ROLL
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LOCAL I T Y
RECORD S
RECORD
SAN FRANCISCO
COUNTY
CERTIFICATES
..)
r
•v ,'
M I CROP I LMED
TH E GENEALOG ICAL
SALT
CA L I FORM I A
DATE
APRIL
PH OTOGRAP HER
MAX JOHNSON
CAMERA
no2683Hred 1
yo
''"«N>.
EGIN
)'iW^'
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5t.
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t / ;* .
••
i,b«r <^ ^'
V <. '*^~WV.
/\
Jj/
DfiFUTY.
I
rfl-
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
Board of fUalth- I- No i- "^-^^S^UiKV Co
REFER TO BACK OF CEWTiriCATC FOR INSTRUCTIONS
IW.
290\
I)(ffr Fi/e(/,
(LiyoL.^ cLov-t<. Deputy Health Officer
Jie^istcred J^o,
1010
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of Beatb
( "CI. S. StanC»arC> )
4
%
PLACE OF DEATH: — County of OOyW; JA.'avvc\.acc. City of'^'-O-A^ >J.>UX-v-a^
'No.
A SO MUvtlA.Mcv,.i
^^. c_ c
St.; I Dist.;bet. cLCL>\^VLla\; and OvLVicL-
/ .r OC*TH OCCURS *W*V FROM USUAL R E S I D E NC E G I VE FACTS CALLED FOR UNDER "S PEC I AL I N FO R M ATIO N < \ V .r DEATH OCCURRED ,N A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STR E J! AN D N U M " « )
FULL NAME
oj\.A.cL' v^Ll
PERSONAL AND STATISTICAL PARTICULARS
DATK ni Itik 111 0
A(.K
fVear)
\X\JX^^\
MEDICAL CERTIFICATE OF DEATH
DATE OK DKATH /"I
L
(Month) \
(Day) (Year)
i
I )■-.;,
11
M.mth
/'<
/ 1 A
'^iNi.i.K MAkun;i>
\\ iDow i;i> (IK iM\ I >krKi>
(Writtiii siH-ial <lt si^'iialion)
MIK llll'l.Ari-: ' State or l"i)unt r\' '
NAMK <U FA I 111. K
lUk lUlM.ArK Of- lATMKk
'State r)r CiMiiit r \-
MAIDKN NAMi: <)!• MoTHKk
nik riii'LAr}-. <>i M< nil Ilk
'State or t*(»miti\ I
I HI'KI'HV C1;RTIFV, That I attetided tleceased from
•H "^ Itp'- to LL.^...|..^ T^p'l
that I last saw h •. alive on LL"..\„n • j^q
ami that death occurred, on the date stated above, at 1 \i M. The CAISK OF III^ATII was as follows:
rOLh-xCrL
<1 J 'I'.'AA.
i
JL'^'v^*>va/v
1
-I
I )r RATION Yt'ars
CONTRIIU'TORV
Mo)iths
Da v.v
Hours
\^ \
V, r V<.. ^
1 . ^ .
DTRATION 9v r/V7;'5 JA>;/M.?
(SIGNED) Jyi^-ft-^VUX^ WcrL^ci
dv.., o
I()0
Pays
T Q . V
flours M.D.
( A d<l ress) (o ^H U 3 <X\.N„L-l if'. ■ J '^
Special information only for Hospitals, Institutions, Transients, or Keccnt Residents, and persons dying away from home.
OCCrPATlON
M;>,fll^
/),n.
IHI-: MjdVK sTAri:i» I'KksoxAi, i-xk ri.ri. \ks aki; rki k tm rin-: iihsT OF Mv kv()\vkj:i)(,f: and iu:i.n:i-
'I
"f..rinat.t UJ OjLdLX'^V>
^^
\<l<Ii(
former or Usual Residence
Wfjen was disease rontrarted, If not at plare of death ?
Hew lonq at Place of Death ?
Oavs
DATlv (jf niRiAr, or KKMOVAI,
wq i'!.
I'l.ACK OF" lUKIAI. OK KF:Mo\ \1,
indf:rtakf:k VI V O A-<Xvi . '^'^-^ ■(.
(Address 5..S.1. 0-^\XLjL^ .C!±
o ^0
190 1
^- ^- Kvery item of infopmution should be carefully Hupplied. AGE should be stated EXACTLY. PHYSICIANS should
state CAUSE OF DEATH in plain terms, that it may be properly classified. The "Special Information" for p«r- «on« dyin^ away from home should be |»iven in every instance.
I
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
J<n:ii(! <if !!( :ilt)i \' Vo. i ', *'^v5«?^5^ US;, I' Co
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
Ihf/c Filed,
I V
Deputy H
100\ Officer
Be^Lstcj'cd J\^o.
1020
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of Deatb
( XX. 5. Stan&at? ) PLACE OF DEATH; — County of J<Xa\) J/v<X >VCt^C(. City of OoyTu 0;uX/>vculcc
'No.
blo
v(X,\.|^J.
St.
5^ Dist.;bet* ll ^ and IXfrXXk.
r \r Dt4TM OCCURS *w*v rnoM USUAL RES I DENCE Givt facts called for undfr "special information- \ V if death occurred in a hospital or institution give its name instead of street and number. )
FULL NAME
PERSONAL AND STATISTICAL PARTICULARS
SKX
DAi}-; «>1 IllKTlI
OJJL
COI.OR '\
\
?
1
•Moiithl
A<,K
I 1 )ra>>
(I):iv)
M..iilfts
(Year)
n,i \s
OJUu
SFNi.I.H, MAKKIHI).
W inoWKI) OK DIVoKiKl)
(W'litriii >-<)ti,'il <ltsij.'ii;iti<)ii)
lilK rni'l.ACH (St.'itf or i/oiiiitry)
\AMi-: Oi- l-ATM i;r
HIK rHI'LAiH
OI-" iAini-:K
(Stat( or I'oiiiitry)
MAM)I-:\ NAM I.
oi" .mothi-;k
HI KT HIM, An-:
OI-- MnTin-;K (Statt.- or Coiiiilry)
OCCri'ATlON
MEDICAL CERTIFICATE OF DEATH DATE OK DKATH -^
(MoiUh) (| (Day) (Year)
1 HIvRHBY CERTIFY, That I atten(T^.r(lcrca^>(rfroni up - to LL*.^oOb ^^ 190 H that I last saw h.7AL>\J alive on vAa^^a^q; IC- joo'i
and that death occurred, on the date stated above, at '0-^0 U^M. T^ie CAUSK (.)!• DIvATII was as follows:
1
•C L ^.
DTK ATI ON Id )'ears
CONTKIHUTORY
Man tin
Da vs
I /ours
A.
hi
O
CL^^^V1
DIRATION
INED) M/L
(SIG
V
dU
:iAl in
}'cars Jfoj/Z/is Days Hours
90 1 (Address) S.JoS UXX^v A.>{Xvl<N.
O /CX^^j^kxM_ M.D.
?''^9'^^ Information only for Hospitals, Institutions, Transients, or Recent Residents, and persons dying away from home.
VM-V,A. I '^- T 00 ' 1 r A d d ress ^ 1 (c S O /a/^^ s \J\X I /V 0 (J, .
Mnuth^
Ihl
rm-; ahovk st\ti:i) pkksonai, paktuti.aks \ki-- tkik to tiii--
IIHST Ol- MY KNOWM-DC.H AM) UKMl-iF '
Former or Usual Residence
When was disease contracted, If not at place of death ?
Hew long at Place of Death ?
Days
ill
Q%v.
VOlm
r\fl dress
bio
Vh.KQV ()!• lURIAI. OR RHMoVAI, I DA'IMv^of Hr«,Ai. or KKMOVAI,
^% Crlw-L^uo-^i^ I CLwv^....a. T9o'i
INDKRTAKER
^^
(Address 1^1 \l fAA-^^A-V^^O
t
""' ^'~^tBU CXU^t Ov7r^^^^ 1" '■«-«*"">' Hupplied. AGE «houId be stated EXACTLY. PHYSICIANS should
state CAUSE OF DEATH m plain terms, that It may be properly classified. The "Special Information" for dt- son.dym^ away from home should be ftlven in every instance. ■mormaiion for per-
f
!
t
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
Hoai.1 of Health » Vo I ■. T^^|S^ H& I' Co RCFCR TO BACt{ OP CERTIFICATE FOR INSTRUCTIONS
|(<5 lOO'i
cMro_A^ ckX'XMH^ Ljcp'ut, - . , Officer
Begiatered J^fo.
