 

I I 



li j 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

.fUcalth- KNo. is^?^^H&I'Co REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



h 



{ > 





'X'h 



190 "{ 



Registered A''o. 



524 



D/ifc Fifed, 

'Lfrv^/)' (LtW Deputy Health Officer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



PLACE OF DEATH 

rNo. v/'Ml,, 



Certificate ot H)eatb 

( Til. S. StanDar& ) 

(3n ^ 



: — County of UOu^nj >v<X'VWC.A.4C^ty of CJ^CL^v^ 0/WCLax 



St. 



rs 



Dist»: bet. 



.f. 



and 






I 



(ir OCATI 
IF oc 



H OCCUnS AWA 
ATH OCCURRCO 



V FROM USUAL RESIDENCE Give FACTS CALLCO FOR UNDER "SPCCIAL INFORMATION" N 
I IN A HOSPITAt OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / 



ItC^i ) 



FULL NAME 




xiu 



CL' \A\J^ > wIvolwa/ 



PERSONAL AND STATISTICAL PARTICULARS 



si:x 



Qlui 



"■■"" lU Uu 



l»ATH OF lUKTIl 



(Mnnth) 



(Dny» 



rib . 

(Vt-ai) 



AT.H 



oX% 



I ■/•(/ 1 > 



.V.tufAj 



n,i\ 



-^IV'.I.K. MARKIKI). 
WtlM>\yKI> OR niVORCKlJ 
NVtitciii sociiil >l>.siKtiatioil) 



I'.IKTHPI.At'K 
'State (ir Country) 



\ AMI- n|.- 
KA iii):r 



RIRTIIPI.ACR 
nr I'ATMKR 

'Siat«' or Ouuiifrvi 



MAIhKN NXMJ- 
HF MorilHk 



niRTHIM.ACK 
«»F MOTHKR 
'^tste or Cmintrv) 



m cnXa > vcL 



MEDICAL CERTIFICATE OF DEATH 
DATK OF of: ATM 



,\.V. 



f 



(tknnth) I 



a»av) 



(YenrI 



I^IIKRKBY CI:RTIFV, That I at^tcinlcl ilcceascd from 



.'.lLh. \\ 



190 1 



to . Y^^W ^'^ n)oH 

that I last .saw h • alive on jV-Ct%^ \f^ . 

and that «lcath (K*currc«l, on the date stated aliove, at 11 
^J;^A|. The CArSI^OF^IlHATII was as follows: 



1 



^lU 



m 



{ Ai-- 



I)r RATION I Years 
CONTRIIUITORY 



^fotiths 



Days 



Hours 



\ /n / 



ft 

H 



i»:ClI'ATlON 4u 



DIRATION 

(Signed) 



Vvars 



Afouths 



(\ 



1. 



Days 



Hours 
.D. 



II I , n i 1 



SPECIAL IN 



- 1 i 



„_ .. J FORM ATI ON only for Hospitals, Nsmutloni,Triirie«$, 

•r lecnt le^(Nt$, «ii4 pfmns dyiflfl ^wdy from lioinf. 



I\f\ltii-J 1)1 Sil H /■ I ll III ISl'it 



} Vrr I 



M.itilhf 



IUi\ 



^"o^n*?^KHTATF!I) I'KRSONAI. I'ARTlCtl.AR?^ ARK TRIK TO TH H 
BRhT OF' MY KSc»\vi,i:i>r,F: •.M) MFil.IFlF 






\ I 



Hxxmm 
Usual ftesMtMc 

Wlien wif As^w cMlracM, 
tf RotatMireofleAUi? 






Days 



ri.ACK OF IIIRIAI. OR RFIMOVAI. I IIATHof BfRiAi. or RKMOVAl 



an 



1 



190 



(Addreisi 



N. B.«-Bv«ry item of tnfformatton shoyld te ciir«f«lly supplUtf. AGB sfiould b* staMd EXACTLY. ^HYSICIA!«IS slMMild 
•tats CAUSE OF DEATH In plain g»i>[^« that It ma^ b« pfH>|»eHy t^laaslflsd. The "Special Inffopmatloa** fm* pei** 
sons dying away from home should he gtvsn In evspy instance. 



If 



•II' 



t 



I? 



♦f* 



i 



' ♦ 



i. 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

M ar.l <.f Hcalth-F No. n^^^feU&PCo HgFCR TO BACK OF QgRTIFICATC FOR INSTRUCTIONS 



ft 





li 



m 

i 



Date Filed, 




^<^,,o. 



190 "i 



Registered ^o. 



535 



{HwW^ ds.!L\>u Deputy Health Omcer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



(No. 



Certificate of Death 

( Til. S. StanDarD ) 
PLACE OF DEATH?— G)unty ofOo^^vv J XXXAVtULCC Gty of J/O^Vu nJX^^\^<. 4 c 

U aawLli ) 




^^^ 



t 



St; 



Kst.;bet. v^VVU 



and 



(\W DCATN OCCUMS AWHV wmom USUAL RC8IDCNCE OIVC r»CT« CALLtD ron UNOIN "SPKCIAL inrOHMATION- "\ 
ir DKATH OCCURNCO IM A HOSPITAL OR INSTITUTION GIVE ITS NAMC INSTEAD Of STRCCT AND NUMBCR. / 



FULL NAME 




SEX 



PERSONAL AND STATISTICAL PARTICULARS 

I coi.oR ^ 



DATK OF BIRTH 



AGR 






II 



\ 



iMo^ith) 






{ Day) 



v. >»////< 



(Yenr) 



A/ 1 



^INC'.I.E. MARKIBO. 
WinoWRD OR niVORCKD 

UVtitf in itocial <lcsi»rnatif>ii) 



BIRTH PI,AOK 
(State or Cnnntry1 






VAMH OK 
I AT III-: R 






MEDICAL CERTIFICATE OF DEATH 

DATS OF nKATH A 



B 






cosy) 



rgos 

(Vcsr) 



I HKREBY CI:RTIFV, That I nttended tieccasea from 

- 190 — — to .....„...„.,..„„.. 1 90 ■ . ■■ 

that I last saw h ^::-"~" •live on 190 

ami that death occurred, on the date stated abo^re, at 
M. The CAl'SK OF DFATIl was as foUowfi: 



iiilcwhJb-tn V, . 



i^ 



„„„fA*^X^O. 






BIRTH PI..\CB 
OF FATHKR 
(ftlateor Country) 



MA1I>KN NAMK 
t»F MOTHKR 



BIRTHPf.ACK 
OP MoTHKR 
(fttate w Country » 



ulavI 



^ 



I* 



nr RAT ION Yeai'S 

CONTRIBUTORY 



Months 



Days 



Hours 



1)1 RATION 



Years 



Months 



Days 



( SIGNED ) L&\erVUAi .^6, Uj. "dJuii.0. 



Hours 
M.D. 



(H 



«:CI?PATION 

Resided lit S,!i! /'i ani iseo »/'• 'w )'ents 



A/nnfA> 



Ihn: 



THH ABOVE STATED PPRSONAI. PARTICfl.ARS ARK TRIE TO THE 
BB«T OF MY KNfJWI.EDGE AND BELIRH 



(Iiif«>Tmiini 



vAw>v«-vw \A C w4 



r\<!drewi 



iM\ 



M 



<4 






SPEci AL iNrORMATION Miy fw Rt^KiH. li^Mdi,^r«etab, 



•r Recett lesMnts, Mi pentn #taf a«iy fras Nsr. 



rfflRf If 

Usui ReMncc 

VflN irts 49(t» CMlricM, 
Nirtatiiiceifi^fll? 



Www nWi ^n 

nartff Inll? 



^ 



PLACE OF BlRIAt. OR R8MO%'AI« I D^TE of HtRiAL or REMOVAJ* 



y III 



kjjh t 



<^4 



INDERTAKKR 

(AddreM 






V 



T90H 



1 w -» 



R, 



AOV 



vci»y Item ^ tfiformntlon should be carsfully m^^lm4 
•t«t« CAUSE OP DEATH In plain terins. that It m^ %^ . 
MHis dying awdy ffiNNW horns should lis given In mvry Instancs* 



id b« stated BXAGTLY. PHYSICIANS 
claaslflsd. Tim *'ih>Mlal lnf«H>niatl<M** far 



•»4tl 



• \% 



I ■' 





I 



1'^ 



t \ 



il 




'I 



i 

I 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

Boar.l of Health-F No. 15 <t^&>B&P Co RCPCR TO BACK OF CgWTIFICATg FOR INtTRUCTIOWS 




'. » 



('• 



Registered *A'o. 



520 



Date Filed, WJLm. '-J^H 190H. 

3^{rVu^,.-ix\H^......0eputY.^,HeaIth,. Officer 

DEPARTMENT OFf UBLIC HEALTH=City and County of San Francisco 

Certificate of Death 



(Vh>. 



PLACE OF DEATH:— County 



( Til. S. StanDar& ) 
of O/Cu-Yv J,>\»CL-yvcutco,GtT of ' )'<X'>v J.va > 



VCC4-CC- 



>'Mr*w4 



St4 Dist>; bet 



and 



A il ir DEATH OCCURS AWAV mOM USUAL R CS I DCNCE OIVC PACTS CAtLCD WOm UNDER "SPECIAL INrORMATION" \ 
y V 'F DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / 



) 



ro 



FULL NAME 




.rux^^-^w.. 



PCRSONAL AND STATISTICAL PARTICULARS 



SKX 




COI.OR > 



II ATE OK niRTH 



Q)Uv 



1 1 ' ' f 



otolith) 



a«;r 



'^ ^ 



J V<7 > 



M 



(Day) 



Miwtli'. 



\ n 



(Year) 



Af vs 



SIN<;i.R. MARRIED. 
WnxnVED OR DIVORCED 
(\\'riteiii metal de^itrtiatioti) 



niRTH PLACE 
(state or Country) 



NAME 01. 
FATHER 



(1) 







MEDICAL CERTIFICATE OF DEATH 



DATE OF DEATH 



(Month) 



1 



iDsy) 



(Year) 



I UKREBY CHRTIFY, That I attended deceased from 



190 



that I last saw h alive on 



190 



and that death occurred, on the date stated alx)ve, at "—^ 
.-T^TTrnTtM. The CArSR OF I) i: ATI I was as follows: 



i 



BIRTH PI.ACE 
OK FATHER 
(fttateor Cotintry) 



MMDKN KAM8 
<JI MOTHER 



HIRTHPUACE 
OF MOTHER 
(State or Countr>-) 




^^CU^W\j 



I (' K T fi ^ 



w W"-^^ WW*^ W U^W fS 



DURATION Years 

CONTRIBUTORY 



Mouths 



Days 



DURATION Years ^ Months Days 

Mddr#»iiM> L%*\-d^\X^tii 



(SIGNED) 



mXu 'XS 



Hours 

Hours 
M.D. 



n) 5 



\ 






OCCUPATION i'^u 



fifS/dfd IN Sftn I'ltiiuirii 



) 'fll I s 



.\hmths 



navf 



THE ABOVE STATED PKRSONAI, J'ARTICFI.ARS ARE TRIE TO THE 
BEST OF MY KNOWI.KDr.E AND HKI.IEF 

f Informant HCJCC^Tlr 





''~ r \xL.cc > V 



(A'Mrewi 



nn - iH 



w » 



^^ 



Tnr» • 



JPECIAL INFORMATION ^ Itr ItsHtHi, listMitteih. Trmrinta. 
m lecnt IrsMeats, iM pcrwn tfyiii tway frM ' 



VbH 



rMWf If 
l^i^lnMnct 

WNi WIS 4lsei$e CMtrictei, 
NMtitilarctfieiai? 



RtwlMlil 

PUrciflHlll 



Ui% 



PLACE OH BURIAL OR REMOVAL | DA^K of BttRiAl. or RHMOVAI« 

T90*i 



UNDERTAKER K 

(AddreM 



J'K of BttRIAI. 



f* 
A 






N. 



vspy lt«m of InropmatioM akovid b« carsfully supplied. ACB should bs atatsd BXACTLY. PNYSIGIAMS ^imiM 
•tatc CAUSE OP DEATH In plala icrms. that It mny b« piH>p«Hy cla^Mlad. Tks "Spselal lafformatloii** for 
•awa dying away fnan Itama should bs glvvn in svsry tnstampa* 



! 



'I 



) 1 



% 



<i 



I I 



m 



\ 



, 



I , 



i 



III 




$ 



III 

I 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

Hoar.l of Hcalth-K No n^<^^fe»&F Co WCfCW TO BACK Or CCWTIPICATt row INtTWUCTlOW 



Date Filed, 




iPO'i 



Registered n^o. 



527 



DEPARTMENT OFTUBLIC HEALTH=City and County of San Francisco 



Certificate of Death 

{ TO. S. Stan^a^^ ) 



(No. 



PLACE OF DEATH:— County of CJ Cnxcr^^vO, Gty of 



o^vrLcu^ val 



.ilAiiq^l 



and 



IV ir Ot*TM OCCURS *W»Y ^ROM USUAL RCSiDCNCE OIVC rACT« CALLCO rOH UNOKN "•^CCIAL INrONMATION" \ 
UV IF OCATM OCCURRCD {)* A HOSPITAL OR IWSTITOTION GIVE ITS NAME INSTCAO OF STRCCT AND NUMBCR. / 



-) 



FULL NAME 



PERSONAL ANP STATISTICAL PARTICULARS 



SKX 



^cd. 



COI.OR 




r Vk 



f 



DATK OF HIRTH 



ajJf\k' 



I Month) 



(Day) 



/X.L1 

(Vear) 



C 



:'>:\"U./V^;.. 



Is 



^A.U\jY\^jJL^^ 



MEDICAL CERTIFICATE OF DEATH 



DATE OK DEATH 



(M0nth) j_ 



(Day) 



rpo i 

(Year) 



AC.K 



11 »„., IC) 



Months 



I 



r>,i V. 



SIN<'.I.E. MARRIED. 

WIDOWED OR DIVORCED () 

IWrite ill social desiiiriiation) ,^ 



K \^i 




BIRTHPLACE 
(State or Country) 



NAME OF 
FATHER 



A 



RTRTHPI.ACE 
OF FATHER 
< State or Country) 



MAIDEN NAME 
OF MOTHER 



^ 



I HEREBY CERTIFY, That I attended deceased from 

- to - 



ri90 



ngo 



that I last saw h --^^rrralivc on - - 190 ^^^ 

and that death occurred, on the «late stated above, at ~ -..•• 

M. The CArSE OF DEATH was as follows: 



LWjLc.i:\ArVL 



DURATION Years 

CONTRIBUTORY 



.^foHths 



Days 



Hours 



Hours 



BIRTHPLACE 

OF MOTHER 
(State or Country) 



\ ( I V V ? w I 



OCCUPATION 



CJcL 



J W w WiA^%_ w 



rs/^ » r% 



Resided in Som Fiam i,<fo X\ Yeats 1 ^' A/imths ii /)ays 



THE ABOVE STATED PERSONAL PARTICIM.ARS ARE TRIE TO THE 
BEST OF MY KS*OWLED<IE AND BELIEF 

(Informant H>. M. ^ ' J^ A-^UV > Vi^^tt 



( 



A.Wre^s.. iDliH Q.WcttxK., 






DURATION y'tars Months Days 

(Signed) XAjj^mx^'^ /^.\<xh 

4\.4JLm 3>^ iQO ■ (Address) LiUih^4^4. k^ 

kpslciAL INFORMATION tnly ftr RMpltils, h^tiUiiS, TrNsletts. 
•r Recent ResMeits, and ^rsMS iying away frMi Nae. 



A^ 



Usval RfsMfiCt I 0/lH^ ^^^ 

WkeR wis iHmt MatractH, 
H not at place ffleatk? 



Hfw iMial 
Flirt tflNtl? 



ftiys 



PLACE OF BURIAL OR REMOVAL 



I)^\TKof BiKiAL or RRMOVAI* 



INDKRTAKER U.- U).- m|W^Xw^ '*H ^ C 

(AddreM...... ll^ O'^aJOwjUytl^i^ 




N.B, ] 



Bv«py Item of tnfopmBtton should be ciipefully supplied. AG6 should bs stated EXACTLY. PHYSICIANS ahsald 
state CAUSE OP DEATH in plain terms, that It mm^ bs pmvpeHy classified. Tbe **S|M«lal Informatloa** tor psf- 
sons dying away irwn home shoald bs given In mvmry Instance* 



\m< 



■m 



f 






^■■ 




iij 



t' 



»' I 



It 



I 



I 



li 



4i 






ii- 

i 
i 



WRITE PLAINLY WITH UNFADING INK — 



11,,! ! ,.r IlLiiUh— K No. n 



n&l'Cn 



lOOH 



THIS IS A PERMANENT RECORD 

WCFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



Registered JV*o, 



Da/r Filed, WUr ^H 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of Death 

( H. S. StanOarD ) 



^ 



a^ 



II 



U 



PLACE OF DEATH: — County of ^ CCvu OA-O/vucA^c^ Gty of n<x^>^; J X<Xvv- l^ 

. .^ n;cf .. k»f. S tjk and 1 A4\j 



No, ll*^ 1'^ H^i^ St.; '^ Distjbct. n AJKi and 

/ irnocATM occurs *\w*Y rnoM USUAL RESIDENCE Give r*cTS callco for ONorn * s^tciAt iwroiiMATioN • \ 

\ ir DEATH OCCUnncO in a hospital or institution give its name instead or STREET AND NUMBCR. • 



) 



FULL NAME 




MX/VNX 




1.^, 



PERSONAL AND STATISTICAL PARTICULARS 
'-I X A - ft I COl.OR 



^oL 



\\}Lf. 



MEDICAL CERTIFICATE OF DEATH 

DATK OK I) HAT 1 1 






il):tv) 



/go i 

(Year) 



|\ 1 K n|- ItlKTIi 



x',!-; 



^IN«".I,K. MARKIUn 



(Month) 



} 'ra » . 



30 

(Day) 



Mi>uffi^ 



(Vtar) 



X^ 



Pit vs 



winowF.n UK niV»»K("Kn A a 

'Wtitf' ill socJMi >i«'-ij.'niiliiMi> -^f 11 



RIKTHPI.ACK 
estate nr OomUry) 



I A Tin: R 



lUkTHPI.AC'E 
«>l' t-ATHKR 
'^tatc or Countrvl 



MMDHN NAMF 
«M MOT I IKK 



ntRTHPUArH 
0|- MOTHKR 
(State or Couutrv 



OCCrpATION 



/^ 







QflW 









I inU^i:nV C1;RT1FV, That I i^ltciuUMl <Urta5ed from 

^^JLu i^ iqo'i t... iuJUi- 1.3> 190 U. 




•<. H. 



-^ i 4t 190 1 

tliat I last saw li a. • ^ alive 011 ^^'^'^ ^- 19° 

an<l that death occurred, on the <late stated alwve, at t) 

M. The CATSR OF hi:.\TH was as follows: 



Df RAT ION ' Years " Mouths " Days %, Hours 



CONTRIIUTORV 



«^^ 



nr RAT ION * Years H Months '^ Days 



Ah ■ 



AV,/,ff,7 //< .SV;« Fi nfi, iu'ii I )>'(?> 5 



^fi.ijt/ii ^ .-', /'in. 



THi; \HnVE STATK, D PFRSOXAL PARTIOI'f.ARS ARIC TRTK T< » TIIH 
HKST OF MY KNO\VM:nc.H ANP HKIJFF 



'liif'Tmant 



f\«ld 



reKS 






^ 




■i 



(SIGNED) 



A %H 



Hours 



I.D. 




4- 



t 



Trjri 



/ A,ldr..««'> H&O^H.^.^Yw^^oUAUUa. 



SPECIAL I N FORMATION ^"i »w Hospitals, InstituliMS* TrMSteiHs, 
or Recent Residents, and persons dying jway from Ni». 



former or 
Usual Kesidenct 

^Mmi was dheasf contracted. 
If not at place of deaM ? 



How loRf at 
nacfftf Oeatk? 



I^ys 




V\ 190H 



PI^CH OF lURIAl, OR KKMiiVAI, I DAl^l ■-! Uimiai. of RKMtJYAI, 

1 

INDFRTAKKR > V SJ \^'>^^S\,^\> -vWu 



f AddreftB 



N. B.- 



-Every Item of Infortnntloti shoulil toe cii;»«fMlly aMpplted. AGB should be stated EXACTLY. PHYSICIANS slMHiM 
state CAUSE OF DEATH In plain terms, that It may be properly classified. The "Special laformatlon" for psi*- 
•ont dylnS away from boms should be fttvcn In svsry Instance. 



•» 



If 






w 





' I ' 




« i #1 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

to,„i uf ii.»ui-FNn ,. ^^,mvca KKrtn to back or cewTirioTc row iw8twuction» 




IH. 



190'\ 



Date Filed, 

t^vvo llxv^, Deputy Health Officer 



Registered JVo, 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



fNa 



Certificate of Death 

( "a. S. Standard ) 

PLACE OF DEATH:— County ofOCtT^ J A^CV ^4.Cf City of (X> 

]^ I ^^ 

St.; H . .Dist.;bet-.U-CL.U.aX'tLU:L. and ..'.^.^'- 

/ ir DEATH OCCUR. AWAY rROM USUAL RESIDENCE aiVC rACT. CALLED 'OR «H«>ER .'•"^'•^ '!'';?; JJIL**"*' ) 
V ir DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD Of STREET AND NUMBER. / 



a>xe\.*LXc 






\Xv.\x 



FULL NAME 




l^ 



DjU^XlJiAr.}k£Lj.^y\M... 



SKX 



IMTK OF lURTH 



PERSONAL AND STATISTICAL PARTICULARS 

4^ 




a 




COI,OR S 



K 



\j. 



V 



^^ 






AGR 



<^^ Vrats t) 



(Day) 



Monlfis 



(Year) 



15- 



Da 14 



SINT.I.E. MAR Kir. D. 

win<nyKi> or nivi>RCKD 

(Write in social desiiirnation) 



HIKTHPf,ACK 
'J^tate or Country) 



NAME OF 
FATHER 



BIRTHPLACE 
OF FATHER 
(State or Country) 



MAIDKX NAME 
OF MOTHER 



niRTHPUACR 
OF MOTHER 
(State or Couiitr%) 




MEDICAL CERTIFICATE OF DEATH 



DATE OF DEATH 



(Month) 



H 



(Day) 



rgo : 

(Year) 



I HEREBY CEfeTIFY, That I attended deceased from 

190 3^ . to .. .^vut .X..'!V 190 H 

that I last saw h "- ' < alive on i^-^-. ?iww i-j 190 

and that death occurred, on the date stated aliove, at ^ ^.h... 
) M. The CAUSE OF DEATH was as follows: 



-\ 



-YVj 







& 



OCCUPATION 






X 



^\. 



Rffided in San /^lamif^a rS S }>ais 



Aftmths 



IhtM 



Till.: ABOVE HTATFI) FHKHONAl. I'ARTICILAKS AKF: TRIE TO THE 
BEST OF MY KNOWI.I^DGK AND HHMKK 

Cliifor.nunt MK\4 yl^\. 

U.1dre«, 'iUH- iLXiw^ 



DURATION Years Monttn Days Hours 

CONTRIBUTORY LLL.CKCrrrV^:tLMI.<tiar:v O-avCL 



DURATION 



Vcars 



Months 



\X- 1. BcrWci 



Days 



Hours 
M.D. 



(SIGNED) M^ <^' JCT^M^U 

SPEdlAL INFORMATION only ftr Nt^ltlls, iRStitiUMS, Tfiislnts* 
tr Recent Residents, and arsons dyin^ awiy frts N«e. 



•r 
Usiit Restdenct 

Whet Wis disease CMtracted, 
If Mlatplacetfd^Mi? 



■AMI ^HAfl W^ 

HVW mil M 

I'toct if llM? 



Nys 



PLACE OF nrRIAI. OR REMOVAL I DATE o( BfRiAt. or REMOVAL 

rM ..._ A .1 N^^s- J901 



ini>i-:rtaker 



(Addtremi 



^iX^ jXv4-^V:^> 



\ 



N. 



of information should be c«i*«fttliy nupplled. AGE should bo stated BXACTLY. PHYSICIANS sliMiM 
E OP DEATH In plain terms, that It may b« |»i*o|Mpl|r clasattlMl. Tfca **^Mci«l Informatloii** •wf pii>- 



very Item 
state CAUSE 
wms dying awsiir from horns should hs glvsa in svsry instance 



iV 



If 



I! 

il 



yi 



u 



I 



i 



\ 



\ 



<• 



.(^ 



-: , < 



y*' 



I 



< I 



■a 



1 




HfKir.l nf IlfMlth — I- No. n **:; 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

,l&,.Co WgFEW TO BACK OF CERTIFICATE FOR INSTRUCTIONS 

" ~~ 530 



l)„fr Fifed, ^(^'y^ 3vH l^O^i 

Icrv^ "Lo^ Deputy Health Omcer 



Be^istered J^o, 



DEPARTMENT OFPUBLIC HEALTH=City and County of San Francisco 

Certificate of Beatb 



PLACE OF DEATH:— County of 



A 



( "Ul. S. Stan^arD ) 

a^x- ^t\X5.^VCU.C0 City of ' CC >V vJ \ a ^ V C^ c c 



St 



Dist.: bet. 



and 



) 



> ,r ot.TH occuni .w*y r«oM USUAL RESIDENCE eve r*cTs c.tLco ;«" 7"" .^cti^ino 'n J-JI'iT"'" ) 

% ir Ot»TH OCCUWWtO if* * HOSPITAL OH INSTITUTION GtVC ITS NAME INSTEAD OW ST«CtT AND NUMSCR. J 

FULL NAME ^^^^ v..v-^^c; . .. 



SKX 



PERSONAL AND STATISTICAL PARTICULARS 



C01.0R> 



^CUL4 



U.iva- 



n\Ti: Ml luKTii 



A< ". H 







^s- 



) • .%/ » 



3^ MnvlU^ A O 



(Vear^ 



Ant 



SINT.l.K. MAKKIKI), 
\VII»n\VKI> OK l)JV(»Kt*i:n 

(Writ' ill "K-i:)] ilt'^ij.Mi.'itioii) 



FUKTMPI.AOH 
'Hlntt or Couulry^ 






NX Ml r>t.' 



niKTHPl.ACB 
fil- lATMKR 

M:i|. iiT CiHTlllry) 



M\I1»HN NAME 
OF MfrrilKR 



niRTmM.At'V 
«»F MClTIll.K 
fsinie or Cuuutrj'^ 




>l 



.M.A.^-^-€U 



1 



ft 



s^^^/y\Jr^y\^'^^^ry^ 



^UkAJ^^ 




Kfhiilfd hi Stitf I't itu< lu'if 1^ i>rl».» 



Mnllth- 



/hn 



THK ABOVR STATi:i> PHRftOKAI. I'ARTIlf I.ARS ARH TRTK TO TIIK 
nP.HT OF MY KNoWl.HlMlK,*NI> HKIJi:r- 



{Infotinant 



11 



f A'li1rc4H 



ILlsO 




MEDICAL CERTIFICATE OF DEATH 



DATE OP DEATH 



1 1 



(j^onth) \ 



ai 

i|>oy» 






I 1II:RRBY CHRTIFV, That I attciulcd ilecea^d from 



Hv^lu 



TqoH 

that I last saw h ^ alive on n^vv^ hjo 

and that death occurred, on the date stattil ahovr, at » 

M. The CAl SIC 111* DKATII Nva« ««; folUmst 



^^ 



'^^♦^ow'v cL WV A^ 



f .'^^JtCM 



I)t* RATION * J'M'-i * Months X^Davs * //<>«#jr 
CONTRIBUTORY 



DERATION 



Vt'ars 



Mouths 



Days 



Hours 



(SIGNED) L . -. ■V'^ UU4^%^ M.D. 

Special information only for Millite, IkWiHms, Trandnts, 
•r Recenl Residents, and persons dying away from home. 



Ftmerir 
Osiri Reskleiice 



< 



=^ • 



)jwa\^ ^- 



Hmv Ittf rt ,1 



Wlieii was tfsfise contracted, 
If Mtttiliteif tfeatk? 



PI,ACE Of ntUIAI. OK RKMoVAI. 



INDERTAKKR 

CA«Wre«« 



IiA tK of HiRiAl. or RHMOVAt, 

^^.^JUu 2H i9oH 



N. S.— B*ery lt«m «f Information shoMfd b. c.r.fttlly .lippiled. ACE .Hould «»f««»t«i; EXACTLY. ^ PM^SICIANS .hmiM 
state CAUSE OP DEATH In plain tewns, that It miiy be pf^>«Hy classtflad. Tlw Special Intaniiatlon for par- 
•oit« dytng away tiH»in lioma aliouM be At^vn (n m^m^w tnatanc*. 



I ' 

■ 



I, 



!•! 



« I 



•I •• 



t 



) I 



!• 



f 



"•• if 




p<,:ii<l<.f IlLMlth— FNO. 1% 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

„&,.Co WCFCH TO BACK OF CgWTinCATC FOR INSTRUCTIONS 

Registered J^o. •^^>J. 



Dafr Fileih N^UXu Vi ^^^H 

du>-wu Ix-u-u. Deputy Health Officer 

DEPARTMENT OF PUBLIC HEALTII=City and County of San Francisco 



Certificate of Death 



( m. S. standard ) 












PLACE OF DEATH:— County of ^ <VW 1 Xam.ta.CO Gty of ^ 'a>v J \Xt>xc^ 



.^c 



(Na^ 



a^ 



aid^\i J\2H.UsAoJ. .St4 -^"^^— Dist.;bct 




and 



^„ :^<:c:n,i^A,.»»i^^ ."jf •?;„".a^'L'«;«T: ivt'c" .^.".vjr .t%'.'.';':«"'":«'-'"" ) 



CATM OCCURS *W«T FHOW W»Wi»w »»».- 1 »»-."».- " ' .J- .-- mVmV i^.Tr^n or ■TBCKT AMD Ml 
OtATM OCCUmiCD IN A M»«FIT*I. OH IWSTITUTIOM OIVl IT« NAME INSTEAD Of STNCfT AND Nl 



I 



FULL NAME 



SI \ 



PERSONAL AND STATISTICAL PARTICULARS 

1 coi. 



^Mol 



U 



UATK OF MIRTH 



?-c(r 






I Month 1 



.\«;k 



S INC. I.E. MARKIEI) 



t 



) '<'ti I 



(Uny) 



Mntilhs 



(Year) 



Da vs 



WIDOWKD OR niVORrKD I 

iWritf ill M)ci»l (leMtKtiHtioti) "^ 



niRTHPUACK 
fstale or Connlrr) 



NAM!-: iW 
PATHKR 



BIRTHPLACE 
np FATHER 

(State or Com n try) 



MAIDEN NAME 
<M MOTHER 



y. 







VJU.CO 




\e\ t^ ^^v 



Lf. . 



cKt^ 



(ii 






BIRTHPLACE 
OF MOTHER 
(State or CoiitUrvi 



' r w r W V.^ I 



„ ^ ) &\t^ ' 'VvCi. 



•HX'IPATION 

Kfsided in San Fi a»t iisfo 



Vftttf 



yfoiifhs 



na v$ 



THE ABOVE STATED PERSONAL FARTIt II.ARS ARE TRTK TO THE 
BEST OF MYJCNOWLKDCiE AND HKLIEF 



(Inf.. 



nuant 



/V«*4A^WA, 






MEDICAL CERTIFICATE OF DEATH 



DATE OF DEATH (^ 



Lul 



(pioiUh)J^ 



(D*y) 



(Yesr) 



I HHREBY CKRTIFY, That, I attemleil deceased from 

V|^,vlu 1.'^.,. 190 I to. ^l.iJU^..JiJ3ii. lyo ' 

that I last saw h ^.> alive on H^^^H ■- 

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



190 



M. The CAl'SK OF DIvATII was as follows: 

^ 3 .^^-■<.M..^^:cvvCa,'v' MIVl^x.^ -v.^^i^t^» 



Dl' RATION Yeai-s Months Pays Hours 



} fai;s 

CONTRIBUTORY L J^cU^^m.ft» &|^ 



^ji^».^-W- - h 



■ V • 



DURATION ' irars * Mmiihs o Days 

(SIGNED) l-.A. ()w H^HXXt^ 

^vJ.M ^ ^ iQO ' (Address) 5"^ j ^^wfcb^. 



/fours 
M.D. 



SPECIAL INFORMATION w»y ^ MnplWs, ItstftytlMs, TranMs, 
•r lecMt ResMeib, 4i4 penMS ^\ft% away frM Nse. 



Usui IrsMfict I '^W^xcc. 

Mn «as ihMse caatractd. 
ffiililplinaKeatli? 



llvW im^ «l 

nartflf iMtfl? 



^fi 



PLA<^ OF BfRIALOR REMOVAL I DATE of Bf RIAL or REMOVAL 
INDKRTAKER ^ H ^ ' TulLy^JAj 



CAddresR 



N. 



^v.ry Item of Inform.tlon .houW l»« crsf-Hy -pMl.d. AGB •^^^^^^^^J^^'^'^^ \ , ^"^^ nli-'ljfr:!! 

•tate CAUSE OF DEATH In plain term., that It may be ppopeHy elM^M. Tlia Special Information Iof 

•ona dying away fiH>w home should b« glvsn In vtm^w Inatanca. 



■■| 



»» 





1 t' 



I', 



I f 



•p 



H 




1 



1 



' I 




9 li 





I)(ff(' F/h'ff, ^ 



.0-vuvo 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

nS:l'Cn REFER TO BACK OF CERTIPICATC FOR INSTRUCTIONS 

532 



H<.;ii.l of IU;ilth- K Sn. n ^^^^^g 




an 



loo'i 



Megistered JVo. 



DEPARTMENT OFPUBLIC HEALTH=City and County of San Francisco 



Certificate of H)eatb 

( •Q. S. Stan^ar^ ) 
PLACE OF DEATH:— County of^<:t>vOAa>VCvuL^ City of ^^O^O ^^veut^Ci. 
rNoJ C) '^Xa^T.u St.; 3. Dist.;bct. -'crlJk and 

/ .r Dt*TH oJfcuRS AW.y from USUAL RESIDENCE give r*CTS "^i/° ;<>'V ";;"^ „%%";*i^^^ 

V ir oc*t4)occurhcd in * hospital or institution give its name instead of street *nd number. J 






FULL NAME 



.UJVA.OH^' 



.CJA{tc„i 



PERSONAL AND STATISTICAL PARTICULARS 



si:\- 






yyjxXx' 

1 



C(>I,<»R \ 



II 



X ' . I-: 



MuiitlO I 



bl 



)V< 



J» V 



II 



(Day) 



M,>Hlll> 



IH 



(\'r-;ir) 



lUiv. 



SIX'.I.H MARklKl). 
WII>M\Vi:il OR DIVORCKI) 

iWiitfiii MMJiil <ksi}ftiation) 



lUUTtlPI.AOK 
isiati' or Country* 



NWIi: Of. 

I- A I'm: R 



HIRTH|'I,ACK 
<>»•■ lAfUKR 
•Slatf or Coutilry) 



MAIKI-'N NAMK 
<»l- MOTlUiR 



l-IkTlH'I.ACK 
OF MOTIIKR 
(State or Country) 



<H'*. ii'A'I'lON (h^ 




,dUH-.A>c<x 



1 1 




MEDICAL CERTIFICATE OF DEATH 

DATE UF DlCATIl 

(Day) 



(Month) 1 



(Ycnr) 



I HI':KI:HV CPIRTII-N, That I atteiukMl deceased fitmi 

Unit I lasl siiiv h ■•.''- iilivcoii >'-'-^H ■^-■' «/> ' 

mill that lUiiltl ocnirncl, mi llic dale staliil almvc. at V> 
Q. M. Tlio CAISIv Ol" DKATII wa-s as follnws: 






LMr^xu. JA^XKj 








) I'll I 



^f.nifhs 



/).n 



I'm: \HOVF. STATJ:I) PHRSONAI, I'ARTHTLXKS AKI-. TRfH TO THH 
IlKST Ol- MY KNOWI.l^H'.K AND HKUIKK 



'Adc 



^^ 



no 



ilire,. I 000 A).La-Vu it 



or RAT ION ]\ars 

CONTKIIUTOKV 



.Votitfis 



Pays 



Hours 



r)rRATM)N 



Afonlfis 



(SIGNED 

i,; 






/><n.^ 



4 



1 '1 






/A,hi.,.«.> Rli ^AMhAi ^t 



Hours 
M.D. 



SPECIAL INFORMATION only for NospiUis, Inst 
or Rfcpnt Residents, ^nd persons dying awdy from lionie. 



FMiRer or 
Usual Residence 

When WIS disease rnntracte<l. 
If notttpiiccvldt tk? 



Now toll at 
n«re if lettb? 



Trnistents, 



Days 



PLACE OF DrRIAl, OR KICMoVAI, 




I NDKRTAKKR 

(Adcln"*'* 



OjUkkjiA^ 



SH\ 



DATKof nt HiAi. or RHMOVAI, 

^^ t9oH 




N. B.— Bvery Item of Information •hould be carefully .upplUd. AGB .hould b« .Uit«dBX^TLY. PHYSICIANS should 
•t«te CAUSE OF DEATH in plain terms, that It mny b« properly classlftod, Tfc« 8p«clai Information for per- 
sons dying away from homa ahould be ftlvan In v»»i'p Instance. 




\ 



I I 



f 

H 





.p 



WRITE PLAINLY WITH UNFADING INK — 



Boiird nf H-:tltli — 1-' No. 15 



^feU&PCo 



D((h' Filed, 

i 




WO'i 



THIS IS A PERMANENT RECORD 

REFER TO BACK OF CgRTIFICATE FOR INSTRUCTIONS 

5.33 



Bcgisterecl J^o. 



Der 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certifkate of 2)eatb 

( H. S. StanOarO ) 



^? 



4 



PLACE OF DEATH:— County of 'CX^M J\x\. ^vC-v^coCity ol CL^\^'^ \(X 



(p»».^t;. 



^f. 1 4 I 

(ir DCATH OCCUMS fcWAV TROM ». . «- r .^.,,.„ ~r .▼« 

ir OCATM OCCURHCO IN » HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD Of STR 



St.; 



Dist.: bet. 



and 



H OCCURS fcWAV FROM USUAL R E S I DE NCE GIVE rACTS CALLEo rOR__UND^^ ^SPtC^AL^IN FORMATION- ^ 



FULL NAME 



JX^A^Oj 



l ^iA 



SH\ 



PERSONAL AND STATISTICAL PARTICULARS 

TN \ I coi.oR ' 



':v. 



DATl-: 1)1 lUKllI 



^" 






A».H 



X\ 



)'nn ^ 



il);tv) 



Motiths 



W 



I Vtar) 



Pa 1 .« 



^IN<.I.F.. MAKHIKO. 
UllxiWKU OH DIVoKt'HI) 

i^\;:t'iii ».(M-ial lUsiiMiatioti) 



I'.IkTUfl.Ai'K 
M.it. .,! C.iuntry) 



NVMi; in- 

rATin;R 



'HRTHPi.ACK 
«>'■ 1 \TMKR 



MAIDi's NAMK 
<'• MOTHHR 



''IkTlU'l.AfK 
"I MOTIIKR 
Mntf or Country) 




MEDICAL CERTIFICATE OF DEATH 

DATK OF U1:ATH 

nay 



(>iiiiiitii) i 



I go • 

(Yi-ar^ 



I iniKIUJV Cl'RTIFY, That I ;^tten.lc«l dcccascil from 



11 



i\.wWu IQO'I to ..)^VVM4_ JX3.. I<)0 1 

lat I last saw li alivt- dm 

ancLthal lUath occurred, on the ilati- staliMl above, at » '0 
'j . M. The CATSK t)F HIvXTI! was as follows: 



Wi-* 



Hours 



DURATION )'eats Months •■ . Days 

C ( ) N T R nU • T ( ) R Y ll>W OO. WV^ tX. , Ls, C. vCt^ 

' .^Touths .^i Days * Hours 



DERATION 



ycar% 






^n^ a 



L<xJU^i^^^nA 



rj , 



occri-xTi,)^ 

Kf^idfd ni San /rani i^t'o 



)'rain i '^. Month ' 



/hn 



THK A!;, ,\j.- ^TATHI) PKUSON M, l' \H riiT f.ARS ARK TRt K T< • THK 
BEsi ul- MY KNi)\VI.HIi<,K AND HHl.l»:i" 

CAtlrlrcss 5 3 



/>\.4^a. 



(Signed 



) UJ, C. Lk^U^^>w 



SPECIAL IN 



M.D. 



^, ^^.^,_ .J FORM ATI ON mIv lor Hospitals, Instltollwis, Triis^iils, 
orTe'crni^fsMents, and persons d^N «w«y *"» lM>»w. 



UsMi ResMence ^<^ VCVM,^ 



How long it 
Plvf tf Deitli? 



i 



99f% 



When was disease contracted, ,4. /i t 

H not at place ol death ? '^^Vr^ O vu^M^Ha 



I'f.ACK OF III RIAI, OK l-:r%f'i\\I. 



^\^ -^, 



\ Si> 1 : RTA K F l< D AA, "S"W 




N. B..^B*«ry Item of Inform.tlon iho»W be c«r.f«lly •applied. AGB should ^ •*«*»i^BXACTLy. PHYSICIANS .hould 
•tote CAUSE OF DEATH In pl.li. tenms, th.t It mmw b« piH^^rty ^•••Ifl.d. Th« Special Information for pr- 
wwa drlni eway from homo Rhoyld hm ilv«n In •vspy Instance. 



\[ 



II 

(I 

I 

I 




I 



)• 





4' 
It 




II 



jViai.l 'f Iliiilih -I' No. 1^ 



])((/(' tiled , 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

B&PCo mrCW TO BACK OP CERTiriCATC FOB INSTRUCTIONt 

~" 534 





as: 190^ 



Registered JVo. 



KAJi 



Deputy 



Dfflcer 



DEPARTMENT OFPUBLIC HEALTH^City and County of San Francisco 



Certificate of 2)eatb 

( Xk. 9. Standard ) 



PLACE OF DEATH:— County of CL^^-u 









.MXavca.^ 



01^ 






St.; 



Dist; bet. 



IS t 



iv. 



and *> ^ 



ft 



V tr Ot»TM OCCURRIO IN A M««PIT«L OH lN»TITUTION CIVC ITS NAME INSTCAO OF 8THCET *NO NUMBER. / 



r^ 



ii 



FULL NAME 



,A.,a.v. 



.Cn^1,,Ou"»:iA.\, 



PERSONAL AND STATISTICAL PARTICULARS 



si.:\ 



fnAv 



COl.oR 



\'1 



DATl-: (tH BIRTH 



A(,l." 



(Month) 



>^tN«".I.K MARRIKD. 

wrnowKi) OR niViiRrKO 

(Write in social clestKtiatinn) 



»</». 



i|)i»v) 



MnttlfiS 



\ ta 



r) 



PiJ 15 



'h^ 



KKKJ^<k 



RJRTHPI.ACK 
(State or Countryi 



VAMK or 
f-ATHKR 



niRTnri. xcf 

«»t' lAIIIKk 
<^^t:H( ,,r <.'iiiiiitrv 



<'l- MOTHER 



ntRTHPr.Ai'H 
'"• MoTltlvK 
(Stntt (,r Country^ 



•HCll'ATioN 



(ft 



i\ 



ft 






MEDICAL CERTIFICATE OF DEATH 

DATK OF DKATH 

(IHiy) 



ilotith) f 



(Year) 



^ I JIJiRHBY CHRTIFV, That I attendctl deceased from 

190 — to ■- 190 ■ ■• • 

that 1 last saw h :: alive on ■^"^ v::.rrr-^7r:^ 190 

and that (Uatli occurre<l, on the «latc- stated alxive, at 
M. The CAl'SIC t)l- 1) HAT 1 1 was as follows: 



M. 1 ne V.AI r>r. v/r i'lv.n * n 






K * 



4 



Rr-idfi1 III Siiii f'l oil, i>i<> jU )V«/' < 



4 



M,<,itli- 



Tin; M<i»vK si-\ ihn I'KRsoNAi. I'XK'rrrr!. \Ks AKi, tk' h r-> rm-: 
HHST 01 Ms kxo\vi,i:i)<;h and ru:i,iHK 



•tttf..-)n:int 



<\i\<\ 






ress 



U 



nr RAT ION Vtars 

CONTRir.rTORV 



Dl' RATION ^ Vcar^ 

( SIGNED ) L&'vr»\X^\i 
O.J...r . 



Months 



Days 



Hours 



^ (E k ^' 



Pavs 



Hours 
M.D. 



t 









A 1 f*'. 



1 I 'I J 

lit 



«jPECIAL INFORMATION only for Hospitals, In^tilutlons, Tr«nslf«l$, 
or Recent Residents, and persons dvlng away from Um, 



Former w 
Usual Residence 

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



N«w lonq al 
Plarcof De4tk? 



Days 



I'l.ACi; t>l IJIRIAI. Ok NHMoVAI 



I SnilRTAKMR 



DATi: .f Bt H!Ai. or KKMOVAl, 




XhW \j)\^^iL 



J 



190' 



w*>^ 



N. B— Bvery Iten, of Information .ho«fd ^ cnrafull,. aupplled. AGB ahould ^' ^-^'^f ^^T*^?;; Jil^JSL''^!:!*,^*^ 

atat« CAUSE OF DEATH In plain term., that It may he properly ^la.alflaJ. The Special Information for per- 
aona dylnft away from homo hHouM be tlvea la every Inetance. 



i 



\ 



II 



«l 



!•! 



« i 




• 4 




II 



it. 

I I 



s 



m 



i 



W( 



H 



li 





<«' 



WRITE PLAINLY WITH UNFADING INK — 



Hoard <>f llcnlil 



, ]■ So I ', "^"S^S^ H& |» Co 



THIS IS A PERMANENT RECORD 

WEFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



Re^iiifcrod J^o. 



ihitvinioii, ^UaJ^ ^^^H 

^M.<^ Xt^ Deputy He . 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of S)eatb 

( ta. S. Stan&ar? ) 



A 






' 



PLACE OF DEATH:— County of^Va>v v1 Va^vt .i CCGty of 'a^v >JA.a %vtcA 

/ ir oc^H occuWs AWAV ri»oi« lASUAL RESIDENCE Give tacts call 

I ir BeATM OCCUHHCO in a MdiplTAL on INSTITUTION GIVE ITS NAW 



Ot) V^^W^ 11^*-^^^^^^ St.; Dist.;bct. _— ^-^^^ ^nd ^ 

/ .r ocAh occuU away r.toi» JsUAL RESIDENCE give tacts called ;o« 7"" sT%'EE/iNrNu"ir« '«*""" ) 
V ir Beatm occuhbed in a mJIpital or institution give its name instead or street and number. y 



- ) 



FULL NAME 




:)iAl/YV 



IfcxcU^ 



SI-X 



PERSONAL AND STATISTICAL PARTICULARS 

COI.OR 



Jx^w-cJuL 



I'M'l", 01 ISIKTH 



A<.)-: 






MmiiHi^ 



J'/iK 



iDiiv 



M.nil/l! 



(Year) 



3. 



n,i 



\K n>'t\\]-f) OK r>!V(>kri-:i> 

'Writ. I'l 'Alicia! «U'«-iv iiali'iil) 



IHRTniM.Ai'l- 



'1 



(Stat 



r "T 'iiiiiury 



\ WW nl- 

I vrin-.R 



i!!K riin.ACK 

'>' IM'IIKR 

'^*'iat. .If rmnitry) 



MMDKX NAMF 
<>l MOTMHR 



HlkTHIM,ACK 
J»J MoTlIKk 
^Mi\w ur Contilry) 



nccri'ATlON 



Horn; 0>wo 

lu! 



ri "vxO*^V'"w 



)Vrff.« C5 .V-'"'-'/' 



WEDICAL CERTIFICATE OF DEATH 

DATE Ol' DKATIl jj y 






CDjiy) 



(Year^ 



I m<:Ri:nV CIvKTHV, Thai I attciule<l dctcastMl from 

I (' ^ . 

tlmt I hist saw li " alivt- oti * ' I90 ' 

ami that doalh «)ccurrci1, nii the ilatc statcti above, at 

31. The CM Sl«: (M- I>1:ATII was «•« follows; 



(^,^CV.>xtcU 



Dr RATION Yeats 

CONTKIIUTOKV 



.Vonihs 



Day 



Hours 



DIRATION 



Ytuu-s 



(SIGNED 



) Uik\.w<i 




Months Days 



f fours 



M.D. 



JlKuiin., 



^SPECIAL iNrORMATIONOBly f«rH*s^W$.1ii! 



w RfCfnt Residents, and persons iYm ««'">)' ^•n' h*"' 



tustitttions. frii^nts, 



FomMfr w 
Usual ResMence 

Wliff was iMsease contracted, 
if Mt at plare of death ? 



nwttf UtiHi? 



Daj'S 



HI- \ uf >v !•: s r A r 1 ■: u p k r »^<)N- a i, p a r t i r r i , a r s a k i: r k t ' k t< » r n h 

HKST oi' MY KNnWI.KIH'.K ANI> lUU.Tl'.l' 



Unfo 



rtnntit 



f\cl.l 






PtJiCK «H' nt'RIAf, nk kKMi»V\I. 



%_aL 



■t^^ 



rNlJllKTAKKR 




i»A^i:»>f lit HiAi. or ki:m«»vai, 

'Xk. 1901 

v.! 



A. 




CA.i.h... obi 5^- IH liv Ji 



•t«tc CAUSE OF DEATH l« P%n\n term., th.t U may l»c pr.>p«rly cl.ssimd. Th« Specl.l l»form«tlo« for p«i- 
■««s dying away from horns should be glvsn In svory Instance. 



r 






■ !• i 



ill 





He 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

„,,.f ,U .,.h-. No K t^l^^mtl'Co mrCB TO BACK OP CERTtFICATC FOR INSTRUCTIONS 



1! 



!i 



4 



i\ 



t 



f 




i 



I)(f/(' Filed f 




Re^istet'pfl A^n. 



XiA-u Deputy Health Officer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of Beatb 



PLACE OF DEATH:— County 



( U. S. StanSatO ) 

1 






City of 









tNo 



.4 




<X\ua 



lbcH.K\A,CX.' 



St.; 



Dist.; bet. 



and 



/ ir ocaX occufifl *wU rmom USUAL RCSIDENCC ^'ve '*CT8 cM-uco 'O" """J « 
V. ir o]3*TH occunnco in « Me«PiT»i. on ii««titutiopi oivi its NAME iwst«*o or %r 



SPECIAL INrORMATION 
RCCT AND NUMBKR. 



) 



FULL NAME 



'tV^VX 






PERSONAL AND STATISTICAL PARTICULARS 



4 



si-x 



^L 



I'M i: Ml ItlRTH 



Ai,H 



?!., 



I Months 



COI.OR 1 . A 

1 r " 

V \ 



,11S 



IS ,-, t 



1A.w/A> 



(V.siri 



Ai V. 



wiiMnvKn OK nivoKiKo 

tWrit( in MKial i|i*iv'jintion) 



I'IRTMI'I.AOK 



(k 



'■ATIIKR 



niRTun.ACH 

<>I" l-ATHKK 

(Stfiti or i"iiinilry) 



'M MOTHKK 



ntKTlHM.ACK 
i"^t;itc oi Couutrj 



«»*C1 I'ATIUN 



?). 



(I 






M^Hitlv 



!h 



THK \liOVF. ST\T»-I> l'KRm»N^I. rAKTIi-ri \KS ARKTRJi: H> TlIK 
HI'STO) MY KNu\Vl.Hr)«*.K AND HHI,1»':H 



' A'ldfe** 



1 



% 



^'yx 



,0 



MEDICAL CERTIFICATE OF DEATH 

UATK OH DHATH 






IMV» 



(Vcflr> 



♦ * * • 

I 1II:RHHV CI;RTII-V, Tlmt I atteniknl acr^Hsi.l from 



I«)n 



that I la'^t saw h .LA>^ alive on 

EUi.l that jlcath »>cciirrecl, on the .l.iti- stated nlM»ve. at 1 -iCi 
^ M. The CAr^I-: HI- IHiATII was as follows 



DrRATION }Ws _ ^fonths Pays 



Hours 



DTRATION 
(SIGNED) 



dvt 






Pavs 









Hours 
M.D. 



nUfli 



Special Information ""'^ forjiospiiiis, inflUuttois, iranMnts, 

•r Rfcfnt Rfsldents, iN persons 0lif tmvi \tm " 



1% . i1 ll«»l«i|* yQ 

rontra< 
If not it plof e of death ? 



Fornix « 1 
Usual ResMeuce 

When i»is df^a^f roMracted, ^ %^^^4^v^ U^N^ 



ftiys 



I'l.YCK t(| nt H'Al. nR ri:m«»va!. 




t NIUIRTAKKR 






fUT^C of 111 KiAi, c,r RKMOVAL 



9oH 



Aa<ircH« Ibl M rU.4,*M*-«>v 



^ 



•t«t« CAUSE OP DEATH l« |»li.l» term., th.t It may he propcHjr cl.«.in«il. Thm Special Nfoi^.tlon for — - 
»'»n« dyl»g away from hoiw© should be *lv«n In •v«ry ln«ta«»c«. 



* 



<Md 





Ij 

1 






« 



i 



jj,,Mi.i ..r I! .nil I' Nn- i-^ ^ti: 




,\ 




m 



I t 



1 1 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

„& ]. Co REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 

537 





as- 



lOOH 



Dale I'lh'd , 

cL(m^ "ixA^M Deputy Heatth Officer 



Bos^Lsfprcd JVo. 



DEPARTMENT Ofr PUBLIC HEALTH=City and County of San Francisco 



Certificate of 2>eatb 

( XX. S. Stan^at^ ) 



f»e.U) 



PLACE OF DEATHi-County of OO/^ J.^aA^.tvC r City ofC'a^v J/va-vxCca 
oil OMU\xxL JctHtK'-^' 



— ©ist.? beV 



»r DC»TH occurs nwAV rubM USUAL residence <i'" J**;;' ZT^ZTr ,J«Tr*o or btneet and NumBtd. / 

ir OCATM OCCUHRCD IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD Of STREET 



FULL NAME 



li).Jl^>vi^3 a ybAv^NxL'. 



'•I \ 



PERSONAL AND STATISTICAL PARTICULARS 

i COI.OR 



QlVl 



HA I I. «ii. itlUTll 



X 



iMontli* 



ll'? 



I 



A I . I- 



) 'lUl I 



Day) 



!/'»»//'//< 



*»'ear 



MEDICAL CERTIFICATE OF DEATH 

DATK OV PKATIl 

(Dfiy* (Year) 



(Month) T 



/hn 



SIN'f.I.l-: MARUIHl), 

wn>(>\yi:i) OR niV()Kri:i> 

'\\!if( ill MK-ijil cltsiji^iialinii) 



niR rnvi.AOK 
i >iia!i' iir Cuniitry 



•■Allll-R 



lUR riiri.ACK 

<>I* I ATllKk' 
(stiitr or Coniitry 



MMDKN NAMU 
<>1- MuTUHR 



HIHTIU'I.AOH 
<>!• MnrilKR 






YVfi-VV^^ 



H 



'»CCri'ATU>N 



^ 



Ri'siitfit nt Sitii r I iuu i^i'n 



J 'i'ti t 



I/,.;////' 



} hi V. 



TMi; AHoVK STATKn PKRH<lN:At, |'\RTI(M |,AK>^ KKl'. IRl K TO Till-: 
HHST Ol" .MY KNOWI.llx.H AM) HHI.n:H 



niiformant 



u. ^.a. -^x^xtv^ci %^^vtcwi 



fA.1.1 



rv'.'i 



1 



""^ I III«:KHBV Ci:RTirV, That I atUnik'il .ktvasol from 
/^V\.\x->1 *' I<pH tn tt^,li^ Ov^ IC)0H 

tlirtt I last saw h ^ "k ' alive on 1^' > ' Kp '» 

an.l that death occurred, 011 the .laU ^tatc<l above, at I A >0 



U-M. The CAl'SE OF DKATIf was as foHosvs: 



,0: 



DT RATION Vear^ 

CONTHIBrTORV 



Months 



Days 



Jhntrs 



nr RATION 



(SIGNED 



Vi'at's 



V 



.Months 



/hiv^ 






•44 



^ 



1 «K> 






Hours 
M.D. 






SPECIAL INFORMATION •«!> tor Hospltjis, lnstilntlMS. IfMsletts, 
or Recfnt Residents, «Ri persons #>lii| ai»*y frow Miie. 



F«rmer w 
U$«il RfsMnce 

Wlwii WIS <lse8« conlrar tf#. 
If not at plirr of tfrttfi ? 



How ion) it 



^ 



rLiXCK OH lllRrAf, OK KHMOVAI. 



n 






I»A'fHo|' ill Kiu, ..r KKMoVAt, 

I90H 



I NlilRTAKKK 




Sr^-V 



N. B.— Evrj, Item of l«form.,1o« should be c«..f«lly .-l^pH^d. ACB .hould ^ •••••±B'lii?;j;^,^! ,„frj^1!fllt^4f^i'' 
•t«te CAUSE OF DEATH In pl»m term., that It m«y \m pi-operly cl-wlfled. Th« Sf>««lal l»fopm«llo« for psr- 
•on« dying away from homo whould be given In •y^v li»«t««e«. 



I 



I'i 



•i 






t ^1 




IV 



I 

1 1 

I t 

( 



Itofl 





WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

^, ,f „.„,„_.. vo .. ^^^^^^ H8:l- Co REFER TO BACK OF CERTIFICAT E FOR INSTRUCTIONS 

5:^8 



Registered JVo. 



DnI,' Fileil, V-^ 0.S- l^O'i 

dUKA^ iuv^ Deputy Health Officer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of Beatb 

( "a. S. 5tanC>arD ) 



PLACE OF DEATH:— County of 



ini 



i 



vO ^ 



\.aJ .City^^^^A<ct.\' 



T, 



>vL 



^Uu. 



i 



No. 



St 



Dist,; bet. 



-and 



^ — — ^t.j uist.;Dct.^ «•"- 

„"_^„ ,,-,,., prSIDCNCE Give FACTS CALUtO FOR UNDER SPtCIAL INFORMATION' A 



— ) 



FULL NAME 



rLvlO "fi 



i 



>Ui\/sUt^i 



si:\ 



PERSONAL AND STATISTICAL PARTICULARS 



DATi; (>!• lilK ill 



AC}-: 



(Mumht 



^ 1> y,',„. 



(|)JiV) 



Months 



r Is I, . 

(Yt-ar) 



/', 



/ I A 



SISC.l.K. MAKKIHIi 

\vn>fi\\F,i) UK i)iv(»Hri:i> 

(Wiit.-in s(Ki:il (Itsiv'iiiili'iii) 



niurniM.Nr)-: 




NAMl" UI' 
HArill'.R 



tUKTin'I.ACK 
•>1 > NI'Ill^R 



'»! MOTHKR 



•nu inpLAri.- 
iu Mm|||1-:K 
"^'11' Mt Coniilry) 



LlW-i/Yxev*.* 



ui'cri'ArioN Q ft 



Kfsidfit in Sdtt I'l mil tst'ti 



) fii I 



\r.,t,th^ 



/hi V 



I'm: \RoVR 8TATKI) PKR'^ON-AI, I' \RTirr LARS A K !■; PRVK T< > IIIH 
HKST OF MY KNUWM'IX'.K AND Ulll.Il'J* 



'Inf'Tiiiunl 



f Atlilre«4«s 






MEDICAL CERTIFICATE OF DEATH 



LI 

(Month) 



(Yfnr) 



DATE OF UKATH 

I K (i>ny) 

I illCRHBV CIvRTU'V, That I atlcii«kMl aeceascMl from 

_ I9O — to -— IQO 

that I last saw h":^^ alive on ' — — IQO 

and that death .jccurrc*!, on the »latc- •<tatf<l a!)ove, at 
- ^y. 'fhc CAl'SI-: t)l" DlCATll was as* foU<»ws: 



Ur RATION )'rars! 

CONTRint'TORV 



Months 



Days 



Hours 



DT RAT ION 



(SIGNED) iW-ta 



Ycar^ Months Days 



Hours 
M.D. 



111! 






)i.u.^ 



X 



H*<J 



/ » t 1 _ . \ 



A k &h n 



\ O i 



Special information only for Hospitals, Institutions, Transtents, 
or Recent Residents, and persMs tfying away irom Ijonie.^ 

Former or "i ^ U 
lesldeiM:eOM.<Vl^>^ .^ 



How lonq at 



UsNal Resld€WcUAA<Vix>^'^^^^t J U^i < piare of Death? 

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



%9tf% 



PI.ACK 0|. niRIAI, (>K KFMmVAI, | D ATK of ^HfKiAf, or KKMdVAI, 

- 1^0^ mHa.4 4v#>x ''^ 



(Address 



mtmUQAVSE OF DEATH In pl«ln term., that It m»> be properly cl«..lfleil. Th. 8pe«t.l Information for par 
WW* dying away from home should be ttven In mypy ln«t»nc«. 



m^' 



F 

i 



' I 
I I 



i • 



r 






II" 




WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

H<x,r.l . f licnlih-F No is ^^^H&PCo WCFCR TO BACK Of CCWTiriCATC FOR INSTRUCTIONS 



Da/r Filed, 




%S 



100 "i 



Registered *^o. 



r^* 



>.'50 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



PLACE OF DEATH:— County of^)<Xo\^ iXai^ 






No. 



o 



Certificate of H)eatb 

( Ta. S. Stan&ar& ) 

City of -a^v J 



C *.,4 



A.a ^ 



k^,h,^.u^.: . St*5....^ Dist^bet. :;OAV, . and 

/ .r DEATH OCCURS *W*Y FROM USUAL RESIDENCE G.vt r»CT8 c*ttto ;<>« "J*"" 'JmltT^AHS'Sumiln'*" ) 
V ir DC»TM OCCURRCO IN A M««FIT*L OR INSTITUTION CIVC ITS NAME INSTIAD OF STRKCT AND NUMBER. / 



FULL NAME 



^ 



b^CL:^\.SL.Lj^. 



X\.(Y-'S.A.'.. 



PERSONAL AND STATISTICAL PARTICULARS 



si;x 



h 



DATK 111 lURTH 



A«.K 



COLOR ^ 



( Month) if 



T ' iVtjts 



(D«y) 
M„»ths 



\ far 



/)rf 1 ,v 



MEDICAL CERTIFICATE OF DEATH 



DATE OF DKATH A | 



rofoiith) f 



(Day) 



igo 

(Y«ir) 



SIN<.l,K. MARRIKI). 
WltXlWKI) OR DIVORrKO 
(Write in Mocial fli><9iKiiatioii) 



HrRTflPI.AOH 
'Stat«i or Country) 



NAMK OF 
FATHKR 



HIKTHPl.ACK 
OK FATHKR 
(State or Country) 



MAir)HN NAMK 
OK MOTHER 



niRTHPi.ACK 
OF MOTHER 
(State or Cotuitrv) 



OCCUPATION 



on 






VCC^vCi^ 



mV^CLi^ 



tb 



I |lERIvBY Cl'RTIFv, Tliat^ I atteiukMl «lcceased from 

j^^..\ 190H to ^\^tLu...X^ 190 S. 

'alive on ^a,C\.s ,k 190 » 



at I last saw h ^^ 
ami that death occurre«l, on the date stated al)ove, at v Q 5. 
A M. The CATSIC OF OICATII was as follows: 

I? i 



DURATION Years Months 

CONTRIBUTORY -fXfnx^. 



Days 



Hours 



Years 



(hi 



rs h 






r"D 



T AA A . \ h fr K 



U. 



\ U ! \- 



Rfsiil^ii in Snn f'lanth^a I't )><;/« 



\hniths 



thix. 



IHK ABOVE STATED PFRSONAI. PARTICULARS ARE TRIE TO THE 
BEST OF MY KN<>\Vl.i:Dr;E AND HEMEF 



(Inf, 



% 



^rttiant 



it^V-'e. 



l^ 



U.l<1 



rc!«s 



an I 



^ 3o' 



aHA.AAc 



<ui ^ 



Months 



Pays 



» T 1 



DURATION 
(SIGNED) 



Hours 

M.D. 

t 



SPtCIAL INFORMATION wHy Nr Ifwfltoh. Iistftitltis, TraiyMts, 
or Receat ResMents, and arsons 4Hnfl '«'<)' Iron home. 



Fomifr or 
Usual ResideRce 

Hkn was tflsease coitracfei, 
If not at place of deatk ? 



MW MRf M 

Flicetf kati? 



Days 



PI.ACE OF niRIA,!* OR REMdVAI, 1 DATE of III RIAL or RKMOVAI. 



T0O4 



INDERTAKER 

(Addreiw 






N. B.—— Bve 



-Every Item of Information should be carsfully Rupplled. ACB should bs •tatsd EXACTLY. PHYSICIANS shoiiM 
state CAUSE OF DEATH In plain terms, thst It may be propcHy ela««lfl«4« Tfca Spsclal Informattoa for psr- 



•«ms dying away from horns should be given In svsry Instance. 



• It 



f 



I. 



I 



i 



< 



i^ 



♦r 



♦ 



M 



K 



^liot 



Ill 



Ul 




♦* 



«l 




I'i 



n<>!iii 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

,,Ml..uh-l No i^^4fS^H&l'Co REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



l)nh' Filed, 








ldO\ 



lie ii sic red JVo. 



5^10 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of Death 

( "U. S. Stan^arD ) 



PLACE OF DEATH: — County 



of-^l 



<X''VXA.AA^. 



City of 




tMJ'>>V^W>V vCu4 



c 



(No. 



St 



Dist.; bet. 



and 



/ .rotATH OCCURS *WAY FROM U S U A L RE S I OE NCE G.VE r*CTS "'^i/_^';f "^^J^^" :^;";\' '^ 

V ir OC»TM OCCURRtO IN » HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. J 



^ 



FULL NAME 







SJ^\ 



PERSONAL AND STATISTICAL PARTICULARS 



(yyiaL. 



lX)JkAXi 



I'Vll. Ill lilKTH 



\(.H 



Month* 






I Day) 



M.tul/is 



' Vtar) 



/),n 



^iNiIJ* MAKKIHIJ. 
iWntijn wK-ial cUsij;,naliiiti) 



tUKTHlM.ACl-: 
(St It, ,,! Couritrv 



NAMK Ol 
lATUHR 



nikTMIM.ACK 
HF lATIIKR 
'Stale or Coimtrj' 



<»1 MdTHKK 



l!IKTHPI,ACK 
"1 M<»THHk 
(State or Contitrv) 



Cr\A' 



f^U. 



V v\ n 



-X '1 ' 



MEDICAL CERTIFICATE OF DEATH 

DATH in- DKAI It A f, 

I in:Ri:nV CI^RTII'V, That r .itten.U.l .U-crasd fnmi 

— tti — "■ — ■ — —^ip 



(Yfar> 



■ , ■ - : — — — — — 190 

that I last saw h • ahvu ou — — — — 

ainl that death occurred, <>ti the .late stated above, at 



•190 



M.^ The CArSl'! ni' l)i:.\ril uas as follows: 






)\a^ 



n 



^r^X 



a 



L^Q, 



v.a 



1)1 RAT ION }'rars 

CONTRIIH'TOKV 



Mouths 



Days 



Hours 



I)r RATION 
(SIGNED) 



Years 



Mitttth$ 



nCCrPATION 



} >rf I 



M,.uth^ 



!h^^ 



lUK AROVF. STATl'D PKRSoVAf. 1* \K T H' r !, \ K< AKl". TKI'K TO THH 
HKST Ol- MY KNo\VI.l.:iH,K AM) l!i:i,n l" 



'liifuTtiiatit 



tHJl^vJk> v^ 'i/CXA^k^>v 



\AAu-^ 6xX'"v\j 4x\.«>xA.-> 



ii k\ 
I .1 



3. (Aildress) y U^ 



nays 



Hours 

M.D. 



Special Information »«'> ^ Hfti^iuH, iMjUiyiiwiii, T(*«ifctii, 

or Recent ResMenfs, and persons dvlng andv from home. 



former flf 
tisual Resi4ence 

WiM Wis <lse««e contracted. 
If Rot at place of tfeatli ? 



Now lofli at 
n«^eol Death? 



1^ 



ri.ACK ol- HrHiAi. OR ri:m*»vai, | i> 



V 



C1-, o 






\ 




i iiiHiAi. or ri:mov.\i, 

%^ T90H 



{Adclrciui . . W 



3^5 Ol\^>\t4iv4 



N. B Every Hem o# }„form«tlon .hould he carefully •uppHed. AGB should b« •t.ted BXJIGTLY. PHYSICIANS .hould 

Mate CAUSE OF DEATH In pinin term., that It mny he properly «l«««lfled. The Special Information for par- 
R-Mia dying away from home should be given In avary Instance. 




I 



1 


'1 


\ 

) 

i 


ir 



>l I 



I 



I 

It 



V 



< .1 






' 



:»! 



t . t 



•I 




WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

Homh! ..f liL.ith- I No. 15 *^^^H&P Co _^__ REFER TO BACK OF CERTIFICATg FOR INSTRUCTIONS 



190^ 



Thih' Filed, NkAXu %^ 

L^yvuus laA>M Deputy Health Officer 



Registered JSTo, 






DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of Death 

( tl. S. StanDarD ) 

+ City of '^ CX^>^' OA.a>\ c 



PLACE OF DEATH: — County of^^Ct^ J^>.cv>vCv4.co City 



rl^.mt).dt, L^dvL 



XK 



St.; 



Dist.; bet. 



and 



) 



/ .r DcX occurs *w*y rHOM uiuAL RESIDENCE G.wt r*cTS cALtro ^ow "NO^" JnlVy'^'iHo'Hu^Bzn*''' ) 

V ir 4*TM OCCUBRtO IN * HOSPITAL OR INSTITUTION CIVC ITS NAME INSTEAD OF STRCCT AND NUMBCR. / 



FULL NAME 



^ 



.<X>UXuJl^V 



tij l1 \x t 



PERSONAL AND STATISTICAL PARTICULARS 

COI.oR 'i 

DAT) ul I'.IKTU 

I 

(Dav) 



« 



f\W>nth) 



TOO 

(YtMlt 






A. l- 



) >.f 



M,,ii!hs 



s% 



I Vt ar 



Af 1 



\V!t).,\VM. UK I>!\'MKtl-:i> 




^ ' \jy>uok^ 



'Siat( or i".»untrv 



I vnn:R 



RlKTHPl.\rF 
•>t- I ATHKR 
'•^l.it. or Comilrv 



MAIhl-tN N-AMi- 



'iK i HPl.Ai K 
(M- MnTHKk 
'^tatf or Counlrvt 







MEDICAL CERTIFICATE OF DEATH 
DATK OF DKATJl 

■ -V :^ 

r (I>av> 

I IlI'iKIinV C1{RTIFV, That I atUMulc.l «Uriasci1 fmni 
.:vu^ 1 igoH i" %^^W '^' iqoH 

that I last SMW h alive on '^ ' I90 

and that <ltath occurred, oti the date statf<l above, at 
' M. The CAT SI'; ( )|' I H*: AT If was as follows: 

nr RAT ION ycai<i . Mouths 

CoNTRinrToRV 



IhlV 



/fours 



It 




I III ><■/•'> 



!,„•;. 



\r,,>iffi 



THK AnovK ^TATIUJ PKK^ONM, I'AR ri-r I, \RS \Ki: rRlK T<» T 
HKHT OF MY KXOWI.HIX.K AM) lU'IJltF 






•tumnt 




f \f1,Ire 



DERATION 
(SIGNED) 



)'i'iltS 



Mttnt/is 



IhlVK 




^x^^ 






f fours 



M.D. 



%v'.,, mo (Addre^^)^^^ ^^tilkU-.-.^ 

SPECIAL INFORWATION «rty hr Hwpttih, l«s«!i«««. Trit^^ 
or Recent Residents, and persons dyinq away from \\fim. 



Usual Residence 

Wfcen w$ disease contracted, 
If not at place of death ? 



How Im| tt 
Ware of Death ? 



Oays 



IM-iCK «»I IHRIAI, OK KKMftVAI. 




^ 



crv^^L v-'^^^^-'ft-'t' 



+ 



I)ATi:.)f nfmAI f»r KItMoVAJ. 



Vk 



%k 



190 



rNIH.RTAKHR 

fAd<lrf«ji 







«. B ^Bvery Item of Information •hould he c«raf«My iiuppr.ecl. AGB .houiU ^J^^^^^t^^,^^^^ \ , ^"^®'f '^^.^ ■•'*"''*• 

•t«tc CAUSE OF DEATH In plnln term., that It may be properly cl«««lfled. Th» Special Information for p.r- 
«on« dyint away from homo should be given In msmrif Instance* 



'f 



ti'lli 








M 



I 





WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

Boiud f 11 ith KN'o i^l^^JB^IJ&PCo REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



542 



nhl'ih'<1, |vJL as lOO'i Brgfsfrrrd J\ro. 

i^'Llc, Deputy Health Officer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Certificate of Death 

( XX, S. Stan^ar^ ) 
PLACE OF DEATH: — County of^^V ^^^ wia' ^ City of vlo ^ ' 

<-n^f^ lDCh^K^.to-V St.; ^— Dist.; bet. ^— and - 

/ .r or.TH OCCURS .W*Y riiOK. USUAL RESIDENCE ovt r»CT8 CM-ttD ;<>« "-^O" ™^;*iJrNuiJ«lf ** ) 
V ir Oe»TM OCCUHHtO in a MO«PIT»t on INSTITUTION CIVC ITS NAME IN«TC*0 Or STUttT «NO NUMBCH. / 



fNo.^^'tc 



FULL NAIVSE 



€Lh„^.L^^. 



M \ 



PERSONAL AND STATISTICAL PARTICULARS 

j COI.oR ^ 






OftlJx 



I 



I»\ri Ml lUKTIl 



i) 



(M<.nth) 



\< : I- 



^ #T 



)V,n 



(Day! 



^r.'fitfn 



i ■»«ar> 



/><j 1 



'^IN'.I.K. MARKIi:!). 
WlDnWKn OK DIVoKt'KI) 

'\\ Titi in -..loiul ilisij.'iiatit>ii) 



l'.IR TMIM.AOK 
(State nr Country) 



KAMI oi 
PATIIHR 



HlkTHIM.ACK 
<•! I ATIIKR 
'^'tnu ur Country) 



^'MUnN NAMJ' 

ui m»»thi:k 



"I MnrilHR 
'^lait or Cuuiilry) 



OCCCFATION 



(B 




MEDICAL CERTIFICATE OF DEATH 

iDav' 



fMiimtli 



I go 

iY»ar> 



I IIF'RI'HV Cl'RTIl'V, That I attciuUMi rlcrcascd fr<Mii 
A up 

that I last saw li ~ alise on ■ ^— ^ 19° 

anil that «Uath ucciirrctl, i»ii the date stati-il above, at 
M. The CAtSI-: OI- DHATII was as follows: 



nr RAT I ON Years^ 

CONTIUIUTORV 



A/oHtfl.t 



i)a\s 



IfOHfX 



a^\/>-^ 



,_a^ 



fiffidfit III Suit Ftamisrn Ah ' '■" 



sr,.,)ih> 



r\t\ 



TlIH AIJOVE STXTKI) fKKSnXAl, )• \u rfif !.A KS AK I! TRI'K To THH 
in<:ST OF MY KNi»\VI,i:i)C.K AM) HI-I.Il'H 



(Inf.. 



ntirim 



^\rldrc^^ 



aj - w icx>u^\-4.o 



DrRATKlN Yciir^ Mouths 

(Adilriss) LvaA 



Days 



(SIGNED) 



Hours 
M.D. 



"^W Lc^ 'l'j> iqo't ( 

SPECIAL INFORM. 



vi^v*.*-^ V 'I 



or1lK«irtlF!di«i(s7M4l pemns rfylnf iwi* Irwii N«f. 



f MM" if , , 

Usual ftenMriice i » 



r ' i 



Di)s 



Wleii was disease conffacted. 
If not at plare of dratli ? 



190 






PI, AC K OF ni RIAL OK HKMoVAl, I IJATKof BrRiAl. or RKMnVAI. 



(Atl«lt. -•. w I ^- W ^' 



N. B. Bvery lt«m of Information •hould be c»p,f«lljr iitti»plled. AOB should b. .t.tod BXACTLV. PHYWCIANII .ImmM 

•tate CAUSE OF DEATH In plain terms, that It m»> l»e ppoperly cl»««lf1«d. Tl» •p«cl«l Infopmtillofi for pii- 
•<m« dying away fiH>m lionto should b« given In svspy in«t«nc«* 




I *1 




-1^ 




! 



« 




WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

Honr.l of ih .Uli-F No .. ^ ^^n&PCo RCrCW TO BACK OF CgWTiPICATK FOR INSTRUCTIONS 



Wed, WLi '; 



■XS ..., 190'i 



Registered J\/*o, 



548 



, Deputy Health Officer 

DEPARTMENT 01^ PUBLIC HEALTII=City and County of San Francisco 



PLAOE OF DEATH:— County 



(Tertiffcate of Death 

( '01. S. Standard ) 

ofOaTV J./ 



Xk 



Gty of 



6^ 






n 



(No. 5^11 



.4 



Dist.;bet. ll Axd. 



\,a.:k*\.t . '^ St; 10 Dist.;bet. AAAX<%. and 

»r*TM aeeuns *w*v rnoM USUAL RE8I0CNCE Oiwc r*CT8 callco ro« UNOt« '•••cci*!. iwroBMAtio 
r rr*TM ScJ^lTcO .H rH..'.Tl: ?'r».tT,TUT.OH O.V. ITS NAME .H.T.AO Or .T»CT «N0 NUM.K... 



) 



FULL NAME 



y^o^Xu yji mxsK 



i 



PERSONAL AND STATISTICAL PARTICULARS 



SKX 



DATK OF HIRTH 



a«;k 



Q)i<^l 



COI«OR 



b. 



(Month) 



^ < V,ots 



*Day) 



yf.mtfis 



\J 



(Year) 



Ha vs 



SIN'i.I.K. MARRIKH. 
WIDOWKD OR niVOKCKD 
(Write in social (lestKiuition) 



BIRTHPI.ACK 
(Slate or Country) 



NAMK ()!• 
FATHKR 



a 



(iKx, 



mRTHPI.ACH 
OK FATHER 
<StJite or Country) 



MAIIlKN NAMK 
OH MOTHKR 



'•<H » ilPl,ACK 
«M MOTHER 
'Htatc or Country) 






MEDICAL CERTIFICATE OF DEATH 
DATE OP DEATH 



J 



(Month) ! 



(Day) 



rgo 

(Year) 



:^ . 



„f«.,,«fc. 



I HERRRY CTiIrTIFV, That I attciuled dcccase<l from 

190 i to |*..vLi^ XH iijo '• 

alive on « wtc 190 

aiitl that death occurred, on the date stated alxive, at ^ ^ ^' 
M. The CArSlv <)|£ DHATH was as followi: 



that I last saw h 



/^ 






vV^WQ 




l 






(? 






OCCUPATION Q 






lAiw/Z/i 



fhi 1 .^ 



THE ABOVE STATKI) PERSON \M'\KrrCf1.AR>^ ARK TRIE TO THE 
BEST OF MY KXf)\VUKDr,K AND HHI.IKF 



IJllf.*! 



mant 



cnvu 



(\AA 



resd 






v..>v. 

Dr RATION years 

I 
CONTRinrTORY 



I 



Months 

4 - ■ 



Days 



Hours 



!\f truths /yays 



DURATION ^ Vi 
(SIGNED) 3 



'ears 



Hours 



H^S-Ui ^ * 190} (A.ldrt«»i) -^^n* Tfc% w* 

i ^» i l ' " 



M.D. 



:\ 



SPECIAL iNrORWATION «^ ^ Ita^Wi, l««tatto«. T^*^, 
- iKCit RfsMents, inl perstis 4yfN iway fr«« *•«• 



Vr9SP^n Hv^^^^^^^w4> 

WHfM WIS 4lK«e cMrtracM, 
If notatplaeetf 4eifli? 






P1,ACE OF BIRIAI. OR RKMOVAI. 




crtdU^ 



-i 



DATE of peitiAL or R8MOVAI. 

" % 



ll^vda ^' 



rSUERTAKER WCrVa.J.^V ^^*^ V^^^v^a 



(Addre^ii 



N. S.— B^.ey u.^ ^ l„ft„.«,tl«i •lK>uld b« c«r«f-lly •upplled. AGB .hoiild b. .tot^d BXACTLY. ^SiCUNS alf Id 
•tate CAUSE OP DEATH !• plala term*, that It mm^ b« property claaatHad. The 0pMM IntamMtHM l*r par- 



Mma dying avmy ffwn liaaia alMMild b« gtvan fa mvr}/ taataac*. 



li 



• I 



l.i 






I 




♦ 



*!l 



i I 



) »l 



M 



. I 







WRITE PLAINLY WITH UNFADING INK — 



jkxtrd of II. n 1th— F No. i.n 



n&pco 



Dfffe Filed, 




190 "i 



THIS IS A PERMANENT RECORD 

WgFCR TO BACK OF CCRTIPICATC FOR IN»TRUCTI0N8 



Begistcred JVo, 



(No. 



DEPARTMENT OF PUBLIC IIEALTII=City and County of San Francisco 

Certificate of 2)eatb 

( XX. S. StanOarO ) ^ _ 

J? <?[) i ^^ 

PLACE OF DEATH:— County 0^0^^ J^JX■^' ' : ; City of" ^<X^^ ' 'vo^v 



T r* 



City 

.tU OCCUf.. AW.Y r.<OM USUAL RESIDENCE G.vc r*CTS CM-LCO ;0" "•.•>« .■;;jcT*iNO 'hJiTm'.J*'' ) 
>t%H OCCUdHtO IN A HOSPITAL OR INSTITUTION CIVC ITS NAME INSTCAO Or STRICT AND NUMSKR. J 



r 



) 



FULL NAME 



SKX 



PERSONAL AND STATISTICAL PARTICULARS 

COI,OR 



T\\A, 



U'^ ■' 



DA IK OF lilKTII 



AGK 



Month) 



■s L J 

SIN<.1,R. MARRIKD, 
WllXlWlil) OR niVOROKO 
<\Vrit«' ill KtKial (Icsijriiatioil) 



'fa f s 



(Day) 
Moulfis 



(Year) 



An.< 



lUKTHPi.ACK 
(Statf or Countrj-) 



VAMK OV 
I'ATHKR 



RIRTH PLACE 
Ol" lATHKR 
(State or Country) 



MAIDHN NAMK 
OF MOTHKR 



HIKTHPIMCE 
ni- MOTHKR 
(State or Country) 



4 I 



I 






' LUL:.>\: 



MEDICAL CERTIFICATE OF DEATH 



DATE <•»• I>HATH A |\ 



V 



iVonth) 



4 



(Day) 



I go 

(Yenr) 



I HRRUHV CI:RTIFY, That I a1tteii<U«l ileceaHed from 

ylla..M 1^ igo H to ^4^W- -^ i 190 "<.. 

that I last saw h . alive on 1\^' igo i 

an<l that iloath occurred, oit the date stated al)ove, at -' •< 



M The CArSJC OF I»I:ATII was a^ follows: 



(M>WC^^L«t.^a..*-a Cr^ A. a.H-^vfk^/v t V % X ri 



..k..'... 



IOXA^VU (A>UMJ-V'>\J 



.\.L- 




^v 



,4 



OCCUPATION I* I . 



(hvvtJL< 



(fiiforTnant 



Rrsi'dftf in San f'uDuisfo ,4%,^ )Vvf/< 

'HD vnv 

KNOW I, 



^r,>itfh< 



I hi 



IHK ABOVE STATED PRRSONAI. PAKTUM" I. AKS \KE TRt 
BEST OH MY KNO\VI,EDt5E AND llHI,n:i' 



E TO THE 



.<5t^X4waJ 



\ 1 



(Adtlreiw 



WW- ilU 



ft 4' 



DURATION Ytars 

CONTRIBUTORY 



Mouths 



Days 



Hours 



DURATION >/«''l Months 



Days 



n (li 1 

(SIGNED) ^ Wl ABJLOwC^ ^ 

(Address) H5b 8.wCtU.*^ 



Hours 
M.D. 



\^JuL44 .A- |c>0 



SPECIAL INFORMATION wily lit Rts^s, ltsUhitiM&. TritMctb, 
•r Recent ResMents, aii4 perseus 4yln| «i»ay frwi k«w. 



Former tr 
Vsial ResMeRce 

Whe* was HsMse cwtricte4, 
IfMtatMittirieitli? 



HvfifleMl? 



•«^ 



PLACE OF Bl'RIAI, OR RKMOVA!, I DATE of Bikiai, or RKMOV 
tSDERTAKKR W>VO.V<3. W^t^rtX -^ . 



Al, 

90H 



T 1 f) , . 



N. B._Bvry Hern of Information should be carefully .upplUd. AOB .hould «>«»««*«i EXACTLY. PHYSICIAWS^M 
•tots CAUSE OF DEATH In pinin terms, that It may h» prop«Hy cl»a«tfl*ii. Ths Special Informatloii for par- 
•on* tfyhig aiNWjr fi*om horns should he glvsn In svsry tttatpncc. 



I . 



'J 



•1: 




A 



M 



I . I 



i . 



1 




ji,,;,,.! ..I II. alth-»- N'o. i*> 




", 







WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

„&Pco wergR TO BACK or cgWTiriCATg roR instructions 

Regiatered J^o. 0%M 




as- ^»0H 

Xu>M Deputy Health Officer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



ds^-C^tWO 



Certiffcate of 2>eatb 

( "d. S. Stan^ar^ ) 



PLACE OF DEATH:— County 



q{0o %\,. -in a 



J 



Gty ofC' a> 



rNo. 



UH 



aXtc... 



St; 



(? 



Dist.;bct AJJXC^^^ 



and Ir^ ' 



\r ocATM occuns aw»v rnoM USUAL RCSlDtwct oivi: ^*ct» ^^^" ,««•»»» o? «TiircT and numbch. / 

• r OCATH OCCUHHtO IN A M»«^ITAI. Od INSTITUTION OlWt ITS NAME INSTEAD Of STdtET AND NUm.li*, -f 

^^ .\/ f 



FULL NAME 



> 



s!-\ 



PERSONAL AND STATISTICAL PARTICULARS 

COLOR 



=# 




<xta. 



UATK OF niKTH 



ai;k 



Q^o- 



(Month) 



) 'I'O I 



0. 



(Day) 



Months 



I I r 



(Year) 



/',n 



SIN<.I.K. MARKIKD. 

wrixnvKn or divorcko 

(Write in isocial de-siKnation) 



BIRTHPI.AOK 
fSlate or Conntrs-^ 



NAMK oi 
HATHKR 



BIRTHIM.ACE 
or FATHER 
(State or Conntry) 



MAIDEN NAME 
OF MOTHER 



niRTHPI.ACE 
<»F MOTHER 
(§late or Countrvi 



O-c^wa/Vt' 



(!?\ 



i u A 

I - 

(1 

if 



MEDICAL CERTIFICATE OF DEATH 

DATE «>l- DEATH A 



il.A..Lu 



f^fonth) 



i — 



I Day) 



/QO 

(Yewr) 



TlII^KHBY CHRTIFV, That I attenacil (Uncised from 

r -r. 190 — to :— '-rT:::—:^^:.... I9O 

that I last saw h -?-— ralive on iqq 

an<l that death occurred, on the date stated above, at 
M. The CAIS^C UK 1)1*: AT II was as follows: 



i^l\^.r^^.^.t. UJ vAp c. a.*v 



OCCl'PATlOX 



.'•\ I 



fifi-idfti in Sun t-'i am ."rtt t v )yat 



M,mfh^ 



Pa v.- 



THE ABOVE STATED PHRSONAl. PARTUM I. \R"^ ARE TRIE TO THE 
BEST OF M V K No \V I, E D< *. E AN D lU : I , ri I 



finfonnnnt 



i: 






DIRATION Vrars 

CONTRinUTORY 



} 'lutrs 



Afonlhs 



Days 



flours 



Afnttths 



DERATION 

(Signed) V 

^ ^ ^ iqo (Address) ^Hb 



na\ 



:s 



•-\ 



Hours 
M.D. 



Ki^KA^lH) 



SPECIAL iNrORMATION n^ ^ ^9^Ws, lirfKstlMS, Irat^its. 
or Recent ResMenls, ati pemw ^N «**y »f«» ^*^' 



NflMT M- 
Usiil ResMmce 

WHei wfs disea^ contricte^, 
HMtitplireflde«tk? 



nacetf leatk? 



•m 



dU^^ 



D^\rK9f BfKtAi. or REMOVAL 



PLACE OF niRIAL OR REMOVAL 

I? I ^ 

INDKRTAKER <S.A-*.-frYU3L ^ O^i^ OXX^VX^ 

<Ad<lrc«». I w« - Al_ V . » „ 



T90 



N. B._Bv.ry lf« of Information should be CTsfully .^p^UA. AGB should ^^^^^^"^^^l^ J^^^^^'^^'t 
•t«te CAUSE OF DEATH In plain terms, that It »«y bs propeHy clasalfM. Ths SpscM liifer««tl«i lor psr- 
•Ofis dying away from Home nhould he givsii In svsrjr Instawcs. 



^ 



u 




t 



> ^ 


1 


"' ^ 


I 1 

^^ ■ 1 


r i 


- f 1 


r 


J 


-i 


' 1 


. P 


^ 1 


~ OJ, MM 1 


^ ^n 1 




il) ' 1 1 


l!i^^ ' 






( ' ' 



i \) ! 



ii 



t. ii 








#< 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



Boiu.I ..f H. altli -F No. 1^ t-rj^m^n^V Co 







1 



as 



2i^(?S 



HEFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 

lie fii tile red ^'"o. 



546 



Deputy Health Officer 

DEPARTMENT 01^ PUBLIC HEALTH=City and County of San Francisco 



PLACE OF DEATH:— County of ^ t<Vru O.'UXAv^ixA^Gty of OO/Vv OA.a'v 



Certificate of Death 

( "Q. S. StanC>arD ) 
of^/CVvuO.'UXAv^LA.A^^oCity of VJOyyv vlAXLAvf iv 

.No 1?^C) ^*' • ' St.; I Dist.sbet/JO-V'-^^^ and 

~ r " """ o""" '""' "■>•' "«"•'• ""'"'"•^^ °'",;,";;'. NAME "."teT" .T-'EtTin'o "o"."'-""' ) 

I If Dt«TH OCCURtltO IN • M0»P1T»L OR INSTITUTION OlVt ITS NAME INSTtAO Or STREtT .NP 



ifr . 



) 



FULL NAME 



jj 



^i:\ 



PERSONAL AND STATISTICAL PARTICULARS 



vuxL. ^ (wtx 



bMl-: .IF BIRTH 



,111 



Motith) 



A<.i-: 



) V(» I 



il):iv) 



A/,>uf/i< 



(Vrar) 



/'.n 



^IN< I.r. M \KK1KI» 

\\ IlMiW J I) «)K IHVi iRi"KI> 



IStjltf Mi ('MUIltl> 



A 



WV 



r^ 




uo^4^' 



NAMl' «H 
I AT Hi: R 



lUK TltPI.AOK 

«H I aiiu;k 

'SfrUf fir Vnutitr5*> 



MMUKN NAMK 
"I- MoTHKR 




y'\jfi^ixf: 



1 1 



lUKTHPl.Ail- 
;>r MftTHKR 

' '^r Cimntryi 



(Stnt 



R^tidfJ ni Sit 'I /'t ani i.<-ri> 



)'tiH 



\J,.„lh. 



/>,i\ 



rni: miovk sththo pkr^ovai, r\K rin i, \ks aki; ikif t« 
BKST oi- MY KN«)\vi,i:i)(.K AND Hi:i,n:i- 



» Till* 



diifunnri 



f K.lilic 






>\. 



^ 



MEDICAL CERTIFICATE OF DEATH 

DATE «)!• DlvVni (\ | 



TOO 

(Yriil 



I in;ki;HV CI^RTII-V, riiat I attciuU.l (UHrasi.l from 



I in;ki;HV CI-.KIIIN, i Hai i aucnucu uvii..^^.. n 
yYUuM ^ icpH t.> WU^ %^ nf,'\ 

that I last iw h -i^* alivi- on >iv- Cc* I90 

a 

aiulthat .U-ath orrurrnl, ..11 (lie .late <tati-.l alxn-c. at O 
0. -^I. The CAISI' OI" J';i5S^'''H, ^^^'-^ ''^"^ follows: 



nr RAT ION Years 

CONTRinrTORV 



Months 



Pavs 



/fours 



Dt'RATION 
(SIGNED) 



Years JfoHfhs /\ns 



Ivdn "•" To o^^ f A.Mr.-..) I 5%H ma\^.a 



I lours 

M.D. 



SPECIAL INFORMATION "(»'> '"r Ho^liH, IrsiiIiiims, IranteMs, 
Of Recent RfsMfnls, aii4 pcrwns d.ing awa) 'rom homf. 



Former or 
Usual ResMnite 

When was dheise cwlraf fe4. 
If not at plire of death ? 



H«w IfiHi at 
Hare of Oeatti? 



teys 



rM.KKTAKKR ' rLt^^OwCXj ^ 




^^. -^\ 



(AtMt <••*•* 



i5~ 0>V 



\A^ Vft^\ 



~< 



•fte CAUSE OF DEATH In plain term., that It may be properly cl«-lfl«d- The Special Information for par 
anna dying away from hema ahould be given In avary Inatanea. 



1 


r 


\ 






* 




i.' 


t 1 




. ! 



f. 




l! 




I I 



°^JlSSr.J^ 



in 






'I 




\i,y.iu] .,!* I!. :i!lll I 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

v„ ., *:P?S^^H&l'Co REFER TO B ACK OF CERTiFtCATE FOR INSTRUCTIONS 




llegi^lercd ^Vo. 



54? 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

(Teitificate of IDcatb 

( •Q. S. StanOarD ) 

i ^ i % 

:-County of ^a>V Ka --t City of '^Oav ^^va^vcc^- 



No. 



PLACE OF DEATH:— County 

U n \Th nh ^/vvi «t M \ ' St.; Dist.;bct. and 

/ ir oe*TH occuns *wav rMoM USUAL "^S'^'-'^'X. °' V^iJ* ,," name instead or stbeet and numbch. / 

V «r OMTM OCCUnnCO in a MOSPITAt or institution Give ITS NAME INSTEAD 



{\ 



FULL NAME 



\ 



^aT^vU^ 



si \ 



PERSONAL AND STATISTICAL PARTICULARS 



i^ 



i.u.^ 



^\j. 



ii 



t 



l>\IK ni" lUKTH 



/ i. 



(Miiiithi 



1 r 



(Dav) 



Miitifff 



I hl% 



>IN«.M- MARKIV.t* 

WIDOW j:i) ok i)iv(iKii:i> 

'U'riii ill votinl >1« ■^is.'iuitiuti) 



(Htatf nr Cijiintry 



FATHF.K 



'nuTun.ACH 
'" 1 \rni-:k 



^ C-v vOiAJL 



,y^ 



C'-..v 







BIRTIUM.XCi' 
"^tiitf or Couiitrv> 



ri /n i t) , V |w^A 



JLL, 



^A fi 



I I 



^ 



<H"i-i-i'AriuN 



vlK 









) ■ it 



\r,,,>f/,. 



fhi 



VV. T'* J'llH 



■]ur,. 



1-1. nit 



., Vvfr-U. 



X"-.^ 



I t 



■1> 



riiH AHt)VH sTAri'.i> PKumixAi, j-ar rfiMi \ks akj* tk 

BKST Ul MV KNtiWI.l.tM.K ANU BlCUIMl- 

f Address i l5 ^^..^^Ci 

^. B.— fiver. Hem of l«Wm,llon •hould b. ...efH. •uppll.d. AliR .Hould »- •«»«i.f .?^?;^,^^^ ,„fo11*J,1Lt^*^fo';?^I.t 
•tat. CAUSE OF DEATH In pl«l« termp. th«t It m«» be property .I«s.l«l.rf. The Spe.l.l Information for pm^ 
wins d>-1nA away from horns iihould be ftHen In svsr^- Instancs. 






MEDICAL CERTIFICATE OF DEATH 

I MI-RMHV CliRTIFY, That I alK-ii.U-.l <Uha asc.l fmni 

that I last <:i%\ li ^ alive .)ii iV^' .^ igO 

aiuLtliat .katli ..rcurrcl, (hi the .lati- ^tate.l ahnve. at 10 
\J >L The CAISI-; or DKATII was as folltms: 



DTK \T ION & y'rars * .1A'«M< 



/hu 



^ Hour a 



CONTKini'TOkV 



.1 



.1 



W V VvC3U.^.^l. i-e v%. 



) r<?r 



MotUh'i 



Pay 



Df RAT ION 

(SIGNED) ,- ^ 



k h -^1 



Hours 
M.D. 



^SP^IAL Information «Mr i«r ^n^ttis, lnsMtatiMn, IrMslnh, 
«r tettrt fc^iite, «•< pxwn m% «»w fr«w> I**'* 



Ustal lesMeiKt 



ft 



tew iM^at 



ftiys 



Wkei »« 4l»a« conlractd, 
If Ml it iim »» <Mtfc ? 



I»f ^R OK nt R!AI. OR RKMmVAI 

■ V 



% J 

iNI>KRTAKKK Mil KX^UM^W ^H 



ItAT^of |H RiAi, or KKMOVAI, 



Tf)0 t 



fAdar.HS 



[4 i 
i 1 



Ji I 



«:i 



!.! 



1 .1 



' It 



5r- 




^ 





WRITE PLAINLY WITH UNFADING INK 



Hoaii! .if !!■ .iltii I 



No ,^-fr^*^^&l•0. 




1 



xs 



190 'i 



THIS IS A PERMANENT RECORD 

REFER TO BA CK OF CERTIFICATE FOR INSTRUCTIONS 

' 548 



Ecsff^frrofl J\^o. 



DEPARTMENT OF VlBLIC liEALTH=City and County of San Francisco 






Certificate of 2)catb 

( XI. S. Stan^ar^ ) 



PLACE OF DEATH:— County of 



L J\ 



a^ 



h n 



(No. l^'i l<xJ 



■City of '"'.C 



U 



X'^x 



t w 



St.; i^iaM, 

M USUAL RESIDENCE OIVC rACTS c 
ATM^'oCcJuVcVlN » MOSPITAL OW INSTITUTIOW GIVf ITS " 



(ir DtATM OCCUHS AWAV FRO 
ir or 



Dist.;bet.U O.OA'uUUC and ')X<K\u 

CALLED rOR UNDER ■SPECIAL I N rORMATION ' \ 
NAME INSTEAD or STREET AND NUMBER. / 



\, 



FULL NAME 



A 



^^xvrTXJ 



i^ 



si:x 



PERSONAL AND STATISTICAL PARTICULARS 



I'Al! n|. lURTII 



TRoJa, 



f%^^ 



MontlO 



Ar,i- 



•^'N« IK MARkll.:i> 
wi[)it\v}:n «>K i)iv«>Ki*i-;i) 

'Writ, ill •^tuial ilf-ii^iuUimil 



(D:iv) 



M.>Hl/n 



». ar> 



thi % .1 



ci 



A^^V^ 



HtKTm-l. Xt'K 



I ATIIKR 



HlkT!ll<i,\i-K 
r»»' I XIHKk 
tStjili- ur Country) 



MMiux xwtj.; 

"1 MoinrR 



II 







li 



>!• MOTHKR 

siHU- ,,r ^•(.u1ltl yt 



wrti'M [ 



K^^uhd in San rtatunfo NO >'">' ** ^''"''^ 



/>,? 



HH AKfiVK HTATl'I) I'KK-^OVXl. T'XUr I*"(!, \K*^ A K I' T 
HKST c)F M%' HN<.\VI,KI)i;H AM> Ml- l.H'i' 



K!K T<» rm-; 



\.Mt. 



MEDICAL CERTIFICATE OF DEATH 

l»ATH Ol- nHATII (^ ^ 

I HHKF'HV ri.RTII'V. That I ;itti-ii.U'.l .Urta^cil frMtn 

-'^ to 



ion 



!</ 



that f last saw li aliv. .hi 

.111.1 tliat .Kith ocinirre.l. ..n ili.- -lat^- stati-.l a»>nve 



TCJO 
Up 



, Ht 



M. Tlu- CAlSr-: <)!■ l)i:\TH was av fnll.iws: 



DT RAT ION >'•"* 

CnNTKIIU'TOKV 



Months 



nav< 



Hours 



nr RATION 



)\ar$ 



rSlGNE 






M.nif/lX 



Pavs 



//ours 

M.O. 



IvJUi- ^'ui^H (A«1.1ri«>H) C^'tCTrxAA,^ ^ 



■^ 



or Recent Residents, and (»efs«iis dylni wi) fr^ Nue. 



Fwiwr if 
UsMllBifcwe 

tAM w« «sease wntracted. 
tf ii«t it ^ire •! de ttli ? 



1^ taMfirt 
«*t •! Death » 



Days 



I'LACK «>!' ntKIALnH RKM«>VAI. 



1 I 

y . ■ 



i 



iJATKof »r«lAt. or KKMtlVAI. 






^- B B 



i? II -«««lled AaB .hould b« »tiiUH BX4CTLY. PHYSICIANS ^um%4 
•Bvery Item of Information .hould h. ♦^-•«»«f"^ f"^^''^?; „ropeHy cl...lfled. The "Specl.l l«form«llo«- »or fMir- 
•tate CAUSE OF DEATH \n pXmn Urmm, that it m«> ne proper y 
•on* dying away Iinhh horn, should be lt»ven in -very miitaiic». 



',M 



I I 

\ I 



tl 



' A * I 



.1;; 




^11' 




nil 




WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

Ho.i.l of IRalth — K Xo, i», t'O^ H&l' Co 



Date Filed, 

i 



v\Xa 



%S 



190H 



WCrCW TO BACK OF CCWTIFICATC FOR INSTRU CTIONS 

Registered J^o. 



' JO 



^XK^KA d u Deputy Health Officer 

DEPARTMENT OF PUBLIC HEALTM)- and County of San Francisco 

Certificate of Death 



( m. S. standard ) 

,\i si ^ 



n 



PLACE OF DEATH:— County of " O iv Xo. City of^-a >v va v 

St^ ' Dist.jbct.llx'U^t 



V 



Ww-Vk, 



-"Na b.O.H U'-' 



( 



and ' ^ 



'^ f/tl*!,***^*^""' ***** '^''**** USUAL RESIDENCE GIVE r*CT« called rOR UNDER ••PCCIAL INrORMATION 
ir DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD Or STR EET AN O N U M « R 



kil 



v^ 



FULL NAME 




) 



a 



■VH \ Ol 



h -^ 



si;x 



I 



PERSONAL AND STATISTrCAL PARTICULARS 

I COl.OR 



^ 



UATF or niRTIl 



ACK 



il 
(1 



Hotith) i 



) V<J / 



as 

(Day) 



.\tontft.' 



(Year) 



/?d 



MEDICAL CERTIFICATE OF DEATH 

DATE OK DKATH 



(Jk^oiilh) 



(I):»y) 



(Ve«r) 



^IN'IvK. MARKIHI). 
WinnWKn OR DIVOKCKI) 
tWrileiii social (lesiKnalttm) 



lUKTflPl.AOK 
(!^t.itf or Ctiuiitrv'i 



c 





I 



^I HHRHBY CKRTIFY. Tlia|^ I attemlc.nicccased Uoxu 
• ' ' 190- tn V-A^Ui JIH 190 .. 

that T last saw li alive on *'.,l.I.^ iqq 

ami that rkath ocrurred, on the date state<l above, at I 
M. The CArSlC Ol* ni'ATII was as follows; 

4 ■' ■ f 



N'AMH 01- 
PATllKR 



"IKTHPI.ACK 
<>!' FATHKR 
estate or Count rv) 



«)1 MOTHKR 



HIKTH PLACE 
<H" MOTHER 
'M:i!f. or Comitrv 



tKCrpATlON 



^ M^ 



C*.(X 



DURATION Vrars 

eONTRlIUTORV 



MoNths 



Pay. 



Hours 



W 



^Jl^v« 



^cL 



l)f RATION 



(SIGNED) 



>..k.'. 









Hav 



•Si 



.-i K 



lc»0 



{. 



Adilrtss.) I 1 H CH i i 



Hours 
M.D. 



SPECIAL INFORMATION wly f«r ll«s|it«ls, listitvtloiis, TrMSlnts 
•f Recfnt RrsHlfBfs, and persons dying «ndy from hoNie. •-»^»s. 






) 'I'll I 



Afotiffyf 



/hi 



'"nK^Tm-'iTx^ !.*;!» f'P-R^'>N"AI. IXKTrrn.ARS aKI: TR!K in TlIK 
uhST Ol- M\ KNoWI.lClx-.h; AND lU Mil- 



formff tr 
Usuai ResMfRce 

Wkei MS tfhease coitrx^M, 
IfiiotitpliterflNtt? 



WW lfR| M 

ntretri^l? 



Iqrs 



(Informant 



Qlw'^. 







I-^A^OF m-klAI, OK RKMoVAI. j DA TH uf Hr«,A,. or RJ-MoVAl/ 

JC^ riu ^^(Ht^ I 1^-*^ 3*1 T90S 

I XDHRTAKKR V<.^vs^ v%xcLL»vt:i 



^W^ (4-(i„ t > w. 



"^••**' **•"» o' Infopmatloii should be c«i*«fully suppttcd. AGB shmiM Imi atatcd EXACTLY. PNYMCtANS gfimtj 
•t«te CAUSE OF DEATH in plain tei*ms. that It ma^f be ppoperly classified. Th« "SptcM Infopmatloa** fiJ^J! 
•WIS dying away ffom horns shmild b« glvsn In avary Instaaca. ^ 




■ < 




■l.lil 





li 



f 





►t .--.:: 



"t 



• • 







y 



H 



I ill' 



m 



^m. 



Ill 



n 




WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



It,.:,..' .'t Hciilil) I' S'o. ir '**«i>'ag^^ H& F Co 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



/)„/(■ Filed, \jAm as- nwi 

"k^y^ju^ Ixam, Deputy Health Officer 



Regifitcrrcl J^o. 



550 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of H)eatb 

( "a. S. Stan&arD ) 



^ 



PLACE OF DEATH;— County of^'a/^^^ J^<X>^'^V4C0Gty of^^tX^v- 

.lit 







'vMlKcl.^ 



Sxa Dist: bet. 



and 



A / ir DtATM OCCOnfe away FBOM usual residence Give r*CTS CALLED FOR UNDER 'SPECIAL INFORMATION" \ 
\) V IF DEATH OCCiyRRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / 

1vy\' U ADAu, 



FULL NAME 




PERSONAL AND STATISTICAL PARTICULARS 



■#■ 



"'" Ol\c.,K 



COI,()R 




\i 



i>^ 1 1; oi- niKTn 



\c.i-: 



i 






f9nH 

<S-<-nr> 



OX 



iMoiit 



h) 



'S^ 



) rii , 



(Day) 
M. -Dills 



(Vi-ar) 



/><; 1 A 



WJDOWKI) OK DlVoKCHt) 
tWiti,- in Micial iksiKiiation) 



'Mntc iji (Niuntlv^ 



1 A 1 Ili-R 




MEDICAL CERTIFICATE OF DEATH 

i>.\Ti-: «)!• i)i:.\TH A * 

i otolith) K 

I HH|{I-:BV CI:KTIIV, That I atten.lcMl .U-.-.i.sc.l fiMiu 
,|\AAi, ^l 190H to. ||aXu. 'X% 

that I last »;!i\v !i alivo nn |\.\-Lv4 i,p 

ami that (leatli occurred, i>ii the date '>tal».| uhdvc. at I 3» H 



M. The CAISI': ()F DIIATII uii< as foil 






il I '''Pi 



ows 



'»!■ t 1 I'llKK 
'*^- It'- i.T Cinmti V 



<Jl MoTIiHK 



"' MoTIIKR 
>lai. ,,1 Countrv 



Oi'cri'ATION - 




A-X^ 






H 



I )r RAT ION )'rars 

CONTKIHITORV 



Months 



nay 



Hours 



si ' » 



DrRATION Atars. Months 

(Signed) J ^ '; ^ i 



Davs 



o 



Hours 



M.D. 






<X^v^ 



JL 






Special Information only lor HispitaK. instHaHMs, fran^ieih 

or Recent ResMrnts, and persons dvinq aw«> fron tiMe. ' 



V, ,: 



M ;<lh 



/'.M 



"'L^':'*^'' ^'•'\'l>''.t' I'HKSOVAI. l'\RTIi*|-fJM<> ARK TKI f* T« » TIIK 
»s» >1 ni. MY KNOWI.ia)!-.!-; AM.) ni<'Mi;i- 




ik. 



/D 'mo 



Former or s 

Usual Residence 

When was disease conlrsfted, 
If not it place of death ? 



Row tonq It 
n«ireof BeiUi? 



8jjr$ 



190 i 



fl.ACK or- lURfM. MR RKMmVU. I D\TIC,,1 llr^iAl, nr KIMmVAI 
1 1 '\'^ I i^ 



INDilR lAKKH 



* * ^•""Bvepy Item of Informntlon •hnuhl hi cai*efutly »upplted. AOb iihould Im atntcd BXACTLY. PHYSICIANS aliouM 
•tate CAUSE OF DEATH In pinin term*, that It m»> be properly clusstftcd. The "Special Infofmatloii** for |Mr« 
•ifis dying «wa|r irwn home should be ilven In ev^ry Instance. 




• ' 



11)1 





HI 






WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

Hi' 1^ H.altli-FNo. i ^ "^^^^ H& I' Co REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



Jhtfc Filed, 




290 H 



Begisfered J\^o, 



>51 



Deputy He?^ft*- -^ffir-^^ 



DEPARTMENT OFPUBLIC HEALTH=City and County of San Francisco 



Certificate of H)catb 

( H. S. StanDarD ) 

I ® =? (ft 






PLACE OF DEATH: — County ofO/Ouru J JUXa \.cc4 e^ City ofC'/CLno/ U A>CUvvci.4>eo 



^ Wv^rd^ IbcK l\,^la.i St.; i)ist.;bct. and 

(ir DEATH occur/b awav mom USUAL RESIDENCE Give facts called roR under "special iNroRMATioN" '\ 
IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / 

FULL NAME VlllaXH -" > ' ■ 



?.i;x 



PERSONAL AND STATISTICAL PARTICULARS 



•^ 



r»ATi.; OF niRTH 



COI.OR I A 

I, ^ ''' , ( 




a^ 



1 Month) 



1 



/ i. 



^ ' . 1-; 



3^ )v<„. I 



Dav 



Mntitin 



■x\ 



\ tar) 



Ihi 



(Year) 



wriiMU i.:i> MR DivoKiKr) 

'^Vriti ill MK-ial <lf.ivnat ion) 



HIKTllPI.AOK 
'Stall' lit (.'ijuiitrvl 



LLi^-d^Cr^ 



v?^ 



\XMK 1)1.- 

»■ \ rni;R 



inkTiii'i.xcK 

'>'■ I M'ttKR 

^^ ■ ' ■'ll!l!vv 



^^\ll>^•.s• namj.- 
"i MnTilKR 



fHRTitPI^ACF 



'K' I-J'ATION Q 



j\ux% 



lujii 






MEDICAL CERTIFICATE OF DEATH 

DATK OI- Dl'ATII A ft 

'hi ^^- 

(Jloiith! \ (Dayt 

I jn-Rf-nV ti:RTlf-V, Th.it I attcn. id ,U'»hmsc.1 fn.in 

that I hist saw h • alive on >\-^» ^^k\ 4^ i^q t 

and that iKatli occurreil, oti the datr sf,,ii-,l almve, at I **^ 
M. The CAI'SIC oi- I)i:.\Tlf was as follnws : 









I )r RAT I ON Yrars 

CoNTRlHrTORV 



Mouths 



U 



/?./l,? 



Hon 



r<i 



%.%. 



4 i % si 



I )r RAT ION - Yiaxs 

(Signed) ) 

A 



Mont ha 



% Jv 



h 



^tewL^ 



I^avs 



f^ i^. 



//ours 

M.D. 



\\.^.Lu ^H UynH ( \th\rvs^\VUu, ^U V^ i 



SPECIAL INFORMATION only for L 



_.- only for HosplUls, Institutions, Trinsle nis. 

9f Rfient Residents, and persons dying d»»dy from home. 

4' 



FofiMr or 
Usual ^sidence 



1'^ ' 



1^ 



Row I0119 ^ 
Plafeof Ofith? 



A>Miirif ut Siiti ft (!»,.■■,, I 



1/»//V/> 



/),M' 



I 111. \t!,>\K STA ri.:n I'KK^^nNAI, PARTfi'f;. \KS \U1 IKI K T< » THJ-: 
i»l%>l OF MY KXo\VI,i:r)<'.K AN1» mijio- 



O. '^ 



U}mv 0>\ 1 



When was disease rontrarted. 
If not at plif f of death ? 



^ 



I'UACK OF BTRIAf. OK RI'MoVAI. 

A 




IJ \ t'l; .if JIH KI.M, .,r KKMoVAl, 



VSli K R T A K K R V.OJU.|r C\/> V\.4X L\, \ \ H. h %, e 



^.vl^ 



TOO 



I AU«lrt*«i!« 






Bvery ft«m of Infapmntfon ahould H? cnfefully Mupplled. ACB alioyld bo •tat«d BXACTLY, PHYSICIANS nhould 
■tate CAUSE OF DEATH In pinin term*, thm It may be properly wlasslffcd. The "Special Inrormalion** for par- 



N. B.^ B, 

atate ^ 

a**!!* dying away from liomo Mhould be give a In mvmrsf Inntaace, 



1 



li! 




« . i 




I. 



I.* 



." I 



• - • 



/'^ 






'K 





■ 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



IlnMll ..f ICvfiHli- I'No. I«, 



nsipco 



WCFER TO BACK OP CCRTinCATC rOR INSTRUCTIONS 



Dale Filpdy 



CMH-A.>U^ 




100\ 



Registered A^o, 



5^0 



T%a, 



f% I J *'» 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Certificate of 2)eatb 

( n. S. StanOar^ ) 
PLACE OF DEATH: — County oi^ CLy\) U\.a'>vaw4Cc City of ^^ a >\ 

No. Ol^k \^\.^acl<.*^'^- St.: I Dist.:bct,\nU^xt-CCv 



St.: I Dist.;bct, M ' Kr^X^CtVl and Ja \ 

UNDER "l^CaAL INroRMATION" X 
DEATH OCCURREO IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD Of STHErr AND NUMBER. / 



(ir DEATH OCCURS AWAY rR0M USUAL R E S I DE NC E CI VE rACTS CALLED roR 



FULL NAME 



vi vx<x4.A.4Xa " 



a. \ 



A 



PERSONAL AND STATISTICAL PARTICULARS 

SHX (\t\ a I COI.OR \ 



'J Ji'y woJL 



CVLC 



I 



1' • I 1 .11 lUKI'H 



A«.K 



iMojith* 



)')iti 



I Dav 



Miinfi'is 



(Vt'iit^ 



/iii\ 



MEDICAL CERTIFICATE OF DEATH 

DATK OF DKATH A 



too 

(Star) 



•-iM.l.K. MAKKIKH. 
WinnWKIi UK DIVORCHI) 



iHtati lit f..iintiv> 



► A rilKR 



I'lKTHPI.ACH 
"I- f ATHl-K 

'st.iti- nr (.■.mtitrv 



OoL lilt, ■ 



'Day) 
* l|lHKKnV CHRTII-V, That I attcn.ltil <leri-ase«l from 

tliat I last saw h alive on ^vs ' ^^ 190 H 

ami that ikath ot'rtirred, on tlu- dati- statvfl alwivf, at *> sO 
M. The <^'Al'!^y <>i- i'i:ATll was a?* follows: 



e 



1^ 



X'CC 



IL" 



Dt'kATK^N ^ y,,ns 
CnNTKIlMTokV U <CUh 



'Months I r\i\s 



Hour Si 



I I V 



"J MOTHKK .^ 

WW f V wA^'t WVC-C W www w vW » 

inUTfll«|,All-- 1 

OK MoTFIKK A m 

"^t.it« or Country) •» H iv 

•HCri'ATlON ^ 

Kfsi'ird /« SV/M Francisea *t l JVif» 



^-4X VO! 



t 



ni'R ATION 



(SIGNED) 



\ 



fcjo 






Hours 
M.D. 



SPrClAL iNrORMATION ^1 ftr Nospit4h, Inslitutitss, frandetts, 
or ReCNC ^sidfiits, aN |irr$«its dviflq ana) frm 



»/,,i;/A. 



this 



iJhsr or- Mv KNowi^:i>r,K AMI r,i:iji;i' 



,«.fc 



(^ 



Former m 
UsNal ResidMce 

Wkef was disea^ CMlrarMt 
HMtitpiarfof^fOl? 



N«w Itiitf 
Ptort«f Sratli? 



Da>s 



190 ! 



AflilrcJi 



5.0 



4 



I'I.A<"»: (»l JtfKIAI, MR HKMoVAI. I I> U"K oL IIihiai. ,.r KKMtiVAI, 




\ M.i:krAKi:K 



<X,Vwvw *^L^ 



'^%. 



^i. B.^ — I 



Every Item of Informntlon slioHld be cUFcfylly nupplled. AOB nhoulcl b« stated BXACTLV. PHYSICIANS ahmiM 
•tate CAUSE OP DEATH \n plain terms, that It mtiy be pptipeHy «;las»lfied. The **Spaclal lnfoi*mailon** foi« par- 
won* dying away from home nhould l>c given In avsry inatance. 




^ 



« 

I 



'I 



I 



•j 



Mi 




' i\ 



1 





. llPf 



^.*-' i 



#► V 



?li 






: I I 
I 



* 









f! 




WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



IhxuA ,,! Hcillh— F No. 1^ ''•f^S^ ''"^'* ^" 



Dfffc Filed, 

i 




190H 



Begisfvi'ed J\^o, 



553 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of 5)eatb 

( "XX. S. StanOarD ) 



PLACE OF DEATH:— County 



unty of^'HX>v Xa.l^ 



Gty 



rNa 



HIU 



it 



^ 



St4 ^ Dist.; bet. V^i 



ity of ^ '^ \a> 



vew4^f, 



V\xail^0^tKand 



(ir DEATH OCCURS AW*V FROM USUAL R E S I DE NCE Gl Vt rACTS CALteO ron UNDER 'dytCIAL INroNMATION \ 
ir DEATH OCCURRCO IN A HOSPITAL OR INSTITUTION CIVC ITS NAME INSTEAD Of STfiCET AND NUMBER. J 



FULL NAME 



t'LLlO 



%.. ( 



>-VC\v. 






a 



S I 



PERSONAL AND STATISTICAL PARTICULARS 

I COI.OR \ 



^oL 



I'X I J or niKrii 



a«;k 







} 'fii # 



(Dav 



MoMtiH 



I < :iT : 



t\t I ,* 



MEDICAL CERTIFICATE OF DEATH 

DA IK 'il- I>KAriI A A 






1 % 



<Ve:ir> 



*^fN< I.l' MAKKIKH. 
Wnxiwi.D OK I>1Vnki-Kl> 
Wiitt ill sfK'iul (hoik'naiiun 



TUKTIIPI.AOK 
■^t it< fir Oo!intr%') 



> vni}:K 



niK riu'i,\('K 

"1 lAniHK 
state rir CouiJlrv) 



<tf" MOTIIKR 



ntHTHl'i.u'H 
'•(• MoTiiiiR 

■r r..utiit% 




1 iii:Ki;nv ci:rtii'v, tihh i aticii.kd UiMxa-st.i fnmi 

that I last saw h a*i¥<' «m iVvtct ^A ^^p \ 

anil that lU'ath uccurrcil, nn the tlalt' stattd above, at M 



M. The CM Sii OF IH:ATI! was as follinvs 

rV 



The CM SU OF I) 



fr*\ I *-v^ *i /-I 



I) r RAT ION Years 

CONTRIBITORV 

DT RAT ION _ y,itrs 



Months 



Days 



J louts 



Mouths 



Par 



1 



' 1 1 U ale , 



Hours 
M.D. 



'»t.'i, 



ft 

n 1 



C^Lu 



'•I'Cri'ATiON 



f^'f":.f^<f fti S'.'j^ f'l an, isi'ii • }■ 



* ^f,„ifh^ * 



THK M!nv i" ^ j- \ I ,.j, i«KK^f>xA|, p \ K T It" f !, \ K ^ \ K I! TR T'K JO rilK 
»K>r 01 Mv KNoWl.KIXiK AND HKI.JKl- 



(Signed) J V-r^x 

^PEcUl information mI^ fw HosplUfs, luslltulkws, frMsieats, 
9r toceat lesMeflti, «M persMi tf)it| iwiy fmi Nm. 



foniier w 

IMwt iws <he*se coiirratW, 
ff Nf It pMre 9f ^m ? 



H<w iMf at 



Al^A 



nt 



\ ,', 



'MiO- It ti, 



I'l.ACK OF BrHtAI, ok KKMoVAf, | r»\Tr 



t KlMoV M, 



^ ^:_^'w 



INIjHRTAKKR 



t"^^4- ^5' tgoH 



)oJU^J^ "M. L^ 



iHt Oa 



l! 



UA.^ 



N. B. Every item of infofmitltoA should hs cup.fttlly SMppllecl. A6B should bo stated BXACTLY. PHYSICIANS sHottId 

state CAUSE OF DEATH In pl«l« terms, that It mnj He pr^id|p classtfted. The **Spe«lal InfofMatlon** for prnf 
n*n% dying away from home should hs glvsn Is svsry Isstaaes. 



I ( 



iu 



I ' 






- ^ 



\. .. 



ll 



M 







|l 



(M 



l ilt 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

Hoar.l.f iiniiih-FNo. it^fl^H&PCo WCFCR TO BACH OW CgWTiPICATg rOR IN>TWUCTiON» 



0.S 



lOO'i 



Date Filed, 

A^tvu ^^vNu Deputy Health cmccr 



Registered J^o, 






DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of Beatb 

( in. 5. Standard ) 



PLACE OF DEATH:— County ofUaA\ J \a 



4 '^f 

City of 'a-'vO.Va 



fffti. w^\.CVNv\iJ„vO. .St^^vta\).Dist4-4«t. WV^V' / and 

(ir DKATN OCCURS »«»«» moM USUAL RESIDENCE oivt r*CT8 CALLCo rom %mptm "•^iciai. iwronwATK 
ir OCATH OCCURNCD IN A HaSPITAL OR INSTITUTION GIVI ITS NAME INSTC^AOr STRCCT AND NUMBER 

n i\R ft ^1^ 

FULL NAME LL:vx.->.:vcX' ■:1ll.:ULi LL,.v...a. .■ 



) 



PERSONAL AND STATISTICAL PARTICULARS 



HKX ^V^ 



I>ATE OF IIIKTH 



A'.K 



COM)R 



u 






MEDICAL CERTIFICATE OF DEATH 



DATE OF DEATH 



^Moiith) 



1^ 



(IMy) 



(Ye«r> 



i^nnth) 



%-^ 



} >«i I 



I ^ 



(Day) 



Mitnths 



(Year) 



Dii vf 



SIN«.I,K. MAKKIKI). 
WIDOWED OR DIVORfED 
(Wtitciii flodsl (k'KiKoatiun) 



^ 



I 



I 



niR THPi.ACR 



NAME Op 
FATHER 



niRTHI'l.ACE 
OF FATHER 

'Statr or Conntrv) 



MAIDKN NAME 
OF MOTHER 



HlKrnpi.ACE 
<>F MOTHER 
'State or Conntrv! 



^ 



5^ 



1 IIUREBY CRRTIFV, That I attended deceased from 

- to r-^— ^ — —- --' tqo -— ~ 



190 



that I last saw h ^r~- alive on 190 '^ 

and that death occurred, 011 the date stated al)Ove. at 
M. The CAl'SK Ul* I)I:ATII wa» as follows: 



w. 



i-A. t.' 



V 



ftYV 



ft 



li' c 



^u 



(m. 



i 



44. W4 



\ ! 



^ 1 i i 



Dl'RATION Years 

coNTRinrroRY 



AfoHths 



Days 



Hours 



Dl'RATION )'tars Mouths Pavs 

(SIGNED) VCUn-vtV 



UC Uu 



Hours 
M.D. 



i'^ *, 



A, 



[L 



^VW^^A-^tC^V^w^ 



OCCUPATION 




(^-VA^^X.A^^' 



J V<7 ; .r 



\f,iitth^ 



Pii n 



THE ABOVE STATED PFRSONAI. PAKTnt t,AKS AKK TRTK To TDK 
HEST OF MY KN0WI,ED(;E AND HKLllCF 



^nforiTinnt 



fA.l.j 



rc*>«» 






,^„% 



d. 



I 



yj. 



H ^S 190H (Address) LeVe%\.l*U V |_k 



SPECIAL INFORMATION Miy »w HwplWs. lastilitloiis. TfMSletls, 
or Recfit l^sidcnts. aid persons iy\n% «w«y Irm Nw. 



Usiil RKM«€t9*'e^ i ' y)U%MOt "kk nre •! InM? 



toys 



WhN WIS Msnse cNtricM, 
ffMtatpltce«f<Mtli? 



PLACE OF nt-RTXT. OR REMOVAI, 



^ 



i\ f, 



I 



DAfEof Bt itiAi. «r REMOVAL 



! NDERTAKER 

(Ad«lrc«* 






\.AjI. 



off Ififfbrmotlofi should he cupsfully -upplUd. AGB shoold hs stotcil BXACTLY. PNVmCIANtt skMiM 
C OF DEATH In plain terms, fhst It m«> H« ppopcHy clMsimd. Ths SpmsM tofSPiMilloR** far psi>- 



state CAUSE 

Mfic dying sway from horns should h« given In svorjr Instance. 



I I 




I « 



11 



:ilH 




I 



• i' 






I 



I 



II i 



,«T 






i : 




i 






il 



1^ 



i: 





; i' 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

Boanluf n, 1.1th -PVo. i^^^^jH&FCo WCFCR TO BACK OF CeWTiriCATC FOR INSTRUCTiOW 



Dafe Filed, 




u Deputy Health Officer 



Registered ^o. 



555 



DEPARTMENT Of PUBLIC HEALTH=City and County of San Francisco 



Certificate of Death 

( 'Q. S. StanDarD ) 






PLACE OF DEATH:— County of <X^ru o VCL^uCUlco City of U A.>v sJ 



Ko.. 



No. 



H'yo 



^>\v.. 



su 



Dist.: bet* 



»ti. 



and 1 1 ^ ^ 



(ir DEATH OCCUnS *W*V FNOM USUAL R C S I D E NC E Ol Vt FACTS CALtCO fOB UNDER '•^CCIAL I N rOBMATlOW '\ 
ir DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / 



FULL NAME 






.,!.U.'.\..1\ 

it 



X. 



PERSONAL AND STATISTICAL PARTICULARS 



HKX 



ma. 



COLOR 



DATE OF DEATH 



DATK OF BIRTH 



M'.V. 



(Month) 



} 'ra > i 



(Day) 



M.nilhs 



.15 0. 

(Year) 



Pit IS 



^IN<'.I,E. MARKIKI). 
WIDOXVKD OR niVnkCKD 
i Write ill wxrial (lesiKiuition) 



niKTHPUACK 
'State or Countrv^ 



4 vat 



e 
1/ 



'y^^/^o 



NAMK OF 
FATHHR 



RJRTHPI,ACE 
Ol FATHER 
(State or Country) 



MAIDEN NAME 
OF MOTHER 



BIK IHPI.ACE 
OF MOTHER 
(State or Country) 



I 



lv» 



MEDICAL CERTIFICATE OF DEATH 

iDav) 



(Year) 



(\ 



(Month )^ _^ 

i IIHREBY CKRTIFy, That I a|temlecl deceasKHl from 

to iwJLH.. %^ 



> i^ ; to Y^<iw^iLi.. »^ .« iqO 

■ ' li fl 

that I last saw h alive on j . KjO 

and that death occurred, on tlie date stated alK)ve, at 
tV. M. The CAlSr: OF I)I:aTII was as follows: 



DURATION }'€ars 

CONTRIIU'TORV 



Months 



Days 



Hours 



Mmtths 



Da 1 • 



oecrpATiON ^ 

R fs I'lffil III StlM t'tanriffo \ *3 Yfrtts ^^^^^__ 

THE ABOVE STATED PKRSOXAI. PARTICIKARS ARE TRt E TO THE 
BEST OF MY KNOWLEDGE AND BELIEF 

Unfurnuint 



DURATION 



Years 



Mouths 



Days 



(SIGNED) 

ikk.L4 :^S f90 ■' (Address) titH Ji^i^»^v% t. ^ 



Hours 
M.D. 



Special information •«'> fw Hispiuis, iisutitiMv, Tf«i$i«it$, 

Of Recert RcsMcuts, iN persons ^yini awiy frtii " 



f \<!ilrc!Mi 



(l\P 0W <X/^ s. ' v\' 






Nrmer or 
Usual RrsMfOce 

Mm IMS tfseasf coitracM, 
IfMtilplicetftfeaai? 



rtontf teitti? 



Nys 



PLACE OF BFRIAI, OH REMOVAL | DATE of Bi KlAi. or R f:MOVAI, 

Sm-^'-^ ^^ 190H 



^ 



rSDl'KTAKER >0- 

(A<l«lre»« 



in^e 



d.^1 



N. B.— Bv«,.y Item of Information should tee c»r.f«lly .applied. AGO .hould ^^^*^^^^f^^^' , WIYSICUNS irtimiW 
•t«t« CAUSE OF DEATH In plain tefms, that It mmy b« properly clpaalfl«4. The 8|Mel«i laforinatloM ^> p«^ 
•«w« dying away from home Rhould be glvep l« .vsry tnatanc*. 



! 1 V 




< I 



. ! 



< t 



^^i 



I I 



» ' 



« I ; 

i 

1 



'fr 



II • 






!: 



! 

I 



it 




WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

„,,.,! . f H :.1th F Vo I. 1^^^^15&P Co REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



190 

Deputy Health Officer 



B('sff'Sfr/'p(l J\^o. 



fi56 



d^^^vu^ dUA> u uepuiy neaiin unicer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of Death 

{ "d. S. StanOarO ) 







PLACE OF DEATH: — County of UxX^ J/VCUWO^C^NCity oi^Onnu OXa>x-. ^ -^ 



'\XJLA^X^oJb ol'\.^H^ ' -St4 Dist.;bct. and 

t.TH OCCURS .W.YlFRO.* USUAL R EjS I D E NCE G. VE r*CTS ^A^i," ;°'V "';°" ST%%%TiNrNUMBeB°''" ) 
DC*TH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / 



(ir DEi 
ir I 



FULL NAME 



(1 



n 



L \ \,s. 



V 



SHX 



PERSONAL AND STATISTICAL PARTICULARS 



I)\ rj- ttl" lUHTll 



A(.K 



. is H 



(Month) 



!^ ^ r.;n 



(Dav) 



M,iul/i^ 



(Year) 



Ihiv 



'^INi.I.I', MARRIHI) 
WllHiui:!) ((R I)lV()K(l-:i> 
i\\iit( in sfx-ial (U ^iKnatiun) 



l'.IRTinM,\i'K 

St.iti- ,,r i'.)\intrv'l 



^ . ,.aL 



M) 



Z\ 



MEDICAL CERTIFICATE OF DEATH 

DATK »)I" DHATH 



i 






(Yen 



Ii.nth' I 

I ni':Ki;HV CliRTII-V, That I itUu.kMl dcrcascd from 
that I last ^aw h • alivt-DH i • ' \ % 190 i 



an<l tliat <Uath occiirrcil, nn the <Iatc* statcil above, at 



II 



(T 



M. The CAI SK UF Dl^^XTII was as follnws 



« ATincR 



HlRTHl'I.Ai-K 
•M- I ATIIKR 
iStutf tir Cdiniti vl 



M MDFN NAM}- 
"1 Moth MR 



Hii;rm'i,ACH 

01 MoTHKR 
"^l:Uf ur Ct)uiUrv> 



A 



it 



\ 



DTRATinN 1 
CONTRir.rToRV 



)V(7/*i Mo II I /is 



Day 



Hon 



r& 



DIRATKIN 
(SIGNED) 



YeatK Months 



Da\ 



•s 



I()0 



M.hlresO H X'l ^ThxX^ 



I /ours 

M.D. 



'vKj^L 



I"', 



^.1 



'n'Cri'ATlON 



JL,<3Lt '■^^/ ^ 

/\f:iiftf) ill Siifi I'l mil isi'o 1 ) fill f 



\f,wlh 



THI- MU)VK SIATJ- I) fKR^ONM. J- M< T h' f 1, \ K ^. AKi: TKIK T" THH 

iu:sT OF MY KNo\vij;ric,K AM) ]ii:i.n;K 

U) 



''"'■"•iiinnt 




U 



f \(|ilresN 






Special information only for Hospitals. Institutions, Transients, 
or Recent Residents, and peritBS k^Sn «*«y <»«» ''O'^f- 



Usual RcsWenre^^^^ '^. r.,r, 

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



Now loRf at 
Ptareof Dfjtk? 



Days 



ri.ArK «)F rU'RIAF. OR RHM'tVAl 

10 



CW^v 



U '^^ 190H 



!• r\Ki%R 

1 \a>lrc-' 






lit 



D 



f^^ 



?^ 



I 



era '^ 

I 

r 



fcjci 









^t. B.— Bv..;item o» l„fo.m«.io« should be co.^fufly sapplUH. AGH .'loufcl «»« -t-ted RXACTLY. J"^»»;^»;^:;* f »«W 
state CAUSE OF DEATH f« pl»1« terms, th.t it may he ppoperlj. classified. Th« Special Information for psr- 
sons dying away fiK»m horns should be ftlvsn In s*er> instance. 






< f 




I i 



1: 



fill 



I 



>4 




t 

♦: 
i 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

)5,,MMl f Ilca)Ur-l No i^l^^^&H&I'Cn WCPER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



,d-t' 



v^iLv I Deputy Health Officer 



MegLsfrred JV^o. 



r> 



Date /v7r^</, .%jJLu IId 

i7 

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



y 



J 



Certificate of S)eatb 

( la. S. StanDarO ) 
PLACE OF DEATH: — County of OOm^ 0/vCt ) City of ^ 'A^>V ^ Aa i\ ^ 

Na bl Lil' ^ St.; X Dist;bct.^'XO'^^^fr^^' and 

/ ir Dt*TH OCCURS *w*Y TROM USUAL R E S I DE NC E G, vc r.cTS "J-i/^^j*" "'l"",';";*i '^'^^^^^ 

V. ir OtATM OCCURRED IN * HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD Of STREET AND NUMBER. / 

c 



FULL NAME 



FACTS CALLED rOR UNDER ! 
IVE ITS NAME INSTEAD OF 81 



ff 



Ove<. '. ' 



»XOA. 



-UA^ . 



PERSONAL AND STATISTICAL PARTICULARS 



si:\ 



\l')l cv t 



cni,«»K i 



\. 



H\Ti: nl- lilKTll 



Ai'.K 



i a , . 

IIM.mth) 



SIN«",I.T'. MAKUIKIl 

\\ l!>n\Vi;i> OK I>l\'«»Kfl-:f> 

(Uriti HI >-fii ia'i ili '■ij/ii.-itidii'l 



b 



(liity 



1 /.,»////. 



I Vcal I 



fhn 



MEDICAL CERTIFICATE OF DEATH 



UATK t»F I>i:ATH 



.lu 






l)av» 



/9<i \ 

(Yenr> 



I'.SK TMIM.AOK 

^\:i{v nr I'oinitryl 



^■^^t^: m 
•• x 1 H i; K 



I'lKTinM.ArH 
'>' I \ THKR 
'>lrUf or <.*oniJtrv> 



"!• MoTllKK 



;" MOTHHR 
'^UMt or Countrv 






CWh. Ct'O 




D-Uuw\xx/vu vL^ \ 



a 



JL 



JA'^nxo 



1 1I1':1nI:HV tllRTII'S, Thai I atteiuli'd •!i'4i;iscil from 

— 1 go 1<> ■ ~-" Itp 

that I last saw h alive on IqO 

an<l thatiUath ortiii ri-il, un flu* «lati- statnl abow, at 
M Tlu- CATSI-: Ol" I H-: A Til was as follows: 



I MR AT I ON ifars 

CoNTKIIU'TnuV 



Months 



i^a j'.f 



Hours 



Ihn 



\v. \ 



s/ijxsji\/v^ \AJ t w 



ii 



fH'. I I' ST ION 



c^ 



]JLK.' . , .J- - 



aV 



//ifurs 
M.D. 



DIKATION i'^ns Months 

(SIGNED) l.ff\rv\JA» ^ mw JuXoa^^ 

(\.,, 



Special information »«'> 'w iiospit«K, inMifatitM. rrMsie«ts, 

or Rweiit ResMenh. and ^erwus ism «*«) •'••'■ 'MM»e. 



f^fi'ided iit San f'l iliihsi-a J'-i JVvt» 



M ,,,ih^ 



n.n 



THK A1IOVR STXTI-'l) TM'-Ksc>V\L I'NKltt'ft.AKS \I<1 IK' K I< » THH 
BKST OF MV KN<»Wl.i:nr,i.: ASH lU.I.IJ.I 



•Itif, 



:tii;»nt 



LLcv-ru^ wuk,t\ 



K-I-Ik-.^ 



IH o^^^. 



ll 



formrr or 
Usial Rnidmce 

Wfceii was dlsfa«;f imXmXti, 
If not at plarr ol death ? 






Days 



IM, MK ol nrKlM. OK Rf-MoVAf, | r>\TH<>C BfBtAf, or RKMOVAI. 



fNt»i:KT\KI*M 



Aildrt".'. 






1 901 



N. «._Rvery Item of Information .hould be cnr.UHy .upp^UA. AGB .Houl.l «»• ••-*^«I J^XJUITLY PHY8ICUNII .I—Id 
•t«tc CAUSE OF DEATH In plain term., that It mny he properly v^lM.ifled. The Special Inform.llwi for p«r- 
•tons dying tmmw fwMii home iihould he HUen In •very Inetnnce. 



I h 



i 



% < 



! 



'! ' 



•I 



n 



'r 



\ i 



t 



I HI 



' f 



i| 




> 



i 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

„.,,,., .,f ,U„„„-K NO ,s *^ WEPER TO BACK OP CERTIFICATE fOR INSTRUCTIONS 



Jtegiafered Xo. 



nttr Filed, \uJLu %^ I'JO'i 

Lv^ lt;v^u Dcpuf ""^'t- -«^^^. 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Certiffcate of Death 

( m. S. StanJJarO ) ^ _^ 



^58 



PLACE OF DEATH:— County 



C4ei 



;^lo. 



t, 



C)M.|\' St.! Dist.!bet. and 

dmtI oceumico in • mo»pit«l on im»tiiotion give it» NAME in»ti«o or •tmit akd nu»i 



) 



FULL NAME 



kfrk 



^I) w<X\^fr 



SK\ 



PERSONAL AND STATISTICAL PARTICULARS 

r, I coi.tiR 



%. 



CC-Li 



u 



DATK «)F BIRTH 



A« , K 



(Month) 






(Day) 



M-mlfl> 



(Voar) 



/),; I . 



*^IN<.I,K. MARHIKI). 
WID(>\VKI> OR niVORCKD 
IWriti- in social <lesij!rnali«>n) 



HIKTIiVM.AOK 
'Statf (It Country) 



N'AMK ()|- 
FATHKR 



HIRTIII'I.ACK 
Of FATHKR 
ist.it«' or CiMintry) 



MAIDKN NAMK 
<>I- MOTIIKR 



RIKTMIM.AlK 
•>F MOTHKR 
'>»iai( or Coutilrv) 




n 



I 



S 






\i,.|,„„.^ 



MEDICAL CERTIFICATE OF DEATH 

DATK OF UKATII (^ % 



Mo^th) i 



(Day) 



(Year) 



r^KRIiHV Cl-RTII'V. Tliat-I attcnacMl actvasca from 
kAiu lb rgoH to ...4^JLi^ 1% 190 H 

that I last saw h Vv^^ alive on ylcti„^ .. '. 190 H 

ati<l that ileath occurred, on the dati- stale! above, at t nO 
.1 M. The CAISI^ oF DKATII was as follows: 



I )r RATION Years 

CONTRinUTORV 



A/onlhs 



Days 



I /ours 



OCCIPATION 



\xX<x 



K^sliteii in San Ft ani ift'o ,t4 w )i'tii 



^f.Hilh^ 



na\ 



rni: AIMIVK STATKD PKRSONAI. l-ARTtCTI.ARS ARK TKFK n» THK 
iJKrtT OK MY KNi)\VI.KDt,K AND m'A.UW 



'InfoimaTi! 



*. ^ / I 







f \.Mi. Kv 



1^11 jJ-4/U-WC4?.4U» 



1)1 RAT ION Years .)fo)i(/ts /Mys 

(Address) ot \f ll aVi^ 



(SIGNED) 
^SPECIAL IN 



/fonts 

M.D. 



>^ 



r ^w.^- ,. J FORM ATI ON only lor Nospitifs, flistitittois, frM^Ms, 
or*itceiit fesWeiits' and persons dying d^ay Irom home. 



Hirecr IMI? 



Usual Residence ^^ H ^J^^U.acU\<.^ 

Wlifii was disease contraeW, 
If not at plare of death ? 



teys 



ri.ACH OK nrRIAI, OH RKMuVAI, I DATK of Hi kiai, c»r KKMtJVAI. 

ksdkktakI ^WtcLdA...^^iM.a^^^%^ 



N. B.— EvePy Item of lnfoP„,».lo« .hould he caP.Mly -PPH^^i. ^GB «ho„ld »»J««-»*i B'^.^f^^.^t ,„^"L1It1lt- tof^I^ 
.t*te CAUSE OF DEATH In plain term., th.t It m»> be ppopcrly .LMlfWd. TIhi •pecl.l l»form.tlo« foi* p.^ 
•on* «l»^lng away from home Hhould he given In every Inetance, 



.! i' 



» > 



■!,i 




I 






i 



1 \ 







H 



• I 



1 • 



\i 



if 






I 



mi 




I I ii 



WRITE PLAINLY WITH UNFADING INK — 



n.i;iiii "1 n 



, ,1111 I- N'o. 15 *^^ HS^»' ^'> 



190 H 



THIS IS A PERMANENT RECORD 

REF ER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 

550 



Jleo'i.sfr/rfl J\i^o. 



l)aff> FilrfJ, luJLu ^b 

DEPARTMENT OT PUBLIC HEALTH=City and County of San Francisco 

Certificate of 2)eatb 



■>A 



/^ 



( "a. S. StanOacD ) 

j{ m 4 i 

PLACE OF DEATH: — County ofC)<XAV d ^a v.c^. City of ^J^>^' ^^ 



:<.a.Ci 



w^ 




<1L> 







Cj^K^ 



bio-' 



Dist.: bet. 



and 



( " :^v^^vi:^t: "to^^ t.'?^^^~u^4r<f,;.";;-. s.Vm7 ,;v.c7c°j? ,^:ii 



SPCCIAL imrOHMJITIO*!*' \ 
T AND NUMSCN. / 



FULL NAME 




.CL-^xJXj 



-- ^ 



PERSONAL AND STATISTICAL PARTICULARS 

COI.OK 



JL»xo 



AiiK 



1 I I 



^1 



(Motitht 



' ),•<// A 



il)a%') 



M.IHtllf 



fV.ar) 



An. 



•^IN*!.!:, MAKKIHn. 
WlDnwi:!) OK I)IV<»KrH» 

•Wiitt in sooial ik'iij.^iiatiuii) 



HIHlMlfl. Ai'l" 

■^!.fi II! (.■.)unti.v 



V \M1 «»l' 

1 \ in j-.H 



lURTfHM.ACH 
'•' I'ATHKR 
'^tati nr Country) 



luJ ^ 



"vxtr^-^'^v 



MEDICAL CERTIFICATE OF DEATH 

DATK «1H DlvMH (\ 



(JHoutb) i 



(Il:i%'* (S'rat* 



J llIvRI'iHV CKKTII-N. rii.it I .ilUii.UtI tleriMsf.l from 

— — IgO tn \fp 

that I last saw h alive on lUO """ 

jiii.lthat (Kath occurrcil, cii llu- dati- state.1 alxm-. at — " 

— ■ — y\ '\•\x^. CAISI-; tM' 1 > I A r II .\vas «H folln\v»< : 



DT RATION )Vi7r.? 

CONTKIBITORV 



Mofitin 



na\% 



Hours 



MAJDKN NAMK 
«il MoTllKK 



HIKTHIM.ACH 
•H- MOTUT-H 
'?^tat<- Df Countrv^ 



'^OCfPATlON 



Kesidfil III Siitt f't tinrisrit 



) , ,/ / 



^^,'llffl- 



/'.n 



Tin-: Aiun-K ^TNTf-n I'Kksonm r\K ritM-i,ARs aki- tri'K to 
itKsT OF Mv knowi,j;i)<;h and !'.M,n:K 



TIIK 



flnfi.rntnnl 



WW 



<A.l.ir. --s 



DIRATION 
(SIGNED) 



Ytiirs AfoHthi /hivs 



i 



A.a M 



lt)0 



(Aililn-Hs) 'vt\ft>uww 



Hours 
M.D. 






Special information wHy »•' Hw^Ws, hnUdiifcM, TrM»kib, 
or decwit Residents, and persons d)ln5 ai»«y Stm ^m. 

113% Ml...' • 

Wfien was dhease ctMrarted. f k ^ » ^ 4 . 

If notatplareofdeatli? v Ao i v* 



Fnrmer or 
Usual ResideHCf 



Ptarett ftrath? 



toys 



PI \CK <»F niKiAi. OR ri;mov\i. 



IJATK ..f lit KiAr. nr RKM<iVAI< 

> • ■ i '' ' igoH 






i 



t-NI»l%KTAKHR J ^wCCu ^C 

1 1 *i~* 



1 -^ 



Mm^ 



^, « .^ ^ « II ..»»ii«d AGO •hottlii b« •lated EXACTLY. PHY8ICIA1N* sliaiiM 

?i. B— Every Item of l„f.r,nntSo« •hottid Inr a«r.fally «"W»I ed- J^^^^^ ",,.,|f|«|. The -Spccl-I Information" for p^r- 

state CAUSE OF DKATH In pl«1n term., that It mny He properly ..i»MiTie«. m- m- 

««m« dying away from homo should he gUen In every Instance. 



• I 



* 



•J 



I 



( 



I 



•♦ • I • 



II 



!» 



'■"I 




H 



linanl , f llc;.llh-FNo. !«; -^ti; 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

lJ^?^iltS:l Cu REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 




Eeo'isfcrrd ^^o. 



^ 



Deputy Health Officer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Certificate of Beath 



60 



^ 



{ "a. S. Stan&arD ) 



PLACE OF DEATH: — County of ^O^v J iv^v - ^ - ' City of " 0.>v CI^^a vt 



,^0. ct 



N( 



\l I UL^^LA^^^^trvu 



St.: '^^ Dist.;bct. 



and 



RESIDENCE Give r*CTS called for under r5^5fl*l^J^*^"^*Ilf ) 



(..^■■>i B PC i nciur cr r- lur tacts CALLED FOR UNDER S»»CCi«L i ni » w" "•»» i ' w 
IF DEATH OCCURS AW*V FROM USUAL R ES I DE NCE GIVE FACTS "'^^/i' °" " STREET AND NUMBER. 

IF DEATH OCCURRED IN A HOSRITAt OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET 



FULL NAME 



hwYV 



1) 



(K; 



Kojyw^^ 



PERSONAL AND STATISTICAL PARTICULARS 

IX A . A I Ct>l.«>R 




<»! JilKPH 



11 ! • 



MEDICAL CERTIFICATE OF DEATH 

DATH »>1- 1)1- ATII A 



I WI'Milli 



VVtM 









• Month 



Ml 



o.'A 



•s r,',( 



(Dnv) 



i;,'»r'//. 



(Year) 



/>(! » . 



I I" MARRIKD. 

\ 1 i> I »u i>ivuKri-:i> 

1 lU '-. iiiai (If-iKUiitiiJu) 






XAMI- ()| 



BIRTHPl.At'K 
"' i \ i IlKR 
>i.iS( .,! C«.iinlrv 



"I MoTllKR 



i'SHTili't. \rK 
"'laii .,r t'.iutitrv 



J. 






I HI:KI;1?V CI-lUTirV, Tli'f ' itti'n<l tl tlcriasiMl fnuii 



igo 



iqo 



tliHt I last saw h 



alivf on 



lyO 



an. I that .Katli nrcurreil, .'ii flu- .lalt- stati-.l abnw. at 
>I. Tlu" CM SI-; Ol' hi; ATM \va< R« folbiw;: 



CWMw^-^^ 



DTK ATM >N )'t'ars 

CONTkimToRV 



.^/,>N(As 



/hils 



II 



;t> i 



DlKATlnN 



(Signed) 



Yiart 



Us\^ 



Xi* 



Months 



\X^ 



/hns 



/fours 
M.D. 



V)0 



'HATl'ATIDN 

t\fsiitdi i)! Snti f't an, isri) 



) ,.1 ' 



/><7 ■ 



THI M;mvk srxTFI) I'FR'^oxAl. I'SRTtCl-: XK- \K1 IKII T<» TIIK 
••) -1" Ml MY KN«)\VI,ia)(,K AND HI i.lKF 



fT< 



n nit 



\.^^-\^«r% 



^ .V ^ 



Adilresft 



i\X^ 






SPECIAL INFORMATION •*^»« W#^ilH 
or Recfflt Reside«ts, iod persM* lytfli iw« fnw li^e. 






UstrilNMeicr 
IfBtlaf plarrof tfe«t(i? 






0^ 



FJ,ACK ol HrKr\l, «iK HKN!««VAI. 



rSUKRTAKI K 

f Adt!ic«.« 



IJAT^: i.f Hi KIAI. or RKM »V.%I. 




3b 1^- IH t4v» .. 



•^ R c , ^\ ^ , *„ ij w #.ii. .t.i.iat*d AGB tiliould b« Btated EXACTLY. PNYStSIANS shMiM 

W. B.^ ^Bvepy Item of tnfopmatlon sImmM be corouMy mupt^lmm, f^ua •nou « "^ ..««-i«i iMfc«M.Mtln«** tnii m.>. 

•ftc CAUSE OF DEATH « pl.ln term., that It m«y h* p^^ri, .l«.»mcd. The »,.c.liil l«fer«.llo« for pr- 

•on* dytng away fpom homo should he feixen in e^ery Instance. 



I 
I 



!. 



i 1 

( • 
1 I 




IT 



^^d^^MWIHdMM 



'{ 




I ! 



F*. t 



li I 




Hoiir.I of Health !•' No. i« 



Dfffc Filed, 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

R EFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 

501 



»&PCo 



5.b 



190^ 



Reiintered Xo. 



i^ucu) "iw^ Deputy Health Officer 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of 2)eatb 

( H. S. StanDarO ) 



PLACE OF DEATH 



: — County of ^'-CLAx 



. ^ . 



City of 

\1 






cx >v uAa >\ ci4 



and 



fNo.R^?^ <^Vc/\lLiLV>\tlv l^'^^^. St.; Dist.; bet. 

•INa J > X.VWV,^TVWIV ,,-,,., areiDENCE GIVE FACTS CALLED FOR UNDtR SPCCIAL INroRWI«TION- \ 

( "^ ""."_°""''«Ar_\r"?"".jyAy,*l- rff^fx'il'u^T^ON GIVE .tI name instead of STREET AND NUMBER. ) 



IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAI 

cr 

FULL NAME 



a^^vt^WwC^ 



r 



^•^ 



si:\ 



PERSONAL AND STATISTICAL PARTICULARS 

COI,OR \ 



i\\ 



<X.' 



[\ 



DATK ()l- niRT!! 



AC, K 



iMoii'th^ 



) Vifj 



'Day) 



^f,>n//>.< 



/ICH 



1 



Vf-ar 



/><! 



^I\<".I.K, MARKIKI». 
WIDnWKU OR I)IVoR«^-FI) 
'Uritciii scM-ial iksij^uatiun) 



L 



still (ir riMuitrv) 



N\M1- <>! 
I ATHKR 



HtRTIIf'I.AlK 
'»! » ATHKR 
'St.it I (,i Ccutitry 



«>(• MUTMHR 



^ 






MEDICAL CERTIFICATE OF DEATH 

DATK OF I)1;aTH 



n 



(Monlhl i 



(Davt 



I N I .1 1 



I HI:KI:BV C1:RTI1'V, That I atUn.U-.l tU*iasc.l fnmi 



K,S.:LA.i 



I9O ^ 



to 



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



ifpH 



^ »90 

aii.l that death occurred, 011 tht- .Int.- stated al.ove. iit <i* 
LL M. The CAlSf-: (H* DI-iATI! was as follnws: 



0LA1V<X\U 



) . "» 



Aul 



M n ,A.^ T />, H 



1 



ri^ 



tnRTHi'l.ACK 
;»»• MoTIIKk 
'Mate or Cniintry' 



• "VV^O' 



r^vJUi 



"^ ' I I'ATION 

Re silt fit ill Strtt f'l atn isr'<> 



)'riji 



\f,„,tln 



/ht^ 



THK A1U)VK STATHI> J'KRSOVAI. I'AR rn f I. XR'' A K »' TRfK TO THH 
UKST OF :UV KNOWI.FDt.H AND HKMIU- 



-^^^^CU 







I )r RAT ION 
CONTRinrTORV 



i'l'ais Moutin 



Ihn 



4 i ». ?• 



Hours 






(SIGNED) U^' 



/OL/\x >X • 



M.D. 



(Address) 1%00 VtaucA -illv 



•r Itecent ItesMeiits, and ^ersoos dying «»dy from homf . 



Pormff or 
Usual Residfnce 

Whfii w«s disease contracted, 
if not at place of death ? 



Flare of Deatt? 



Days 



I»ATH<4 III KIAI. or KKMMVA!. 
rSliHRTAKKR UaiaAxti Mf^<X^^-rXU ' t 



ri.ACK OF Bt'RtAI. «>K UI:M<»V\I, 



(Aria!.- 



15XH oIo-wKUvw 



« • s .. II J AfiK ■Hnuld Im «l«t«d EXACTLY. PHYSICIAN* should 

N. B,_BvePy Item of I„f.,rmntlon should be c«rof«liy .uppHcd. ^^^^"^ll^^;;* ^^ '*St^c\mi Nfofmatlan" for por- 

•late CAUSE OF DEATH In pinin terms, that It m»y h« l»»'«»P«My «•••••"•«•• ""* •^ 

••Jns dytag away from home should be t^iy^tn In svsry Instance. 



» I 



Ji 



• ( 



I,. 




I» 








WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

,. , ,,.|,..,i,l. ISn...^gg^.»'^''C° UtrtR TO BACK OF CERTiriCATt FOR .NSTRUCTIONS 

Jki/r I'ifert, " ' "• '" ' 






/^ ^r • 

iU/VM. Deputy Health Officer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



"^MAA^ 



Certificate of 2)eatb 

( "a. S. Stan&arC» ) 



PLACE OF DEATH:— County of 



City of 




A\xa. Wrld* 



rNo. 



— St.; 



Dist.; bet. 



FULL NAME ^^:'-<-^-''i:>-^^-^ "^ 



and 

NOER "SPtCIAL INrORMATION ■ \ 
r STREET AND NUMBER. / 



Sj<KO. 



A 



M' \ 



PERSONAL AND STATISTICAL PARTICULARS 

I COI,<JR , 



DATK t>I' HIRTII 



[ y LoXt 



LLcco 

(Month) J 



A(,i.; 



YD )>,/>.» 



II 



11 

(Day) 



yi.ml/is 



f -^ 



II 



(Year) 



/\! 1 . 



■"IN' l,H MARKIKH. 

wiixiWKi) OR nrvoRo:!) 

NViitt-iti Hix'ial (It-si^rnation) 



niRTltlM.At"!-: 

(St;ili nr riitintry) 



lATMKR 



HlRTMI'l.ACK 
f>I' I ATHKR 
iSt.iii or Cotintry) 



mmi»i:n n\mi' 



••I- MOTHKR 
(State ur Cotuiti v 



OCCUPATION 



i 



MEDICAL CERTIFICATE OF DEATH 

DATE <>l" DHATH 



(Yenr) 



(Vjotith) I '!'•«>' 

TllIiRlUiV CI;RTIFV. That I atUiKlcil «UHt'asccl frnni 

njO in ^^ 

that I last saw h aHvc on »90 

and that .U-ath occurred, on the dati- ^atcl above, at I .^ 
M. The CAl'SH (»!• DIvATH \va^ as follows: 



^ 



Si^^i 



\^vv. > -wJ- -«. V 



DIRATION Vt-ars 

CONTRUUTOKV 



.]/,'///;?< 



Pays 



/fours 



I )r RAT ION 



Years 



^fouths 



Pays 




vu. 



m 



vwo 



Rf sided rn Snit I'l iiii, i>i'ii 



5 I'll I 5 



\f,»itlr 



Da I 



THK AROVK STATHD PFRSOVAI, PAR rHMLAR-^ ARK TRIK T< > THK 
RKST «1F \IY KNOwi.HDr.K AND »!• Ml". K 



'Infnnnant 



U.^^ 







I \<Mress 









(SIGNED) "i . Vi>. \1 1 1' ^1 rtX»U.4X/\x<L ^ 



Hours 
M.D. 



I '1 . . ^. _ ., ,.». «„, H»«M«I 



SPECIAL INFORMATION •£) twMj^ltals, 
or Recent Residents, dnd persons dying away frwi Home. 




^U 



Usual Resideace 

WkeR WIS disease cMtrae ted. 
If Hit at M«^e of death ? 



naretf Deitk? 



>, T^Kkftts, 



^s 



PI ACE ()!• H1K1 \I, OR RKMoVAl 



W^ tA>^U^ 



T90H 



DXJI'.f HiMiAf. or RKMOVAI, 

|vwCu Xb 
iNi.ERTAKKR Ca>UAAr^^ UVXO^^VCI^V 



^Adclrt"* 



J.H w<x^v 



^ 't 



», « - .t J A^u .hrtuid h« •tated BXACTLY. PHYSICIANS ^miM 

N. B.— Every Item of Information .hould be cnr.fujly jiupplled. J^ •^^/.^'.^^^if 'Ih'; ..^^^^^ |„»orm«tl«.- for p.^- 
•t«te CAU8E OF DEATH In pl«ln term., that ft m»> He properly vl«»«ifwa. me op*^ •- 

... . . ■ *^ • ^!..._ t. ,.»>»» IdfltaBce. 



a»asc W^UOE Vi" UE;A I n in piwin &c^rinv« »..«• ■• •- — ^ 

«on« dying away from home should he ftUen In •>inrv Inatance. 






i 



I 



1 c 








r* 



»j 



It 



f- 



\ ■ ' 







WRITE PLAINLY WITH UNFADING INK 

A ti 






rL. 




1V0\ 



THIS IS A PERMANENT RECORD 

REFER TO BACK OF CEBTIFtCATE FOR INSTRUCTIONS 

Rcilslcred JSl'o, OuO 




Depu^ 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of 2)catb 

( H. S. StanOarD ) ^ ^ 

PLACE OF DEATH:-County of"' a>^ J/vOAaCUlC^Gty of X>x 



n 



(No. 



IS^ • \X UXy 



St4 



Dist; bet. 



A4,«l-un^ 



and 



ll. 



/ ," oc.TM oceu-. .w» r.o- USUAL ""jP^.^J^^^JVi.V'^VAMCms'r^V" .T*.".'"i-.'o rr^'."" ) 
V ir ot*TH occuimco in a hospital or institution giv* "• 



FULL NAME 



H^-rk/i^ 



X 



1. 



^*wi ; 



si;\ 



PERSONAL AND STATISTICAL PARTICULARS 

COI,OR ^ 



•)l\aU 



V 



U' 



DATi; OF HIRTII 







AOK 



) Vii > 



I 

(I)ilV) 



.1 /..>////.' 



(Vfar) 



/'<n> 



WjUnWHO OR ntVORCKO 
(AVritr in siK'ial <ksijrnali<>ii) 



i 



I 



niRTHI'l.At'K 

(Sti!' M- r.Mintry 



I A riiKR 



HIRTllIM.AiK 
«>l I ATIIKR 
tStat« .,r Ci)untry> 



MAIDHN NAMK 
OF MOTHHR 



IIIKTHIM.ACK 
«>»- MnniKR 
(st;,t. ,,r Coumry) 

OCCrPATluN 

K'f^fd^d iM San fianiisfo 









K^. 







>\^ 






^JX/y^^J^ 






5V.f» 






1 '..- 1 



THK AH(>VK STATK.n PHRSilNAK PARTtOlI.ARS ARK TKl K T* » 
imST ni- MY KNilWI.HrW.K AND UlU.lKF 



rnH 



fliif.xtiiant 



'V.i 



( \ili!rc«is 



1^,5 - iitix 



J 



MEDICAL CERTIFICATE OF DEATH 

DATK Ol" nJ'ATH 



rgo 

(Yi-ar) 



f Month) J '>»-«^ 



K^^^i^ 



I*/) 



to , H'W'JIh 



'1 K- 



190 

that I last saw li alive on r '- ^H '9° 

and that ileath occurrcl, on the .late <tate.l alH.ve. at 
M. The CAISI-: (Ij; DICATH \vas n^ follnxv^ : 

Di; RAT ION ><'"''•« 

CONTRIHl TORY 

DIRATION ^'''%) 



.!/,»;////' 



/)ays 



Hours 



Motitha 



Pays 



Hours 

M.D. 



artOIAL INFORMATION Mly ♦•r »«»«<*»*. iMtHittow, IritiiwU, 

Of Utccnl Residents, and persons dyln| wiy ff«» home. 



Usui! ResMeRCf 

WfifB ws disease conlracW, 
If Rot at plare of deitfe I 



lltwlMf M 



Dtys 



PI.\CK«>F mKIM.oK Kl M«tVAI, 



r 



INUHRTAK 






^^JU^ ^1 190H 



f A«l«lft"»'» 






, „ .„.,,,, AGB .hayW b« .Wt.d BXACTLY. PHYSICIANS .hottld 
ftf Irtform.tlon should he ^•rsfuHy |iuppl»e«i. . , cl.sslfl**. The "Sp«cl.l lnform«llo«'» for psr- 

E OF DEATH In plain terms. th«t It m«y ^_^^^'^ 



N. S,™ -iUvery Item 

State CAUSE OF DEATH In p.«... - i«.tsBC«. 

•ons d>tn4 -way from home should be tlv.n I" •-•^^ In.tiinee 



I I 

I 

1 1 




^ 



(' 



^ * 



ie •! 



' I 



!! 






'! 



S; 



ll 



I: 



I . .1 



Boiitd >il' Hi;iU 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

REFER TO BACK OP CgRTiriCATg FOR INSTRUCTIONS 

lle^isterod JS'o. ^64 



h - 1- No. n ^*^;2^ ns^H Co 



l^tw. iiA>u D^p"^y «"'^^ o^^^'' 

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

Certificate of Beatb 

( tl. S. StanC»arC» ) 
of <^ €1'^ J K<X. n c* ^ City of ^ <X.ru U vctivc • ., o 



PLACE OF DEATH:— County 



No. 



R 'Hoa^vki^^^ ) la^.. St.; ^ ^'t:^^.. ;o. V.^ "..re... ..~.o. >.' ' 

/ ,r oc.TH UcuRS .V..V r«OM USUAL "f f •",^J;f^';'Y„7*=,;i 5,a'me .nstc*o o? stVcct *nd numbc. ; 

V ir DEATH OCCUHHeO IN A HOSPITAL 0« INSTITUTION GIVE ITS ri«iwi. n» 



) 



FULL NAME^J<>-^^^^«^^ 



c^ 



i i\juLi 



i^.^^Jk 1. 



4 < 1 



PERSONAL AND STATISTICAL PARTICULARS 

I n' 






H 



Month i 



\<.K 



O^ Ytun > 



( DayJ 



M,,ut/i 



A 



I Vt-ar) 



/>,; 



^INt.I.K. MARKIKI). 
WII»ciWKI> OR I)IV(»k('K!> 
'Writriii ssociiil lU-siv^iiatiutt) 



IlIkTMIM.ACK 

^'i.il I I It ( '( milt 1 V 



Ba. 



v%^< 



Jc^x % v4. V ^>\><X 



I AT UK R 



HIKTMIM.ACK 
OF HATHKR 
fJ^tHteor Country) 



maiiu:n namf 

<>»• MdTUHR 



I'lRTUlM.ACl.; 
'»1" MOTIIICR 
(*^taii- nr Country 



e 



\ 



i 



MEDICAL CERTIFICATE OF DEATH 

DATK OF lUvXTII A 



IQO 



I |II:KI:UV Ci;kTII'V, TluU l atUniU'l <liiva^iMl IrcJiii 
lip. to \V.vl.L^ X'i IqO i 

lliHt I last sau h alive on ^'f^ 

an.l that .Uatli nccurred, on the .latr statoil abnvr. at > 
M. Tlic CAISIC Ol" IHiATI! was as followst 

8 



"?.. 



. 1 



^ 



t, i 



OiOrpATlON Q\ 

3L) Va-,V 



... « ..4- 



V £ . , 






i^ 



.-1,4.' 



ffi'sidrtf in San /'f iirti i-i'n 3'^ ^ 



\r.,iif/f 



//,n 



THK ABOVRSTATFD 1'KR*inN\l, l'\K I'm I \""> Aki; fKlK T« » IHK 
nieST OF M\- KNOwi.J.Ix.F; AM) 111 l.il 1 



i< ^' 



♦ 



'lnf.,.„,ant 1 ^ 'A: 

fA.i.ir...s R at €c-»^vKtt>A. ' ^ 



-n '• 



Dr RAT ION 
CONTRIinTOKV 



/^rfl.« 



Hours 



y<at$ - Months 



}V.7;.t ^f tilths 



nrRATioN 

(SIGNED) 

A II 'J 

H\,^ ' t.^ • ' H)0 ' (A<l 'lrt sv) I &H 



Das- 






Hours, 
M.D. 



SPETCIAL INFORMATION onl) fw^K^ ^««tl«w, Frjisletls. 
«r Recent Residents, and persons djlnq awn fr« *— 



Nriwr w 
UsHal RrsMence 

Whrii was disease coBtrac tei, 
llMlat ptaceolileatli? 



HtwiMiirt 
Ftoft d Death? 



ll|S 



Pl.ACK OF IIFRIM. oR KFM«»VAI, 



I>Ai;i%.>f JtrstAt. or RKMoVAI, 




I NriFKTAKKR 



^W 



iAda. 






^ iT^ ArK .hould b« •tatvd EXACTLY. PHYSICIANS sluMilil 

N. B._Bv.ry Item of Inform.ilon •hould b^ c«i..f«ll|r '•"Pl*"*^^ p*„^rty .l.wlfNd. Th« ••»,»ecl.l Information- for ^.r- 

•tate CAUSE OF DEATH In pl«ln terms, that It mny he pro^ny 

sm», dylnft away from home •houW be %\^«n In svsry Instance. 



\\ 



i • 



'*! 



lii 



I 



I* 







I 



i 



i\ 



WRITE 



PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



1 fii 1,1, |- V(i 15. "ft^?^^^} Hi's:!' C< 




R EFER TO BACK OF CERTIFICATC FOR INSTRUCTIONS 






"V{KWU) ^Mahj Deputy Health Officer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of S)eatb 

( XX, S. StanOarO ) 
PLACE OF DEATH:— County ofCWv VO City of ^ 



) 



FULL NAME 



11 



cLLca>tv 



i,n 



1 



SHX 



PERSONAL AND STATISTICAL PARTICULARS 

j COI.OR 



DA II-; o|- HIKTH 



WoL 



\ 



i 




At.K 



(Month* I 



(I)av> 



\/.,iif>'i 



\'l 



(V<'ar) 



/>.f 1 .< 



"^IN'I.i:. MARklKI*. 
WJlxiWKlJ OR DIVORCKD 
'Write in MK'ial tksit^nnti«»ii) 



HtRTHlM.AOH 

I st.it i- i)t Coiintrvi 



NAMJ-: <»l 
FATMJ.R 



IURTinM,\rK 
*>F lAIUKR 
'Stall (,t Conntry 



.U^<^C w^' 



nAy 




"1 MnTllHK 



niRTHPt.ACK 
«H MOTHKK 
(State or Cmintrj-^ 







.-vxa-vn A= ^ 



nccrpATioN 






%/,»ff/t- 



/hn 




THK AnoVH ST\T)' n PKRSOSAK PAKTIiM' I.ARS AKlC TRfK T« » 1 »n. 
HKST OF MV l<^)\VI,HI><*.K ANI> Iij:i-n"» ^ ft 



(AfUlrt-^^ 



MEDICAL CERTIFICATE OF DEATH 

^ I UKRMBV CIvRTIlV. That I attcnacd .Icccasi'd from 
AvLVVw V\ 190'. t... I^^W -^ '*J°H 

that I last saw li ' alive on ^^'^M Uyo 

.,uu\ that death occurred, on tin- date stated abov.-. at 1 ^0 



iYrai 



M. The CAl'SH CM" ni- ATll was hh fnllnws 



y .<tl \^vvX<3w^j dJ^' 



JUkX^^^J^M C'> 



. ' V S't. 