1021
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of H)eatb
( XX. S. Stan&ar? )
PLACE OF DEATH: — County ofOoL/\X) vJAXXAvcM-^/C^City of ^^O.yVu J XXX >V/Ca.<l.c<.
^No.
0 JL\yY>xxx>v
(KL.
■\0^
O.
St,; — — Dist; bet/
and
f IF DtATH OCCUBS *WAV ^ROM USUAL R E S I DE NC E Gl VE FACTS CALLED FOR UNDER "SPECIAL INFORMATION'S V IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. J
FULL NAME
PERSONAL AND STATISTICAL PARTICULARS
•'^HV A ,. A I COI.OR
XL>^^LC
:t
DATK nl HIKTII
AC.K
^■OJ
CAJL
MEDICAL CERTIFICATE OF DEATH
^V\j
<M<)iith)
\- N ) I II I .
(Dav)
.!/.»;////>
Ml
(Year)
/)>n>
SINC.I.K. MAKKIKI). WIDOWT.I) OK DIVom K.r)
lU'iitt ill >.(>cial dtsij.riiatioii)
lUKTHIM, Xrj-: (Slatr or c*<nintr\)
FATin.K
lUK rniM.ArK
()!•■ I ATHKK
• Stal< or l"oimtr\>
maii>i;n namj:
«»J- MOTHF.K
HIRTHrUACK 1)1- MOTMKK (State- or Countr\
DATK OI" I)1:ATH /"^
(Month) ^ I 1II:R1':HV CI':RTIFV, That I atten.lc.l .Icccased from
(Day)
/go
(Vtar)
-V. \ \„^_
i I f
190
to
tliat I last saw h -^i/vw. alive 011
I
^
Uw..A..A^
190 H
and that death occurred, on the date stated above, at X-'^L -^ ^I- 'I'lK- CAISH Ol' I)I-;aTII was as follows:
}'ears '. Mouths
.'ONTIillU'TORV \J
DIRATION
Da vs
crV ^SsAA^'v-.o,
Hours
occ
nr RATION (Signed )
^O.yftw^VW^-:^.
)Vr7;-5 Mouths ^ /^//v.v
'vKa/vv^
/fours M.D.
VAx/^q^ 15 TQo 1 (Address) UXVwvQ^v K ^v'J, j.
f\f^idfi{ ill S(i>/ i'ltiu,
) V(M
Miiuthy
I >a \
TUK AROVK STAT)-,I) I'FKSonm, J' A KTI.T i. \ k S Xkl- TKIK To IIKST OF MV K\o\VM:I)(;k AM) in:MKF
TH1-:
(I II forma lit
O X^v/^^vA/cx^v Jb 0-<i.'i'V\jtvtx.l.'
?''^9^fi^."^^Of"^'^T"'ON only for Hospitals, Insfilutlons, Transients, or Recent Residents, and persons dying awav from home.
., .n"^,. (O I." D Howlonqat
Usual Residence WoJkXo..v-^ ' Place of Death ? . .. Days
When was disease contracted, If not at place of death ?
'X.Mrt'ss —
I NDl.KTAKHK
(Address
T90
y/^-^^^'''j> "IK'-^I. OK KFMOVAI. DATKo; Hikiai. or KKMOVAI.
m (? y
(D 'cvk.itx,.>x^ Lx.L,
"^' "■~rt«Te''clr*s?Ap*nTri'M" •*'7'*' "^^ ^"-«»^""y «uPPi-d. AGE «houlcl be stated EXACTLY. PHYSICIANS .hould state CAUSE OF DEATH m plain terms, that It may be properly clarified. The "Special Information'* for D.r- «on« dyinft away from home should be ftJven in «very instance.
r
WRITE PLAINLY W|TH UNrAniMi^ iiviv
I k #* » • •
Ho;t!'l of Ifc.'iltli !•* No. i^ t*^^5S^ WScV Va
l)(((r Filed,
'^UV'V^
RgFER TO BACK OF CERTIFICATg FOR INSTRUCTIONS
\h
190\
Registered JVo.
1022
AM^
Deputy Health Officer
DEPARTMENT OF PUBLIC HEALTH-Cify and County of San Francisco
Certificate of ©eatb
PLACE OF DEATH: — County of vJXa.cxx.\
City of
(No,
St.;
Dist; bet. ~
and
( " ,v.r.,:%c"c-!.;ro',^-r„<.".-- t^^:^^^-:-^'iti^i:::.-v; ,;%%%Ti„TS;r- )
FULL NAME
A.<VxLcui I.:
L-
si:\
PERSONAL AND STATISTICAL PARTICULARS
'f
DATK nl' MIK 111
AC K
LUJva
Ll.lvVA.i
I Mont'li )
1
) III I
H
(Day)
M.-ut/is
JL
(Year)
I (;
n,7 v.s
SIN(.I,K MAKKIHI)
\vii)n\vi:i) OK i)!\()Kri;i)
(Wiitriii MK-ial <l«sivMijiti<.)i)
lURI'ni'UAOK
'State or Coiiiiti v)
NAMI-: <)}
fatiii:k
HIRTMI'I.AiH OI- l-ATUHR
'State or Country)
maii)i.;n namk
<H- MOTHKK
niR'riiiT.ACH
Of MOTHKK (Stat.- or Cotintry)
'^-XxJ^CL^y^^J
MEDICAL CERTIFICATE OF DEATH
DATE OK DKATH
(Day)
(Month)
(Year)
I HIvRIvHV ClvRTIFV, That I atte„<le.l .lercased from
^90 ■ to T90 —
lliat I last saw h .Tr-r-r~ralive on .. ^^
and that death occurred, on the date stated al)ove, at - .^^n '^^^ CArSiC OF J)|.;ATII was as follows
'%ju^>Oi^ ^I^.
Dr RATION }'(^ars
CONTRIIU'TORV
Mouths
Da vs
//oius
DTRATIOX
y't'ars
C ^'■J<.U
\\jJLaxs x ci
Over PAT ION
^'f^idfii ni .S\i,r /'nnui\,;> C>\> )'r,n y
(Signed)
ECIAL IIM
.Vi)/i//is
Pa vs
JVcva. Y\.t ^1
90
(A(Mress) J Xa^.> a4^,« J, v . O ' .
//ours M.D.
."^^'iifh^
Ihn
"'''r^^^'i'i^i:.^'^^::^^^^^::^:^^^
flrfprrn^^P^i;;J'^„J'°'''^?T"ON ?"'y f«r "ospita'S Insfitutlons, Transients, or jfcent Residents, and persons dying away from home.
Former or % () P 0 H«v
Usual Residence \J Kk^^JL^^JUL, Kxxh pi^j
When was disease contracted, If not at place of death ?
.a
y^« Days
f rnfotniatit
.9
Address O A.A.,A^-Q^HK_C
i'i.A^y>K mRrAx „k rkmovai. | D-vaCof H.-k,.,. or kkmovai.
.<u
I • N D 1 : R T A K I.; R jfo oXaXjlS^
I90H
(Address ...
r »
-^^dSS.
i^x
m
i|
i
WRITE PLAINLY WITH UNFADING INK— TWic: i
tk DCDtmAKlPKI-r- r% w» ^^ ^s. r* w^
Mo.-IIil of
Hr.iltli- K No. K "^^^^^ US: I' Co
REFER TO BAC»^ OF CERTIFICATE FOR IN3TRUCTIONS
Deputy Health Officer
Registered J\^o,
1 02;
DEPARTMENT OFPUBLIC HEALTH=City and County of San Francisco
Certificate of S)eatb
( la. S. Stan^arO )
PLACE OF DEATH.— County of Clcx^ 0 AXXoxCvaccCity of 0,CU^3xa.^
'No. 110 5 \i n.
'V<lCvlC.(.