CONTUinrTORV 



Hours 



DTRATlnN 
(SIGNED) 



Vfiirs 



Afouthx 



Davs 



Hou 



rs 



t. ^ 



^ 






M.D. 



9PE61AL INFORMATION ••<> Itr Htsptt^ listttot^n, lM«ie»b» 
$r Rffful Rtsldents, and perwiis <yli| wiy Nn !•■*. . 



Former »r , 1 | 

tISMi ResMrncf v w v w 

Wm WIS Ifseiw centrictei. 
If not it plif €•!#€•»? 



nvttl 1^1? 



•^ 



»M,\ri" Ol- ttl IU\I. OR RKM«»VAI. 



IIATK of lit BlAl. or KKMOV*AI, 
H^^^WV^^ %'\ I90H 






^ ^l 



> w 



,. ^ ACB •ho«1d b« •t«i«d BXACTLV. PHYSICIANS ahould 

N. B. Every Item of Informfitlon mhouUl h. crtr.fttll|r •»»«»"*f' ^'^..^ ^|,„|f|«d. Th« "Special l«fow»«ll«ii" ^np p»p. 

•f t/cAUSE OF DEATH l« plal« term., th.t It mn, ^J^'^^ ^'•••'"* *" 

-•^n, H> Ing away from homm .hoyW b« *lv«n In •v«r> lii.t««««. 



^ 
R 




I. 






Iil 



n 



i f 



<tiii 



P 



h 



I* 






f 



Mi, 









Hoard. .f IL nil. I No. i 



WRITE PLAINLY WITH UNFADING INK-THIS IS A PERMANENT RECORD 

REFER TO BACH OF CERTIFICATE FOR INSTRUCTIONS 



H^^ H& P 



Jfcs^^/s/c/'Cfl JSTo, 



"t -^ 4 ^ Deputy Health Ofticer 

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

Cevtiffcate of 2)catb 

( x\. S. StanDarD ) 



PLACE OF DEATH:— County 

(0 ^ ro '^ 



City ofv^^^^'^^>^ 



^No. 



^^CATH OCCURS^.V rR^USUAL B^^B.DENCE o -; - „,^„ .o^„^ .^.^ocR ^s^^^^ ^^^ ^^^^^, 
ir DEATH OCCUR^kO IN A H^OSPITAL OR INSTITUTION u 



( 



) 



D IN A Hp! 

FULL NAME 




a^>\. 



-u — 






4- 



M.\ 



PERSONAL AND STATISTICAL PARTICULARS 

loi.okA ft 



^Ja. 



a. 






!»A'n: t)i HiKTU 



r%Sl 



(Moitiht 



(Day) 



^•■K 



\[ )<UltS 



.1 /,.»////' 



( Vtarl 



/'.r 



"^iN'.i.i:. MAKklJ'I). 

\\ llHtUK.n OK DIVoKCHn 

'Wiitt'iii ^<H'inl ^U•^iK1lali^nl) 



Siafi- iir Coiiulry 



N\Mi-: or- 

lATlll.K 



nikTHi'j,\rK 
'»»•" FATHKR 
•Stutf or Cmniti V 



«»F MOTIIKK 



"IkTlllM.ACK 
«il MnTllHK 



n 



oi.rri'ATioN .^ 



kMx/ 



'W<5U 









%'A^ )v," 



M.niih: 



Pitrs 



TtIK AHC)VH>ATATl.-1>l-FKHUNAM-\KTfi'lI AKSAKHTKI I- T" nn-, 
lUCs't iM- MV KSOWI.!,!)!,!-; XM> lU 1,11 I- 



'I'lf'i-mntit 






r>\* 



te 



MEDICAL CERTIFICATE OF DEATH 

I 









iY«-ar) 



I IIHRI-r.V n-RTn-V, That I atlcmk-.l .kHHascd from 

— -— — — ■ — — f qO — "" 



i; 






up- 



to 



i 



that I last van h aliM' nn ~ ^''^ 

an.l that .loath occurrcl. on the .laU- stati-.l ahove. at 



M. The CAISH OF DICATII \vas as foll«nvs: 



CONTHIIUTOUV 



Months 



t>a\ 



'i 



Hours 



.1fon//is 



( SIGNED ) CoVO-VOhi ' Ai^m iLjlo^Ywdw 



Hours 
M.D. 






#I»EC<AL INFORMATION «*? »•' *«iP«Ws. l«lHil»»»i, TfM^U. 
•r Infill RfsMents, and penens dyta| «iay ftm Imr. 






P 






« 



i 



Former or 
Usui Itesfdenct 

tMm wK «sei5e cwlr«ctrt. 
If notat plafP»f<e*tli? 



Row loR^ at 



Itoys 



I-KACK OF IITKIXt. '»K KF;%Im\M, 






^ 



li\TKof m*BiAl. or RKMOVAI, 



%K. 



190^ 



(Ail>;;' 






f 




..,^ ACB .hmiW b« •t.ted BXAGTLY. PHY«ICIAfM« shoMld 
N. B.— Bvery tt«m i^ l«f««f.«itlo« •hould be cw-.f-Jly f.^^il t properly .I.^WWa. Th* -Spe^l.l Information- for p.r- 
•t«te CAUSE OP DEATH In plol" ««•••»•. «»»•* »* """y t^.f!^.. 
•tw dyLA .viray from fco«- .hould be »lv.» In .vry In.t.nc- 



AA 



trnjl 




f 



WRITE PLAINLY WITH UNFADING INK-THIS IS A PERMANENT RECORD 

R5PCR TO BA CK OF CERTIFICATE FOR INST RUCTIONS 

^ ^R*? 




DEPARTMEnWpUBLIC HE ALTH=City and County of San Francisco 

Certificate of Beatb 

( Xi, S. 5ta!iJ>ar? ) 
PLACE OF DEATH:-County of^^V^v J^^^^me^^ ^ty elvl^l^L.^^" " 



(No, 



/ ,r OC.TH occurs *W*Y rUU USUAL «CSIDENCI 
I tr Ot*TM OCCURRED l4 A HOSPITAL OR INSTITyT 



Dist.; bet. - 



.c O.VC ::;;rc::r5:;p ^o^^^? :;:-:*ij^r:;c""' ) 



vkaA.Li 



FULL NAME v\\aA.U^U^^<|^ 



to'^vr .TS NAME ..ST..0 or str.ct *no .u..cr. 



sHX 



PERSONAL AND STATISTICAL PARTICULARS 

COI.oR \ 1^ 



I)\l I. (>l- lUKTU 



ai;k 






4 



(MolitlO 



«( 



.?* »3 ) Vi/ 1 * 



(nay) 



A/,»/f/r 



r u 



't'«-ari 



I la \ 



•^IN'.l.V. MARKIi:!) 

\\ iii<i\vi-:n «iK niv(turi;i) 

'^Vtiti. Ill stK-ial «U'sij?iiuli<in) 



k 



h 



BIRTH PI. AOK 



«'Arin;R 



"IKTHI'UACK 

f>l I XTIIHR 

t Stair (ir CfJiuitry^ 



maii)i:n namk 

»»1 MoTHHR 



niRTHlT.ACK 
OF Mo'l'IlKR 

(Slat,, nr V'()U11tr%'"t 



^X.CM-4^J 



Q^A.tLa/>v 



<L 



\l..,<fh-. 



/',;v 



OCCrpATION ^i 

Kf^iiUd in SiiH f'l ftii' ■•'■' _^— — ^^^^^— 

THK AHOVK ST\'n-n pkr^i^NAI, PHRTU-ff ARS ARi: TRI F, T« ' 1"»'- 
HK-^T OF MV KNO\V1,f:1H'.K AND liFI.H.t- 



frlv 



MEDICAL CERTIFICATE OF DEATH 

DATK OF PHATH 



^ e 



I HI:RI:HV CKRTrFV, That I altcn.U-.|.U<Ha«c<l frimi 
Umt I last saw h .. al.vc n„ -|A.c«.t 



/poH 






an.l that .Uath occurre.l. on the date stated above, at 
M The CAT SI-: Ol' I)I:aTH was as folLms: 



Dr RAT ION )Vv;r? 

CONTKIIHTORV 



MoHfhs 



Dav 



Hours 



Hours 



( SIGNCD ) ij . i "hx^Aitu 

diAL INFORIVIATION only tor N«sptt4ls« tRslttHtims, 1r«wwiti. 



M.D. 



PE 



nr RecfBt Residents, and persons dyinq away from home. 



Former «r • >,^ Zj t / 

Usual ResMencf i "^ ^ w^wW^ • 

|^« was dhrasr contracted, 

If not at place of deatfi ? _^ 



l*lareor Deatk? 



Uf% 



ri.\^»:<>F niRiAi. »>R kkmmvai, 
1^ 




FNUFIKTAKF'R 



DATF.J BIWIAI or RF'MoVAI, 

Hv^-aaa 190H 



KjOlSJUj^ *^< V>xa ^ *-«- * 



A.Mr,-' 



'€L''YU 



aV._«.i 



,, . Tri .hnuld IM staUd BXACTLY. PHYSICIANS slMttM 
N. B._Bver5. Item of lnf..m«tlo« •hottld be carefully f«PP"-?- ^^^^^y «|...lflcd. The "Sp^l.! l«for«.tlo«" far H-P- 
•«.te CAUSE OF OtATH In pW« term., th- .t moy »»« f^^^; * 
Ron. dying .war f««. hom. .hould be given l« •^•rp In.t-nc. 



r • 

o 



hi 



•> 



• 



I 



♦ 



til 




Ifl I 



I. 




fl 




WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



noiir.l of Ilf.ilth— F No. 1^ 



1)& I' Co 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



Dale Filed, 

i 



^\X\Ji 



Xlo , VJO'i 

Deputy Health Officer 



Registered JSI^o, 



5G8 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of 5)eatb 

( Ta. S. StanOar^ ) 
PLACE OF DEATH: — County ofU/QyYV) 'UX'W/i.ui'Cf City of HXV^v jAXLA-tCLA^t^i 






fNa 



9.S1I5 



. 1 



Dist.;bct. w 



^ 



'<-^>^-^ St. . ^...., 

■■• Tl- "" •-•»''■ >-nvwi vawi^k n K. i3 I WE. l-v v«c bl VE FACTS CALLED 

DEAT^ OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME 



AXA.^r>\ 



and vi 



f "^ .V*"^"* 4CCUR8 AWAY rROM USUAL RESIDENCE GIVE FACTS CALLED FOR UNDER "SPECIAL I N TOr'm^TION • \ 
\ IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION r.iwr .T« MAMr INSTEAD OF STREET AND NUMBER. ) 



JUU 



Kt 



) 



FULL NAME 



PERSONAL AND STATISTICAL PARTICULARS 

I).\TK OF HIR TH 



-Xu lLcyouIhXI' 



y 



u 



U.I 



?) 



' Month) 



(Day) 



ACR 



ib )>«».( I Vr.w///. A*! 



(Vtar) 



/^<f > A 



"^IN'.l.K. MARRIKD. 



d 



Xvcu 




WfrjowKD (»R niv<»Kri:i) /% 

(Writf 111 social drsi^Mialion) ( VIa 

\ ^' ? 

% 



HIRTHPI.ACK 

(Stall' or CoiMitrv) 



NAMK OI 
FATIII-R 



niRTMPl.ACK 

<»< ivruHR 

stilt,. „r Ccnuitry) 






niRTitrr.Ac f: 
«^F M()thf:r 

tStatf or Couutrvl 



______ MEDICAL CERTIFICATE OF DEATH 

DATF. OF 1)F;ATH A fc 

(lyonlh) J (i>„y) (Year) 

I HHKHBV Cl-irni'V, That I atU-ii.lcil .Icrcasct! from 

that I last saw h rt.-- alive on ilvvlvv 'XH igo't 

and that tUath occurred, on the .late stated ahovi-, at 1^!: 
-^ M. The CAISK OF DIvATII whs as follows: 



ncsJLK 



.U wVtrV* ' 



cLjMxtJk 



'I 



^t 



H 



Dr RATION ' )evir^ 
CONTRII'dTORV 



^^-^l-vl^t^ 



Months Days 1 //o«rj 




DIRATION 



)'i'ilfS 



^fonths 



\ P -i M 



^ays Hou 



rs 



•HCrFATlON ! 



r^f 



Rfu'ilf,! hi Situ /'ianri<fri Ste irm 



(Signed) 

^^ T«)oH (Address) bb% 



M.D. 



or Rfcen! Residents, «i« persMS <ri«l «w#^ IfWi kMK. i""sieiifi. 






^fmiffi' 



lU.M <»1_\!\ KN4>\\ l,l.;|M,H AND HHl.II'F 



Fwiierftr 
Usual Residence 

Wfcen was Msease r«nfwte4. 
irnotatplareof deitii? 






Bays 



<H! forma nf • VtX 



>A \, 



I 



' A»l«lrrj««t 






P|^'K^,F m RrxUoR KHM..VAI. | » ' VTK f Ile«,*l. or kKMuVAi; 

^* T90'» 




"In '^ 









{Adi!tri»B 



<». 



ini 'Thv«.4^n, ii' 



M-l- 






t- 




I • 




\r 




WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

Bonnl of lU.ilth I No 15 it^^^ H&P Co RCPER TO BACK OF CCRTIPICATC FOR INSTRUCTIONS 



,1 
\ 



Registevfid Jl'V?, 



5fi0 



t^^i 




Date Fileil, \Au Xb W0\ 

\ ■ M ^ 

r^^vcM dULA^u Deputy Health Officer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Certificate of Death 

( "a. S. StanDarO ) 




(No. 



PLACE OF DEATH:— County of^^a>\; 1 \artC\j4^^ City of ^^ O, \X' J A,a >\cc.; 
1 1 Igi A! U-^xuk St; ^ Dist.; bet V ' lu^C(rK and h 5^aKX>UJL ) 

(IF DEATH OCCUnS AWAY mOM USUAL R C S I DE NCE Gl VC FACTS CALLCO FOR UNOCR "SPECIAL INFORMATION" \ 
IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / 



FULL NAME 



PERSONAL AND STATISTICAL PARTICULARS 



LWaXcL ^ 




aKXv^x 



V l)xLa Ks^yx* 



si;x 








COl.OR 



DATE OF IHRTII 



AGK 



ll U 




MEDICAL CERTIFICATE OF DEATH 
DATE OF DKATH 



(lion 






( 1 )li V ) 



I go 1 

(Year) 



}V(r/ 



(Day) 



Months 



fVear) 



/ifi rf 



'^in'.uk. married 
w?do\vf:i> or divorced 

•Write in stxrial ik'f«iKiiation) 




.' J 




ntRTH PLACE 
'State or Country) 



NAME OF 
FATHER 



niRTHI'l.ACK 
OF FATHER 
(State or Country) 



OF MOTHER 



BIRTHPLACE 
OF MOTHER 
(Slate or Country* 



A 






c 



n 



A 



^% 



Ol 



'\.Lla 



a 1 




OCCfPATION 

Kffidfd rii Sum I'nini iseo 



^ I HRRRBY CMRTIFV, That I atttn.kMl lUctascl from 

:^\,sjLh XH. 190H to I^VL ^5^ up^ 

that I last saw h alive on Vs. tt^ ' igo i 

an.l that death occurred, on the date staled a1)ove. at 1 
' M. The CAISH OF DliATII was «» follows: 



Ur RAT ION * Years '^ .l/»n/As * Days ^ Hours 
l>rRATK)N Years .^rouths Days ^ Hours 



itONCD ) 



M.D. 

^'^ 190 H (Addfe«i) \XK ^Ij^clXk^ ' ' 
?f ?9JftK'NFORMATION oiil/f.f »«pM$, IwMliiW. 1111^^^^ 




} t'li » 



Afiiiffyt 



/itif 



f9nmm 
lisMl RrsMence 

^i Wis tfisMse CMlracM, 
Hii«tatMicr«f ^aUi? 



Nt» iMf It 

niretflHM? 



Days 



^" ht^'-!.*^ *^ HTATFI> I»KRm>XAr, PARTICfLA Rs ARE TRIE To THE 
ni.sr Ol" MV KNowi.Elx.E AND Jii;i.n:F 



(Informant 



\<1ilrci»i« 






FUACE OF lU RIM, UK RFMoVU, | D\^TEof IIihiai. or REMoVAI, 

\ ^u. C^>4^ I J^^^ '^3" f 90H 






INDERTAKER "^iX "^ <X^i-<i4. VV NJ fV i^ \i.<X.sJttr^ 



4:, 



(At!<|rrH(i 



1114 ^VUa^l^^^vJi '^ 

N. B. Bvory Item of Infofmntlofi should be tfarofully suppllsd. AGB sfcottld bo staUd CXACTLY. PHYSICIANS sImmM 
™**i^f "•^ ®^ pCATH In pinln terms, that It nay b« properly elaaalfflsd. Tbo **8p«etirf toformallon** for psr. 
««Mis dyiag away from home «hould be given In avary tnatancc. 



i 



lil 



! t 



i 














WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



M...ii(I of H. .a nil -I' No. 15 



H&l'Co 



NCFER TO BACK OF CCBTiriCATC FOR INSTRUCTIONS 



t 'H t I t t I t * f f . 



^ 



ai 



190 H. 



Re^istcied jYo. 



5?0 



X^-uX6 do^wu Deputy Health Officer 

DEPARTMENT OF PUBLIC HEALTH-City and County of San Francisco 

Certificate of H)eatb 



( ra. S. StanOarD 



^^ r. .,..() VXX WCUl.^^ City of ■ ^ OuyXf 



No. 



PLACE OF DEATH: — County of^^XX>\) Va WCUl^^ City 

m 



K(X N 



( 



%W DCATH OCCURS A#AV mOM VSUAL RE S I OE NCC Gl VC FAC 
ir OCATH OCCURRtO IN A H^FITAL OR INSTITUTION GIVE I 



Dist.;1)ct. 



and 



FACTS CALLCO FOR UNDER SPECIAL INFORMATION* 
TS NAME INSTEAD OF STREET AND NUMBER. 



) 



FULL NAME 



M\/>.v 



X.k 



PERSONAL AND STATISTICAL PARTICULARS 

I COLOR 

.4. 



"'" '^ci. 



\x: I 



4^ 



MEDICAL CERTIFICATE OF DCATH 

DATK OF DKATH 

ITT 



DATK n|. niKTH 



A«-.K 



L 



i>lbtith> j 



} tUt I 



(I)nv) 



ytiinlfis 



(Vfar> 



fhi I . 



^IN<.I,K. MARKIKH 
WIDOWKU OR niVnKCKt> 
iWritfin social «k-si$,MJHli»iti) 



lURTHIM.ACK 
'State or Cn\>ntrv 



l-ATHHR 



inRTMI'UACK 
••I lATHKR 
'Sine ,,r Country) 



<»1 MOTIIKR 



lUKTHIM.ACK 
<)F MOTITKR 

(Slate or Conntrv 






'iA.'V>X]AA 



fMttnth) h 



Havt 



TQO 

iY«-.ir> 



IftHRRKHY CIU<Tn-V. Tliat I aLten.lo«l Ui. t a^cl from 



atfc 



v\ 



W.sXK.i^ V\ 190 i to H^*A<jL ;jk^ 190 H 

that I last saw h • • alive on W^ ^V *^ I»p i 

Hinl that dt-alh i>cciirre<l, on thi- datt- stalnl altuvf, at D 



CL M 



M. The CAISP: (M* DI-ATI! wan as follows: 



CC>X/C.^vl/^^ 



g A,4t>V^ W^aJI 



DIRATIOX * )Varx " Mouths 3 p^jj'* * Hours 



DURATION 



)Vari 



Motiths 



Pnv^ X /fours 






(Aililrc 



Special information only for NtspNtts. InstHttlon, Trattieits, 
or Recent Ini^its, mk perwns tfyiif ffiiy \nm ' 



OCCtPATlON 



THH %novi: STX ri:t» l»KRS<>NAI. r \RTfi*fT.\Ks \KKTRtK To TMK 
HKST Ol-- MY KNOW I. L IX, J.; AND UIIUJIF 



'tnf,, ni.uit 



Qf)\ ^.QUovUvoJUL 



X'Mrc^^ 



%^^t 



m 



^xXX^w^u. it 



Former or 
Usial fesMencf 

^eN was tflseave ron!rarte4, 
If Mt al plare of death ? 



Nwlni at 
Hare tf 1^1? 



layi 



W^ACK OF niKlAl, OR RIMoVAI, I HXTF.f nrwi^t, or RKMOVAI. 
rNUKRTAKKR V V 0^<V^.^W ^< 



u-l-^ |t^ ^j 



4h 



N. B.^ 



BverjF Item off Infofmntlofi sliottM b« cafsfully RU|»plf«4. A6B •hould bs statsd 6XACTLV. I>HYSICIAN(I slMMld 
state CAUSE OP DEATH In pifftn terms, that It may be piHipeNy classified. The **Speel«l litffopmatlon** fep psp- 
R-^ns (fylng away from home should he ^Iven In svsry tnstaiics* 




It 



i 




:i; 







WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

RCPCR TO BACK OP CCRTIFICATE FOR INSTRUCTIONS 



M..;nrl(»f lU^iiUh-H Vo. n -ft^aSS^ 5*^*' ^'" 



Dato Fileil, ;kAJUi 0.1 




190 \ 
Deputy He • Officer 



KonSi ^fri*e(i J^o, 



571 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Certificate of H)eatb 



( Ta. S. StanOarD ) 



PLACE OF DEATH: — County of 'aw^ 






A ^ 

:ity of Oa>v t\a 



^No. 




fc d^ ytK^ikl^U lUuU St.; — Dist.;bct. 

i ir ocAth occuWs awav rnoM USUAL RESIDENCE give pacts callci 



(ir ocJti 
ir ||c 



and 

OCCUMS AWAV rnOM usual HESIDE.nbK. give facts callkO POR UNDEn "special INroNMATION" 
ATM OCCURRED IN A HOSPITAL OR INSTITUTION OlVt ITS NAME INSTEAD OW STREET AND NUMSCR. 



) 



FULL NAME A.Cr\A,>xt 



4- 



PERSONAL AND STATISTICAL PARTICULARS 

SHX ^ ~ \ COLCR \ 

tiATH OH IlIRTH 



lo i . 



A(,K 




11 

iDriv) 



(Year) 



MEDICAL CERTIFICATE OF DEATH 

DATK OK DKATfl 

as 



^Montll) j 



I go 

(Venri 



} V(/ # , 



MoMlhs 



lb 



/',ii. 



'-INi'.I.K. MARklKn. 
WinoWKIJ OR IMVOKt'Kn 
<Writf in wx-iul <le«i>ftiattoii) 



BrKTHIM.AOK 
'Statf or Country^ 



NXMH OF 
t ATHKR 



niKTlllM.AOK 
Ol- lArHKK 
<Htati- tn Cfnnitrv) 



«>F MOTHKR 



niRTHlT.ACK 
o}- MoTIIKR 
fstntr or Coumr%) 



<X*Cl'|'ATjON 









UavIvv 



I inCRICBV CKRTIFV, That I atU'ii.U<l .Iti rasol from 
A^W 5 190H to^ e^vvU^ %% 

that' I last saw h ■ 



\ ' - 190 t 

ami that death occurred, on the date "^tatcil a1ti>\t\ at 



alive oti i" 



M. The CAI'SH Ol- Di; ATM was as follows 



c^.^4a^tvU ')) 



LtX\ <X4.-v\ vLA^., 



X^wU 



I w 



»i 



Dr RAT ION }'fuus 

CONTRIIUTORV 



Moiiihs ^^. /)a\% 



Hours 



I )r RATION 

(Signed) 



Years 



Afofiths 



CUivLa.^ir\a., 



Pnvs 



•- J fa I 



\f.-oth 



X\c 



SPECIi 



u 



Hours 
M.D, 



M tqoH (AfMres**) 



i/i; '^| 1; ti a 



lAL iNrORMATION Miy fer t^pHils, lisllMtois, TrMSints, 
or Recent Reslfcats, «tf pniMS 0lii| iwiy frni Immt. 

•lys 



U$i^ ftesMeice 



Pbtttf li^i? 



Ilt!\: 



THK AHOVF. STATF:n PKR-sONA!. I'ARTIOFf, ARS ARK TRfK TO TIIK 
in:sT OF MY KXo\VI.»:i)«,H ASM) inU.IFK 

Clnfonnant U^M^tl^hj MrXO-M^ 



1 \.Mrr. 



M^ was 4lse«« coitracte4, 
lfiiMaIplire«f4eM? 



Pl.^^ OF niRlAl. OR RKMoVAI. I H \^F <»f HtniAt. or MKMOVAJ, 






rNlJKRTAKKR 

(Address 



N. B.— »Bvery ttem of Inroi*iniitton sbouid be ccii*«full»^ nupplUd. AGB nhould Im •t»t«a BXACTLY. PHYSICIANS MlMlM 
•tate CAUSE OF DEATH In plain terms, that tt mn> h« pi*«i|HrH>^ wlaaslficd. Ths "Social laformatlon** ffop 
Mnns d^'lng away fr^MM home nhould he given in •v«p|' Instance. 




( 


1 ;f« 




1 


i 

< 


i 



1^1 



'\ 



\ 



«l 



V 



I: 



iti m 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

H 1.1 ni iK.Uh -I No IS 3J^s^^H&PCo REFER TO BACK OF CERTIFICATE FOR IIMSTRUCTIONS 




MegLsfered J\^o. 



r;*-^o 



Da/r Filed, %\A^ ^tp WO'i 

i (1 4^5 

d^vcui . ckxxKu Deputy Health Officer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of H)eatb 

( 13. S. ^tan^ac^ ) 



PLACE OF DEATH: — County of 




\ 



ds^ 



/D f^ 



City of ^ ' (n^%<x 



f ( ^ 



^Na- 



(IF DC 



St. 



Dist.; bet." 



land 



ATM OCCURS AW«V FBOM USUAL R ES I DE NC E Gl WE FACTS CALLtO FOR UNDER SPECIAL INFORMATION- \ 
DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / 




FULL NAME 



EdutL OlL^ k 



a 



-,i, 



» %• _ I 



PERSONAL AND STATISTICAL PARTICULARS 

si;x (Ys ^ I coi.oR 



OXA^^<xXi; 



^> 



DATK OK niRTIl 



M.K 



1,*frntlth) 



1^' 



\ y,ii> 



it 

(Day) 



Moul/is 



MEDICAL CERTIFICATE OF DEATH 

D.^Tii OF I)i:ath h 



l.mtli) fl (iMv) 

J IIERKBV Ci:kTn-V, That I attciKkMl (kHcascil frum 



(V«ir» 



CiiMl I 



Da rs 



SIxr.i.K. MARRIHT). 
Wn>n\VKIl OR DrvORCKT) 
(Write in social dcsijrnatioii) 



A 



^jy\. 



IHK PHPI.ACK 

Stiff or CoiiTitry) 



NAMK Ol' 

I'AThkr 



UIRTMIM.ArK 
Of- I'AI'UKR 
(State or Country) 



MAn)!-:N XAVIK 
<»f- MOTHKR 



HlKTinM.ACP: 
<>l MfiTHKR 

l^tate viT Cniinlt v^ 



«H ci p.i\ riox 








-190 



tci 



tli:«t I last saw h 



alive oti 



•I90 

^<>o 



ami that (kath occurred, on the dati- statt'i! above, at 



M. ^he C.\I Slv OV WV.WU was as follows 



I) r RATION Vrars 

CONTKIIirTORV 



Mtniths 



Days 



Hours 



/vvq'w'^ 



nrRATioN 
(Signed) 



Years 



Motithn 



/hiv 



ot 



J Jours 

M.D. 



WlulHiQoH (Address) 'ft-^WOL..' ..,.\' 

Special information ^ fw N^tals. Imtrtitioas. Traiis^h, 



•r Rpcfflt Residents, iod persons dying 4wa) Unm Nik. 



Femiertr 
lisvil i^i^we 



^0 




Kf^liffii in Sillt f'li!ll,'^l'l> 



) Vii t 



yi,uiHis 



ItllM 



Tin: \HoVK V^TATKT) l'KRS«»NAI. »' \ RTtCll \RH ARK TRl'H To THK 
HlCsT Ol" MV KN(»\Vl,],I)(.l-, WD l!i:!,n F 



(Iiif.i^Tiintit 



LUrvvo nJk.&-^^ 



f \iMrr<is 



^H5 



<l<Vvvti 



^ 



^^R wts 4iseiw rsRtractf^, 
If not it ^ace of 4f«tk ? 



4^ r Rtw iMf 4 



Itoys 



I'MCK OF BIRIAJ^OR RHMtiVAI. I l>^K (jf IH i.f*i, or RliMo\ A!. 



Y'^naa-^ * '^ 



1 



1 



190 i 



I.SIMKT 



AKKR W^.^<X.W^ V^^^^- 









■\%. 



D. L 



^* B. BvcP)f Item off Information should be cnrafully Rupplled. AGB should b« stated RXACTLY. PHYfllCtAMS sh-tuld 

state CAUSE OP DEATH In plain terms, that It may be properly claaslflsd. The "Spci^lal Information*' Nir psr- 
■«Mis dying away from home should be 4!% en In svsry Installs* 



"I 
t 



! 



v'i 



^ 



f 



! \ 




Ili U i H 



7 



il 



I \ 




mi 



I 



II 




WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

I?,mr.l ..f lle.Mlth-r No is ^^^^ H&I* Co REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 






Registered J^o, 



573 



lU 100^ 

Xtrvujs dJuM-iDeputy Health Officer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Certificate of H)eatb 

( "Q. S. Stan^arO ) 

^ ^ i ^ 

PLACE OF DEATH:— County of ^CX-^ru J \<X'>^C^<LCX) City of ' 'a >a 



xa 



(No. 



10 :^ 



% 



St 



Dist.: bet. 



bt 



r\j. 



and 



/ .r Dt.TH occurs *w*y trom USUAL RESIDENCE Give r*CTS c*llcd for under J^lV-^'L^^^uZV^'m'*" ) 

V ir Dt*TM occur--- •- - —«-.■»*• na INSTITUTION GIVE ITS NAME IN«TCAO OF »TRi:CT *ND NUMBER. J 



IRRCO IN A MO»^IT*L OR INSTITUTION GIVE ITS NAME INSTI 



FULL NAME 



Olilo 



PERSONAL AND STATISTICAL PARTICULARS 
si:\ (^ A I COLOR \ 



f 

DA'II-: Ul- lUK lie 



1. 



t 



(Moiilli) 1 



A<.K 



I ) i-ti > 



M, nil lis 



\ t ai 



n,t\ 



MEDICAL CERTIFICATE OF DEATH 

DATK <>l ni'ATH 



I 

(Monlli^ \ 



(I»:tv) 



I V.-ar) 



t 



^1N<.I.K, MAKKIKD. 

wiixnyiu* OR nivimcKi* 

i\Vrit<iii stK-ial dfsiKiiation) 



lUkTHPI.AOK 

'Stiiti or Coutitrv^ 



N'NMK OF 

I A I in: R 



HIKTHPI.ACH 

OF I ATI IKK 

• Stalt or Cotintry) 



M UIU'IN NAMJ-: 
"I .MuTHKK 



'>!• MiVrURR 
(Stat- ,,r i,:cMnnry^ 



0^ 







I HI'lKIUiV CMRTIFV, That I MlUtuU«I <U(iasi-il from 
t'.s_'^j.j 190'*, to .>vwLu W^ 190 H 

that I hist saw h v* ' alive on S^V-IU^ iqo S 

an<l that <leath occurrdl, on the <hito static! above, at 1 it) 
M. The CAl'SK Ol' I)I-.\TH uas as follows: 



DTK AT ION 
CONTRIin TORY 



Years 






I hi 



I V 



oCCrFATlQN 



r 1 1 



J/iiu//iS 3 /htvs 

( SIGNED )Xtl^tk ^' .A... 



Dl'RATlON }'i<u'S 

e 



Hours 
Hour.% 

M.D. 



\vciu^ %k'> 



t 



I<|0 



H fArhirtss) u c^ L ai 



a. 



SPECIAL INFORMATION •«ly fw iMpttiH, l«lltiU«B, f r^isleils, 
•r Rcccit ftesldents, «im1 pfrsons rfying away fr«w N«e. 

fwwerw fry i HowloHrt 



UsMi ResMmce^ 



:.a-4.0L 



Hire of kiti? 



Itays 



1/,^ -/'/';■ 



THl" AHOVR HTATrn PKUSOXAl 1' A K f f sT !, \ K '^ A K 1-: TK11-: T' > illK 

HHsr r»F MY locctwi.i'iM, K XND iu:i ii;!-' 



(Itifo'ittant 



fAfId 






XCUAXJ^^ 



aX*> 



:%4 S^a. 



IfkeR wiS disease cMtrartetf. 
If not at flare of death? 



IM,ACK Ol IHIUAI. nR K1-M<>\\I 



\s 



^ 



LC 



wCU 



I NUKR lAKKR 

f Ail<lrr«« 



tlAXKof mniAL or KKMOVAI, 

|v.J^ a.1 T90H 






N. B.- 



-Rvery Item «»f lnform«tlfm •taould be capefttfly iiupplleri. AGB Mfiould b« •tated BXACTLV. PHYSICIANft aliMild 
state CAUSE OF DEATH In plain term*, that It may be properly classlftad. The "Special InfwaiaHon" !«• ^p- 
annv dying away fpocn hem« atonld IM given In msmr^- Instance. 



|l 



I 



'M 



I 



I • I 



I. 



Ul 



H 



1 



•• - 



f 



^m 



tH 



mm> 




'^ 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

Hnanl of llenlth-"! No ,. 1^ RKFER TO BACK OF CERTIFICATg FOR INSTRUCTIONS 



Dfffr Filed, 




190 H 



Registered J^o, 



^^-4. 



.^ LCA,^ 



Deputy Health Officer 

DEPARTMENT Of PUBLIC HEALTH=City and County of San Francisco 



Certificate of Beatb 

( tl. S. StanOarO ) 






4 



i V 

PLACE OF DEATH: — County of ^lOAv J.^<X-^vCL4-^ City of OO/^v J \^^vxi 
No. ^5 3 L<\l\.lv St.; ^' Dist.;bet. Xl Mj and X\ 

( ir oc.TM OCCURS *W.Y rROM USUAL RESIDENCE GIVE r.CTS CYtto ;<>«"'*"" "^"^;*iJDH°ui'itii°'* " ) 
V IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / 



<w4. C C 



FULL NAME 



LLrkalr\J>^4Jb M UjlhA.\.tl 



PERSONAL AND STATISTICAL PARTICULARS 



^K.\ 



^VoL 



COLOR 



lO.lvcL 



DA ri-: OK niKTH 



A«,K 



I Month > 



n 



} 'ra I 



% 






Mntlths 



rV' 



I ■» car 



/hi I. 



SI\(,i,K MARKIKr). 
\VI1H>\\KI> OR niVOMCKI) 
(Write ill social iksi^rnatiiMi) 



l:iKTHPI.AOH 
' M:\\t- or Conntivi 



N'AMK «>l- 
KATHKR 



niHTHIM.Xt'H 
OH KATin:k 
estate or Cujiiitiv 



mmi)i-;n ^•A^^l•: 



HIRTIfJ'l,ACK 
OF MoTHKk 

("^t:it(^ .ir Contitrv 



OCCITATION rVv. 






<X4,^MX C4 VA.4.4^* 



MEDICAL CERTIFICATE OF DEATH 

DATE OF I)1:ATH 

(I)uv> 



(Montli) 




/QOi 

(Vrari 



I UliRIUJV Cl-RTII'V, That I .'UUMi.lcl <U'«iasc«l fMiii 
^lu-^A^i I up i tu^ l^hjL-Xki 190 H 

that I last saw li ' alive 011 V-A-^U^ j-%> iqo i 

ami that iloath occtirrcd, 011 the ilato stateil alH>ve, at 11 
CL. M. The CArSI-: OF DI-ATIl \%a^ a^ follows: 



.KJt 



III 



%^\^U'^V 



DIRATION }'inr.i 

CONTRIKTTORV 



.I/0H//1S 



Pay 



/fours 



or RATION 



(SIGNED) 



an 



)'t'at s 



Mnnth.^ 



/hivs 



!^,Cmiu 



Vvl. 



i 



H>0 






Hours 

M.D. 



fCfsidfti hi San I't nm hro * ) ' (' 



1/,,,,//,, 



/J..M 



Tin-: AMOVH STATKI» PKRSOVM, r^RTIftl \KS ^KHTRrK To THK 
Rl.ST oi- MY KN«)WI,1:1)i;H ANI> hi I.M.I 






\f1(lrr«i<« 



SPEtJIAL INFORMATION o«fy f»r MwplWs. ItsUtitltts, TfMlMls, 
or Recent RRldents, and persons (fylnj at»av from hoM. 



Forn^r or 
I'siai l^sMeiice 

If nttatplireoftfejtft? 



HOW loiif n 
Flireof Death? 



Oi)^ 



PLACE OH II! RIAL OR RKMoVAI. I DATKof UiRtAL or RRMoVAI, 



igoH 



rNt»KRT^KFR 

<A^I^^rr*^ 



Oc^U 



^X^'V^^ 



^ C 



<x.*. 



N. B. Bvery Item of tntorm^tton shoyld bs cnrafuliy iiui>plied. AGB Rhould H* •tutcd BXAeTLY. PMY^^ANS alioiild 

•tate C^USE OP DEATH In plain terms, that It may He properly «;l«sslftcd. The '*S|>c«t«l Information** lor prnw 
«nn« dying ftway fi^Nn horns «hould be given In every InRlvnce* 



1 

1 
S 

I ' 



I. t 
I . 




il 

#1 




|: 



Jif 




i 



!■ 




Ro:ir<! of HLaltli— I* So. 15 ^^ 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

li&PCo REFER TO BACK OF CCRTIPICATE FOR INSTRUCTIONS 



Dfffe Filed, 




Ifc 



190\ 



Registered JVo. 



5?5 






r.^t 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of 2>eatb 

( m. S. StanDarO ) 



H-ACE OF DEATH:— County of 



City of 




CX^-v^unXLi '^AJy 



^No. 



Sxa 



Dist.; bet. 



and 



/ ir oc*TM OCCUH8 .W*Y rnoM USUAL RESIDENCE Give r*CT8 ^.^Mr .'.fTT *'?»'*«; «? 
V ir otATH occunnco in a hospital or institution civc its name instcad or ST 

1 (i ^ 



special information 
rcet and number. 



) 



FULL NAME 



LC^>\,a_^ 



sj.:x 



DATK OF lURTH 



AC.K 



PERSONAL AND STATISTICAL PARTICULAR^ 

COl,OR 




U ;..U 



(Month) 



Ml 



(Day) 



I 1 A /»////> 



(Vear) 



/ht 1 ■ 



StNT.I.F. MARKIKU. 
WIIH)WKI> OR niVOKiKI) 
(Wiitt'in Kociul <U**<iiniation) 



HIKTMIM.AOK 
'stall or Country) 



N'AMK OF 
I ATHKR 



BIRTIin.AfK 
01* FArHF:R 
(State or Country) 



MAIDKN NAMi; 
iiK MOTHER..^ 



HIRTHPI.ACK 
OK MOTHKR 
(Stnte or Count rv) 






MEDICAL CERTIFICATE OF DEATH 
DATK OF DKATH 



MIonth) V 



(Day) 



(Ycnr) 



I IIRRHnV CI':RTn'V, That I nttcinlc«l .U-rcasol from 

-— ■ 190 to — -190 - 



that I last saw h 



alive on 



•190 



and that death occurred, on the date stated alK>ve, at t> 
M. The CAl'SI-: OV 1) I! ATI I was «s follows: 




^\.«%^ 

^%,^-^< 



or RAT ION i'ears 

CONTRini'TORY 



Moutfn 



Davs 



I lours 



OCCUPATION 7^ 



n- 



VvvO-V^'^'C^ >v» 



R^side,1 in Son 7'nin,isf-o - i'fdf t *■ ^f.'^l^t "^ /^".t ' 



THF ABOVE STATFI> PFRSONAl, FARTHTl.ARS AKH TRl'K TO TIIK 
HHST OI MY KN'oWI.KIXiK ANI> HKI.lKF 



t\M 



re«tii 



DIRATION 



(Signed) 



}\'ars 



iL,loQf)\vci 



Mouths Days 



Hours 
M.D. 



KcLu "l-l TqOA (Addre<«s) 



4 i-k Tq 

CIAL IN 



_ _ _ _ FORMATION mI) (•' Hospitils, MmMm, TrMSieils, 
•r deceit I^Meits, mi penHs lying iway frtni ktmr. 



FtfiRcr w 
Usuil RnMrnce 

WkeR IMS li^aw ctitrirtN, 
If Rotatpiaretfliatti? 



Ftoretf Oettk? 



Diys 



Pr,4lCK OF BlRIAf, QR RFM<»\ \l. | IIATjt: uf (li kial or REMOVAL 

W^ ai T90I 






INUHRTAKKR 



7 ^ t 






N. B.- 



-Bv«py Item of Informatton should be ciipsfiilly sappH**!* ACB •hotiM Im stated BXACTLV. PHYSICIANS 
■t«t« CAUSE OP DEATH In plain temns, that It may b« propcHy claaatflcd. T^ **«pacl«l toformatloa** far 
a^« dylnS awi^ fi'om iMms should ha ilvsn In wary Instaaca. 



I 

f f 



f 



' ' • I 



♦ 



r 



M 



I l li ^*^ (I P 








WRITE PLAINLY WITH UNFADING INK — 



Bonn! of Hi-aUh- I" N'o. i^ ^^^^ H&l* Co 



THIS IS A PERMANENT RECORD 

REPCR TO BACK OF CERTIFICATE FOR INSTRUCTIONS 

A |p 2U0\ Begistered J^''o. t^fO 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Dale Filed , 




Certificate of 2)eatb 

( Ta. S. Stan&arD ) 



PLACE OF DEATH:— County of <"'07>V J ^UL>vx^ciCC Gty of ' ' CX^ O.VO,^vCv 



'J 



No. ujtuNi L 



^\^^ 




% 



^X 



St.; 



Dist.;bct. 



and 



I . Y i . .»■•&■ BC-einr Mr r riur rACTS CALLCD roB UNDtB "SPtCI*t INrOHMATlOW \ 



FULL NAME 

PERSONAL AND STATISTICAL PARTICULARS 



I»A TK «)1' BIRTH 



,Lib 



COI.OR \ 



II 



, % '< ■ 



(Month) 



AC.K 



O b }></»> 



il)av) 



M,itif/n 



Vfurl 



/»(/! 



^IN'.I.K, MARKIHI). 
\Vri)u\VKI) OR DIVoRCKD 



Vri)u\VKI) <>R DlVoRCKD \ 

Writf in sf)cial <lfsiKnatio>i) \ \ \ 



niRTHIM.AOH 
Stfitt f»r Conntry^ 



MEDICAL CERTIFICATE OF DEATH 

DATIC <>!■ I)1:aTII 

''ax. 



I (jO i 



\X.K.KJi 

..ntht f •l)ayi 

I IIFKI'IIV CI:RTII'V, Tliat I JiH^fiKkil <UriastMl fmni 

H't 

anil tlint death occurred, on the date stated ahnvc. at w ^ ' 



.VS-Cm - I90H to ^>^-^ ^"^ *9° ^ 

that I last sawh«*Ai alive on ^vC"Lc^. '\ \ 190 



-*Lm 



M. The CM SI-: Ol' ni:A'»'II was ns follows 



(jLA^JvvAX«wa aJ-^ir^. 



N'AMK 01 • 
FATIIKR 



niR rniM.ArH 

f>l' lATHKR 
'Stiiti' or CfMiiitry 



MMUKN KAMI- 



niRTHT'l.ArH 
JH MOTHER 
(Siat«- or Cfjiintry) 



1 



(i) 



\A,C.C 



nr RAT ION 

CONTRIBt'TORV 

lURATION 
(SIGNED) 






)Vvi 



'^ 



Mnutfn 
Af.>nlfis 



/hivs 



I/ON 



rs 



I hj I'.f 






M.D. 



•»' Ctl'ATlON 



-1.' ^-v^ 




txw^^ 



f 






M.itth- 



I hi 



rnv. MiuvK sT\ ri-.i) pKR^o^•Al, psRTfrti.ARH ari: TRt k Til Tin-: 
HHHT OF MY KN<>\vi,j;i)r.i; wd mi:i,ii:f 



(Informant 



Address 






Q.Uu 




M=|%^ 



%aX4 ' T()0 ^ r Address) ^'-W '^^ v^ y ' 
SPECIAL INFORMATION on»y Jw iftsfHils, tiistititlm. 



or Recent ResMents, Md pers««s dyinfl ai»ay Iran N»e. 

Win WK disease cwilr«de<, 
IfMtatplaretfdntli? 



vMJvck vlLU4#||fe tf Deitk? 



TrMsimts, 



Diys 



I'l.ACK »>r HIUIAI. i>K K|-M4»\M 



l»ATi:of IliHiAi. ©r KEMoVAI, 



a*i 



T90 



INIU.H r^KKR 

fAd*!rr*« 



30 f ^\fr> 







IL. 



N. B. Bvcry Item of liifnrm«tiofi •hould be carefully iiupplled. ACB .Hmild IM StBttd BXAGTLV. PHV»ICIAN« sImiiM 

•tate CAUSE OP DEATH In plain tepms. that It mmp hm properly cfaMlftod* Tli« * Special l«form»tloii for p«r- 
•'»«• dyln^ pwsy from hom* Bhoulcl he given In cvary tnalnnce. 



» ) 



I 



•^^■i^ 



III 



> 





i 



M, .,..:.' ..f Hviilth— F No. !«, '^'^' 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

,j&,.Co REFER TO BACK OF CERTIFICATC FOR INSTRUCTIONS 

" 577 



Ditfe Filed, Wiu Xt 

J TTl 



100\ 



Registered JS'^o, 



DEPARTMENT OF PUBLIC HEALTII=City and County of San Francisco 



Certificate of Beatb 

( "d. S. StanDarD ) 



PLACE OF DEATH:— County of^O^^v l^cu^ voOLC^Gty of ^^^^^ J ^C^ 



4, 



^?» 



Pie. 



Wy\L^aI) C/YnJUs.^ 



n 



H Lstjo. 



Dist.; bet.- 



—and 



MAY fhoiI usual residence give r*CTS CALLCO ran unoci» spcciml mwommhtion" \ 

CO ,N J>0«P" ••- O" .NST.TUT.ON C.VC .T. NAME .NSTC*0 Or .TP.CCT *HO HUM.f... J 



FULL NAME 



PERSONAL AND STATISTICAL PARTICULARS 
SKX A . ft I COl.OR \ 




rwAA^ 




xAL^ 




[\ ■ .\ 



I>ATK «)F mRTH 



(Nfonth) 



A(,K 



V-{ 



\ Yrat: 



fDay) 



Mmlln 



(Year) 



MEDICAL CERTIFICATE OF DEATH 



DATK OF DKATH 



(■onth) 






/90 H 

(Yenri 



I HERKBV CI':RTIFN\ That I ntlcmlca «U'<Ha*?cMl fnjin 

— to 



that I last saw h 



190 -— 
— 'alive on 



^90 
190 



Da 1 v 



SIS' l.K MAKHIKI) 

WfnowKi) OR nivoRt Ki) 

(Write ill social tlcniruation) 



lUKTUPKACK 
tst.-itc iir Country I 



N'AMH or 

J-athi;r 



HIRTHPUAti; 
Of I ATHHR 
'Stnu- or Counlr%) 



m\ii)1.:n navik 



HIKTIIIM.AIK 
«M MnTHHR 
(Slatr or C«Mniii\ 



OCCll'ATlOl^ 




and that death occurre*!, on the date stated alK>ve, at - 
M. The CArSK ()!• I) K ATI I \va<i as follows: 



Ci.A.^%Jb,^5.-4.^^ 6i- iwt 



DTK AT ION Years 

CONTRIHl'TORY 



Mouths 



Days 



Hours 



A 






/Vwti- 



Rf'idfii in Siiii /'i itn, ii'i I ^ ) 



ftf » « 



\f,<tirfi* 



fht s .<■ 



THi: AHOVESTATHD PKRHONAI. I'^KTICfl.AR!4 ARH TRl E T«P THK 
fcRST OF MY IOCO\;n.F.I>r,K AND HHMKF 

(Ififurniafit 



fAddreiiii 



i 1 ^ >vu. ^ 



DIRATION 

(SIGNED) 

A I 



)'t'ars 



Monthi 



Days 






Hours 
M.D. 



Lfr\4">VUu 



^. -JiAL INFORMATION ••lyfcrfci^^ 

•r innrt RrsMeits. wk lersMs tfytof m^ frM Niie. 




If5% 



FfTMrtr ^ 
UsMil irsMfuce 

Viet wiS iisefK ctitricte^, 
H Mtalpltrr«f ^atti? 






Irmletts, 



•^ 



PI^CR OF BfRIAI. OR RKMoVAf. | OATH of llfKlAL or RSMOVAI, 

* " ■ ,1 I A 



■^ 



L 



'is^JUi %l 



CKHKRTAKKR 1 U t oJUU/VV U H ^ ^ 



190' 



CAddreM 



-f I V 



ill I 






n, B.«-«v«py Hen, ©f InfformatSon slioMld li« carafully supiMtc^. ACB aliotfld Im stated eXACTLY. PHYSICIANS "l*^*' 
State CAUSe OF DEATH In plain term*, that It amy b« pi»op«rty claMlflM« Tfc« **l^«clal laforaiatloa" f«F - 
■mi« dying awi^ ft««i hmmm alMald Im Al%«n la avary tnatanc*. 



I 



' > 











I 

i 




I 



^nj'jtblifWT^J^r-r- 



Hfuird of Henltli — F No. i^ * 



J«&I^Co 



Dafe Filed, 

i H 




WRITE PLAINLY WITH UNFADING INK-THIS IS A PERMANENT RECORD 

w erew to back of ctHTiriCATc roR iwaTRucTiona 

XL 



RegiNterod JVo. 



578 



7.90 S 
^^-M.« iX\Mu Deputy Health Officer 

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

Certificate of Death 

( •a. S. Staneat6 ) 
PLACE OF DEATHS— County of H a^v l^n ^ *^ 



^No.C 





City of v.lct^v 'vo, 1 vav 



<^ 



kd 



a 



St 



ir DtA/M OCCURS AWAY rROIHr USUAL Br«"fnViu^r ^-'ISt.; DCt. — - ~ ——- ^jjj 



Dist.;bet. — 



FULL NAME 




a,\.:a - 



SKX 



PERSONAL AND STATISTICAL PARTICULARS 
'^ ^ j COLOR 

. 1 j2 





) 



) 



i^ 






u 



MEDICAL CERTIFICATE OF DEATH 
DATK (H DKATH 



r 



I«>nth) \ 






<VeHr) 



'Month) 



At -.I.! 



tl 



) lUl I 



(Dny) 



lA»»////.v 



^tNf.I.T'!. MARKIKI>. 

\vriMi\vi:i) OK f»rv(»K(i.ri 

•Write in s<M:ial .Icsivnati.ni) 



'V.ar) 



/hi 



^ I IM-RI-IiV CICRTM-Y, Tlmt l„,,e,„lc,l.l..,,..,M.,l fr.„„ 
H^VAVL IX ,90 -1 to - HvJu^ , IS. ,qoi 



FUR rif PI.AOK 

^Sl.itf or CfMuilrv* 



N'AMl-; u|- 
r ath};r 



"IRTHIM.AfK / 

ni- r-ATJiKK { 

'"^tatcor Coiintrs-) 



^'An>i:N' N\Mj. 
'• I * » j» ii j^ 



HlkTinM.AiK 
"I Mf»THl-:k' 




^„- 



;'^ 



that I last saw li 



ali\-c oil 



'^M 



:V '90 

atul that death (KTt.rred, on the date- stated „|„,v,.. ai ', 
^L M. The CAlSn UI; IM-ATII wa. as foIln„.. 



f\f 



U <wL\M^VV 



\M..vMXh; 



%' 



o 



■^ ^^, 



a 







vL'" 



^IL "J' 



CONTRIIHTORV wL1Ll»lo^ V. O.^ 

^Signed) ' ' 






thix 



U 



Hourx 

M.D. 



-"v%^ 



n 



'Hi'ri'\TI(»N 



Av.1 



a^^L 



4 






r ( J' ) 



(Ad«lrt-«<s) 3uX U CI' 



Sf.,„!lly 



""'■'-'-" ^i^■^^i;.^;•;:^^,:^^^^;;<^-,--— -K'-KT,. 



TIIH 



'Hltll 




rvwXe 



' \di1rf^n 






^Wifi! WW rflwav f Mtrif IN, ^ ^ 

If not af plare of (kith ? >l\. ^ vL I H ! ' » ; , 






K-tv >>vo^ 



*~««Ve*gi78E'oF dTa^h*^ "''TI** ••' •^«'-«?««li' -PpHed. AGE .HouW b« .ft.H BX4CTLV. PHYWCIA^II JZT 



fl 



i4 
J 



, I 

I 



I 'If I 



k^ 




\ 



'WK^^m 




j. 




hf 




i 




WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

Hii.inl ,)f Hfiiltli- I" No. 11 "f^^^^:^ H&J' Co 



Dfffr Filed, 




WCFEW TO BACK OF CgRTIFICATC FOR IN3T RUCTION» 

Res^istcred J^^o, 



579 



It lOOH 

A Deputy Health Officer 

DEPARTMENT Of PUBLIC HEALTH-City and County of San Francisco 



CettfRcate of ©catb 



PLACE OF DEATH:— County of " a^^ 6kxl ^ cuccc Gty of ^<U>v J Vol »vcm.cc 



I 



^No. 




fO 



L il A 1 

O h S Lw^^xX-cLkj St.; 1 Dist; bet. V( IM; and ^ ^^ <lt ^t 

( *' f/ltliV®*^'^"''* **'** ''''^•" USW*«- RESIDENCE GIVE r.CTS callco roR UNOCR 's^rcut iNro«ii.Ti«-- \ ' 
V ir Dt4>H OCCURflEO IN * H08P.T.L OR INSTITUTION GIVE ITS NAME INSTC.O OF nimttrJoMvUilm ) 



FULL NAME 



.i\..tn:^fXCL^ 



DA_'^- n 



>^i;x 



PERSONAL AND STATISTICAL PARTICULARS 

COI,OR 



n.\TK »>I lUKTH 



M'.K 




bu.Lt. 

as- 



MEDICAL CERTIFICATE OF DEATH 



DATK OF DKATII A |\ 



- )>iUS 



(Day) 



V.O////' 



fVf.'if I 



/hn. 



Okfonth) 1 

* ft '1^ 



1? 






WlDoxyuu OK DIVoKiKI) 
i\\'riti- in stxjal (Usi^nutioii) 



^ 



HIKTIU-KAOH 
(Slate «»r CoutJlrv) 



NAM I- <>|. 
»• ATIIHR 



HIKTIUM.ArK 
«H' I AIHKK 
'Statt ur Countrv) 



maii»i:n namk 



•lIKTHI'i.ACK 
"1 MoTHKR 
i-Malf or Cull till V I 



<^>vclJ 



I m-KHUV CKrTIPV. TIuU lyttvM.h-.l.lcrtasea from 

tli.'it I last saw 11 ... • alive on - . loo ' 

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



M. The CA! SK Ol- DI.ATII was as follows 



^ 



% 



'•CClTATioN 

. KfshUd iti Siiti I'lr.n 



_ Cij 



>^V<^</ 



^^k 



t'w ^\K^ 



Dr RATION Ytars 

CONTkllU'TORV 



AfoHths 



Dav^ 



//ours 






DlRATrON 



) 'cars 



/^avx 



(SiG^^ LUi>uudL A^ . 

^kXu:%L U)0 . (Address) 5 JD C ^A.cC' 



\ I t 



//fyurs 

M.D. 




«^ Kttil HsMfBts, iN pmwis ^ia| Miy frMi ^^m. ••«3«ins. 



JV.ji 



Mmlhs 



"hSl ui- M% KN<)\VI.K1"-.J: \M) HHr.lHF 






Former tr 
Uwal Rp^fdfwe 

M»R wa^ di!^av rontrxtei, 
ffiwtitplirt^^itli? 






Iqt 






PT,X^ OF HFRLM. uH HHMnvu. I HATE^.f ,i, km. „, KKMoVAi; 
INI.KKTAKFR ^ W U t^^X >\^\i '^ \^ ^ 



^ , ^ , ^^ ^ ^^^ ^^ carefully supplied. ACB .Hould te •ft.d BXACTLV. PHYSICIANS ,ImniW 

•^l d^fJl f ^ I" *" **!"*" •*'••"•' •"•• *• ■""* ^ property cLsslfted. T^ "Sp^l.l l»for«.tlt»- %^ 

•tws dying away from horns should be fttvcn In m^wt^ Instance. «f 



. 



I [ 



, I 



- I] 
■J • 



II 



f I i 



•i 



t 






WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



lt..aT.l ..f llr.'ilth— 1- N'o. i«, *^i»S)B&PCo 



PtCFER TO BACK OF CCRTIFICATC FOR INSTRUCTIONS 



'rf 



i «•* 



Date Filed, 




Deputy Health Officer 



Registered •A^a 



580 



l! 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of Deatb 

( m. S. StanOarD ) 



PLACE OF DEATH: 



— County of^^tX-w' J AxXavca^C^^ City of ^^^<V.ro uXcv^xti^t ec 



(No. 




\Uw 



«.« 



^^aXu 




M 



k\Xa.i 



(ir ot 



ATH OCCunsTAWAV FROMi USUAL R E S I DE NC E Ci VC rACTS CALLCD roN UNDCN "BFCCIAL INFORMATION- 
DCATH OCCUpnCD IN A HOSPITAL ON INSTITUTION CIVC ITS NAME INSTEAD OF STREET AND NUMBER. 



St.; 



Dist,: bet. 



and 



) 



FULL NAME 



(?d.vO' 1)^.^1 



PERSONAL AND STATISTICAL PARTICULARS 



SKX 



^Ax 



COl.OR 



DATK t»l- JUKTH 



I Month) 



Ir 



(Day 



"ear) 



AC.F. 



7" 



m 




/ 



MEDICAL CERTIFICATE OF DEATH 

DATK OF DKATH A h 



f Month) » 



(Day) 



(Vc«r) 



^ 



I hi; RICH V CI-RTIFV, That I aUiMnkcI .!ctvase*l fn 



\.kX\ 



X6 190 1 



>nt 



J 't'li ) .'■ 



Mimlfis 



Pii\ 



SINT.I.K. MARKIKD 
WinoWKD OR DIVOROKD 

•Write in wx-ial lUvijruation) 



/ 



BIRTH PI.ACK 
(Stale or Country^ 



N'AMK t)F 
KATHKR 






sy 



M -^^ 190 1 to ^X^i.^^ XA I90 1 

that I last saw h X • » ^ alive on 1A.M.M - ' 190 *1 



1 



an<l that death f>criirred, on the «late stated al»nve, at > ^<^ C 
M. J'he CAl Sf-: (»F^)I:aTII waM an follows: 



RTRTH PLACE 
OK FATHKR 
•stitf or Coiintrvi 



MAIDEN NAME 
«»H MOTHER 



HIRTHPLACE 
OF MOTHER 
(suite or Country 



<5/ 



I>r RATION Vtars 

CONTRIBrtORV 



.VoHfhs Days /fours 

t -, 



/ 



I) r R A TI O N nX*'"'^ .'^fonths 

I (SIGNED) T. 'a. JbOAJb 



/>a\s 



Hout % 

M.D. 



/ 



/ 



y 



/ 



OCCrpATlON 



\ 



^^L 



^ 



Ic^ 



(Arl.lrvJ^s) 



'! 



SPEieiAL INFORMATION ^ tar 
•r itceirt llesi^irts« mI p^sNS 0^ tir^ frta Niie 




VC 



1 1' '.^ . 



ItitttirtlMK, Umakm%t 



)'ritt 



.\f,Hlh',- 



WIfi was #^M CMirartei, 
IfMtitiliretftfraNi? 



i 



n«rtlf IMI? 



•■r* 



^"«^"i-^'^ STATED PRKsONAI, PARTlCfl. \RS ARE TRIE To THE 
BEST OF MY KN«»WI,ED<1E AND IIM.IIF- 



f Informant 



U)m^,.Qi\ X 



iDuwt^ 



111 I 



f Afldrc^s 



UXu " ^ vL vL c J b 6-4.^x^1 <\ ^ 



PLACE OF III- RIAL OR REMOVAL I D^TEnf Hi miai. or REMOVAL 



I .NDKRTAKKR 

(Atidrr** 






v\ 



T90 



*%l 'i m^ 



Wl%- I 









N. B.— 4vci>|r Item of Information should he carafully nuitpltcd. AGB should b* stated BXACTI.Y. I>NY«ICIANS ahoaM 
•fate CAUSE OF DEATH In plain terms, that It mmy he property <;laaslfl«d. The **9pecU»f laformatlMi** lor per> 
■ofis dytnft pwajr frooi liame ahoMld be given In every inatance. 



' 



m 






f 



M 




W: 





«t 



rl 







1 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

ardufUcaitl;-! No i.lS^^^n&PCo REFER TO BACK OF CERTiriCATg FOR INSTRUCTIONS 



I)((fe Filed, 




i.96>H 



Registered J\^o. 



581 



K\.^ 



OVU 



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



Certificate of 2)eatb 

( "CI. S. Stan&arD ) 



PLACE OF DEATH:— County 



of '^XX^VAJ JAXX-vvC^A^cCity of ^' C^>v n 



(X>x. )\<X 



\ \ 



^ 



(f^ ^JXK'^y^J(xr^a^.JSi).^'^\.^AM^ 



Su 



Dist.!ljct 



-and 



/ ir oe»TM OCCURS nwavlrnoKi USUAL RESIDENCE civc rucrs callco row owocpi 's^tciAi. tfiwommhrioH- \ 

\ ir Dt«TM OCCURRCO IN A HOSPITAL OR INSTITUTION CIVC ITS NAME INSTCAD Or STRUT AND NUMBCR. / 



-) 



FULL NAME 



/vux^JLuJ■ 



si:x 



!)ATH OF BIRTH 



\('.H 



PERSONAL AND STATISTICAL PARTICULARS 

CO 1,0 R 




\XU... 



\] 



■^% y,;,,. 



ll 

(Day) 



.1A#«/A5 



» t-a 



r) 



MEDICAL CERTIFICATE OF DEATH 
DATK OF DKATH 



(Month) 



i 



'XL 

(Day) 



(Yr«r> 



I UICKIIHV CI'ikTII'V, That I attctukcl iltnasiMl from 

l\..t.. •, .... ... V^' 



/hi I » 



^INT.I.K. MARKIKD. 
WIHONVKI) OR DlVOKfKI) 
(Write in stxrial ilesiKimtion) 



HIRTHPI.AOK 
<Stntc or Countrvi 



N'AMR OF 
FATHHR 



niRTHPI.ACK 
HK FATHKR 
( Stall- or Country 



MAIDKN NAMK 



lilKTHl'I.ACK 

f>F Mother 

! Stall or Country- i 







l-^H 



I 



190 i In r^^^H ^^ »9oH 

that Mast <^a\v ll ilivcon ^^^^U J»t 190 H 

ami that rUalh cjccurreil, 011 the ilati- statcil alwivi-, at li 
^^ M. The CAISI-: OF Df-ATII w«« as follows: 



nr RATION 

CONTRIHrTORV 



} 'ears Months 



<ldL 



oCcri'ATION 

fifsnifif hr San /> aiirtsm 



Hays 
r*avs 



Hours 



Hours 
M.D. 



Dl RATION Years Mottths 

(SIGNED) W. JJ A 

Special Information ^ hr nmpiw^ iMtitatiMs, TmsNts, 

tr Recent ResMeits, vtA per»i$ #lii |wiy lr«« N«r. 

FtfiMr m \ Rtw iMf ll 

UsmI ResMeiice v ' ^ » Ftarttfl^l? 



•Vi 



} V(i / 



M.nith^ 



Afvj 



THK ABOVE STATFUJ PHRSOV^I, l'\RTIi'll,ARs \RH TRl K To TIIF. 

UK ST OF MY kno\vi,f;ih;f: and ru'i.iJ:F 



< \(Mrc««<* 



Wkei W$ disease fdntrar lei, 
llMtatplarftfieatii? 



pr.ACK OF HFRIAI. OR RHMoVAI, I DATK of Dmiikt. or RJ&MuVAI* 



r.S*lii:RTAKKR 




'A»li!rf*» 



L aJ^J.^OL^>v^ 



N. B. 



-ovcry Item of lntoPm.tlp« should be carsf-llr R-PpMed. AGB shoyld «*-»*-««i EXACTLY. PWViCIAWS .ImniM 
•t«te CAUSE OF DEATll \n platn teptns. that It mw h« properly cloMtfted. Ths Special lafomiBlloa fM> — - 
•ows dylMg away from horns should be glvsa la svary tastancs. 



\ 






f; 




♦ 




WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



ii. .,,!.) <»f lli-rilth- F No. I"; -i^a^^ liSii' Co 



REIFCR TO BACK OF CCRTIFICATC FOR INSTRUCTIONS 



m 







»l 




x\» 



190*i 



Begi.stcreil •A''o. 



m2 



Dale Filed, 

DEPARTMENT Of PUBLIC !iEALTH=City and County of San Francisco 



Certificate of Death 

( TH. S. StanOarD ) 



PLACE OF DEATH: — County of '^^CL^yv J.MX^vtAACoGty of '^'CL^ru 1 >v<X^\Cc4t€ 



'No. 



Hn 




SU '^ Dist.; bet 



ntL 



and 



11 Uv 



(ir DEATH OCCURS AW»V FROIW USUAL RES I DE NCE CI VC raCTS CALLCO rOR UNDCR "special INFORMATION" % 
ir DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVC ITS NAME INSTEAD Or STREET AND NUMSCR. / 



FULL NAME 






yVVV^ UAXX/"V^^C4 ^^UO.' 



S1^X 



PERSONAL AND STATISTICAL PARTICULARS 

I COLOR \ 



^<xL 






iJATi: nr HIRTH 



A(,K 



(Month) 



w t) 5 >•<; , ( 



iDav 



M-ittt/n 






MEDICAL CERTIFICATE OF DEATH 

UATK OK DKATH (\ t, 

XH 



filutttli) T il»av) 

I III:RI:HV CICRTIFV, That I atlcritltM! ckctaseil from 



(Vcnr I 



Pavf 



"^fN^I.F MARKIKU. 
'Writf ill social {lesij?nnli(in) 



-=aa^ ---35^-- 



HIKTMl'LACl-: 
I State or Country^ 



NAMH OF 
HATICKR 



I'.IKTHI»I.\CK 
OP FATHKR 
'Stittf or Crnintry) 



MAIDKN NAMK 



HIRTH PI, ACK 
"F MOTirF:R 
'Stat.- or (•..untrv) 



'"■' ri-ATHiS 



?) 




I 



that I last saw h 



IgO "-~ to 
■ — alive on 



icp 



and that lU-alh «ictiirre«l, on the ilati ^taft <1 above, at 
M. The CAI SI-: (M' l)i;.\TII iira.^ as folhms 



^ vvO*^ w • 



1 



nr RATION ifars 

CONTRint'TORV 



Moutlu 



Days 



Hours 



Dl'RATION Years . Mitnths /hivi 

(Signed) Ld\^rv\iA^^ ^ It ^aXo^^^ 






,z).K CrVv^owCfr-» 



x.. 



HlU^m X'' TO 

SPECIAL IN 



Hours 
M.D. 



i^p*^ 



JFORMATION w^^lltipWs, lnMltBll««.Tw^eiilf, 

tr ftNort l^^nts, Mtf persons lyiiif miy Nn Nut. 



J V"ff > 



StMith< 



ihts 



THi: AflDVF, ST\TIH I'FRsnXM, I'KKTrrT! SRS AKK TRFK T«» TIIK 
!»F>,T(iI' MV KNn\VIj:i)C.K AND in:i,!i:F 



(Itif,„ 



ttiriiit 



t-wvv 



fAfMre*«« 



cm a. iv^- 



Formf r «f 
(Isvii KesMeiKt 

<Hwi WIS «IHea« fwfriclrt. 
If Ml at N«<^e of tfedtli ? 



■vw ^mf n 

nit«tf tnai? 



iq^s 



PI,ACR OF ftlRIAL <»R RKMOVAf, I fJATK of U« rijii. or RRMOVAI. 









1 90S 






N. «. Every Item «»f Infofinatloti should be enrefully nuppllcd. ACB shmiM bs stilted RXACTLY. P^HYSICIANSiAeiiM 

state CAUSE OF DEATH In plain terms, that It mmy he piHipeHy clMslfled. The **Spe<lal Informatloa'* far 
stns dying away from home whould he ftlven In every instate*. 



: 'ii 



I 



r 







vl. 



l!lr. .. i- 




l! 



I I 



>llN> 



in 



1^ N 



Ij 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

REFER TO BACK OP CERTIFICATE FOR INSTRUCTIONS 



Horirrl of Hcnlth—F N'o. 15 *^^^B&P Co 



%k 190 "i 

Deputy Health Oflficer 



Registered JV^a 



583 



J}afe Filed, 

DEPARTMENT (}F PUBLIC IIEALTH=City and County of San Francisco 

Certificate of 2)eatb 

( in. S. StanDarD ) 
PLACE OF DEATH:— County of '*''(Xr»V -1 \XXA^vXA^COCity of ''OL/TL' -J Va vV 



41 



^ 



No. IHla nA>LiUvAA^irirt*c 



\ 



"'. I 



In 



St. 



Dist.: bet* 




t4-4C(!>V 



and 






(ir DEATH occuns »w*v rnoM USUAL RESIDENCE Give facts called roR UNDcn "s^ccial iNrowMATiow \ 
ir DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD Or STREET AND NUMBER. / 



LL NAME 



Lu 



L. 




1) 



OLA'VV. 




uiKo 



SEX 



PERSONAL AND STATISTICAL PARTICULARS 

I COI.OR ,^ 



DATK OF niRTH 






n. 



MEDICAL CERflFICATE OF DEATH 

DATK OF DInATII A a 

%^u 

(Moiithi ^ 



1^ 



IQO 

(V.at) 



(Month) 



(Day) 



W.V. 



a 



i f 



} 'tUl I s 



M,>uths 



(SVar) 



Da v.. 



^IN<.I,K. MARKIHI). 

\vino\vF:n OR divorckd 

'Write ill social desij?nation) 



IXwl 



niRTMPI.AOK 
(Htateor Country) 


(T 






yjt/VL/>"cQ,A.y 


IahX/>v^uol 


XAMK 01 
FATUKR 


\\ V 






\Xr\\Jf^ 


^\.^Cr\^jn^_ 


RIKTHPl.ACK 
OF FATHKR 
(State or Country) 


*t 




MAIDKN KAMK 
»'» MOTHER 




HTRTir PLACE 
•>K MOTHKR 
(State or Country) 


4 J 





I HEREBY CERTIFY. That I atUn.lca .Icivase.l from 

— to— - 



190 



igo 



that I last saw h - ^ alive on '" igo 

ami that <lcath occurreil, on the date stated alMive, at 
M^ The CAl'SE Ol' I)i;.\Tll was as follows: 




;J.A-*i^L'>^\.e 



I^-iz-vvv^x^x^ c^-i 



1 ^ 



i 1 



nr RATION Ytats 

CONTRIBUTORY 



Months 



/)ays 



Hours 



occ 



rPATlON /p 



C<X^%^ 



OfVujV'^'^'' 



DERATION Years Months 



IMys f fours 

(SIGNED) Lcr\.<^TUlKiy hd "LLX.aix.dL M.D. 

WW %^ looH (A.Mress) Cfr\(r\xi^ ^ l^' U - 






eIi 



SPECIAL iNrORMATION mIv f«r NnpHals. NstilHtimi, Triisleies. 
or l^cflit I^MMts, n4 penwNs i^\H awi) frM ' 



tffxidfit ht San t'lnmi.uu} *^ JV^rt » Afnuf/if *. thus 

THK ABOVE STATF.I) PKR-nONAI. PARTICft.ARS ARF: TRFK To TIlFt 
BEST OF MY KNO\VI,F:iJr,K AND BKIJIvF 



Former «r 
UsMl ResMeice 

Hfkm Wis disease CMtractetf, 
If notaMaeetftfeatt? 



Ptatff if IcM? 



lirs 



(inr 



nnnant 



c 



(AfUlrcMs 



in,.W:K OF BFRtAI. OR RKMoVA!, I r>.^K of BtMtAt. or REMOVAL 

H.....,..,. \l^ii.^ I ^^^^^ ^t 190'. 



v.vi>f:rtakkr 




f Athlrritji 






N. B. Every Item of lnfopm«tion should be cspsfully aupplied. A6B should b« stated BXACTLY. PHYSICIANS 

state CAUSE OF DEATH In plain terms, that It mny be properly classified. Ths **Sp«elal Informatloa** foi> 
•ons dying away from horns should be given In m^mry Instance. 



-9 

I 
1 



I 



P 



i I 



m 




i 



!• 



if 



l\i 




li 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

HoMnlof Hcnlth-I No i v^^^S^ "«^ »' Co REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



J)(ffe Filed, 

A 




XL 



190'\ 



Registered JVo. 



584 



tx^q 



Deputy Health Officer 



DEPARTMENT 01^ PUBLIC HEALTIi=City and County of San Francisco 



Certificate of Death 

( in. S. StanC^arD } 



:unty of^CL->v •lA.a'>%c^w4.cx Gty of ^<X>\/ JAa>ve^LA,tic 



A) 



PLACE OF DEATH: — County 

(No. ^ I V(K,kjLcX \X : '... SkA ^ Dist.;bct WvuCLla>\<i and I' 

(iV DCATH OCCURS «W«V FROM USUAL RESI DENCE GIVE FACTS CALLED FOR UNDER "SPECIAL I N FORMATIO M - \ 
IF DCATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / 



FULL NAME 



iLtlxccM ^ 



V>UCLL > 



PERSONAL AND STATISTICAL PARTICULARS 



si:x 




i 



COI.OR \ 



DATK UF IIIRTII f^ 



(Month) 



AHK 



J V'lJ I 



II 



(Day> 



Months 



\\ 



i"* f ti 



(Vt-ar) 



Ai 1 .< 



SlNt'I.K. MARKIKI). 
WII>o\VKI> OR niVOROKI) 
•Write in social ile^iKnation) 



niRTMIM.ACK 

(State or Cotuitry^ 



NAMK i»l- 
KATHHR 



niRTlin.ACE 
OP FATIIKR 
tSlateor Country) 



A 




MEDICAL CERTIFICATE OF DEATH 
DATB OF I) HATH 

(Day) 




igo H 

(YcarT 



. I HEREBY CKRTII-V, That ! ntteti.UMl <ln t asctl from 
^'^" '^ ■-"* to .. IvOq. ^H 



• 1 tlliKUKV 



190 H to , ^^-^»c^. 'XH 190 H 

that I last saw h ^ » ' I alive oti j^vvv^ ... icjo 

ami that death (Rn'urre<l, on the <latf stalcMl above, at ' 
M. The CAISK OF DKATH was as follows: 



■1' 



^ 



CL^x- -^ K<X 



,1HJL 



\\M} '^y\XAXx 



•• ..jji^.-t j>AMH 

OF Mother 






n 



DURATION Years 

CONTRIBUTORY 



Months I T Days Hours 



HIRTHPI.ACH 

OF Mother 

(State or Count ryl 



.ucrt'ATlON 

^^^^^^ Rfsiiffti in Sun Framht'n 




DURATION Years 



'^ \ 



Afoul /is 



Pay 



(SIGNED) 



% 



H (A.li1re<is) Vh^i \nl 



A^lA^e^^ 



Hours 
M.D. 

14 



SPECIAL INFORMATION 9»h fer N^IMs, listitttfMS. TrMSlmts. 
m iNort lesMNts, ntf iwimi lytaf «»<y (n«i ^w- 



THK ABOVE STATI't) I'KRSOVAI. I'ARTIClf.ARS ARE TRl K To THE 
HEHT OF 11V KNoWI.Jinr.E AND IU:i.Ii:i- 



(!«f 



orntant 




4JJv 



U 



YsXM^v^vq 



/t 



' \ililress 



\l Ihj^AXs^^ ^ 



FwiKf w 

Mmi wiS tetie CMtrarM, 
HMtat|lirffr4ettk? 



Itertf intt7 



^yt 



ri^ACE OF BIRIAU OR REMOVAL j UATi: ..f Rt mial or RKMOVAI, 



H 



1 



O^w^*-"^"^ 



(Ad«lre,« ^Hl"^ Of>\v4..4,^^v ^ ^* 



N, B. Bv«ry Item of tn^i*m»tton should be c.r.tully .«ppll#d. ACB nfiould bo slatsd BXACTLY. PWY6ICIAWS rfMNiltf 

•tate CAUSE OF DCATH In plain terms, thot It may bs pi»op«H|r vlosslflcd. Tlw Sp^M l«f»r««tlo« for psr- 
^M« <lylng away from homo should be itven !n svspy tfistanc*. 



I 






• i 



f 



l« 



Vi 



\ 



I /' 



i 




i I m 




WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

REFER TO BACK OP CERTIFICATE FOR INSTRUCTIONS 



linat.l r.f lUalth -l- No. I!; ^'^iiS^ l*^"^** ^^ 



585 



Dole Filed, NUaJIu XIo J'^0^ Jfcgrstci'cd A'o. 

Xo-vwj "sLyvKi Deputy HeaUh Officer 

DEPARTMENT OFPUBLIC HEALTIi=City and County of San Francisco 



Certificate of Deatb 

( "d. S. StanDarC* ) 



PLACE OF DEATH:— County of ^ Ct^W iXiX^ru<U4^^ City of '^<X^v IKa^xcu ^ < 



flo. 





-and 



1 
^^ VCH^UvCbLi 'jl05-^kLto..L SU Dist.;bct.- 

(ir DEATH occundl AWAV moil USUAL RCSIOCNCE oiwc r*cTS called roR undeb "special information" \ 
IF death OCCa)<REO IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / 



FULL NAME 



r 



LLLvCla^^ 



1 



PERSONAL AND STATISTICAL PARTICULARS 




si.:x 



i>A ri: OF niRTH 



,\<;k 



o. 



L 



COI.OR 



.Ijif 




iMulull) 



k>l 



I 'I'U t . 



(Day) 



.^foHf/l: 



rill 

(Year) 



MEDICAL CERTIFICATE OF DEATH 

DATE OF DHATII n 




L 



(]W<»nth) 



fDuy) 



( Yea r i 



/>,n: 



^in<".i,f:, maruiku. 

WinoWFl) OR DrVORi'KD 
'Wrilf in sfx-ial designation) 



hirthpi^acf: 

'Slntf or Coiintrv 



NNMK OF 
lATIIKR 



nnniipi.ACK 

Ol I AI'HHR 
•Statf <»r Country) 



•ililJi..-* iNAMK 

oi N!OTHf:r 



HIKTHPI.AOK. 
«»F Mt)T»IKR 
(Stafi- or CoHntr%-) 






I mCKlinV CI«:RTIFV, That I a^ttcmlcl clcceascd from 



M/LcLu ?'u up'' to .3^\,4-tu 



TqO 

that r last saw h ;ilivf on ^V^,\,u loo 

arnl that tlt-ath iK-curred, on the dale statc<l above, at o 

' M. The CATSI-; Of" UIIATII was as follows: 



La?U' 



CA^W*V>V<X. u 



irt t)jjL<^|vt 



-> -s 



Dr RATION )'i(in 

CONTRIIU TORY 



■^ M on I lis ^ thiyi 



• J/out s 






() 7 



Ivl 



CLYuL 



Orctl'ATION I ^ 



nr RATION 

r SIGNED) 






thtx 



'^ 



/fours 



M.D. 



kiiu V\ iqnH ( 



Ail.lress) Uiu^-^ fltft- ' t 



_ FECIAL INFORMATION •rty 

•r Receit ResMwti, m4 perstns tfytai vmti frtn 



ly for Nbs^ils, lastlti 



sthMS, TrMsietl$« 



ll ^Uv^e>\ ' ' 



K^X^*^^ 



Hrfiiifd in San FriiMri<:fn 



) ri! ' < 



M...i!li 



fh! 1 



THI-: AlUtVK STATF:n PKRHOVM. P A.R T lOI' I. A R.S A R K TRIK To THH 

BKST OF MY kno\vi.f:fj<;k anh iu,i,ii:f 



rK'Mri'Sji 



Uiiitf lesMence 

Vl^ WIS 4sene CMfrirM, 
If ii^ftplaceof4eiHi? 



narrtlB^i? 



hn 



ri,ACK OF Ht RIAI, OR RF:M«»VAr. I HATIC "f fH hial or MKMtlVAl, 

Qfli.-- VfW4^ I V-^^': ^'^ I90H 



^ 



INIJKRTAKKR UK^AXi^ . r \^V^YV(3,-^v^ 



\«M!. 



iHo^ jYU^^^^v ^ 



^^y Hem of lnfoi»m»tlon shottM be cnrsffully •up|»ll«rf. ACB iiHftuld b« «taU4 BXACTLY. PHVSIGIANSi^iMild 
te CAUSE OP DEATH In plain terms, that It may he pi*o^i4y <;t««stfle4. Th« ' «p«€l«l InfoPiwatlon** !«• pOi»- 



N, B.-— >Bvei 
•tate 
K«tns dying away from homo should be given In mvur^ instance. 




t 



^j 



;^i 



ii 




WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



l;,..u.l of lli.'iltli- 1 No. 1^ '^^^^33H&I' Co 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



i. Vf 



m 

m 



nwi 



Begiaicred ^''o. 



586 






^ -,i«-t.. r^ 



Date Filed ^ 

DEPARTMENT 01^ PUBLIC liEALTH=City and County of San Francisco 



Certificate of Beatb 

( "CI. S. StanOarD ) 



% 



Ul) 
PLACE OF DEATH:— County ofO.OyYuXVa.w'- 'City ofvJXX^v OA.XX/^x^m-<i 



*^ » 



^ 



/I) 



'No. 



%\ 



lib UUL^ St.: X Dist.;bct.U^CrVU-CU^ and ^ / La4.r> 

(IF DEATH OCCURS AW*V FROUd USUAL R E S i DE NC E Gl VE rACTS CALLED FOU UNDER 'SPECIAL INrORMATtOM ' "\ 
IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVC IT» NAME INSTEAD OF STREET AND NUMBER. / 



FULL NAME 



urtOA.^ 



PERSONAL AND STATISTICAL PARTICULARS 

I COLOR 



DATl-: t>l- HIKTH 



(Motith) 



iL.i 



I Day* 



• Vcnr) 



MEDICAL CERTIFICATE OF DEATH 

DATK or DI'.ATII ^ 






n.tvt 



(Ytar» 



AC.K 



' ♦ 



"1 



oJU) 






J V(/ ) 



\hnitli.'' 



fta 1 ' 



■^INC.I.K, MKKKIlCIi. 
WrDoWlU) OR DIVORCKF) 

'Wiitfin s<x-ial dosiKiiatiim) 



HIKTIIPI.XOK 
I State or I'ouittrv 



I IIICHICBY CI:RTII'V, Thii I aiiLii.lol .ktcascil fruni 

' -~ -^ igo " tf) ' IqO ~ 

that I last saw h alive otr^ — — —— —^ 190 

aii«l that (U-ath orciirrcMl, on llic <1 itt statii! aliovf, at 
M. Tin- CAf Si: 01 1M:.\TII was as follnw<: 




XAMK O! 
J'ATUHR 



«>1' I'AI'IIHK 

' Stale or CmuUry) 



MAIIj|;n NAVIK 
<»1 M()Tin-:K 



HIKTH PI. ACK 
<>l' MOTHKR 
(State or Countrv) 






/ 






-^ 



DERATION Y,ay.s 

CONTkini'TORV 



M<nilhs 



Pas 



II 



ours 



DTK AT ION )V</;,v _ Months 



Ihns 



Hours 



^ Signed^ Lfr^^n 



M.O. 



4 1 i . l> 



SPECIAL INFORMATION M»y tor HtSflliK lnsfHyttoM, TrwHieiits, 
•r Recent RrsMents, aN perMNs iiFtNf iniy frMi ftMW. 



JV<T» 



\r,.„fh' 



Pit t . 



THJ' \H(iVF, STATI-:!) rKK'^ovxt, PKHTtt^fT NK-^ AKH TRIH To TlIK 
in-.ST (II M\- KNOW J,i;i)r, H AND rilF.Il 1 



flnf, 



irmaiit 



Lft*W«r^- 



Femieror 
Uttal RfsMfRce 

Men was disea^ cantrntetf, 
If notitplaceof deatk? 



Rmr hHi|4 
Ftoretf IMI? 



^ 



PI,ACK Ol' Bt RIAL OR RKMOVAI. | DATHof Bimiai. nr RKMOVAI, 



La->x ^vvi 



I NDIIRTAKKR 




(A till re M 







XI fgoi 



N. B Every Item of Informiitlon ahovld be cnrefully Hupplled. ACB should te alMted BXACTtV. «!¥««»*«« •ImmM 

state CAUSE OF DEATH In plain terms, that It rnsy he pfo^rty ctasstftod. The "8|»«*;!«l |«fo»w»tlo«*» lor pmr^ 
•on* dying away fr«Mn Home nliould b« glvsn In svsry Instance. 



1 



I 



I 
f 



I t. 



I I 



7| 



J 



f 



i<\ 



I 



I 



!»' I 




11 



1 



•I 



m 




WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

nonni ..f iTcMith- I- N'.v i^ »g^^. Hf;.!' Co REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



190^ 



Registered J^'^o, 



587 



Date Filed, Wtu 5.t 

DEPARTMENT OF f UBLIC HEALTH=City and County of San Francisco 



.A.>-ti 



Certificate of H)eatb 

( "Q. S. Stan^a^^ ) 



-« 



PLACE OF DEATH: — County of^<X"ru J^tX^ vca,4^ tcCity of ^^''Ct^v 0A.CL>ve<w4 



^ 



(ISo. 



vCtu ^ Wu^-rX^^ '%0-ilwl''^ ' St.: 



uCc 



Dist.: bet. 



(1 Z' " Ot*TH OCCU^SJAWAV mOM USUAL RESIDENCE GIVE FACTS CALLED rOB UMOCH 
J V 1^ DEATH OCCUiNEO IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF 

FULL NAME X^WJ^u 



and 



SPECIAL INrORMATION 
STREET AND NUMBER. 



) 



si:x 



PERSONAL AND STATISTICAL PARTICULARS 

1 Cfil.OK ^ ^ i 



vITLoJjl 



DATl-: OI HIRTH 



I Motith) 



A<iK 



OJoX 



i, JV,n 



I H;iv 



Matilft^ 






Diivs 



^IN<'.M*. MARKIKD, 
Winn\VKI> OR niVOKrKD 

tN\i!t(ni s.KJal (Usij/natioti) 



HIR rilPI.ACK 
*S(ati-<ir Cntintrvt 




>\ 



NAMH iW 
'-ATHHR 



HIKTJlPI.ArF 
f>l' I ATliKR 



MAIUHN NA Mi- 
ni • MOTIJKR 



l'n<TIIPi,,XCF 

"' M'»thhr' 

""l;m- .,r Countrj-) 



"* >"l'i'ATIi)N 




MEDICAL CERTIFICATE OF DEATH 

DATK OK DHATH 

I HHRiniV Cr-RTIFV. That I atUii.kMl .kvcasi-.l fn.in 
I90 to 



AXJ 

f Month) 



/go 

(Vear) 



that I last '?aw h ~ 



alive on 



w»w»^w tm i Mi to o 
-" 190 



"Wt^W^ 



u 



>x 



I I 



r • I 



ami that death ix!currecl, on tlie ilate stateil ah.nr. at 
M. The CAISI' OF DI-ATIf %vas as folLnvs: 
^ ^ X.CC oU^C4^<X^ OVX^W-rwl.^Xi^* IvfrWv 

Dr RATION Yt-ar^ Afonihs /h,ys 




Hours 



CONTRIIUTORV 



OrRATION 



Years ^ Mouths /\iv% 

(Signed) U^^-vOAi U.^J6 LU JLii.a,vvxL 



kvl 



'^ 



Hours 

M.D. 



ik—— --I22. 

ECIAL INF 



H (AiMress) L^V^^U^Va W fv 



SPEblAL INFORMATION wrty hr Nts^Ms, (•stitiifioiis, TrMsteih 
•r Rece«t ResMents, and persMS ^^ Mti^ frwn kMie. 



La--'- 



* } Vti I .<■ 



.1 A -','/■//. 



/'.; 



"m\"i^^ ' ?^TAT1:T) J'KRSONAI, I'AK rur I, KRS ARI-: TRrK TO THK 
"H^ro}. MY KN-o\Vl.Knt*.K AM) lUil.Il'F 



I 

FWTRtf 9K % 

tlsHiil RfsidfRce 

WheR Wis tfiseise contr^tH, 
tf mt»tplare«f4e«tli? 



Ntwtoi^^ 
flare •ri^r 



Nrt 



'li'fn'inant 



\^! 



cc>"wdLi/u$ 



<A.1fl 



ress 



I c 



Q^^ 



%^ 



"V% 



\ 



PI^EOF m-KIAUUK RKMMVU, j DAI'Kuf nr„TAU or RKMOVAI, 






'Addresn 



I'xfi^ Ok 



V4.4,4^1 



'i 



. Every ttem of Information •hould be eapefully nupplleii. AGE Nhoulil b« ■tatcd BXACTLV. PHYSIOIANS slMtiltl 
•tate CAUSE OP DEATH In pl«ln tepms. that It may lie ppo^Hy claMlfWd. The **Sp««ial Infofwatloa** tof mi*. 
•«i« flying «w«y from lwm« Khotild b« gtv«ii In vvepy Instance. 



I 



I 



#■ 



f 



I 



I 



I, 



I 



ii 



Kl 



I 



•f^F«SF 



.i 






WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



lUiiiuli.f Ikulth >• No I'- "*^i25i^ US: P Co 






J90H 



Registered JVo. 



588 



/)(i/e Filed, 
i 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



4,^^jus "tuvv. Deputy Health Officer 



Certificate of Death 

( "CI. S. StanDarD ) 
PLACE OF DEATH:— County ofCl<X-ruO v<x-rLe>L4/C0 City ofC)/<xm.vlAa> 



(No. 



W 



U 



It 



(ir Di 



!r^"^\CX St.; ' Dist.;bct. i V vv and 

DCATM OCCURS «W*V rnOKI USUAL RESIDENCE Give rUCTS CALLCO ro« UNOC« "SPCCIAL INrOltMATION 
DCATH OCCUnnCO in a hospital or institution Give ITS NAME INSTEAD Of STREET AND NUMBER. 



) 



FULL NAME 




PERSONAL AND STATISTICAL PARTICULARS 



•^KX 






n\TK tn- niRTii 



A<;i% 



v<xL '""'U)l^ 






iMnlltlO 



tX )V,/n 



mnv) 



Mini t its 



(Year) 



Ihi 1 .' 



^IV«.J.K. MARK IHI) 
WIDOWKH OK niV«»Ki'KO 



iWritf ill MKJuI (ieti|<rn:*tiuii) j . . 



niHTIII'I.ACK 

I Stat ( (ir (.'iitmli vi 



(V.'art 



MEDICAL CERTIFICATE OF DEATH 

DATH OF DHATH A { 

Y^M- ^^ 

tlfonth) 1 (Day) 

I iJi:Rl<:HV C1':RTIFV. That I attencUMl.lcivuscil frum 

that I lakt saw h V\> alive on nLwU^ 'XH. 190 H 

ami that death occurred, on the diitr 'stated alxne, at * 



^ M. The CArSI*: UF DlvATII was as follows: 



rV\^v\./0 



'<\X, K^ 



IAT11J.;r 



HIkTHf'l,A(*F 

ni- I A Tin: k 

(Stnte or Comitrv) 



MAIDKN NAMK 
OK MoTHHR 



HIKTHl>t,AC« 
'>F MOTHFR 

••^iMf or C.Mititrvt 



A » 



Dl" RAT ION % }'i'at's 

coNTRinrroRV c^^-i 

U.tcl lU, c 



Mouths '- l)ay^ 



/fours 



OCCUPATION 



A 



.\T..„>r, 



1)1 RATION C Years Mouths Days 

( SIGNED / KhJOiysi <^ ^ I W SjQlK 
JUAAj.^^ Hjo H (Address) 






Hours 

M.D. 



Special information mN for Hospitals, iRstititloiK, TrwsletU, 
•r l^eRt ^sMents, and persons tfytng wmi \nm * 



Dax 



twv. ^novF: sTA ri:i> PHKsoNAi. ivxHTfctrARS akf: iRrr t«» thh 

BF'ST (»!■■ MV KNoWIJlx.H AND I!KMF:F 



fTnr...nurn lU JlLc<5W^l^^ \> . U) ^0.. 



>a \x^ 



(ArMlf 



^)^a \ 



CVi,^>i\- 



Fftfiier Of 
Usiil IfesMeRce 

WlM Wis dISMSf fonffiKW, 
If rM at plare of deatb 7 



li«wl«ii|^ 
Rirerf ImUi? 



Biyi 



ri.ACK t>F ni HMT. ciR RKMoV^I, I I* \ TF! .f IlritiAi. or RKMnVAI, 

'"lAv C^».<L<i.. I \^'^'% ■ ISO'. 



FNinurxKii 



\tMt«-H- 



N. B. 



v^py Item of Inform ntloti shouM he cnrefully suitplled. AGB sHould bs staUil BXACTLV. PHY8ICIAW* ahotiM 
State CAUSE OF DEATH In platn terms, that it m«> he properly (.lasalflcd. Tlis **8|Melsl l«formatlt»«'» ffw #«r- 
•l<Hls dying •way from homs should be given in evsry Instance* 



i 



f 



I 'I 



i % 



'ii 






I l» 



W 



r, 
♦ 



i 



w 



I 



-A1 



IV 



( fl 



I 



T 






I 







'!■ C 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

Huanlof lIcaith-FN'o n-^^^^^U&HCn RCPER TO BACK OP CCRTiriCATC FOR INSTRUCTIONS 



Dfffe Filed, } 




%^ lOO'i 

Deputy Health Officer 



Registered J^o, 



589 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of Death 

( "0. S. Standard ) 






PLACE OF DEATH:— County of ' CX.^ v Ivct vv^^^^ C 
No. /-^Ibk dL^*.' . St.; "i Di^t.. l^t. ^M^ 



:ity of '^ 






tVcck 



!• 



1 



aV- 



(ir OC*TH OCCUnS »WHV from USUAL RESIDENCE GIVE FACTS CALLED FOB UNOCH 
IF DEATH OCCURRCO IN A NOBPITAL OR INSTITUTION GIVE I 



.^ u^v - » V -^-^ .- w w . K and 

SPECIAL INFORMATION" N 
TS NAME INSTEAD OF STREET AND NUMBER. / 



e 



FULL NAME 



l*r\i»f{?l«>r. 



I\} IL' w 



.ua 



PERSONAL AND STATISTICAL PARTICULARS 



si;x 



DATK OI-- lURTII i" 



COLOR 



ll\!v±c 




a\' 



(Month* 






(Year) 



MEDICAL CERTIFICATE OF DEATH 



DATE OK DEATH 






X5 

(DayJ 



rgoH 

(Year) 



7^, 



I HEREBY CERTIFY, That I attendtMl ilcccascd from 



M.V 



J ■»•<? I 



A/,>ttfAf 



IS 



n,t 1 A 



^^IXi.I.K, MARRIED. 
WIIxnVKD OR DIVORCKH 
(Write in social <ksiKnutit>n) 



BIRTHIM.ACK 
(State or Conntrv) 




NAMK OF 
HATHKR 



HlRTHPi.A* K 
OK FATHER 
<Htate or Comitrs) 



MAiDKN NAME 
OF MOTHER 









V\aXu.. .i' 



to -WW iqoH 



ftV^iti 



190 1 
that I last saw h -■ alive on ^V^vij .r^ \ i^o 

and that death cxrcurred, on the date state«l alKive, at i 
WV M. The CAl'SE OF DIvAJH was as follows: 



HTRTHPLACE 
OF MOTHER 
(State or Countrvi 






I)r RATION i'tars 

CONTRIBUTORY 



MoHlks 



Days 



/fours 



X. 



\> 



occr RATION 

Rf. fulfil in Sun /'i i7n,!f:i •• )><r».( ^ .\fintths m f^ax 



duration 
{ Signed) 



^ 



190 



)'ntrs 



Afotithx 



/Mys 



Hours 



WW t X'S. 



M.D. 

(Ad.lress) Xlftl ila)LH-V>v%a ^ 



SPECIAL INFORMATION only for Hospitals. liistitBftoiS. Twnslwitj. 



tr I^Mt leMeiits, iMi persMs 4yi«f «tw<y >rMi liMie. 



THE ABOVE STATED HHRHONAl. PARTTClf.ARS ARK TRtE TO THK 
BEST OF MY KNOWLEDGE AND UKIJKF 

^ ^ A ^ 






A<l<lrc«»!« 



> 



Nrmertr 
lIsMi ledleiet 

Wlieii was ilseax CMtracM, 
If HOtitplaretf^eatli? 



nicttf 1^1? 



tays 



Pi,ACE OF Bl'RIAI. OR REMOVAL I DATK of ^|liii|*|. or REMOVAL 



S^ 



1. 



iXH-M^ s^<Xm-''^vv 



fSDERTAKER 

lAUilte^M 




H 




5^W> T90H 






-2^^ 



-4-U, 



N. B.— -Bvery Item of lnrof»mNtkM slioald be cursfully supplied. AGS shoMld b« fltatvd BXACTLY. PHYSICIANS akMiM 
•tatc CAUSe OP DEATH In pl«iit terms. th«t it may be properly claMlflcd. Tbs "•p4Mel«l lafprmatloa** %m> 
•ons d^tng wmw^f ti*cMi lMm« sboyld Iwr given In every Inataace. 



I 



f 



1 



! r 






i 






' I 



t 




I 



H 



I 



II 



m 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

Hani of Henlth-FN'o i^ ^^^»&PCo REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



Dfffe Filed, ii. 



.^LH^V,^ 




^b. 



.100 "^ 



Registered J^o. 



590 



K^. 






Deputy Health Officer 



^Na 



DEPARTMENT OF PUBLIC IIEALTH=City and County of San Francisco 

Certificate of 2)eatb 

( xa. S. StanDarD ) 
PLACE OF DEATH: — County of O/a/^v OA-OAVCti '' City ofO-Qyvv J/v<t>vCA.c '' 
V\<X^- St.; n 



TH1 




n 



(ir OCATH OfCURS *WAV FROM USUAL R E 8 1 DE NCE Gl VE FACTS CALLCO FOR UNDER "SPECIAL INFORMATION" \ 
IF OEATH'OCCURRED IN A MOSPITAU OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / 



Dist.; bet. lAJvCU^Cthj and 

FACTS CALLEI 
GIVE ITS NAME INSTEAD OF STREET AND NUMBER. 



FULL NAME 



a.k-.!i 



KJL^ "^^ 




PERSONAL AND STATISTICAL PARTICULARS 



<^IJ., 



10^. 



MEDICAL CERTIFICATE OF DEATH 



DATE ov I)};aTH 



DATK UK lURTII 



AiiK 






as 



^m.. 



J V(f I s 



Months 



CVear) 



Pa 1 



^IN^l.K, M.\RKIKI». 
WIUnxyKl) OR DIVj>KI I'D 
'Wfittifi mx-ial f!<siv'natioit) 



M;it. nr '■•milt r \ 



VXMl- CM- 
lATlll-R 



HIRTIIIM.ArK 
'H I ATMHR 
'Sim- ,n Cmititrs') 



MATTiKN NAMH 
<»H muthkr 



lURTII PLACE 
<)1 MOTHKR 
<Slntf .)r Coniitrv) 



I HIT PAT ION 



A ^ 



/\-\.-:\,. 



1-A.A.A4 

oiUh) T 



^k igo 'i 

fl)ay> iWarl 









.C*JV>V^ 



K^siilftl in Stjn f-'njMfisi'n "^ S'tuitf 



ytnnths 



Ihi 



I HI-;HI:IJV CI^RTII'V. That I attenckMl .leccHscd from 
:UL,L^ XH igo'i to...|uLLu. aic igo H 

that I last snw h - alive on V'^^^lc^ I90', 

an<l that di-ath occurrt-il, mi the dalf stattd alxni-, at -o 
Cl.M. The CAl'SI' OI' DICATII was as follows: 
O -^VCX. > Xa„ V V <r > \ 

Dl'R.VTION Yiars Months Days ^% Hours 

CONTRinrTORV 



1)1 RATION Years Mouths Hays /lours 

\\\ \\\ \\' 

{ Signed ) , v\^ m^ . vv \\ M.D. 



yu^Lt 



\ 



%n 



TQO 



( 



AcMrt^s) I 5" U/tttl>vC\n , f 



SPECIAL INFORMATION a«ly »w Hos^tifs. Instltalloiis, Trwislfpfs, 
•r RKCBt Residents, and perstns tfylai iw«y from ktm. 



Tin: \n()VK STATKr> PKRSOVAI, pAHTrOT-I.^RS AKK TRl'K TO TIIH 

i'.);sT 01 MV K>yj\vi,Ki)r,K AM) ni:i,n:i' 



VM... THl 



N. B.- 






Fttrmrr or 
Usuil Residrncr 

When WIS dfnfase co«trac»»<. 
If not at place of dcitk ? 



Now toil at 
Rare of Dertli? 



1^ 



l'I,ACH OF nt'RfAf. OR RHMuVAr. I DATK of IH riai. c,r RKMnVAl 



^ iW^^^ 



"r^M^^ 



1 






{A.I.h.^H 



-Bvery Item of tnfoptnniloti should be cafsfully supplied. AGB should b« sliitcd BXACTLY. PHYSICIAN* Amild 
state CAUSE Of DEATH In plwln terms, that It may be properly tilMstflcd. TM **SpMhil Itiformstlon" for psp- 
m*m% dying away fr^m tioms should be Alven In svsry Instanc** 



I 



I 



hM 



1 , ii 



ri 



i.«^* 



'M 



'^ !f^^ 



I 



X 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

no:.nl of llcnith INo !^ t'-^SJ^ H& H Co REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 




4 



t 



JOO'i 



d.^-cvu M\H.( Deputy HealttiQ 



Registered J^o. 



591 



u^^cr 



I 




DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of Beatb 

t *a. S. StanOarO ) 



PLACE OF DEATH: — County ofC^ar^t J .MX'YUMjMI^ City of 0/0/ Yu Jxa/vv^c^ 



-f 



No. Ill (LuvfrU Xjlo.tX^ St^ 3L Dist.;bct. N^tTTUA a^xd, and VU\c 



(ir DEATH ofcURS AW«V FBOM USUAL R E S I DE NC E Gl VE FACTS CALLEo/ifoR UNDER "SPECIAL INFORMATION" \ 
%f DEAThToCCURRED in a HOSPITAL OR INSTITUTION GIVE ITS NAME (INSTEAD OF STREET AND NUMBER. / 






1 



a , 



FULL NAME 




Jbo) Li\M.<la. , L 



PERSONAL AND STATISTICAL PARTICULARS 



l>\ I 1% «)l lURTII 



t 



ojl\^ 



Mniilh) 



Day) 



tib 

(Vcar) 



AC.K 



D ) ',•<! > 



MnuS/lS ( 



Da I 



MN«.1.K, MARRII-.I) 
\VflM)Ul-,lJ OR DIVORCKIJ 



fWritf ill «*<»(>ial «lcsi>.Miiili«>n) «Jl () 



i?^tHto or t'ouutrv* 



NAMl-: ni- (VS 

fatjii;r U » 




V 



vJX>V(Wruxmx)U vioM^i 




MEDICAL CERTIFICATE OF DEATH 

DATK OF I) DAT 1 1 




/QO 

(Yi-iii > 



(Uay) 
I UHRi'HV CHRTIFV, That I attoii.U-.l .Urvast-il from 
aS" 190 H to , I^M. ^31 J IQO M 




L 



lliaf I last saw ll-*--^J alive ot! n|.WVVl ,K^ Up \ 

aiitl that <lfath nmirred, on the ilati- statiil alxnt-, at %. 
SL M.^ The CAlSIv Ol- IM-ATH was as follnws: 



»UKT1U'I,A(*K 
ni- I APHHR 
(State or Cotiiitrv) 



MA!n|.:N NAMF 
<>1- MoruHR 



HIRTHPI.ACI? 
«»F NSDTHI.-.R 
IStut' ,1 t'.,itnti\ 



ea^ 






1)1' RAT ION )V(7/:^ 



CONTRIin^Toi 



Months <*l. /^(/j'.v 



Hours 



DTRATION Yran Moths Days 



Hours 



<>*>*ClFATlON 

Rf^fdfii in Sun I'latui^cn 



Q^^xiu 






1^ 



^ 



a.1 looH 



( 



M.D. 






I'/rfr.* 



Month % 



I'iUM 



flir; \1U)VKST\1 j-.n PKRHdVAI, I'AK rU'fI,\RS XRKTRIK To THH 
HHsr OE-JIV KXi»\VI,Hr><', H AND HKMKK 



TiifontMiit ZJOsMJ^^YsJOsjyoOu^ \X'\M-<Mt/' 



vs^ 



^ 



' \.Mrcv^ 



N. B,. 



ai M^-^''lo- 



SPECIAL INFORMATION mIv lor Hwpifals, 
•r Recent ResMenls, aN persons tfytofl «wiy Iron 



Former or 
Usual Residence 

Wton was disease fonlracled. 
If not at plare of deitk ? 



^ 



How loi^ it 
Ptoreff le^? 



tteiis. Transients, 



%^ 



'l>-of jjtiOAl. «.t KKMOVAI. 



I'f.ACH OK BfRtAl, OR KI-MOVAl. I D A TJ* of Biioai. 
INDl-KTAKHR Ot/O^cdvUv^ ^ -^.A-.'tX^^ ^^. Vd 



;l 



-r.vepy Item of information should be carefully supplied. AGB should bs stated BXACTUV. PHYSICIANS ctieMld 
state CAUSE OF DEATH In plain terms, that It may b« properly elassinsd. Th« "Special Intormatloa** fw ps*— 
•<Nis dying away fi*ofn horns should be ftlvcn in sv«i>y Instaass* 



f4 






• < 



I 



ifi 



.^1 



'll 




^^^^^^■E 



1 ' f 



l''> 



H 



'ii 



I 



i"# 



M 



i 



n.. 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

n.l.f iKMitl.-l No KiS-SgJ^H&iCo REFER TO BACK OF CERTIFICATE FOR IMSTRUCTIOW8 



190^ 



Registered JSTo. 



592 



1)(tto Filed, %^ '^T 

X^Ua/5 lo^vMj Cepwty '. 

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



rWo. 



PLACE OF DEATH 

^^ J I n I 



Certificate of H)eatb 

( "d. S. StanDarD ) 
; — County of Hoav J A a A^n a <-a r:*^ ^f '^^rt.m) J 



CLAV A^OAOCU^eo City of 'CUYU ^' \a >VCA4 ^ 
— Dist.;bet« ^~and — 



^l.4.AA.'CL>U.\vn VA.'^uA.ci n St., 

RESIDENCE GIVt FACTS CALLED roR UNDER "SPECIAL INrOR MATION" \ 
OR INSTITUTION GIVE ITS NAME INSTEAD Or STREET AND NUMBER. / 



(ir DEATH OCCURS aWVv FROM UjSUAL 
ir DEATH OCCURRED IN A HOSPITAL 



FULL NAME 




SKX 



PERSONAL AND STATISTICAL PARTICULARS 

I COl.UR 



i>ATr: oi- niRTH 



AC.K 



fa 



(Month) 



JV"<f< 



SIN«.|.K, MARKIKD, 

wn)«)\yKi) OK nivoKi'Kn 

(Write in nticial (ii"»i^iiution) 



i 



-f % 



(Stall- or <<iimtrv> 



NAMi: ni- 
FATHKR 



RIRTIIPl.AOK 
Ol" lATHKK 
IStatr or Country) 



MAIDHN NAMI-; 
OK MOTIIKR 



nik Tfjpi.ACK 

OF MoPHHr' 
(Stair nr C<)untr%") 



OCCrt'ATlON 

Rf stiff li in Siin Ft anciFt'o 



:f 



li\i 



1^ 

(Day) 



M.tulhs 






\j^X 



MEDICAL CERTIFICATE OF DEATH 

D.\TIC «)K DKATII 



/4L'i.. 

(Vt-ar) 



1 aw 



/7<» 15 



^j Cuy\) ^ J .^ CCA V ca^ c^ 



(Month) 




(Day) 



/QO \ 
(Yf.il) 



I I^KRlUiV CliRTII'Y, That I atteiKlea aeoeasetl from 

JkA^Li I 190 4 to Y^^ ^^'^ 

that I last saw h alive on ^VwLu %^ I90 , 

aiicLthat death occurred, on the ilate stated aljovc, at I I 



^- 



The CAT SIC (.)F DIC.XTII was as follows 



O^^' 



!t*\.ti w>^X 



l.^.^lv 



Di; RATION Years 

CONTRIIUTORV 



Months 



JMys 



Hours 



nr RATION y'ean Moufha 



"i 



/hiys 






Hours 
M.D. 



I'VcLu ,-.vj igq n 



(Address! 



SPECIAL INFORMATION only f«r BosplWs, Insmutions. Tritsleiits, 
or Recent Residents, and arsons dyiR| awty from btiK. 



Yi'Ktts ) \ffinths 1 ,JL A^i* 



THK AnoVK STATKD PKHSO%-Al. I'XKTirf L \KS AKl-: TKIK TO TH1% 
IU;ST OF MY K.XOWI.KDCK AND nVAAV.V 



(inf. 



ormant 



Qou^^ (Wa 



\ 



t >v 



I \4.1reH« J &1^4^AV<MbrW'>V<L vLA,M,A.i 



^A^ 



U.A^\. 



Former or 
lisuil ResMence 

When was disease contracted. 
If not at place of deatli 7 



How loiiQ at 
Ptareof Oeatk? 



Uf% 



TLACK OF BlRIAl. OR RKMoVAf, | DATK «f^ m-RtAT. or KEMOVAI, 



.V'l.^VlXM 



I NDHRTAKHR :'W*€LC^a->V ^4. 



±1l 



T90H 






N. B.— «v«py Item of Inffopmatlon should bs carsfully supplted. AOB shoulfl b« Stated BXACTLY. PHYSICIAN* •hoald 
•tttte CAUSE OF DEATH In |»l«ln tcpms. that It may be properly «;laastftod. The **mpm\^ lafoititatioa** for 
•<Mie dylnft away fii*mn home «hoyld be given In every instance. 



I 



i 



'M 




I • 



I •■ :• 



m 



I A 
I . I 



III 







• I 





*>k 



11 



I 



'ti 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



II. I of lltattlj — I' No. \% '*^l*Pf^lifk.VCn 



Ihifr Filed , 

i 



Regisfej'od J^o, 



593 



ai 190^ 

Deputy Health Officer 

DEPARTMENT OF PUBLIC HEALTII=City and County of San Francisco 



b\K^J^ 



Na 10 



PLACE OF DEATH 



Certificate of 2)eatb 

( TH. S. Stan&arO ) 

i — County of'^'^>"V'JACt'>VCc4^C,0 City of '^^CU"V\' *.Va • ■ ^-i cc 



St.: X 



Dist.: bet 



FULL NAME 



J iLcLfu 



i 



aC4v^M\ 



and 



(ir DCATH OCCUnS AWAY TPtOM USUAL R E S I D E NC E Gl VC FACTS CALLED 'OR UNDER "SPECIAL i N FORMATION" N 
IF DCATH OCCURRCO IN A HOSPITAL OR INSTITUTION GIVE ITS NAME'fNSTEAD OF STREET ANO NUMBER. / 



PERSONAL AND STATISTICAL PARTICULARS 

I COI, 



I»ATK t)I- lURTII 



I.OR N A 



MEDICAL CERTIFICATE OF DEATH 

1>.\TK OF DKATH 



\<-.H 




Ofbnth) 



) V'(/ / ,< 






.V'/«///,v 



(Vf.'ir) 



'kd 



Month) K 



r\ '~f 



(Day) 



IVcarl 



I^lll-KIUIY CI:RTIF-V, Tll.it lattl'll.U'.l.lii.Hsol from 



U 



n,j 1 A 



;;jN<'.I,H. MARKIKn 
\WI)u\VKn OK DIVoKil'l) 
<\\rnv in sfx-ial <l«-Hi-ii;itirMi) 



HIKTI?rM,ACK 

'^t.tii or Country I 



N'AMi: Ol" 
'ATIIKR 



"ikTin.i.ArK 

'"• JATHKR 

'"^{•'ttr- ur Cctintrv^ 



MAIDK.N NAMK 
<'^ MOTHKR 



niRTni'i.ArH" 
;•»■ mothkr" 

iMatt' or Country) 






l^i^-'xw. 



190 i 



to 



--- i 



that I last saw h - alive oil ytCvu %L up *\ 

and that <loath occurre<l, on the «late staUil afxive, at I 
1 M. The CAISK OI- Dli.XTII was as folNnvs- 



W ^ %AxH.v.t.C5 



!!' 






/>ays 



//ours 



CONTRIIU TOKV 



K rt AA c 1? 



t 



>0^4^cca 



i 



DURATION )V5y^ Afotiihs i /Trtiv 

7) 






\^CUW'^i* 




(SIGNED) 

'^^ TQoH fA.Mrc-ss) I Git .Uw^U "^t 




//ours 

M.D. 



^EcIaL INFORMATION only for HosNtils. InstHirtiMs, Tran^ls. 
or ieceiit Residents, and persons dying awiy from fione. 



"Hsroi- MY KNUUMCnr.H AND nKIJKK 



IWIKI W 

(IsmI ResMeRce 

Him Wis disease contracted, 
tf not it plif e of deatti ? 



Mw ta^ jrt 



Oiys 



aiif,, 



rill ant 



' \dtlrfss 



5 Lcuv^ 



"^ 



Wwl. 



1 Xo^^t 



PI,ACK OF lURIU, ..R RKNf..VAI, 1^11-^^ «. «.A.. or Rl MuVU 



rNDKRTAKKR 

i.^dilrei* 




• . Every Item of Information should he capstttllr MpfAUd* ACB •hotfld Im stalsd BXACTLY. PHY8ICIAIV9 lAsiiM 
•tate CAUSE OF DEATH In plain terms, that It may he ppoperly classified. The *'8p«elal Information*' for psr. 
•«!• dying away from homa ahould he 0^mm In avary Instance. 



( f j 



I 






Ml) 



il 





iLI 



♦f 








II • 








WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFtCATg FOR INSTRUCTIONS 



I Ihaltli 1 N'o. i:; "S^^^^lKtr Co 







Deputy Health Officer 



Registered J\,^o. 



594 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of H)eatb 

( "a. S. StanC»arD ) 
PLACE OF DEATH: — County of 0,<Wu 0,V<X,>vc\.C 

No. AX^wJk) Hd O^kct o. ' 



J? % 
^tcGty of C)/<X/>v J 



AxX/>xc.vA a 



St. 



^ Dist.:bet. 



and 



/ ir DCATH OCCURS j«W*V FROM USUAL R ES I DE NC E G I VE FACTS CALLED FOU UNDtR "SPECIAL INFORMATION" \ 
\ IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / 



FULL NAME 



t 



PERSONAL AND STATISTICAL PARTICULARS 



CUYV; vIj^M^A^OILC^^I 



-i;\ 



<kJL. 



COLOR \ 



I>VI I; nf lURTH 



\ • ■. !•: 




bl ,v.„, n 



il>:ivt 



Month: 







I tar I 



r>a 



■Hti:,. HI M.H;,' .i.s,:,„ati<,ti) 



lUKTlfPfACi- 



2) 



>Uv-tr\t,i cC 



• H iii;k 



"IHTHI'i.xcp 

;" • \t[n-:R' 






"' mothhr' 

"'I;'!"' T Counttvi 



"'■^^ll'ATiojsT V"2 

. IS 



il?r ,', 



v 



h /> 



WEDICAL CERTIFICATE OF DEATH 

I>ATK OF UKATII 

(I)av> 
II{KI;HV CMRTIl'V. That I attcn.kMl iIimh ms.-.I fn.nj 

th.'il I la,('s:i\v h X^ alive on yVWW IH up^ 

and that iltatli .irtiirrcd, nn the »lau vtaleil abovi- at v 




\ i 



M^Thc C.XI Si; Ol^ DI'ATH was as foll.nv 



Dt RATION 

CoNTKllil'I 

1 



Ye^j^ 



Months 



1 



I\ 



n s 



fh 



>llt s 



()KV WA\,dLfrt,o\ 



u 



^ 






nr RATI ON )V,/rf 

( SIGNED ) S. ^ tinA^o 







//out \ 

M.D. 



1:. 



PffclAL INFORMATION mIv Itr H«|rtW$. lMtit»M»K. Trnslnls 
w Recent ResMenls, «ikI perwns dyr»i| wn frwi hMie. wsiaiH, 



FtnimM* 



1/..»/A. 



/>(f I 



lU.sroj. MV KV«.\V1.I-I)GIC AND lill.lKF 



(Illfii-1Hr,lj| 



O'lw 



?^ 






(1 

ilsyalResldenff ^^^^^WL^w 

When Wis Usease rtitr^ M« 
If MtalM«reef^«tli? 



Hiff •! Be«tk? 



liys 



Pr^Fo, HlK.Al.MK l<KM..vu. I L HXF , . H « , ,, ..rRKMovu 



I 



(Adcif cin 



t'l'V 



l) JdJUy 



•^ 



Bvepy Item of infofmation should be wiiryiull»' MupplUU. AGB •Hotttd Ni stated EXACTLY. PHYSICIANS s^wld 
•t«te CAUSE OF DEATH In plain trpmv, thnt II m.iy l»e prupepl^- clMstmrf. T%m **8p«€ial Infopmalion** for Mr- 
•«»• dylag away fMMm ho^e «Ho«iM be gtvcn In mvap^ Instance. 



IJ' 



I T r I I 
I 



♦ t ; 



} 



I 



f 



ui- 



U 



Tf 




I 

' j 



mi 




WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

n.l,.fnc...Uh-FNo.i.i^^n&l>Co WgrgR TO BACK OP CCWTiriCATC FOR INSTRUCTIONS 







lOO'i 



Registered Xo. 



595 



Deputy Heaffh Offfr^ 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of 2)eatb 

( Ta. S. StanOarO ) 



PLACE OF DEATH:— County ofC'xx>v ^A^CU^vccv^ w^^Gty 



ity of 'CU>v J. 



<V>v JAa . ^ec^ 



Na Hll Xc^^ St.; a Dist4l)ct•liaa^t^vuJr1J^t!and - 

i ir DCATH OCCURS •»•¥ mOM USUAL RESIDENCE Give ruCTS C*LLID ron UNOCR "•^rclAt INronMATIOM* \ 
\ \T DEATH OCCORWtO IN A HOSPITAL OR INSTITUTION ClVt ITS NAME INSTCAD Of STNCCT AND NUMSCR. / 



and ' -^ytX 



FULL NAME 



, \ I n i ^ V K «, 



si:x 



PERSONAL AND STATISTICAL PARTICULARS 

COI.OR 



QUJ 



I'Ml' ni HIKTH 



W 



L 



I . 



'Mmitlii 



A<.i-; 



JV, 



I D.iyi 



M,n,tfn 



iVeiir) 



A/ 1 . 



MEDICAL CERTIFICATE OF DEATH 

DATK OF DKATH A ft 

(ifonth) f 
I Ifl{Ki:HV Cr^RTfl'V, That I atteii.kMl .kroascd from 

— tn — ^— 



f|>av) 






■ ■ ^ ^^ ^ -'90' 

that I last saw h alive on 



;;fN;«.I,K. MARKIKI,, 



>MiH>\vKi) uR niv.»RtFr> x 



BIRTH PI.ACK 



aii.l that ik-ath occurred, on the ilatt statc<l alun v. at 
- M.. The CA4 SIv OI' Di: ATlf was as follows 

A, 



■f90 
igo 






^fAMF MI 

PATIIKR 



RIKTHTM,\(-F 

"1 I atfikr' 

iStHtf'or Country) 



'" MoTHKR 



niRTIIlM.ACK 
pf \foTllKR' 



' !' \ri<)N- 







H 



DTK ATION Years 

C ONTRIIirroRV 



Mouths 



Days 



Hours 



DIRATION 



Vears 



J font /is 



' miVSn^ 



/hlX'S 



{ Signed ) s^0^^o>x«a> ^ i> uU <^^ rs 



It)0 



(AiMrt'Hs) Wt»>\AM \ i 



/fonts 

M.D. 



itl 



h'f:--iJr,f 1,1 Siiti / 1,111, n,-€) 



}>,t 



%/„um> 



Ih; 



•f iKtiit tosW«t$. iN penMs IriN **«) frwi llwse. ' »««««$, 



I 



"HsruF MY KNoWijaiOl^ANO JtHl.lKt- 

""'— » 2) (J. Sr^^e ' ' 

^ 5 t!. 



Nnwr «• 
UsmI lesi^iKf 

Win VIS 4sft%r rMtfacM, 



RtvlNlit 
Wiretl Drjtti? 



no's 



o 



H>l.l!,-«* ^,5 



ft fc\ > 'tis u • ^^ I HAlHof II, „,Ai, or RKMoVAl, 



* Every Item of lnffopfn»tiofi should be cAt^fuily sunplted. AGB sHuuld h« stnlcd EXACTLY. PNVSICIANS m^mmI^ 
•fate CAUSE OF DEATH In plain term., that It «»> he i>r,»perty tflssslfled. The "Sfiecial liiferin«tlo«" fJlT^ 
•««• dying away ffrmn home shottld b« given l» •♦•py ln«tMn4.e. •*•■*" 



I 



i*l 



IC 



r 



II 



i.|i 



f 



;fi 



I j 



I I: 





I I 



^m 



1 ' I'i 




I* 



llllll 

pirtii 



i, 



1 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

nu,,.r,K..U„-,-No,.ir^^n..:,>Co REFER TO BACK OF CERTIFICATE FOR INSTR UCTIONS 

Jle^h'fered JS,^o. 



Thtfn FfJcfJ, 



^y^^r^rVKAJ^ 




190^ 



596 



r ^ ^* 



DEPARTMENT OF PUBLIC HEALTH-City and County of San Francisco 



Ccitfficatc of Seatb 

( "a. S. Stan^ar^ ) 



m 



No, 



PLACE OF DEATH: — County of^CUru 't'uX/>xcc4.e€i City oi^Ou^x^ i \a^vev4,ac 
. "^ J ^VrulivYU^ lUuU^. . . St.; DJst.; bet.— —and ~ 

( '^ f/ll","^*"""* 4'*'' '^"O^'WSUAL RESIDENCE GIVE rACTS CHLLCD rOR UNOCR -SPCCIAL INFORMATfON- \ 
V IF DEATH OCCUR^tD IN * HbsPIT*L OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER ) 

FULL NAME lYaljv\.-c.H wL 



^a 



'^KX 



PERSONAL AND STATISTICAL PARTICULARS 

I cm. 



iJAli: OF 151 KTH 



Af.K 



^Ji 



^A^Lj 



■■■■• liiLtc 



MEDICAL CERTIFICATE OF DEATH 



DATH MF I if: \Tn A h 



iMj.iith) 



5 V(7 / 



I 

(Dnv) 



^t.lt,'/l^ 



Day) 



<Venr) 



(Vtari 



It 



/></ ) 



^-^'N'.l.i: MARKIKI). 
'\ IlM.W f;i, ok DIVoR^'Hf) 
H MTf HI soii.-il (li^ijfiiatioii) 



'•nrrifFFAOK 

"-!:if( nr Cniintrvi 



N\\ti: (>F 
t-AJ HFk 



''■!lni||M,A('K 
'" I VrHHK 
•^\Mv ,,r Coimtrvl 






A^V 






^ 



I^JIHRI-nV CKKTIFV. That [ atUn-U .1 .Icrcasva fnmi 

'^^^ ^l '90i to 1^^^^ '^.b ,gO H 

that I last saw h i. » alive on UjcU.i. %%, ,gQ •. 

and that tlt-ath orcurreil, on tht- -I.tt >.tait<l al.nvc, at H 



M The C'AI SJ: jij- DI-IATH wa-. a^ follows: 




I>r RATION Vnus 

CONTRIIUTOKV 



DI'RATION 



Mouths 



Days 



Hours 



'^IKlHI'r.ACK 

^tat< <,r Couiitiv) 



fVu 4 A A , 
f SIGNED) \\\^^ 1/l/OLMufvo 



thlVS 



Hours 



fc|0 






SPEdlAL INFORMATION «Hy fw Mw^tils, InaitHtloiis fraiKlMtt 



HKs'r'l.l^ ^T.V'''''* I'HKS()\AI, rAKTiril.AK"- AKH TRt K Tn THH 
'S'.HruF MV KNnWI.HlM-.K ANI) BHIJHF 



Fmwm' or 

l^«i w« Use iw ctttrtcM, 
If flof«lp|jretf4eiHi? 



Ntivloiif it 



SiQS 



'fnf.,.„i,,,„ 



(y)w^m- 



j^^ \m!^ ' 



Aw 



I 



A'l<lrc!«!« V, 



V (KWui^t»^-WCI vLc^Y^^v>\v 



rr^cK u, niKiAnnR RK^mv^r. j i»a i t^r ^, «,^,. „, ^KMi.VAr 



4 



AA^^i V t 



wv^xAvu V a.C 



I NI»HK TAKKR 



190 H 






every Item of tnfopmatloti •houhl he capcfully aupplled. AQB •finuld b« atated BXAGTl,Y, PHYAICIANa -« .^ 

•tate CAUSE OF DEATH in plain term., that It mm He prnprrl, wlasstffled. The "•pwlal l«formaH«i'« f«^^ 
««• flyiitg awajr ff-om home nhnuM he Aiv«n l« •*«ry tnatance. ^"^ 



V 



i'i 




f I 



• I 



w 




M III 



'i i 



i' ' I 




n 



f 




"""■^E ^LAINLY WITH UNFADING INK -THIS IS A PERMANENT RECORD 

I! iiti! .if Hiriltli - »• No. i:; t-^^^^ J}&l'Co 



REFER TO B4CK OF CERTIFICATE FOR INSTRUCTIONS 







an 



/^OH 



Regi\sf('rofl A^o, 



597 



DEPARTMENT OF PUBLIC HEALTMy and County of San Francisco 

Certificate of H)eatb 

PLACE OF DEATH:— County of C'a^. J'va^VCCi.et City ofnc-^v J/lC ^^ C . *<■, 



J 



n 



4x (I , I dsv 

No. ' J^ Wa.Lk.+v« % ^^: ! 



\l 



St 



Dist.j bet. 



Q ( '^ :;^o;:t^i-j — .;-^ --t r^^?^?l^^;^i;rs^if^ .^^-? s?;^^;- -^^r-r ) 



FULL NAME 




OlKU 



^1 IN- 



PERSONAL AND STATISTICAL PARTICULARS 

i COJ.OR \ 



VLtna. 



1 



l"kTJ-: <U lilKTll 



Aciv 



L 

^ Motif h; 
y 



ll 



MEDICAL CERTIFICATE OF DEATH 

DATH ol I)1:ATII 



cL 



'M<it)th> ,f 



UMyt 



•V' .III 



Vi 



f 



)V< 



II 



iDnv) 



Moithf 



^ I IIHRKHV CHRTIFV, That I -ttcn.U-tl .K, .a.ol In.n. 



/'. 



^yixiWH,) OK i>iV(iR(*Kn 

«nt, ,„ social tU-siiriiiitioii) 



niKTin-i.AOH 






'" 1 ^fHj-k' 



TIMLIN- NAM,.- 



'!n<TlllM.A<I- 



%x 



IqO 



Ol;v^^^.^4:C 



LaLw4<5' 



flint r last saw h •• alive- on .' ' tu -IS „^ 

anil that .U-ath ..rcurrcl. on tlu- .Int, ^taii-.j alM.vi-. .u 5 
jAjM. TJie C,\I SH (>!• IM-! \TH w... as folI<ms: 



trWvV CCC^Ia^a 



Dr RAT ION 

covrRiiirToRv 



yf'ci4;s 



Mi^nths 



, th^Ou 






//<•// 



Is 



'^ 



H V 



DLL ^ 



^Vu ^JbC^VCUuL 



DIRATION 



r Signed ) 






A^JLolt IqoH 







Special in 



MinUfis Pays 

I 



//ours 

M.D. 

4 t 



\ V 




wwLcL', 



er Recent ResMents, «Mf pwsMs dyMi Jwa» lro.n fcome '"""""»•*« »Mii$le»|$, 



)V,n 



yr,,>''ht 



in M ,,1. M^ kX<*\\LKD..K ANJi IIHIJlii 



fonner w i 

Usual l^sMfiice v wC>wi 

Wieii WIS iHseasf (onfwfel. 
If not at plare of death ? 



Hare of Dettk ? 



Bi)s 



> I'm; 



Itlfottllfltil 



\AAu 






,A/V\J 

3 



I 






Every Item of InffjPmellon ahayld H; cnrafttlly .applied. ACIB sh ,ul«l b# •n,tc.| B\'4wTLY PMVRlciAv* ., * . 
•i^l'/f *i*^ OF DEATH l« ,»l.t« ,er«., ,h«» I, «„, h. pt.„,.«H, .l.«,«.d. The 't^cW l„^l.* M^H^^'^ 
•'m, dying i,w.y frmn hamn .Nmild be given In every l««ln«ce. ■»»••«•««• for per- 



M 



;|«ii. 










!•< 





• ^ 




Iff 141 

I. 



m 



ii 





WRITE PLAINLY WITH UNFADING INK-THIS IS A PERMANENT RECORD 



Dfff 






RgFER TO BACK OF CERTIFtCATg FOR INSTR UCTIONS 



598 



^MA. 'deputy Heafth Officer 

DEPARTMENT OI^PUBLIC HE ALTH-City and County of San Francisco 

Certificate of H)eatb 

( *a. S. StanDard ) 
PLACE OF DEATH.— County ofOo^ J Vct^VCv^Cc City of ^a'>v ', - ■ . . 



^'0?) 



No 






cv\\ 



St.! I Dist.;bet. TO-UCU. 

ITUTI 



"fj^^^^.?-".""!"-" '»- "^"" ■■-cc. ,..»'»"„li^^^'^'^^' 



/ IF DEATH OCCURS AW«Y FROM USUAL 



FULL NAME 



^<x.\xc 



u« 



.<x 



-^i:\ 



PERSONAL AND STATISTICAL PARTICULARS 

I COI.OR 



QTloJL 



"VI I-: «u lilKTil 



0)V 



■CUV 

iMniitli» 



M.I-: 



) 'r 1} , 



IC i 



(I)fiv) 



V,»>/,'//> 



(Vt-ar) 



x^nx.wi.:!, OK r)tvnKri.-f> 

t^^iit. ,„ social <U-.is.Miati.,n) 



I Sc.iri 



/>./ 






Mik IJIPI.ACF 

'" 'Ariii.'K' 



MAfi.Kx XAMK 



HtRTHIM.At'K 
|H Mr.TllKk' 
'"-tati or Voimtrv) 



"* vri'Ailov- 



4 I. 



MEDICAL CERTIFICATE OF DEATH 

DATK 01 DlCAIll A k 

I m-RlUn- CI'KTIPV. That I MttcMMh-.l .kMv.isnl frn„ 

th.il r l.isl s.'iw h alivf nu 

lyo 

• ui.I that «Ualh Mcrurrcl, uii tht- .hitr stad-.l alxn-e. at 
^ M. The CWrsi^ (.F DKATir was as follnus: 






DIRATION )V,;,, 

CONTklfUToKV 



.1/i>f///lS 



/?.7JC 



//r>// 



; ^ 




Df RATION 



}'t'firs 



J/f ';//// V 



Oavs 



dct^o 



V! ) 



^4 



(Signed) ^0\^rr*.uu j'1£ U) Xiln ^ 



M.D. 




LaM^U 



0/ S'lJf, /", ,; 



) ,%/; 



1/,,.'/,. 



I -JN^s Nt tu I.! ri< .)■. wii lu I n I 



SPECIAL INFORMATION «»ly for HospifaH. MsHtutiwis If«,Mi;" 
Of Recem Residents, and pffsons dylni «ay frofn Niw. '"^'""'w*. IfitStfiN. 

Whfn Ha<; disfase confraclol, ^ 
If nof ii pl#f e of death ? 



I tit 



Xi HKi O. 



J -I 









INIiKK lAKI K 






^CX*VV4. 



•tn^»7Jl*i^?*«^''kT-**"" "*"'"''* **- -"•'•'M»y «upplkMi. AOB .hould be •t«t*.l KX4CTLY PHVMICIamm .. . 



!!li.;, 





1 I! 



III 



) ' 



H 





WRITE PLAINLY WITH UNFADING INK -THIS IS A PERMANENT RECORD 

'" n^FtH TO BACK OF CERTIFICATg FOR INSTRUCTION! 



r 

na/c Filed, I. 



Deputy Health Officer 



Begisiei'cd J\'*o. 



599 



DEPARTMENT OF PUBLIC HEALTIWity and County of San Francisco 

Certificate of Death 

( la. S. Stan£>arP i 
M ^^^■^"^-^"""'y °* ^^^ ^^"^ ' City of ^CL^X. ;j V awe . C - 



FULL NAME 



x-vwrvM \ 




^i:\ 



i»\ri.; ciF lURTir 



A(;h 



PERSONAL AND STATISTICAL PARTICULARS 



MCDICAL CERTIFICATE OF DEATH 

II 1 1 



i 



' '-U 



1^ 



I go 

lYtnr 



Mntiui) r 






if).(V 



1,' ,„<!, 



\jn)M\vi'i, MK r)!v..kri.r) 






f v rni:R 



RlKTril'F.Ai'K 






I IfHRI-BV CfO<Tll^V; Tl.aU ,.uc„.l..l .le.oas.,l frn„, 

that I Inst saw h .. alive nti V • ' . ^ ^ , _ , 

fiiid that .Icatlt o, furred, ..n tli< -I .t, sf.,i,(l ahnvf, at S 



■!J 



"^' '!• Mr LN.nntiv) / 1/ ' L 



^ ^w V > V^^ w 



cIm^ 



M\ini.:\ NAMl- JN 



iX/v ,' 



(? f' I'"' ^"^'^^'^'V''^^^''''^ ^vas as follnus 






nrRATlOX _ y,ar, L ^n,nth, ^ nav< 



J/oUt s 






(Signed) g 



A . I 



fr>x<xl^ 



'^ 



'iiiitrvl I 



e 



PECI 



too 



3 fAd.lr..s) ^51 ^aIILi. 



/ ftttfft 

M.D. 






K^ . _ ^, CcUaj-Ol^^ CajlLd 



or Recenl RcsMeiils. iiM perww dHRf *»•> fr»» liMie. '"^""'"••s, rr«s,f nh. 



AV..,/^,/ ,„ -s',? „'/',„„,, 



) Vjj , 



A f, it, ft, 



fvmnm 

Wlie« was disease conerif ted. 
If iJ8t if Nife if de«rt ? 



^iMf at 



Bays 






I 






P 



\.M 



r(«m 



vwcrUi. L^ft-^A. 






«r Ri:Mm\ Al 









190 



\iMr»**i 



■ihAj<., cKiXii 






1 








m 



f 



f'^H 



1*1 



m\ 



i I 



if II. Ill til I" N'o. i^ ■S'.'? 



»: IKS:!' Co 






Dff/r Filed, 

i 



WRITE PLAINLY WITH UMMDINO INK-THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INST RUCTtONS 

Megi\s/erc(l J\^o. 



•A 



1 



^1 



lOO'i 



t W\.^ 



J^ 



600 

V ., Deputy Heafth om'^'r 

DEPARTMENT OF PUBLIC HEALTH-City and Connty of San Francisco 

Certificate of 5)eatb 

( Ta. S. StanDarD ) 
PLACE OF DEATH:-Coun.y of^ CL>^ i\cv>xav^ccGty of^<V>v'^.>U>. ,v-- • - - - 

I 4- % ( W '^ 



St.; 



Dist; bet. 



and 



H ^vrE-.Tr*.ro^^"^„i;-l^7^^^i--'/, — ^^^^^^^^ 



FULL NAME 



10. 



1 



L\.ii<X^rw uwD-^ 




PERSONAL AND STATISTICAL PARTICULARS 



Hi-;x 



iTUl, 



<«iI<c)R 



UATi: (»l HI K Til 



Ar.K 



i I 

i|^ !.»tHll) 



MEDICAL CERTIFICATE OF DEATH 

DATH dj- DJCATH (\ ft 

4A.U as 



71 n-.„ 



10 



M.m/h' 



/! 




<Hiltf>n .<km:,1 (Ir^iiMiMli,;,,) 



n,i 



""♦''1 I .I>r.v) 



fV.iir' 



KwwL 15 i,p-. 



I^^^Y 



fURTHl'I.Arj.: 

iMiit. ,,t O.i.mfrv 



I- ATIIKR 



HlMTHPI.XrK 
i^tal, i.r Cuuiltl VI 






^(1 ^ ]r 



that I I.ist saw h s. . . alive mi "ivtUt \h , ^ 

aii.I that .Uath .K-rurrc-.l. c, the date stated al.nve. at S I 
^-M. The CAI SIC OF DHATrf was as follnus: 



LfUXX^' 




0^ 



t) 



,e 



'ViH' 



CONTRilU TORY «-CVU.jp%^C^Cct Atci^^^ ^ 



lioHtS 



r t 



lUkTlllM.ACF 
"I MoTIIKr' 




? 



''^K^TMK'^';V■';'^!:A;M';n•'^^' '•■'^ ■• '^^ M<sAKKTRrKT.. nil-. 



I 



(SIGNED) J ^^ ''^^^ 1'^ 




SPE^tiAL Information «, ,« ,„ 

or Recent Residents, and persons d>inj «»iy frM |««f 






M.D. 



itftoMoBs, TrMslesls. 



W i^eflcem^da >,a ' Xl7^^ H . ,^,, 



Vlief! HIS disease confraclerf. 
If not at ^ire of lealfc ? 



(Inf. 



lIlMflt 






Ul.\> 1: Ml III RIAI, OK K1-:mi,\m, I l,>v,, . ,,, „ 



3: 



> %.iAqj 



IM'IK J AKI K 



1 









I 



r 






Piv 



'ill 



|« 



iJi 



l« 



«' 



K 



1 
t^ In 



< t 



'l-- 







I 



li 



\ \: 



i\ 





WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



p., ,11,1 .,\ ll.^ihli )■ N'o. !«; t'*?^^;^;: V.Si C Co 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



4^ 



njo'i 



Be^i-'<fri'r(l A'^o, 



mi 



.^O^CA^ 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Certificate of Beatb 

( "Q. S. StanDarD ) 

: — County of ^'Ct'Tu h^O.^^ '^' A-fCity of^XXA-u ^K<X^\<^\.^ - ^ 



No, 



PLACE OF DEATH 
S 



aib5' 



ty 

a.^xaA^ St.; ' Dist.;bet.a.vi^ rvcv^ and i 

caTH occifls AWAV rROM USUAL RESIDE NCE give tacts called for under "special IWrORMATIC 
f DEATH OtpURREO IN * HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER 



k'^HtU ) 



FULL NAME ^^^ 



0"V- 



U 



\^ 



PERSONAL AND STATISTICAL PARTICULARS 



- 1 \ 



(i>\ 



iiH.oK ^ 



u 



ij\ ri-: oi" lUKTii 



\<.K 



Lik^ci 



•mAiiHi' 



) -.-a I 



(Day) 



1 /.»«///« 



■» . Mil 



/h. 



\v n»n WKH OR inv»»Rri;n 
Wiiti-iii wicinl <li<iH''i.iti"n) 



HrKTHi'r,\oi-; 



NSMl- 111' 

I A rm;R 



nik Til n, \r J.; 
OI'- I AIUHK 
(St«tc (If C«)UiUr%i 



oi MuTliKR 



i''H rniM.AtK 
"' MoTIIKR 
'tit. .11 Countrv) 



ox^^voLl 






MEDICAL CERTIFICATE OF DEATH 

DATK oi- in-: \TII 

AW 



lA 



I(>nt1i> X il>;iy» (Yr.ii 

I II 1:K i:i'.\' t.i;Kril'V, That I attimli-.l «kMi;isi(l frntii 



I90 



to 






Itp "^ 



that I last saw h . • alive nij \ ^U **»*» Itp 

and that (K'ltli occurred, »ui t!ic ilalc vfatitl ahov*.-, at 5 O 
V. M. The CAl SI-: (M- l>l':,\Tn was as follnws 
3t) A-<XA>v,4vM.<X^ a^\A-d». v v%1.4AjCt^o 



I»r RATION )Vv/;.v 

C ONTRIlUTdRV 



Motsths 



Pax 



Hours 



a\\^ 






•Kcri'ATION 



Dl'RATION 



)V<?/'5 



.Vtiiiths 



Jhiv 



(4 ft 'i 
( Signed ) \A Ucx^Laa^^uLLo ^ 

SPECIAL INF 



I /ours 

M.D. 



FORMATION on'v 'or Hasplt jK, In^tltulloris, TMHsfciih, 
Of tocMt ResMfnh, and pfrsens d>ln3 awaj lr«a fcvm. 



1/,.,.*^. 



THi: AIU>V1-t HTKTI- I) f'KRmiXM, r\RTICT*T.ARS Akf'. rRll- T' > Till-: 
llKST OF MY KNOW l,i;i)(,K AM) MHIJi:!* 



Formff or 
Usual Rfsidfdce 

When i*as dKfa'»f cflnfraffed. 
If not at ptare of dratti ? 



H«w foRf at 
Pi«^eof DfiHi? 



%ti% 



V\,\£l\UV lit RFAt. OR KKMOVM, I I»ATH •>( fU miai. or RKMuVAl^ 



\ 



^K 



INIil K 1 AKKR 



'^ 



Ui 'kK 



IQO 



< V 



CLvw4XK 



^v 



N. B. Kveps- item of Information •hould ht ciifwfully «u|iplled. AGB should be stnted EXACTLY. PHYSICIANS sliouM 

•tatc CAUSE OF DEATH In plain term*, that It may be propcHy claitslfled. Th« "«i»«cl»l Infopinotion*' fop pap- 
•on« dying awajr from home ahould be ftlven In evepy Inatnncc. 



i 



V 



II 



^\ 




• V 



,>' 



-''/ 



It 
lit 

:; ( 




* 



-I • 




WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



.>;il ' 



of H.-alth- !• No. i. *-?_^"W^^ MS: !' Co 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



JRp(!Jsfei'0(l JS^o. 



602 



Date 7'7/^v/, MvJLu ^1 I'JO"^ 

LhuJlilu, Deputy Health Officer 

DEPARTMENT (fF PUBLIC HEALTB=City and County of San Francisco 



Certificate of Death 

( U. S. StanOarO ) 



4 m 



(No. 



PLACE OF DEATH:— County 



of ^a>v 'v<XY\tA.t<i«Gty of VJ/Ct^i^' OAavv 



CC4Ct 



I •>■ 



Dist.;bet. 'Jo-Lh 



\ 



St4 3> Dist.;bet. 'JC^^t^ and I \ »v 

/■ ir ot»TH occuns «w«y r«o» USUAL RESIDENCE olV€ r«CTS c.ttCD ro» UNOC" ' SPCCi»L iNroRM.Tloi." ■) 
i. IF OC.TH OCCURRIO IK • MO»RIT«L OR INSTITUTION OIVI ITS NAME IKSTOO OF STRUT >» O NUUSIR. J 




FULL NAME 



,0 



^ 
■J 



■-KX 



PERSONAL AND STATISTICAL PARTICULARS 



<i)iJU 



hATi-: ni" niK rii 



\<;k 



n\ 



iMoiith^ 



Ht 



J 'tUl i 



H 



L^ 



I K.iv 



M.iHtli: 



f 



MEDICAL CERTIFICATE OF DEATH 

UATlv ul- UKATH 



;ii I 



Af t 



\\inn\vi;i) (»K i)P*i)K(.i;i) 

iWritc-in ".iH-ial (1< vi<.Miati<>n) 



^l^a^• . -t 



lUHi'in'i.Aoi.: 

M.tic or i/i)iiiiu \ I 



I A 111 i:r 



niRTlirM.A* K 

•n- lArnKR 

'Siaff iir Country' 



M \ I OKN NAM K 
•'1 MOTHKR 



I'.IRrilT'I.ACK 
<M MOTIII'R 
'Slats or Ciiiiiitrvi 



% 






(I)av) (Vr!ir» 



VAw V 4^i -^1 TOO 

I lUiKIiHV CliKTll'^V, That I aUcudu.l «lcccascMl fr.)iii 

— tci 



tip t<i ~ "^ IqO 

that I last >^a\v h """* alivi- nn Ic/i 

ami that <Ualli i»riurriMl, on tlu- date slated above, at 
^ ^!. Tlu- CAl'SI': (M' in; ATI! was as follows: 



A 



0-v4^>\^ ^ a 




^^U 



hXXo 



1)1 KATION Vi-ars 

CONTRinrToRV 



Mouths 



J>avs 



J loin < 



IL 



O^ \A.L c A v<L 



LoK^ 



o*'».rrA 111 iN 



)Vi7rf Afoul /is Piiv^ 



DlkATlON 

r SIGNED) WvfrAV 



!Iouy% 
M.O. 



■dlAL INFO 



t 



^fr>vtM 



t' 



I 



'SPEdlAL INFORMATION onH fw Hospitals, fii5tirullMS,Hr«»sleiils, 
or Rfcent RfsMwIs, «Btf pfrwii^ dvinj «»JV Iren ta«. 



n u >'<"f H M.>„th' I A /) 



Till" \!U»Vi: SI'A I'lt) PKRSDN \l. !■ \R rrct I XK'- \K!:TRCK !•» I'HH 

in-;^T <u- Mv KNi>\\t,i:iii.t: and iu;i.ij;i- 



(itif, 



" mant 




(A.l.lit^^ 



L1- oiv<xvku4 



Former tr 

^i was dlsfa^r (onfraflrt» 
if R«t at j^mt of drath ? 



R«w h>H9 at 



^ 



I'l. \CK"t" nCKIAI. liR RKMmVAI. 



'% 



^"■l 



I)\r' • IltuiAi or KKMtiVAr, 



t 



Ni.KKT\KKR WoXwWVVs.V<\. vl Vvd^ U 



I Aililrr*«( 






* 



N. B. Kvcry Item of Information .houhl b. ..irofully supplied. AGB «'»n»hl ho iit«teU BX4CTLV. PHYSICIANS .limiM 

•tate CAUSE OF DEATH In ulnln lcrm«, that It may h« nftperly «.l«Mtfle«l. The Special Information ^i^ pap- 
•«Ml« dying away from homo Mhould be ftlven In ovary Instan*,*. 



T 



1,1* 



• . 



1 I 







'' i 



u 



( 



'ki 



II IV 



m 




WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



IV.ard of IliiiUti - I* Nil. i-^ 



*-- 



V.^VCn 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



/ )((/(' Filed , 




ai 



100^ 



Registered J\'*o. 



603 



.^^\KKA ^Jta^M Deputy Health Officer 

DEPARTMENT 01* PUBLIC HEALTH=City and County of San Francisco 



PLACE OF DEATH 



Certificate of 2)eatb 

( *a. S. StanDar^ ) 
: — County of O/Olaaj "^ -^ - ' '"••- -' ^' 



m 



l/CL^ru 0/uCtA 



i 



No. oi'i^ (j-iAM^%X4X 



/>v w St.; 

ilOC 
OCCURRED IN A HOSPITAL OR INSTITUTION GIVE I 



LA- City ot ^^ 

Dist.; bet. Vl I tujtv 



City of ^/CUVu J K<Xjy\/^ . 



ITYL and Ct ^WAKL*\^ ) 



/ ir DEATH OCCURS AWAV mOM USUAL R ES I DE NC E Gl VE FACTS CALLED FOR UNDER "SPECIAL INFORMATION \ 
\ IF death""-'-"" '- • uo^PiTAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. J 



^ 



FULL NAME 







ruiiu 



*■ 



PERSONAL AND STATISTICAL PARTICULARS 

CUI.MR 

1 n \ 



"" (iUoL 



UU- 



DAT1-; Ol* HIRTII 



AC. !•; 



AM 



(I 



toiith^ f 



'^.r 



) VtT / 



in.'iy) 



M, I til Its 



\ tar 



Ar I . 



'>fN<.|.K. MARKIKD. 
WIlH>\VI-:i) OK DIVOKCKI) 
(U'riti.in social ilisiyiiatioii) 



HlkTHPI.ACK 
'Mate or Counlryi 



NXMK OI" 
I- \tiii;r 



\ 



^t3U%A\JU 



HIRTII PI, ACK 
't|- lATHKR 
'SI iif or Cotnitrv^ 



M MDKN NAM1-; 
Ol- MOTHKR 



ntkrupi.ACK 

<>l- MoTHHR 
'Si;iti' or Coijnirv» 






MEDICAL CERTIFICATE OF DEATH 

DATH OF DKAIIl A y 

rWontli) r (Dar» 

I HI':ki:UV CI^KTII'V, That I atuiKli'.l .kitrisctl from 



I on ^ 

(Yea I 



I9O t) t<jO 

tliat I last saw h ■«wv»% alive <m ' I I90 

and that death m t mrrd, mi the datr -t ili d alnivc, at H 
M. The CAl'Sf': Ol- MlvATH was as follfms: 



r-1 



,'VLA.^ 



rs 



')WuU 




Dlk ATION I )V-;/v *" Months * /hiv 
COS T R i IU'T< > R V C vl wa,ww«-t vo ^<. 



J /ours 



1)1 'RAT ION 



)'<''! rs 



.l/of///iS 



Pav^ 



liour^ 
M.D 



^ Signed '^ L H 4 4 f-o * fi • .^ 

^ A J* 



|A\.tL' 



tijn 



cw-wc 



L 



K Cn-ATION 



M.oith^ 



fhir 



Tin- \Ti(ivi-: sT\ rj:i) I'KRS'ix VI. i'\k ruri. \H-^ xKt: rK!}-: n* tiih 

lUChT OK MV KNOW I.HDt.H AM) HKIJKF 



(Ttifiinnafil 



^^VwuK? S) 



0->A^4A>O^^V 



Adiltt- 



%^r 5 



r 



iPCCIAL Information Mir tor Hospitals, Inslifyllons, rMiislenh, 



Of R«e«t RfsMents an4 pewns iylnq awj^ fro» Htm, 



Formf r or 
l)sn*l RfsMfwe 

When was disrasf coBtracted, 
II Bof al place ol ilealh ? 



Mm to«4 at 
l^eri Beftli? 



•^ 



I'l.ACE^OF HrRlM.iiR HHMOVVI, I HA p- <.r Hr h iai or RKMiiVAI. 

'X t ion 



INhl KrAKKR »V 



lAUi.i-*^" 






N. B. Every Item of |nfopmntlf>« sliould bs vnfofully supplied. ACB •h,uil«l ho ntnUd BX4CTLY. PHYSICIANS skould 

state CAUSE OF DEATH In plain term., that It may h« properly vl«««l«€d. Th« "Special Inrormatlon** f«» |Mr* 
mnnm dylnft awar frwn home should be Atv«n In mvmry Instance. 









•I 




V* r^ 




hf 



)* 



I 




WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

REFE R TO BACK OF CERTIFICATE FOR INSTRUCTIONS 

604 



v„xiu\ i.f HiMltli-l- N'o. !«; *-t5i^^ ''^'^'* ^'^ 




Ovl 



7.9(94 



Jlci^istererl J\'*o, 



])((fv Filed , 

l^v^ IlIu Deputy Hc?nhO 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of Beatb 

( "a. S. Standard ) 

i f i f 

PLACE OF DEATH: — County of ^<L>^ 0^a^\tA^e^City of vl/aTu OXaYXC^cCC 



^1^ 




. Utu, ^^ L^lA^^\tu. lb (H4\ '. ' '^ ' St.; ^ Dist.; bet. — ^- and 



A / ir Dt*TM OCCU«s4w*V f^"©!* l^SUAL RESIDENCEGIWE FACTS CALLED rOR UNDER "SPECIAL INroRMATION \ 
\ \ \T DEATH OCCUpln'^r. IM A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD Or STREET AND NUMBER. / 



TUTIC 



FULL NAME 



U.\^C€U 



d. 



\! Uxc>>i \ 



a 



PERSONAL AND STATISTICAL PARTICULARS 



xirtcLu. 



DATH (tl- r.IKTII 



A<.J' 



IN 



I Month' 



\X 



y, 



u 



3t 



^r'Ufln 



3.3. 



\ i;ir 



/». 



MEDICAL CERTIFICATE OF DEATH 

DATK Ol- UKATII 



i^H>1lth) K 



K.iv 



ron \ 

IV earl 



I ^niUllBV Cl'RTII'V, T!i;a I aitLiJ«k-.l (kvcascil frmn 



'^IM.I.K MARKIi:!) 

\\'in«i\\Ki) <»K niVMKi j:n 

'Wiit'iii -iii-i:i] iii-ii'ii;itii»n) 



"-"t-iti ,11 ' ■' milt f y 



NAMi; III 
I A 111 l-.R 



lUK': IIIM.M'K 
<>t- I AIHKR 

'^t-itc .ir Couiltiv 



MAHIKN' NAMK^ 
Ol- M(>TIli:k 



"■t.iit (.] Contjtry 



<H c I rA'rutx 



^ 



i 






\ 



^a>v\i 




icc^v.o 



.1 



UiA 



.. io 



.iiv.n„ %3^ ^ %% 



190 H 

190 



tliat I la^t n;i\v h 
aii«l that «Ualli im ciirrtMl, nu the ditt- st.itid mIjovc, nt w • J» 
J^ M. The CAISK Ol" l»l-.\ Tlf uas a^ follnu*. 



CI 



v^-<r>v\.c. L>xcCfrC-<x 



•k .>! 



1)1 RATION Yiars M'*ulfis Days //oii$s 

CONTRriUTORV W»V\.^^Xv ^ 'lit Iw k\ *,*...., 






iX>v»^Ctvvu 



H 



t 



|)I*R ATION 
^SIGNCD^ 



)'• ars 



MontiiK 



Pav 



MO 






Special information «'* hrit^UH, Instifnlion'i, frafislfflh, 
«r 8«eiit Residents, *«d persons im% aw«iy frtw fctWK, 



Kesidfil in Sitt' / I iiti, nt'/i 



: I 



1 ' . -»/. 



Tin: Mui\"r sT \ r )■ ti i'KK -MX \i. i> \K IF" r I xk-^ \k k ik ' 1- i' ' i^t ' 
Hi:"«T(ir M% !x V. i\\ 1 1 1 n , 1; \Nii iu!,ii;f 



It' -til int 



•t 



] tcLt 



:1 jUtxq A 



Former or 
IsBal Resldenre 

Wlien »*«< disease fonlrarW, 
If Mt at #l«^e of death ? 






^^^ niftofOMii? 



U9f% 



11 \, K • 'I Hi RI Si, liK 



M. 



IS 11 



"H 



INtiKKT \KHK 



it 



C,^ 



M ..f R KMiiS Al, 



Atl.h,-.. 






N. B.^ Every item of informntlon •hnuld h^ tofefully •uppli^d* AGF. fiH.ild b« ntnted RX4GTLV. PHYSICIANS «Hould 

•tatf C41ISE OF DEATH In ploln term*, that It m»> be ppop«Hy vittustfled. Th« "«i*rcl»l infoi'itiatioa'* for ^•r- 
mnnt d^\n0^ away fr<Nil hom« Mhould be ftiven in svery inmtmnsm* 



I 



'< 

1 



if 



1'! 



.11 







41 |i 



.\\ 



* 



\' 



»'! 



f 







i 



I m 



I 




"<'i 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

n ar.l .,f !i. aUh- I No I. if^^i^^ lUt P Co REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 

605 



Dfffr F/IcfJ, 



190H 



J^eo^/stri'cd JV*o, 



./laJLu ^1 
A^tVL^j^ 6JU\^ ^epu- *. c , 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



PLACE OF DEATH:— County 



Certificate of 2)eatb 

( *Cl. S. StanDarO ) 

i to 4 '^' 

of /Ov^rv i A.<X/>vc^v4.'Co City of ^ /<Xa v .' 



(IF DEATH OCCURS A^AV FROM USUAL 



'/OvTrv v3 A.<X/>vc^v4.'Co City 
St.; ^ Dist.;b€t. OXJU/>Xi 

to 

Z 



and 



w .<x.uLi( 



^ 



RESIDENCE GIVE TACTS CALLED FOR UNDER "SPECIAL INFORMATION" "^ 
DEATm'oCCURr'eD IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. J 



FULL NAME 




K.' 




ff 



^ 



>w 



A.! 



PERSONAL AND STATISTICAL PARTICULARS 

I)\l }. Of- lUKTM 



Lu^vvCb 



M..iU)i> 



\ < . H 



.^V 



)%.!l 



Davl 



M.inth' 



/ISO 

(Year) 



MEDICAL CERTIFICATE OF DEATH 

UATH (»!• DMATH 







f>it I 






Writ 



» i 11 »iH in 1 i\i V i: I ii) 




\ 



niirrnpi, \r\; 

(Sliit. Ill t ijiiiiti \ 



N\M1 OI- 
lATIlKR 



inu riii'i.AfK 
"t I \rirHk 

""t I'l nr ("onittrv 



<'i Mill in K 



I'.fHTHJ'I. \(K 



i 



L 



<X- 



J\JUcy\^'>voJLi» 



\A 



I ^ 



I'lKny) (Vf.nl 

I lIlvRI'IiV CI'kTlf''V, That I aUcii.lc<l <k-i t-Mst-a from 

tlirit I l.i'-t saw ll alivi- (III ^|,A,vto %h t«>o' 

aii<l that <K-ath ncciirrcMl, nii tin d.iti- stati**! ahnvi-, at 
M. The CAISI-: <)|- |»i; ATII svas ;i< folUnvs : 



^ 



'\ 



(y\AAJsJk'\^^u>^^ \X\^<%. 



y 



% 



^l i wet 



^.,a.X*^< 



1)1 RATION )'tuir<; 

CONTRIIUTORV 



Months 



/Jav! 



//. 



f.'n s 






^XX^A^^^tA^ 



< ►' ■ c \ I 



""-% 



ci Lo^* ^ i 



J/r;;/M.f 



r)rRATrr)N )r,?r? 

(SIGNED) UU.AX«\v^<i LCLtdLt>vr^% 



/yavx 



Hi 



nir% 



I'VAwtu, it icjn' 



( Adilri'^sj 



^ 



siH Mricu 



^^0^-W 



M.D. 



is PEC I AL INFORMATION o»b !« H»i|NWs lnstlt»ih»i«, Traisieiirs, 

or RfCfBf Rfsidfnts, and persons dylnj #wiy from ho«f. 



fsf^iiifil in Sail 1 



K 



\f.„iftv 



I his 



lit xn'ivH s r \ri- It I't^ K^^i i\ \ 1. 1' \R i riTi \ ws \ k i i x ' k Th nil': 



Iiif'.-iiifinl 






i 



o^K . 



X 



Formff df 
Usaal Resldenrf 

Whrn »*as diseav contrarlfrf. 
If nol ii pl«rf ol death ? 



mretrf Deatft? 



Itys 



i'i,\t } Ml m ki\i, mh kj;mia \i. 









HKMnVAI, 



I N 1 1 1 ; K r A K K K 



^ 



"^ 



+ ! 



ioH?5 w a.<w*».w 



\ 



n. B,— Bv«py Item of \n%nrmnX\nn •Hoolil bs c»f«fally Mupplled. AOi; h'v.uIiI ha ntiite.l i;X*CTLY. P»fV«ICIAN8 sImmM 
•fate CAi!8K or DllATM In plnln terms, that It mny he properly cia«iih*te(l. The "Special N form i»t Ion" for p«l»- 
m*m% dying away %^WKi home Mhould be ftHen In «*«py Instance. 



I 

I 



It/ 



F 






1. 



V • 





I 



!>^i 



" r 



I 






f 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR IN3TRUCTI0N9 



I!,,,n.l ..f llciini— I" N.' : =. "^-'Llr?'-^' H»"^^ !' t>"» 



McsHsfrrcf? J\^o. 



606 



(\ (1 

.V^yvcvA JoLx- , Deputy Health Officer 

DEPARTMENT OF ^BLIC HEALTH=Clty and County of San Francisco 



Cevtificatc of 2)catb 

( XX. S. StauDarD ) 






Ji % 



» 



No. 



PLACE OF DEATH:— County of ^^<Xnx> vl ^a v\ Gty of <^a>v 0>UX 

b Slk ^ CKA^tlX St,; I Dist.; bet, U \1X >\; and U > 



fr^A>tAjU St,; I Dist.; bet, U\JLLvu and w\vxi. 

(ir OK»TH OCCURS *w*v rnoM USUAL RESIDENCE give facts callcd roR under ■spccial iNroRMATioN \ 
1» OCATH OCCURRCO IN A HOSPITAL OR INSflTUTION GIVE ITS NAME INSTCAO Or STREET AND NUMBER. • 



FULL NAME 



.<XKK.a' 



x 



PERSONAL AND STATISTICAL PARTICULARS 



fiATK n| niRTIi 




I 

I Day) 



<V»;iri 



MEDICAL CERTIFICATE OF DEATH 

UATH nl- l>i;.\Tli 



4 



1 I 

il>ayJ 'Vt'.»ti 



A«'.l<: 



J . „• . 



^!N<.|.F M \Rl<II-l> 

U Fii'i\y l-lli <»K i»|\ I >- in 

'Wiiiriu •iiKJii] ih*is,'n.iii'iii> 



IUkTni'|,\OK 



NA%tl III 

« A'l hi;r 



niRTHlM, M'V 

•>i I Aiin-K 

'^Itilt i)t Coiiiitf v) 



' I ■ > » 1 . ■• .1 .■» \l I-, 
"I MdTIIKK 



t'lKTHPr.XCR 
• U M«tT|IHR 

' '^t;!!' <ir Cotnit! v 






Ab 



/>««. 






S^KA,' f 



m 






.a .wC^4, 






f*loiilJi) rt 

1. II1<;KI':HV CICRTII-V, That I atun.k-.l *kHxnscMl fnuii 
^U.iu. QlH 190 H tn V • ' up 

tfiat I last saw h alive <in up 

ati<l that tkath orcurro*!, nii the- >l,ili '•tatrd ahnvi-. at 4, l W 
M. The CAISI' (M- I>i:.\TII was .,- |V.I!..ws: 



nr RATION ^ i'l-ars - .l/.>/////c !lt /;<n v - //oins 
CON TK im'ToKV Vl I V<X,L'"^A.v,^l*v«^' 

Itr RATION ^ i'tars ^ Motuhs it /^.n-.v ' fIour% 

A '^ ^ • 



r Signed 

(^ I ... 



IqO 



SPEbiAL Information •«'* '"f Hospiiih. ihsihiiiim*. TrMijeih, 

«r R««t Residents, ^nd ptrwis ^tai wiy lr»-n kmt. 



Kt'fidfif nt Silt) ft. 



) 'rtJ r % 



^f.xflU ^to /'»IJ 



Till' \TU>VK <\- \ rK!> -I- '•"^oxM, f\H rir|-! \K> AKH TKt'H T«« THK 

iM:-r<ii M\ KNOW i.j ill, H .'SI* iu:i,n:r 



f flfBef w 
(Issal fcsMf Rce 

IMfR was 4lseaw cMtr«M, 
ft mi A fiSatt fff 4eiM ? 



Noik («t| it 
ntretf ^Ife? 



Otfs 



l*t*At*F <>r rUKfM.OR RF%!ii\ \I, 

1% 



\ \. 






i \ 



rsiiFRTAKFR Ua.U.%\t4 JrX^Ux^^^vu M Lo 



N, B.- 



-Rvepy Item of Inf .nnwtloti should hi cnfefully ftuftpllcd. ACB shivjld be stated EXACTLY. PHV«ICIAWS showld 
state CALlSn OP DEATH In plain tcpinit. thnt It m»y be prnpcply wlasslffed. Th« "»p«cl«l Inforwstlon" for |mip« 
•♦ifis dying awajr fiNMt* home shoald be Atvcn In every Instance. 



< 1 






• • I 






.^l» V 



%" -♦i; 





I :. 




r 




J 






WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

Hnanlof lIcMlth I'NV; r, t^^^fc ll&P Co REFER TO BACK OF CERTIFICATE: FOR INSTRUCTIONS 




Deputy Health Officer 



Beglstered J\^o. 



60? 



ih' Filed, \ 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of ©eatb 

( H. S. StanDarC> ) 



ill 



PLACE OF DEATHj— County*of^<X^n; JtUXAUX^eo Gty of 'CL>\i ' *UV^vci.4 



"5nx.,1^ 



rNa ^ \A 



(IF DCATH 
ir DEA 




UalLu^. 



wCU. SU 1 Dist.;bct.J3^<X<iu^M and 

Av riiioM USUAL RESIDENCE Give facts called roR undeh "special information- \ k 

INSTITUTION GIVE ITS NAME INSTEAD OF STREET IaND NUMBER. J IJ 



OCCURS AW 
ATH OCCURRED IN A HOSPITAL OR 



FULL NAME 



%. 



/S\ 



0L^^C4vC; 



I- 



X 



PERSONAL AND STATISTICAL PARTICULARS 

HKX ^ , I COLOR 







I>ATK oi- HIRTH 



\«.K 



IuJL 



MEDICAL CERTIFICATE OF DEATH 
OATK OF OK ATM 



(sA)iith) f 



Oavl 



<YfarJ 



Montli) 



Av y.utif \ 



(Oav) 



}/.>nf/is 



(Vesir) 



Pa 1, 



^IN'C.I.R. MARK IK t>. 
WtDoWKO OR niVOKCKO 

iWritciii social <lt>irii:uiiin) 



niKTin'i.ACK 

(Hlate i>r Coiuilrv) 



N'AMH UK 
J-ATHKR 



HIRTH I'l.ACF 
or- lATHKR 

tSfatf or CniuitT V 



MAIDHN NAMF 
«iK MOTHER 



HiR rnpi,ACF 
o|. mothrr' 

(Slate or Count rv 



<1^ 



^ f 



I jn':Ri:nV CI-RTIIN. TIhI I atUMi.lcl .Itrrast-.l fn.m 



'^,Jlu X' 



-1 .^ :^ 1 90 1 
that I last saw h - . » * alive on 



I hat I atUMui 

to IxaJUu 



aifc 



wli^ ^%i 



ati<l that ilcatli occurrc<l, on the «l.il«- slate«l above, at 
J M. The CATHH U\' DIlATir was as follows 



190 H 



Kuk 



cUr' 



-N / 



> 'ears 



Dr RAT ION 



%' 



Months 






■f J /ours 



vm.a. 



kiv 



■\ 



or RATION 



(Signed 



)'iiirs Mi'Hfhs 

-^ 4- V. 



JhlVS 



Hout s 

M.D. 



*H:crpATioNfY 




VcJvo 

Kfiidftf III San I'l ant ht'ii |, Vfats ~\ Stnuthi I hi 




\^Xm/^\ loot fA.Mres^) IHQlH "^ J^U>wtlH 



;iAL INFORMATION only lor ^tt^, luditirtoffs, TrMsktts. 
or ftecent RrsMents* ifld fiersofls d^iaq awi) Nn hMK. 



THK ^Ho\ K STATKI* Io|<-.nNAi, T X K C H T !. \ RS AR K TR T K To THK 
I»hsr <»!• MV KNoWlJ.pOH ANO HII.IIIF 



iliifntmant 




CW"v\A.vX^ 



iCt 



\XX\M. 



CA.Mrf:» 



% XjfKKKKjdrs, III 



V 



Usui fesWeticf 

Wkrn w«s Vkytnt caAlractH, 
II m\ it iH^rr 9I detlft ? 



www IVff^ w^ 

nirrof Dutk? 