-A<i V. c >
.d
FULL NAME
St.; Dist.;bet. IT .A^\; and
► IDENCEgive facts called roR under "special informatio
OR .NST.TUT.ON GIVE ITS NAME .NSTEAO OP STR E ET AN D N u M " «
I. n
( " .v*o;".,°„=^c"c"j,;ro\;."rHo",^pr.t c%^fj^^?u';Li"/,/«:!^.vi.^° -".--!' i--- .-o".t..,o... ^
\IU
\,
)
si:\
PERSONAL AND STATISTICAL PARTICULARS
I COI.OR
>J,
1/ .
iJx
i>Aii- <)i liik ru
AC.K
iMoiitli) K
]
MEDICAL CERTIFICATE OF DEATH
!'■
) ra I >
Moulhs
(Year)
n,t\
DATE OF 1)K.\TH r\
(Month) K
i:i
(Day)
(Year)
I HKKICHV ClvRTlFV, That I attcmlcl .IcHcased from
..U^Q U igo S to SAA/vn
that T last saw h .. alive on LL
...IH.
SIXC. 1,K. MAKKIKD
wii)()\y}:i> Ok i)[voKri:i)
(W'titi' in v.,HiriI il< si^'iiation)
lUK'rm'i.AOH
'St.iti- or Comitrvi
\\M1-: OI
HIKTIllM.ArF: OI' I ATMKR iSfatr or Couiiti v
<4 I
aiKl that death wcurred, on the date stated aln.ve, at 1 \ M. The CAlSlv OF I)1;aTH Nvas as follows:
()v>^\.ivJL>''vjt
vXXAXx.v
CL'-^
* -V\ i^JC'''>
.V^:
\
ihr.\tion
MAIDKN NAM1-:
oi- M()thf:r
nikTiii'i.ArF: oi- m()Thf:r
(Sialt or Cojiiitry)
-^ '^font/is Days
//ours
AJouth^
l^avs
//ou
<r^\
I )r RATION . Years
( SIGNED ) Aj^j^A, U UA..av> M c
^u^a il ,(
■<\ Iv I()0
Address) V.^ 11). O
M.D.
■A- V^X^-> X '
«r?''^9'^^. "^^O^'^A'T'ON »"'> f"*^ Hospitals, Institutions Transients or Recent Residents, and persons dying away fro.-n home. '"nsients,
Kf.^idnl 1,1 S,ni /'i ,ni,/.u;> ['X ),-,r
^■>iitli<
/hi v.
rwv. amovf: sta ii-.d i'kksowi FXR-rrriM au< iot.- i-Di-t.' ■,. — ~!
lU-SToF MY KNN.\VlJ.:iM-.K AN,) MHilij.ii'''^ ^'*^- ^^^ ^- '<' 'IIH
Former or Usual Residence
When was disease contracted, If not at place of death ?
Hew lonq i\ Place of Death?
Days
(Info/maiit
'Address ^lOS \l /U^^
v\;
I90H
N. B.-
'"'f7^7' ""l "^'%''' '"" KK.MCVAI, I nAi;F of HrK.A,. or RKMOVAI,
.on. d,i„g aw», fro™ h„„e Should hTtiven ?„ '.v.'.T uZT. ' '""''>"'■ ■^*" "«-"-' ""fo—ion" for p.r-
#*«"■
WRITE PLAINLY WITH UIMFAniNn ink -ruie
• •«»• » %^ f-» I ^r-iiTir^i«E.ivl
laa M Ikl r* iki^- m^ mm ^^ ^m. mm ^,
Jtoiiid .if ll(;ilt)i I- Vo n -^'^^SiOj^I^ H^l' Co
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
Registered JVo,
io;24
'XAjx)^ Deputy Health Officer
DEPARTMENT OF PUBLIC HEALTH=City and Counfy of San Francisco
Certificate of 2)eatb
( m. S. StanOarD ) PLACE OF DEATH: — County ofCJ/a-^ J.fLCL^n^^ivxw^oGty of Oo^vv i>La.. vci-;i.cc '"^^ ' '^ .V,;:.:: ;cc„.s ^t.: I Dist., bet. O KXX^x^^L ^nd J -cll L- J .
'No.
)
FULL NAME
dA.^'v"J- ^ .
PERSONAL AND STATISTICAL PARTICULARS '^'•^ (J?) (j j COLOR \
n.\'n-; <n- iukiu (y>j a
x^
I Month)
AC. F,
) Vi/> >
(o
1-5
(iJav)
Motilfif
MEDICAL CERTIFICATE OF DEATH DATE OF DKATH , 1
U,A. v.,n 1 5-
(Month) (
(Day) (Year)
(Vt-ar)
/hi v.v
siN'r.ij.:, MARun:i)
WIDOUFI) OK DIVoKiFI) iWiitrin M>rial <h-si^^iiatioii)
lURPMlM. M'F (Stall or rotintiv
NAMF »H-
fathi:k
niKTHI'I, \(H OI- lAIIIKK (Statt or I'oiintrv)
MMDl'lN NAMF <»1 MOTFIHK
niRTHI'I.ACF, oi- MOTMHK (State or t'oiintry)
I HHRI-:i'.V CKRTIFV. That 1 atten.k.l <lcr.ase<l from
^^^-C^ V 190 'i to . .LLi.v.CL LL i^ ,
that I hist saw h ... .■ alive on UoVa^c^ ' i^o
and that death occurred, on the .htlc stated above, at ^
A] M. The C.\rSH OF DIvATII was as follow.s
^^^CX-Ivv-^UL-Ol*
I
'-^
occri'A riox
cjO
'<X '^vv-L
.L
nrR.ATiox (Signed )
Years
OIL I
3 (.Athlress) H'ia T^U A \ I O-M -J
Hours M.D.
44-
/^</ 1 A
Tin: AHOVF STAIl-I) I'KKSONAI, I'AKTItM" I AKS XRFTKI-V n » rii.^ HKST (>!• MV K.NOWI.FDC.K .\nI) nKMKF ' ' ' * ' " '*'
nr?*L^?'M^J'*^f^'"^'^TION only for Hospitals, InsfitutW Transients or Recent Residents, and persons dying away froii home. '"nsients.
Former or Usual Residence
When was disease contracted, If not at place of death ?
Hew long at Place of Death ?
Days
fx>
^X'Mrvss
l^^oviWvK.iirit-
ri,ACK OF BrRIAI. <,R RFMOVAI. I DATHof n..... or RFMOVAI,
K
190'!
1
'^-^-^-A.O^vl 'H,...L<.
(Addres.s.. .\dX% ^Jl) 7v^ OU rU^v-tX^ .^^ ^
N. B. K%'ery item of Information should be cnrefullv suDnilerl ArR-I , , . . _ '
..a.» CAUSE OP DEATH .„ p,„i„ .,.„.. ,C U "J 't p*opeHr:,L*'.,''u,:i"''.;!h^'^^i=^7; , ^"^SICIANS .hou.d «on, dyint away from home .houlil be tiven in ,»,ry Instance. ""••'"«•'• The Special Informsllo.i" fop per-
i^akiiM.
Wmt WRITE PLAINLY WITH UMrAniivir^ iKii.r i-Ljie> tt^ «. .n.-^.« • ii...... »
/>^^/^' /•>/<''/, LLu^Aa-v^
Lb.,
f\ A
190 \
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
Registered J^o.
1 025
V^V^A^
-u Depuv
DEPARTMENT OF PUBLIC HEALTH-City and County of San Francisco
Cettificate of 2»eatb
( la. S. StanDarJ> )
J? ^ J? Qj^
^^^/^n ^^ ^EATH: — County oiOcuy-o 0 AXX/ixo^CcCity of C)<X^k\; 1v<X.>v^^<l o.l
No, ^3.lo U[\xxtl
Ot/O.
St.; 10 Dist.;bct. 1 I ^t
and Jv,Qs 'V(A.'
FULL NAME
)
s !•: x
PERSONAL AND STATISTICAL PARTICULARS
'Month) (Djiy)
A^O.:. U NXLcLc.
1
Vw
\<^
XJL
rl%X.
(Year)
MEDICAL CERTIFICATE OF DEATH
date; ok dkath
Q,
IS
fDay)
(Year)
A ( ; V.
ll )v.,« U;
M.ivtln
Pit 1 .