•W» 



PI.ACK OF IH Rl\f. c>K RKM«AAI, I I>UKo^ lU kiai Jir KKMO\ \l. 



rW. 



brlu Iv 



I NJil k i AKI K 

(AiMs 






T90H 



■^0 5^ ^J>\0-lvt%^^ S.U4 



N. B.^ 



Bv*py Item of tnfr»pmatlofi should bs carefftflly HHpplted. ACB stiotild b« alated RXACTLY, PHYSICtANS ^mmN 
•tflM 6AUSE OF DEATH In pinin termn. that It mwy be properly vl«Mifi«d. The "Special Intormallon** fop j^p* 
•WIS dytn^ mmmy fpom home nhiMild b« ^Iven In evep|r Iniitance* 



4 






\i 



\ 



f 1 J 



:i 



i 






, Iv 




•. r 



> - vV 



II ' 



■•(! 



f 





) ''• 



I 



;»i 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



j;..;ii.l .if Hfsilth— F NV). ir t-?'^S>^i: 15S: I' Co 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



rUffc FiJcfl, |wL 9.1 



.KJsA 



Deo 



lOOH, 
health Offff^er 



Mr^fsfr/'pfl J\^o. 



608 



DEPARTMENT OFPUBLIC HEALTH=City and County of San Francisco 

Cevtiflcate of 5)eatb 

( XX. S. StauDar? ) 
PLACE OF DEATH; — County of ^^<X>\« \a>\CaC'0 City of'^'CV^Y- "^'laixCv 



iNo. 



In ^ itJb lA • Stj % Dist4 bet. UxiA^lo\/>Xia. and LUvwC^ 

(ir DEATH OCCURS AWAV FROM USUAL R E S I D E NC E Gl V t rACTS CALLED rOR UNOiR "SPCdAL INroRMATION " N 
IF DEATH OCCURRED IN A HOSPSTAL OR INSTITUTION GIVE ITS NAME INSTEAD V STREET AND NUMBER. / 

\ I In - I 



vi 



FULL NAME 



) f l.a\c 



r 



PERSONAL AND STATISTICAL PARTICULARS 

•^Hx fX\ ft ! coi.ijR ^ A 



J. 



DATI-: OF niKTH 



L 



n 



r 



Crw>vtt^ 



c 




MoAth) 



I);iv 



AT, I? 



O I )%;n:- 






!/,.»/ ',// 



'1 n 



:i! I 



n.i 1 > 



WEDICAL CERTIFICATE OF DEATH 

datf; of 1)f;ath 




r()o 

lVr;.l) 



^in'I.f:. MARkn-:i). 
\vii)(»\yi.:n «»K r)ivoKrFr) 

U'ritfiti >ioi, i;il (!« si-jfjiiitiKii) 



r . 4 



h 1 



''nrrm-uArF 

' St;ite (jr C'.uiUrv 



NAMJ- (»!■ 
FATin.k 



HlKTHIM.ArH 
pF I ATIIHK 
!St.i|. or Coimlrs- 



MAnn-lN N-\M1.- 

"I' M<,»Tin:R 



J'.IRTHI'I. ATI-; 



>'Ct lATIoN fy\| 



%^ 



/CL4 %v^o 



. I H!;[n;HV ClikTIFV, Tli.U I attni.lr.l .K*.;is,m! from 
. Nj\A.:^\.«. 1*. 190 H to K^^H '^^ I()0 , 

that I last '^rnv li -' alivt- on |v\.'vU • |,p 

an<l that death occurred, on the ilatc «stateil ahuve, at t I 
- M. The CAISIC Ol- DI'ATII was as follnsv«j: 



rm^ru 



fi 



^^trVt 



n 






V i 1 ' i 






OA-u 



\ r ^4 



, > a 



J/CU. 



WUX^VUSj 



Dl' RATION N. }\urs H Mo>it/ix 
DTK AT ION 3L J>,j/v S }r'>tiths 



\ Signed ; 

(1, t 
4 



/J.n-f 



Hours 



/hivs 



SPECIAL INF 



fA.l.trrvO I 



ll'W*.': 



/fours 

M.O, 



SPECIAL INFORMATION wlv fw Ht^ft^. iMtittttltus. fr«ii$leils, 
«r Rnent ^Mmts, an4 persons tfviftg jti^y frm hMf. 



d^<.^*UA3»V 



f\r-i,1r,1 it' Sfftt f'tnih cri 



V 



':% 5 >i7 » 5 



Ar.j,ffkf 



]h1 



former tr 
Usual Rfsldfurf 

When Ha^ (IKeasf fonfr.Ktf<, 
II Ml at plarr of dratb .' 



H«» ton! at 



D^ 



HF \tSMVF sr \TFIi i'FR^.iv M. PAR ri'T! \R^ AKF :' H 
ilFsr i>| MS KM iWJ.I.lH. F AM) Wi\\,\V.\- 



M TIUC 



Mtif. 



in uit 



r 



i Nr»FRT\KFR 




N. B Bvcpy Hem „| information should be cnrefully Ruppi; » ^^f. ^S . iM bo ■lat#4 RXACTLY. PHYSICIANS sboiiltf 

■iBte CAU9C OP DEATH In plntn term*. th«t It mtiy ».^ |ir..|»4:rl» ^IsMtffod, Tile **S|^elal InfofmBtlon'* fof ^i^ 
«»wi« dying away frwti homv should h« ttvc» In s*«f'y In-move, 



Pl.ACF OF in Kiy, cm RFM«»V\I. I IiU-K.f HmiAi. or kKMoS\i. 



A.l.lff *^ 






I 




i •! 



I -•' 



^- >? 




^11^ 



i',1 



111 



r 



41 ii 



I 



t 




1^ 



II 



i 



I 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

REFER TO BACK OP CERTIFICATE FOR INSTRUCTIONS 



liM.ir.! nf Ikiiltli- I' N'o. 1% *-f^^> 1«5; 1' Co 




0.1 



lOO'i 



Registered J\''o. 



609 



.^ KA^KJs 



"^ H 



I)(^fr Filed f \\^J 

i 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Certificate of Death 

( •Q. S. Stan&arC» ) 



^ HI ^ 'fill 

PLACE OF DEATH: — County of Cct^V t^a vvcc^ C( City of ^A,0%' JXa vvaA.4„ c t 



m ISlH 





(IF Ol 
IP 



FULL NAME 



St^ 1 Dists bet. AXLa<. A./>\.A 



and 'Hl^C 



ko/ 



r DEATH OCCURS *WAV rROM USUAL R E S I DE NCE CI VE r*CTS CALLED roR UAIDER "special INrORMATION • \ 
DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / 



yux:>) 




U^OXrvyx^^nv. 



d" 



1 



SIvX 



PERSONAL AND STATISTICAL PARTICULARS 

I COI.OR 



WlcJ^ 



HATK OI IlIRTH 




M'.H 



1 ,. (o 



"^INf.l.R, MARKIHT), 
WIDOWKI) OK DIVOKCKf) 
iWritfiji social ilesij^nation) 



niRTHPLAOK 
(State or Country) 



FATMHR 



BIRTH FM.ACK 
Ol* FATHKR 

'St:ite- «)r Couiilrv' 



MAIDHN NAMl 
<>l- .MOT! 






iDav* 




(Year) 


Mnulfis 


^ 


/hrx.s 









MEDICAL CERTIFICATE OF DEATH 
DATK OK I) HAT 1 1 



^V"nth) I 



n I 



H 



I go 

(Y«-ar^ 







I JIIvRI-nV ClCRTirV, That I iltott.kMl ilcMvascl from 

'^ctii i% 190'i to K\.Lu aL KjoH 

that I last'saw h V = . . alive on S^^-^Lt^ %,^ upH 

ami that <loath occurred, on the <latc statml ahovc, at \ 
U M. The CAlSf? OF OltATII was as follows: 



w^ 



xL.- 



i 1x\Mk 



HlRTIfPr.Al'K 
OH MoTHHH 
(State or Countrv^ 




u:4\.axic3 



0*.lxv&X'ixux. 



\ TION 



DI'RATIO.N' )V«7/? 

("ONTRIHrroRV 



DIR.XTIOX Years 

I Signed ) w^^-m^m^o^w 



Months 



/yays 



Hours 



?i 




VoHtfis '\ /livsXX //ours 



v--^ 



>^ 



"^1 tqoH (.\.hlrcss)l5l U' J a'HV^Lk ^ < 



FECIAL INFORMATION only for HMpHils, lastltutions, Trnsldts, 
•r Rerrnt Rrsidrnts, and persons dyinq a^ay frra hwie. 



f?^ 



sitli'ii ,„ Satt rtatuiffo % Vfatf SO ^^"'f^^ ^ ^_J!^ 



Tm- AHOVK STATKti I'K K'^t )N Xl, I'VKTirn. \K-^ ARK TRfK T<» TH!C 
UKST Ul- MY KNt>\\ I.KDt.H AND ni-lJJ.i 

flnformnnt JtoXMMAX ^ ^\' 



( KAi^tenn 






f or«»f or 
Usual RfsMfRCt 

When «as disease centrartN, 
If not at plare of death ? 



Hew t«Rf at 



ftajn 



190H 



ri.XrH 01 HIKIAl, «»k Ri:M«iV\r, 1 OXIKnf ntRIAf. or RKNfOVAL 

3C 5 fht >vk^»-r»%la44 ^" 



<Ad.hr 



N. B.— Every tt«m of tnf. i-m.tloii should b? cui^fttllr attppltetl. AGK nhould b« stHted BXACTLY. PHYSICIANS cImmIiI 
mtmu CAUSE OF DEATH In plain terms, that It mny he ppoperly clMslfled. The **Spwial Infonnatloii** ^ per* 
•W« dying mmp from home should b» given In svsry Instance. 



I 



^ 



ii 



hit 









; ;" 



^ 



V 



i 



* 






I 



I 



^ v^^ 




M 



i» 



illlli 





1 

1 


1 


1 






\ 


( 1 


1 

1 


II 




WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



!!..;tt.l ..f IK ;iUli- I-" No, is T^-?^:ar=.5iJ nfkV Co 




IfJOH 



Jiegi.s/r/dl J\''o. 



610 



/)((/(' Filed ^ 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Certificate of Death 

( U. S. StanDarD ) 
PLACE OF DEATH: — County ofOO-^w J'Va/Yvt\-4.a« City of C' a vv A. a 



k 



^Na Ui^>>xot'TV vvD5-^ 




kJ..o 



St.; 



IF DtATH OCCURS Awkv FROM USUAL R E S I DE NC E G I V E FA 



Dist.; bet. 



" and 



(IF DCATH OCCURS 
rF DEATH OCCU 



RRED IN A HOSPITAL OR INSTITUTION GIVE 



CTS CALLED FOR UNDER "SPECIAL INFORMATION" \ 
ITS NAME INSTEAD OF STREET AND NUMBER. / 



FULL NAME 



I 



''^W'^V V "^ 



'^ ' 



PERSONAL AND STATISTICAL PARTICULARS 



MATI-: «»l lUKllI 



AC.H 



i\!()iith) fC 



MEDICAL CERTIFICATE OF DEATH 

DATK <)i- i»i:ath a 



(I»ay> iVt III 



a6 

(Day) 



/U1 



lb 



r 



11 



Mouths \} 



5" 



/>,7I 



\vii)<»\vi:!) (IK ni\oHi|.:i> 

(Wtiteiii si)(i;i; lit -.irilaf lull) 



siatf ur Cniinti v^ 




I HI':Ri;n\ rikril-N', Thai I atU-u-Ud .Ic. i^^t.l from 

\iis,o ^i ,,^, • to ^ 1 H ^^^ ^*^^ 

that I last saw h .ihvi> on ^VwVv.^ up 

ami fliat dtath occurrcil, mi tlu- dati- statiil af«iv«', at i '> « 
M. Thf CAI Sl{ (>l- IM'ATir was .,s fnll.ms: 



N'XMM OI- 

f\thi;r 



I^n^THPI.ACR 
ni' lATHKR 
(StiiU- or Couiitrv) 



oi' M(»TIII;r 



nTRTHlM.AClC 

OF- MoTlIHR 

( State or Countrv^ 



>.l I'ATION A 






\.ifL'WtrV4^->%' 



( I S /n % "« ' ^ 



Ltvwft' 



I)( RATION ' Yttus 3 Months 

\ 1 I 

CONTRNU'TORV .^ tCwn-\.w 



/'<ns - //o,, 



tr^ 



DTRATroN 
(SIGNED) 



)',-,ii\ -^^ .^tiuit/ix " /htr< " Hours 

1^ u\ rD ^s .: 



M.D. 



./W-0"V<>^>%* 



XV^AX X 



it>" 



A.l.lri'ss) 



Special information •^y hr l^lteh. ItilKtttlMS. Trwstaib, 
«r Recent Residents, and persons dying #w*y from hM*. 



iV\X 



Rfyiitfif HI San / tinii 



) V'lJ » 



1A.../A. 



rin-: An()\ 1.; sTA'ri-"n i'kk>-' »n \l r\K ricr i. \ks aki- ik t ! i > > in i; 

HI-;ST u}. MV KV(i\VI.i:i)..H AM) Hl'i.n.l- 



■ Infill inaiit 



\ililrt'«n» 



53.5- ■^fr-vvo/, 



FWBW w 

llsvit Resfdeoce 



I , _ -5 f J Ho* loin «l _ 



Oiys 



Wfcen MS disease confr^^led. 
If not at plwe of death ? 



ri,Ail "I FU HIAt, OH KK%fiiVAl, I UATJf 



( lit w A. ■/ I >^-*^^^^ 



190 1 



! Niii:KTAKI K 



A<!tlr«*»«t 



N. B. Every Item of inropmatlon shoulil be cnfelttllr iiuf»plleH. AOB tiHould b« statca BX4CTLY. PHYSICIANS •howM 

•tate CAUSE OP DEATH In plain term*, that It rnny he pro|»erly cl«a»in«4. Th« '*SpMl«l tafafwatloii** ^m* |i«r- 
wins dying sway from hom« nhould fc« gl»«n In «*ery Inslnnce, 



t 

i 









« \. 




I 



ill 



»fwl- 



1^ 



i i 



I 





m\ 




I ,.. 



m 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

REFER TO BACK OF CCRTIFICATC FOR INSTRUCTIONS 



,t.l .,f II, Mith I- No l^ -i-'^s^Xi'.hSiV C 



1)1, 1 r /'VVfv/, iiJLu xn, 



J90H 



Itegislci'ed ^'V>. 



611 



cs 



&LUU l.iv ' Deputy Health Officer 



DEPARTMENT OF PUBLIC liEALTH=City and County of San Francisco 



,4 



Certificate of H)eatb 



( TH. S. StanDarD ) 



4 



PLACE OF DEATH: 

No. '^X^<x-v> 






-County of ^'<^^^' vi\a/vu:A^.Ci City oCT^^^xj 
c\aA St.; Dist.;bet. 

(ir oc*i!h occurs ^wav rnoH US1JAL RESIDENCE give facts callcd ron undcb "spcciau iNroRMATioN- 
ir OCATH OCCURRCD IN A HOSPITAL OH INSTITUTION OIVC ITS NAME INSTCAD Of STRCCT AND NUMBCR. 



n 



)EATH OCCURS 



and 



) 



,•" ♦ 



n 



■ 



m 



i: 



FULL NAME 



.XCt^xCci 



i\'viL^ 



PERSONAL AND STATISTICAL PARTICULARS 




U'u. 



»M K UI- lURTII 



A«.|.; 






51 



) <,(< 






Mtniffn 



fV«-Hr» 



MEDICAL CERTIFICATE OF DEATH 

DATK <u- i)i:ath 

^1 






Il>,iv1 






n.i I . 



''IN*.!.!': MAKKIKU. 

wii><>\vKn OR nivoKCKf) 

'Write In Mx-ial ilrsi^nntt<in) 



lUk rill'l.Ai'K 
^t.ite or CouiUrv^ 



VAMK or* 

FATHKR 



inkTHiM.ACK 
OF I \ I IIKK 
<Htnti or Coutitr5- 



M\n>i:N NAMK 
<'t MOTIIKK 



HIRTHPI.ACR 
ni- MOTHKR 
estate or Coiintrvl 



f\ ^\.\.i^J^ 







I H1':RI;HV CF-RTIFV. riiat I .itUti.U-.l .kHHasc«l from 
VL^\->- %i I90H tn iVclu n IgO H 

that I last saw h 5, m. alive on jvvLiA. %\ igo I 

and that «U'at1i ocrnrrcil, on the ilati- statijl al»ovc, at 
M. Tlu- CATSI': (H- I)i:.\T!f was a«, full. .us: 



a-.^ ^ 
»*-*'•-• 



HCri'ATIOX /T) ^ ^- 






> 






^fiwlh^ 



1)1 RATION * Vf-ars * Mouths 10 Days 
D!" RATION . Ytius .^foHths /hux 

(SIGNED) u-<^\ac ^ WVX*wqUA, 



//ours 



Hours 
M.D. 



_ f^ceiAL INTORMATION •riy for NtsyiMi. IntltitfMs, rraninU, 
or RrcfRt InllNis, ^nd arsons dyl^ wm^ %nm Ink. 






Ftmer 

Usutf SrsMeme 

IHM was li^m CMtricM. 
If not at place %\ 4ea(h ? 



I 



ntHr N^ n 

nart^l^ft? 



OlJrS 



Tin: AncnKST\TKt>PKRSoVM |.\KTirri.^R>ARKTRl i: TO TflK I I'l.AOE OF tU R lAI, « .k KHMmV.U. I HATi: of IIihiai, or RBMOVAI, 

HKsTo.MVKN„WU.M;K\Nn H,,.... ^ (i JD ^^ 6w.^VX<.K. ( ^Vcl^ 






U<Mrc« 



{X^vO, 



1.% foc^H 



I NlJl%RT\KKR 

1 Atl«lrc«» 



351 "4Ll±.i^. -dt 



N. B. Bvery Item of lfiforiti«tlo« .hould He cnnofully nupplled. AGB •hould k« sliitcil EXACTLY. PHYSICIANS ^m>N 

•t«t« CAUSE OP DEATH In plain term., that It wny be pi-opcpiy clMslfWd. The "SiVMlail InformRtlon" for 9«r- 
«on» dying away from home nhould he nlven In every loetance. 



r 






•^ 
^ 



!•! 



-» . 






r Tl t 



,# 




i'l 





% 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



i'.i 






REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



Regi^tevecl J\'*o, 



612 



Jwft-M-vS ]u ■ . Deputy Health Officer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Cevtificate of Beatb 

( tl. S. StanDar? » 



PLACE OF DEATH: — County of^^^ >^' ^ ^^ " - Gty of ^^^Xa\ 
No. ot>v lX^-vvJtVce<v>%, n 1 St.; Dist.; bet. 






v^ 






A r. 



and 



( 



IF DEATH OCCURS AWAY rROM USUAL R E S I D E NC E Gl VE FACTS CALLED FOR UNDER SPECIAL I 
ir DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AN 



NFORMATION- 
O NUMBER. 



) 



FULL NAME 



_J 



<x 



^, / 



^i:\ 



PERSONAL AND STATISTICAL PARTICULARS 

Coi.oKa 



\K<xL 



UWV. of r.IKTU 



a«;k 



\rr\cu^ 



\ \ 



Month 



1 

Davt 



( .ari 



MEDICAL CERTIFICATE OF DEATH 

HATH iH- DKATII A *l 



'f 



(Motitlil 



I>itV» 












'J J til t f 



M.'tti 



-INt.l.K MAKKIKH 

V. nil t\\ I i> UK iMX'oRi f:i> 

' U t u. ill *.Hial .h-.Si.Miat i».ti) 



' "' .1 • '-.x rminti V 



ll>vj 



vvw^w-^-v 



v\ 11- oi- 
I ATllHR 



JHH'lHl'l.ArK 

"I I AriiKK 

'Siaii i,r i'.iiintr%- 



MA 1 1 It. S NAMl-: 

(>i MiiTrn;R 



i»n< I iiiM.ArK 
"1 ^!'>■rflKR 




lluit I last saw \\ alive nn ■ ' ' ' ' , ' 

aliil tJiat ili-atll ocriirrfil, fni thf i|aU' ^tati«l a' i 

- M. Tlu- CAI Si; ni- hi; Mil wa-. a- fo!l..w>. 



Up 



?^ 



r 
? 






C^w 



w>v 



-s -H t ^ 



pr^ 



])\ RATION )Va/v 

f 

foNTRinrrnRV ^ ' 



niHATION 



)V 



// V 



\ rioN 



^ 



1^ f\ I 



TIP 



i SIGNED ) ' 



:CIAL INI 



,1/. »/M, /^(/i t //,';// s 

M.O. 






A-f 



t 




M- 



I 



< J 



Special information •«»y far m«ni<h. inMifufhin. iwnMfnis, 

♦f Mnt RwMfBts, «•< pffsoBi i>ii»| jw*) frtw 
fmmm 

Ilnilit^rif #fltli? 



• j 









» t « I : r K I I ; J ' • ill*; 



tiinnt 






13 



l%ACH or in KIAI, CiK -f I 

<^ i A ^, ** ^ U O^LA, 

r 



t NI»i:K lAKKK 



At, I iJ^iK ,! »! NSAI ..r HKMfi\ \l. 

looH 



^^.^Uu %1. 



Ad. 






•%% 



^ ■ H. 



N, B. Bvery Item of Irtfarmfitlon •h»»ultl hs ^i»»*ofttlfy nu^ftHerf. AfJB aTintiltl bo atatcU KX4CTl,Y. PHVSICIA^H aAMvtd 

•late C4U8E OF DEATH tn pliiln lepm«. Ihiit It in»> »»« pp'»perty «,l«««ifl«<l. The "S|wrcl«l lnforin«llnn** #«»#• p«r- 
Rn«« dying Mway from hoi»« ithoyld be ftHen •« «*•••» l««l»»ce. 



'I 




r 



h 



ill 




f 





WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

i; ,1 ! iumUIv-I No i. *-?^'3^ H& I' Co REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



Ihffc Filed y 





Deputy Health OflHcer 



Begisfri'i'd J\^o, 



613 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Certificate of Death 



( "a. S, StanOnrO ) 



City of ^ -CVWU 



^Je. 



PLACT OF DEATH: — County of' '^ >^ ^' ^-^^"^ - ' C*tv of ^ ' a >v OXdx r < s, 
V L(rUw^vtu J w 0^ !^ ' - 1 ."' ' St.; — Dist.; bet. 

/ ir Dt»TH OCCUB^ AW«V FROW USUAL R E S I DE NCE Gl VE FACTS CALLED TOR UNDER "SPECIAL INFORMATION 'V 
( "tEATH OCcJrRCD IN JhOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. J 




-and 



) 



FULL NAME 



I 



\ 



PERSONAL AND STATISTICAL PARTICULARS 

I C<)I,<Hi 



■" ^A. 



>\ 1 1- MI iiiu rii 



AT, H 






A 

H 



WEDICAL CERTIFICATE OF DEATH 

IJATK Ol 1)1.\ III 



'^ I 



1o 



^rSi.l.i: MAKUIK.I) 
Wfl)(i\vi:i) nu Iif\ »>K( l'I» 

' N\"i itc ill v,„i;il ■If'-is.'tlnl ;..iil 



Sf.'nlfi^ 



\ .-III 



Am 



4 



BlkTUlM.ArK 
(Htali- or <'iMiiiti VI 



I' A'rii i:k 



lUK'nilM, ACK 

"I 1 ArHi.:K 

'Hlatf or Coiiiitrv 



<M- .\I(»TIIHK 



»UKTIirr,A('K 
Ml. \!(iTin;K 
(Slate (It r>iiniiiv 



\ 



CI.. 









I Hin-JlUJV CI-kTlI* V, That I aUtnU-.l .kctascd from 

U '1 . I ' 

tliat I last 'iaw li • alivtnn t '•'% i<)0 

aiul that di'atli octnirrcd, cm tlu- >\.\\v -tatitl ahnve, at 1 A-ot 

(1\^I. The CAISi: <)l" I)i:\Tn was as foll.ms: 






1X'»vi4/ 



U) 



aX^tr"V'\) 



DtR ATlnN )'t'ars 



Months 



J\u^ 



Hours 






a) ' 



f\ri,lf,f i» San I < ,'. 



DIRATION 



(Signed ) 



)'i'iit 



^fouift.% 



/>./! 



I XI 



//f'urs 
M.D. 



it, w 



X 



H/l 



SPCfcfAL iNfORMATION 

« Rfcent RfvMfBts ^ perwn^ rfvinq di»«> froii 



r Aih!rt>.> .) LO-u ^**<^ Lfe '^^^1 ' " 
•at) f«r hA|M«Is« lR%lititlMn. TrMsteitts, 



tCi- 



.. 1 



J.-. 



• /..,/^. - n 



run MinVK ST\ n- It l'l^K-,.i\ M, l'\K Ti*! !.\k- AHi: IKI !• I" THK 

JtK'^T nr MY KNtiw i,j;iM.H AN!) lu i,n;i 






Fftrwwr w 
UsmI ResMence 

Wfifn Wiis (IKeasp {m\m\H, 
If not at pt4rr of dfath 7 



t* 4 



lit* |4NI| 4 



Bar^ 



l'I.\CI-: "II IH Kf\f. <tK NKM«<\ \!, I I»M! 



f Ai|(1rf*4« 



V<»-'l. U 



U IMoV \f, 

inn 



c L 



1 W 1 \1 )V\^4w4- 



N. B.— Kvery Item «f Informntlon .hould b« crafttlly •upplled. AGB .hould ^•*»*«i R'^^TLY. PHY»ICUNIIj,ho«W 
•t«t« CAUSE OF DEATH In plnln tcrma, that It ma> he nr.peHy tfl«»«1flcd. Th« Social InfopmBtion tor iwr- 
ii'Hi« dying mmmw fi"«ii home nhould be Alven In •v«ry lti«*tnn«e* 





1 



I 



)«ti 



wi 



im 





/ 



«!|i« 



!• 



ill 




» 



I I U^ 




I li 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

REFER TO BACK OP CERTIFICATE FOR INSTRUCTIONS 



li.,:ir.l ..f Hc.-illh 1- Vo i> '*T,':^;.-~i IKS: P Co 







Beglt^fei'ed JS'^o. 



i \,' u 



Deputy Health Officer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Certificate of IDcatb 

( XX. S. Stan^ar^ ) 
of L<rrJ}v€u L^mIIo) City of 'V^clv>>ue^vd W<Xl 



PLACE OF DEATH: — County 



Na 



St.: 



'Dist.; bet. 



and 



(ir DC*TH OCCURS *WAV rROM USUAL RESIDENCE GIVE FACTS CALLED roH UNDER "SPECIAL INFORMATION • \ 
IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / 



FULL NAME 



*kiVK.^)\ lllLt! 



PERSONAL AND STATISTICAL PARTICULARS 



i)A n; Mi- HiRiii 




(>tntlth* 



A»-,K 



1 k )V„,> 



31 

(Drivl 



M,n,th^ 



r% I 



, ::ir) 



/',,' 



MEDICAL CERTIFICATE OF DEATH 

DATK <»1- nivXTlI A |i 



a I- 



I ()<■> 



(^!.>iilli>f (|>av» iVt-ai' 

1 Hf':RI';nV CI:RTII"\'. That I ntlin^U.l .UnasiMl fn.iii 

■ to — 



Wit'iiWHl) «»R I)IV( tKcI-:!! 

i\Viil. ill social ilcsij.ri);,! :• mi) 



i 



v^v 



nikTH!'I,ACK 

I state or foiiiiti y) 



J-.\ THKR 



lUR rin-i, \CH 
<'» i\riti:k 

'St;l1i or l'.)i|litl \\ 



\! MIU'X N \M1- 

t»i mi)Tiii:r 



HrKTnfi.xrH 
"I ^!*tT!^^:R 
(st:itt- or Countiyi 



uccri* \ri( ►N 



n 



r 



en 




C 



m 



^ UirWtt 



190 



tli;tt T last vau h " alive on 

atnl that <l«.alh r »r{iirre«l, nn the date •^lat*.*! alxtve. at 

M. The A" AIM-; <>1' IHIAIII \va- a- foll.nv< 



"IqO 



IXO.V 



4 



/a4,a^ 



nr RAT ION 

CONTRinrToRV 



)Vr7r.? 



Mofiihs 



Pa 



r.v 



Hours 



U 



/Y^ 



A 



tfr-.ia 






Dl'RATlf >N 



Signed 



y, (US 



Af< Nfhs 



IS 



/hi 



%'.< 



f fvut s 

M.O. 



3*1 lc)oH (A.l.iri-.-) \,tC i V . Mffvui. V 



SPEdiAL Information »«!> lor Hospiuis, NsiitBtiMs, irdmsifiih, 

or Recent RfsWents, and persons dying «i»#) Irnm Nwr, 



Kf sided III Siiti I'l ,111, I'lO 



111 M'.dvr, sTATl-.I) f'KRsuNXL p \R iirif.ARs ARK TRrK 
ni;sT t>l- MY KNoN\IJ I>< .K W!) I.M.I) F 



. IHH 



'In 



"Tinrillt 






Ad<lre« 



OoJu^ 



-w^Oua w<-»> 



Ftrmer tr 
I'sBil ^Mencf 

When was dtsease cMtr«KtN, 
II not at |»lareof death? 



Nmt iMMlit 
Pbre tf Death ? 



k%< 



I'l^x ! 1 »r nt k i u. 


. iii 


K !M' - 'I 


• » 'i^i > ■ ' . . 


i ; I 


K f Mii\ AI, 


^ C>-'- - ' - ^^'^ 


( 




4 * 




fooH 


t MUiRTAKHR 




- = 




<AtI.lr< 


■«j'» 


S.C>v 


= * 



N. B. ^Bvepy Item of lnfoi-m»tIo« .liottW hs c»«fttlly Mpplle^. AGB .hould b* .tul..! BXACTLY. PHYSICUNB m\nm%A 

•t«te CAUSE OF DEATH In ploln terms, th«l H mm »" properly «;tsMlfte(l. The ••«iiccl«l InformaHan'* for pmr- 
momm tfytng nwsy fi^m home nhould be ^Hen In avery inMtane** 




ij^'i 



Ivl 



r 



.• ■ 




/. 



'r> :,, . 



• • 










Ill 




I 



' I 



* 







WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



Honr.! .if H.rilth — !■' No. i^ ■*4^-:^^; UM' Co 



Ihffr Filed, \J\ 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



Deputy Health Officer 



Re^isteved J\'o. 



615 



DEPARTMENT OF PUBLIC HEALTH-City and County of San Francisco 

Certificate of 5)eatb 

( "a. S. StanDarD ) 
PLACE OF DEATH: — County of C'CtTuOXa^^CV^C^ City ofHCtm; UAa'>vec4 Co 



^ !^. u!tuNi L VU.A %tli 



1R> 



\c 



tak 



St.; 



Dist.: bet. 



and 



(ir DEATH OCCUlte AWAY FROlM USUAL R E S I O E NC E Gl VC FACTS CALLED rOR UNDER "SPECIAL INrORMATION \ 
IF DEATH OCCJJRRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEA3 OF STREET AND NUMBER / 



FULL NAME 



iva^v. 




'O-Z. [ 



>K\ 



PERSONAL AND STATISTICAL PARTICULARS 

coi.oR ^ 



QlwL 



i 



1>ATI-, or lilKTH 



\<.K 



MEDICAL CERTIFICATE OF DEATH 

i).\Ti': oi i-i; \ III 



Day) 



/QO I 



l^ 



Month) 



3 ■-■„'- 



(I>ny) 



/ i 



I V<.!lt ) 



Pa 



uii)n\\i-i) OR i»i\-«>RrHn 

'Wi\U in -. .-m! '1. ■is/natinii) 



inKTHIM. AO}.: 
istntf (II Country) 



I 



m 



n 



HtJL 

(M^nth) I 
, I.III<Ri:nV CI-KTII-V, Thai I atlcn.lcl <k'(v:ise<I fn.nj 

)vV^Au^a ,^H to W 190 S 

tJnit I last saw h A.^ ^ alive on ^^ III ^ %'l ,^0 S 

atnl that fUatli occurrcfl. mi the «lati- statt-il ahovo. at i 



M. The CAISI-; OI' I)i;.\TII uas av, f< linus.- 



t-A'iin:R 



iMRTiir'i.xrK 



*'l -MtJTUJiR 



JHR rnpF,Ai'F 

"-t.'.It .j! (.'cHlilrv 



"i^Cfl'ATION 







^ 



>^ ^ 






I) r RAT ION )'rajs Months Ihn 

CU^TRJIUToKV CvVUnXVt. MTIcL 



,i» 



fr\M V 



J louts 



VOLKi. 



i 



.C^U-^^^C 



Df RATI ON Wars 



€ 






IL 



-NX 



uXV'ryx<XAA.4{ 



Months /hiys Hours 

f Signed) U^a^vMK K<xkj^W\ m.d. 

CIAL In 



FECIAL INFORMATION offlH 

•r Receit ResitfeRts, iN persons d^inq <ii*d> from \mm 



or instils, lasti 



I 



MWms, rrMsifiti. 



Fffwiff w 
I'sudt ResMrncr 



A^vk v\.«- '■ 



H«ii l«M| it 
Wared le«tt? 



0«)i 



I.' ;'// ,Ni//' / ; tin, I Wit 1 



5 . ,; 



^l/.w'A^ 



I HK AHiix I-: sr\Ti:n f'krsiinai, par nci r.Aks ark trik t<» 1 hi: 

BHsT ui- MV K VoWLHIxlK ANI> HJUHF 



M^Lr*v 



v,l 




if not at pl«f e »f tfealk ? 



ri,\CI^ nl jit RI\f, OR kIMMVAl. I DATKof |H kiaI. »r k) MmV4I 

ft * 



. U^ 



»,v O-iK^to.^ 






rMiKRTAKHR 



(A«lclrc*^ 



•^^ B.— — lUery 1t«m of fnfofmittion •hould he carefully supplied. AOB nhnultl be ataUd BXACTLY. PHYSICIANS sImmM 
•t«t« CAUSE OF DEATH In plain terms, that It mny i»e properly daeiilfted. The "Special Informs t ton** for pmt" 
nnn% dyln^ awair frooi home «ihould be Aivcn In every Instance. 






. < 



'In 



I ' 



44 





iv 



if*. 



!>■ 



FT 




llf 



f 






>V{I 




WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

H".!'.] of H.;ilth I- No. I > "^'^ ^^^ nSi. >' C' ■ 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



i 



fr-LA^A^ 




Registered JSI'o, 



616 



%% VJO'\ 

? Deputy Health Officer 
PUBLIC HEALTII=City and County of San Francisco 



Certificate of 2)catb 

( tl. S. StanC>arC> ) 



PLACE OF DEATH: — County of 



City of 




aanxla. '? ^ 



fNo. 



St.; 



"Dist.; bet. 



and 



/ ir DEATH OCCURS *WAV FROM USUAL R E S I DE NC E Gl V t r*CT8 CALLCO rOR UNDER "SPCCIAL I N roRMATIO N ' \ 
\ IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD Of STREET AND NUMBER. / 



) 



FULL NAME 



tdU 



'"VV\.^r^X^dL 



^i;\ 



PERSONAL AND STATISTICAL PARTICULARS 

COI.OR ^ ^ 



ftuL 




14. \ . 



\ 



1 

i? 



^\.>ivLi\.atva 



MEDICAL CERTIFICATE OF DEATH 

DATK Ml' DKATII "^ A 



i»^Ti; <»i HiRTn 



a«;h 



Li|vvJ 






too i 

(Yrar) 



/ 



• Mutith) 



JV,/ 



I Da V 



M.mlh- 



("r«ar) 



rht\ 



'^IN'.I.K, MARI<n:[) 
\VnM)\\ HH UK DIVdRCKl) 

(Wnttiii <(.oial <](. s!j.'tiati<ii)) 



'State or Countrv^ 



I Illikl'I'.V I liKTH-V, That I itteii.lcil .kccasuil fruui 

" Iqo t«> — — 

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



1c)0" 
190 



and tli.it tlcath occurreil, <»n tli«- .litr ^Iati.l almvf. at 
~^.M. Till- CVrSH OF I)I{\TII was as follows: 



N'AMK 01 
^ATUKR 



HTKTIIIM. \ri.- 

'"•■ •■ \ riiKk' 

'St.it. Mr ruuiitrv 



Maii)j;n- namf 
'>»• Ml J III HR 



'lIUTiri'l.AOF 

tst.'iit- ,,| roiiDtrv) 



1^ * 






'/ 



I>rRATIC)N Ytars 

CO.VTKinfTORV 



Months 



Days 



Jlour^ 



r>! RATION y,ars Mouths 

( SIGNED ) 11 )\ IJ &^1X^1 
LljfXtv^ :iliQoH (A«l«!rtss) \fiLQ^^XwCOL I 



f/ours 

M.D. 

1 




r^A<^' - 



Stoulh^ 



SPECIAL iNrORMATION onlv for H«^«h, Itstltittow. rMwleitH, 
or ftfceflt Resists, ^ntf perioRs tfyJng rfi»«y frtn ' 



Whea was 4fw«sf coRlrarfH, 
If not A i»t «f df^th ? 



Nm Iti^ at 
nare «l kaM? 



•vi 



I HK \|U)\|/ sT\Tl D F*HRSf»XAI. PAR rtitl.XKs AUJ: IRt K Tu JIIK | ri,\CK()l- IHRIAt.UR RKMnVAf I l»^TI'r»« lUkiAi ,,f Uf^lt.n ti 
Hhsr ni- MY KNnui.IDr.i; \M, nri.n I I ^ -I 1- . h k.a. .,t k I.M. .\ AI. 

"0 



< Iiif.inniuit 







d^. -i-.- C^ 



I, M i: iff ji 



INUICRTAKl-R 






too 



N. B.. 



-Bvery item of Infofitintlon sliottid h? cnrsfultjf supplied. AOB •Hoold Ni stated RX4CTLY, PHYSICIANS slioiiM 
•Mite CAUSE OF DEATH In piMin terms, that ll may l»e prnpmriy classified. The "Spevlal litformattoa** far ^f»<. 
••iiB dying away from homo should he ftlven In svery Instancs. 



I : « 

I'll 



" I ti 



I 

i S'i 



( 



1 





i It 



I • 



^"^^ -^^ i -JT ", 



!► 




WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

H<.:ii(l of llirilth I-' No. It, «^^^^: it.S. I' C, 



Diftc FiJi'fl 



.^^cvi 




at 



100 H 



REFER TO BACK OF CERTIFICATE FOR INSTR UCTIONS 



617 



'X.^U 



Dep 



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



Certificate of ©eatb 

( la. S. StanOar? ) 



X — County of^<^.^vv 1 VO/vvO^A/t^o Qty of '^Ww J \a >v^iACt 



Dist.; bet. 



PLACE OF DEATH:— County 

^r^. ld^Uvu>^tL St.; 

I /" ir OCATM OCCUnfe AWAY molM USUAL RESIDENCE Give r*CTS called for UNDCR "special INroHMATlOW • \ 
I \ \r DEATH OCOpRREO IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD Or STREET AND NUMSCR / 



*and 



FULL NAME 



^.0 



PERSONAL AND STATISTICAL PARTICULARS 

I COI.OR 




\t\VV. n|.' niRTII 



A<.j-: 






(M<iiith1 






15 



MitltOl: 



aI'^T 



MEDICAL CERTIFICATE OF DEATH 

DATK OF I>1% A I'M h f, 

iWoiJtli^ 



I iJ.tvi 






/). 



/ 1 \ 



^INT.I.K MARHIKTI. 



"Writ.- in -.Hi;,; I, .-;;.n;i!i..n) mX ll 



XI ^ 




lUKTHfM, \(|.', 
(Stntc or C'liiiitrv) 



NA\fK (»! 

»Aiin:K 



HtRTUI'I.ACK 
f>K f-ATIIKR 

(Sf.it. ,,r Cmintrv) 



ma!ih.:n namf 



HIKTIIPI.ACI' 
nj M(»THKK 



'>CCl I'ATUJN 



e. 



^ ' 



. I lfi:Ri:nV CI-KTIFN-, Tli;itJ atten.li.l .krcascMl from 



itp 1 



tt> 



iqo N 



that I last «;aw It i < K alive on 'HA-ltt '^* ' joo 

ntnl that tUatli urrurred, <»n the A.xiv sf.iU«l hIkivc, at I 
tl M. The CAISI- Ol- DIATII was as foIlr)ws : 



'Itoivw^ (P.^U 



^-vx^n 



"^ i 



I 



,1^ 




\^<X<^ 



IM RATION Years 

CnNTUim'TORV 



Months 



fhtvs 



J/iUlt s 



H ^^ 






vtr 



I )r RATI ON )V,?ri ^fiU,lhs 

(SIGNED) ^' *X ^.: i^ 



/^ij 



ifotits 

M.D. 



* '"I 



ftf^idfd ni St!H r .11'. ■ ,,> 



;PECIAL iNrORMATION «i»y lurwt^tils, iKHttflMi. Ir«sleil5, 



if RecfBt ResMfnfs, iiRd fersofls tfytaf av^ f^ Nae. 



b^•^■^U 



rui: AHnvK 'sTATl'H I'HR'^OVAI. I'A HTIi't lAHs ARI-: TRrii TO TIIH 
IIHST OF MY KNoUIJinCK \Mi H»:i.II*f 



^Inf.rmant wU('Vy\j . Wt\ Tw 



,^CXA. 



fwmtw 
OMil ResMenrr 

!M^ was Msfise cMtrartN, 
If Mtat^l«rf4rf4ratti? 



nan af katk ? 



0^ 



PI^CK t»l' niRIAI. MR RKMtiVAl. | IiAXK "f M' v lAr .r IUMmVM. 



I 



' \f1(Irr«« 



j^Xm ^^ L^ 'Ao ^^Kwto 



^ 



flO^ 



C^i 



1' 



t 






fOOl 



rNiiKHTAKKK ''I^Di/nAAJ H JaU »a' 



(AclUrefw 



^dW ^ t 



^* ^ ^Bvcry Hmm of lnfo«»niatton •Hould be carefull^^ MuppHed. AGB nhould b« iit«t«fl BXACTLY. PNVSICIAWR •hovltf 

state CAUSE OP DCATH In plain terms, that It itiay hm pfttperh classified. The ''Special Infopntatlon" for p«p- 
«mi« dying away fi^m tmmm should he ilven In avsry tnataacrs* 






I ' 



. t 






K I 



r 



H ' 



H 



1 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

i'..,aHl ..f n..->lth^-F Nn. u i^^^. UScV Co REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 








a^ 



IDO'i 



Dff/r Filed , 

ifrvcv4 itvMj Deputy Health Offlcer 



Registered JVo. 



618 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of 2)eatb 

( 'CI. S. Standard ) 



>. 



PLACE OF DEATH: — County ofC'-ar^ J.^vaivcvAC City ofC'-COv I'v.Ct'AxCt.v 



m 



%. 





Na I 1 S LUxctn^ St; I Dist.; bet. ^^UL0LA>4A\^\Hr\iliind V > ^ 

(ir OCATH OCCURS AWAV mOM USUAL RESIDENCE Give facts called rOR UNOCR "SPeclAL INroRMATI^N- \ 
if OCATH OCCURRCO IN A HOSPITAL OR INSTITUTION GIVC ITS NAME INSTEAD OF STREET AND NUMBER/ / 

FULL NAME LA^vLd C 




vOLlc^fLiL 






I ' 



PERSONAL AND STATISTICAL PARTICULARS 



4- 



^ - I 



\<.H 



MEDICAL CERTIFICATE OF DEATH 

1>\TF; Ml- KlvXTH A A 



fM 



l.iiUO f 



I lav 



(Yrari 



v., I 



(l>av> 



^f.>nf/is 



V<ar) 



Da y 







Hl|)«)\vj;n OR I>!V( 

' U'l it( in -.11 i:il y\i-^\y 


>kri;r) 

Ilal ir III ) 


»iK I'nr'i.Ai'H 

l>ttiili- f»r C imitiyi 


i 


N \M1<: OF 

> \'i'hi;r 


n 



A 





i 



k 



i 



HIK riipi.xrF 

"•■ 1 mhkk' 

iStntc- or Cniiiiti V 



mmi)}-:n nam J.' 

'»! MOTIIHK 



JURTIIIM.ACI- 
f)F MoTHKr' 
(Siatt- or Couiitrv 






I in- Ki: 14V CICRTII-V. Th.it r ;iniii'lt<l .lorMsiMl from 
\vJLu %1 IcpH tc, ^VaL|. X'l ,^H 

lliMt I last s;i\v li - alivi' on * ' j<jo • 

aijil that lUatli tM-rurred. nn tlic date slated ahove. at 
M. The CAI SI-: Ol- iMvATr? \vi^ as fV,ii,,„s: 



i%M (S.^vtl. att^i. 



Dl RATION }'t'ars 

CUN'IRIIU'JOKV 



Mouths 



IhtVi 



//( 



outs 






\ 



\ . I 
-^ » W-V" W wV \.^ vW w*w w<^4 

! 



Ju \Ji! 



\ 1 



1 *^ 




Ycai s 



l\i\ 



Moutfis 

ic^iH fAddnsw) ibXb me 



Kao 



Ifout^ 

M.O. 

„ "At 



OlvTl'A rioN 

fyf^iiffif lit S'lin /'i ,}ii,:<i-n "" IVif^f •* ^furtfit " f hi \ 

'^"l'L^'l''^ ^"- '^'f'^'*'"" ''»'''<^<'N'AI. I'AHTrt'lt. \RS ARK TRIH To Jill" I fr. \( 



• PECIAL INFORMATION o»l> for Ho$^tlli. lastilntiMs, IfMsleits, 
m ^rnt ^rsldrRts, aM ^rs»Rs ii\f^% away from home. 



FMiRfrtr 
Usual flrsti^im 

Whrn Ha$ disease confractetft 
If ftot at ^lare of death ? 



^wv ^^^ at 
Ware 9f Death ? 



i^s 



HK?.T ul- MV KNoU^jcni.iyJAM, rU.MKK 



("Xd'ltCiS 



int 



LI TV Wt lb 



1 Ml !U K!\f. OK KKMoVAt, I I»UI:.,i H'|i|*i, or RFM.»\VI. 



INlHiR lAKl K 



N. B.- 



-Kvery Item of Inforitttttfon should be cnre^'ull|r- Mupptled. ACB should 1^ slated BX4CTLY. PHYSICIANS sHmiM 
state CAUSE OP DEATH In pinin terin«, that tt mtiy he properly glassifled. The "Special Infformallon" for psf 
•9fl9 dying away fimNn home should be given In every Instance. 



■'I 

\ 

1 

'I * 



f 



'V 



1 



' I ] '. ' 



Jr.) 




' 



n 



I' ' "^ ^' 

: 1 .1 ji 

I 
I 

r 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

ar.i..nh.-.itl.-FVo. ,.iS^S!^H&l»Co REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



i 




CrWA^ 



0.1 7.9(94 

JUxMu Deputy Health om 



Bo^lsfcved JS^o, 



619 



cer 



DEPARTMENT OF PUBLIC HEALTH=Cily and County of San Francisco 



Certificate of 2)eatb 

( "U. S. Standard ) 




PLACE OF DEATH: — County of ^ ' a/t.\^mxt^X 



^ 



to City of L^AKAXcX-VwdL Val 



^No. 



St,: 



Dist.; bet. 



and 



(ir OtATM OCCURS AWAY rPOM USUAL RESIDENCE GIVE rACTS called for under "special INrORMATION" \ 
IF DEATH occurred IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD Or STREET AND NUMBER. / 



— ) 



FULL NAME 




Ct^Vv^X' 



si-\ 



I'A 11-: Of. HIRTII 



a«;h 



PERSONAL AND STATISTICAL PARTICULARS 

! coi.oK 



4 



itHtt 







X/X V U*.H 




> 



I , ) 



rl% 



(Months 






(Dav 



M.mllr 



(Vrar) 



/hi I 



MEDICAL CERTIFICATE OF DEATH 

DATK OF DHATH A h 

I IIMRHIJV Cj;KTn«'V, TIiHt I attcM.lc.l <lf.i;is,Nl fmn, 



1 

<I>1IV) 



<Ventl 



that r last Haw h 



190 



to 



alivi" on 



^IN'.I.F. MARUii:n. 

^\ n>o\yHn or niV(»KtKi> 

'\Viiteiti -social <lcsij.niation) 



t>\ 



HIRTfflM.AOK 

isi;ttc or Ciiuntrv 



NAM I.; oi-- 

« ATIIKR 



nrRTHf'I,Al'K 
f'l" l-ATHKR 
(Slalf or Country^ 



^f\^>^;^• namf 

OF MoTHHR 



HIRTHPf.ArK 

OF- MOTHHR 

1 State or CountrvS 



«»CCrPATlox 

Rfftiffft III San I'litii, 



L 



1 



\ 



\ f 



~It»o 



afjil that cliath orciirrcd, on thr dalt- stattil .ihovf^ at 
— M. The CAtSfC OI- 1>|{.\TH was as foll.ms 




VfW>V^^*J 



J-^.^ 



DIRATION ycai'$ 

CONTRIIUTORV 



Mouths 



/hlVs 



Hot, 



rs 



I)l-RATI(>X 



Yoats 



Ar<'n/fi<i 



n 



'avt 



(SIGNED) W J "tJ^^vUaa Ir • M. 



4 ^fc tQO 

XI AL iNF 



M.D. 

D 



SPECIAL Information wi> fw H«^tjh. insfuutiw. fr*Mktfs, 

w iKMt ftesMeitSt «M i^sms tfyiag ii»4y km Imk. 



•" IVrJ*- 



%t.ittfkf 



'^^*l'i,^'^*'^*K ST^ ri'O »M-KSos-\l. rVKTriTT \KS ART* TRIK T«i THK 
HhSroi- MV KXUW I.FlM.H AM) JtFlI.Il'h 



fwtm or 
tituii ResMence 

Wlifii wts Mmse ctntrac IN, 
HMlatplirv^4e«Mi7 



f>tarc«f Ofitli? 



teys 



ailfr 



iniiarit 



O'VU^ SX^^vffv-txC 



1 \<lilre« 



Pr.ACl* OF nf KF\f. OR RHMoVAI, I I>\TF..f Miumi. or RFMoVAI. 



I 



FNIiHRTAKKK 

fAil«! 






^' * Bvei-y Item of In form nt Ion •houid h; cnrofiitly supplied. AGE •hould hm «tated EXACTLY. PHYSICIANS flllMlM 

•tate CAUSE OF DEATH In plain terms, that It mM» tut properly claaalfled. The "Special laformalloa** 9m> yar* 
•^m« d>ln4 away fi*om homa ahmild he tlv«>* In av«p>- Instaac*. 






Ill 

4 





II 





il 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



u 



l>....ir<l (if !h:ilth- I- No iv t--^^' -ir, ]iSil> Ci, 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 







n 



lOOH, 



Kegi.slcrcd J^'o. 



^20 



\^u Deputy Heaft*' O^^'^or 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Certificate of Death 

( "Q. S. StanC»arC> ) 
PLACE OF DEATH: — County of O/CUV^ OAXUVUXOCoCity of U.OuTV O.^xt v\C vv :- ^ 

Dist.:bct. U 





No. llo I lo LUxJU^.l • • St.; T Dist.; bet. U oXXxl^ and 'h ^^ad 

(ir DtATH OCCURS AWAY FROM USUAL RESIDENCE GIVE FACTS CALLCO FOR UNDER 'HSPCCIAL INFORMATION" N 
IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF i/fREET AND NUMBER. / 



I ' 



FULL NAME JXt-^a^ vc 



s ' 1 ^ 



XX.avCi 



PERSONAL AND STATISTICAL PARTICULARS 



""" ^m^ 



, I 



DATl-: <)l' lUKTll 



Ai.K 



(MHhIIi* 



MEDICAL CERTIFICATE OF DEATH 

DATK <)l- 1)1 : ATI I "^ 



So 



)V 



a 

I I»;)V 



Mouths 






as- 



» I'll . 



ihi 1 



^^)l..iith) /t tl»:ivi (Vcnr> 



\ 



.\x,Kj. 



IljO 



w itH)\yi.;!) UK niV(»R(i:i) 

iNVritfiii suri.i) <l(>^it.'iiatii)ii ) 




'iikriij'i.ACK 

(Statf (ir Coiinlrv 



namt: Ol- 
FATFIKK 



niKTHPI,\CK 

f>|- 1 athkr' 
i still, ,,r Ciititrv) 



M\n)KN NAMF 
OF MDTHKR 



HIHTHPl.AC}.; 

<>!■ motiii:r 

(Slate or fnimlry) 



OCCl I'ATIOX 





m 



^ I in-:Ki:i5V (.'1;RTI|-V, That I ittfn.lc.l (UMxast-a fn.m 
.d)xc.' II upl t., )[vct4.^1 up\ 

that I last >ia\v h alive oti H -'-^^;^ - . 190 '1 

and that (h^alh nonirrctl, mi the date statnl alH»ve, at I i- w T 
M. The CAISIv OF DKATII was as follows: 



1)1 RAT ION * Ycins 1 Months ^ l)av$ XX/Autrs 

CONTRinrTORV vk\0-iv< b.^..fir>\.C-Kvt^."» 

' I VC V^ V44 

DIRATION 5.0 )Vr/r5 Mouths /htv; /fours 



(SIGNED) ^Jj. J. g ,UlA-kVV%v<3 

Y'TS 



\ 



SPECIAL IN 



M.D. 

IqoH (A.l.liess) 11 ^v. J ;.'.v\%\.e%X it 



FORMATION ^^ fw Hwpiyis. Inslttiltoiis, Ffiisktrts. 
or Reient Residents, and persons dying «Hdy frvm Nne. 



h'fsNfrif at Situ I'l till, isi'ii O '^ )' 



MoiOl,. 



Ih 



Former or 
Usual Residence 

Wfcen WIS Aw«e co»lr«W, 
If net i{ place of deifh ? 



Now tenfil 
H^eof Of#tl»7 



fi»$ 



THK AHOVK STAIi:i) PF.RSON'Af. PARTU'fl, \RS ARK TKI K i<i IHK 

HKsT uH Mv KN'o\vi.i;n(*,H AM) Fn:r,n:K 

(In 






f Ad«!re«««i 



IDI mKtWU^^j^ IW 



Jl.ACI «)l! m klAl. OK kHM«»\A1, I IiAj'H»»f HrKiAi. .r KJ MtiVAl, 






Ad«lf. 



1 



N. B.- 



-Every Item of Infopmatioit should b? cafeftttly iiuppned. AGB nhoytd he stnted EXACTLY. PHYSICIANS shottld 
state CAUSE OF DEATH In pl«ln terms, that It m»y be pm>|>«l»ly «^ia»slfl«d. The "Sjteclal Infopmnllon** for |^p- 
«of»» dying A way fi*om horns should be given In svsry Instance* 



I > 



I J T 

' I 

( { > 
I 

I 

i , 



U 



1^ 



I 



l< 



f 




h 











WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

) i.r l.r ?k.iltli-KNo i^ i«^^?i:Ik«t!'Co REFER TO BACK OP CERTIFICATE FOR INSTRUCTIONS 



I)((h> Filed, \Kh^L '^ 



100\ 



Registered JS'^o. 



62J I 



A>AJ Dep' 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Certificate of Beatb 

( ia. S. Stan&arC» ) 
PLACE OF DEATHj — County of '^^aiv J Va>\C\4<-' City of ^ 'Oj^X^ 1 \aivaui eo 



No. ^O'i dJl^aHLAxt\rtr\lt 



St.; 2^ 



Dist.;bct. W J.a\\,tLl) and 



M 



(ir DtATH OCCUBS AW^V mOM USUAL RESIDENCE Give tacts called rOR under special INrORMATION \ 
ir DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / 



FULL NAME 



,Ctwv4-^rw (JUOl^q 




kt 



^):\ 



PERSONAL AND STATISTICAL PARTICULARS 



l»Ari-. MI HIKTII 



^loL 



cor.oR 



li.L. 



w^%^ 






I Month) 



\ ' . 1-: 



II Y,a,s 

wiiiowHD (»R r)ivt»Rri;j) 

'Write in scx-ial (U-sifiiation) 



(Dnyl 



M •tit/r 



\ t;it I 



Pn I ^ 




lucL'^a 



() 



mRTun.ACH 

i^tafi fir Oonnti y 



I \'i'in:R 



HIRri||.i,A(F 
"I- I AllIKR 
istati- or Country) 

^'^Il'l-X NAMF 
"1 M< •THICK 



IlIRTlll-LACK 
'U MmTIIKR 
<!^tat.' .,1 (Nnintrv) 



«HCl l-ATION i^ !_. ,< 



MEDICAL CERTIFICATE OF DEATH 

U ATK ()|. D); \TII A A 

iliay) tV.ar) 

I 

I HI:RI:I{V CI-RTII'V, That I atuii.it'.l .Ittr.isc.! fr.. 
- """190 tf> "~~ ~~~ ~~~~ ■ IqO 

— -l<p 



(Monliri I 



ttl 



that I last saw li alive on 

ami that death f>cciirretl, on the 'laU- ^^taltil ;ib<»vc, at 
^I. The CAISIC Ol- !)J:.\Tn was as follows 



cr^ v 



'A. 



DC RATION }'t''tr 

CONTRiniTORV 



M,i>iih% 



/hn ? 



//o,4 



ts 



U/wi^Wfr-w^n^ 



•I 



Dl' RATION Vtiirs Afanths /}a%-s //ours 

rSiGNED) Le-^-rv^-i-^. I -B-U) iO^touviA M.D. 



^uwU ^^ 



TOO t ( 



A.Mrjss) v^ 






^l»C@iAI. INFORMATION ©irtv Nr nn^UH, l«Hliitlwi Trw^rti, 
m iw* IrMwH, «m4 j^rsws <yl»3 way from Nae. 



1 '- ,;^/ 



/>< 



nil-. AIU»\-I*. ST \'n:i) I'KRSnS'A!, PXKTini, \Rs ARH 

H-;sT<i[ M\ K N' >\\ i,i iM ,1-: \M> lu.ijri- 



TRl H I <» lU H 



'Inf., 






(\MrvMs 



HmtT or 

•Wliefl was iHsejse coBlrw W. 
If nflatM«reof4e4tii? 






Ot^ 



PI.ACK <>I lU l<m, OK KHM't'.M. 



I 



»\Ti:..f in K I A I. fjf RKMoVAt, 

!-ni*hrtaki;k Uwa.A.^ VA-t ^ '^ Vi 



N. B Bvery Item of li.ff»pfni.tloii should he cai*«f»My nupplled. ACB iihr,uW h« •••«*j;.'»**f ^''.^: . ^''^•'*?^!I*_f^''!*' 

•late CAUSE OP DFATM In Diatfi !«!•»•. that It mni he properlir L-laaaifl 



-Bvepy Item of Infrtrmntlon should he eai*«fitMy nupplled. ACB iihf»uid b« utated RXACTtV. ^HV«I 
•tate CAUSE OF DEATH In plain tefMv, that It may he ppoperljp tlaaalfled. The **Rp«^!»l tnlttrmm 
R'^ns d}lag «wa|F fiiMm horns should he given In svsry tnstanvs. 



lion** tor ^r« 



. ( 



. -5 



i r. t 



•I I 



1.1 

I * 

ii 



■I 



• 




lil! 





U 



m 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

i!.:.nl.,f Hcnltli- rxo. i^ ^^^.ju^l'Co PtePCR TO BACK OP CERTIFICATE FOR INSTRUCTIONS 



! f 






i J i t 



Registerecl J\^o, 



WOH 
AMj Deputy Health Officer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



622 



Certificate of H)eatb 

( "Q. S. StanDarD ) 

ri^ T 



(^ 



PLACE OF DEATH:— County of'.-a-.\ J \.a>v <''-*"' City of '^<X/>V' O.Va-v\C(.4C.c 
'No. l^^ll^v Uj<X<t|vCAYO'^,'. , St.; \ Dist.;bet. -ILvUl! vCl and 'J -Uc til 

(ir DEATH OCCURS Awiv FROM USUAL RC S I DC NC E CI VE rACTS CALLED roR UNBCR "SPECIAL I N roR M ATION ■• N 
ir DEATH OCCURREQ IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / 

n 



1 



FULL NAME 




rt^-t^x<i(. 



PERSONAL AND STATISTICAL PARTICULARS 



•-i-X 



QfUcUL 



t.oi fiK 



l>\i'y, MF IMKTH 



AfiK 



rlHl 



M.nHhi 



O %>}>ais 



( l)n V I 



M..utli' 



I S't'ftr) 



DitM 



MEDICAL CERTIFICATE OF DEATH 

(M^Mith! j il);iy) 

I IIHKItllV CI-:RTIFV. That I atteii.lcil .K- c oi ,1 frntii 



(N'. :iri 



'^IN'.I.K. MARKIKI), 

\\n)f»\vKn OR Divom-HH 

iWriu iij wxial (ksiKHalii)ti) 



nn< riiPi.AOK 

^^tntf .,r <"(iiititr%*1 



L 



() 



that I last saw h 



I90 



t«> 



alive oil 



fqO- 



aiitl that (kath <»ccurrei1, ofi the «l.»te -.latiil ahnve, at ^ 
y M. The CAISI-: (IL' DKATH was as foIIu\ 



)ws : 



kJAJ^ 



i>-^»vt^*^w'^< 



v\MH or 
I AinHR 



ttlRTlIft.AlF 
Of- I ArUKR 
'HiiUv or Coutilry^ 



^'AllM.N \\MH 



inRTifr'i.ACK 

[»!• MuTHHR 

'St;,,, ,„ Coiiutrv' 



'Lfrck ll) 



fr^Xi 



^ 



y 




'HHTPATIUN 



"iv<VAJ 






DIRATIO.N' )V<// 

CONTRimTOHV 



DlRATIuN Viars 



Monih.^ 



Days 



//i>ut s 



^T 



A/<>ff(/is 



/)avx 



(Signed) 






VLwtxXV 



^)Vv>tu ->.l fqoH (AthlreSK) k)Ht 



y)U>wt 



Hours 

M.D. 



|\XXmt 



SPE61AL INFORMATION wly l« li«^ii»s« IwlKitlti*, Iraistefh. 
«r Receiit ftesMeRt$, Mrf pmoos <H«I «w^ fn* kMi^' 



?-^-*\J.^»VJ 



R^sttifii nt Sau /'niHi /frit A 'i )'-if/ 



1 /..«/// 



If not at fldte ol dralli ? 



Ntiv Im^ it 



^ 



rUH AmUK SiT\TKn I'RRSONAt 1'\'<ri. f I \k-s \K1- TRfK n» THK I Pr,ACK OF llfRIAl, OR RKMilVAI. I DATH of Bi«lAL or RKMOVAl, 



hf:st iM" MY KNit\\ij:iM.}- wn nii.iici 



f\.1.1t 



ls%k dlo^ 



\W>VC^t'' 



t NIM^RTAKHR sA^ 






looH 









N. B._|5very tt«m of informntfon should b^ car-efutly siippilcd. AGB should b« ■taisd BXACTtY. PNVSICIANR ■hcield 
state CAUSE OP DEATH In plain teptns, that It may be pi-operty classlflsd. TiMr "Speclfll InffoPinstion" for psp- 
snns d^laH away fffwm horns should be Al^*" in svspjr Instance. 






!l. 




I 




WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

i; i! f II. .Ilh ! No 15 U-^^fcfcB&P Co HEFER TO BACK OF CERTrFICATE: FOR INSTRUCTIONS 




%% 



n)()\ 



Jleg/\sfrrr(l A^j. 



623 I 



fffc FiJi'd , \v 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



i\'M Deputy Health Officer 



(Tertificate of H)catb 

( tl. S. StanDarD ) 



PLACE OF DEATH:— County of I 

(ir OCATI 
ir oc 







4> -P 



\ 



City of ^'.am.' 'xLa^vd^u voA 



<vcvt^.'"v^v<j^^^l St.; 



Dist.; bet. 



md 



:nTM occuns *w«v 
:ath occunnro ii 



OM USUAL RkSIDENCE GIVE FACTS CALttO ran MHOtm "special INroBMATION- \ 
A HOSPITAL OlT INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. J 



^ 



FULL NAME 



NXtA-J 



1 




a \.^ vv-cU- K 



>H\ 



I'M i: '»(■ lUK III 




fOl.iJR \ _ j\ 



PERSONAL AND STATISTICAL PARTICULARS 

,1 



M.)iun> 



I 1 ».l V ' 



MEDICAL CERTIFICATE OF DEATH 

I)A Tli Ul' lUvATH 



Mont 10 




Ii 



/on 1 

i 'iC.il 



\ I . »•: 



^IN«.I.K. MARkTKn. 
^VnicnVKI) »)K rHVciRCKf) 

•Write ill Koti.-il ilisitrti.'Uiiiii) 



HIRTlflM.AOK 
(Stntc or Country) 



»'ATIIHR 






HIKTIIP!,A<K 
<>'■■ I ATIIKK ,, 

Siiitf (If i"(innti v^ 



maiiu:n NA Mi- 
ni. .Mi>THKR 



ini< THIM.ACK 
•»l MoTllKR 
(SUiii iir Cu(intrv) 






^ « it t 



/l,l 




I HICRI'lHV CMRTII-V, Tli.il I aticmlcd ilctva'<iMl from 

— ""igO to — "^ ~~~ ftjO ~ ~ 

t!iat I last saw h alive cin un 

ami that «U-atli <«rcurrc<l, oti the- diit staft»l aliovi-, at 
M. The CArS!-; ()!"^M:ATH wa^ as folhms: 

I «. .■ . 



^wC"rv^..^■'v^-^XAM. J,4,^4si4-^< 






1)1 RAT ION }'i*ir 

C<)NTKnn'T(»RV 



Afontlis 



/hu 



//on I < 




t)l' RATION Vrars Months 



/ht 



IV 



(Signed 



^^4X14 %" ft)0 



//ours 
M.D. 



f 



A,l,lr.Hs) uXo.^^^-^^^ 



,CLAr^\^4X^ W4 >, 



'•CCrpATlON Hi. J . J ^ 



K^:.!r ' 111 .S,iil / I il m.'^t'ii 



r 



1/..,, 



TH1-: X?i(>VH sT\'ri-'I1 I'FRHONAI. I'SK 1 It I I XK'^ AKK TRII-: Tt > lin: 

uhht jn- *tv KNn\\ i.i:!i«'.i'; AMI iui.ii:f* 



SPECIAL INFORMATION •«h i^ Hn^Uls, IiisHNHmi, Thw 
•r lecftl feslfcirts, wi pef$»iw <yli^ «wiy hiw ' 



sWfts, 



FtrMer tr 
Ifsi^ lesMenre 

I^B was ^wiw confrwW, 
tf Mt at ptof e ^ lealh ? 






9m 



ftiifftfiuatil 



wX<X,avCa.^ 



'\«l<lr« 






II V. J.' (>1 ni RIAL t>K KI Mov^l, I DATK of Bi MlAt. or MKMOVAI, 



.^■ 



TK of IM MlAt. 



, VI.KRTAKHR J J^U^ %, VV,>V^W 

A.M... H^-^^i 



190 A 






•tuts CAUSE OP DEATH In pMm tcpm.. th.t It mi.* be property .l«..lfted. Th^ SpcvUii Woww.twii »«• p. 
wm* dylpg awpy from hom* ■ho«W be given In mvmrw ln»wnc«. 



f I 



(.1 



I 



t^ I 






I (( 



'Iff 



If 



.i 






■I 

I 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

Ho..r(1.>nUaltli-I- No i^-6-?S^RS:l'Co REFER TO BACK OF CERTfFICATE FOR INSTRUCTIONS 



Begisfcrcfl JS'^o. 



624 



i)(,i,' Filed, V^Lu "^"i I'-^o'i 

(MrVMj) 3sX\H^ Deputy Health Officer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Ccitiffcate of 2)catb 

( 13. S. StanDarO ) 



^ 



PLACE OF DEATH: — County ofvlCtVyj vj h^OLTVC^ACCity of V'O^TV ' 
rNo. 5^'i^ H.t^'<5LXM. St.; U Dist.;bct. "^H tvv 






(ir 4c*TH occuns away from USUAL 
IIF DEATH OCCURRED IN A HOSPITAL 



RESIDENCE GIVE facts c 

OR INSTITUTION Give ITS 



and A 5 L S\ 

CALLED FOR UNDER "SPECIAL INFORMATION" N 
NAME INSTEAD OF STREET AND NUMBER. / 



FULL NAME 



11<uIki. ()1uL,.... 



SKX 



PERSONAL AND STATISTICAL PARTICULARS 

COLOR 



(liccL 



DATK OF IJIKTII 



AC.K 



JL. 



l^t 



iMiiiithl 






lo 



(Dav* 



rVcDr 



MEDICAL CERTIFICATE OF DEATH 

DATIC ul- ni.A TH 



I, 
(NlViiitlii 



L 






(Vcar> 



5H ,-...,. 



VJ 



SIXr.l.K. MARKIKI). 
VVIDOWKD OR niVoRCKI) 

• Writriti social (le>-iv.'!i;iti<»irj 



I V Mouths 



• Siari 



— r^i vs 



IIIRTHPI.ACK 

(State or Counlrv' 



NAM)" Of- 
FATUHR 



BIRTH IM.AV'K 
OF FATHKR 

(Stntf or CfJiintry) 



MAIDKN NAMH 
Ol- MOTHKR 



HIKTliri.ACK 
«»1 MOTHKR 
(Slate or Ctjutitry) 






M f La vwo-dL 



. I HHRIUiV CI;RTII'V, Th.it I Jitun-U-.I .kivasf,! from 
\CC>V i^oH to ^vJUjL. %k> up H 

Hiat I last saw h ^WYwalivc on ^| wL^„ Xk) upH 

aii«l that (liatli occurreil, mi the ilatc staled ahovi-, at tl- o 
NJ. M. The CAlSIi OF DICATH was a. foll.nvs; 



Pars 



ItOSi 



f 

U 



ace 



1%JU 



ixu^ 



I 



KA^<X) 



DIRATIUN^C) };ars Afonths 

CnNTRIIUTnkV 

Afifuths Pavs /fonts 




e 



^CX^^o. Lc-tvLV<XC^vt 




oCCri'ATION,V\'» h 

Rffitffil ni Sail J't n*i, :'tui %}>{ 5 



KaAX) 



IH'RATroN Vtars 

(Signed) \j:t\j^s^ H'O^aci; 
A 



i-cUi 



iw 



(A.Mrtss) llo"! J^CtV 



Special Information «ni> lorHispiiiH 

•r Recent Rrsidrnts, «mI j^rsots tfyltf tmti \tm ktne* 



M.D. 



- M.„,ths - /' 



Fonwf r w 
llMil Rnidrnrr 

When Has disease confrartftf, 
if not at plarr of tfratli? 



R«tif iMf il 
n«re^ Deilft? 



Iiys 



THi: ^novn ?^TATFIJ fFRS<»N-Al. I'AHTUri.XkS AkJ, TRT K Hi TIIJ! 
HKST OF MY KNo\Vl,Hl>r.E AND HKUIKF 



!Iiif>:ma«t 




tur^ yYuUvw- 



f Adtlrcis 



03^ 




^v 



x^<^ 



v 



I'LACK Ul m R!AI. ok KFMoV\i, | l>U^; .• IIimiai or kHMoV\|, 



^oXl/ 



H 



^1 



Ml 



♦ ^^^H. <L igo 






N. B.^ Cvery Item off fnformattoti should he carafully sttpplied. AGB shoulti hm atatcd BX4CTLY. PHY6ICIA!<V8 alMrald 

•tatc CAUSE OF DEATH In pinin terms, that it may be ppopeply cl«sslfl«d. The ''Special Infformstton'* for psf 
■9it« dying away fi*om horns should be 4ivsn in svsry Instance. 



V 



* 1 



f . 




I 




WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



IiniMl of Hc:iltb-r-' No. r^ ^%'J^'^-' "''tl' Co 



Jfc^Lstered J\^o, 



625 



ficer 



I)a/r Filed, yUUx Xl lOO'i 

dU^^VM cL^M. Deputy Heaf. 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Certificate of 2)catb 

( m. S. StanDarC> ) 

% 4 % ' 



PLACE OF DEATH: — County of Q.<XA%) J Xa^vcui c City ofCjCUru OAa^vec^e<; 



rNb. 



UmXdAArvv(^ 




r\ 



( 



M^-xs. 



It 



St.; 



Dist.; bet." 



-and 



ir DEATH OCCURS AWAY llROM USUAL R E S I DE NCC CI VE FACTS 



\f DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE I 



TS CALLED rOR UNDER "SPECIAL INrORMATION" \ 
TS NAME INSTEAD OF STREET AND NUMBER. / 



FULL NAME 




XXy^u lifUrr^ 



cr^crvvu. 



V^^ii, 



PERSONAL AND STATISTICAL PARTICULARS 



SKX pp\ IS I COl.oR 



f II 



L 



DAIIC UI 1 IKTU (K\ 







MEDICAL CERTIFICATE OF DEATH 

I) A IK oi- I)i;ath 



o^Jlr 



I Month) 



Ai'.K 



JV'd/ 



iDav) 



M,ni!h: 



^^'h 



\ rat 



Da r, 




siNc. i,i:, MARun':i>. 
WIDOW Ki> OR nfvokii:i> 

(Writfin ^(n-iiil (ksit^iiat'oii) 



niRTin'I.AOH 
(State or Country) 



NAM1-: or 
FATHKR 



BIRTHI'LACH 
OK lATHHR 

(Stutf or Countrv) 



MAIDICN N\Mi; 
o|' MOTHKK 



HIRTm'I.ACK 
oi- MOTHKK 
(Slate or Cunntry) 



OCCIPATION 







Day) 






>nth) fV 
I JllvRiaiV CI'RTrFV, That r attiMiiK-.l .ltr<;isi.,l fnuu 

UwJlu '^'h 190H t..^ JvU^ 3^"^ i<pH 



that I last saw h -*kA' alive on 



^.IL 



an 






I«/5 H 



and that lUath ocrurreil, on the date- staticl altuve. at ^ H5 
wLm. The CAl'SI- OI' DI-ATII w.is as follrnvs: 



'^x,^t^v^A,<.' . 



Dl' RAT ION Ytius Mouths T /^ar? Houts 

CONTRIiU'TORV 



A^'^^^^X' 



u 



\^ 



fririviu 



1 




,A 



Kj^ ^Ltcclc^v, -^ 



DTRATION 



Mouths 



/hns 






)\'iirs 

( Signed )\S.UX/Ywc4\x w4Xav Axc^v. 



Hours 
M.D. 




lAL Information only for Hospitals. Institutions, Ir^nsiriits, 
or Rfcfnt Residents, and persons dying away from home. 

former!^ 1 i er M » *+ * "ow lonq at ij 

Uj 'iS^t rnace of Death? 1 



txtMiln; ill ."•ii»,' / 



rm: auovk htati:i) PKR^ctXAi, rARTiiMi,ARs ark trik to thh 

UHST ol" MV KNo\Vl,J.;i)<'. K AND HI-.l.lHK 



(Inrottitant 



(A eld few 



lis MCHj^fc ^i. 



Usual Residence 

IWicn was disease contracted, 
\\m\*\ ^f of iMatli? 



Iiys 



i'UXCK 01 niRIAl, OK Ki;Mt»VAI, | nXTHof Ht-KIAL or HKMOVAf. 



(.-.UHRTAKKR 

fAtl«lr«-«»i 



CCk.A^T^ 






N, B.^ Bvery Item of information •hould be cnfefulUv Rupplied. AGB should b« utated EXACTLY. PHYSICIANS shotild 

state CAUSE OF DEATH In plain terms, that it mny be properly wlanRifled. The "Special Inforitiatlon" few per- 
•ofi« dying away from home should be l^ivcn In avery Instance. 



riij' 



.III 



;lfl 



I- 



„Hfj 



III 



II' 



>l 



>h 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

Hoard of II. alth-F No. 15 3^?^^- H&I' Co REFER TO BACK OP CERTinCATE FOR INSTRUCTIONS 



i 



4i 






Mr <f I. sic red A''o. 



626 



Date Fifed, V^, '^'^ ^^^H 

Xcrcvv^ dXA^u Deputy Health Offinor 

DEPARTMENT OFPUBLIC HEALTH=City and County of San Francisco 

Ccitificate of ©eatb 

( *a. S. StanC»arD } ^. 

PLACE OF DEATH; — County of U/CU^ 0\a>\Ci< City^of "'/CXa\. vJ.>UXAvet4 C^ 

ffffo. VV^t.k.; 'OCL^tdU^xq. St.; ': Dist.;bct. \( l^a\,kJ. and '^v* 

/ ir DEATH OCCURS *W*V FROM USUAL R E S I DE NCE Gl VE FACTS CALLED FOR UNDER 'SPECIAL INrORMATlOW \ 
V IF DEATH OCCURRED IN A H'OSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / 



FULL NAME 






SKX 



PERSONAL AND STATISTICAL PARTICULARS 

COI.OR 



^fKol. 



DATK OI" IHRTH 



M.K 



rlbl 



iMotilh) 



ob )%;n.^ 



iUny) 



yt.<tif/i' 



f>.'ai ) 



A; 1 



MEDICAL CERTIFICATE OF DEATH 

DATK nl- DlvATH \ ,» 



/QO 

(V.Mit 



SIN<,1,K, MARUII-:n. 
\Vr?>(»U}:i) OK T>IVnRCHI) 

(V\'iitiiii sfx-ial fIesi!.'iiatioii) 




\qC\X^^^ d- 



lUKTHPI.ACK 
(Slate or Contitry^ 



NAMK or 
FATHKR 



niRTHPI.AlK 
O!" I-XTHHR 
(Stati or Country) 



MA[r»i:N NAM1-. 
<)1' MOTHKR 



niRTHPI.ACK 
(H- MOTHKR 
(State or Cfunitrv) 






I Day) 

1 HI':RI-:HV CIvRTIFV, That I atlcii'lcd .kcx.isotl froiu 

— — — 190 '■ to - — ~-~ '■-■■ IQO 

that I last saw h rr— alivi- <>n ' ~ np 



Afmith) } 



ati<l that (U-atli occurrdl, on the 'latt- stated ahovc, at 
^ ^M The CAl'SI-: Ol' Di; ATH was as follows 








f\JX/\y\Js 



occrrATioN 



t 




^^X^O^'^'^.O 



nr RATIOS years 

CONTRinrTORV 



Dr RAT ION )'riirs 



Mouths 



Pars 



Hours 



}rouths 



U\^ 



(SIGNED) UarvU.\» 
i()o'i (A 



y^l4 Vl i()oS (A.Mresv) L 






Pays 



Hours 
M.D. 






Kfsiifi'ii in Siin /;ti>hnrii 



) /(f ' A 



.i/.,ni/n 



THK AHOVK STAri;!) I'KRSONAI, 1' \ K TfCfl.AKS AR H TKIH To THH 
HKST t)F MY K.VO\Vl,}:i)<,H AM) HII,IKP 



(Infonnant 






CAddresfi 



vJLco^amXI^ at 



'Special information o"'* ^^^ MospUiils, liistitutitWs, Iransleflh, 
or Rfffnt Residents, and persons dying a^av Ironi home. 

Former Of y kQ "^^^^ ^< I Hoi» loni al 

Usual Residence iv& \)r^A^X:|rV PJar e ol OeaMi ? • Oayi 

When was disease conlracletf, ^ 



ri*ACK ni' HI KIAI, OK RI:Mo\ ,1. j DVII ..; !! 1 u of Kl.MoVAI, 
INDHRTAKKR ^wOAJtM^" '^^ ^^\A ' 



e 






(AiUlre«i« 



a,^\}(3w>v ^ 



4^ 



N. B.— Every Item of information .hould be c«refully supplied. AGB .houlU b, .t«ted BXACTtY. PM^S'^IAf^S .h^ld 
•t«te CAUSE OF DEATH In plain term., that It may he properly claMlfkd. The Special Information hM> par- 
sons dylnft away from home should be given in ••vory Instance, 



1I 



, 1 W 



I 



i 1 1 





^11 



f I 



iLVl« 



k*'i 



i- 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

l.ntMltli 1 So ..lt^^H."^ICo REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 

627 



/)((/(' Filed. 

4' 



Be^isiei'ed JS'^o, 



'\ju\j^ Deputy Health Oflflcer 

DEPARTMENT OFPUBLIC HEALTH=City and County of San Francisco 



6^^<XA^ 



Ccvtiftcate of Bcatb 

( "d. S. StanDarC ) 



m 



PLACE OF DEATH 



; — County ofCi/CV^A; JXCtwC^oi/C^ City of ^'<X^v vj 



X<X > vc 



npfo. 



^v 



U/OL/"v\AiaA.».W^ .St.; 



Dist.; bet. 



and 



• / ir ot»TH ocotns AW«v fbom USUAL RESI DENCC Give facts called for undeb "special information- \ 

( .r«lTMdfcc.!RRCD IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. J 



FULL NAME 



^\^.i 



LCwVu. J V 



^i:\ 



PERSONAL AND STATISTICAL PARTICULARS 



MATH UI- HI K I'll 



M,H 






t Month* 



as 



} V<; / 



^ 
^ 



[Davl 



Motl/n 



^^■^•:lT) 



/)wi. 



WllMiWHI) OR DIVORCHU 
iWritf in social «Iesiv:nation) 




<X^^ 



niRTm'i.Ai'K, 

(Stat<- I -J t"i»niti vl 



KATIIHR 



niRTnpi.ACK 
OP i\i-iii':k 

' *<l:iti' or i:tiiintry) 



MMIH.N' NAMK 
<)l- MOTMKR 



lURTlUM.ACR 
«»1- MoTHKR 
(Slate Df Cotititrv 



^''^CHttcrvv 







'• I. 
!l>av) 



(Yi-ar) 



MEDICAL CERTIFICATE OF DEATH 

DATH of- ni-.ATH A 

r 

,>w Lin':RI'!BV CI'iRTirV, That I attcn.lctl "Uti ascl from 

^jJr -'\ 190H to . ^r * ^<>o *^ 

that I last saw h alive oti >f-^-M^ 11 i.p H 

and that lU-ath occurred, on the date stated a!)(n-e. at o • o 
J. M. The CAl'SI-: lH- hl-ATH was as follow^: 



V. ^XH-tX^^Ct- 



n 













(Iv^. ^. 






nr RATION 



■^ y't'ars ' Months 



'% 



Davs 



Hours 
, \,Q^^ 

1)1' RAT ION )?</rj X Months >- /?*n'.v Hours 

(Signed) . HtAi^wC5 'U, >-ivo^\. M.D. 



C ( ) N 1' R I lU "TC ) R V Ci\;v^-rww^ '3 > ^tu.X^ ti^ M 



J 

■^1 TQoS (Address) W\\ O.^vlA^n. 



\ \ 



f>.\jJL(X'TvcL 



<K:cri»ATION 

Rrsiilnl in Sati I'l am isid AC ) 1 iii .- 



yr«nth> 



Das 



THK AIJOVK ST\Ti:n I'KRSONAt. I'ARTirf I,ARH ARK TRTK T<> THK 
HlvST t)!' MY KXOWI.KDCK AND BHl.IlCr-' 

AJUb <^ 



(Iiiff)ntianl 



(AddrcHs 






N^U^ti..^ J^ A. TQO 1 

SPEtlAL Information only for Hospitals. Insfjtatloirs, TraR$lffits« 



or Recent Residents, and persons dying dway from home. 



-¥ 



Former or 'N 1 " i , 

Usual Residence ^^ <sXVU- 

When was disease contracM, 

if rittl dl pliie ft) ttCiih i 



"* How \m% at 

' - Place of Death ? 



Days 



n A 



I'l.ACli (Jl- Ht'RfAI, OR KHMoVAl, 




iJATKof lliKiAi, or RKM«»VAI, 

igoS 



I r, "I III K lAi, !»r 
^^3 



fAdtln-^s 



^ ^^^^ 



N. B.— Bvery Item of Information should be carefully .upplled. AGB should «»• •»«*«i BXf GTLY. PMYSICIANfl should 
state CAUSE OF DEATH In plain terms, that It may be properly vl»sslfl«il. Th« Special Information for per- 
sons dying away from home should be given In every Instance. 



t 

m 



1 ♦< 



11 

I 

I 



iJU^ 



11 



■1^^ 



' I' 



» ■• '- 



' If 



II 



• 



#»l 



!r 



»**ij 




WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

.,.1 „f Ii.aUh'^F No. IS i^^Sl^ HS:l> Co ^„_____^ REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



Begistered *A'*o. 