SI\(.1,I-: MAKKIIvI)
wiix >\\j:i) ok i)!\-oKrj:i)
lUriti in vojj.-il <1( >ii>^!i;itioii)
HFRTHl'I.AOK 'St.itt or t'oiititrv^
NAMI-; «)l
I A thkr
lUKTHI'F.AlK Ol- l-ATMHK 'Stale or I'oiiiiti v
MAIDKN NAM1-; <>I MOTHKK
HIKTMIT.ArK •>l- MOTIIKK 'St.itf or Coiuitrv)
(Month) J
rjp I IIHRHBV C1:kTIFV, That^r atteti.lc.l deceased from
A"^ Xt 190 H to .
that I last saw h ^^iA; alive on LXa.-
IS" iqoH
'^"Cl • ' 190 ;
and that death occurred, on the date stated above, at ( 0 • 2> 0 LIm. The CAlSlv ()]< I)I<:ATH was as folI„ws:
-C-^
<c
oK<x^aj 0 .\ <X <it /
^
.-^^
i:-
Ij
DIRATION )W,;-5 1 ;,«„;//;^
(SIGNED) .L<iA.^>cuvdL 0. ^i)
DCCr NATION
AV.\ /(/('(/ /;/ S",,->/ /'i ail, isi-i) ^^1 JV-,/;
A^v^c^
Days Days
Hours
^ IQOH (A«ldress^ IHH^ 0^0^'.
Hours
M.D.
orf.LrJ'^'-J'^f^^'^'^T'ON ""'y f«r Hospitals, Inslifufions, Transients or Recent Residents, and persons dying away frcn home. 'f-nsienrs,
1 A <;////.
/),n
Former or Usual Residence
When was disease contracted. If not at place of death ?
Hew lonq at Place of Death?
Days
THi: AHOVH STATi:i) PKKSONAi. PAKTICri \KS \K1- THIK r. , rtiu- "77777! " . ■ -
HKST OI-- MY KN<.WIJ.:i„-.K AM, nKMHF"''- ^^' '" '" ""-■ ^'^'^K '%,"''''A'' ' "^ ^HMoVAI, | I.ATJi^of M, k.a,. or RHM(,VAI.
(1
A-^CrO-O, r^;
^
i
T9o'(
'^' ^' J^very Item of information should be cnrefullv a..»»i:.,i A/>«r^! TTT """■■■"■
«»«to rAiicp: rkc nuTA-ru . """ "e cnreruiiy Huppliecl. A(jF. nhould be stated EXACTLY. PHYKiriAisia i. ... state CAUSE OF DEATH m plain term*, that it may be properly clasiiified Th^ ••« • . ^"^^'^'ANS should «on. dylnft away from home should be ftiven in .very instance '""'"*'*• ^^^ «»>«^'^'°' '"formation" for p,r-
«i^«»
^•y -A -i"
•'^ ■ /•*'
..^■^.
f
^B^ WRITE Pi AINI V \A/ixu iiivirAniiu^ iiui# — . <t-i-iie> »«. m r^i-i^
i — ^ ITT IT n T I ^ ... . ...... 'vivtriaviiv >M ll«l« llll «ii3 I «3 *» r" C l~»
Hoard nf Ikulih -■ I" N'.i. is, 'i'f^'s^^^^ H&l* Co
/)((/(' Filvil, \
• *=» « f-u mviMi^ c. 1^ I ncv^V^KU
REFER TO BACK OP CERTIFICATE FOR INSTRUCTIONS
l(c
wo\
Re^iNfcred JV7;.
1 0J^G
DEPARTMENT OF PUBLIC HEALTH-City and County of San Francisco
Certificate of 2)eatb
( "CI. S. Stan^ar^ )
(^
A %
PLA^ ^P" DEATH: — County oiO lO^y^j 0 AyO^>VC^4^f Qty of Oclaa; 0 AXXaa^cia.^
e
ao
;v<lr
Dist.; bet. vA.'V^A
( '^ "'!^l",°*'^"r.®A^*''.r''°** .^.®^*'- RESIDENCE GIVE F*CTS*CALLCDrOR UNDER
r,^..,.. I T""- . r,^™ wwwF^i. nt^oiL/ciiv^E. dlVE F*CTS CALLED TOR UNDER SPECIAL I N ro R M ATin m •■ \
DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD " STR Ee/'nD N UMBER )
v(h-*U) LlAM.y )
FULL NAME
> vx\. ^ vo... UA>CH;L^rLo
PERSONAL AND STATISTICAL PARTICULARS
Cni.nK ', A
i» \ ri". <>»• III R in
iLvvcU
M.jiith)
(Dav)
(Year)
MEDICAL CERTIFICATE OF DEATH
15... (Day)
/go •
(Year)
Af, K
H?
5 Vi/»
M'nitfn
Da y.
SINf.I.K. MAKUIKI),
\vii)(»\y):i) <»K i>!\i »Rri;i> 'Write ill social <1( sii.Miatioii)
MIKTHI'L^CK ' '^tatf or t."Miiiitr\'
FA riii.K
DATK OF DKATH r\
(Month) K
I JJHRliHV CI:rTIFV, That I atten.lc.l (lecease«rfr(«i;
^^- 190'^ t.) CLv^Mrj. )..S:
190 H
[90 tliat Ilasrsawh :.' alive on VAAA-O^. ■ j,p ;
and that .loath occurred, on the date stated above, at 2> .... ^J M. The CAUSH OF DIvATJI wis as follows:
^ &
e
X \>-VwOL/CXA-»
> \.K
HIKTin'f.ACF: 0( J-ATIIKK
(Stiti- or Country)
MA1I>)-.N NAM! <H .MoTHKK
MIKTm'KACH 01 MnTlIFR (Stiiti- or Countryl
OCCrPATlON OfVP
'XV L XcC\^ O V j (n-^XO- V »v
T 0 R \' X/KA/(in^.\.^
Mo)ilhs
Days
Hours
^ ^
r)
C
^\L\d~
DrRATIOX - Years
/Mrs
X/Cr LU ) \j
*^ J -^^Ayyvux-^xq
(Signed)
^
n 4 'V V ;
190S (Ad.lrtss) 1 n dUUXv>^-^A.>L.o trxltv :\ f
Hours M.D.
nr?p^„^?!!fl^, "^ir^'"^'^"'''^'^ •^"'y '"^ ""''P'^^'^' Institutions, Transients or Recent Residents, and persons dying away from tiome. «"^«-.u^
f\f>ulfii in S'tn/ 1^1 ttn, i^f',> \ \ ' J>/m^
/>,.'i
* "V;. ■>?!!.* ^'''- ^'''^'''>-J» '"HRSONAI. I'XRTFilLAKS ARF TKrK To TU K Hi:ST OI- MY KNo\VIj:I)<-,H .AM) in-IJl-F '
(liifornKiiit
> .■■■ ' >» I, 1 , 1 »i I /-, .1 .-s I /
.\A.A../^wO \Jj. 0 h^'CHQ^'VV v-O ^
Former or Usual Residence
When was disease contracted, If not %{ place of death ?
Hew long 9\ Place of Death ?
.. Days
\i
190 \
r:X''!';.'0^ '^"'"' ^'^ '^^^^"'^■^'' I DATK of I.rKi.K orKKMOVAI,
I i..^^r. ui- lu KIAI, OK RK>r()' IXDlvKTAKFK V-XCLaX) V^-^t;:^
^VM..
.on. dyinft aw«y fro™, home should be tiven in .v.rt in»t.ll«. "'""""'• ^'" «"«'"' '"formation" f.r p.r-
■i'j^BI^
;«*'?
r-;^
>-♦ /'
"^-^.l
"-'■nl..fH.....,„.-..N-o.K:»^.g^lU^,>Co REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
I)(f/(' FiI(^(l,iLu<XYJ^ Up
7.96^^
JRegititcred JVo,
\ o;37
Deputy Health Officer
^No.
DEPARTMENT OF PUBLIC HEALTH-City and County of San Francisco
Certificate of H)eatb
PLACE OF DEATH: — County oK'Ct'w 0 AXX^^vxcwco City of OaXat^ OivxX'^'c<^ < M' Ua. .^ 11: (y^ Ixx '. - \- St.; — - -: Dist.; bet. -=r^ and
A IF DEATH OCCURS AWfV FROM USUAL R E S I DE NCE CI Vt FACTS CALLED FOR UNOtR "SPECIAL . N FO R MAT.n « ■• \ V .F DEATH OCCURRED .N A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD oP STR E E^ AN D N U M B t «° '^ )
Cl C" C
FULL NAME
\AhXX\j:Xj. vAA^;X.4y|.v, . '
si;\
PERSONAL AND STATISTICAL PARTICULARS
'■1
DA'I'I-: nl- HIHTII
-Month)
ACH
y,\i.,
a
(Dav)
M. '),/>!'
(Vt-ar)
/)<7 1.
SINCI.K. MAKUn:i). WIDOWKI) Ok IHVoKiKI) 'Write in social <l«sij/ii;itii>n)
HIKTHI'UAOK
(St.itt or (.'omiti \1
N\Mi-: Oi- l-ATM i;r
MEDICAL CERTIFICATE OF DEATH DATE OF DKATM 1
L'Ll^^o is
(^<'"th) ij (Day)
I IJl'iRl-HV Cl-RTIFV, That I atten.lcl .kTcasod from
"^^' ^- TOO' to . LL\.^ra. \S., up\
(Year)
I9O '
^
that I last saw h alive on \X.
and that death occurred, on the date stated above, at
^■'^ M. The CArSH Ol' DJCATIl Nvas as follows
1(/D
niKTUF'i.ACK
f)I" lATHKR
'State or Country)
MAIDKN NAMl-- 01 MOTHKR
lUK Tin- LACK ol" MOTUKR 'Stiite or CouTitry)
OCCri'ATlOX f}pU?
//ours
rCi
DIRATIOX 1 Years Mouths /)ays /
C()NTR IIU-TORV L'i>^.<ll^A„^..clv^..^
'>''RATI()X rears ^ Mouths Pays //ours
(SIGNED) LLv.\.n • (3.
Res id fit ill Sat/ /-'i ,1 1/, /.',', 1
- - - -y
lL
'^
M.D.
^^, '^ TQo' (Address) 1 '^ 5 JjLO..'\^.«
) 'I'li I
M.oith'
/)./
Tin- AHOVK STATi:i) PKKSOXAi, I'A K P KM' I,A KS \RK TKIF To TFIK Hl-ST OF MY KNOWI.FDC.K AM) lU" AV.V '
(Infoiinaiit
ck^<j-v^<^^
^ \fMrcss
nr?.L^9*fi^J'^!r°"'^^"'''0'^ ""'> '""^ "o'ipitals, Insfjtutlis, Transients or Recent Residents, and persons dying away from home. «"s«rniN,
fTrV-. %^ f. HoHlonq at
Isual Residence (lW>a.^v|c ' Plare of Death ? Days
Wtien Has disease contracted. If not at place of death?
190
■CV'-w.IUjXcL V^
n.ACK ..I- HIKIAI. OK K1.:moVAI. I DATFof HrniAr or KFM,,VAI. INI ) !•: R 'l- A K F R J -Aa^^M^I^O-X' oLll r ' '^
^•■^'^'iress .n.5.' nXvA-'^rr^rr^rw c].l.
IN. B. '^^^••yjt/';" "^ •"f«;''"«t.on should be cnret'ully nupplled. AGE nhould be stated KXACTLY PHYSICIAN* u .. «t«te CAUSE OF DEATH in plain term,, that it may be properly clarified The -S„T J 1 . ^"^^'^'^'^^ «»^«"«d Ron. dyinft away from home should be liiven in .very instance ^'""""'**'- ^^^ «''*^^'"' '"formation" for p,r-
.^n:^
T
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
HomkI (J Ili:'lth I-' No ! r '^•sTiSRS^ USiV Co
/)((/(' Filed ^
^^ V.
.t lb.
VJO\
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
10^28
vu Deputy Health Officer
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of 2)eatb
( U. S. StanOatO )
%
A T -A ^V
PLACE OF DEATH: — County of vJOyAV JA,(X-~> vcoft.ci.City of ^) lO^ywj J A,<X >^.X-v^ C
; 1 Dist.;bet.\I)^-CK>.d.c^icx.u. and UciLUXtt,
'No. lOl^VnU^lqt ,-.v..
(IF Dl IF-
r OCATH OCCURS *W»V FROW US DEATH OCCURRED IN A HOSP
St.; 1 Dist;bct.\l)^"^-<K>.d.c\.'CXLi and VQl
UAL RESIDENCE GIVE FACTS CALLED FOR UNDER "SPECIAL INFORMATION • \ •ITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AiIiId NUMBER. )
0
FULL NAME
.dA.l'k.
,£\.
ik
<x\.xx.
si;\
PERSONAL AND STATISTICAL PARTICULARS ^ I COI.OR
i).\ri-: «>i' I'.iK iM r\
-u-
\l \,
,r
w
Ai.K
..iith> \
\^ r.....
<I):iv)
1 A '.,.///'
L O... . . <.
MEDICAL CERTIFICATE OF DEATH
DATE OF nivXTlI /— ,
(Montli) \
^Vcai)
/'•n.
Sl\<.l.i:. MAkKIKD WIDOUKI) (>K niVORCKI) 'Wiifcin "-iH i.tl (l( vi;Mi;iti<tn)
lUkTHIM.Ai'K (St.itf ur «."<)Miiti V '
XAMK oi FATM) k
Hik rm'!. ACK OP lAriiKk
(State or c'uiiiili \
maii)i:n' NAMi;
OI- MOT I IKK
HiK'nn'i.Ari-: OK motin':k
(Statf or CoviiUryi
' I go .
'I>.-iy) (Year)
I ni':RiaJV CI-RTIFV, That I aUcti.kMl .leccasea from
> ^ 190''^ to L:WvwriqL.....I..S iQoH
tliat I last saw h alive 011 l^l.v^..a_ 1'^ |oo
aiidLthat (Uatl) ocrurrcd, 011 the .late stated above, at ^
^M. The CArS^{ OF Dl-iAXH was as follows:
■^^UL'
■V .i v_0
DIKATION }\'ars
CONTRinrTORY
Mouths Days ' o I /ours
I
A
DURATION Vrars
'^Y\Ar\^^'y\j
Mouths nav<
V ' Aj:iJ^-\
sJ^A
occri'A'iTox (Jj^
kVMilril III Sail f''iaiiri>fo
N-L'D^LU
( Signed ).L<x^rpuJLL<i \ U- \. ■■■ n i i iQo ' ( A >i(i i-fssM ric--^ vt<:(.t V ^
?''^9'VJ'^^0'''^'^"''I0N only for Hospitals, InstUi or Recent Residents, and persons dying away from home.
//ours M.D.
>'i! I
}F.>„th'
n,n
rill-. AllOVK STATi:!) PKkSoXAl, I'.\ KTIC K I.A K S Akl- rkCK To THI- HKST OK MY KNOW I,};i)C.K A.M) HKI.IKK
" a
Former or Usual Residence
When was disease contracted, If not at place of death?
How lonq ^\ Place of Death ?
ranslents,
Days
Oiifor tn.-int
a^^^\^\^\^
\ \.. O
J.
V ' • I > V IN I .A 1
[90
I'l.ACb: OK niRIAU OK KI.M..VAK j DATK of M,K,.vr. or RKMOVAI,
^^ I AJ-^vo 1.1 I,
(AddresH I 5 1^ jt^tt k-^ c ,. 1*.
N. B. F.very Item onnformatlon .houlcl be crefully supplied. AGE «houIcl be stated EXACTLY PrtYSICIAIMK u .^
lTn:^'\ "%''^^T" '" »*•»'" *— *»•«» '» -»> ^'e properly classified. The ••SpTcili InZIatlln^' C ^^r sons dyinft away from home should be Itiven in every instance. ■nrormation for p.r-
I <
.*^'
^♦' i
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
""""'"'" "^■'1"' ' N'^ i^t-g^^H&PCo REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
I'JO'i
Reglstet'ed J^o.