628 



Ihitf FUeil, HaxUl XI I'^O'i 

X^s-v^^ UovM. Deputy Health Officer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Certificate of 2)eatb 

( TH. S. StanDar& ) ^^^ ^ ^ 

a p ^ ! ^^ 

of \i) ctIhtcxj Cit y o f V /a.vL<xo J y 



PLACE OF DEATH; — Cnuiity 



No. 



St 



Dist.; bet. 



•and 



/ ir DCiiTH occurs *w*Y rnoM USUAL RESIDENCE give r-CTS caclcd ;or uno" :^;"'*i '!'"°"^JJ'°*' " ) 

V ir OC»TH OCCUUBCD IM * HOSPITAL OH INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / 



FULL NAME 




PERSONAL AND STATISTICAL PARTICULARS 



x/yyj\ja 



ir 



=SJ 



XO -. { 



x^ 



■^ ^Ju 



Ic.i.d. 



1>\ Ti; nF lUKTII 



M.K 



• Mont III 



) lit I 



I Day I 



yfoHt/is 



< \ t-an 



/),/ 1 



>INi.I.I-: MARklKI*. 

witMiwim OK i»ivnRi'Kn 

'Writriii ■MK-ia! ilt"sj?ti«|i«>fi) 



IUkTHIM.\<'K 

SI.|!( I ir I ■, ,,, III I y'\ 



MEDICAL CERTIFICATE OF DEATH 

DATH »>i- in;ATn 



U^ 






I. 

(MonllO (Day* 

I m:RI':HV CI-RTIJ^V, Tlnit I atttiKlcd .UuHasca from 

■ 190 to ■ - ■ ■ I9O 

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

ami that (Unth occurred, on the date 'italcd above, at 
— ^ M. A''^' CAl'Sr-: Ol' DI'IATII was as follows: 



N\M|.; ni 
1 ATHICR 



BIRTMPI.ACK 
<H I \TIIKR 

(Sli(t« r)r i'otiiitr%*) 



MAIUKN NAMK 
«>F MOTIIKR 



HIU rill'I.AiK 
•M MOTHKR 
(si.iti- or Country) 



<: 




or RAT ION )Vw.? 

CONTRIIUrORY 



Mouths 



Days 



Hours 




Reaittfif iit Satt f'tituitMUi 



) 'fa I f 



\r,H>thy 



f I/I % ^ 



THK AHOVRHTATl'l* I'KKSos \l, 1' \ Kll**! I \ RS A l< I" TK ri' T« » TIIH 
HKHT OK MY KNOWJJIX . K AND mi.Il'l 



fliifiirmant I / V 



CL^iTu C CL 4jJ^V-^ 



( A^lllll'ss 



h 



a, 1 ^i) 



Dr RAT ION Vt'ai'S Moulhs Pays 

(SIGNED) yn\ . 'tI (TV^XXa 

vi^l^ %£ ,oo-^, f Address) \f}\<X/VwL<X U 6- 



Hours 

M.D. 



SPECIAL INFORMATION «"'* '«' Hospilals InMitutiSRS, Transleits, 
Of Recent ResMents, iad pefMBs dying jwd) from home. 



Former or 
UsiMt itosMcnce 

WNl w« *sease contracted, 



fmt lonq at 
Ptifcof Deatti? 



Days 



ri.ACK <»l' ntRfAf. nK RKMOVAI, 



IJAIJ;.!!' llrRfAI. or RKMOVAI, 

^^JUi X'\ 190H 



rsDi 






•t«t/cAUSE OF DEATH l« plain term», th«t It m«y ^ properly clM.lft«d. The Specl.i i»form.tlon for p.!-- 
m<vtk% dytng away from home should be ftlven In every IneMnce. 



', 



^ . 



1 



^ 



I ' 



». ' 



I 



( 1 



F„,;inl r.f lIc:iUh--f' No. i -, 




WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 

629 



Il&I' Co 



Re^istei-ed J^''o. 



Ihili-Filed, "jtvcUj al 1^0"^ 

itruLvo'W^ Deputy Health Offir.<>r 

DEPARTMENT OF PUBLIC HEALTB=City and County of San Francisco 



Certificate of Beatb 

( "Q. S. StanDar? ) 



Q^^ 



PLACE OF DEATHt— County ofOcc-^'J^UXAVC^l^^ City of '"^/O^^v J^vcx >vc^ ec 



No 



. x^ 



%. 



a. 



St; ^ Dist.; bet. J -VOz-Vvklx^ and D <X >v v Um.^ ) 



/ .r^r^rl^Hculit A^T^Y rROM USUAL R E S I DE NCE Gl VE FACTS CALLED rOB UNDER ••si»ECI»t •N'^O"*** J '<>••■ ) 
( "rCATH Ica^RV^D IN rHOSPrrAL OR .NST.TUT.ON GIVE ITS NAME .NSTEAO OF STREET *ND NUMBER. J 



FULL NAME 




<J.JU«-Ul 



PERSONAL AND STATISTICAL PARTICULARS 



SHX 



^ 



A 



e-f H.oR 



DAT!-: <)t" lilKTII 



.1 



Ail 



I Month 



\'.K 



11 



] I 111 



<l)ftvl 



Mnitli^ 



< » t-;i I 



Iht 



"^TNr.l.K MARKlKn 

U ?I>n\VK.I) (»K niV(>Rii:i) 

iWrJle it» ««'rtial ik-HijftmtioiiS 



^Ic^.- . . 



lUR'nuM.^rK 

>t.itf or « '.111 iitrv' 



N\Mi: (H 

I- \'iiii:k 



niRTlUM. \rK 

<»i I ^ II! )-:r 
•Hi;ii» or Country) 



MMUKN NAMH 
«>l MOTIII-.R 



UIRTHl'LAriC 
nj- MoTHHR 
isiatv or C««intrvi 



m 







OJsjX U(V(Lv 



iHCfl'ATl 



"^ Cn^ 




MEDICAL CERTIFICATE OF DEATH 

DATK <)l* DllATII A K 

\i ¥ 1 ""^ LI 

/KMonth)/] HJajO (Year) 

I llF'iRllHV CI;rTIFV. '•'''!*$ I a^tetnU-tl (Icocasfd fnmi 

%i 190 S to |a.^Xu. 0^1 190 H 

tliat I last saw h • alive oil F^^^^ ^^ ^^O *» 

and that death occurred, on the ilate -.tattd al)ove, at ^ 6U 




M. The CAl'SI-: OF I)i:.\ TH \va< as follosvn: 



D 



r'vjv(r>'vc/^ 



OA-c:tx>V4^vtwojl uUu|vi\^u„a 



Ur RATION >Vrt/.f 

CONTRlIUruRY 



.I/0H//1S 



/hn 



Hours 



DIRATION 
(SIGNED) 



Years 



Mouths 



fhrvs 



n 



1" 

h'rstdrd in Snn frntutyrn ^y % 1 nn ^ 



THI.; AHOVRHTXTl*I> PKRsONX!, 1' \ R Tfi* f I. \ RS ARK TRl K T«> THK 
HKHT OF MV KNOW t.Kl^c.K AM> H^:^.^^^' 



(IlIfofmant 







XjlihcHS 



XD 



TooH (Address) SCd^^a^IUh^^ 



Hours 



M.D. 



"speSiALINFORMATION ofl'y fw Ho^llils, iKrtltiltots, Traiilnrts, 
or Recent Residents, and persons dyinj a^«») Ifoni home. 



Former or 
Usual Residence 

Wli'i was disease contracted, 
If Ml at tlare of deatli ? 



Htvr Itllit 
naretf Death? 



%9i% 



ri.ACH Ol- HIKIAI, OK RKMOVAI, I DATHof IlrmAt- or KKMoVAI* 

1^ \)o^x, 04x4^ CW 




rAchh'S'- 



iJML 



V . .. ,, , .fc _^-ul«l ha AtAted EXACTLY. PHYSICIANS ahoald 

N. B. Every Item of Infoi-ftiatlon •houW be c»r«fulfy .upplled. AGB .houW •^J^'^^'f Z^™' ,,, ,„form.tloii»» for p.r- 

•tate CAUSE OF DEATH l« plain term., that It m«y he prc^erly clw.lfl.d. Th« Special Informatloa for p.r 
«ow» dying away from home should be given In every Inetance. 



r " "j 



? 



1 ^1 :: 



S 



\ i 



Pi 



I. 



li 

if 



i 




WRITE PLAINLY WITH UNFADING INK 



,.,,:,,. I. .f !I.alth-l" No. IX. TS-r*!.^ HS: I' Co 





Dftfr f 




190H 



— THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIPICATC FOR INSTRUCTIONS 

630 



Ee^istei'ed JS^o. 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of Beatb 

( "U. S. Stan^arC* ) 
PLACE OF DEATH:— County ofOa^v Va^ vCUi : .City of U/CVV^OX.<X>\.CULCt. 




Sx-d' 



No. IHS VlflovTvO.' St.; - Dist-jbet. ^ ^<*■;. and 

/ „ DC.TH OCCU.. .W.. TROM USUAL RESIDENCE O.VE r.CTS C.LLID '<>« "-<»" ""I'i ' " '"J,?*;'," " ) 
I IF Ot«TH OCCU«l«EO IN « MOBPlT.l OB INSTITUTION GIVE ITS NAME INSTEAD OF STREET «N0 NUMBER. / 



Htlx, 



FULL NAME 



PERSONAL AND STATISTICAL PARTICULARS 



-f 



^t^-^JUVV' 



.fr^U^O. 



(kclt^ 



LL.kvt 



i>.\Ti-: OF lUK rn 



a«;k 



t Month > n 
11 JV./>.v I 



Dav) 



.v.. >////> 



.1 



( Veur) 



Pax 



^ I NT. 1,1%. MARUIKD. 
WnntWMI) (»R DIVoRCKn 
(Write i)i .scKJal «U "-iK'nalitm) 



ntKTHl'I.VOK 
"-' It' iir Ciiutitry^ 




NAMF <)l' 
lATlIHR 



HIKTlllM.ACK 
ni- lAI'MKR 
(State 1)1 Cotnitry) 



MAHiF.N NAMF, 
OI- MOTIIKK 



HIRTMI-r.ACK 

'»!■ m..T!:i:h 

'Slatt ut C«>mitrj') 



? 






AAXX-Oo 



1 

( 



>^ I JIHRI-BV CI- 



(Yrnr^ 



MEDICAL CERTIFICATE OF DEATH 

UATK c,F DFATH A | 

• yvcLu L\ 

{(ironth) j fl)ay) 

RTII'V, That I ,ittfn<li-il (hri.isod from 

190 H to "^vsXa^ Vl 190 H 

that r last saw h ■'■■ i alive on ^tVAV^ '-' igo ' 

and that death orciirrcd, on the date stated above, at O 
^J^ M. Tin- CAISfv OF DI! A flf was as follows: 



DERATION Vrars 

CONTRIIUTURY 



Montha 



Davs 



Hours 



I)rRATU)N Yiats Mouths 

:d ) ^v ryiv . L' ,jVc"U.M 



I^avs 



Hours 



(SIGNEI 



OCCII'ATION 



dLoJ6-o^i 




sjSjx-^O. 






« » It, 



THF AROVK STATl'I) PHRSOVM, I'ARTlOfl. \RS AKFl TRl H T« ) TUF: 
IJKST OF MY KNtJWI.FDCK AM> I!KIJI:F 



(Itifortnant \j^ 



TUWOU 



\jl'\^-X^<VM>'^ Ka) 



(Addre 



ss 



3i 



Q^ 



jvU 




V^ 190 H ( 



Address) %% lUhfrtt ySXd 



M.D. 



SP^IAL INFORMATION ""'y '«'' Hospitals, Institutions. TranslfRts, 
or Recent Residents, and persons dying dway from home. 



Former or 
Usual Residence 

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



How lonq at 
Place of Death? 



Days 



PI.^I^K OF BrKI.\l. OK HFlMiiViiI. 



c> 



I»\XF: otftHrKiAf, or KKMOVAI, 

30 190H 






N. B._Eve.y Iten, of Information .hould be c...f«H. -upplled. AGE sl^ou.cl «- •*-»«£f .^^^^^j .XirMTon^^V.'^l-l 
•tote CAUSE OF DEATH In plain term., that It mn> be properly classified. The Special information for p«r 
aons dying away from home should be given in every Instance. 




-« I 





h It 



'. .' ' 



!f 



I 



j < 




I 




J)f(/r Filed t 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE TOR INSTRUCTIONS 

a3i 



lie Mill, I' No. ^k-^'^-Sp^.WScVCo 




JRc^isfrrod J\'*o. 



jj^^j^ Deputy Health Officer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



(K.^-uuj5 



PLACE OF DEATH: — County 



Certificate of Beatb 

of<^'aTuO»UX\vCUi,CO City of ' -''<X'>\J Va>vCvAt-C 



No. 




l\-d:> 



and ^ -^ 



3. "^01 ''^^^UJ^Kd; St.; 5^ Dist.|bct. 



FULL NAME 




a> 



i 



I 



(xtWot 



t * 



PERSONAL AND STATISTICAL PARTICULARS 



^'^^ B 






I»\I1-. ol MIRTH 



X'.l-: 









SI\(,l.l.-, MAKKIKn 

wnxiwi-ii OR nivokri-:!) 

iWritt in s.wial (U-vij.Miati>'»j) 



Its 

(Day) 



M,,uf/i; 



(■»iat 



Am 



niK THI'U^CK 

Slate or C<)iintt >■ 



XAMK nj. 
F AIIIHR 



HIK IHI'I.ACK 
Hi lATHKR 
St.itr r»r Ctiuutty) 



MAIDKN XAMK 
<)1" MoTIlHR 



niRTlUM.ACK 
(H* MuTlIKR 
'State or Country 



t>CCl I'AilON 







KJX'YW 



Kail 



A 



/*^ 



MEDICAL CERTIFICATE OF DEATH 

DAT!-: <>I' DllATII 



(Montlif 



t\ f 



tDay* 



(Yf.ir) 



I HIvRI'inV CI-RTII'V. That I attended fleccasca from 




OJ>0 



Im. "xa 



190 H to fV^^W "^^ *9° "^ 

that I last saw h ••iA' alivi- on ^4'^*-^^ % l 190 

and that «Uath or«iitred, (»n the date stated above, at J*. 
M. The CArSI-: Ol' UI". ATH was as follows: 



.t,V^X^^^VOw 



V ^\J^\. 











I 



DlRATfON Vi-ars 

CONTRinrTORY 

DURATION _ )'t<irs 



J /on //is 



/)ai 



'S 



//(yt/rs 



Mo tit /is 



Pars 



Hours 



Resided ttt Satt /1 attitsfn 



1L 



i^ ) 1 11 1 



T»H ABOVF. SiT\ I'll) l'KRS<i\\I, TARTirr I,ARS A R l! TRrK TO TIIK 
IIKST OF MY KNOWT^HIX.l-; XNI.) lUCIJllF 



9.501 



dii^ccM' 



(Add 



rcis 




-VCk/YW 



^LA.>^\CL 



4, 



H^cluXl iqoH (Addres.) 5^0 dA^ cttU ^t 

SPECIAL INFO 



(SIGNED) 



.^- ..J FORM ATI ON on'* '•"■ Hospitals, Institvtltns, Transimts. 
or^Re'cent'ResWcnls, and persons dyiny dv»dy fro;n homf. 



Former or 
Usual Residence 

When was disease contracted. 
If oof at plare of death ? 



Hnw lonq at 
Piare of Death 



Days 






I'I,AC1-: OF lURIAI. OR KKMOVAI. I DAT K of Htm At. or KKMOVAt, 



rNDKKTAKKR 



• VO"-***.. 



- .. i. J KCV .hnuld ha «tated EXACTLY. PHYSICIANS slioulii 

N. B.— Every Item of Information .hould t,e cnrefull^ «uppl.ed ';^^^;,^'*;4^J^^^^ inform.tlon" for p-r- 

state CAUSE OF DEATH In plain term*, that it may be properljf cl0»siii«a. 1 nc ^v^ m 
•on« dylnA away from home should be given In msnry Instance. 



• 1 



"H 



i I < 




V 




|M I 



IT 



II 



1 


• 
i 

• 



^W^TB W 



l!^^ 




li 



iji 




WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

P.,...,.,flK:.i, h KN.,. ,.^>r^^MU^PCo RgFER TO BACK OF CERTIFICATE FOR INST RUCTIONS 

632 



i 




1% 



-% K.( 



■( 



De 



JOO'i 
^•1 Officer 



Be^h^tored J\^o, 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of 2)eatb 

( "a. S. StanDar? ) 



PLACE OF DEATH:— County of 



City of 




JC^V^V>-C>\J 



a 



Na 



St 



■Dtst.;bct. 



and 



k^V*t »^ -wry — — _ . 

• •<>■■«■ Breinr Mr F nivr r*CTS CALLED FOR UNDER SPECIAL INFORMATION" \ 



FULL NAME 



xvtJ 




•.^fL-- w' w. 



PERSONAL AND STATISTICAL PARTICULARS 



>i;.\ 



O-L^v^-x^xJut 



>«4i 



i 



DATH <)!•■ UIKTH 



.MK 



COI^OR ^ , A 



lAA. 



• t»H<>ni'>^ 




?)0 ,,.„,, - 



1 

(I>:iv) 



Months 



41S 



^a 



(Seal ) 



I>,t 



\viiH)\VKi) ok iM\«iKri:n p 

(Write in " K-ial .U ^iiMiaii.in) — ^ 



nikTinM.\rK 

'Stntr fir «'. milt I v' 



N"\M1-: <•! 

FATin:R 



HIRTin'l.XCK 
Ol I \IHKK 
Stat* or Cotmlrs') 



MAIIillN NAMI-: 
OI MuTIlMR 



RIRTHIM.ACK 
OH MDTHKR 
(State or Country) 



tJCCri'ATIUN 



1 






t 






MEDICAL CERTIFICATE OF DEATH 

UATK OK DKATli 

fl)!ivl (Ytnr^ 

I lIl':RI{r.V ClvRTIFV, Tliat I .ittcmlcMl ikHH-ase<l fn.iii 

— —190 ■ to ■■ ~np 

that I last saw h — alive on ~ ~" IQO 




ami that (Icalli occurred, oti the «lato state«l af»ove, at 
~~' >r. The CAISI-: i)\' DI'lATIl was as follows: 



DTK AT I ON y til IS 

CONTRIIU'TORY 



.!/();////? 



Davs 



Hours 



DrRATION 
(SIGNED) 



Years 



Months 



(Jl. Ux^xlrCLL*. >> 



Paxs 



Hours 

M.D. 



Rf^idfif III Sati / iniiiist'i* 



} r it 1 



THK AHOVH ST Mill IM-RSOXAI. 1' \ RT H T" 1. A R H ARK TRIH Ti ) THH 

ni-:s'r OF mv knh>ui.i:im.i% and it):Mi:K 



(Inf.iimruit 



a 



fw<vM 



f Addre««s 






s 



iPECIAL INFORMATION only for Hdspitils, InstiNtions, Trinskots. 



or Recent Residents, and persons dyina dHdy from home. 



O^ys 



When wis disease contracted. 
If not at plare of death ? 



I'LXCK OF lURIAl, <)U KHMOVAI, 

- 7^ 



!er»v4 V 



D.VrHqf Bf RtAI. 01 RKMOVAU 



rSDl'KTAKKR 

fAiMi- 






"^ *r»f3 .hniilrf ha Atated EXACTLY. PHYSICIANS shotild 
N. B.— Every Item of Information .hould be carefully •«»»P»«J- „^^„^;,^'^,.,5fM! The -»p*cl.l lnform.tlo»" for per- 
•t«te CAUSE OF DEATH In plain term., that It may be properly wiaaawiea, w 

sfMic dying away from home should be given in every Instance. 



< 



' I 



•I.I I 



•I 

M 






% 







m 





WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

,, . ,,,„,l, lN'nn»?g9»H.'t'"-" WtFER TO B«C^ or CERTIFICATE FOR IN3TRUCTI0N8 

633 



Be^l'Sfri'cd JS^o, 



'XjtrCuus lutovu Deputy Health Officer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate ot Death 

( la. S. StanDarD ) ^ 



(^ 



No. 



PLACE OF DEATH:— County of '^J/CL^ MS^'C^'CoGty of'JCXAvOXa 



n c <.^ 



H Dist; bet. H Xlv 



^■^^^^ MO. 1*1 OF«;TdFNCEGIVE FACTS CALLCO for UNDER "SPEC.AL I N FOR MATIO N • \ 






) 



FULL NAME 



CI 




CrCrV 



AXXU 






Sw wV 



PERSONAL AND STATISTICAL PARTICULARS 

I COI,<)R \ . 



■'' (kd. 



.ruJbi 



It \ n-, (11 lUKTn 



\ < ". 1- 



i 






Si 



S'l'itt - 



10 



an 

(I)av) 



M.nith' 



fVcari 



n.i v. 



'Writt ill MHi.'il iU-iv,'ii;iti'»u) 



lUKTm'I.AOK 

(Stall or (.'iiiinti yt 




<X^AaX<L 




A^TVfr-^^ 



MEDICAL CERTIFICATE OF DEATH 



DATK «»l. I)1:ATII A A 

(Month) 



(Day) 



/go 

(Ytiir) 



{ilonthl i 
I m':Ri:i5V CIlkTIlV, Tlmt I atteiKk-il (Unnsc«! from 



LA^V^v,^► i I90H 



to 




tliaf I last saw It ^ > - alive ntt HVSelu, ^b 190 H 

and that iUath oocnrriMl, on tin- <lato stated above, at 1 

ex. M. The CAl'SrC (»!' IH-ATII was as follows 



'^^• 



N.wii-: «>i" 

t ATIIHR 



lURTUf'I.AOE 
oi I ATHKR 

' Stat*- or fnuiUry^ 



^tAI^KN NAMH 
ttl MOTUKK 



Hiu rm-f.ACK 

"I MoTIIHK 
'I. ill lit Coputry) 



OlUtkiJlL 



x>x^c^ 



H (.1 l-AlioN ^ 



WYYV(XA.O^ A vOu 



in San Pianthi'o \ )>iii 



^ .Uiiiif//' 



TMK AnoVKSTATKI) I'KKSONU. I'AKT fOf I. \RS AKK TKIK T<> THH 
BKST ()1* MY KNOWI.l-Ix'.H AND HKI.lhf-* 



Infonnant N fAA-Si W 



V^>>-w-v^ 



luJJ^ 



,vMr.„ J^'ilW Jb<XVu..*.<r>v ^^fc 



D I ■ R .\ T I< * N ) I'a f'S • ' A ' >f tft^ 



Days 



J /ours 



y'l'iUS 



WV-V-O^ 



)f,}flt/lS 



/hivs 



UIRATION 

(SIGNED) wk^YV^i Xxlte 
K^clu'X'l igoH f Address) ?)^ b ' M 1<V 6t 



Hours 
M.D. 



J --* 






SPECIAL INFORMATION only ^^^ Hospitals, lasritntlaiis, Trtiiile«ts, 
tr Recent Residents, M persons (l)inj away from home. 



Former or 
Usual Residence 

Wkei was disease contracted, 
\\ MMf ^ari> of death? 



Httt lonq at 
Plire of Dratli? 



Days 



PI.ACK OF niRIAI.OR RKMOVAI, I DATK ..f lU kial or RliMuVAI. 




INDliRTAKKR 

f Ad<lit-H«i 



|Q,?,qCMvJu.t -'t 



Ml 



""""^'^ ATF .hnuld be Stated EXACTLY. PHYSICIANS attould 
N. B. Every Item of Informatloti .hould be cai-^fuHy iiuppi.ed. ^*;;^ ""° , .^^j^ ^he 'Spect.l Information- for p«r- 

■tate CAUSE OF DEATH In plain term., that It m»y be properly *.laa»lfle<l. me -P 

•on« dying away from homo should be given In ov.ry Instance. 



i| 



1 



> I 



i 



I 



• II 



^« 



I 




I'., ..I I 



t ' 



l) . 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

,, „, „, „„„ , s„ „ *€^* MM' CO REFER TO BACK O F CERTIPICATE FOR IHSTRUCTION3 

634 



/)f(/f' Filed 




, NkA^Lu Xt 



lOO'i 



Ee^isfrf'pd JSi'^o, 



.U) JotAj-cr Deputy Health Oflficer 

DEPARTMENT OFPUBLIC HEALTH=City and County of San Francisco 

Certificate of Beatb 

{ tl. S. Stan^arD ) 

i (?rp Si m , 

PLACE OF DEATH-.-County of'^'a^ d;uX^XC^A/aoaty of '"'<V>>' J V<^ - ^ ' 

cL< St.; 10 Dist.;bet. iX-vcC and 1- ' ' ■• 



No. ^ 




AKXAXX 



^V-V>^WWV W . uR.,*L BFSIDENCE GIVE FACTS CALLED FOR UNDER "SPCCIAL INFORMATION \ 

( " rr'r»T°„"ec"uV."V,"rHO.*-a*c o"»s,.tu"'; o,v. ,t. name ,nst„o or .T.r., .no »u«.t.. ) 



FULL NAME 



(i-^>v lO 



^Ca_v. 



I 1^ 



II 




1^ 



I 




si;\ 



PERSONAL AND STATISTICAL PARTICULARS 

,t, 




""■'■■ lilt 



\ 



DAT!' «»!• lURTIl 



Ar.K 



iM.mtli' 



*J lb J V</ , 



iD.'iv 



1 /.->////' 



■» till 



/i.nv 



winowi-.n <>K nivoKi'Ki) 

'Write 111 stHMiil <lt. >ivti.iti<>n) 



niRTHIM.At'H 
(Stnli' or Ountilry) 



lArnHH 



niR IHI'I.ACK 
tn* I APHKR 
tSt;itf (»r CnnntryJ 



MMIM-.N NAMH 

<n Mf)Tni;R 



mRTmM,A».'H 
iW MoTHKR 
(Slate or C«)untry) 







MEDICAL CERTIFICATE OF DEATH 

DATK <)l- Hlv\TII 



(Vcar^ 



\li 



1 



(MoiKlO J l''v' 

I.IIi:KI{nV CI'IRTU'^V, That I :i.Ueii.U«l .Icrcaso.l fmni 

thiit I last saw h - alive on y' »90^ 

ail. I that iUath occurrcl, on the tlatc slated al>ovi-, at I v 
M, The CAI Sh! Ol" IMiATII was as tollows: 



.w* 



JL 




ci^JL'L<x^ 



V 



^uxx^Axfc T^ucUr>^ 



%sj 



riAxLou^vd. 



occ 



ll'ATlDN ^ p 



%r,iiifh< 



• /^(fV 



THK ^mn-KST\TKI» PHk s. >N AI. I'A RTIff I.A RS A K K TR I K T«) THH 
IIHST Ol* MV KN<)\VI,i:n«lK AND IIHIJK»'' 

•Inr.irmrmt \J f v\^ . A/O-'^V^ 



^H 



(Adilrcsj* 




'V 



4 



DC RATION ^ )V<rA.s ' Moufin ^hus * /A'//rir 
CONTRinrTORV jlviU.^^^^-- - 

V 

r)IR\TI()N " Ytaii ~ .Vo'illn \ /'.n ( * Hours 



(Signed) 




M.O. 



SPECI 



c)oH fA.hlKs.) S^g dx^tUH) 



'3PC(^IAL Information »nlv for Hospitals, iRsNtHtiMS, Iratslfiits, 
or Recent Residents, vA persons dying d^ay Ifoni home. 



Former or 
Usual Residence 

Wken was disease contracted. 
If iietaf f!i««f ^a**' 



Now lon<) at 
Piare ol DeaOi? 



I^s 



I'l.ACK '»F nrKIAI. OR Ri:M<»VAf. 



INIHIRTAKKR 



fA.Mrc^s 111 VI FW 




.^^w^v\. 



'"'"^"""■"'"■^■"'"■"^ •• J ArE .h/iulrf be Htnted EXACTLY. PMY»ICIA!N8 fthouldl 

N. B,_Bvery Item of l„form.tlo« .hould be carefully supplied. 'f^^^^l^^'f^l^^^X^^^^^^ lnform.llo«" for p.^- 

state CAUSE OF DEATH In plain terms, that It may be properly classified. I ne p«c 
sons dylMg away from home should be given in svsry Instance. 



J 



I 



i. \ 



I 4 



I 



1 



II 



\ i 



( 



^\ 





' , •. I 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 

a35 



l>.,anl of ll.nlth 1 Nu ■■■■ -^'^^ea^ ^^^^' <-«^ 






Regislci'ed J\^o. 



\ju\MA Deputy Health Officer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



PLACE OF DEATH: — Coun tr 



Certificate of S)eatb 



^la 



Ci 



/vvxurwc 



rNo.- 



-St.; 



■t)ist.; bct.- 



-and 



..e^iiAi DreinriMrr rivr facts c*llcd roR UNDER "sPtciAi. information" \ 

( '^ .V;rATr^OCc"u%rcV.N''rHo"s"prAi 0%'fN^f.?JV^N^0'^.;r.;i name .NSTCAO of STRC.T ANO NUMBCR. ) 

FULL NAME 




PERSONAL AND STATISTICAL PARTICULARS 




--lix 



!»\Ti: n! niHrn 



\<.}-: 



<x 



COI.OR ^ 



M«.ntli» 



(t)av) 



M.inlhs 



^(Wv'Ax) 



/'rn. 



U'litciti '^ncinl ilrsii'iiat ioii) 



niKTHPI.AOH 

(St:i!i.- i>r Country) 



NAN! I' OI" 

katiii:r 



lUKTHPI.At'K 
ni'- I ATHKR 
'^t,it« or Country) 



MAIDKN NAMK 
m- MOTIIKR 



luu'i-npT.ACE 
"I- MOTIIKR 
'Mile or Ci»timr\ 



oCClJ'ATloN Jl( Q 




R^si,Jf,f (H SiiH I'l 'Hii iM-o 



) rai 



Miiiithi 



Tm; AH<)VKsT\ri:n i'KRsonm. par iicilaks ark TKfK t.» thk 

IIKST OK MY KNOWl.KDC.K AND mWMA' 



IIKST OK MY i 
(Infotniant \l I 



(A 







MEDICAL CERTIFICATE OF DEATH 

DATl-: <»!• nilATH I In 

(Month) 'I>ny* 

I lll'iKI'BV Ci;RTn-V, That I .ittt-nrlcl .Uciused from 

— ^ to .-^- — — — 



(Yt-ni) 



1 90 

""alive on 



that T last saw li ~ 
and that <lealh occurred, «»u the <latf staled ahovo. at 
M. JThe CATS I-: Oi" D I',. XT 11 w.k as foll»nvs 



190 



Di; RAT I ON )'i'ars 

CONTRIIUTORV 



Mouths 



l\u 



//ours 



(SIGNED).^K t)d. AIU 



Months 



/hivs 



Hour 



(SIGNED)>A. \^. ck MUv^\%w^^ 

MUaxjic tooH (Ad.iress) \lfla>va^- 



M.D. 



■^ A 



SPECIAL INFORMATION o"') lof H»npHaH. lisUlytlttiis, Twiislfiits. 
or Recent Residcnis, and persons dvin j mts \\m home. 



Former or 
Usual ResMencf 

When was disease contracted, 
M not !A place of death ? 



Htw Itii at 
n«r««f fleath? 



Ulfi 



PLACK OK IHRIAI. OR RHM<iVAI, 



|-Nl)K:RrAKKR 

(Addrfs- 



n\TI ..f,IH in.^i. or KKMOVAI* 
,VAJLU QkH I90H 






■■»— -hould b« •tated EXACTLY. PHYSICIANS •hoald 

N. B. Bvepy Item of Information .hould be carefully •uppllecl. ^^"^ " ^.^ .„,j. xhe "Specl.! lnfoi-m«llon" for iwp- 

•tfite CAUSE OF DEATH in plain term., that It may He praperly wl«»«iti.«. »- 

•tw dying away from home .hould be given In .very Inntance. 



i^ 



' • 



•I 1 
■(1' 



*l 



♦1 ♦ 



\ 



•I I 



:^< 



4^ 



1 



I II 









WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

,,.;,i.| ..t II,-,illh- P No. l« tX' ^iimfi-n 



l)<i/i' A 



100^ 



"L^wvo Xt^-M Deputy Health Officer 



REFER TO B ACK OF CERTiriCATE FOR INSTRUCTIONS 



' 4 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of "©eatb 

( 'd. S. StanOar? ) 

A 



PLACE OF DEATH:-County of Bcu^v C)xa>xCv^a City of C)a>v ^av^..4C0 



,.Uv ffi n. 



dv^' 




L(n vadrv. St.; L Dist.jbet.:— 

...L. _ — — .•i.pu^r .-■wr' r&fTe CALLED roR 



and 



) 



rUn.CVAKA' VAAM. ^^^^^iH ; „'^^YdPNCEG.VE rACTS*%iatED r^ UNDER ■SPECAL INFORMATION • \ 
\ ( '' r.-DrAT^H^O^JuRrcVl^THO^S^Py^t O^R^ T^Jt^^^T^O^N ^O^vV Ts NAME INSTEAD O. STREET AND NUMBER ) 



FULL NAME 




% 



L^ 



Lu., 



UAA.adLLU-L :nJJb ^valU 



■1 



PERSONAL AND STATISTICAL PARTICULARS 



si'-.x 



511 f 



C()I<<>K ^ 



UL,u t 



nxi 1, «n- juKTU 



A <■.!•: 



'^I^•<.I,l^. MAKKn:n. 

WinnWi:!) OK DIVoKCI-n 

'Writ'- in s<H'ial ili si|.'nat ion) 



mu rillM. \c}-: 
' state or C'luntryi 



NAM I n| 
l-ATHI'K 



IllU llin.At'K 
<»|- I ATHHK 
iSiatf or «."MUMtry^ 



NtMItl'N NAM1-: 
»U MOTHKR 



niRTIIPI,ACK 
or MOTHKR 
(State or Cotnitry^ 




,ni. 



).H 



I Vt-ari 



Ihns 



^sU/trVH 



d^.nx La >x<^ 
LL^vrv 



AVfr^<^> 



OCCrPATION fjNP 

Rfsidfd ni San /'mutiMi 



'^\i^tou>x 



dL 




I f <( . 



/),7I 



THK AHOVK STATKD PFR^ONAI. PARTir r I, \ KS ARK TRlK H > THK 
ni:sT ()!•• MY KXO\VI,i:i>C.K AND Hhl.tJJ- 






MEDICAL CERTIFICATE OF DEATH 

DATK ol I)i;ATn 



flMontli) 



t 



(Day) 



tgo \ 

(Yt-ari 




lI'RMliV CI-RTU'V. Tliat I iatfn.lf.l iIccl-m^lmI from 

1% i9o4 to. N^vJLh ^^ 



that I last saw h '^^' "live on 



y.L 



\ 



1, 



upH 



%\ 



190 i 



an.l that death L,ccurre<l, on thi- .hitv •stated aliove. at » 

LL M. The CAISK (>U H HA Til was as follows: 



Ur RAT ION 
CONTRIIUTORV 



Years 




Months 



Davs 



l/oiip 



CL-Crv 



1)1^ RAT ION years 

(SIGNED) \i 



cucrvv^v-i 1 



Months 



\ V 



/^<nx 



I/ours 






(A.Mn-ss)H^fe.^M)U4.^cev. "^^ 

FECIAL INFORMATION ""'y '"^ Hflspltdls. iBsHtutloM, TfMsleils, 
or^cfflt Residents, and persons dving away from home. 



Former or 
Usual Residence 

When was disease ronlrarted, 
If not at piar e of deatli ? 



How lonq at 
Plareof Deatk? 



Oars 



PLACK OH BrRIAI. OR RH%fOVAl. 



^t 



A 



I).\^il.; of, nrwiAi, or RKMOVAI, 
WCM- ^0 T90H 



fSIiKRTAKKR 






„ ■ .pK .hould b« «t«ted RXACTLV. PHYSICIANS ahould 
N. B.— Every Item of Information .hould be c«rafully f«P»»«f J' J^^^J^ .l.wlll^d. Th* -Specl.l Inform.tlan" for per- 
•t.te CAUSE OF DEATH In plain terms, that .t may •'^J^^^^^^^ 
•out dylnft pway from horn, .hoyld be given In ^vw Instance. 



\ 



' ft ' 



' i • 



I 



\ 



*\ 









il 



<^. 



^7 

3 



it' 



:ll: 



■ I 



"f 



WRITE PLAINLY WITH UNFADING INK-THIS IS A PERMANENT RECORD 

REFER TO BAC K OF CERTIFICATE FOR INS TRUCTIONS 

I, 1 .,f ii,.iii.-i- So. i^ *i:&£^ "■'^'' ' " 

Re^i.stcrrd Xo. OOY 




• I 



n 




i 



»♦ 



ij 



IM^I 





Deputy Health Officer 



DEPARTMENT OI^PUBLIC HEALTH=City and County of San Francisco 



Certificate of Beatb 

( "a. S. StanDarC ) 



PLACE OF DEATH:-County of ''V^- ^XXX.vc^cc, City of 



No. 1511 MCrVOv<.ll 

(IF DC 



*TH OCCURS AWAY F 
DEATH OCCURRED I 



St., I Dist.; bet;„^„^lVi-k'„c,.. .-.f^.c-.-Y'' 



) 



FULL NAME 



lUluJL 



V 




VO^'^^CtW; 



, L^k^ 



-j:x 



PERSONAL AND STATISTICAL PARTICULARS 



V 



XwvoJU. 



ll\ 



rX^- 



l»A IK »>f IJIKTH 



\(,K 



i^tnUh) Q 



) ■#■<» I 



%1 

(Day* 



M.mfhs 



(Year) 



/).f ) 



>1N<,!,I- MAKKIKl* 
NVIDnW)-:!) OK I)IVnKri-;i> 
iWiiltin ^ucial dt-siKnatiun) 



HIRTHPLAOH 
isiatc or Counlt yi 



VAM1', <)l' 
FATIIKR 



lURTHPl.ArK 
()|- lAI'irHK 
(State iir Cottntry) 



MAn)J.;N NAMI- 
<U- MOTHKR 



HIRTUPI.AC'H 
OK MJiTlIKR 
(sti,i, ,)r Oonntry^ 



OCCri'ATION 






Ltk ^ 



v 







R^»ttlfd in Sun I '"H- 



m, tV,F( 



- \r,>iith^ 



n.i v.i 



TMK AROVK STATKD PKRSONA1, l^)Hnor I.ARS AKi: TRrK To TMH 
IIHST «)1- MV KNOWl.lCDC.K AND lU.I.H.t 



MEDICAL CERTIFICATE OF DEATH 

DATK ol- DHATH A ft 

\1aaJLu ■ " ^ fQO \ 

1 in-:RlUiV Cl-RTIFV/Tl.at I atten-lcl <lc. tascl fnmi 

— -— ic/3 to- -— -I'P ' 

that I last saw h t:— alive on — " '9° 
a„a that acath occurred, on the tlate staled above, at 
^j^ 'Hie CATS!' Ul- Dl'ATI! \vas as follows: 



ft 



DT RATION >V<i/.v 

CONTRIIU TORY 



.V<>n//is 



/)ays 



//(>//>.< 



DVR.vnos 



Years 



Afotiths 



Pavs 



i.i..%t ...oH (A.l.lr..;<>\X6n B.utU^ 



/fours 

M.D. 



SPete7AL INFORMATION only lor Hospitals, Institutions. Translfnls. 
or Recent Residents, and persons dying away Iron home. 



Former or 
Usual Residence 

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



flow lonq at 
Place of Death? 



Days 



ri.ACK Ol- IHRIAI. OK Kl-.>i«»»^ 



(Infdtmruit 






(A«1clrcss 






%^ '3l^ T90H 






(AlMlCHH 



— ^»^— — — i^—'^^'^'— '^'^ , FVACTLY PHY8ICIANII •houW 

E OF DEATH in plain t.rn..; th.t It m„ -o pr B« 



N. B,— Every Ite 

state CAUSE OF Dt A i n m »'■"""■ •":';",„ ,^,py Irt.t.nc*. 
«on» dying away from home .hould be given in .very 



. 


TJ 


1 : 


*T^ 


« 


> 


1 




>i 


1 i 


1 
• 


1 , 


(' 


I 


(1 ' 


■ 1 


i 


' 1 




1 


i 


i 
4 


. 



: r- ' 



1 



< 




tl 




I. 




ll..:it. 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

BEFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



.,f I I,;, 111) I- V<> '^ "**13S'''-'^ l'.>^ !•**.. 




I 



Dah' Filed , 



\^ 



\ 



11 



100'\ 



llc^istci'cd J^fo. 



638 



Deputv Neatth Officer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Certificate of Beatb 

( "a. S. StanDarD ) 

St ^ 4 f 

PLACE OF DEATH:-County of 0^>x. vj/UX >va^ : ^ City oi^Ojyv ^ KO-^^^^^i 
JrU^^Vu St.; H Dist.;bct. b .tlo) and "1^' 

U U V-M-'TJ 1 T W ,,«uaL RESIDENCE GIVt r*CTS CfcLtCD roR ONDCR "SPCCUL INFORMATION \ 

( " .Vrc:TH"cC^%;ro\rrHi',^r.!: Jr^Ns'^u" ^ OIVC .TS name .NSTC.O or STRCCT *NO NUMBCR. ) 



No. : 



u 



FULL NAME 



llllHAt wuivk C 



i 



PERSONAL AND STATISTICAL PARTICULARS 

I COI.OR 




CL 



U 









.\r,'ti/ii 



%\ 



?>KX 



DATK «U' lUkTII 



\<.K 



WllmsVj-n OK I)i\nRri:i) 
'Writiin MK-ial «l«'».i>fn;iti«>ii) 



f statf or I'liiiiii \ 



\ \M}'. ol" 
I ATllHR 



niKTtnM.\<'K 
<>l- l-ArilKK 

' St:itf nr Oniilltrv) 



MAlIiKS NAMH 
HI- NH)THKR 



nikini'i.AOH 

OH MuTIlHR 
(Slate or Country 



OCCIPATION 



I Month) K 



(V«.'ar) 



An 




;uiX) 



MEDICAL CERTIFICATE OF DEATH 

DATK nl- Dl-ATH 



VlolltJl) 




at 



iVftir) 



(Hmv) 
I Ill'KICHV Ci:i<TlFV, That I atton.lc.l .Ictvasctl from 

to ^~ 



I90 



I<)0 

igo 



that I last saw h ~^ "alive on """" "" ""'^ 
aii.l that (kath occurred, on the date stated above, at ~ 
31. The CAlSr: Ol'UDiiA'PIl was as follows: 

nr RATION )'i'(ir^ .Vouifts Dav^ Hours 

CONTRinrTORV 



Dr RATION 

(Signed) 



Yiars 



Mnnths 






Pays 



Hours 
M.D. 



s, Triflsicots, 



has. 



THK AR<)VKST\TII» VKRSnXAl. PA KTKM" T. \ K H ARK TRIK TO THH 
IIHST OK MY KNOWUHIX'.KANl) lUajlJ' 



nnf.yimnnl 



mu> (>YU!UV 



(AddreM 



W\x 




or Recent RcsWents, and persons dying dwdy Irom home. 
When was disease contracted, 

II I1U4 a* p*«= . _ 



Oiys 



PI.ACH Ol- lU KIAU ok K1:M«»\ AI, 

Cn\t t' Wit 



I>ATJ«:ii!' Jl' HtAr. or Ki:M«>\AI. 
XtL ^l T90H 



rSDKRTAKKR 

(Adihcis 




f ^. 







ii 



"— "— "~"""^ nlrf AGB should b« .tated EXACTLY. PHYSICIANS .hould 

Item of Information .hould be c««fully supplied. J ' ' ^ « cl«.«lfted. The ••«p«cl«l InfonnBtion" for p.P- 
:AU8E of death in plain term., that It m«> he properly wi...iT 



N, St-*»Bvcry 

•tate CAUSE vr m-»-^ .- , , !««»«„ce 

Mon. dytnA .way Irom horn, .hould be ftlven In .very In.tance. 



t 






1 



I 



(I 



! • 



•1 • 




i 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 






r :n 



m 



liii 



' f • 



I 





Jju I'i 



Regislrrod J\,''o. 



639 



Dale Fil I'll, VOu M 100\ 

\.<r^^^ Iw . Deputy Health Officer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Certificate of Beatb 

( *a. S. StanDarO } 



'J' 



No. 



PLACE OF DEATH: — County of^<t^v Ka>\CvO,CO City of n(x^ liux^^ec^ c 
hl'^ 0\X.»vr>vt St.: S Dist.; bet. ' Cr-i 



St.; S Dist.: bet. 'J ^i^^cr^Yv and 't ah.^^4^>V' ) 

OR INSTITUTION GIVE ITS NAME INSTt*0 OF STBCCT *ND NUMBER 



f ,r DEATH OCCURS *V..Y rROi* USUAL RESIDENCE GIVE r*CTS C^tJ." ;«''"•;"; str^et^nd 'n°umber*"* ) 
V IF 0E*TM OCCURRED IN * HOSPITAL '^- ■"-—'.■■""« '"..wp ITS NAME INSTEAD OF STREET AND NUMBER. / 



FULL NAME 



ClvtldL c^ L 



C\>XtltU.3 




'v< 



llw^ 



y\^YX\JL dU CL 



ih 



) .. 



■ !:x 



^' 



PERSONAL AND STATISTICAL PARTICULARS 

a I C<>1,<»R 



DAI i: <ir umni 



,vd 



a<;k 









MEDICAL CERTIFICATE OF DEATH 

DATK t>F I>1:ATII ,^ y 

I 



iDhv) 



J 'e'll I 



M.,1,lh' 



at) 



/'<? 1 



\\ lUoSVlI) i>K I>rVoK<'Kf> 
Wiiti' in HtK"ial tlcsit'iiatiou) 



^ .,.1 



HIKTHPI.AC'H 



NAMK Of 
1 ATHHR 



lUK rillM, \iK 
"I I ATIIKR 
■>J;i(«- or Countrj- 



mmiii:n namk 

•»i MoTHMK 



lUK IIIPf.ACK 
n|. MoTHKR 
(Si;(i. ,,r Country I 



X -^ 1 






Mbnth> ^ 



^Mbnth> A 'Dav) (Yenr) 

I lll-:RliBV CI'KTII'V, That I atltti.UMl dcix ascil frnin 
•Xl 190 S to |wlU^ at nyoS 

that I lasl saw h -^ alive on •- •- - I90 • 

anil that death occurretl, on the <lat«- statiil aliove, at 
M. r..eCA,S>.:o,...H.Vn.„,,s„.fo„..«.: 




*wtv>v<:^^vV4 



t T^.wxliv 




.t^\) 



\jJLol>v 



<L 



Dr RAT ION )'ears 

C()NTKIin TORY 



DC RATION . )'t'<irs 



Mouths 



Pays 



Hours 



Months 



Pavs 



(SIGNED) AJXAXU^i ^^ct\;^^U>*^ 

I FECIAL INFORMATION ^) '»' Hospitals. InstituUons, 



/fours 

M.D. 



if leailt tesMeBls, and persons djing ii»a) fr«ai home 



nccri'ATioN 

tCr>iitfi1 ill Sail Fi tiiirisrit 



) I ii I 



\r,,nfii 



/ht% 



TIIK AIWJVK ST^Trn I>KR>^ciNJiT, I'AK rii'« LARS AKi: rR' I-. 1«» I H »•. 
nKST OF MYJ<NO\\ I.Hlx.K AM) liKI.IKl- 



Wv^y>jXu.c« 



U'Mi 



SX3j 






Formrf er 
Usudl RrsldeiKf 

l^» was disease cetfracted. 
If not at piarr of death 7 



Row toRf M 
Plareof Oratli? 



Transleots, 



^ 



I'l.ACK OF BrRIAI. OR RIlMoVAI. | I»A'^h mI In i' 1 u <.r HI:Mm\a1, 



A. 









t 



N. B. ^Bvery Item of InWmntlon should be caPsfuIly supplied. ^^^B .Houia ^ •tateaa^J^w 1 ^ 

State CAUSE OF DEATH In plal» terms, that It may be property classified. Tlie SpeU.I Informal. « w»r p. 
sons dytag mwmy from horns should be Itlvsn In svsry Instance. 



^f 



f 



.♦ 



i 






I i 



1 






I- 



I 



■4. 



*» 



Ii 



>i 






ill 



>'1 



I 



?l 



I f 




til' 



Ml 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

I„ M.l.f Ih.Uli I Vo K ^•fJS^M.vtlCo REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 






Regisfered JVo. 



640 



Dalr Fih-il, XjJui '\'^ ?^^H 

iX'.j^i, Deputy Health Oflflcer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Ccvtificate of 5)eatb 

( *a. S. StanDarD ) 
PLACE OF DEATH: — County of<^^a>v 0-\xx>vc>cxLa<, City of OOvJXo^vXtc^e^ 

-We, % . 



t-^LtivVv^ ll:^0-^kA.iixt St.;— Dist.;bct. 

/ ir DcixH occuns *w*v rhoM USUAL RESIDENCE Give rACTS CAttc 



and 



) 



CE Give rACTS CAtttO POR UNDCR "sPCCIAL INroRMATlOW 



/ ir DcixH OCCURS AWAY rhoM USUAL RESIDENCE Give rACTS CAtttD rOR UNOtR SPtC.AU iriroff«ii.in 
V ir OCATM OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTCAO OF STRCCT AND NUMBER 



) 



FULL NAME 



NJl-cLiA.\^ k XjL'Vv, 



tl 



■ j;\ 



PERSONAL AND STATISTICAL PARTICULARS 

CO I. OR 



OftuL 



i>\i i: <)i niKTH 



A«.K 



^y\<xy^ 



Ijo^Lti 



iMotith 




Ho 5V,?».' I 



ax 

(Oav) 



Motilhs 



( Viar 



Pil vs 



^tM.I.K, MARKIKU 

u iiM)wi.:i> OK DfvoKrKn 

iVViit' in social ilesiKuatiuti) 




KxxA, 




lUkTrnM.vcK 

(Statt ur C<iiuitry 



NAMK iiV 
f ATHKR 



RIKTIII'I.ArK 
OI- 1 ATllKR 
(Statr fir Country) 



M \I!ii:N' N'AMl-; 



nikTm»uACK 

<>»• MoTURK 



h 



cv4/vuo^Lca 



a 



MEDICAL CERTIFICATE OF DEATH 

DATK OF DKATH 

(Dav) 



[Mouth) 



K} 




fV«arl 




I lII':RJ:nV CICRTIFV, That I atlcncUMl <liivase«l from 
3L^ lyoH to \vvW. Xl igoH 

that I last saw h ^v^^ alive nti ^Vvtu ^1 I90H 

and that death oecurred. r)ii the «late stated above, at I oO 
- M. Tlie CAl SI-: (>I- 1)1:ATII was as follows; 



% 



J .UL \vk.^H.cC J,*. 



X^ii 



Dl'R.XTION " )'t(itSr " MoHt/is 6 /?<7j v * /fours 






LoLt/l 



'VX-^-V^^J^ 



\\ 




DURATION 



)\'ars 



k 



THK A«(1VK STATi:T> PKRSONAl, PAKTHM l.ARS AKH TRII-: T« J THH 
HKST (31- MY KN<iWl,i:i><*.K AND nin,!!:!" 



( SIGNED ) IUa>v <^ <XA,w-^\vaa' 



Afiifitfts 

1 



Pars 



Hours 

M.D. 



%% 



TOO 



{^ 



^^e6iALINFORMATION only '«•" Hosptih, InstilBlions, Transieib, 
or Recent Residents, and persons dying dway from home. 



former or 1 ^ e a 

Usual Residence I w ^ 



lA 



If not at piare of deatfi ? 



^d^>v» 



llfwiMif irt 
Plareif Ofitli? 



Days 



(liiforninnt 




(Add 



ress 



1 



^ 



H-^.^'WV^ 



I»r KQV 0|- lURIAl, t)R RKM«iVAI. I rJATK of BeRtAi. or RKMOVAI, 
l-NUKRTAKKR J ^CLtN* 'V^ ^cU,Ua.U 



IS. B.— Ever,. I.cn, of InfonmBtton .hould be c«..f«lty .-f^nlle.i. AGB should ^•'-^i^!^^'^^^:^ InfoTJtTon^' Vr^^I-^. 
•tate CAUSE OF DEATH In plain term., tli.t It mny he properly cl«..lfl«d. The 8pccl.l Inform.tlon for ^r 
•on* dying away from hom« Khoutd be ftlven In my^r^i Inntance. 



i J 






, 



%\ 



U' 



I • 




I H 







WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

.rn.iHh vsa K^i^^^i^.nSiVCn WtPER TO BACK OF CERTiriCATC FOR INSTRUCTIONS 



ifn)H 



Begistej'cd JSi^o, 



641 



IXilr Fil('(l, %jdxi V\ 

L.^ li^ Deputy Health Officer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Certificate of Death 

( tl. S. StanOarD ) 



PLACE OF DEATH:— County of 



City 



\ 



Na 



St 



Dist.; bet. 



and 



— — ______ ^^^j — i^ist.; DCt. «na 

/ If oc»TM occu»»« *w«v rwoKd USUAL RESIDENCE oivr r«CTS callco ran under "•#«ci»i iNronMATiow \ 

V ir DtATM OCCURRCO IN * HOSPITAL OR INSTITUTION CIVC ITS NAME IN«T(t*0 Of STRCCT AND NUMBCR. / 



m 



FULL NAME 



'^' 



"w^ct 



lUa 



PERSONAL AND STATISTICAL PARTICULARS 



^i:\ 



^i 



C<>1,<»R 



0^ 



I' 



i»Ai i; oi liiRTii 



M.V. 



Muiith) 



J '(•(»> .» 



I 



at 

(Day) 



Motltfis 



MEDICAL CERTIFICATE OF DEATH 



(Vciul 



/ t 



IS 



(S'tai 1 



/■'./ 1 



\vnH)\yi:i» OR i)iv()K('Kr> 

(Wiitfiii wKMal ill «.iv;iiiiti<)iO 



HIH run, AOK 

(Stnt' iir C«nnitrv> 



N'AMl': oi- 

jathi:r 



lUkTUn.AOK 

OI" l-ATHKR 

I Stall or Country) 



MAIDHN NAMK 
<>1- MOTIIKK 



niKTfriM.Acj-; 

iHlntr or Cnunlrv^ 



^x^>xaU 



aU 



DATK OI- I>KA rn (S ft 

(M.ttillO \ fl):ty» 

■ » 

I HI':Ki:r5V C I-RTII-V, That I ;iltcnc|i'«l <k(cascMl from 

I9O to "^ I9O " 

that I last saw li ~ alive on ' ~ """^ tgO 
an«l tliat ileath fxrcurred, nn iho <latf stateil above, at 
M. Thf CAISIC in- DI-ATII was as folhnvs: 



K -^ 



-I: 



tu 



<X4,^i>v 






nr RAT I (IN }>iirs 

CONTKIIU'TORV 



.Voufha 



/hi\M 



//ours 



DURATION 



}'t'iirs 



O. 



c 



/hjys //oi/rs 

^\^ri\jL\> M.D. 



f\f sided in San J't iini isrii 



tix^^\ 



\a 



( Signed )... L. l> KcuC^ 

N FORM ATI ON only io' Hospitals InsiHatioiii (rM^nts, 



SPECIAL I - , ^ 

or Recent ResWents, and per^ions d>iny dway iroafi home. 



) V*(j > > 



\f,nifh< 



thx 1 



THK AHOVK STXTKI) PKRSONAU IV\K Tier T.ARS AK H TRlK TO THK 
niST OF MY KNOWIJ.JX.K AND UllI.tlCK 



(Tiifi)rinant 






(Address 



I?. 






i 



Former or 
Usual ResMence 

^^en w#f 4I<^4^ f Mtr«fff4, 
If not it place of death ? 



How IM^ w 
Hare of DeatH ? 



%m 



PI 'iCF OF rURIAf, OK RKMOVAU I UATKof m HtAl. or RHMoVAI, 



stale CAUSE OF DEATH In plain term., that It m»y be Pfopcriy ti»»»iiwo. • n h^ 

«on« dyln4 away from home should be ftiv«n In ev.ry Instance. 



I 



♦ « 



. \ 



1 ' 






1 



t*«l 



I 



iM 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

H„, l.f II. Mlth I No i.iS-SB^H&PCo REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



I 



i 




i!l( »ih 




IKlf " 



lOOH, 



Dale Filed, Vvlu X^i 

<^^<.cu> kX'Ju Deputy Health Officer 



Registered J\^o, 



642 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of Dcatb 

( xa. S. StanDarD ) 



n 



PLACE OF DEATH: — County of U<X>V \ 



'^<LQ 



City of ul^lllctfrv 



o 



No. 



-St 



Dist.: bet. 



and 



f ,r Ot*TH OCCURS *W*Y FROM USUAL RESIDENCE C.VC r.CTS CALLED ^OR "N^R '^^^IH^'^'-^^^'^^^H'^'*" ) 
V ir DEATH OCCURRCD IN A M08RITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / 



FULL NAME 



PERSONAL AND STATISTICAL PARTICULARS 




U^jyyax' 



si:\ 



XA' vvo^^ 



COI.DR ^ 



I 



KAIl-: «»l- lUKl'H 



%<.H 



^ 



(Month I 



^ I )VcT»^ 



q 



(Diiv) 



Mnutin 



tar) 



Pit 1. 



MEDICAL CERTIFICATE OF DEATH 






siN<,I.K. MARK IKK 

U IDoWHn <>U I>I\nKri:i) 

iWiilriii vociul ih»»i!.'ii;it ion) 



ni«Tin'i,\0K 

(Ht;it»' or fount t\ 



NAMK «M' 

I A Tin: R 



RlKTllPI.AfH: 

<»I lA rHKR 

I St, 111 or Ctjuntry) 



MA!1m:n NAMK 
0|- MOTHKR 



niKTUPKACK 
<>1' MnTHKR 
(Stati- or C««intry^ 



^ 



mWvt \l| -irOk 
yawoLo vlK" \\juxk 



DATE OF DHATli A 

; Month) \ (Day) 

I JUiKlUlV CI*:RTIFY, That I aUeiulcd ilcccascil from 

, 190 ■ to --■•■ 190 " 

that I last saw h alive 011 Trrrnrr: — up 

ami that death occurred, on the date stated above, at 
M. The CAT SIC OF DICATII was as follows: 



DIRATION Years 

CONTRIRITORV 



Months 



Day 



Hours 



nr RATION 



Yt-arSt 



Pavs 



A • do 



/tv4.¥Lt>CU>v 



A 



) 'ra I s 



.)/.nif/i} 



/hn. 



OCCIPATION 

Kfsidi'd in San /"laniisi-o 

THK ABOVR •^TATKD T•KR^ONAl, rAKTlCtT.ARS ARH TRlK TO TIIH 
HKST OF MY KNOWI.F.lniK AND »'"'±i^'*'' 



(Informant 



(A»lilrcss 




aMX<X:\x 







k 




Months 
(SIGNED ) ik./t Bo. ^L\*. • , 
Mil %t ic,o (Address) C^ifr^Vite>vA.a 



Hours 
M.D. 



hi 



SPECIAL INFORMATION on'y '»r Hospifals. Institutions, Transifnts, 
or Recent Residents, and persons dying away from tiome. 



Usual Residence 

WMi m% disease confraetH. 
If not at place of deatfi ? 



Oiys 



ri^\cK OF nrRiAi. or khm«>vai. 



\Ua,iLiA.vv(i K.O' 



I>\TF:i>f HiHiAl, or RKMOVAI, 




i 



.< r > -s ' 



INDKRTAKER WwCMwH 

(Adare,«bl-' ^^O^blH V><^>.. \>U.^.. 



"^ 1: ArF Mhould b« •tatecl KXACTLY. PHYSICIANS should 

N. B.^ Bvery Item of InPormntlon should he cnrefully •upplled. ^^^ • cl.««lfled. The •'Special Information" for |»ar- 

•tate CAUSE OF DEATH In pl»in term., that It may be properly claaalTIed. i« «pcc 

non. dying away from home ahould he ftlven In .very instance. 



I I 



i 



■h 



r 

t 

'1 



.1 



V I 



ll 



in 



. -^ • • 



J 



h'.' 




r 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



REFER TO BACK OP CERTIFICATE FOR INSTRUCTIONS 



D(ttc Filed ^ 



190 H 



Re^Lsfered J\'*o, 



643 




<:Ld-M^\^ dOAXu Deputy Health Officer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 




PLACE OF DEATH: — County 



Certificate of 2)eatb 

of C'<X/TW J.'vQ/W'tU.tti City of C'«(X'>v J/uX/w tci " < 
rNo. T Hllkct^viu Ot crtl 3^t.tL St.; '.'■ Dist.jbet. OxX^yvcJvtv and MVa>v(lo>.l 

f IF DC*TM OCtURS *W*V l|)tbM USUAL R E S I D E NC C Gl VE FACTS CALLED FOR UNDER 'SPEcAl INFORMATION • \ 
V IF DEATH bcCURRED I* H HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREEtf? AND NUMBER / 

m 

FULL NAME 




PERSONAL AND STATISTICAL PARTICULARS 

SKX 0^ - j cOU>R 



DATl'! HI- mKTH 



lUktt 



iMc.ntJiiT 



Ar.H 



■^ta 




)'(•(/» 



lb 

(Day) 
Motillis 



(Vf.'l!) 



MEDICAL CERTIFICATE OF DEATH 

DATE OF DKATH 




(I>:(v) 



IVr.u I 



A/ I .s 



ii 

mi 

i 



'^IN<.I,K, MARKn-:i). 
WrDoWFii OK DIVdKv'Kr) 

! U'l ill- ill MK-inl ilt^i;'nati.)ii) 



HIKTHIM.AOH 
(Staf«- or CotitUrjO 



N'AMF or 
FATHHR 



niRTHIM.ACK 
n|- I-ATIIKK 

'State or Con ii try) 



f 



I nin^ICHV ClvRTIF'^V, Tliat I atfon<lol .U<rasol fmm 

'■' ■ •--■ ^"^—"igo to -..————— r,^ 

that I last saw h -- - alive on — — ~ — np 

and that death occiirreil, on the ilate stated ahcive. at 
M The CATSlv OF DI-ATIf Nvas as follows: 



i,<. 



1 



MAinHN NAMJ- 
n|- MOTIIHR 



nnniii'i.ACK 
<>i MnrnKk' 

•state or Coutitry> 



OCCri'ATlON 



» I 



DTK AT ION Years 

CONTRinrTORV 



Months 



Ihiv 



J lours 



DURATION ,. Yvars M.'uths Pays 

ftAwLu'^'l TQo'i fAd.lrefi**) We\rM.\« ^ 



(Signed) 



Hours 
M.D. 



•ici 



SPECIAL INFORMATION on»v for Hospitals, Inslif unions. Iranslenh, 
or Recent Residents, dnd persons dyin^ dw^y fiom home. 



Krsuied in San I'l am /yro 



) lUl I > 



.^fnlltlls 



lhl\ 



1 HK AHOVF, HTATF.n PRRSOVAI, PAKTfCfT.A RS ARK TRfE T») THH 
HHST OF MY KNOWI.FIX. K AM) nivI.IICK 



Former or 
Usual Residence 

When was disease rontraf terf, 
If not at place of death ? 



HoH lonq at 
Plareof Oeatb? 



Pays 



(inr 



nrinaiit 



Wwfr^vMA^ ^4l\^ 






90^ 



( \(1(lres«« 



PI..>X:K of BfRFAT, nR RKM«»%AI, I riATK of nfRiAL or RKMClVAf, 



'Ad.llCiH 




N. B. Every Item of information •hould be capsrully supplied. AOF. nhoulil ho fitnted P.XACTLY. PHYSICIANS alwnM 

•tate CAUSE OF DEATH In plain terms, that It mn> be properly clasiill'ied. The "Special Information" for iwir- 
•oti« dying away from home should be given In 9\mry Instance. 



■ii 




'.I ' 



I 



I 



L r 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



4 



I 



I I 



^ 



I!,,; ml >:f HlmUIi- »■■ No. IS, •9"iva^^, Hftl' Co 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



m 



Dff/r Filed , 




190 "i 



Deputv Health Officer 



Registered J\^o, 



644 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of 2)eatb 

( *Gl. S. Stan^ar^ } 

-f ^ i 

PLACE OF DEATH: — County ofOOyvU J,\.(Xn^tv(lX.oCity of Oo^YV- JA^avvccilCO 

ivcLaO St.; Dist.;bet. ~ and 



I 1 



^U/IV 



ID(H, 



\ f \r DEATH 0< 
y \ ir DEATH 



CCDRS AWAY FR 



3M USUAL RESIDENCE GIVE FACTS CALLED rOR UNDER "SPECIAL INrORMATION" 



OqCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. 



) 



FULL NAME 




xxxXo\) U- 



Ci^»V>> w\.V. 



PERSONAL AND STATISTICAL PARTICULARS 



SKX 



HATK ni- lUKTlI 



Ac'.K 




WW 



"■■■■" lo i 



vet 



h 



Oct 



iMonthl 



'^ I y,'<t> 



MEDICAL CERTIFICATE OF DEATH 

DATK i>F DHATH A ft 

L 1" 



Kt\^ 



TOO 





I 

(Davl 


1* 

/ 

i'>< ;ir) 


s 


Minth^ 





\vri>n\yKi» OR Divourj'f) 



If 



lUKTm'I.Al'H 
(Stalf or CiJiiutry'l 



I AIIIHR 



^C^WOL' 




HIRTHIM.AfH 
<>!•■ lAIIIKK 
iStntf or Cotuitry) 

MA!tH<:N NAMK 
Ol- MOTHKR 


n?R 

' Sl.i 


TIIPT.ACK 
MOTHKR 

tt' <>t Conntryl 






Ov 



fsA»iith) > fl)ay> 

1 m-RI-P.V Ci:UTlI''V, That r attcmltd .ktxasiMl from 
IsXii uio'l to .. Uvi-W Xl Kjo H 

that I last saw h . ahvc on ^^^^H ^^ T90 \ 

aii<l tliat <U>ath ocrnrrcil, otj the <latt> statt-d ahovi*. at i v 
w M. The CAISK <)F in- ATI! was as follows- 

VOlnxvav^»vCu ol^ 'XA^aKfr 3M.|vva- Jlx\\.cvt 



Months 



Ihns 



IJony% 




JLA^W^A.va' 



CoNTRnUToRV 







Dl'RATION 

(Signed) 



y cat's 



'H 




Af(Uit/is 

oxt 



/)<7r.^ 



/ fours 

M.D. 






HOC r PAT ION ^ y 

/ffsiilfft in Sun w-'mifi /st^it ^^ 5V.»/,- 




^ 11 TQoH (A.l.lross) iLtc^^'^Lo k 



Moiilh'^ 



fhiv 



THK AU«)VH STAT|.:i» I'KRSnVAl, PARTfOri.ARS ARK TRIK TO TIIK 
UKST OF MY KNo\Vl,i:i>t;K A-NI) m-AAV.V 

(Infnrnmtit LU (>'>X' M l\ aUX^V-Le"V 



SPECIAL Information «nl> (or H«^piNh, Insmullons. Iranslfnls 
or Rfccnt Residents, and wr^ons dying away Irom home. 

Formfrar / , e I ^ ^— How lonq al 

Usual Residence ^ ' "5 g Oxy 

^B was 4fW3Sf rftfltracfrt, ^ 
If not iX plare of dealli ? 




nare of Oeatk 



? foS^ 



Davs 






I'LACK o|- HIRIAI, OR RKM(»V \ I. 
INDliRTAKKR JVUAA44 ^- 



n\j'f '■! iuKt\i, (ir ki:nh>\ai. 



(.\dclft"!S 






looH 



o 



I .w. 



N. B. Every Item of Informntlon .hould bs carefully supplied. AGE should b* .tated EXACTLY. PHYSICIANS should 

state CAUSE OF DEATH In pluln terms, that It mny be properly classified. The ' Special Information Tor psr- 



sons dying away from horns should be given In svsry Inatance. 



,: I 



'I 
i. 



1 1 ' 



^ 









I 




WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 




I I 



l!,,;,t.l of n.:i!tll- )■ Si, 1^ •S^ 



lUS: 1' Co 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



l)((fr Filed , 




X. 




VWi^ 



"xyu 



De 



WOH 

fth Officer 



lieglsfcred J\^o. 



645 



DEPARTMENT OFPUBLIC HEALTH=City and County of San Francisco 



Certificate of S)eath 



( "d. S. StanDar? 






^ 






i. 



PLACE OF DEATH: — County of ^ '<X/rc' 0Xa>\Cc4CCCity of i<X>v JXa >vc^^ 



1' 



^No. 



;it1 



wWuLc<w> 



St. 



Dist.; bet. 



and 



(ir oK*TM OCCURS nwfv rnoM tisUAL RESIDENCE Give facts called roR under special intormation • \ 
\r OCATH OCCURHIp IN A MOfPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / 



FULL NAME 




tC.vV(rv(X4; 



Ct^v4e >\. 



>KN 



PERSONAL AND STATISTICAL PARTICULARS 




\ 



OL 



US IK Ml niKTii 



A 1.1.; 






} 



ilU 



u \ 

I I)a\ I 



M'lilh 



MEDICAL CERTIFICATE OF DEATH 

IiATl-; <>l DI'.ATII '^i 



O t ' 



I ;il I 



'(/ \s 



*'1M.I,I* MAKklKI*. 
WIDOW i: I > i>K IXVnRiKli 
•Writr in mmi.i; ilrst«,'it;iti<>n) 



lUK I'lUM.^k")-: 



NAM} ni 
F ATHHK 



MIRTIU'I.At'K 
'M- I ATHKK 

isiati ,,1 r'.niitryl 



MAim.N NAMK 



niKTHl'F.AOK 

"I' M«>riii-:K 

(StaU' or Country) 



CX YV. 






L 



(I>:ivl 



(V.art 



\ 



fMoiitli) r 
I III-:KI;I!V CIIRTII'N', TIiuI I .itun«lccl .kTia«,c(l fn.iii 



>V\- ^V-C 



ftp \ 



tc, ntU 



Xk 



igo 



s 



that I lii-^t -^.uv !i ' .. alivt-Dii i-LcLu ^ Q.fc Itp H 

ami (hat death crciimMl, lui the flalt- v^tati-il alHtvf, at 
CLm. The C.MSIC ni" DI'ATH uiis as follows: 



V^^W-CU^^XA. 



r>v^|v 



\\^ 



t-a 



LL'vuk^ 



V^rv*.'^ 



(! 




I) r RAT ION I**'*?/-.? 

C<)NTRnUT«>RV 



Months 



/yav 



Hon 



f <i 



occi l'AT^o^■ 



DIRATION 
(SIGNED) 



)Vf//*v 



Months 



Jhivs 



y^ i; ft 



/fonts 

M.D. 



XIAL INFORI 



SPECIAL Information •"♦* *«' Ho^uk, instituitens, TrMs^h, 

or RecenI Residents, anil persons dyinfl dwrf) from fc«»e. 



th! 



THI-: JiHovr, s r \ri i» i'KK»^t)NJii. r\Kri(*n,AK^ \ki:tkt h i'o run 

1U;ST OI' MV KNtiW IJUJCli AND ril.MKF 

.til 



iU-,M OI' MV KNOW IJUH.li AND 
(Infotmanl \| l\- "3. xllX^ 



('\dijre)!« 



/YSX^Uj 




former or 
Usudl Residence 

When Has disease contracted, 
It not at ptareor tfeatlt? 



HoH lonq at 
Place of Deatti? 



Dayi 



rj,A(*i: Of m kiAi, OR »^i;movai. | r».\TH..f in rial ..r rkmov^i. 



r N D 1: R I \ K I- R xR^ WV^-4 



^vvic4 "iO 



II 



tA(lclrt'< 






N. B._Bvery Item of l„fo.„,«tlo» .hould be cnra.^«M.. .upplUd. AGE Rhould »- •'"^-'f.f .i^V^^^; ,„^,",^*J,1Lt^.*,^" 
•tate CAUSE OF DEATH In pl»!n tcrm^. that It mny he properljr ^l.wrfled. The Spe..«l Informmlmn for p«r- 
•mi« dylni away from home whould be given In av^ry Instance. 





t I I 




) il 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

I,o:,r.l ..f lUalili I- N" "i ^^S^HScl'Co REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



( 



I! ■ Vi 



i 





i*'i 



Dafr Fih'il, N^v 




k » 



%^ 190 "i 

Deputy Health Officer 



Bo<^isicro(l J^^o, 



646 



I . 



DEPARTMENT OF PUBLIC HEALTH^City and County of San Francisco 



PLACE OF DEATH: — County 

-< XLKrvxA 



Certificate of ©catb 

( XX, S. Stan^ar^ i 
of ^ CX^^ JX(X>vac4.C<) City of J a^XJ J ' 



\.a>xet.si cc 



No. ^^0 5^ 'iULkrvC^; St.; X Dist.;bet. ^i^CVU. and vala<fU>xux. ) 

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



FULL NAME 



A<xcta\^ ob^vcL^iva-tc 



1 1 



• » 



; 1 



1 



PERSONAL AND STATISTICAL PARTICULARS 




'^I:\ 



OXTI-: <»F IlIRTH 



M.K 




COI.OR 



^l^U.,^ 



Moiiili) 



'Year I 



MEDICAL CERTIFICATE OF DEATH 

DATK OI- DHATII 'S I 



llL 



(Mjiinth 



t>av1 (Yinri 






)'l ll I 



M,.,i!h 



SlNt l.J- MARKIKH 

wnMi\vi-;i» (IK ii:vo!. ^K [» 

•Writ'.- in >'K'ial di >»it'natii>u) 



iukTn»M,\i*K 

■ st:it. ..T Counti V 



\\\ 



axN-ced 




NAMK OF 
FATIIHR 



Hlk IHlM.ArK 
Ol I AIIIFtH 

< stair nr t'oiititrv) 



maihi':n nami' 

<>1 MDTHKR 



inRrniM,\( }.• 

•»l MtirFU.R 
(Stat. I If Cmuitiy^ 




I HI;R1:!5V CI:RTI1"V, TIimI I .itfiri.k'.l .Uti.isc.l fnmi 

tliat I last saw h ■ ^ alive oil ^'^^H ^^ IqfiS 

anil that iU-atli ocrurrcil, on tin- ilati- ^tatr.l atti.ve, at K 
(j. M. The CArSI-: <>!■ hi:\'rH was 11'^ follows: 



O 

r^ 
Jf 



—J 



? 



'J 



-^ , 



DIRATION 
CONTKIIUTORV 



J 'ears 

ns 



^% 



Months 1 3k />«n s 



Vft>vCiv.C 



Hours 

>Vw^CM »-CA VWflL 



DLKATlnN Years MuNths > /hivs Hours 

A.l.lrt.s-) 5CS ^-U.lvt»l at 



(SIGNED) 



Q 



OCCrj'ATlON I ' 

Rthtr,! in Sa» !'ntnt i>f<> *" ^ f'ln ^^^^^^^^^^^^ 

THK AnoVKSTATl-n PKKSi.XAI. r\KT!rri, \ KS A K l! TXrV. To TJIK 
BKHT OF MY KN()\VJ,HI)«.F: AND \W.\AV,\- 



U ,/,f/f 



nm'.i'inant 



vfUxX^cw ^ ou ku 



fAfl<lrc»!» 



^D5 



^. 



vv^\.r% 



^. 



-V . 



y. 



m. r 

- 
P XT 

-- r <- 



"1 f 



vvtu^ 



TqO \ 



r 



SPECIAL Information on'y Jo^ Hospiuis iR$ufitto«, TratsMs, 

ftf Rfcefll Residents, dnd persons d)ing dwa) Iron home. 




Former or 
llsudi Residence 

When was disease contracted, 

if nvl iX ^t4i« c m amIh . 



'xXk \ 



CttU 




Ham lonq at 
Pf* e of Oealli ? 



t 




kri 



P1,ACK OF nrKfAf, OK kKMoVAI. I UATF.if If «tAt. or RKMuVAI. 






I I. ii; 



'Addrc«iH 



^' I*- 



CAUSE OF DEATH In plwtn term., that It m»y He prf»perly «.l««»itwa. • "« ^»»«^ 




N, B»' Bvery 

state CAUSE .. 

•««• dytii4 away from home nhould be ^iven in wvery Inntance. 



fi 




WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

,.,,,<! . r H. .nil I N-o i^ tl-fl^J^D&lCo REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



J 






i^* 



'i^* 
t 



Registered J\/*o, 



647 



dcfrvvu) ix'WM Deputy Health Officer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of S)eatb 

( H. S. StanDarD ) 



PLACE OF DEATH 



: — County of Ca>\' 0\a^\C City of '^^Oov- J\aA\ ^^^ 



No b'i^ ^tw^vi St.; " Dist.; bet. hL' U.k(mt and 6 

/ ,r OC.TH occurs .W.y r«OM USUAL RESIDENCE give facts CM.LCD ;o« "•,* .%%%^;*i^';''-°;;*J'„°'^ 
V »r OC*TM OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. 



) 



FULL NAME 



' jlLxS) Sxxl^ 



L/kU 



•HX 



DAT!-: <>I lUKTII 



\<.H 



PERSONAL AND STATISTICAL PARTICULARS 




/U3 



Mtiiilli^ 



O I ),,!> 



I);i\ 



M,.ftth^ 



( Vtar> 



/><n 



>.lM,i.i- M\HI<n.I> 

whjmwku c»k r»iviim'Ki> \ 

'Write in sfH-ial »lrHii»iiii!irin> i 



HIHTHPI. \rK 

' 'iti .1' I ■ U 111 1 \ 



^vR^vfri 



MEDICAL CERTIFICATE OF DEATH 



DATK nl- UKATH A | 

fSlnllth) K 



il>:iv> 



fQO 



I ni'KI-inV Cl-RTIFV, Tli;«t I atlen.kMl .UrvaKc.l fmiu 

up' 



I90 to 

~ alive t)li ~~ 



tliat I last saw li " 
ami that dtatli i)criirre<l, on tlic «lati- stalf«l al).»vi', at " 
M 'flu- CAISI-: <>I'* !)1-:ATH was as foll.ms: 



190 



>JAMK <»!• 
FATIIHR 



niKTniM.ACK 

"' I \ riii-".K 



itf Cemntrj-) 



MMI»j:n' NAMI-: 
Ml M.iTHKK 



IHKTm'I.ACK 
<>! M«»THHK 
'siatf or Cmuitry) 



I )r RAT ION >V<7/.f 

coNTRinrroRV 



Monfhs 



/)avx 



//ours 



(SIGNED) WtfUTMA J. 0.^ ^sJwJUa 

tepE^AL Information »n'y *« Hospitals. InsUtutlw^, rNnsifnls, 
or Recent Residents, and persons d)in9 a»a> from home. 



^l^xWu^ 



fif'-idfii III Situ !'i (till ft''' 



J ><r I 



THK AHOVH ST \r|-I> F'HUSf ,naI. PAK Tim \RS AKK TKIK To THh 
HHST OF MV KNoWl.Klx.H ANU inil.ni 

(iiirotttiam Wft''WO'VsJtA^ ^ • 



r^<l<lfe«s»« 



I>rR\TI(»S Vtars .Ui>ft//j< /^vs 



//our% 

M.D. 



Former or 
L'sual Residence 

When WIS diswe cwlracted, 
If m\ «t pl*^e flf death ? 



tioM lon^ at 
Plare«r leath? 



Diys 



I'l.AjCK ul m KIAI. f»R KKMuVU, I I>CII-m; H.«,a, ..r KI'MoVU, 



t NDMRTAKKR 







'Arl.hf *« 






,, , Trp .hould b« stated BXACTLY. PMV«ICIAN« ^MttM 

N, B.^ Bvery Item of Information .hould be cHf-sfully •uppHed. A^'" » ci--,|f|«d. The •*8pecl«l Informntlon" for pmr- 

•t«te CAUSE OP DEATH In pl«ln term., th.t It m«y be properly wl.Mim-. P- 

•mi* dylfi4 away from home .Houid be given In ev.rjf l««t»Bc«. 



i \ 



: 1 






m 




I 



\\ :4\ 




WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTrFICATC FOR INSTRUCTIONS 



H,.ai.l..f H.:.lth I Vo ,.1^-tg^n&I'Co 



Begisfcred J\^o. 



648 



Iw-^lLvvM Deputy Health Officer 

DEPARTMENT OF ^BLIC HEALTH=City and County of San Francisco 

Certificate of H)eatb 

( 'CI. S. StanDar^ ) 



No. 



PLACE OF DEATH: — County of ^^^CL^ J\a Axe44 ^^ City of^>anv Ua >xq..c 



St.; 



Dist.;bet. — ^ 



and 



FULL NAME Jolxa | v 



— ) 



PERSONAL AND STATISTICAL PARTICULARS 

\l'lc^- - / 



:> \ 1 i: Ml niKTii 



MmIiUH 



KCV. 



(I)a\ > 



Mntiftn 



U IlMiWl |» nK DIVok*. Hl> 



iMK run. \cv, 

'State or C'lUiitiv 



vcLt-v- 



N'AMK Ml 
I AT I IKK 



nikTin-I.AiK 

Ml' I \THKk 

' stall- or CiHUltl y I 



Ml MmTHKR 



niRTHPI.Ai'K 
M|- MfiTHKR 

(Siatt (ir r«)uiitiy 



Ml V 11' \T [ON 




\ < :i! 



Diiv 



MEDICAL CERTIFICATE OF DEATH 

I>ATK Ml- DHATll A | 

iMutltll 

I ill-KI-nV Cl-RTU'V^ Tha^ I 

tluitnastsawh -*^'. alive on t^^ -^^ IQO 

aii<l that <k"ath (Wciirrcd, on the datf statt-il ahow. at \ 

LLm, Tlu? CArSI-: OI' IM'IATII was as folli>s\s: 



0, 



<k'<l (Uniasctl froni 
i()oH 



Id^ 



,-1 .^ 



l\ 



VMU 



1)1" RAT ION Years ^ Months 

CONTRNSITORV 



1 '' />u),v 



Hours 



DT RATION 
(SIGNED 



Years, 



Motith.s 



Pars 



) \X. C Co-^rvLc^^ 



Hour\ 

M.D. 



.. %r.,.tl. 



I>, 



hfintfil lit .'^iirr I I iiiu I I <i O \ 

TMK AnnVKSTVI-T-D !'KU^M^■\I. j- \KThM' r. X KS A KK TRlK TO THH 
lU:sT Ml-^AIY KNmW I.I.lx.H AM» lil'IJl '' 



flufejrniatit -' 



\<3L.>vk Uw n .ilAv^*^ v^ti 'lA^vt 



f AilflresH 



Ci^\.4.iv 



SPECIAL INFORMATION only for Hospitals, InstHutions, Translfnts. 
or Recent Residfnts, and persons dying awdv from fiome. 
r/vrm« nr I Ho* lonf it 



I'sual Residence 

Wlien Has disease fontraded. 

If not at place of death ? ^____ 

I'J.ACK DI* BrKIM. mK KliMMVAI 
IMtliKTAKKR 



it\ 



IS' iiAi 'tr HKMMVAI. 



iv^l 



U 



1 00 ; 




fAdcIrei* 



V% -Hi 



Q^>V 



■■"-""-■------^—^■— ----■— -■'"'^■'''■"'■"■"'■''''■~'~'*'''"^ P hould b« •tated EXACTLY. PHYSICIANS shouM 

N. B. Every Item of Information .hould be c»r«fttlly MPftHed. ^**^ * J*". „,f,^j. The '^Special Infofm.tlon" for p.i- 

•t.te CAUSE OF DEATH In plal« term., that It ma|. he property .!•.•.«« 

•<MI« dying away from home should be ftlvea In every In-tance. 



ii \ 



I 








. i 



Ji 




WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

H.,.nl -i IK.<!th-FNo i. t-gS^. H&l' To WEFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



Ihf 



190H 



Eegistered J\^(), 



649 



DEPARTMENT OF PUBLIC HEALTII=City and County of San Francisco 

Certificate of H)eatb 

( in. S. StanOarD ) 



No. 