1029
Deputy Health umccr
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of 2)eatb
PLACE OF DEATH: — County ofO CL/YV OAxXAxcc^Ct City of CJ <X/>\; 0 X.Ct/>x aui o <.
(No* JaJL^WC/A'V' (
(IF DEATH IF DE*
OCCURS
St.
Dl
0
Dist.; bet.
• WAY FROM USUAL RESIDENCE GIVE FACTS CALLED FOR UNDER SPECIAL INFORMATION • \ ATM OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. /
FULL NAME
[^
'\0
\ I
LdxAj<^_''..'.l
^
L^
and
lU
I.
s !•: \
DAIl". «)I- lUKTM
M'.K
PERSONAL AND STATISTICAL PARTICULARS
iK
M..tiih)
] 'rii ;
SIN'(,I.K, MAKUn-;i) \\II)»»\V}-:i) OK IM\()kt,-KI) iWiitriii >-orial dcsivMijitioii )
1%
iDiiv)
Months
MEDICAL CERTIFICATE OF DEATH
DATK OF DlvVTM
/
(Vfur)
II
Da 1 .
lUk TMIM.AOK 'St;itf or I'ounti V
NAMK Ol' FA TMHR
niKTIlIM.AOK <)I' lAlMKK (St.'ttr or Coutitrv*
■vvoaJL
(^
— ^c^q
(Month) \
I'l
(Day)
igo
(Year)
I IIHRl'HV CivRTlFV, That I atten.kMl ,lccease.r7roni
>-^-^^CL \'X 190' i to LLa-A^Q .i.'.\ igo .
that I last saw h ■'• alive on LA.s_ua '. ' t 190'.
aiul that death occurred, on the date stated ahove, at i . I L' L . M. The CArSl- Ol" DI-ATII was as follows:
k
kJ-CYX^'
..'-..... X. '..... C//^rw\.v,\.^.^v,.v.<i t-^lv^ '
K.\J'^i.
DC RATION CONTRIHUTORV
)'i'ars Mouths -^ Pavi
Ho lit
MAIDFN NAMK Q
OI- MOTHKK wY
iuktmi'i.acf;
o|- MoTHHK (Slate or Country)
V^
duration (Signed )
}'r(jrs
Q
AMo)iths O Pax^
Hou
rs
-(r\<wvcn
OCCUPATION \
h'cyiJrd III S.ni /'/,;;/,/>,■,> j )V-<mc ] .M.nilli- \\. f'hivs
I'ln-. AMOVK STA rKI) I'KKSONAI, 1V\ K TUT I,AKS AH I- TKVV Po ruF
ni;sT Ol- Mv KNOW i,i;i)r,i.: and i{kmi:i-
'O^ ^'^ i()0 ClAL INF
(Address)! C) 0 ?j
M.D.
Special information only for Hospitals, institutions, Transients, or Recent Residents, and persons dying away from tiome.
Former or Usual Residence
When was disease contracted, If not at place of death?
flow lonq at Place of Death ?
Days
( IiifoiinanI
*
?^..«i. %_,.lt.
(Address
aa^
v.<t'^ 3.1.
rr.ACK OF HIKTM 01? KKMoVAI, I DATFof M.hial or KFMOVAI
VnU ^1^^M^' I ^L^^-^J:^ '90'
INDICRTAKHK
(Addi.ss
Mil
(y)\
v<t<ivcnv d.^
N. »•— »;-Y*^riT«;i-^n"Jnni'M" •''7''' '"■* -"""f""*^ ""PpHecI. AGE should be stated EXACTLY. PHYSICIANS should state CAlJSfc OF DEATH ..1 pla.n terms, that it may be properly classified. The '♦Special Information" for D.r- sons dyinft away from home should be ftiven in every instance.
fstfj^tmk 'i'-JF'
write: plainly with unfading ink — this is a permanent becord
n.Mnlof HiMlth J No I .; *-5?~^ H& P Co REFER TO BACK OF CERTIFICATC FOR INSTRUCTIONS
])<(/(' Filed,
voot It l'JO\
Ocpuiy ('iOu^iLii. O-i'iiwj:''
Registered J^o,
1030
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of Beatb
{ TU. S. StanDarO )
%
On
PLACE OF DEATH: — County of ^CLA\;OA>a/lvCLNiaCity of U/CUWj 0 ^CXyVL^<^cc
-No.3l\lK
f
(\
(
O-Vu-A K'iV<1.1\aA.,o..I' St.,
IF ocathAjccurs away iTrom usual res
iAAA..O..l'
Dist.; bet.
and
y^V
IF DEATH OCCURRED IN A HOSPITAL OR I
FULL NAME
ilDENCEGIVE FACTS CALLED FOR UNDER "SPECIAL INFORMATION" \ NSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. /
/
si:x
DATK or I'.IK'IH
AC. K
PERSONAL AND STATISTICAL PARTICULARS
I COLOR
>
(WJJ^
h
I Month
/VV
U
'-7
)V,/,
I \
(l)av)
Minilhs
(Year)
Pay:
SINCl.i:. MAKKIMI). WIDOW KI> OK DIVoKiKI) (Write in scxMal desijf nation)
I$IKTm'I.ACK
'St.iti- or CVmntrv)
NAMi: 01
I-' A r 1 11; R
RIKTm'F.ACK Ol' I-Al'UKR
(State or Country)
MAIDHN NAMK 01 MOTHKK
lUKTJnM.ACK Ol" MO'rnKK (State or Conntryl
vvo.
MEDICAL CERTIFICATE OF DEATH
DATK OF DKATH
Ll
(Month) \
(Day)
/go ,
(Year)
. 1 IIKRKBV CivRTIFV, That I attended deceased from
M.V^sA,^^.. !i. 190'! to ..LvL^s..^ 1.1.. uyo\
that I last saw h •• . alive on Lv^.^vCl ^ \
and that death occurred, on the date stated above, at sA. M. The CAISR OF Dl-ATII was as follows:
It/)
1 1 t.
L
Dl'R.ATION Years CONTRIIUTORY
Months
Days
Hours
T'
X
occrrATiON J?
O
X.C4vcrO
-4
Dl'RATION
(SIGNED)
}'iars sMouths
Pays
a>...
ail
IC)0
(
(XW:)
Ad<iress) at VnL
Special Information only for Hospitals
or Recent Residents, and persons dying awdy from home.
, Instifutlons,
//ours M.D.
4xt.
Transients,
,ii
Former or 1 \
Usual Residence U A.-O.D..
'^-0
Rfsidrd ill Si7 H I'l iiiii iM'ii
) 'tUX I .
1 Months ' *.
/J,n
How long at ,
PJareof Death? 1 ^. Days
When was disease contracted, If not at place of death?
THI. AHOVK STA'n:D I'KKSOXAI. I'AKTICn.AKS A K K TKIK lO TIFK
iiKST Ol" Mv k.n<»wm:d(".k and HHMHF
(IiifoiniaTit
\\ \
(^
A.A-CX-^'V^v.tx^
l'I,ACK Ol- BIRIAI, OK KI:M(»VAI.
rN'DKRTAKKK Jc . \L. 0 <xLL<X^kX' ..
Address ^ aO - 5 1%. 4*
DATKof HiRrAi. or RKMOVAI,
L'Lcvq I'.,
TQO
M. B. F.vepy item of information should be cnrelfully Kiipplied. AGE should be stated EXACTLY. PHYSICIANS should
state CAUSE OF DEATH in plain terms, that it may be properly classified. The "Special Information*' for p«p- Rons dyin^ away from home should be j^iven in every instance.
mm
r
ii^i
Hnai.l of Hialth - V N(V i^ t^'^l^^^ USt J' Co
•vi_iie> ic* ii t3 r emii A ivi c ivi *T' iaxrr*f\tir\
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
lUi
((' /^V/fv/, IJ^a-^axV-aA^ f^ ^'^^
^>(9H
Registerecl JVo,
103 1
cMrLwo Aju
\>^ Deputy Health Officer
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of Death
( xa. S. 5tan^ar^ ) PLACE OF DEATH: — County ofCVO/ru J /vcv>vcuiccCity of CI/CL/Tu 0 /VC^^vcA^^ac
No. 1 C)C)1 ll->\.v.,c--^
^.
St.; i Dist.; bct«
o
and
(IF DCATH OCCURS AWAY FROM USUAL IF DEATH OCCURRED IN A HOSPITAL
RESIDENCE GIVE FACTS CALLED FOR UNBER SPECIAL INFORMATION OR INSTITUTION GIVE ITS NAME INSTEAD^JOF STREET AND NUMBER.
)
a.Aj-voi.1 )
FULL NAME
11
^ c- 1 V.
K
.t...--^
SHN
PERSONAL AND STATISTICAL PARTICULARS
'iLo^lx
UJyVVA.tjL
DA 11-: nl- HI KIM
Ai.i-:
t
C ^
J v.;
II.
10
Dav)
}f.>iitfn
/I HA..
(Year)
Pars
SIN'C.I.K. MAKUIHD WIDdWKI) <»K I)IVi)KrKI) 'Uiitiiu "iiKMal <Usijrnatioii)
HIK rni'LACK
(Statf or (."MUiitivl
1,
ojxaaxxI
'VCU^XClA.
N\MK OI I- A Til l.K
lUKTllI'I.ArH Ol- » AIMKK
(Slat< or i'<iiiiitT \
MAII»i:n NAMl <)!• MOTHF.K
niK rni'LAOH
Ol- MOTIIKK (Statr or Coiiiitrv)
(XXrPATlON
on
^ /vex. ^'^<UL
0
MEDICAL CERTIFICATE OF DEATH
DATH t)l- DKATII r\
UwA.V/Q
(Month) K
IS.,
(Day)
7pO I (Year)
I HICRICRV CIvRTIFV, That I attended deceased from
^^.^A^"v k<: 190 0 to iJsA.A,,/n )..^. 190H
that I last saw h-^ y> . aUve on LXa^v^CL- ' -^ igo 1
and that death occnrred, on the date stated al)Ove, at _ M. The CAI'SK OF DIvATII was as follows:
.rfij'^-.fr-Wu VAw^v,<\Jk^<>r-^,A^ .:>... 0:W... J^
/O'V^rCU-yv
ev-^-f ^ •
DIRATION S Yt-ars Mouths,
CONTRIHUTORV La/vaJ^
Days Hours
V<yAA^...01r.....3wAA,S^.;.!
I )r RAT ION S Years Months Pays Hours
(Signed) 0--Uj Ja.,.^hi^;i. m.d.
\Xv.uq. .15. iQo'i (Address) 3X^ JULQJvaa^^ lit.
SPECIAL INFORMATION only for Hospitdis, institutions, Transients, or Recent Residents, and persons dying away from home.
Rf sided in Sap I'l tiiii iu'it v> )'roi>
M.nlih,
/',/!.-
THK AIU)VK STATI-.I) I'KRSONAI, I'AKTirn.AKS AKK TRl K TO TIIH HKST Ol" MY KNOWI.KIX'.H AND IIKMICK
(7. (^
(Informant
-V.Mir^s OOo
frixA^a c-^mjLV-o
a..
Former or Usual Residence
Wlien was disease contracted, if not at place of deatfi?
Hew long at Place of Death ?
.. Days
PLACE OF UrRIAI, OR RKMOVAI, I DATK of III KIAI. or RliMOVAI,
i\KV\xvL /^OS \l 'L(r^AX<xV Lls^^:,
N« B. Bvery item of informotion should be cnrefuily supplied. AGE should he stated EXACTLY. PHYSICIANS should
state CAUSE OF DEATH in plain terms, that it may be properly classified. The "Special Information" for psr- Rons dyin^ away from home should be ftiven in every instance.
■'H^i^syt
'jmb..
. •• v« Ba«l^ir«lki<
1 i t i
ii
WRITE PLAINLY WIIM UI>I^MUllNVJ mr\ — inio lo m
MnM.infii.aitJ, FNo Ki^-gSJ^H&l'Co REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
Ihtfr AV/rr/, (Xu..OL^^ |(o JOCi
lieglatered Jfo,
1 Q'Vl
<j^^.^r\..^<,A^
Deputy Health Officer
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Cevtificate of Beatb
( xa. S. Stan^arD )
J? ^ J ^ •
PLACE OF DEATH: — County of ^ CCo^ J-^xxXz-v^^cuirCcCity ofO/(V>^ JXXXAve.A_>^c.<.
^No.
b\l \l KOL<i.Cr^v St; I Dist; bctA. a.A.A u ^ and ■JA..U...)
/ \r Dt*TH occults AWAY FROM USUAL R E S I D E N C E Gl V E FACTS CALLED FOR UNDER "spCCIAL INFORMATION ' "\ V IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STiicET AND NUMBER. /
■^\
FULL NAME
I) e
PERSONAL AND STATISTICAL PARTICULARS
s):\ (K\ \ I coi.oK
"J'
1
DATl". «)1' III K Til
yW^^
\
Mouth) K
AC, 1-:
) V-,;
(Dav)
Mniithy
I
(Vcar)
Oti \s
SI\<; l.K, MAKKII.l) \VII>t)\VKI> <»K DIVOKrHI) iW'ritt in sot'ial dcsijj^tuitioti)
lUKTMIM.Ai'K
(Statr i>r I'miiitrv*
NAM1-: (H- FATin.K
RIKTmM.A^H OI" lAPHHK (Stitt«' or C'oiiiit ry*
MAII)I:n NAM1-; <)1- MOTHKK
inKTHl'I.ACH oi" MOTHKK (SiaU' or Country)
OCCrPATION
vcc^^.^^
'>\.0„ .'
MEDICAL CERTIFICATE OF DEATH
DATE OF DKATII
\
(Month)
(Day)
igo
(Year)
I H!<:RIUJV CICRTIFV, That I attended (Icoeased from
LLvA^^ IH 190'', t(i . . AAa«a^....1H loo'i
that 1 last saw li •: alive on LcV\,\^A:y. W up .
and that deatli occurred, on the date stated above, at O
■J M The CATSIC OI- Dl'ATI! was as follows:
O nf\yCK,y^^^.t,^^ t . s.
DT RATION )'ears
CONTRIIUTORV
Mo}itln
Days
Hours
\^oJLkJ^ ' w \ V '_ c
Di; RATION
(SIGNED)
/ C U / J
Months
'0
\X^
LLv.^q W i()o'. (Address) .iS.5.^.
Cf
Days Hours
O^bJr:. M.D.
SPECTAL information only for Hos;)itals, Institutions, Transients, or Recent Residents, and persons dying away from home.
Resiiifif in S(in /'i itm i<ri^
) I'll I
:/,»////.<
/)<;i.
rin-: ahovk stati;i) i'kksonai. pAKTicri.AKs ari-: tkif: to tiif: nF:sr of my knowi.kix; f: and lua.iKF
Pa
(Informant w^CV
f Xd.lrcss
<X<I. ^ ,
■\
Former or Usual Residence
When was disease contracted. If not at place of death?
How long at Place of Death?
Days
PI.ACH of BI'RIAL ok KICMOVAI, I DATF: of m-KiAr. or RKMOVAI,
'V^A_ I
190
r\(Mrc«s
n).0..5. yX(r^l/c\;\^....Li»A,>^
.>^.
N. B. Rvery item o? information should be cnrefully Rupplied. AGE should be stated EXACTLY. PHYSICIANS should
state CAUSE OF DEATH in plain terms, that it may be properly classified. The "Special Information'* for p«p- sons dyinft away from home should be ^Iven in mvcry instance.
xAiotTc Di AiiMi V lA/iTu I iMrAniMr^ iMK xu I c: I c: a Dr BMAMP NT orrtr^nn
n..;ii.l .r il.Mlth- I No u*^^fc5H&l'Co REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
I)n/(^ F//fV/, CL^OL^^ l(0 ie9^i
oUi-vx^^ d^x^>-u Deputy Health Officer
Be^Lstcred J\'*o,
1 083
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of Beatb
"a. S. Stan^ar^ )
PLACE OF DEATH: — County ofOxX^ru 0 AXXwcuiCij City ofO<X/-r\; vJXOl/>v<<^v.nLC.o
f No. Uiv^LdAJy^
xxi UO O^Y^tccL St*; "
(\T Dt»TH OCCURS AWAVifROM USUAL R E S I D E NC C G I V C FACTS CALLED TOR UNDER "SPECIAL I N FOR M ATIO N •' "\ IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. J
Dist.; bet.
and
)
FULL NAME
JLC^aL^.'..