PLACE OF DEATH: — County ofOo/Tv vJ/UX/> 
51 ^'.:' • ■» 



City of C'KX^ru oA/CV ^ 



, , St.; ^ Dlst.; bet. ' T ^^^ and !^ ^ ' 

• •eiiKi DB-einr Nrr riwr r*CTS C«LLtD fOR UNDER "SPECIAL INFORMATION ' \ 



) 



FULL NAME 



oXu^e^ 



PERSONAL AND STATISTICAL PARTICULARS 

ULiv, 

l»ATI-: rtf- ItlKTU A/i^ 



" (^aU 



A«.K 



) 



Mnultn 



\ *1 



' »■< mi) 



Ih 



SlN«-.l,i: MNHKn.l* 

wiiHiwKiJ «>K nn'oKCKU 

(Writf in wifiiil iliHitriuitioit) 



i 



K^y^ 






I .^TIIKK 



lilK'nilM.A*'!-: 
<»l* lAfUHK 

Htnli lit l'«,iintt\ 



MMIHN NAMi: 



lUkl Hl'I.AiK 
o|. MoTIIHK 
(Slate or Coiiiilrv^ 






MEDICAL CERTIFICATE OF DEATH 

H/LcLu ^- rgni 

I UI':RI-:HV Ci;'KTn''V. That I atU-n.ka •UTtasc«l fnuu 

that I last saw h alive on ^-^ 19° '^ 

an. I that .Katli occurreil, on tlu- .latr stati.l alM.vf, at 4 3W 

M. Tlu- CAISI-: Ml- I » I', ATI! \Nas as follmvs: 



o 



\iruxA4. 






1)1 RAT ION ' yt^ars 
CONTRIinroRV 



Mouths > C Ihns 



Hours 




»#..#* 



•H'CI i'Ai ION 

Hesided in Sati / i <in, irii ^ ' " ' ' ' 

THKAnoVi: S-. ATin fl-K^oNAI. PHKTrrn.XRsAKKTKt H K ► »HH 
HHST OF MV KNnWl.KlX.K A>h^I» l»l>J,n%f- 

/\ s\ ^f it 



' I 



(Atldf f *• 



(A«1<lrf«ii« 

„ . .pp ,Hould be .t-ted EXACTLY. PHYSICIANS .lioiild 

N. B.^ Bv.ry Ifm of l«Wmiitlo« .houici b. c«r.f«Jly f"**^"'-- „;„'J;Hy cl».»lfM. The "SpcclBl Information" for ^.r- 

•fU CAUSE OP DEATH l« pl«l« term., th.. It m..y »« ^^^^^f ^ 
«on« during away from home .ho«id be ftlven In evry I«et.n«. 



5l ^)Wv^dt 



DIRAlloN , Years "^ Jfont/i^ 
(SIGNED) W \l i ^ • ' 



Pav 



^ 4- 



Hours 
M.D. 



Special Information only for Hospiuis, institutions. rr,insifnts. 

ir Rctcnt Residfnfs, dnd persons dyinq ai»ay from liome. 



Formfr or 
I'syal Residence 

When WIS disease conlracfed. 
If not at plare of deatfi ? 



NoMf ionq at 
n«re0f Oealli? 



tarS 



PI ACKOF lUKlAl. MK HKM.»VAI. I I'VI : I^'k.a,. ..r KKMnVAI. 

111! VimA^^-^vv 






<i - 



I 



^' 





Ill 



I 



m 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 

650 



11,,;,. a. .r ii.i.iih- 1 ^'n '-■ *":?Ey>-i'''^i'' " 



Bes^isfci-pil JVo. 



l^vcv. Wu Deputy Health Offlcer 

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

Certificate of IDcatb 

( 'Q. S. StanOarD ) 

4 1 i ^ 

PLACE OF DEATH : —County of '^ CL-YO \.<X^\<:x^Z.b City of a . v ' • 



No.Lla\a' 'navtcni; ilv<,lixla' St.: Dist.!bet. 



and 






FULL NAME 



-I.X 



PERSONAL AND STATISTICAL PARTICULARS 



i' \ I ) Ml lUKi'n 



L '' "llVlvJ:. 




iM..iUh 



X < . !•: 



HI 



Tf (/I 



lb 

IIKIV) 



M.'filii 



(V»*ar) 



/'-; 



•^IN«,M" MAKKIHU. 
\Vtl>«>\VJIt OK l>I\'«)Kt'i:r» 
•.Writ" in s.h lal fksi<,;uati<>n) 



!UK run. \cv. 

Mat' i>! • "0111111 \ 




\(X\MJ.cl 



\ WW O! 
I \ I H J-.R 



lURTlll'I.ArK 
<»!' 1 xrHHK 
'siati iir fontjtrv' 



MMhKN NAMl 
01 MOTHKR 



niRTIU'UACK 
»>F MOTHKR 
(Slati- uf Country^ 




MEDICAL CERTIFICATE OF DEATH 

DA PK <)1- Dl'.ATH 



iiotitii^ 



i 






(I)av) 



IQO 1 

(Vt'!ir> 



IC)0 



I H|.;i<|.:i5V CI:KTI1"V, That I .ittctukMl ik-tvasd fnuii 

tbatllastsawh-/ alive- on f^ 5.1 i.p H 

Mii.l that (Uath (.rrurred. on the dak- staft-.l ah'.vf. at 
M. T!k- CAISJ' (»!■ Hi;.\TII \sa< as follows: 

i\ , ,'♦•(■ 



C\. %v \. > ■> 



vi,* 



DrkATION 



T 



} 't-ats 



Moulin 



/hiVS 



% 



Hours 



CONTKIIHTORV W\SU.^U.^--k^-i-v.v<- " 



Rfsiifrii iif San I'laui i>,,j *- i "Ti 



Tin*. AnoVR HT\TI I) l'KK<.<»\AI, I'AK ri' M l.AK^ A»<'- ■"^* ' ''^ 
HKST OF MY K>5i>\VhHIH;H AND HKI.I!,!' 



(Infonnant 






(AddreHH 






I )r RAT ION 
(SIGNED) 

'SPrciAL INFORI 






i » . 



/)avs 



I 



A.Mrcss) 3^b vVvO. 



Hours 
M.D. 



J M ATI ON fln'v 'or Hos(>Uals, Inslilulions, Irdnsients, 
or^Recentlfcsidents" Vnd persons dying nnav (ro.-n homf. 

r „, «r ^1* , , . I How \m% al 

Ke^ence^ll^^^^^^^ ^^ Plare of Death ? Days 

When WIS dlsea« contracted, .^ta-JUti vvt^-c^ <xn 

If not at plare of deatti ? ^ ^^^ ^__l— 






ri.Aci-: oi- niKiAi, <»k hkm<»vai. 

,.,,h.^. SOS OUd>^lc|v| 



I>\TF.if Hrin.M. «>r KHNft>VAI, 



190 



ini>i:rtaki:r 



iB^^«„„^^,,,;^^„„.^^„,^^Bi^i^i^«^ii^— iii^-"!"^"'"'''*'^"'"' IH K« t t d FXAGTLY PHYSICIANS nhould 

N. B.— Every Item of Information .hould be carefully «^»H»I1-J^ „^^Hy'^a.«lfled! 'Th^ -Speclai Inform.llor.- for per- 
•tate CAUSE OF DEATH In plain term., that It m»> »- J-J^'' 
«.««.• dylna flwy from home -hould be given In .very ln»t»n.e. 



s I 



II 



.1 



It 



' I 



i ;' 



> 



•» 



!l 



I'l 



111 



^1 



t1 



J 



Hi 






Mi 

(11 



I s 



» ■ 

i 



.1 



'•I 




.•■I!! 



.>^ 



(• \'(). i«. 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

REFE R TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



M.vr Co 





^-M-^^ 



Deputy Health Officer 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of H^eatb 

( "a. S. St^m^ar^ ) 



PLACE OF DEATH:-County of ''^ a^v>1 ^aAvC^COC^ty of 






No. 



\ 



. 1 Dist.;bet. '5-^^^-^' 






4 o. , I Dist • bet. u^w-^^u' and ' • -^ ^' 

VV »r DC*TM OCCUBHED IN » HOSPITAL OR INSTiru^ « 1 (\ "^ 



) 



FULL NAME 



mxKjy^o^^yyj Htr rvw \i I Ic^ ' 



PERSONAL AND STATISTICAL PARTICULARS 



- 1 : X 



A 



W ' 



C'ni,( »k 



ii\ 1 1-: Ml 111 Kill 



(^ 



,^1..!1«>lt 



K'.K 



"-IMII MAKKIHIJ. 

U 1 1 »« I U !•• 1 1 I > K I » I Vn K 1" K r> 

Wiitf ill •^irtiiil lit ''it.Minlif 111) 



iUKTniM.Ai'l*. 

"^tati i»r »"<nintry ' 



A 



1 



11 



I Dav 



M„nth' 



•^ . i. -» 



/J,;i 



.M 



g-i 



N \NTK ni 
1 A niJR 



HIRTHI'l.ArK 

«»! I NrHKR 

I SI. (If lit Ciittntryi 



MMIH-.N NAMH 
«>1 MoTIIHR 



BIRTH PI.ACK 
OF MciTHKR 







ll 



\ 



-I 



1 



« HiTi'A'l'I 



"^'(l 






A'fshfftf III Siiii / >,nh •-' 



) ,,7' 



yj.'ufh' 



/).^» 



THK ABOVE HTATKr>PKKm>NAU i;^ «;':!^'',ir^'''' ' ^ '' '''""'' '" ' 
HHST ()|.- MY KNOWI.KIH.K AM* Hl.I.U.f 



Uiif'finanl 



KNOW 1,1, in. n •'» ^ ' ' ' • 



r\'Mi.-.s 






MEDICAL CERTIFICATE OF DEATH 

PATH ol- DKATH ^ 



Month I 



I D.iv 



tV. II 



I UKRHBV CKRTIl-V, That J alMMi.lc.l.UHHasta fro,,, 



\ 



\cp 



iu , ^^^ 



that Ila<lsawh-i.>>^a1iv<on • '*P 

,,„.l that .Uath urcurre.l. on the .1 lU- -4aU-.l above, at » 
M. The CATSI- <'l- l»i;.\Tn uas a«; foll.nv^- 

j 



nr RAT ION J'"'"''' 

CONTKIHITORV 



Months 



fhjy 



/fours 



r)rRATH)N 
(SIGNED) >w 

MP 



Vt-ars 



Month 



Ihns 



'^' -^1 ^^ 



/fours 

M.D. 



Aihlre-is) 



t n 



"^SPECIAL INFORMATION «nH »«r H.HpJUK iHstitutloPS, Tr«sif«h, 
or ReTent Residents, and persons d>lng a..v Iron, homr. 



Nrmef w 
Usual Residence 

When »»as disease contracted, 

II Mvi o« |»m' ' -' ' 



How loif at 
Plaieof Oealh? 



^s 



V\,MV.OV m RIU, OR RKMoVAI, 

1 
' Acllltf -iH 



Ii\XK*»f H'KiAi or H1;N!«'\\I 



-H 



TN 






E OF DEATH In pl»!n t.rn... «'«'•'""> ,„..'.„„. 



N. B.—— Every Item 

•fte CAUSE OF DEATH In P.i.." " 7" ";;;„":„, very in^fnce 
•mi. dying .way from home shoul.l be 4.>en 



. 




1 • 
I 




I 




I 



I 



It ^ 



'I 



WRITE PLAINLY WITH UNFADING INK-THIS IS A PERMANENT RECORD 

^m^j^ScV<:n REFER TO BACK OF CEBTIFICATE FOR INSTRUCTIONS 



/)(f/i' Filed , Y^^vu 



Ee^lslercd JSi'^o. 

"LvvJlt^vu. Deputy Health Officer 

DEPARTMENT OF PUBLIC HEALTH-City and County of San Francisco 



Ccvtificatc of IDeatb 

( -a. 5. StanOarD ) 



PLACE OF DEATH: -County of Occ^X J >va.xt.^ o^Gty of 



VCC-^^/C^ 



f \ 







tnd 






"1 ( ■' r/r».°-"i%r;,"r.o",^",-.t „%'?^?^.'4r/,;";; 



FULL NAME 



a I' 



nic' 



^ 1 . \ 



PERSONAL AND STATISTICAL PARTICULARS 



!»\rH «il lUKTU 



\>.K 



LL%x.o i " 'A to 



Mciith 



c 



0L\ 
iDnv' 



!/ .'.'/• 



'S"i;ir' 



/',.• 



^t%<.|,I' N1\KKIl".f> 
W n>. i\\ !• I> < >K IMV* iKi 1!) 
Wiitt in -.uial lit— ii,'t)atii>u ' 






N\M1- OI 
I AT 111. R 



niRTnri.Ai'H 

<>l lATIlHK 
•stall- fir Ci)iiiitrv' 



M \!I»j:n NAMK 
<»1 MOTHKR 



HIRTIlPKArH 

<»!■ M(»rm':R 

'Stall- ur Ci)untry'i 



\ 



A 






*_ «. 






(1 



{\ 



(>;u. 



1 r> 



Kfsidrit III ^<iii / I < iin /w-,> 
THHAm>VKSTATKni'HKS.>NAI. l-XKnrrKNHsAHKTKri- n. iHh 

IJHST OI' MV KN<>Wl.»:n<".K AM) ''J:-''"' 



Informant J XOU^xA U- 8 /t^' 



MEDICAL CERTIFICATE OF DEATH 



^tviontli 



I».iv" 



/QoH 

lYi-nti 



I III-KKHV ClikTlFV. ThaMaUc-n.lcMl.Uria.c.l (nmi 

that I last saw h alive on '*^^ 

,„a that .Uath ,.rr..rrc.l, on llu- .lati- ^tat.-.l al.ovc. at 
' M, Tlu- CArSI" Ol- l>i:ATn was as follows: 



„ri<ATI()N >'«''- ^ J/o.mn Pavs 

CONTRir.i'TORV 



J /oil IS 



nrRATKlN 
(SIGNED) 



Viars 



Mo)ith<^ 



Pars 



CV^V 



//ours 
M.D. 



Va^^B iqoH fA.l.lri-ss) til'. . 



"<^prLlAL INFORMATION only lor Hospitals, Institutions. Transients, 

or Rerenl Ments, and persons dyinq away froii home. 

Fomifror 1 1 f .,, ^ 
UsualRfsldcnce V^^^^^'^- 
Whfn was disease contracted, 
If not at piif e ot death ■ 



K- 



How loR4 at 
Place of Oealfi? 



fkyi 



VI ^CKOF m HIAI. ..K UHMUVAI. 



DXTl-'i'! Ill HIM "1 RHMt'VAI, 

ft' ■' 



INUKKTAKKR 



'KdL "^^ 



(Addrt'ss w * ' - 






190 H 



lAMv^^n VWWWV PHYSICIANS .hottld 

' H Id be carefully ^uppH-l. ACB •hould »^« "^-^^^^^.rJ^pL,.,;, ,„f„.„«,lo«- for p-r- 

IN. B. Bvery Item of Informiitton .houW be '^»;«"f"^ ^ ,,^ properly cl.s.ifled. The e»pe 

.tate CAUSE OF DEATH l« •;!-- j^T^j.^ „ e"-- '"'**-"^*- 
Rons dying away frotti home nhould be fti*e 



I"' 1 



r 



'■ 



f> I 




•i 








WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

REFER TO BACK OF C ERTIFICATE FOR INSTRUCTIONS 

653 






]h 







Bc<iislered J\'*o. 



Xti-vM^ IvXoMui Depui; , . 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of ©catb 

( -a. 5. Stan^arD ) 



PLACE OF DEATH: — County of 



:3 



No. ^Htl CU^^xtv^ 



St 



' ' >UX'VUC.M/C^ City of ClxXAv OAO . 
Dist.;bct. ^H tA; 



and 



^^^^-*- "^ ^ ^^** ■^ito*^.^rn FOR UNDCR "SPECIAL INTOHMATION ' \ 

/ .. OCATH OCCU.S AW.V PROM USUAL « ^ f^ ^.^.^JV^^J^.^C 7tI NAME iXc^D^r STREET AND NUMBER. ) 

V IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ' " ^ 



FULL NAME 



i»\ ri; •»! luk I'll 



PERSONAt AND STATISTICAL PARTICULARS 




I I 



V 



xLc4.ft>^ 



f ' --, • I. 



\JX\^^ 






\».H 



n:i% 



M.n'h 



••■It- 1 



A( 



-iV»;i,K MARKIKI* 
WIlMiWKI* <»R inVoRiKU 



I'.fk nii'i. \*'K 



t \ T 1 1 I •• K 



iiiK rin'i,A« K 
<»i I \rm:k 

Stilt .,! i",.inilry) 




NfAIhKN NAMl" 
t»l MOTIIKK 



IHk rUl'I.ArK 
n|. MOTHKK 
Slftte fir Coutilry) 



THK ABOVE STATlDPKRsoNU. »' ^ "■.ll^;';!'.^.'''' ^ ' 

HKHT OH %LV KNOWI.I^IM.K AND Hl.l.H.r- 

(Infoiinant 0*^^v 



NLV KNOW l,Kl>t.n v^*' 

^5o 



I go 

iVt-ar) 



MEDICAL CERTIFICATE OF DEATH 

UAIK ol- UMATH 

I m-KI-HV CI'RTII-^V. That I .'j^tleiuKMl .Icrcased fnun 

;.._. ^. . T9o'^ to Wttl '^ ^90 H 

that I histsawh . alive. .11 * ' H ' '9° 

n„.l that aeath occurrcl, .m, the .laU- stated above, at , T • 



:^. The CAISI' OI' DI'lATH was as follnws : 



1,1 RATION y^-ars • -V-zM. /><n- 

C()NTRIIUT()RV U.w^^^-^^ 

niRATloN I. )V.;v ^ Mouths -Pays 

'4' ♦ 
(SIGNED) ^' '^- 



//o/tt s 



Hours 
M.D. 



■1 



U)0 



A.hlress) ^HOu 



wa^. 



"" QprciAL INFORMATION only for Hospitals, Inslifulions, Transients, 
or Refent Residents, and persons dying ai^ay from home. 



Nrmerftf 
Usual Residence 

When was disease contracted, 



How long at 
Marc of Death? 



Days 



II not at pl«e6i M«atli' 






,.j KCK Ol nrKIAt, OR KHM..VM, 



IQO 



I I I I V PHYSICIANS slKNilil 

: " . . H. c«reff«lly supplied. AGB .hould »« •••**|^; .1^;,.,,, information- for p.p. 

IN. B.— Every Item of Information .Hould b*;»;'*;"7^ .^ ^^„, He propcHy cl«..l«ed. The (JP- 
.t.te CAUSE OF DEATH In P'*"" !*l7*:;,„ „ ,vry In.fnce. 
«lOfi« dying sw«r from home should be ft.ven 



I 



I I 



s 






>J: 







• 




« 



WRITE PLAINLY WITH UNFADING INK-THIS IS A PERMANENT RECORD 

REF ER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



„,.„„l ..( II. Hitll '•■ No ..t-g's?*'"^^''''" 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of ©eatb 

( -Q. S. StanOarD ) 
PLACE OF DEATH:— County of 0^>'^ 



311 -\ % 

(I Va^vtvsx^ City of rla^vJMVvvc^C-o 



u 



^ 




S- 



y 



%. 



DisUbct. - 



and 



UvOVq.l'VcCU ^^^-^-'^VK^TTTr^t^^CxV^c'itLED^OR UNDER •sPEC.At.NroRMAT,^ 

„TH ocVJrs awa^Vro- USUAi. rf ^^^f.^JV^'^a./e"! nVme insteao or street ano number. ) 



FULL NAME 



.CU^^vt^ W ^ 



PERSONAL AND STATISTICAL PARTICULARS 

J «.'(»t,<>K^ 

iriaU 

hHTK Ml I'.IKTII A 

tMiiHlh) 



\ ! 






M.I-: 



O w J V.f * * • 



M 



n 



I V«-;ir I 



ha ' 



-!N' .1,1-: M VkK Il"!> 

W I !>< i\V J l» ok n ;\ 1 •'•■ ' I" I> 

'Wiilt in -"Kijtl ilf^iviLit lull : 



'SI, ill .ir I'liMiUiv 



N ilcuuvAjA 



ft 



Ax^o- 



N A \1 1 t»! 

I' A Tin; R 



lUKTin'I.ACR 

iH' 1 \riii.:H 

' Sl.itf I It Ti iitit t \ 



MAIIIKN NAMK 
OF MuTllKR 



B!RT!!PT.ArK 



<»(•)• I* |J \ T!' »^' 






^j. 



<X/"vvcL 



h'r'.i,ir,f III S,ni /'in'i' 



fhir 



UHST OF MY KSOWI.IUX.K \M> nhi.n ' 
{lnf,nmn,,l M/W H U ^T^ 

f \<ifirc««s . I • » ^^ * 



MEDICAL CERTIFICATE OF DEATH 

DATK UF UHATH ,^ n ^ 



(Vtur> 



I HI':Ki:nV CHRTII-V, That I MtUn.k-.l .U><vasca from 

to ■ ""^ 



TqO 



up 

up 
I 



that I la^t sawh rr- ahvc on 
a„tl that .Icath oc-curtcl. <-.. th. .lat. .talc.l above, at I » 
<!■ M The CAlSh: (H- 1)I:ATII ua^ as folln\v«^ 



tcJi^x*^ ^-<Hir^^n 



CDNTRinrTORV 



,)/t)>l//lS 



Pays 



Hours 



) 'ill IS 



Months 



I lours 
M.D. 



Triflsirtih, 



ifrvrw<;v 3 ^^ U). l^ta^A-4 

"sPEfciAL INFORMATION onlv tor Hosjiilals, InsfifuHons. Ir 
orlrcnt Meflts.Vnd persons dyN aw.y from home. 

i 4 j l'' ' Hov» lond a! 

Former or i m 4 g^^t^v ^<^ ' "rf •* '^«*''' "'^^ 

Usual Residence ^ > "^ ^i^J^ i. 4^ 
whM wM diMse conlracted, \ ^ j ^^ 7 mn 4.4 a ^^' 
If not at place of death/ - *— ^\ . 




I»\'r»:<>f I'.iHiAl. 01 KKMUVAI, 

N^I^JUi 35 190H 



t'NUhR 1 AKl%K V-. i • 



f \,Mrc^-^ I » ^ ^ \ \ "*"" I I II II I PHYSICIANS .hould 

-^ . .L .«refully supplied. AGB should ^^ •««*«^^*.fg^^^,,, ,„form»tlo«- fT p.^- 

N. B.— Every Item of Information .ho«ld »;^ f^^'X, U* mny He properly «l.wl««d- ^h. 8p^ 
•t- te CAUSE OF DEATH In P»«'" J^T'l^^n „ .vry l«.f «««• 
«nn« dylnft «w.y from home .ho«ld be g.ven 



•i .. 



* 



I I 

\ 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

REFER TO BACK OP CERTIFICATE FOR INSTRUCTIONS 






liegistet'cd J\^o, 



655 



oU-u-co Xu>u. Deputy Health Officer 

DEPARTMENT OFTUBLIC HEALTH=City and County of San Francisco 

Cevtificate of H)catb 

1 "a. S. StanDarD ) 



:i 



PLACE OF DEATH: — County of C'a>\' JXaiaCAw^CO City of'^^a>\' J \ai\Ci4L ac 



J 



No. I51K 



il 



V^V 



St.: ?^ Dist.; bet. 






^a 



. V % 



and 



sit 



I 




RCSIDCNCE CrVC rACTS C*LLCD roR UNDER SPECIAL I N TO RMATIO N" N 



(ir DEATH OCCURS AWAV FROM USUAL 
ir DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER 



FULL NAME 



PERSONAL AND STATISTICAL PARTICULARS 



si.:\ 






A(.l< 




,\ 



MEDICAL CERTIFICATE OF DEATH 

DATK t)l- DKATH 



A 



iM.Hinii 



I Vif I s 



may) 



Mouths 



Aic 



(Vi-an 



Int\ 



I ■ 



"t! 




■^IN'.I.l* MARKIKT>. 
wriMiW 111! OR DIVOK* KI» 

tW'iiti in 'voi'iat (li"»if nut ioii * 



niRTUt'T, XOK 
(still*- oi' '. ijiintry 



NAM} >l 
FATHKR 



4 



-U^A n 







(Ytart 




(Mjontli) X (I)av) 

liRlvI'.V C'l-kTII'V, Thai J alUii.k-a (kicascil fnmi 
I igoS to ^ ^^-^-iUi XI IqoH 



that 1 last s:i\v h 'ftV hHvc on >V^vt^ igo 

and that <kath (UTurred, on tlu" tl:iU' staled above, at » 
U. M. The CAISI': Ol' I»i; ATM was as follows: 



HIRTIUM.Ai H 
Ol- lATIIKK 

'Stati- tir t_'<)tnitr%' 



MAII)1:n nxnik 
Ol' MOTUHR 



lUR rniM.AOK 
«)i" m(»thi:r 

(Stati- iir t'ountry 



I iCI'f l»4 'I'lOV 



XCW^vK 



.t' 



A \ \ 



. wLcVarw 




I) r RAT ION * Years 
CONTRIin'TUkV 



Mou(h<i ^ U /lays Hours 









CL'wvlV 



XLLCL-^xci 



DTRATION 
(SIGNED) 



Day 



k 



Years Months 

^ /. '^ I 

H fAddriss) ab^b m^WSXKci 




fhurs 
M.D. 



_. _ JIAL INFORMATION onl) fo^ Hospitdls, Institutions, Irdiisienli, 
or Recent Residents, and persons d)ing dwa> from home. 



Rfsiift'.i lit Sii II /iiiiiinf'ti 



) fUl IS 'S ^fllllf/^^• 



/>.n 



TIIH AHOVHSTATKI) »'KR--on\i, p \RTrCf J.ARS AR H TRTK To THK 
IlKST OF" MV KNuWI,i;i)<".H AND HKLIKF 



(Iiif(»rnuint 



X.l.li 






li 



Former or 
Usual Residence 

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



toir h»l|4t 

i»lareof featli? 



Days 



Pr.ACE OF IMRIAI. OK RHMoVAI, I IlATi; of HtKtAl. or RKMoVAI, 
INDKRTAKKR V U , U Cfr VWVW-«p\^ 



N. B. Every item of Information Bhould be cnrefully Hupplled. AGB •hould be •t»ted EXACTLY. PHYSICIANS nhoulil 

state CAUSE OF DEATH In plain termn. that It may be properly claaslflcd. The "Special Information" for p«r- 
Rons dying away from home ahould be given In mvorf Instance. 



h^ 



It 

1 . 

I' 



, • 



I 



•i 



I I 




I 



i4 



II 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

,f II uHh 1 N,, ,. H^^^mvco REFER TO BACK OF CERTIPtCATg FOR INSTRUCTIONS 

656 



J)n/r AV/^W.JkJLu, 'X'\ lOOH 

i^yvcvj Xi^^vu Deputy Health Officer 



Registered JVo. 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of H)eatb 



( ta. S. StanDarC> ) 



PLACE OF DEATH: — County of ^<X^ Iva^VC^^^OCity of a^v 1 Aa >x ^ < 
rl^"^ ^ ^tcKliClt^\3 '"^ll . SU Dist.;bct— ———and -" 

/ .r OE.TH OCCURS *w*v FROM USUAL RESIDENCE G.VC facts c*ulcd 70R UN « ^j;";*i '^^^''r^J'^'"* ' ) 
( lV0C*TH OCCURRtD IN * HOSPITAU OB INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / 



S V 



-) 



FULL NAME 



1 ^ li 



-4 



SKX 



PERSONAL AND STATISTICAL PARTICULARS 



Ci 



r>Arj: oi hirth 



iM.iiHh* 



\',|.: 



h% 5V.7. 



(Day I 



M.,utlt~ 



, 111 

1 Vr;ir> 



Dn\ 



HIN<;i.H. MARKIKU 
wnw>\VKI) nR |»IVnKrKl> 

(Writfiit social >!t "ivii.if iiiii I 



niRrin'i-Xt'i-; 

estate nr t'uunti y 






MEDICAL CERTIFICATE OF DEATH 



I<)0 

(Year I 



DATK OF DICATH \ 

I III«:KI'BV CIvKTII'V, Tliat r atttiiikMl (kHxasid from 

— • — 190 — — to — "^ — \^ — 

that I last saw !i alivf <ni — ^ — — ^-"^gO '^ 

and that 'leath uccurreil, (»n the <lati- stattil above, at " 
"M. The CAl'SH Ol' I)1;ATI1 was as follows: 



""^f. The CAlSh IH* i'»--*ii' W'ls as loiiow 



•\.,r^\x« 



NAM1-; o|. 
I MUKR 



niKTlII'I.ACR 
«H I AlllKR 

I Stat* i>r C<j\i!itrv) 



M AID V. N' N A M I", 
ol' MOTHKR 



HIKTITPT^ACR 
01 MOTHHR 
(Stall- (If i"()iit»lry) 



'LVOpV 



4> 



Vf IV. 



lUvi 



S^^vCr^^J^X' 



\ " " 

DT RATION Years 

CONTRini'THRV 



^ » . • ... 

Months Pays 






Hours 



DL' RAT ION* Years . Months Pays 

(SIGNED) A-C\C^V*A' ' 13 U'- "Ula vv4^ 



I four % 
M.D. 



r<)0 



A . 



>U4, \ r.\ I'i' /N 



"?V\ 



\. 



Rfsulfti III Still / I mil ni'<> 



M.uitli' 



Ihn 



THK AnOVK STATKO PKR^ONAl. I'A K I IsT I \Ks A R K TK IK 1' » iHh 
lUCsr oi- MY XNO\Vl.i:i>«.H^N*D Hi:t,lFI' 

(In fot ,„ant yfUA.^ " K ^ C I ^. ' ' 



ikpECIAL INFORMATION onl) ior HosplUH. Institulion^, Transleiits, 
w Recent Residents, and persons dylni} a>*Hv from Nac. 

K^J^dence t ! H wCiM^M „^e of Oe*lli? Ufi 

H^n **as disease rontr«ted. 

If not at place of deatfi ? _^^_ 



ri.ACK OF IMRIAI, OK Hl'Mo\Af, j nAJH'.f H' wiai f»r KKMuVAl, 



NliJ.KTAKKK ^^M^ VV^ V 



,. . Tgb .hould b« .taUd BXACTLY. PHYSICIAN* Miould 

IN. B.^ Every Item of Information .liould be canekully •upplled. ^**': , , ,f,^j. ^hc **8pecl«l Infafm.tloil'' for p«i- 

•tate CAUSE OF DEATH In pl»ln term., that It mmi^ H« properly U«.«ifi« i- 

ii^« dying «w«y from homo iihould be given In .vory Iniitnnce. 



il 



■ 
.1 






J : 



ll • 



41 ' 'i 



I 




i 






f 



I 

,1 



< 



i 



.1 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



p^LV 



Ji,,at,l ,,f !l.;.llli I' N" i> t'r^^j^H&i'Co 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 







Registered JS'^o. 



657 



Deputy Healt'- Officer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Certificate of Death 

( la. S. StanDarD ) 



a v\ 



Dist: bet. 



and 



PLACE OF DEATH: — County of ^^'XTU J.VCU'^xt.UCoGty of t )i(X^^^ 
No. "^CLT\jl !l: Cs^ix^ta I' St.;— .. . 

/ ir DI-4TM OCCURS *V«*V FROM USUAL RESIDENCE GIVr r*CTS called roR UNDER SPECIAL '^FORMATION \ 
( IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD Of STREET AND NUMBER. J 

FULL NAME 0-i^.<rL<rryvc 'Ctort^^ . '-. 



PERSONAL AND STATISTICAL PARTICULARS 



m \ 



\)\oL 






l» \T!-, «>1- lUK rii 



M.\'. 



A'il 



NT'iiith) 






I Dav 



Mnuth^ 



1»<I 



SI NT, 1. 1' M \KkIi:i). 
WI|M»\VK!> <»K I)I\»>K*^ i;i) 

'W'sitt'iii siu'ial iltsisfunt i')ti) 



HlkTIII'I. MM-: 

^titr lit t'limill \ * 



ita\vuLA 



Xcx. 






MEDICAL CERTIFICATE OF DEATH 

DATK Ol- lUCATH A | 

(»..nth) X 'I>ayl lVi;iri 

I HI':RI-!HV CI-KTII'V, 'VU-a I atu-ii<k<l ilLr«.asc«l from 

that I last saw li ^ ' ^ alivf (Ui ip-^H^ '- <- \^p ■ 

atpl that ik-ath ocourrcMl, on the ilati- stated above, at 10 3 
U M. The CAl'SH OF DIC A:I'II whs 



as foll(»ws 



VCtVCC^XO-^^vCX,' O-jr Ls :tv' ^. 



V.\MJ* tU 

I- A rm.K 



lUK riii'i.ArK 

OF lAIHKK 
(Btntior Coinitrs') 



MAIUHN" NAMK 
«»J MoTMl'.K 



HtkTHl'LACK 

ni' MoTllKR 

' siiitc (ir ContUt yi 



^ '.CXvijWyxu 



XXJJ^^^x 




K i I I'A 1 i«)X 



( 



CcL'L^ 



DlkATION 



)'tiir 



.Votiths 



CONTRIIU TORY t^f tv<Xvva,Cv<rA V '^^vi ^x^v^v 



J /ours 

o 



DURATION * )V«/r5 ^.Unn//is ^ />.ns - 

(SIGNED) W»VA-vv^ ' \.C . 1 ■ ^ 

iuiu -)a TonH (A,Mress) H^S CoJui -\ 

Special Information ahIv for Huspiuis, insihutions, TrMsienh, 



//iH4rs 



M.D. 



^ 



^a 



4* 



K'C^^'VCV^^"^' 



Kesnied in Sati I'l iIik isrn 



) I'll I 



Ar.,nf/i< 



/),/! 



THK AHOVKSTXTl'.f) l'KK<.< >NA I, P AKrU"f I,A K S AKi: rHlH T< > IIU'. 
HHHT OJ.- MV KNiiW^IjH.l-; AN J) niii.u.f- 



(ttifoniiant 



( AiUlrcH«« 






Wuj 



/VVA^ 



Cal 



or Rcttnt Rcsidrnts, and pmons dying dwd) from home. 



Fonwrer 
Usual Residencf 

Whfn m% disease contracted. 
If not at place of deatti ? 



\ 



How \m ^ c\ 

Mare of Oeatfi? » Days 










DA 11 






3)1 



TOOH 



f Ailtll'SH 



1 



I 1? 



'""~**'*'"'***""'"'~^ ATP oHnotH he Mtntefl EXACTLY. PHYSICIANS ahotitd 
IN. B.— Bvery Item of information .hould be cnr.fully «"PP«»-^- ^^^^J^h^^.LI.,'^",!:^? The ••Special Inform.tlon" for p^P- 

state CAUSE OF DEATH In pinin terms, that It mny He properly vlasaifieu. 

•<m« dytnft away from home should be Hlven In avary instance. 









I I I 



r 



i|. 






L .' 



II 



t 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



:,).| nf Hinllh 1 



\,, i^-^f^-mr^iil'.Sil'^'o 



REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 






I. I 



.5^ 




Da 



Beglalered JS''o, 



658 



»8 



I,' Filed, 'WW ^"^ '■''^'''^ 

DEPARTMENT OFPUBLIC HEALTH=Clty and County of San Francisco 

(Tcvtificate of Beatb 

( "a. S. StanDarO j 

\ % \ % 

PLACE OF DEATH:— County of C^OAV JVO/WCAXOCity of 0^>^' "^ '^ '^ •. 

% \ ^ ' ^ ^ 

, J\1.^\,<M\/ dblU-Kclc'. St.; - Dist.;bet. and 

/ ,. O..TH OCCU J, .W.» r«0« USUAL BE81DENCE 0„C f.CTS C.LLCO '■>" ""°" .T%%";*iNo'«u"»«'«°" ' ) 
I If OtATM OCCUmitD IN « MO«PlT»L OK INSTITUTION OlVt 1T« NAME INSTt«0 Or STREET .NO NU«BE«. M 

J, rtl 



FULL NAME 



i 




-1 \ 



PERSONAL AND STATISTICAL PARTICULARS 



X.(r^a4; OUrd>vuxtaA 




I 



o; 



I»,\ I I (U lUK I U 



A I . K 



.Moiithl /f 



5lo 



>V,f 



I Day) 



M.nifh' 



(Vra! t 



MEDICAL CERTIFICATE OF DEATH 



xkXk 



fno 



Pit ) 



WinoWKl) OK l>IVc»KCKI> 
tWril«' in Mnial «U'«*iKiiati<»ii) 



■^latr or <."i>nnt I \- 



A 




1 \Tin;R 



Hlkllll'l.ArK 
'•I 1 \ IIIKR 
'*>tat( i»r Conntrvl 



MMMllN NAMH 
'•I MOTIIKK 



inKTIlPJ.ACH 

<ti- ^!l>■n^HR 

I stall 111 Cimnti y^ 





P } i 

(t 



' Pay' N' at 

1 lll'KI'HV CI'.KTn-V, TiKut I atteiukal .lo castMl from 



^1 



thai I last saw li • mIIvc -m, J^^^- ^'^ «9oH 

ami that iliath ()ccurrc<l, on the dale stati-.l ahnve. at 

,1^ 



V 



M. 



The CAISl*; C)I' DI^ATII was as follruvs 



DIRATION 



i.y ,x.^ . . ..^ Yrars ■■ Afont/ts 

CONTKIIUTOKV OAVC 



/>«/r.s- 



Hours 



,0L^ t'%. 



DTRATION 



^ (1 f 



Pav^ 



Muiith' 



I hi 



Rfsithil t'n San f'l o n, a^r o 

THK AUOVK STATHD PKRSnNAI, 1- \ KTK'fl.A RS A R F% TRTK T. . THH 
IIKST Ol' MY KNO\Vlj:i)'". 1% AM) HLUl-f- 



I) 

1 V<7 < 



(Infoiniant 






(SIGNED) y ^ \.AA,U.<^. 

^^ Tt)0 3 fA.hlress) bX^ U 



Hours 
M.D. 




FECIAL Information onb for Hospitals, InstituUons, franslcflts, 
or%:enl Residents, and persons d)ing away from home. 

Kl Residence ^K\4Vi.«v. ^,a^^ ^ Ns 

Wlien 
I 

I'I,ACH <>l HlKIAl, nk RKM«»\'AI, 



IWien was disease contracN, (V\^ . . . ^ -^ d * ^ L^a 
If not at plare of dcatti? \I fWUA^^rK a Aav >»^ 



OOJ^ Ccd 



IlATi:"' 1'.' lUAt. or KHMONAI, 



H 



rNDKRTAKKR 



A. Ml 






V y vi 



N. B. Bvery Item of Informetlon .hould H-^ c«>*efully supplied. J^^^ •^**" ,,,|,^^. The 'Spccin! Information- for pmr* 

•t«U CAUSE OF DEATH \n plain term., that It m«> be properly cla.«lfiea. 
•on. dying .way from home .hould be ftWen In .v-ry Instance. 



\\ 




* 



— - 



l'i.;ir. 



rii 



1 » 



vnri^i 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

..fn.ntl, ,.No ■.«C^^'»'^»'^" REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 

659 



Ddh' Filed. V^H ^"^ 



WO^ lie gist V red J\'o, 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Cevtificate of Death 

( 13. S. StanDarC» ) 



PLACE OF DEATH: — County of^ a>V 'XCL^^et4C^City 



No. 



R'^S Hack^^>v su X Distjbct. MrLo^c-^x and Jc^^t 

I ) V w%. w I k^^N- w ,,e,,»i Br<;mENCC GIWE r*CT8 C*LLCO POB UNDCB "sfCCIAt INroRMATION- \ 



) 



in 




FULL NAME 






PERSONAL AND STATISTICAL PARTICULARS 




■'I\ 



UA ri: tti I. IK III 



\<.i: 



A 



(X 



Cni.oK ^ 



i. 



I 



'N!,,iitl») 



St 



r, ,,• 



I); v> 



■^f.nith 






/M 



-^INt.l.l" MAkUIl I» 

w ri>«i\vi;i» iiK iii\< >Ki ID 



HIH rill'l. \i'J' 

"-iiii I If I 'ill til t\ 






n 




I A rin;K 



niRTH I'l. \rK 
"I I \rm-:K 



M MIMCN NAMi: 
<») MOTIIKR 



niRTHPI.Ai 1. 
Ul" MflTHHR 
(Slate or CtHintryi 



MEDICAL CERTIFICATE OF DEATH 

DAT!" <»I' I»I:ATH 






(I»av) 



190 i 

(YenrJ 



1 HI;KJ':HV CI:KTII-*V, Thai I .ittctitlcl tlcHXiiscil fii.ui 



UwLm 






u Nl I90 1 to ^"^^*> ^'^ iqoH 

that I laM ^aw h ■'-" "" U^W ^5^ i^o 1 

atul that .U-ath nrciirrcl. 011 the .lati- Malt-tl above, at 



' M. The CArSp; Ol- l>i:.\TII wa-i as follows 



X^vK >\^Lunv 



ti 



Rf^iiti-il in San /'in>n n>'" ^ ^ 'i^' 



M.nith* 



/>,? 



TUT xmnKST\TKI)PFK-"NM.l-\KTf.MI,ARSARI- TRrK To THH 
UlCST Ol- MV KNt)\Vlj;i)t.l-; AM) lu.i.ii-.f- 



(In forma III 



f Address 







.^riv 






Dr RATION )Vtf''.? 

CONTUnU'TOKV 



Mo ft //is I /'fn-f //<?/// 



DTK A T I < > N ) 'itirs JA m/M.« 

:SIGNED) ltV>>^i5 vU;-tr\vy 



/hiVS 



M.D. 



r ^ . _-. I. i». u..cni<3lc Incdfiilinnt Tr,in<> 



SPtCIAL INFORMATION "nb lor HosprfdK, Institutions, Transifnh. 
or Rp( tnl Rrsidenls. and persons dying away from tiomf. 



Fomwr «f 
UsMdl Residence 

I^R mn disease iobIiihW, 
If not at plar e of death ? 



How loflQ ik 
PtiTf of Death ? 



Days 



V-vC^j 



IM.ACK «H nf-RlAI, OR Ri:M<»VAr 

rsi.uRTAKKR \ L<xita.a^>vttt 



DATl't HiHiAi "t Ki:M<i\*A?, 



'l 



190 



Co 



■M 



N. B._Every Item of Information should be carefully f"PP«-^; p^^^Hy .l—lfled. The -Special Information^ for per- 
•tate CAUSE OF DEATH In plain term». that .t ma> "^ J J^ 
•«!• dy1«g awy from home should be ftlven In evry .natance. 



it 



' 



1 1 



' I 



I 






i 



i: r 



H.Mt.l 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

,f lUalth-H No. .. ^'^1^ luS:!' Co REFER TO BACK OF CERTIFICATE FOB INSTRUCTIONS 



pftfc Fih'd, 




llegistered JS^o, 



660 



Ji (J -\ I 

(L«r vcvo Deputy Health Officer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Ceitificatc of 2)catb 

( XX. S. StanDarD ) 



PLACE OF 



DEATH: — County of 6am; OV<Vrc tAACO City of 0<VW 



vei,4 c ' 






^ 



St. 



Dist.; bet. 



and' 



NoJ^ l*c W^V '. Cvw r. w. V . _, Br«;YnFNCE GIVE TIcts^cauJed roR under "special information- \ 

( '^ %'%r..l^li:i::.'o ::iV:^l\'i o"r ?n?t'.?u"o^n"o.ve%s name .nsteao o. street ano number. ; 



FULL NAME 



O^^XKXX.K^ '.'L^ 



i,f^ 



PERSONAL AND STATISTICAL PARTICULARS 

c«iI.<)R 






li\ 11. Ill lilRTIl 






A».H 



J'../, 






!'^ 



1»;.\ 



M,<nf/l^ 



(VfHI i 



/).f 1 .^ 



Unti ill <-«K'i;il i|> -i^'iiatiiiii) 



A 



c>v 



(SUitt 'IT <"' miitf \ 



NAMl: ()1 
I .\THKK 



RIK rillM, \»K 

■'! i\rni-:H 

(>it.iir III r(iumr%-i 



MAn»i:N NAMK 
n|.' MoTUKR 



H1RTHIM.ACK 
n|. MOTHKR 
(stfUc or Counlryl 



4 






MEDICAL CERTIFICATE OF DEATH 

DATK <>1> DllATH A j] 

I niCKlir.V CI'RTII'S', That I atlciukMl ikoiM^cil from 



(Year) 



1^- 



-t«> 



llial I last saw h ^^^^ nlive on 

ami th.it <Uath orciirrcd. on the <latc state.! almve. at 
M. The- CAISI*: ()l- DIC.^TII was as follow.s: 



■190 
■190 



M. 1 He- *. -Ai :^i% wi 1....11.. >,......>- . 

i^VK ft — *' 



!)(• RATION >'<?^.? 

CO.NTKllUTOKV 



Mouths Pays 



Hours 



^v^v^rvv 



M 



11 



» .% • »i 



L. I'. » i , » \), III III' 



/><n 



TIIK MKIVK STATHI.PHK'^oNU.I'NRTU-ir.XRSAKHrRrK T«' TllH 
m%sT OI- MV KN«i\Vlj;i><.l% AM) HI.MJ.I' 






(Infill juaiit 



[jfurs\P^ W^^ 



f Aflclretw . 



1)1 RAT I ON )■''"'■« ,^ -TA);/M.? /'rtv.^ 

(SIGNED) UX^rnJl^ J iS- ^ "^^^^ 
V^it^ „.n (A<l.lrrss) W te^viV^"'ll 



HoHr% 

M.D. 



'Special information onlH«r Hospitals. Inslitunons. Transients, 
or Rerfnt Residents, and persons dying ai^ay from home. 

Nniieror xA^\ [in* ' • 
Usual Residence IvO v W.At 

When »#s fisease tOBtrjttrt, 

If not at plare of death ? _^^____ 



How Innq at 
Pljreol Oeatli? 



Days 



i«r,.vci% 01 lURiAi, HK hi:m«»vai. 



l>\ri;i»' li! Ri.vi. fir KICMUVAF, 

190 • 



it '1 






■^^■■^i— iMwm^^MB^^Miwwi"^^'^^*^"*'™''"'^'^^**''^*™^*™^^"'^"^^^ t t d EXACTLY PHYSICIANS iihouM 

rs. B.— nv.ry l..n, ol Inlorn.«..on .h»uld h. cnr.luM, •-PP'''^ ptt^erir"'— •"""• '^h. "Spc^l-' lnfor,n..l»»" tor p.r- 
..... CAUSE OP DEATH In P'"'" !=""••;;; „".r.;i In.«n«. 



:i ; 



<i 



• 1 



,Jf 







i 



n,,;aa »f lli-aUh-I- No. is 




/)((/(' Filed , 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICAXe FOR INSTRUCTIONS 

661 



-i^-S'^-i) iu<tr C') 



Registered J^^o, 



1F\ 100^ 

Deputy Health Officer 

DEPARTMENT OpVlBLIC HEALTH=City and County of San Francisco 




fNo. 



Certificate of Death 

( H. S. Sta11^ar^ ) ^ 

PLACE OF DEATH:-County of ^^Vav. ..V(X v.C. City of V! a.X, Oxa v.C.. 

1 ( " ,vr»T°H"o?ruV."*;,"rHo"."r.t „"IT^s°,^"u^4';'V,;""s name ,»st»,, or st...t .»» »u,b., ; 



FULL NAME 




J^^XA\.' ■' 



■4- 




PERSONAL AND STATISTICAL PARTICULARS 



-vcu 



.-u 



1»\ M < •! lilK I'll 



\<.K 







1 L 



bC) 



r,.' 



II 



tUayi 



M.mths 



W 



e. '- r 



iS cart 



/J.fi- 



-IN.. I. J' MAKKlKll 

wiiHi\vi:i) «»R nivoKt i:r> 

Wrilr ill •«>oi.'il (Ir-is'tiatiiiii 



M t! ii! i.'iiuii! r \^ 



^ ft 



N\Ml% III' 

I A riiMR 



niRTIIIM.Av'K 
Of? FATIIKK 
(StBle «ir Comitrr) 



MAIDl.N* NAMK 
••!• MuTHKR 







cx.^ 



Rf silted in Sati /t ,iu,i.<r,^ ^ \ ' "' 



niKTiiri-ACH 

nv MiiTllKR 
(State «»r Coiintry^ 



.„ a^ 



THKAHOVKSTMKn.'KKSoNAM'AKTirrLXRSARHTRrKTi* Tl!H 
« H.ST OF ^M^ KN<>Ul.i;i)<".H ANH lUj.Uni j 

(Informant OXCU^^-'H W^ 



cK't 



9^act 



(Afl.If 




MEDICAL CERTIFICATE OF DEATH 

DAll-: nl^ in^ATH \\ 



JMonth) I 



*! -' 



/ 0" ' 

\V.MI > 



I Ill-RHBV Cl-lRTIl'V, ThMtJ altciKlc.l .k«*v.istMl from 

r. , ^ ' _ , 



s-^- 



lyO 



\i - I r . n ' 



that I last "-aw h 



alive on Ni*.'-'-',a 



lip 



an. lethal iUath ..courrcl, on the .late <tate.l above, at ^ I ^ 
J M. The CAISHOF I>HATII was a^ follo^^ : 



J I 



N _ 1^ 



;^ 



C'^'- CC-^^^ w I 



CONTRir.rTORV 



/>«/jv 



I /ours 



niRATION >>'?'•« 

(SIGNED) \X w 



,Uofi//fs 



Pays 



I lours 
M.D. 



i.,. 



SPECIAL INF 



(A.Mre«is) LtC\' w 



,,g FORM ATI ON on'* f«r Hospitdh. Inslifullons, Trjuslents, 
orlcwS^ResMeiitsVand persons dyinq away from iiome. 



Former or I 1 i 

Usual ResMence v - • 

Whew **is uisMK iwn«i«ii*»i 
If not at plare of death ? 

IM.ACK.)! lUKIAl. OK KH^^»VAU 

M ^ if ^^ . 

ISDKKTAKHR JU-^WV^- 

(A«l.l!««,s 0» .1 *. 



How lonq at 
Plare of Death? 



Days 



i»\ij'.i; lu HiAi. 'ii ki:movai. 



,ww^v. 



TOO i 



V f 



— — ■^— ^1 — ■^^^'— — """^ , * M nXACTLY. PHYSICIANS nhould 

„, ,„,„.....o- .Hou,d .. c.«M.x .UPP...-. ^;«^ •;;7;.''..V,.:""t.S ••«p.c... .n»or™....on" .o. p.r- 
E OF DEATH In ploln t.rm.. Ih- 1. ".-» «« P ^^^ 



N. B.— Every Item 

•fate CAUSE OF DEATH m P'"'" """:;*"',■ -v«|.y tn.tance. 
nan. dylnA awajr from hom« •hould be ftUen l« .v.i-y i» 



1! 



Ml 



I, I 





B.,l!'l < 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

RgPE R TO BACK OF CERTIFICATE FOR INSTRUCTIONS 

662 



,r iu-..iili-FNo, i« is^SESfciifii'i'" 




100\ 



£^ . A i oL . Deputy H^afth Officer 



Be0istciril Xn. 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of ©eatb 

( n. S. StanOarD ) 



PLACE OF DEATH:-County of dl(X^.^cLcV Cty of llla^^^l-cLa Lo 



^ 



Wo. Llla-N^vji^d-Oi '^' a A v^ta^ •• 



-A . ^ -A 



-) 



FULL NAME CV^.^s. 



^'v-.W 



coi.nR 



yr i 



4 



PERSONAL AND STATISTICAL PARTICULARS 

-- ^ ft 



M..iitli 



\< .1-; 



1 , 



I);ivi 



M.mttn 



I N'lari 



Iht 



SI NT. 1. 1: MAKun;i> 

u iiMiu I'D OK r>iv«imi-;i> 

Wiitt ill MH'inl lUtij^natiim) 



A 



'^1 



I'St.iU- or Coitntiy^ 



NAM I' J)l 
lATHKR 



<»|- lArm.K 

'■ st.iir (ir I'tmntryi 



MMDHN NAMK 
<>l MOTHKR 



niu rupf.AcH 

t>F MOTIIKR 
(State or Country 



* % t * * ■ 1 ' ', ■ S ' # ' f € * V 



'^VcL>v 












-^ 



( i 



"W< 






a 



K .% Ill 



'-Jl 



^K 



•I 1 



Rf side if III S,nt /'tiTtn ■■fo ^^ * >'"'' 



}r,.itth> 



/hn. 



riU, AHOVK STATKn PKKSONA.. »'^H ncrUAKS AKK TKrH Tc T..K 
IJKST <)1- MV KNOWl.l-.lX'.K AND inj.U.r 



(1 11 forma fit 



n\«=Uu^ 



f \(Mrc«^s 



MEDICAL CERTIFICATE OF DEATH 

DATK OF Dl^AIH ^ 



(Vi.'u I 



(Day) 
I IIMRUUV Cl'KTII-V. That I atten<U'tl .k< r.Ko.l from 

t()0 to ■■••- ■- "-- 190 ""^ 

that I last saw h -r— alive oil — ^-— — ,go 
and that .Icatli occurre.l, 011 the »late statc-.l al.ove. at " 

— M. The CAl'SH OV I|1':ATII was as follows: 



L 



t(N 



^ -"^ ,f -^ '. 



1)1 RAT ION )Vr7/'5 

CoNTRIIilTORV 



Mouths 



Days 



Hours 



nURATION 

(SIGNED) 

s 



Years 



/hlYS 



IQO 



Mouths 



i ^)\ T 



Hours 
M.D. 



« 1 ' 



" SPECIAL INFORMATION <M.IH«rHospltdIs.lnstilutions. Transirnts, 
or Recent Residents, and persons dyin.j away from home. 



Former or 
Usual Residence 

If not at place of deatfi ? 



Now lonq it 
PUre^ Deitli? 



liys 



n,ACK OI- BVKIM. «»K KI-MOVAI. 



lu^\M.3.i 



■^v^ 






DyiHof lit H 1*1. or RHMt»VAI. 



-^-^— ^— — — — '— ^*^* . . , ♦ H FXACTLY. PHYSICIANS should 

E OF DEATH In plnln term., «••-•»"»» ,„.,'.-„. 



N. B, Every Item 

•tat« CAUSE OF DEATH In pm.n J^ •■"-;;-.;„ ^,^^y Instance, 
son. dying .way from home should be fti.en m e e y 






!' 



•f t 



If 



m% 



.t'; 
I 

i 



1 



h ' 



' 1 



>! 



WRITE PLAINLY WITH UNFADING INK 



H.,,!.l ..r HiMlth— FNo. \s 



H& V Co 



i 







XK. 




V\ 



100'\ 



THIS IS A PERMANENT RECORD 

REFER T O BACK OF CERTIFICATE FOR INSTRUCTIONS 

Beiisfcrrd ^^o, 663 



"L^vu. Dc?^-^^ 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



V 



PLACE OF DEATH:— County ofCcv^v vi/va . 



Certificate of 2)catb 

( -Q. S. StnnDar^ ) 

of OCV^X) ^.'wa -. City of ' O. 



';.o 



^ 



St.; S Dist.j bet. 



% 



1 I c i >.. Q* . "i nict • hpt. , '\Xu. and 

( " r/rcirocc%%rcV.;.''rHo's"r.t o%'?^?f.?u^4';'^a.v7rxi name ..sr.« o. st«..t ..o .u.sc. ; 



) 



FULL NAME 



\ 






*>HX 



PERSONAL AND STATISTICAL PARTICULARS 



lUa'-. 



UAl K ni- niK III 




M.V, 




y,,i 



i).t\ 



i/./>/ ''/ 



i>„ 



UII)«»\VKI> OK DlVnki I I> 



■U 






lUHTHI'l.ACK 

St.ltt I)! I ■. Ml \\\\\ 



NAMK OF 
I' ATIIKR 



(il 



<^' a \v >:' \ 



1' 




MEDICAL CERTIFICATE OF DEATH 

UA'l'M t '1 ! il VI H 






1 I I \- I 



( Vi ii 



I IIKKKHV ci:i<TIFV. Tli:.i I .Ucn.li-.l .liHCM^i-a fmni 






190 H 



that I la.st saw h .. alive on |90 ^ 

a„.l that .Ic-ath ncct.rre.l, on the- -lat. .lat.a above, at I 
Q M. The CAISH OF DHATH wa-^ as follows: 



'0 

at 



s • 



IH RATION 



Vt-ars 



Months 



Days 



Hours 



CNTiunr-n.Kv *^.^■vH.. ^^-J^.^■'tt4. 



^i) 



I - - - 



»uK rni'i.ArK 

01 lATHKK 
'Stall- i>r C<Miiitry) 



MMUKN NAMK 
ni MOTHKR 



niR THn.ArK 

"( MoTllKR 
^t;iu or Coutjlry) 



nccri'ATloN 









wlt^^v 



Kf-idril HI S,ni It <nu 



tht\ 



t- fit 



T„KAnoVKSTVrFI.1.KK.oNX,.,-AKT..r^XK.AKHTRrH T. • T . . »■ 
IIKST OF MKKNOWI.HUV'*-- ^^'* HJ.i.n.i 



nnfoiinatit 



^* 



nr RATION 

(Signed 



'.V 




)V<7rf ^ Months ihiy. 



'j.s iQoH (A.Mn-Hs^ ^:4w :c^-v'.->' ' 



) li 



Hours 
M.D. 



^CIAL INFORMATION o«ly lor Hospil-ls. Institutions. Iriosirnts. 
or Refcnl Residents, and pemiis dyin! m^ tfo» hwie. 



Usual Residence 

1^1 »ws disease rontrat ted, 

If not at place ol dediiu 



Now ioN al 
Plirecf fcitk? 



Bits 



r^ACKOF m-KIAI. «»H KFM"<^ U 



\^^■^•y ' l:- 



A ff 



u • \ I •>? 



HFMnVAI. 
190 . 



t NDKHTAKli 



,H UuxiOJU Ib^l ^aavyvao 



«i 















' 



"^'^''''"' 1 I II I PHYSICIAN* .hould 

N. B.— Bvery lf« of ln«orm.tlo« .hould ^e c-^*'"''^ ^^ ^ propcrl, .I..«lf1««l. TIf Sped. 
.ftc CAUSE OF DEATH In ^^^J", J-^'i^.^'J^Urt l«.t.«cc. 
lion* dying away from h©m« •»«»»»«* «>« » 



]\,,,.u\ ..f Hf 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

,.„,„-.' so. ,5 »?S^ »'<:>•«■■> RErER TO BACK O F CERTIFICATE FOR INSTRugTIONS 



»H ^ 




Beiislcred J^''o. 



664 



JUut/i i. Deputy Health Officer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of H)catb 

( Xl. S. StanC»a^^ ) 

4 ^ 



PLACE OF DEATH: — County of a'V\ 



City of ■ 'CVVu '^\.a 






i^.3t) 1^ 



>' 



Dist.; bet.- 



and 



^CVLU l^^-VM ^ or^rNCEG.VE rAC^^CA!:;D rOR under 'sPECAL .NroRMAT.ON" ) 

( " r/irATri^J^RrcV .^THO^.^^T^At o%^?:S^?JV^roVeTTl NAM. INSTEAD O. STREET AND NUMBER. ) 

IT 1 



-) 



i 



FULL NAME ' -^ 



^ '.' 



PERSONAL AND STATISTICAL PARTICULARS 



-I 



ll<i 



\i 



l> K 11. 1 »I lilU I'll 



i' ii.' Ik 



w\- 



Oi 



M«Aill»» 



\«.i.: 



30 ,,,. 









}/.>n;f.' 






IT I 



A.' 



-iV'.i.H M.\RHii:n 

\'. tiMiSVl |> MK rifVilKOK!) 
x^iil^- ni ''Kiwi i|«-Hi|fuatinn) 



MiK rin'i,\rK 

St;it» i.r r.Hllitl \ 






I 

I 



I 



L! 



I ATM MR 



nik TIMM.Xi K 
'»! 1 \IHHK 

i.si.iti lit »'(,iint I % 



MAIUKN NAMK 
Of- MorilKR 



niKTHIM.At H 

• »|. MOTIIKK 

* dilute or Country I 



<H I ri'\'ii(»N 



Ut 



C '! , 



\ ( 



I 






1 



Retfdfd fit Sun I'liinrnfo 



THK A»OVKHTATKIM'KKM,NM.l"\KTU-ri,AK->AKKTKrK 
llIvSTf)K>A1V KNOW I,i;i>'^A^" MM,!^' 

nnfoTiiHini u^VWfrV\./C^ 






^ rtrK C) o 



(Day) lYcuil 



MEDICAL CERTIFICATE OF DEATH 

i)\ii; i»i ui:atii ' 

1 IIKRKBV l1:RTII'V, That I Mttcn<lo.l .ItMva^ol from 

— — T90 — - to - — —-trrr— — 190 - ' 

that I last sa%v h nlive on _— igo — 

a„.I that .Uath orcMirml. on the .late- statol ahovc. at 



M. 



W The C\rSI': OI" I)i:ATn was as folUms: 



-c.^". r ^ 



DTK AT ION >><''''? 

CONTUIIUTOKV 



\ 



■\ 



Months 



Day 



Hours 



Months 



Pays 



DlKATinN >Vr/r.T 

(SIGNED )...wl^U^^^^^' ^ 



Hours 
M.D. 



'..i 



"•SPECIAL INFORMATION only fjr Hospitals. Insfitutiorts. Translrnh. 
or Refent Residents, and persons dyini av^ay (rom home. 



Former or ^ ■> k 

Usual Residence "^ -^ 

WfcM was *l5eas€ contracted, 
If not at place ot death ' 



How lon9 at 
Place of Oeatli? 



Days 



,^AC,<nHiMKIA'--««»^^'"^^''| '»Vn->f n...u - KKMOVA,, 



^ 



v^c 



Hwt^^t 



190 



(Adclr«-H» 






M. 



^ 




r-'-- 
? 

r 



J. 



:;?^ 



r 



I • 



^ ] 



r 



'^'''^''*"' ,111 PHYSICIANS .liottW 

. .houlcl b. c«r.fafly -uPP»-*«- ^«^ f'tl^Tflerxl^ "Special laferm.tlon- !«• p.- 

N. B. Bverr lt«m of in?armat,o»i •hould ^^ f^^* ^/ j, ^^y he properly clM.WIed. in* P* 

.t.te CAUSE OF DEATH In »»'»'" jV'f *;;;;"„ .very ln«t.«c.. 
•on. dylnft -w.y fro« hom. .hoyld be »lve« »" 



Ill 



11 



! 



mi 



I I 



i-pi' 



r • 



t-' 



II 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

-jr^. .... .. ,. REFER TO BACK OF CE RTIFICATE FOR INSTRUCTIONS 

665 



enlth— F No. l^ '^:';*il-^ "''^'* '^'' 



Ihf/c Filed , 

\ 



Re^Lsfcrod J\''o. 



V\ 100 H 

Deputy Health Officer 

DEPARTMENT of PUBLIC HEALTH=City and County of San Francisco 



Certificate of Beatb 

I tl. S. StanOat? ) 
PLACE OF DEATH:-County of^^a^V^ VCV>xec4Xc City of "a 



^ 



Na I 



1 Cucvvv-yvtV' 



IL\.''^t Cr 



■ St. 






Dist.; bet. 



t 



L- \ K 



and 



) 



V ir Of*TN OCCU««CO I* * MO»»IT«t 



FULL NAME 



1 s /v\ ^^ ^A. 



]JL^\ 



PERSONAL AND STATISTICAL PARTICULARS 



•I \ 



^w'. 



Cnl.iiK ^ 



l»ATK nl- I5IRTII 



\'.H 



« 



(iMoiilh* 



5 . 



I i 
I 



t. 



Il 



* Vi-iu i 



/>.»< 



-IN*. 1,1 M KRK li:i». 

\v rjMiWKI* c*R DiVoRCKIi 



IMK THI'I.A*'!-: 



I 









NAMI-: OI 

F ATIIKR 



. 



o 



lUH rniM.ACK 
"l I \rnKR 

' ^\ \\t ..! r..nutry^ 



MAIIIKN NAMK 
UF MOTIIHK 



BfRTHPl.Ai'K 
«H MiiTlIHR 
'Stntr or Ctnintry' 



/y 



la. 



1 .1 



■{ 









K folded in Siin rmtuhr,) 



YrUli * 



M.nillf^ 



Ihn 



•" ^ ,, pKKTICt I XKSAKH TKlK TO THh 

THK AHOVK S r \TI- l> PKK^nN Al »*)f ,\,7, , rp*^ 
HKST OK^- KNoWIJ.lM.K \M' »l'I.'»f^ 



f Address 



il dx,v>oaA 



0^ 



U amlAXA, c^ 



MEDICAL CERTIFICATE OF DEATH 



(V<ar> 



I IIHKKBV CHRTIKV". Tl,:.t I ..tten.U-.Mooased fmn, 
. , , , up . to H^vU. .... up 

that Mast saw h i.. alive on j , »90 

,„.l that .Icalh ccrurrc.l, c, the .Inte statol abnvc. at 
M. The CAI'SI-: DT DIvATIl was as follows: 
'^ 1 . . 



M ir 



Uf RAT ION J'tW5 

CONTRIin'ToKV 



Years 



MoHihs ' /^<n V 



/font < 



Months 



Pays 



n\:'h.-: 



/fonts 

M.D. 



DURATION 
(SIGNED) 

iUpECIAL information «»lv lor HospllaK l«Mi.»ll..s I-anslrMs. 
., tetnl Mfnts'Vnd persons <lyl»g a»ay !"» ^- 

l«.fl at 

.1^ 



(Ail(lre'is) 






Usyal RfsWcncf 

WhfR was disease contracN, 

If not at pta ffOttfMth? 

l.I.^HOKn.HlAK.mKKMuVA.. 



How long at 
Plice^ Oeatk? 



|,^^->.;nf JliKJAi. or Kl.MOVAI. 

" ^0 190H 



fAddre« .• 



^-^^^1rvuU^ 



„i,^^^^ . CV4CTLY PHYSICIANS ■HouW 

E OF DEATH In pl-i« *«:-"!: ^A^L^^v ln«t«nce. 



N, B.— -Evei»y Item - 

•tate CAUSE OF DEATH In »»'-'" "7-:,Ve„''l« .v.ry ln«t«nce. 
«M« dylnft «w-y from hom. sHomW be ftlve« 






II 



1 



i» 



I « 



Ui' 





WRITE PLAINLY WITH UNFADING INK 

f lk.:,Uh-F So. 1. ^i^^- »f^''^^'^ _^ - 



Ihf/c tlloL Hv' 



{^VU^ 



a^ 



lOOH 



THIS IS A PERMANENT RECORD 

REF ER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 

666 



Be^isfrrod ^^o. 



Ijahj Deputy Health Omcer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 




% 



No. 



Ccvtiffcate of Death 

( 13. S. StanDar?) ) 
PLACE OF DEATH:-County of Orvvv i>UX >VC.- City of 'ic >V .XC.. vCv. cc 




8t.i' ' iDistsbet. 



-and 



) 



V ^^^^v:^^"^^^^ rS;^^"H^^ -:^-" :?;it^^:r::!:^-- ) 



FULL NAME 






-r\ 



PERSONAL AND STATISTICAL PARTICULARS 



^aV. 



ll'!.. 



]t\ii: Ml lUKrn 



\(.}-: 



iot»th» 



L 



t 



r% 1-1 
I I hi \ I 



I I 



HI 

siNr.I.K. MARklKH 
Wtl>o\VKI> OK ntViiKiKU 
•Wiite in >«cial i!e«ij?iiiili<>n) 



nTRTftl'l,A01% 



) ..,• 



, I ;iri 



/).; 1 



(^< 






NAMK III* 

I ktiii:r 



HIK IHl'LAiK 

Ol* I ATIIKK 

• State- or Counlry) 



MAIliKN NAMK 
OF MOTHHR 



^.:. 



(\ 






lURTHPUACK 
OF MOTIIKR 
estate or Couiilf yi 



A 



klL^"^ 



«»»Cl?PATIOK U^ 



riHST o». MY KNoWI.l.Utifc. AM> Hf.I.U.l 



MEDICAL CERTIFICATE OF DEATH 

^ I ni:Ki:BV Cl<:RTn-v! Tliti I altcn.kMl .Urcasoa from 



I go 

(Vfitr) 



190 t<» 

alive on 



iqo 

that I la^t ^a\v h alive on — '90 

a„.l that .kath .Krcurred, on the <lalc staled above, at 
M. The CAl'Sl' Oj' DI-ATII %vas as foMous 



^w M. The CAi MV v'i '"vV U , fTs 



o 



w< 



or RATION JVtfrjf 

CONTKIIHTOKV 



Months 



Pays 



Hours 



DT RATION 
(SIGNED) 



Years 



m(^ 



Months 



Ihiv 



' m (Q 



Hours 
M.D. 



i(p 



( 



A,ians.)U^f2i!iiili 



..p/ciAL INFORMATION onK lorHospitals, In.lilullons, Tra-sJeits. 

or ReTfUt Residents, ind persons dying iwty lr«i Nee. 






(Infofinnfit 



Y KNOW i.i^i>«4*i .^ '-' . ■ ' ^ 



-V 



ftrtiertr 

UsmI ResMence ^' 

i^ irK dj-^asf ronfrac tfd, 



PIACBOF niKIAI. '•« HI M<'VAI. 



How leN <t 
Ptjre^ Death? 



D^ 



unijHRTakkr V 



\ 



DAXH-'f HI KiAl. of REMOVAI* 

L s 



lAiltlrt ''* 



111 Knl^AA^-e r. 



^ - ' I ■ , II ,1 II r PHYSICIAN* .hoiiM 

ATH I- Pl.'" «"'"•;♦'••.'*"" l»...»c.. 



N. B, Every Hem o» Intorm 

.t.te CAUSE OF DEATH In "'-'" """•j;,~i„ ',v,r, l«.t.»«- 
.on. dyl.t .w./ from horn. .h«.ld b. tlv.n 



1 



J 



II 



• I 




n. 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

I n,„f.Unl,l.-.-N-o...*-fS»»&'-Co REFER TO BACK OF CERT IFICATE FOR INSTRUCTIONS 

667 



l)((te Filed, 



Registered J^o, 



?5D l^O'i 

Uv u Deputy Health Officer 

DEPARTMENT ol^ PUBLIC HEALTH=City and County of San Francisco 

Certificate of H)eatb 

( 'd. S. Stan^ar? ) 
PLACE OF DEATH: — County of <^Ojy\^ 1 \<tweUlC^Gty of ^ O/^ J.>UX^tA4 CO 
^ I % 1 \ \ 

No. O.Vt'WcK' ouS^K^-laAj 



St.; 



Dist.; bet.- 



and 



1 •■cMiai Breirtr isir r r iwr r*CTS CALLED FOR UNDER SPECIAL INFORMATION \ 

( '^ fF"o;:T:^lcC^%;r;;N''rHo"s"prAL 0%'f.:s".'.?u"TVN"a'^.;ETTl S.AM^E instead of STREET AND NUMBER. ) 



FULL NAME 



Ifl^tLkoxl h 



/QivCU^ 



PERSONAL AND STATISTICAL PARTICULARS 




SH\ 



DAT1-; nl' HIKTU 



AC.K 



\vJjL 



,2^0 



Month) 



IV )«a/' 



<Uny) 



.M„uHi' 



(Year) 



/'-/ 



SINCM-: M\KKIi:i> 
\V1I)0\VKI> MK I)IV«»R<Kt) 
i\\tit«'in *«<i<-i:il rk•^iv:^^ati'»'^' 



HIKTU Pr,ACK 
(State or Country) 




/ji^uK^ 



'^ 



NAMi: Of 
I AT MIR 



HIRTUI'I.AtK 
OI* FATHHR 

(Statr or C'f»iiiil i v^ 



M MDKN NAMK 
oi MUTIIHK 



niRTItPLACK 
OF MnTHKR 
(!«t:itr or ContitryJ 










(Yf.-tf I 



MEDICAL CERTIFICATE OF DEATH 

I HI':i<T:nV CI-RTII'V, That I attemU'l .li<v:isctl fn.iii 

CL^v^L 5- 190H to V^<4'^'^ »9oH 

tliat I last saw h ^L^WV alive on t^^'^L ^^ '9° H 

and that «Ualh occurrcMl, du the .lati- ^I.iIimI alx.vi-. at O 
01 M. Thf CAISI- Ol- pI'MII wa> as follnws: 



V 



CL 







1 \OL'^\'^,i 



>'v^vArW' 



:i^ 



KO^-^'X CA 



OCCri'ATION 



h'fyiili-il lit Sftu I'l a til I -I'll 



)'i ii I ' 



\r,>iitfis 



/>,n 



THH i\noVRST\Ti;nPHKsnNM, P\KTiriI.AHS AHK TKIK Tt » Till-: 
BKHT OI- ILLY KN*>\Vl,i:ii<.K ANI» HM.llU- 



fAcMrc'8<« 



1 ,■ 



.}/onths^ /his 



t 






J /ours 



Dl'RATION >Vrt''J Months /iays //ours 

(SIGNED) i. lb. UvlA-q^^'^^"-! I^-O. 

nU-cL ^n TOO H f A >Mr...s) iiX^ I tvluyD 6\ 
''SPECIAL INI 



ons, 



.., FORM ATI ON only 'oi^ HospHah, Institutions, Transleiits. 
orleceSlResidciits' Vnd prrsons dying a*«y ifO"" '"•'"f- 

^ j W I i. f How lonq at i 



Ftmcrir 
Usual Residenre 

When was disease ctitracted, 
If not at plai r rf fcaA ? 



Plare oi Dcatli ? 



Oa)S 



PIACF OF III RfAI. OK KFM«»VAI. I»^TK'»/ »<««*«. «r KKMl.VAI, 



.^U— 



N. «._Bv... ..e^ of ,„form-tlo« .hould be c...f«1l. .«P.».«^-. ^f «,';;7,L'..^mi!'*Thf '^^^^^^^^^ iX^^l.uL'-'Jc:";::- 
•t«te CAUSE OF DEATH In plain term.. th»t It m«y be properly cl«.»med. w pe 
«on« dying .way from home i«hoMld be ftlven In .very In.tnnce. 



-I 



1 



.Ml 



I 



I 



I 



Dale Filed , 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

n gFE R TO BACK OF CERTIFICATE FOR INSTRUCTIONS 

668 



,„l „r ll,:.lth-l--So. 1^ t^s?" »&''>-•" 




?,0 



100\ 



Re^lsforcil JVo. 



"L^ijLu Deputy Health Officer 



Ml 



^No. 



TlPnl 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Certificate of 2)eatb 

( "a. S. StaiiCiar6 ) 
PLACE OF DEATH:-County of a<J.>vd>UVWCv4^Gty ofOX^OAXl.. - 
V id. c MvLs ^^. ■ ^^^^ ^^^Si.; Dist ; bet .,^^^^,,^ ,^,„and„„.., 

FULL NAME Wk^m^ 



) 



If!? 

t'i 
"I 



si:\ 



PERSONAL AND STATISTICAL PARTICULARS 




^wL 



I)\ IJ: <)| lilKTH 



M.K 



^iNr.i.K MAkUiKn 



/•'*. , 



1. 



11 

I l>:iv 



(Year) 



Di! I .s 



WIIH'WI-.U OK DIVnKi'KfJ ^ 



H 



HIRTHPf.ACH 

(State or ('■nmtry^ 



NAM1-: Ol" 
FATIIKR 



niRTHPl.ACE 

OF FAT in: R 

(State or Country^ 



MAinF;N NAMK 
OF MOTHlsK 



lUR'rHPI.ACF: 
Ol MoTHF^K 
(State or v".iniiti\'' 



C 



i.. 



n'" 



.-i 



1 



CUv> 



ovCl'l'ATION I "J) ^ J 

V ; ^„*„ wW v_-«^ w' 



C) VJU-LcLi/- vu 



Rfsidfd in San Frutmsff) 1 •> ' > ''<" 



Mnntin 



/),n 



THKAROVEHTATKIM'KHSr>SAI VAKTU-ri.AKSAHKTRrKTo TMh 
HKST OF MY KNOWI.I-IX.H AND HI I.I) i 



(Iiifonnant 




( ^dilrcH* 



MEDICAL CERTIFICATE OF DEATH 

DATK OF Dl'ATIl A 



(Month) 




d 



n r 



I Day* 



(Year) 



I III'RIU'.V CI'RTII'V, That I atlin.k'.! <lcrc:iscMl frf.iii 
^Xj^>. too l«' ^^.^»^ 



TOO 

that I last'saw li ^ >^ alive on r^- -'-^ -' • 
an.l that .leath occurred, on the .late ^tatcl ahovc, at 
M. The CAl'SI- t)l' DliATH wa^ as folJi^JWS 



IQO^- 
190 t 



JC 



DURVTION ^ years .Vo'tlhs /^ays //ours 

CONTRIin-TORV ^^Out^^t^U^. ^S^^^- 



or RATION 

(Signed) 



)'c'ars ^ 



Afiinifis 



Pays 



//ours 



M.D. 



^^ A!^ TQO 



( 






^PEblAL INFORMATION only tor Hospitals, Institullons Transients, 
or Recent Residents, and persons dying away from «»««. 



ftriRcr w 
Usual Residence 

When was disease contracted, 
It not 4\ ^wie m yt«ui . 



How ton9 at 
Pliw^e of Death ? 



Days 




I>\TIvi4 llfHiAi, «»r RKMOVAl, 



I'LACK (IF m-RIAf. OR RKMoVAl. 
INDHkTAKKR VA ^V fl^ 

3 a U 3 



^_^^^_^— ^^ ^^11^— ^^— i^^*** . rvACTLY PHYSICIANS •hould 



if :i 



II ' 



• > 






iH 





>lll 



%i 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

, ,.„.„, ,.„-: x„.,..^:^ »..■>■■. nerER to back or ceRT.ncATE roR .nstruct.ons 

669 



Dfffr Filed, Hw 





Re^isfcj^ed J^o, 



0,0 2e90H 

Deputy Health Officer 

DEPARTMENT OI^PUBLIC HEALTH=City and County of San Francisco 

Certificate of H)eatb 

TLKCE. OF DEATH:-Countv of ^V>^ ka>vCUC^Gty of ^ W ^ ^O.^ C. A C 



i4 ) 



■^ "^ '''^^' ^ro'forMrr r.wr t^CTS*c^LEO for under "special INFORMATION" \ 

( ,r DEATH OCCURS AWAY "OM USUAL ^l^^H^^^^^^^.^'l^l^^^X NAME INSTEAD OF STREET AND NUMBER. ) 

\ \f DE/ 



M 

FULL NAME 



',^C\AV 'Rc«^^'^M 



lill. 



S!-.\ 



PERSONAL AND STATISTICAL PARTICULARS 




DATl-. nl i;lkTlI 



At;H 






1 



M,, Hi lis 



r%\\ 



3.1 



Cita! 



Am. 



SINr.I.i: M.\RkIK!> 
WIDOWHU OK I»!V»»K*'i:n 
'Wrilf in >iociiil (U-iiKnatitni) 



st.iti- iir i,"(iiiiU I N 



^liliW^u^cL 




NAMH (»p 
FA IIIKR 



()|- I A I'll HK 
siait or i'otiiUryi 



atrU 



Unat J^Ltkmvt^x; 




MAIDHN N.^'MH 
OF MOTHKR 



HIKTHPUACR 
• )F MOTHKR 
(Slate or Country^ 






nrcri'ATloN J{ 5 



.1/,..////' 



/*(M 



T„1^M.n'KSTATH.M.FH.OXA,rNKT|.rKAK.AKh.K,K Tn T„H 
HHST OF MY KSOWlj:i)«.K \M) HlJ.fJ.l 



MEDICAL CERTIFICATE OF DEATH 

DATH ol- DHATH , | „ ^ ^ 

^^1 









I JIKKF-HV CliRTIFV, Tliat^I alU-n.ltMl -K-ivasol fmm 



that I 2i ^-.ns h ^:m alive on '^^J^ '^^ '<^ H 

a„,l that acath ..ccurrcl. o., the .late statcl ab.nv, at I 
l^l^j I'lie CAISI-:!)!' niCATII wa^ as follows: 



u^ 



nrRATION y^a*s Mouth'^ 

CONTRIIU'TORV \n\ X*. 1 '• -<•^• 



Pas 



Hour 



I)r RATION 
(SIGNED) 



Years ^ M'>»ths || Pays 



//out '^ 

M.D. 



EdiAL INI 



^PECJIAL INFORMATION only for HosplUIs. Institutions, fransifnts. 
or Rc«i!t Residents, and persons dyinq away from home. 



Former or 
Usual Residence 

When was disease contracted, 
It not al pla<« •• «»-*»^ • 



How lonq at 
Plare ol Death? 



.. Oa%s 



VCH ol" '♦* '^ '^ 






(Ad<lreH^ 



3b "11 



•^ '^.^. A 



DATKo! .Hi KiAt. ur KF.MOVAL 

|v4m '^l 190H 



I NlJllK lAKF.K ^ 



^— —■«——* rvACTLY PHYSICIANS shoylii 

TH In pl«t« term., that It mt.> "f J* 



N. B»^Bvepy Item ot' Informa 

state CAUSE OF DEATH In p.».n -■■"••;-,„ ,^,^y |„.t«nc«. 
•or,, dying .way from home -houicl be g.ven 






I 



w 



I r 



1." 



■* 



1i*i 



I 



11 » 



,1 ,.f lUalth- I- No. n :frMt,:»^>> It&l'Co 



WRITE PLAINLY WITH UNFADING INK -THIS IS A PERMANENT RECORD 

REFER T O BACK OF CERTIFIOTE FOR INSTRUCTIONS 

dLb^u^ "ix\-vi Deputy Health Officer 

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

Certificate of Beatb 

{ -Q. S. Stan^arD ) n ^*^ 

f (S A yw ; n a >\ci4 c^ City of ^' cu^v J A.a^vui>ui eo 

PLACE OF DEATH : — County of V I /CWu vJ 0,0, > vvv^ w v-iiy ox 

/^ ft , T\ 



, ^ \U, vCtal ^' U.\VM\AAA\^ St.; ^ ^i',*rc^J;oroR UNDER ••specal .NrO^'lAT.ON ■ ) 

'• ^ / .r DEATH OCCURS Awlv TROM „^ « U A L^ E S^ D^^^^^^^^ J^-^f ^ ^ .^^.^^ OF STREET AND NUMBER. J 

\ ir DEATH OCCURRED IN A H0SPITAL]0R "♦^JJ^"^ " , 



) 



FULL NAME 



c 



.v\-^ n(n>v 




?^ 



SHX 



PERSONAL AND STATISTICAt PARTICULARS 




COl.oR , t 1 



IiATK »»l IlIKril 



A»;i« 






I Moiiih* 



4 W> 5'"" 



iD:iy) 



I/.'"'-'' 



('."(.Ill 



PfM 



sisr.i.K MAKKii:n. 
wiinnvKn <»k iiivr»R*K» 

<Writeiii ^>n:'\n\ iksis?iuitioii) 




HIRTniM,\»'l-: 

I St;i!f iir Country 



N \NTI- I H 
FA IHKK 



niKTHPUACK 
OJ l-ATHKR 

iSt.iti lit i'outjtrv'^ 



M \II)HN NAMK 
(U MuTHKR 



BtRTHPLACK 

(H Mr>THKR 
(s»Uiit or Country) 



a 




fUJU(L 












WEDICAL CERTIFICATE OF DEATH 

DATK or I)i:ath (^ (] -^ . 



Months 



(l):iy) 



(Yf.ifi 



I HI'KI-HV CI-:RTIFV. That I^'Vtcn.kMl.UMvasol fr.m, 

tbHtllaUsnvvhOnaliveon :jVs:in ^i l<P 1 

a„.l that .U-atli cKX-urrcl. on the ,latc ^tat.-l al...vc. at O-VO. 
ll M. Thf CAISI': OF DI-ATH \va< as follnw-^: 









^^ 



9 



r 






xJ 



T 






■-^J^ 



t\,5\>^^ V'CL^^j 



nrRATioN 

(SIGNED) 



}'t'(jrs 



trrLL 



/7a vs 



//ours 
M.D. 



K^ 



^0 



icp 



(A,.,,..ss) m^.m.<ivik.i 




"spec AL INFORMATION ."!> ••' H«splt-K l"*"'«"«»^' "-'"^''"•^• 
or Rrfelrt Vsldrnh, and ptr«ns (l>l«9 «-> l'«i" *««• 



Rf sided nt San Ptaiui%\-» 




I hi 1 



BR»TOF MY KNnWl.I.IH.h ANI) Hhl.n.t 



(Iiif<>Tinaiit 






When was disease contracted, n a .•» -^ 
If no! at plare of deatii .' ^ ' ^ 



Former 

Usual Residence 



How lonq «♦ 'I ^ 

Plife«l Beatlil ^ 0*J^ 



I ( n 



IM ACH «»F m K1AI, «»K KKMOVAI, 



riATT'of lit H! A I. or KKMoVAI. 

Hvs.Ui '^ 190H 



>n 



i ' 






'A<lclrt'*s 




I 



O) 



(AMu s>. SB ^ \ ■) ^AA^ ' ,111 PHYSICIANS .hoBlii 

' ' ; -^., . ,,^,f„„y supplied. AGB .Hnuld *;; ■'•**:J^^f .fg%cl.l l«fo««.tion- for p^r- 

N. B.— Every Item of In*^-"-*'^" •*'T ^« tcrmrth/t U m»y be properly cla-slfted. The 
.f f CAUSE OP DEATH In P'»'", j*^^'";:;,„ ,„ ,v.ry in.t.nce. 
•one dylitft away from horn, should be fttve 



1 






' f 



•I 



im 



II 




I IM M. * Hi 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

H.K.r.lof ITcMithFVo i^iS^^^H&PCo REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



Jhile Filed, 




30 lOO'i 

Deputy Health Officer 



Reglstevecl JSi^o. 



671 



DEPARTMENT OP PUBLIC HEALTH=City and County of San Francisco 



Certificate of H)eatb 

( "U. S. StanDarC> ) 
PLACE OF DEATH: — County of Oa^^ \i KCuy\CxA/ih Cixy of ^ '€ltu * Aa- 



(No. 






n 



Sxa — 



Dist.: bct» 



and 



(ir DCATH OCCURS AWAY FROM USUAL 
IF DEATH OCCURRED IN A HOSPtTAI. 



RESIDENCE Give FACTS CALLCD FOR UNDER SPEC 
OR INSTITUTION GIVE ITS NAME INSTEAD OF STREE 



lAL INFORMATION" N 
T AND NUMBER. / 



FULL NAME 




If 



U\ 



PERSONAL AND STATISTICAL PARTICULARS 



iVfto. 



IJ \\V o|. lURTII 



A'.K 



\ 



II 



f^Iotithi 



I Q 



y,a 






\/,lt/t/lS 



i Year* 



/>,l^^ 



MEDICAL CERTIFICATE OF DEATH 
DATE OF DICATU ^ 

1^' - - 

(ftfonth) / 




n.iv'' 



/go , 

(Year) 



•^I.Nt.I.i:. MARKIKI>. 

\viiM>WKn OR nrvMRi'Kfi 

(Writ** in «iocial tli-Kiirnatinn) 



niRTMIM.Ai'K 
(State or Cutitit r y 



^ 



h 



^ 



\- 



I lllCRl^HV CI:RTIFV, That I attetnltMl (Icrtrisc.l from 

190 *i 
jL ^6 I90 H 



^\jUUa XI 190I to 1^^^^^ 

that I las! saw h A,^vk alive on j'^^-^'H ^^ 
anil that ileath occurred, on the ilatc •<tatt«l above, at I 

CX M. The CATSH OF DI'ATIl was as follows: 



■\ 



NAMK OF 
FATHKR 



BIRTH PI. AOK 
OK l-ATHKR 

(,St;i!t i>r Coutitiy^ 



( 






A 



MAIIIKN NAMK 
OK MOTHKR 



lURTHT'f.ACK 
OF MOTHKR 
(State or Country) 



i 



nr RATION 



}'ears ^ Months 
CONTRiniTORV ^ ^ 



Ihi\ 



Hours 



d,^. 



Vti-UJ-T%* 



-u 



4 



«»cti'pAriuN 



^ Cwv^, w^jy-wx <?^ 



DIRATION 
(SIGNED) 

tcLu '^\ T<lO 

4- 



Ytars Months Days 






Hours 
M.D. 



I 



wiPECIAL Information on'y ^w HospiUls, Institotloiis, Trinsleits, 
or lto:efit ResMenIs, aniJ persons dyinti im) from fione. 



J:.T,SM«c^^.vtu C- 



kfsidfd in Si.'x /<iUitisfo 



Veatx 



Mimfh.' 



Da 1. 



Ilstfal Rnidnire 

When WIS disease contracted, J 
If not at place of death ? 



HoH lonq at 
Piareof Death? 



Days 



THK ^noVK ST\TI-I» I'KK^ONAI. PARTfOri.ARS AKK TKIK Tt > THK 
BKST OK MY KNOWI.KD'.K ANf> nKl.ll'F 



(Info: 



injiii 



(Address N^* U s ■ 



u- 



V\ \Cf. OK IHRIAI, OK RKMoVAf. | DAH 



I'NDKRTAKKR 

<Adclre«»« 



Ht KiAi. or RRMO%'AI, 
I90H 



:1.vtu 3 



K.1^ Wa.. 



^11.1 0>\ 



v« 



« .. It J ArF .hntild ha attttcd BX4CTLY. PHYSICIANS should 

N. B.— Every Item of lr,formatlon .hould be c.r.fully -"PP"«?- ^^^^^Hi^^i.-iTflTr Thr-'S^^^ l«foPm.tlo»- for p.r- 
•t«t« CAUSE OF DEATH In plain term., that It may b€ properly «.la«»if»ea. me op^ • 

•out dying away from home ahmild be given In myry Instance. 



U( 



I'A 



I 




WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

,.,,;,r.l of ii...ith- I vr. ,^ ■J'.f^^iJ&l'Co REFER TO BACK OF CERTiFICATg FOR INSTRUCTIONS 



f'i 



m 



l)((fe Filed, W\ 



^0 ^'^O'i 

Deputy Health Officer 



Registered JS'^o. 



672 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



PLACE OF DEATH:— County of ^ '(Xm)^K<X 



I 



Certificate of H)eatb 

( TX. S. StandarD ) 
'"^ ^K<X. . City of -^ 



CU>\; 



(IF DC 
1^ 



St 



.; t Dist.;bctA Oa^\.i 




and JXa" 



*TM OCCURS »W*V r«OM USUAL RESIDENCE GIVr r*CTS CAtLCO rOB UNOeH "SPtCIAL .NroRMATlOW \ 

^cVh occJ.»«Td .m rHoV»..T.c on .nst.tut.on g.vc its name .nstc*d or st«ct .nd numbei. ^ 



FULL NAME 



.OxAX4A) 



1 



1 



n 



>^J':k 



PERSONAL AND STATISTICAL PARTICULARS 

COl.oR 



fiV'^^^ 



1' * .+. 



DATH ol HIRTII 



AGK 






O V JVa#' I 



(hav) 



Muul/n 



aa 



> < ai 



A/ 1 A 



SIN«.I,K. MARKIKP 
WIDOUKI) OK DtVoRiKI) 
(Wtitriu -(Mial (li -ii'tiati'iii) 



HIRTlIfl.AOH 
(Stale r»r I'MHiitt V 



\AMJ-. n|. 

FAT 111 :r 



niRTnri.AfK 

OF I'ATIIHR 
iSlati' or Country 



MAinj-:N NAMK 
OF MOTIIHR 



lUK rUPUACH 
OF MOTHKR 

(Slate or C«>«inlrv! 




MEDICAL CERTIFICATE OF DEATH 

DATK <)!• DI-ATII (\ § 

ALuXm 

(%.ntli) X <i>ay) 

I III'IKI'IBV Cl'RTlFV, Tlnit I atlfii.U'«l <IcMcasc<l from 
..|tX\v 111 It ^o to .}^u^vU*^ L lip^ 



I go 1 

(Vcar) 



/ . 



.^^ 



that I last saw h ^^^v^■ alive on HVv^^u. J. L up 

aihl that «U-alh occurred, on the date stated above, at 
M. The CM JjJ': OI" I>i:.\TII was as follows: 



1 M. 

G'Jvtl 



\,^^A^sJii 



Di; RATION Id Yean 
CONTRIBUTORY 



,K, ^ 



Mouth a * tyays 



xjjy\^ 



UCCUPATIUN 



Krsiiir,! ill San I'i,t>nis,ui %'~\ ) '-"J . 



Months 



/>,n 



HKST OF' MV KNttWIJ'.lX'.K ANJ) HKI.n-.»' 



(Informant 



Ctv<vJLm 



( AiUlrcss 



5^0 5 i jJJjy^^-^fu, 



n 

V 



nr RAT ION 

(SIGNED) 



}'t'ars 



C xUv 



Mtifilhs 

ft 



/^tfi.T 



Hours 

Hours 

M.D. 



# 



^mJLu 1^ looH (Address) 1 11 1 ItUvk at 

SPEJCIAL INFORMATION only for Hospltils, Inslltufloiis. Traiislfiit?, 
or Recent Residents, and persons dyini} away from liome. 



Former tr 
Usual Residence 

Wlicn WIS disease contracic#, 
If not at place of death ? 



How I0114 at 
Plareof Oeatb? 



IM)F$ 



I'l \CK <1F Bf RIAL OR RKM«»VAI, 

ixi.krtaki:r (fl) J Wrt 



DJlTHQf lit K I A I. or RKM«»VAI, 
SI TQOH 




^ 



Address R H OfU 



0,0-44 



L 



„ ^ .pE .hould b. .tated EXACTLY. PMYUICIAN8 ahould 
tlon .hould be carefully supplied. ^^^^ •;**^",^^^^^ The »8p«ct.l Inform.Uon" for pr- 

TH In plnin term., that It mny be properly cl.s.itiea. 



N. B,— Every Item of Informa 

•tate CAUSE OF DEATH ... k |-«tance. 

•on. dylnft away from home should be ftlven In .vry I«.tance. 



)' 

41 



i( 




WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 



j».,i,t<l of tI.;.H»i I' N'» I ^ "^'^^^S^ HS: I' 




' I I 



• 



l)((h' Filed , 




Co 



HCFER TO BACK OF CERTIFICATC FOR INSTRUCTIONS 



3C 



100^ 



Registered J\i''n. 



673 



'X'^Uw'S^ l^'Vii Deput: 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Certificate of 2)eatb 

( xa. S. Stan&arD ) 
PLACE OF DEATHS— County of -'a>v J.Va^v^u4CcCity of ^ ^^ >v 1 n^vw cv4^o 



'No. 



I5H^ 




v^4,ir>v 



St.; S Dist.; bet. 



II 



tl. 



>• A«i(*« moM USUAL RESIDENCE GIVE FACTS CAtuto ro« UNOtR 'S^CCIAt INrOBMATlOW \ 
N8 AWA* '"<>•« _"_»"*'- r_ _...!;. ...^^ ^.„r .T« NAME iNSTrAD OF STRCCT AND NUMBtB. / 



and 1^ XK ) 



tl 



(,. »-.-ru #«#->-..■• AufAW rMoti USUAL R ES I DE NCE Gl VC FACTS CALLED for umoem at-tw.-i. .r,rw.,m-,.w 
" "rCATH^OCC%«CO*.;"rHO.pyTAl: OR TnJt.TUT.ON O.VC .TS NAME .NSTCAD OF STRCCT AND NUMBCR. 



FULL NAME 




k xi 




/OA. 




•^i:x 



PERSONAL AND STATISTICAL PARTICULARS 



^ 



<x 



DAIi: •>! HI K Til 



A«.K 



iMoittlijI 



) Vi/ 1 



In 

il>ay) 



M.. lit lis 



vaXl 



MEDICAL CERTIFICATE OF DEATH 

DATK OI-' f)i;\TM IX A 



n 



(Vrar» 



A<^1 



i V«'ar 



f\i 



si\r,i,K. MAKUIKD 
\VII)«»\VKlt nK IUVnKi Hll 
(Write ill •.iM'i.iI <lc*>ivMi;ili<>ii) 



lUKTHPl.AOH 
(Stall- or Country' 



fathi:r 



KIKTHI'l.ACK 
t stair or I'omitry* 



MAinKN NAMK 

<U' Mf>T!lKR 



HIRTIIPLACK 
nj- MOTHKR 

I '->i:itf or Country* 







ilLU ^ "it 



It'CLXtLU 



X^\ 






1 



,TltKRi:BV CI'RTIFY, That I atUMi.kMl .Umhm'^lmI from 



t^W 'X'l 



ic)0 i 

up '• 



, 190 n to^ iWVV^IL 

that I last saw li ' > > alive 011 ^^*- ^H 
;iti<l that (Uath occurred, on the «latc statcil a»>nvc, at ^ 
OL M. Tlie CAT SI'! Ol' DIIATII wa-^ as follows: 



DIRATION ' )\'ars ^Monih^ \ti Days * /fours 
CONTKinfTORV >U^ CrUti^ 



* Hours 
M.D. 

rs 



Cat awl 

Years * Mou(h^ 



{% 



old 



OCCri'A TION 



y 

Rfsiiifit in S.nt Jiiiihisrn i V'Qi^ )f'»it ts 



fhn 



THK AWOVF. STATHI. PKRSONAI. T'AKTIcr f.ARS AKK TRri- TO THK 
HKST t)l- MV KNnWI.l'.IX.H \Nn "'^I'V-'' 



(Tnfonnant 



ULiWt 



( AfUlreHS 



5H? 



mui^c^v ni 



DTRATION y'l^af's Monlfis i /hivs 

(SIGNED)/ ^Vlrkv ^K. OO^l^* 



SPECIAL INFORMATION only for Hospitals InstilulloflS. Trjnslfnfs, 
or Recent Residents, and persons dyiny av»ay from Iwmc. 



Former or 
Usual Residence 

When was disease contracted, 
If not at pi^^ ^^ ^^^^ ' 



HMf lonq at 
Ware of Ikatli? 



Diys 



PIACKOJ.- mKIAI, OR KKMi.VAI, | UXViMmnxM. or RKM<nAI, 
CNDKKTAKKR J^ J -^^ 



(Adtli'-'i^ 



llBl ^n\i.4.4.uC>\. 't 



.„^ . EXACTLY PHYSICIANS ^UMiM 
„. B._Bver. Item of Inforniatlon .hould be ca.efu.Iy .-ppllec.. J^f^ •f^t.-m:/ 'tM "Specl.; lnfor„..llo«- for p^r- 
•f te CAUSE OF DEATH In P»«5n term,, «»\« '» ";;^ |„,t.«ce. 
•M« dying .way from home should be ft.ven In .very In.tun 




MV 



I 



ir 



i I 



'I 



f 



i 





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

nrrra TO BACK OF CERTIF ICATE FOR INSTRUCTIONS 

674 



,..f.i,.„ni,-|.-N.. . .^F?-:?^""^''''" 

I 



I)a/c Filed, 





Registered ^''o, 



100 "X 
Deputy Health Officer 

DEPARTlflENf i PUBLIC HEALTH=City and County of San Francisco 



Certificate of ffieatb 

( m. S. StanDarD ) n 

-{ \^ .A 



^No. 



PLACE OF DEATH:— County of ^ a^V 

i'^^^^U^^db St.; ^ Dist.;bet. R tlv 



^ CUICC City of * '' O-VV J^^-^ V C U C 






and 16 



th) 



) 



I M 1^A^ Aj St.; ^ UlSt.; DCT. ^ J ^NDER "special INFORMATION- N 



FULL NAME 



^ 



PERSONAL AND STATISTICAL PARTICULARS 



M.X 



n 






COI.OK 



DATK <)!■ HIKTM 



ACM 



lOlvJU 



Mi'Hthl 



J ■-'(/ 1 






M„tillis 






Da 1 .< 



MEDICAL CERTIFICATE OF DEATH 

DATE OK 1>1:ATII 



\^ 



n A 



I go 1 

(Yf.nr^ 



SIN.M.r,, M\RHI!-.I> 
\VII)n\Vl-.!> OK DlV.tKi in 



L 



ThFBI'BY CI:RTII--v', Thnt I attcn.!..l .Ur.ascl from 

akNvl ic „oH '».|Y'H;^^ . 

„„t 1 ,ast saw h ..• ■ >.r,veon >|kU^ ^'^ >;f^ 

a„,l that .Icuth .Kcrrcl, on the ,lat. stato.l al«.vc. at I 
LUj. TJr. CArSH Ol' l.liATM wa. as follows 



niKTHlM.Vi'K 
(State or C'-nntryi 



NAMl- Ol- 
FATHKR 



niRTIiri.AOK 

Ol- i-\rnKR 

(Stall- ui lOtiiitry) 



MAIDKN NAMK 
Ol' MOTIIKR 



lURTIIPt.ACU 
nl- MOTHKR 
(State or Coutitryi 







OJ\. 







)V/7/-.? 



Months 



/hirs 



//(Ul> s 



DIRATION 
C 



DIRATION '^^"^ '--K , 

CONTRim-TORV M^CV^Ovi. ; <-^U^-U » - 



(SIGNED) 



iO rnv ^ . ^\' ^avtk. 







Hours. 
M.D. 



^AAy4i'\6 looH r^.i. in-'^s) i ^ 

0,1" ResldrM,, and pr-s.ns d.lnq a»a> Iron, h.™- 




(Iwforinatit 



(Addre'^s 






Former or 
Usual Residence 

When was disease contracted, 
It not at plate vl deatf? 



How lonq at 
Ptaceof Deatli? 



Days 






(AtWre^s *• I ^ ^^ ^^ 

of InfoPmBtloti .houtd l». "■"'^' / . He properly cIsM*"*"* 

E OF DEATH 1« Pl»»" *-'••"•: I^^JJL^!^ Instance. 



''• ''■"rtX'clrSE OF DEATH 1« •'!"J:,r,::";;;«"fn .v-y ln.t.nce. 
•m. dying -way from homo i»hould be ft.ve 



I*" 



)-n 



i 11 



i 





ii 



H 




WRITE PLAINLY WITH UNFADING INK-THIS IS A PERMANENT RECORD 

WRITE PLAIN ^^^^^ ^^ ^^^^ ^^ «RTmCAT£^0RlN8TRUCT|0N, 



,,f lli-.nth- I N" 1* 



CSEi^, HJtf Co 



/y(^H 



Jiegiatercd •A''o. 



675 



j^,^.^^,^^^ is.t\M4 Deputy Health Officer 

DEPARTMENT OFPUBLIC HEALTB-City and County of San Francisco 



Certificate of ®eatb 

( tl. S. StanCatO ; 



-? ^ 



PLACE OF DEATH:— County 



of^<V^1;vC.^V^UGty ofC5^>v1WaC.4C0 






St.; Dist.;bct. -sPtciAL iNroRMAnoN- 



) 



) 



FULL NAME 



s|-.\ 



"personal and statistical particulars 




nia 



1 



DAli: 0» lUK III 



(Mnlllht 



\(.K 



5Vi(' 



A 



, I>:.S 



M.iutlr 



ft 



MEDICAL CERTIFICATE OF DEATH 

DATK OH DHATH 






(ilotUlO ] 



V< a! 



fhi 1 > 



\Vn»nWKI> OR I>l\nRi ».l> 
(Writ.- in s<Ki:il ,kmfrmili<»n) 



tSt;itt or t'ontilry' 




rioAAAxA. 



„i,tlUsawl....> alive nu V-U^ .. 
„, that .leath ocourrcl, on tl.e .1... <:'U'^ "',...■, ... 
'■ M Tlu- CAt SI! l.l- l>';vril w«s as folL.ws 



NAM!- Ol' 
I ATlllCR 



BIRTH IM.AOK 
Ol- lArHKK 
(Stale or Country) 



MAinKN NAMH 
»)!• MOTIIKR 



lURTHlM.AOK 
(»l- MoTHKR 
(Stutf or Country > 



ncc r p X T I ( ) N fy 4" .. 




Mouths 



Pays Hour!: 



.....TORY ^ 






,„-RATi()s )•'■"« """in 



(SIGNED) 



M.D. 



Ui -W' 5^-w 




i 



^pllals, Institutions, Traflsletts. 



M,iiifli> 



fill vs 



Rr^h '-' ■■•' ^"^ frnn,'-^'- ■ „ "^^ ^hhTRCK To THK 

THK AHOVE ^TAHU^ PKH;^>^\1;^;*];1;^!iKf'''^ ' 
llKST OK MY KNO\\IJo*'»W^ 



Formfr or I | [^ \J &a> i^^ ^^"^ 



, , us V, LT JOM ^^ mtJMl Njs 

Usual Residence I u J " ^ 
When was disease contracted, 
If ««» Sit ftlarf of deain « 



(Infortnant 



(AflflresH 



\^ (fJUt. 










190- 



l,'t,.VU. fo>^K^---' _ — H EXACTLY. PHV8.C.AN8 .HouM 

1 I AOB .hould b. •«""i.^''..8 ' cl,l Inform.tloii" for p.r- 

E OF DEATH In P'»'" !"» v.n In .v.ry l».t.n«. ^^ 



lion* dylfift -w-y ^••o'" »'**'"*' 



\<\ 




-I 



I -I 



il 




Hi 




ri 



'!« 





WR.TE PLAINLY W.TH UNFADING .NK-TH.S .S A PERMANENT RECORD 

^" „rER TO »CK or CERTinCATr rOR INSTRUCTIONS 

676 








^0 



Deputy Health Officer 



Registered JVo. 



DEPARTMENT 0F>UBL1C HEALTH=City and County of San Francisco 



Certificate of Beatb 

( a S. StanCatO ) ^ ^ 

^^y^\<x^x^^<^ City of Haw J xa vvcu ■ ( 

PLACE OF DEATH :- County of a >\. J XtL ^ fl 

'■ r, ' u* .lVU-rv>V. and •'•V^'^t' ^ 

'VntO, '^'^^-l St.; ■^ D»st.;bet. •' " „„„„ .prciit >NroRMATio«> "j 



) 



FULL NAME 



(^ 



\ 



.a>U-' ^^ 






A 



PERSONAL AND STATISTICAL PARTICULARS 

IHIi; I.I l.lKlll , 1 

Month' 1 






1^ ,.„. II 



l>;iv 



M,,nf/n 



flXl 

i'ivtir) 



MEDICAL CERTIFICATE OF DEATH 

DATH <H^ DHATII |^ n ^^ 






.^<v«. 



IS 



/',! 



vIN-.l.lv MAHKII I» 
(Writ*- ill MK-iiil .1, •.ivtiati.ni 



lUKTIII'I.ACK 

st;,t. «iT t'ouiury' 



FATIIHR 



HlRTHIM.ArK 
tW I ATMKR 
mialr '>r Cuiititryi 



MAiniN NAMK 



lURTHIM.ACl". 
Ml Mi»'niKR 
(SlHti- «r Counttyi 






^v.^>.i^ 10 190H to t ^ 

,,,Hh.tacath occurred, nn the .lat. .!..!.» a1,.v.«t 
' M. TbeCArSU(>FnnATIl.a.HsfoUow«- 



C\W<nw^ J^\r^vc^ 



CONTRIHITORN 



//outs 



lu 



1 J 



AxjJUx^v-^ 



\ •■,»»'« ,1/, </////" 

DIRATION (\ ?IJ 






Hout'i 

M.D. 



Kc 



Im l^ 



\ 



A«l<lrcHs) 



? 

1 > VK'-C ' 



Hare*! ftealJi' 



(HCri'A rioN 

fi^ryiifr(f lit S 



a^^e-wv^i-*-*-^ i ML 5 ■/ 



M,inth- 






(Inf..:iiuiiit /^ ^ 

x^n,^ - %'h ^^ ^'^ 




%(riu Cx<^^ 



wouu^ 



A«ltSt ■•<*•; 



5^ \l<a%s. ' I^^- 



3C)nH • 'S^^ '^^ ^ — — ^r^ACTLY. PHYSICIANS •ho«ld 

•^ — ^TTaGB .Hould b« •«•*«i^»''.^5Sh,| Information" »or p-r- 

:, Mo..-.- .H^i;! - --i^ fr::!:::rt ^^^ch, .....«»^- -- «-*-^ 

E OF DEATH In P^^^j^Hl^^ |„ ..en. ««.«««. _ 



•en. dylnA aw»y «rom home «lio« 



=1 ti 



m 



1 



E*T] 




'I 



ll J 



4 



WRITE PLAINLY WITH UNFADING INK 



,1 ,.f Ihaltlv l- N" 1' ^^w 



, ItScl'Oo 




VJO'i 



THIS IS A PERMANENT RECORD 

o»rp TQ BACK OF CERTIFICATE FOR INSTRUCTIONS 

Be^istered JS'o, Ul'Y 



DEPARTMENT OFillBLlC HEALTB-City and County of San Francisco 



Certiticate of ®eatb 

( TH. S. StanOarD ) 



r n . f rn^v tOAXCv^Co City of '^0->A' ^1 Va 
PLACE OF DEATH : —County of a>v x^ ^ 



'No. 



^l-.'^H 



"> 



St.; 5 Dist.; bet. 



\iXk 



■i\ 



and ! 'i 



) 



--, ^ L)iSt.;Bet. _]",• special intoiimatioi." ■) 

^ „.usU»LRES,OENCEC,,tr.CTSC^.j.„ro_.^u^»«;^»,„, „„„„„,„. ^ 



-".',;r"» NVi-7 r,»o"; s,.»t .»o . 



FULL NAME 




•. I S 



PERSONAL AND STATISTICAL PARTICULARS 



MEDICAL CERTIFICATE OF DEATH 

DA IK OF Dl'lATH 






I 



I 



li\l I "I HIKTII 






AiVK 



I A JV.n 



\ 

(Dnvl 



Sl.mths 



(Veal 




0>^ 



/j<f 1 



iWritr In -H»i*'' .l,.-tiMiali.>ii» 



niKTHI'l.XOI* 

(Slatf iir t'.rtintrv 



VAMI «>l* 
FATHI R 



lUKTHri.ArK 

ni 1 \ rin:R 

I st.ttt 'ir CuittJtt >■ 



MAI1»1"N NAMH 
OF M«Hin-.K 



i»Tk rmM.AiK 

ii|. MoTlfJ'.K 
(Slate oi Cf>iitittv> 



iMTI I' A rioN 




-- , .n.;KI.:HV C.kT...V, Tl..t l a.ten.K.l .U..«.s.,l fnun 

,l,:,t I h.st saw 1. alive- on >V.....) 

J M. TlHCArS.:(.lU>i:ATIIwasasfoUn«s: 



k^ 






L 



DIRATION 
CONTRIIUTORV 

Dl-RATION 
(SIGNED) 



)V<Tr5 



-^ 



Mouths 



Pays 



I /ours 






iX. . ' 



Years 



Jfou.fhs 

•' I' 



A/v.< 



Hours 

M.D. 



Tqn_(AnaiW)_ 






tiili-- r^oMAT ON only for Hospitals, Institutions \ms\nKs. 






)V(T' •> 



Montft^ 



[lit vs 






Former or 

Usual Residence 

When WIS disease fonUacted, 

If BO* al place oNeaUn 



How \m ^t 
Plareol Oeatfc? 



Days 



(Titformanl 



XjVW'^A; m vvv^ 



(Addresss 



^IH &\&-v^^^^^ 



J 




1 ip -^H ^bfr-V^-^^ ' T^^.CTLS. PHYSICIANS .ho«M 



t;:;',;;7..~,^™:;:it;ri-:i.-.".-i.-.;.-;. — 



it 



1 






•^ 




WR.TE PLAINLY W.TH UNFADING INK-THIS IS A PERMANENT RECORD 

^^ n T1 »^.».r.>Tr FOR ■r.STRUCT.ONS 



A (1 ^^ jofiu Regime red J^o. 

Jj ' -A '' Deputy Health Officer 

DEPARTMENT Op^PUBllC HEALTH-City and County of San Francisco 



No. 



Certificate of Bcatb 

( -a. S. StanDacO ) 

^, , /- .„ „* ' CL -^v Xa^vcc^ CCi City of 1^ ''^' 
PLACE OF DEATH:— County of O.^^ ^ ^ 

* ^ 4 ( A 

\1 I la » c<^rNCEO.VC .FACTS CALLED .OR^UNOtRJPeCIAL^^ ^^^^^^_ ) 



^CUV 



l^S 



( 



ir DEATH OCCURS AWAY FRO 
ir DEATH OCCURRED IN 



°:o-r.t o%^?:?l".'=4ro^;r.r. «%" .'»"-" 



FULL NAME 




.Ct^Vww.. "■ 



PERSONAL AND STATISTICAL PARTICULARS 



sKX 



Cl>I,<»R \ 



Ql- 



V 



. ^v^ 



DA IK «H HIKTII 



AI.K 



. Month t 



^ '^ 



r. 



(Davt 



}/„ntJn 



( Vi-ar) 



/),; V. 



MEDICAL CERTIFICATE OF DEATH 

DATE OF DKATH .\ ^ . 

(%^nnlh) I 

1 ,1..:R.;HV CI-KTH-V, Th,.. l .«....1c.1 .U-asd from 

— Up 

190 ""* 



>INr.I,K MARH1KI> 
WIDnWKI* OH niXoKi Kt> 



<st:it< t'T t'oniiti v> 



NAMK OF 
FATIIKR 



KlRTHIM.Kt'K 
01 I \rHKK 
St »n III C«i\iiitry> 



MMI»1:N NAM1-: 
4»l MOTHKK 



lUKTHrUACK 
(U NtoTHKR 
(Slate or Countryi 



rK^rii'ATlOK -\ 




that I last saw h -— alive on 
,„athat<lcathoccurrea...t1,.Mat.staU.aaUove.at 

M. Tin- CAISIM)!^ 1>HATII was as follows : 






Dr RATION >'''^''^ 



Months 



Days iiour^ 



Pavs 



Vr.ivK Months 

( SIGNED ).U^^^^"' ^-r ^" 



//ours 

M.D. 



iu ^C iQoHCA^Mri:^ 






How loBfl at 
Mire of Ofath? 



Days 



rll ' > 



.\r,»if/is 



IhlV 



R,,,dr.f h i Sa» ft a »>,>■'■_ ^ "rrrTRTK TO THK 

(Infuriuant ^'^ \J y 








t " 

\ ■ 



(Adilrcss V. >.*»^ 



(Adtlrc-Hs 



* .rvACTLY. PHYSICIANS .hould 

, III- should bo •*»**i^^ .r«jLcl«l Inform.tiof." tor p«r- 

E OF DEATH In P »'". j'T! v.n 1» -v.ry l""""- 



•<m« ayiB4 -^-y *'^''"' ^ 



I ' 



^ 




'', i; 




I 



li 




BrtJ< 



WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD 

,, ..ni..Uh-l^No..ci^t^^H^l'Co REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 

679 



Vdfo FilcfL \^^^ 






U 



190\ 



Be^ititered J\i''o. 



l^vC« "^ ' Deputy Health Oflncer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 

Certificate of Beatb 

( Xl. S. StanDarD ) 
PLACE OF DEATH: — County of '^'0^>^"J-^<^^^<^^'«City of ^'^^ '^ ^^ ' 



',i r 



No. 



St 






Dist;bct.^'^^^^<^- 



'i ■» 



♦j wti. -^ - -^ ,. ^ and 

ro«.- IIQIIAI RESIDENCE GIVE FACTS CALLED rOR UNDER •SPECIAL INFORMATION • \ 
""..VlTcln^^: ':V'HO^'!.\'i 0%'fNST'?u4"'o.VE ITS NAME INSTEAD OF STREET AND NUMBER. ) 

1, i "«-. 



) 



FULL NAME 






4.CLU-C 



1 I 



luV 



ILibuLd- 



PERSONAL AND STATISTICAL PARTICULARS 

SKX ^ , ' I ^"'••'»< 



^^' 



DATK t)l lUKTM 




\<.K 



lO JV.ii 



IS 

Dayt 



rll\ 



lb 



Yt-ar) 



Pit V 



SI NT. 1,1- M\KU1KI» 
WinnWKD <»K l>IV<ikv!'I) 



\Vin< iNVKl) <»K l>IV<ikv!'I) \ 

iWritf in social (ksit'iiati'm) \ \\ i 



lURTUf'KAi'K 

' st,it< 'ir C'mntrv 



N\Mr: oi- 
l-ATI n:R 



lUKTUri.ACH 
oi- 1-\THKR 
ist;iu- '>r Cmintry) 



M \ii>i;n namk 

OI' MOTHKR 



BIRTH IM<ACK 
ol MOTIIHR 
(Si;itt iir l"i)\uitry 




j 



XT 







( 4i-| ■ I ■ P A'l" II »N 



Rrsfdfii in Sou Finnrisr. 



) 'r,i I s 



1 A ';////> 



A? 1. 



•r„KAmni,STVrK...-KK...NA,rAKrj..;.,AKSAKK.'KrH T,. TMK 
UKST OK MV KNOWUhlX.h AND I-lI.n.i 



(Informant 



(J, 



(Address 



MEDICAL CERTIFICATE OF DEATH 

DATK OF DHATII ^ 



k^li 



iHav 



{V.-ar> 



Month) f 
l"in:Ri:HV CICRTIFV, That I aUciKled .IctH-ascil from 



t.^: 190 1 t 

that I last saw h alive on 



and that (U-ath ..ccurred, on the .late •stated above, at 
^ M. The CAl'iiK OF DICATII was as follows: 



itjoH 
up 



nrRATioN > 

CONTRimTORV 



)'ear.<: 



Months 



/hiys 



I Jo II p. 



DURATION 
(SIGNED) 



Vans AfoNths 



Pays 



Hours 
M.D. 



► FECIAL INFORMATION o"|>_ ';|; JJf «'"''^' Inslitullons, TranslfMs. 



or Recent Residents, and persons dying away from home. 



Usual Residence 

^n m^ ^vf%%f fOBfrarted, 

If not at place of death? 



How long at 
|>|ife of Ofath? 



^ 






n \CE Qli HURIAI, OK KHMt»\ AI, 



I* N 1 ) K R 1 A K h K vv • CH-^A-O. W *- i^ 



DA 11' of III KiAr, or RKMOVAI, 



^ 



TOO 




-. .^ r>Aiia*: np nFATH In plain term*, inni n •"*•* • 

•tate CAUSE Uh utA in k Aiv*n in -v^ry Instance, 

•on. dylnft away from home should be ftWen .n •v.ry 



'i J] 
♦I 



it 









1 



■ 



i, 



t 



I'll 



WRITE PLAINLY WITH UNFADING INK — 



„,„.l ..f ,!. ;.ltl> -I- No 1^ 1^'^^>^»^t'Co 



Date Fih'fJ, 




'JO 



190^ 



THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INST RUCTIONS 



\ i 



DEPARTMENT 0?PUBLIC HEALTH=City and County of San Francisco 



Certificate of 2)eatb 

( Ta. S. StanOarO ) 



% 



I 



PLACE OF DEATH 



:-County of C1<X>v d.»uO.^xe^t0Gty of Ha^x -"v 



(-No. 1 1 1 ll ,c4.ce>v<twv 



X-k' 



Sf b Dist.;bct. ^H Xk> and ^ 






) 



M.; ^ I-ZISW *^"'* "' iiMnrR "special IN roRMATIO N' \ 

r.r ;rAT';'occu«s AWAV r«OM USUAL RESIDENCE o.vr rACTS ca^cl^co ^oJ^^uJ^^^^J ,,%%%% .^„ „,mbc.. ^ 

\ \r DEATH OCCURRED IN A HOSPITAL 



FULL NAME 



i 





I 



a^a'v 



si;x 



PERSONAL AND STATISTICAL PARTICULARS 



^^XcuU 



bJivjiL 



DATK «>1- ItlKTII 



\C.\f. 



lL.c, 



iMoiithl 



4 b }'..' 



\l 



ID 

(Day) 



M,'ii!li<' 



r i'5 'I. 

(Year) 



»S 



A/ 1 ^ 



MEDICAL CERTIFICATE OF DEATH 

DATK OF DICATH a I r\ Qk 



Alonth) r 



(Vcnr) 



I HF{Ri:iJV CI-KTIFY, That I.ittcn.le.l.kccascMl fnmi 
190H to^ WU|^^ lcK)H 



^\.<wlu 



SIM.I.K MARKIKH 
VVII»n\VKI» <»R DIVMkri-.I) 

(Writ! ill •"'H-ial •h'-iKniaintil 




axvut<^ 



UFKTMri.At'K 
(Statf or Country 



NAMK HI' 
lATHl'R 



niKTmM.At'K 
a\> lATIlKR 

(Slatf or Country^ 



MAIDHN KAMK 
OF MOTIIKR 



HIR THIM^ACK 
<)|- MOTIIKR 
(State or Country I 



nccr POTION 






Xu X\s> 190 V tw »- -| 

that I last saw h.V». alive on |vC^ C^t I90H 

an.l that rteath occtirred, on the date stated above, at 
► M. The CAISH OF DHATII was as follows: 

DIKATION ' Years ^ Months 'Pays ^ Hours 
CONTRIBUTORY 



©^\ 




Df RAT ION 
(SIGNED) 



Yiars 








■"'';^i^^:^^i\^^f^!^^^>''^^^'^^ '-""■'■ ■■■" '■'" 



(Informant 



.U 



,^^ f.X.Urcss) aSOlJr 




/Jar? 



Hours 
M.D. 



SPECIAL INFORMATION only for Hospitals, Inslitutions. Transknts, 
or RfTenl Residents, anJ persons dying away Irom tiome. 



Former or 
Usual Residence 

men was disease contracted, 
If not at place of deft* ? 



How long at 
Place of Dealli? 



Days 



PI,ACE OK niRIAU OR RKM<»\ AI, 




\ 



C'0^>'V! 



PATH of lit Ki.Ai or RKMOVAI* 

^wtu hi 190H 

.SI>HRTAKKR I) aL >4X ^<^^^Y^''^U 



(AdilrcH.'; 



■N 



(Address 1 v e«. * w*^ .....^^.^^^m^mmmmmmmmimmmmmmmm^m^'^^'^— 

.^i^^^ ^^^M^— — —^''^'^^ ^ J EXACTLY PHYSICIANS shoula 

state CAUSE Oh ut a in m h ^iven In mvry Instance. 

«on« dying away from home should be given in • • y 






i 

I 



) 'If 



I 




WRITE PLA.NUY WITH UNFAD.NG .NK-TH.S IS A PERMANENT RECORD 
WRITE PLAIN ,„ , rn - .>-..r...»Tr roR instructions 

., ..■,....„ „-.■■%•.. .^-t^B^ ■'&■■' ■" — — ' Wc^M 



Registered J^'^o. 



-Y r -T 



DEPART1«ENT0?PI)BLIC HEAlTH=City and County of San Francisco 

Certificate of S)eatb 

( tl. S. StanCatS ) . 

^ . A o ^3v<x^vt^^r-ccity of cSa^v ixa^vc. 

PLACE OF DEATH : — County of ^ a ' V v^ 



V %f DEATH OCCURRED IN » HO»pit 

FULL NAME 



- ) 






•^J.X 



PERSONAL AND STATISTIC.L PARTICULARS 

COI.OR \ 




m 



l.Mi: «i! HIKTH 




UOJv-l- 



t Day) 



(Year) 



MEDICAL CERTIFICATE OF DEATH 
DATE OF DKATH 



(Day) 



(Year) 



Ar.K 



VtUlt s 



sINT.I.K M\RU1KI> 

(Wiit.- ill -"i:"' '!'-'^"i='l""»' 



;S 



■" Mnuths «^ ♦> 



V^WO' 



P<7 V 



-ThF^^BV CHRTIFY. Tluit Iatten<leaclecea.ea from 

A ' • ^ , i\.. . y . , 11 too H 

N^VVVH ..3^^ 190^ ^' 



V^- '-^'t 




190 H 
190 




niK TIUM.AOK 
1 Slate or Country 



FATHKR 



niKTIUM.ACK 
OF FATIIKR 
(Stale «jr Country 



MAini:N SAM1-: 

1)1- MoTlIKK 



HIRTHIM.ACK 
01 MOTIIKR 

(St:it«- or Country 



ft 






%^-^ '^^ \-r 

that I last saw h A. alive on |^^^ - r . 

an,Ubat death occurred, on the date stated ahnv., at 
U ,M. The CAUSB OF DHATfl was as follows: 

4^ cv^\^. Ly\Uj^^ 



V^^\ 



M 



1% 



) t-a I < 



^f.„tf/ts %k^JMy>_ 






(Infiirtnaiit 



3.5 06 JxJUU^'U^X 



nuRATms >■.■■'" » 

L %^IQ0N_ 



/?rt>'5 /^//r^ 



Pavs 



//ours 
M.D. 



i J ^c^ ,,,S (AddrcssOSOOjJJ^^ 
orlec^nl Resfdents. and persons dyin, away fro. home. 



How long at 
Plafc of Death? 



Days 



'i 

c) 



r 



INDHRTAKKR 






■rJ^CHOF BURIAUnK KKM«'VAI. 

(Ad«lre«is a>» V-^ > 



(AddrcM 3*5 - AAAA 1,1, ^^^„,j 

,«.. dyln4 •w>' '-^ """" " , 



I I 



M* 



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

^^ ^n »r.K o, CERTIFICATe FOR INSTRUCTIONa 

J (1 -\J 



Re^istcvpd JSI'o, 



DEPARTMENT OF PUBLIC BE ALTB-City and County of San Francisco 



(3TI 



Certificate of ©eatb 

( la. S. Stan^a^^ ) 

A /^ . . City of ^O.^ A a -> wC 

PLACE OF DEATH: — County of ^ . 

I ,f OtlLTM OCCUHiltO iN « MO»rn ^ 



) 



FULL NAME 



PERSONAL AND STATISTICAL PARTICULARS 




'^KX 



DATi: "f HI Kill 



COI.OR ^ 



X, 



u 



ai 



M-iilth 



Ar.i" 



) f i» > » 



Day 



\l.»i<li 



t-ar) 



/».n 



MEDICAL CERTIFICATE OF DEATH 

DA IK <»!• l»K^>» Ay ^ " 

xkkx 



(Yearl 



Month H ^ 

1 HIKICBV CI;KT11-V, fh»t Iattcn,U-.l.U.,casc,l from 

A (1 . H 1. » « 



to, V^^ 






HISr.l.K. MAKK1KI> 
WIUOWKI* MR IHVoKt Kfl 

JWTiti ill -iK-ial <1' 'UMi.iti'.n. 



inKTni'i.xii: 

iSt.itf or fiHiiiUy 



NAMK «»F 
FATHHR 



BIRTHri.AfH 
OF lAfllKK 
ISliiU or Country) 



MMIiKN NAMK 
nl- MOTIIKR 



lURTHPI.ACK 
«»J MOTHKR 
(St:ii 1 m Counli y ' 



a 






that I l«sl saw h A .. alive on ^ •- '^ i ' "^ 

„„U„«t .Until .KTCrre,!, ..,. the .UU- <t...-.l above, at 

- M^ The CAI S..: Ol- l)liA,ni «-s as folLmst 



(?^l 



\^v<r^^<»-^ 



o^^^Ima^^*-'- 



(r 



DIRATK^N 
CONTRIHITORV 






4i 



Years , .1/.>«///^ 

"1 



/)<?>.S 



Hours 



DURATION ^ m I 



/?<JI'^ 



Hours 



(SIGNED) 



-ifi iqoH_(A±limL 



'I3i U/avU 



^Kco 



OCCITPATION y^. 



)'i-,ii 



Mi.iilhs 



Pay.' 



(Infortnant 



A'^^ isMents and persons dying a.ay frei, h^ie. 

Jo -^ » H«^ ••"« ** , IL.« 

Pomifror rtMn/^/^A' Plate of Death? - wy^ 

Usvat RcsMence SJ.^<^^ 

Wlif n Wis dhease cwtrae tH. 



,A.am 



QfYuJU^t^ 



MOT>.>r _ ^ -— . . , n, ^,Aj, or KHMuYAI, 



H;^ 



190 






(Address 



I 



(A.tare.« dJlMmi^ gAxA^m^ _ ^ — — . y. physicians .hwld 

•on. dying away from horn* •tioui _. 



! 'tl 




r H 



i*>» 



WRITE PLAINLY WITH UNFADING INK-THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



,,nU :. '.t1r- 1 Nn l^-P^^^ 

luih' Filed , 



n&pco 



30 



vjo'i 



Registered J^''o. 



683 



tv-u Deputy Health Officer 

DEPARTMENT OF PUBLIC HEAlTH=City and County of San Francisco 

Certificate of Beatb 

PLACE OF DEATH: -County of- a >VVCV^v ^ . 

V ir OCftTM OCCUBWCO IN A H08P.T.U ^ i y^^ 






) 



FULL NAME Aai 4 VWv ^^ <^ '^ "-''"^''' ^ 



u M I UaA^ 



,^u 



PERSONAL AND%TATlSTICAt PARTICULARS 



y 



I 



iiAii. i»i HiRin 



A'.}-: 



■'M..iith' * 



JV<T> * 






■>'. .11 



/)./ 1 ■ 



I go 

(Year) 



(Writ* in ^'>«-':»l <!»'.U''i.»«"'»' 



HlRTinM.\t*l. 

S»;it< If fiiniittv 



N.WfH Ol* 
FATHKR 



HlkTini.Ai K 
<>! I ATIIKR 

tStatf or Cmiiitry 



M \n>KN NAM!-: 

oi Morni:K 



niRTiiri.ACK 

u|. M<»THKR ^ 
(Stale or Country' 



Ml IT 1' AT ION 






MEDICAL CERTIFICATE OF DEATH 

UATK or DKATll l» y ^ * 

(ll^I^^H (Day) _ 

, HHKHHV Cl-RTIFNVThat Ia|tcu.lc.Mc<c.asea f^m. 
'.o to l^^^a. -^H 

that I last saw h-^ alive on >^^ > J^ 

,a that aeath occurrea. ..n the aate statcl above, al 

M The CAISK OF UKATIl Nsa^ as follows: 









l)t-RATI()N >Vw^ 

CUNTRIIHTORV 

Dl- RATION i^<^';* 

(SIGNED) V' ^ \l 



•\fflnths 



Days Hours 



.}fotithy 



Part 



^0 



H 



\i I ■«■ *- — ^ 



Hums 
M.D. 



., to" R'sid«t'7nd pt.s.«s d>i., a«, fr« »««• 



Rfulfif i» """> f''"_ 



1' ./ 



//i. XA'*^''^' 



I, I '■'• 



„. CmM^-(BUJvw- 




Hare of Ofith? 



Oiys 






I,A(;j- ..i H. KJAt. *>r KKMOVAI, 



■H 



i^« dylnft -way from hom« .hm.ld »« ft _ 



I 1 




I 



f' 



WRITE PLAINLY WITH UNFADING INK-THIS IS A PERMANENT RECORD 



1!J0H 



Begidered JVo. 



684 



Date Fileil, "^\^KkK\ ^C) 

i>^v. Wu Deputy Heafth Officer 

DEPARTMENT OFPUBLIC HEALTli=City and County of San Francisco 



Certificate of Death 

Xl. S. StanDarD ) 






J jf 



No. 



PLACE OF DEATH: — County of a^^ vj .c^ i 






n 



St; S Dist.;bet. 






3 IL and 

iPECIAL INFORMATION" \ 



) 



( if DEATH OCCUHHCO IN A HOSPITAL 



FULL NAME 




tvVVYXJ 




0-Z 



^v 



SF"\ 



PERSONAL AND STATISTICAL PARTICULARS 



^oL 



,1 



KAir: nl lURlH 



A«.H 



1 M,)iilh» 



y V *../» 






\/..,l!/f 



Vtiir* 



An. 



MEDICAL CERTIFICATE OF DEATH 

DATE OF DKATH ^^ 

akXm 



^loiith) if 



(l)av> 



I go 

(Year) 



TuFRinJV CKRTIFV. Tluit [ cvUcmlc-.l aoroaso.l from 



WnxiUHI* «>K liiVnRi 1 l> 
tWtttr ill >-'"i;i! -!• -I'/nat i< -n ' 



1 
1 



k J 



TIIK TfnM,\^'H 

'St.-itf «»r ».'.>iuiti ^ 



NAMH OF 
FATHKR 



BIR IHIM,Ai*K 
OF lATIIKK 

iSlrilf or Cmiutry' 



VfAim'N NAMK 



lUK THIM^Al'K 
III MOTIIKK 

' SlMtl- ur i'lMllltl N ^ 



iM'Cl- P \ I I< iN 



l] 






„,„! that ,Kall, occurrcl, ...> the .lat. stat.M ahovc, at V., 
M. The CAISH Ol' HHATM «ns as follows: 



IMRATION " '■'•"" 
C()NTKIIU"r()RV 



MoHlhs 4 naya ' //•""> 



(SIGNED) A^ Ivad^Uu-A 



flours 
M.D. 



%a 



(A'Mri'^'^^ 



/■/; » 



\r,,)itlr 



/),n 



J1F;hT OF MV KNOWIJ-.lX.Jj 



( AdtlrcHS 






(Inf.nnuint 'J .A.A^^^'^ 



tpEtl«L INFORMATION only ..MJospitals, l-s.i.«i.-s, T«ns...s, 
„ R " tesidenis, anJ pcts.ns dyln, awa* lf.m h««. 

Days 



formff or 
Usual Residence 

^rn wa5 disease contracted, 

II li«i *k ^»*f "' ^^ 
Ti.ACK01.J.rK.M..~ KKMOVA,. 

c^ 



How lonq at 
Mare of Death? 



INDHRTAKFR UX^^^^ ^^ ^, , 



t,\TFuf llrKlAi, ur RKMOVAI, 

Ui i r . , Si 190 : 



^^^ III <*^*** 

ATH In Pl«'» t^/"«': ***• JL"1' t l„.fnc«. 



"• "-SrHHi'i-. si—i-vi. ■.... ...-«•■ 



t \ 



I 



■f 



\ 




,,.,11.1 i-f ll> ;'"'' 



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

REFER TO BACK OF CERTIFICATE FO R INSTRUCTIONS 




100\ 
Deputy Health OfTlcer 



DEPARTMENT 0^ PUBLIC HEALTH-City and County of San Francisco 



Certiticatc of Beatb 

PLACE OF DEATH: — County of a^\; v ^^ 






Vv^. ■ 



St4 ' DlSt.;bct. ^.^oEB 'SPECAL INFORMATION- 



i.^ 



) 



) 



FULL NAME 




\ 




i^AAA.am\ 



i 
w. 



\< lO 



! 



hj:\ 



ClY 



PERSONAL AND STATISTICAL PARTICULARS 

DSTK «»F lUKTfl j^i ^ ^ 



I 



Uav 



l I ) ,.!».* 



M.nith' 



« ca: 



/)(n. 



MEDICAL CERTIFICATE OF DEATH 



IQO 

(Year) 



\VIUM\VK1> «>K inoKl K. 

Wtitr ill -x'mI ,!< -i-tnition) 



A 



iKcX'.^w 



niKTUlM AOK 



I ATHKR 



HIRTHIM.Al'K 
OF F ATHKR 
iHtnlr or Country) 



MAini'.N NAMK 
OK MOTHKR 



niKTMPI.ACK 
«il Mt)TnK,R 

(Sitatc Of i'.i\iiili\ 






Lr>^^^'' 



DATE OF DHATII \ \ 

vuXu 

" 1 JIFRHBV CKRTIFV. That lattenacaacvasecl frou, 

U.tllalawh. alive on |^%^ ^H 

,.,Uhat death occurre.1, .m the date stat.d above, at ^-^U 
CL M. The CAi:SH OF DI-ATII was as follows: 



A/vy 



'^-Nlt.v'Ww^ 



,W^v'VS-'w', 



tc 



I 



4 



C),Vvi.Vv ''- 






Jfi,>utl<x^vcL 



m RATION - )VU-. - •'/.""/» '^^-: 

(SIGNED) 10^^. ^ '^,;^:^ 



//ours 



//ours 
M.D. 



.VM 



5.H 



)"'(?' 



ytonih^ 



luiv 



HHST o 1 M V K N o \M . ' • I " • * ■ '^ 



(Informant t- "^ ^ ^"^ 



(A«Ulres!i 



%^\X U ^X^C^-OA^-^^^^ 



J 



. Sp^iXTTiTF^^iif^ON only for Hospitals, Institunons, Transients. 
orleTcntRe'sldent ' and persons dying away from home. 

m -tiHowIonqat • 

Former or . /^js Jx-v\wi^A^ Otpiaff of Oeatfc? » w^y* 

Usual Residence vow ^-^ ^ 

When was disease contracted, 
It not at ^ttte »i " 



j^V^viK; \X4^v4^^vs^ 



Otr "S^O-VVV^i ) 



I)\Ti:..t lu lUAL or RHMOVAI. 



rSDKRTAJ^KR 

(Addrf-HH 



g O^^r^^ V^^ 



^\aJwu 3^1 



IQOH 



1X5^ 



A.4.,^-A..«f^ 



3^5 I X ^J ^^ ^^^^^^^""^ ' — .EXACTLY PHYSICIANS liould 

rrrX^TZpHedT AGB .houW ^ •^•»*:J^f .fs^^^.i.; ,„form«tlo«" tor p-r- 

N B.— Bvery Uen, of lnf.r«.«tlo« .ho«ld be --»«J«^^ -^ ;;|»^^ ^ ,,„,er.y .«.-»tl.-. The 






1 1 



Hill 










l.Mi.i -f ll.-:,llh »' N'" :'■ 



«8j V Co 



loo'i 



A 



WR.TE PLAINLY WITH UNFADING .NK-TH.S IS A PERMANENT RECORD 

wr FER TO B»CK OF CERTIFICATE FO R INSTRUCTIONS 

686 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of Beatb 



( 'Q. S. StanDarD ) 



PLACE OF DEATH:— County of tc^X ^^ A.U, v y 






ft 



V hr DEATH OCCUHWCD I W A MO»»-<^-»- 

\ . 1 L . 



) 



\ 



FULL NAME 



'.:< rV 'V ■ 



S 



PERSONAL AND STATISTICAL PARTICULARS 



HA 1 1: <)! P.IK I n 



\<.K 



w » 






) V*ll 4 



I»av 



M. tilth' 



\ , ;il 



WEDICAL CERTIFICATE OF DEATH 

DATE u» I'KATH ', 



K Month ^ I 



(Day) 



(Year) 



(N 



HlSiU.K. MARKIMJ 
WIDnWKn OK DIX'^J'^H* 






niHTin'i.voK 

•StJltC «>r •inllltl V 



SAMK OK 
FATIIKR 



BIRTH n.MH 
OF FATHKR 

•State or Coutiiryt 



MAI! ON' N\M1 
<)! MorilJ-.K 



HIKTHIM.ACK 
(i|. MmTIIKR 

(Ststr iiT I'-.miti 






, HURUBV Cl-RTU-V, That I.tu-.U-.l .U..v.-,sc.l from 

that nasi -Mwl.'-- ^'I'vcon -V^-- 't" ' 

nn,l that .Uath rx-ourred, ...1 the ,late stalcl a1,.,vc, at 1 
Ob M. The CAISI- Ul- Ul-ATII was as follows: 



l.d 



.v^^vlvwvx Du ; (Jtx^%^ft^v 1-- X D 



DIRATION ' JVar^ 
CONTRIBrTORV 



.1A>/////5 H /^'^^^" * ^^^"''' 









M.D. 



iW^SAHt^C^ 



^- ^ ' ,K.rnRMATION «nl> tor H ospitals, lnstitytiOBS. TransieiiK 
,r»Srt Residents, and persons dying ^^ from ».<*«. 



oc *./ ^ i 



Rf^ldi'.f "I "^'i*' /'iil't.'-r. 



)'r-i1l 



\r.,)iths 



Hum 



.v» t |.i W lit fl. AK-- AKI-. I Ki '^ 




ftowloiMiat 
Ware of Oeitt? 



1^ 



rSDKRTAKER 



DATHo/ IMKiAt. or RK*IO%*AI, 

^rtjwX^ 2-w 190'^ 



(Ad<lr<'^«* 






tsO U"V III PHYSICIANS ahMM 

. ^ -, .,.,.,„ .uppllcd. AGE should •>. .»««- BXWiTLY^ ,„,„™.,lo»" tor p.r. 

of lnform.tI.n .hou Id be '-'•'-"» •"^'' b. properly cl....«led. Th. P« 

E OF DEATH In P'-J" "l".';.'.'.'!- .«r!; .""-.. 



"• "•-";.«'ca'"8e of DEATH u p- «-;;.;-;„ .«/, ...«n« 

•9R« dylnA •^^•y »'•*»" •***"** « 



II 



I 



V, 



III 



WRITE PLAINLY WITH UNFADING INK 

,,,„,i ,.f ii,,.Hii i-No. .t-^g^r^i'M'^-" 




THIS IS A PERMANENT RECORD 

nCFER TO B ACK OF CERTIFICATg FOR IN STRUCTIONS 

Registered JVo. 



687 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of 2)eatb 

( -a. s. StanOarD ) 



No. 



PLACE OF DEATH:-County of a^ OXa^ .^^v Uty ot^ 

f J ! - -i St.: ■ Dist.:bet._ ..Jlt^l^' „„./,„,„^1.t 



! X^ r>. ^ ^ St.; ^^^*** ^'^^l^ c« J UND^R '^SPECIAL INFORMATION- \ 

^ ir Dl»TH\occui>«io IN « MOSPn«i- OR I" . ^ ^ ,-J^ ^ 



) 



FULL NAME 



Ice ^ '^ 



u 



eVU.4.' 



-'.wK^ 



tU. 1 



SK\ 



PERSONAL AND STATISTICAL PARTICULARS 



tUcOc 



lliLtt 



HA IK «»l HIKTII 



xr.H 



I Month I K 



(Day 



■» «a 



t) 



i I JV.M 



M.itillr 



n,i 



I go 

(Year) 



- MEDICAL CERTIFICATE OF DEATH 

DATK Of- DKATII i \ y 

1 UKRHUV CHUTirv; That I altcnacMl .leccasc.l fron. 

. T- -~ IQO 

. r-^r-r-lgO—^ to ^ 

that I last saw h ^ " alive on ^"^ 



msr.i.K. MARKim 
WITM»WKI> OK !M\«»Ki l-.J> 
Writr in -»«'al .). «.'K'n;ili..nl 



lUK rinM,A**H 

(State or ••Hinirj'' 



^1 i\ax' 



„„a that acath occurred, on the A.W stated above, at 
M.,The CAISK OF IHvATlI was as follows 



.iv^|wU.\U 



v 






Ix^.^^^^ 



I Ai hi:R 



lllKTIiri.At H 
ill I ATHKK 
<Stfitc or Country I 



MAIUHN NAMJ: 
or MOTHKR 



niRTIIIM.ACH 
OH MOTIIHK 

(stntt iir C«ntnliv1 



LIvv^mx>^ '^^'^^ 






X)\jyy^J>jy^^\ 



I)rRATH)N y^'^*'^ 

CONTKIIUTORY 

DCRATION »^'^ 



^fon^hs 



Pays 



Hours 







> »'t V, 



■ •*-»%♦ * 






Miinthy 



fhn 



Kfsutni in .-i'rr _ .^ r. . ^u,. TRIK m TIIK 



(SIGNED „ 

^ipEilAL INFORMATION oM> '•' «;^'"*' '"^'"""" 

How loni at 
plifeof Dfatht 



[iorhi, Transleits, 



(Infoniwtit 







Itays 



DATl' of lit RiAi- "«■ RKMOVAI, 

I go ' 




t'NDHKTAKl-.R 

(AtUlrrs* 






fA.Mrc.1. 1> v(r\A4/->^A^^'^^^^^^ mm irf«ouM 



wmTE PLAINLY W.TH UNFADING INK-THIS IS A PERMANENT RECORD 

REFER TO BACK OF C ERTIFICATE FOR INSTRUCTIONS 



H.Kti.l "f 111 ■..nil- J' ^■' 



.. tJr^r:t.-.i'..vr 






X 



tvXu s^O 



Registered ^^o. 



688 



Deputy Health Officer 

DEPARtIiENT OI^PIIBLIC BEALTH-City and County of San Francisco 



Certificate of Seatb 

( "Q. S. StauDarD ) 



xau ci^ac^ 



r^ , ^f ^a'^^' l\amC<AAO City of ^^^^rv J 
PLACE OF DEATH: — County of <^'>\ -^^ ^ ^^^-^^ 



PLACE OF DEATH: — County of ^^^ - ww»wx^ - r ^ . 



) 



FULL NAME 



PERSONAL AND STATISTICAL PARTICULARS 

IT rl'h'h 







Month ^ 



\i :if I 



\«,K 






11 



MEDICAL CERTIFICATE OF DEATH 



(|!..nth> /T "•- 



^isni.K MAkKII I> 

tWiit. ill -.. i:i1 fl. -ivii^ttx'Ul 



i 



B1KTIUM.\CK 

(^t.it. nr r.»ii!itry 



S\MI nl 
I ATHKK 



HiK'rm-i.ACK 
«»|- V \ riiKK 



MMIU'.N N\Mi: 
Ml M.»THKK 



lUkTHl'I.At'K 
n|- MmTHF.R 

/si;i!. ..! ri.nntryt 



« H 



^^ 



v^ 



a\^» td 



^ 



L^V-vvlA.*-*-^ 



I'f 



I. ICau-''^ 



LiU.'w LAXrw 



„„,, „.at .kath ocourrcl, on the .C.U- ...icl .l.«v.. at I 
CL M. Tlu- CAISIC or I>1;AT1I «:.s a. follows: 



DIKATION ''l '■'iT'^ 
CONTUIIUTOKV mWa/jI 



Aa 



,€uvui- 







,s.aN«AOll\\lVpWa M.D 



K^ 



^-KlIrAt INFORMATION only 1. Hospiyls, l«.muilon. fra^sienU, 
•r^ fcSenls, and persons dying away from home. 




tew lORQ <it 

niretf Dutt? 



Nys 



nVn- ../ H'K.Al. or Kl-MnVAl. 



flnformrmt 



^^ 



/if 









(Atl«lri"i'5 






„ .-. ..--;s-:^;:™"™ ":^ r -^"""^ '^ "'" '■■""""" " """ 

.talc CAUSE OP f EA^" '" Should be ftiven l« .vry «»•«»««• 

•ons dying away from home sbouia oc k . 



ft 




t 



I 



WRITE PLAINLY WITH 



I >(,/,■ I'iloL \ 



'X-MXO 




UNFADING INK-THIS IS A PERMANENT RECORD 

BtFER TO BACK OF CERTIFICATE FPU INSTRUCTION' 

689 



Deputy Health Officer 



Reilatcrcil J^''(>- 



DEPARTMENT flif PUBLIC HEALTH=City and County of San Francisco 



Certificate of Beatb 

( "Q. S. StanDarD ) 






1 T^ 



:ity of 



% 



PLACE OF DEATH:-Co„n.v ofCia.vT.a^C.C. Ct. .» Oa w 0.^vvcv. a. 



^d 



FULL NAME 



) 



PERSONAL AND STATISTICAL PARTICULARS 






UXTi: «>F lURTII 



C(»I,'>R 



VO. fvd^ 



M.V. 



iMiditht 

H'J. ,, "i* 



D.iv 



1/,. »(,'//> 



at 



(Vi;ir) 



/^.7 IV 



MEDICAL CERTIFICATE OF DEATH 




(Year) 



1% 

. ,u\ I ■Day) 

Ltontn) A 

1 ni'UKnV CiIkTIFv! mat I aUcn.le.l ac.c.sc-a from 

to J^^-Lio^.'^'B. 190"' 






JW.2., 



SINT.I.H MARHIl-:i» 
WIDoWKI) OK I>!\nu. »I 

(Writ, in -<k'i;i! .U-^U'ii-tt ".hI 



(^, 



niRTmM.M'H 

fStai«' "r Counlry 



NAMH ot' 
FATHKR 



niRTmM.AfK 

Of' FAIHKR 

IStatt- or Cimtilry 



MAII>i:N NTAMl-; 
<n MOTIIKK 



lURTHIM.AOK 
(>1- MOTHKR 
(St:it« or V. oniitry' 






^ I?) 



190 ' 

tl,at I tot saw 1. - aliv..,„ '^k "-^ '9° 

„,„, that ,U.atl. ..ccurre,!, on .!»• .lat. .Ut.,! al.ov... a. ■ 

' M. Tbc CAISI' 1)1- l>i:.Vin was as follows: 






(n\ji)v.tdu«Tn. 



Hours 



/hits 



^ 



i 



wk/ 



\x<h-^^T^^ 



t>*.\^» i % i 10r» iy 



ykO 






(.VMr-ss) ^lia^-tU- 



Plaf c of Oedth ? 



Hours 
M.D. 



<,„r,„n,a„. ^<sW b cV. ; , 



(\(UlrfH« 



coNTRiiurroRV U-ixaJi 

(SIGNED), % l-<Xti^^ 

a*-! lo oH _ — , . , 

SPEClITFi^FS^ii^ON only tor Hospitals, Institutions, Transients, 
orlerenu'sfdrnts, and persons dylnq away from home. 

1^ y j How long at 

Former or - , \ n a i I ' a. 
Usual Residence *• ^^vs.v 

When was disease contracted, 
If not at pla f e of death ? 

Im.ACKOF lilKlAUOR RKM.»VAI. 



Diys 



i < 










> 

J!* 
J 



u^Aa'^^^ 



DVn: vf HrKiAl. or RKMOVAI, 

SO 190H 



^ 



(Address 1 l^ i 




^^ ^^^^"^'• ^ "" * "" ~ ^^. PHYSICIANS •iMMild 

"SE OF DEATH 1« P'-'" j""'; •''„" ''.v/rt l-...«- 



"• ••~r«.VcA'u%E OF DEATH .« X'^.a".;:";!;.-'."" .v.ry .-...«•• 
.on. d,in» •w«» ««Hii hom. .ho"" " 




WRITE PLAINLY WITH UNFADING INK-THIS IS A PERMANENT RECORD 

BEFER TO BACK OF CERTIFICAT E FOR INSTRUCTI0N8 ^ 

690 



„.,ar,1 ..f \UMXh I So. l^^-^^^"-^ ''Co 



lOO'i 



Be^isfcred JSTo, 



' .< « ^ I ^ 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of 2)eatb 

( Ta. S. StauOarD ) 



.4 

^ City of ' 



m 



No. 



PLACE OF DEATH:-County of 'O.-^ ^ ^<^ • ^ ^ 

FULL NAME l-v.v>vv<.. d d^vv... 



''? 



■■"""U)Jvju 



■ • 



PERSONAL AND STATISTICAL PARTICULARS 

Ai.K 



^'sn 



!i! 



i ( 



WinnWHI* nK i>iv. "R. »..i> 
Wmr ill si«ia1 <1. -u'n.itwiH 



HIKTHIM.Ai'l* 

iStiilf «»r C<>\inti \ 



1/ oi'/i' 



(Vtar) 



p.i V 



MEDICAL CERTIFICATE OF DEATH 

DATH <H- DHATll A J 

I in«KHHV CHKTIFV, Tluit I ^Iten.le.l de. casc<l fr-n, 






:\.Sr\r\.^ i \ 



I9O 



to 



iu^ht. 



190 1 



NVMI-: «H 
I Al Hl'.R 



lURTinM.MK 
Of I AIHKK 

(Statf or Country 




U,aU lastU h ..• alive o„ V^Uj ^ -P 

,ud that death .>ccurrea, on the .late state<l above, at ^ 
JL M. The CAISH OF DUATII was as foUoNvs: 



Mzj'.v 






//ours 



DURATION 
(SIGNED) 



}v,i,'^ • .-iroNi/is -■ /Hv5 



MAIDKN NAMK 
Ol* Mi)Tm:R 



lUKTHlM.Al'K 
oj. MoTIIJ'.K 
(Slatf or Oouiilryi 




y^vs,. 



ED). ^^. VJ'V. M.. ^^^ 



//ours 
M.D. 



ISilAL INFORMATION only lor lh.s,Uls, ln....«.lo..., Transients, 
or Rerelu Residents, and persons dying away from Home. 



(Informant 






Formfr or 
Usual Residence 

mm was disease contracted. 
If not at p lace of deatti t 

1;LACK0K IUKIAI, ok KHMoVAl 



How lonq at 
Pt«re •! Deatk? 



Days 




a 

t NDKKTAKKR VAX.'VN^tt v 



I » AT Ho! niKiAl. or RKMOVAl, 



( \<ldres^ O a^"yWV^>^ - PHYSICIANS .hould 




J 



} 




WRITE PLAINLY WITH UNFADING INK-THIS IS A PERMANENT RECORD 

.,^^ REFER TO BACK OF CERTIFICA TE FOR INSTRUCTIONS 

69J 



^ 



L 3t 



i^OH 



Re^istevpcl ^'*o. 



,^uwc^ 



1 

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

Certificate of ©eatb 

( -Q. 5. Stan^arC* ) p ^ 

r.. T^ITAXW r ntv of OOAV J ^OAV^AA^ City of9<X>V i\aAL^^ C^ 

PLACE OF DEATH; — County otv^^/Yw ^v^ ^ 

,No. ISO 5 'lltlQa-^- -5.:^ Dist.,bet. "1. 



^k ^^ Dist * bet ^-^ ^ ^^^ 



) 



FULL NAME 



CoLWU. maq, Itvcta^ 



1 '^r 



>-i:\ 



>H 



PERSONAL AND STATISTICAL PARTICULARS 









\ • . H 



3)5 . 



IC 



' |):iv* 



M ,11'ln 



1 



i N'cJir 



/).n 



MEDICAL CERTIFICATE OF DEATH 



JiATlv I'l- DlvATlI 



MmiUi), 



5LS 

(Dav) 



(Yoar) 



■"^ISr.l.l-* M\I<I<1K1> 



UIIM>UII«<»K lllV«»RCht> A, 

^ 



iiiK rin'i.X'*!': 



ini 



N \M I- Ml 

1 Ai ni,K 



niRTHIM.ACK 
<»|? I A I" I IKK 

Mali ..f r.iitntry) 



maiukn nami: 

n|- MUTIIIIK 



HIK rill'I.Ai K 
MI M<»TIIHK 



lO^lLoLmv \Xx\kb 














MIl'Kl-BV CHUTIFV, Thnt I mIUmkUmI .lo cased fnmi 

t,,t I last J h ^ alive on ^^<^ ^^ ^^^ ^ 

,,„.! that .Uatl, .xH-urre.l. on the .late '^tale.l ahove, at , • H ■ 
U. M. The CAl'SK Pl' DKATH was as follows: 



CONTKIIH TORV 



/;<n 



I'.V 



J/Oitt 'i 



nrRATioN 

(SIGNED) 



)V(frv JAM////.? /?<»>'J 



M.D. 



I n I I i A • i* 'ii 



Kfsulr.l in Sail I >ni<^i'''n \ \ 



5 Vif ' 



M..,ithf 



/hn 



. ^ ■ : ,, ..vRfuri \H-. AKHrKiK i<» nil, 

.., fluMv t "^xn 



1505 - 11 tL IAam. 



^ 



Wtu.^^ hpH, 



.\<lilress) t **■ ' "^ 



iprilAL INFORMATION only tor Hospitals. Ins.itutlons, Translenls. 
or Rerrni Rcsidrnfs. and persons dyinj a^ay from home. 



former or 
Usual Residence 

wii-n was disease contracted, 
If not at place of deatli * 



Hoiv loR9 at 
f>lace of Oeatli? 



Diys 



PIA^KHF m-KIAl. IjR KKM..VAI 




i 



INDKUTAKKK 



DMJ 



HiAl. <,r KKMt'VAl. 

'hi iQoH 






'^''"^'^"^ PHYSICIANS .hoyld 



'M 



J 



ii 





II 






M ., 



WRITE PLAINLY WITH UNFADING INK-THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



p(f/r Filed , Nh-^tu ^^ 

Xcr^.^^ Ix/v-M Deputy Health Officer 



7^04 



Be^isteved JV^o. 



692 



:3 



DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Certificate of Beatb 

( "a. S. StanDarD ) 

fC, 



Plo. 



OT> A '^ 

iPl A ->^. 0A.O '•>' ■"' V '^f City of '"'CUW' 0,Aj3y\\c^. - 
PLACE OF DEATH: — County ofUa'^VAJA,^-^ > ^.ty oi 



) 



FULL NAME 




Hi:x 



PERSONAL AND STATISTICAL PARTICULARS 



Cnial 



l»A 11% tH fUKTH 



O^lr 



I Month^ 



\<;h 



(^» }>,»» 



r 



n 



1/,.,/,'//. 



.lib 



(Vt*ar) 



/)./ 1 



)ni 



iWiifr in •;i« ial .1* -u'Hiil'""' 



I 



BIKTHIM.Ai'i: 

CStiiti- ur fountiy 



I ATinR 



HlRTIIfM.MK 
Of- I ATHKK 



MAllJHN NAM! 
OF MOTHHK 



lURTinM.AiK 
«M MOTIIKK 
(Stale or C«>unlry> 









a 



^(XLstOY^J 






MEDICAL CERTIFICATE OF DEATH 

DATE OF DKATH A | 

' I III.RI-BV Clfi^TIFV, That I atten.k<l clcHvascl fn 

an.l that .kath occurretl, on the .late stated ah.ne. at 
.i M. The CAISH OF DKATII w^isas folh.ws: 



DIRATION 



) V<7;.v 



Mouths 



Days 



//lUtfi 




CONTRIIU'TORV a.<l' Cvt^^ 

DURATION ' )V'/;-^ ' '1A';/M.^ 

(SIGNED) lU.^. ^0. 



/hiys 



Hours 
M.D. 



\.*^Ia^ 



iqo 



( 






1 I 



1 



'-a 
^ 




9 

i 



M,;itln 



thi\. 



rif^iiirti < '• ^ . ... 1 •fill," 



(Illfntttmllt 



Ill DL.am.aLj'^ 



SPECIAL INFORMATION ««!> "•' «»'P"'I^. I"^'»""""'' ^™"'"'*' 
0, «e«nt R'^idrnls, and pmons dyl.q away ..m l.««>e. 



Former or i^niAAi^ 
Usual Rfsldencc ^i<-aA,<,^ 

When was disease conlraftcd, 
If not at place of death/ 



ZaX 



How lonq at 
Plate of Oeatli? 



Days 



t K f4 



rt I , t .o 



"ri,ACK«)F lUKIAl-OH KF.MuVAI. 



I)Ag;or^l<t««A»- or RKMOVAI. 



ua,.re„.Hm^JfrtcLl/w . ■ 



f\a<lT.-s ^ I I 1 1 r PHYSICIANS •hould 

.tat. CAUSH OF f EATH l« pU^l" « ^^^ ,^ ,^,^y In.t.nc- 

•on« dying nwny «»^«" •»<>'"• "•*"*" * 






I'. 



I 



I ( 



I. 



\n\ 




WRITE PLAINLY WITH UNFADING INK-THIS IS A PERMANENT RECORD 

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS 



T?..MT,1 ..f II.;.Uh- I- No '^ -^ggil^^^lU^r^- 



Be^istcrecl J\''o. 



"i ij^ Deputy Health OfTlcer 

DEPARTMENT 0^ PUBLIC HE AITH-City and County of San Francisco 

Certificate of Beatb 

( Ta. S. StanDar^ ) 



No. 



PLACE OF DEATH:— County of O.^^ vix i v^v ^ 



>D 



) 



( '^ -™S.rni;^^t --si^^piii j/^if^ ^^- «-«^ 



FULL NAME 




^.a^Ai. il 



i 



si-\ 



PERSONAL AND STATISTICAL PARTICULARS 



i 



1 



v1 ,1 ^ "^ ^ '^ ^ 



Mi.nih' 



\'.i: 



Ip% )>«» 



4 DitV 



M.iulfn 



fVear) 



Aj t * 



MEDICAL CERTIFICATE OF DEATH 



DATE «'«- in: ATI! 



d 



^d, 



I go 

(Year) 



SINi-.l.l* M^KHlF.n 
Wn>nWKI» OK IHVnKvKn 



HIKTHPl.ACK 
fHtntr or C«Hiulry 



SAM»' «M 
lATin K 



niKTHIM.ArK 

OF f Aiin-K 



(H 



ClXH U.^ 



a^>xcct^ Jl<XMA. 



It 



I IIKKKHV CKRTIFV, That I attcn.lcl acccasca froiu 

that Ilast saw h alive on |^^^l '^o ' 

a„,l thHt .Icath occurrea, <.n the am. stat.a above, at 
' M. The CAl'SK Ol' DIvATII wa«. as follows: 



5 



CONTRir.rTOKV 



Months 



Pays 



Hours 



MMIHN- NXMI 
nl- MoTHHK 



niRTuri.Acv. 

OH ^oTHKR 
CSt.Uf ir Country* 



OCCI I'A i luN 



a,^ 



dx 



DURATION 
(SIGNED) 



>Vrtr5 



Motilhs 



pays 



Pours 
M.D. 



1 



A^i' 



iQO t (Aaau-'^s) I Ai ^ 



xxwcL 







BEST OF MY KNuWAJ.Ot.n 



r"V>\i 



(!' 



\ViJ':i>«'H AM' 



LecUl information ;.1, l.rK.s»i..ls. l»s.l..U..s, Ir«.l«ts. 



f offlifr or 
Usual Residence 

fi|Mi wM ^«e«^ cantrKted, 

If not at plif e ottotl»? 



Hsw loiN] at 
Plireof Death? 



•m 






1C)5 






IQO 



(\'^^rcs^ ^ " "" , „ ^^,w,w.. I II Mill nil" •»»«»•«* 

— — ' ' ; hnuld be carefully -PpHed. AGE •hould *f •*"*':Jh^ ..g^ecl.t l«form.tlo«- for p.P- 

N, B._Bver. Item «» «;»"7f i^J", f^^J^^ ^^r": th.'t It m»y !« P-P-^, cl.«.fted. The pec 

;rc^?::;f^ li^ -^ •-«- - ^-- ^- .v.r. i-.*.«ce. 



tH 



i 1 

1 1 




1 



i 




• 



\r 



Ir 



Huai.l .>f Il'^'lth I V 



WRITE PLAINLY WITH UNFADING INK -THIS IS A PERMANENT RECORD 

^r"^ „,„,. PFFER TO B ACK OF CERTiriCAT E FOR INSTRUCTIONS 

694 







100\ 



Registered JVo. 



Dale Fileil, H^^Ut •^ 

cL^vws ''kjLV^'A Deputy Health Officer 

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco 



Cevtificate of IDeatb 

( XX, 5. Stan^ar^ ) 
PLACE OF DEATH = -County of ^W. ^AxV^vC^C C City of^'Am^ ^ 



% 



i^T n I lo I \ \c ^L'\^^'^^UJ-t^^Xru St.; I Dist.; bet. I O^ 

-No. n V I A. ^^^^^ ^'^^ ^"^ ,ri,,., -csiDENCE GIVE FACTS CALLED rOR » 

^^^ f .r nr*-rH OCCURS AWAV rROM USUAL RtSipENCt. G v NAME INSTI 










1- 



FULL NAME 



LrlCCvLtA cLtC-vUXMi 



\ 



^tcvt^ 



>I^N 



PERSONAL AND STATISTICAL PARTICULARS 



WxAx 



i» A ri; «»i lUK III 



At . K 



^)i 



a\ 






M..mh 



15- 



y,-n 



iI>HV 



.1/,.t '// 



Vfav) 



/),/i 



MEDICAL CERTIFICATE OF DEATH 

DATK Ol- Dl'.ATII i\ I) f.^ 

(I>:iy) 









" I JIFKI-BV Cl'KTIl'V, That I attcmle.l .U-ccascl fmiii 
t,at nasi Haw hXA>X alive on ^^It^ ^^ '9oH 



mN.,i.r MxKKiHn 

WIDoWl 1» ->1< 1M\«»U. hi 



iU rit! ill 



. « 1,1 



• !, -iiMiati"!!) 



^ 



i.1 vtlfrVtN'lA' 



lUK iiiri v*"i' 

M.iii ..T 1 . iin! : ^ 



N\M»: «»! 
FATHKK 



niKTiiri.A^ ^• 

(I I- I-ATHHK 



(>1 MO I'll KH 



lUKTHIM.AiH 
m MoI'HKK 
(Statf or Counlty 



i»CCl i'Ai li'N 











a„a that .Uath.,courrc.l. on the aalcstatcl above, at IL - « 
1 M. The CAISH (>r i)HATIl was as folUnvs 



/VCtM„"V%V^ 



> \ *.Ia.^ 



DIRATION 
CoNTRHHToRV 



DIRATIOS 



ytHm Months i C) i>^\y^ 



Hours 



Yiujis 



Months 



Pays 



\\ 



Kftdfif I" 




-^VV^^'C^'W 



A/„ntft< 



fhn 



^ninfS^^^ ■'"" "'"- 



{liifiiniKOit 



/fr^'*-^^l 






//ours 

M.D. 



(SIGNED) ■lvV^5 LMIIclIt 






SPEdlAL INFORMATION only for Hospildlv. Inslilutlons. fVanslrnls, 
Of Rerd^ Residrnts, and persons dyin? away from home. 



former •f 
tsgal ResMcBce 

If not a t (>taf c of death ? 



Now loN9 at 
Plare of Dfatti? 



D^ 



U\;i*Hf>f BiKiAi, or KEMOVAI. 

•^1 i9o4 



1 



i 



w 



I 



NUKRTAKKR 



C4v<X^ 



fA<Mre^«i 



k'^t lU.cuukv^Avit« 



i ♦ 



' ^'''''^-'*'' PHYSICIANS ■hould 

state CAUSE OF DEATH Iti ^'«'" J'^^"' ^.,„ ,„ .,,ry i««t««ce. 





'i 



WRITE PLAINLY WITH UNFADING INK -THIS IS A PERMANENT RECORD 

695 



pfffc Filetl , 





Eegistered JSTo, 



>0-v\.\.^ 



^ 



^1 i^(?H 

Deputy Health Officer 

DEPARTMENT 01^ PUBLIC HE ALTH=City and County of San Francisco 

Cettificate of 2)eatb 

( "d. S. StanOarC* ) 



PLACE OF DEATH: — County 



of^ 



a.y\j vj xa 






City oi^ <X^ ^ ^'-<^^^' 



u u A A J. j\, Wis . \ , • 



) 



FULL NAME 






,xh. t 



t ^ V 



'\oXk.^XOj .^*. ' A.U^ 



PERSONAL AND STATISTICAL PARTICULARS 



S}.\ 




C< 









DAJK nl- lUKI'M 



A<.K 




5 Viii 



^0 

limy) 



Mnillfl' 



(Vt-at ) 



/>,/>. 



MEDICAL CERTIFICATE OF DEATH 
DATK OF DHATH (^ (\ 



(l>iiy) 



IQO 

(Year) 



(KlonthM 

ThHRKBY dfuTlFV, TliiU I attcn.UMl .Icrcascl fnm. 



SIN*. 1,1-. MAKKIK1>. 
Wn>M\Vl II (>U DIVORIKIJ 

(Wrilfiu *<Kiai .U'»»|«niiln>iU 



nik rni'i.At'i: 



v \Mi-: <»i 
I \ riiKK 



niKTIIf'I.ACK 
ni lATIIKK 

(St;it' or CiMIIit) V' 



M\nH-N NAMK 



JUKTHIM.ACH 
,M- MnTHKK 
(Stale **r Ctmiitiy 



iK.cl lAilu*^ 






CJ^a^vqU 



that I last saw h 



190 



t" } 



Wi.M 



\ 



alive on 



190 



thai 1 lasi Miw »» ~ p 

a„.l that death .Kcurred, on the date state<l above. «t ^ 
Jw M. The CAl'SH 1>F DHATII was as follows: 



; w a > 



;^ 






(XsyxuuJ^- UxAAaXs 



d 



j^^^ VS^U VVHX^^V^O- 




Dl RATION >Varj 

CONTRHU TORY 



Months 



Pays 



Hours 



h\jxU^ 



\\i 



,0j 



i I s 



(Signed)., i^- ^- ■^-^'^ 




Days 



Hours 
M.D. 



...._. ^oa^lu±U%.^t 



■^SPECIAL INFORMATION only for Hospitals. Instituno.s. Tra«sle«ts, 
or Refent Rfsldrnts, and persons dying away from t.ome. 



nacMX'^^^^^^^^' ^^ 



KffUifii >» ''"" /■'"'"""'" 



) 'I'll I 



}f,>iiffn 



Ihn. 



,..,.^^.,..|.i:l,IM'K^ONAI.rXKT I.rl,AKSAKKTRrK T<. THK 



(Iiifotnmtil 



dO-/W%AAj. 



11 



.1 



XJ 



HI3. 



il; CX.\'v*,^4..c 



Nnwr w 
Usual Residence 

ffi#Q lyf^ (Ifvasf f oBtracW, 
It not at place of death? 

I'i,.ACKOI' mRIAl,t)K KKMoVAt. 



How lORfl it 
plare «f Death? 



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HATH of lit HiAi. or RKMnVAI, 









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fXcia rr^i^ ' ' ^^ III ill PHYSICIAN* .iMHlW 

•t>te CAUSE OF f^j" ^„„,j ,^ ^,v,„ In .v.ry In.t.nc.. 
•on* dying awpy ftHwn lw«« •houmi ^ » 






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