SKX
PERSONAL AND STATISTICAL PARTICULARS fv I COI.OR \
^
DATi: <)|- lUKTH
Monih)
i
V
<Xjl
Q ,-
\f. K
I
) ■/■</
H
(I)av)
M, mills
ir)
MEDICAL CERTIFICATE OF DEATH DATE OJ" DKATII
15-
(I)iiy)
(Mouth) a"
(Year)
n,i 1 .V
SINi.I.K MAKklKI) WIDOWKI) OK I)I\ <)K( i:i)
(Write ill s«Hi;il (|( si>.'ii.it ion)
m
HiK rni'i.ACH
'State or *_"ountr\'
NAMK Ol KATHKR
mkTMPI.ArK
<>l" I ATHKR
I Stale or Con tit ry)
MAIDHN NAMK /7\ Ul- MOTHKK L
I nrCRHBV ClvRTIFV, That I attcndcMl (UHoased from
\>J. Q^S 190 't to . UwA^A^ IS. 190 H
tliat T last saw h i., . . . alive on LA-'^^~0^ VS igo i
and that death occurred, on the date stated above, at AX M. The CArSH OF DIvATII was as follows:
C3./C/Ow>JLcjfc .vl..r:C.V.-.^:..\'
kA^V^X
as 1 01 lows :
X <5^Jw^V\>-v.':>. v.Q.
or RATION
" } 'ears
O-^
HIKTHI'I.ACK <>1- MOTHKK
(State or Count rv)
oJLu
Mouths S Days
Hours
OCCrPATION
Resided ill Sav /> mi, isro I )V'<7/> \ Af>>>/l/is ~
CONTRIIUrrORY
DURATION Q^^'''^''^ Months 1 5^ nay.\
(SIGNED) h) . y Gu<xJlA\.X^
Vit^^Or \^ iQO^ (Address) UJXwdvt-y
SPECIAL Information only for Hospitals, Institutions, Transients or Recent Residents, and persons dying away from home. '
Former or Usual Residence
XA
Hours M.D.
Pa
TJIH AHOVK STATi;i) PKKSONAI, TAR iUT I.AKS A K l-, TKrK To TIIK
HhST oi- Mv kno\vij:i)«-.k AND ni':Mi:F
Hiifoi niaut
(A (1(1 res
1 ^0 MOM-<xcUv a^/ ']\ Place of Vath ? 1 ^> ^ y .. p^yj
When was disease contracted, x 1 0 I) 1 * i)
If not at place of death ? oX) Jr\)L<k.cJL 0:\r CU-coJk,
I^'ACK OK niKIAI, OK KKMOVAI. I DATK of Hiriai. or RKMOVAI,
c\r>v I vJv\A^qi lb 190H
KNDKKTAKKR
(Athlress
N. B. Every item of Information should be cnrefuliy Hupplled. AGE should be stated fsXACTLY. PHY8ICIAN8 should state CAUSE OF DEATH in plain terms, that it may be properly classified. The ♦'Special Information" fer psp. sons dyinft away from home should be given in •\9ry instance.
(J
r
•I
tl
WmMLi .ItBSrf'
ki r» iki««> i^i^^«^^^
1
i
WHI I t. KLMIINLT Wl I n Ul^irMUmVai ll^r\ imo la #n r-cnrnmi^ci^ i nuwwrik^
REFER TO BACK OP CERTIFICATE FOR INSTRUCTIONS
Hoard uf Utalth— KNo it. >*i^^) 1J& P Co
Thifo Filed , iJ..XAyOi/\^x.^
Ho lOO'i
Reglsteved J^o.
1034
.-CrV^^-^VwO
, D e p -i.e./. He a It h.. Off! c c r
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Cevtiffcatc of H)eatb
( Ta. S. StanC>arC> )
PLACE OF DEATH: — County of Ci Cn^^^r^-^ \^cx
City of O crvx.<rwv/cx,'
(No.
St.;
Dist.; bet.
"and
(IF OCATH OCCURS AWAY FROM USUAL RESIDENCE CIVC FACTS CALLED FOR UNDER "SPECIAL INFORMATION" 'N IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. /
FULL NAME
yj KJL6^sJLKj.,y^Jy\yOj
PERSONAL AND STATISTICAL PARTICULARS
sKx ny\
'
DATK OF lUKTM
AC.K
L
COI.OR
.VW
\JL
Month)
n 0
^
IS
(I>av)
yfnufhs
(Year)
Pa \s
SINCI.K. MAKKIKl). WIIXAVKI) OK DIVOKC'KI) X
(\\'ritt'in s(K"ial (W-sivtiation) i . ^
HIR TMPI.ACK
(Stritf or Countrv^
NAMF. or FATHKK
BIRTH PI.ACH OF FATHKR
(State or Country)
MAn)F:N namf:
OF MOTUHR
inKTuri.ACF; t)F" mothf:r
(state or Cotmtrv)
Lv \.cC^^
IX\ •> >vrL
'>vev^'
MEDICAL CERTIFICATE OF DEATH
DATF: OI- Dl-.ATM
I..5
(Day)
(Montfh)
7ooH
(Year
I in':Ri:iiV CICRTIFV, That I attended (Iccoascd from
— to 190 ~"~~
190 —
that I last saw h ".:- alive on
190
and that death occurred, on the date stated al)<)ve, at :^~j M. The ^^'-"^K OF I)I<:ATri was as foIIi)ws:
ab-Jia/vA' d.^x^Ju^/vA^ ^Va^ix/^vvA-c
...\j../QJLsJ^^V^JL.O./A.:
. ' 1
I I
DURATION Yeats CONTRIBUTORY
Months
Days
Hours
DURATION
occ
U PAT ION (Jplf
f)
Rfsidfd ill Sail I'l ,1 in 1 m n
(SIG
CL
^TION , Years
NED) J. \ a<J
Mouths
Pays Hours
M.D.
\.\^a l!.^ u)0 'i (A.ldress) O (rYvcr>-wA<<cc V^^C^X ).
cIalTn
SPECfAL INFORMATION only for Hospitals, Institutions, Transients, or Recent Residents, and persons dying away from liome.
)■/•(/;
Ar»ii//is
n<n
THi: AKOVK STA if:!) PKKSONAI, P A K IICF I.ARS ARF: TR I'K TO THF: HHIST OF MY K NOW I.i;i)< , K AM) MFI.IliK
(Inforntant
oio. Iro. CcwjL ... .^AA^vt
(^ p
SJL'^^JL^
T\^-iLV.t\A.
i
Former or Usual Residence
Wlien was disease contracted. If not at place of deatli?
Hew long at
Place of Deatli? Days
190 V
PI.ACK OK lURIAI. OK KHMOVAI, | DATK of IJlRlAL or KKMOVAI
cNDi-KTAKHR V yy\jL^H:Lft^ ^ ajLaJk^
(Addres.s ^..^...l...Al..r\A^lAA^tn.\.....D.,t.
'^' **• Rvery Item of information should be cnrefully supplied. AGE should be stated EXACTLY. PHYSICIANS should state CAUSE OF DEATH in plain terms, that it may be properly classified. The "Special information'' for per- sons dyinft away from home should be |t«ven in every instance.
I
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
»
n...r<l..f iic.ui. » No i.^*^^i)i{&pro REFER TO BACK OP CERTIFICATE FOR INSTRUCTIONS
Ihdo Filrd,
.Ait It..
7^i9H
Registered JSTo. 1 0o5
u..
t
II;!.''"
;.ealllb...aiSir - -
DEPARTMENT ofr PUBLIC HEALTH=City and County of San Francisco
Certittcate of H)eatb
( in. S. StaiiOart ) PLACE OF DEATH: — County of^^Oyvu 0AxX/>vCMi<>0 City of ^OOyvu OA/Cu>vq.c^ccj
No. T H 1
Q^V
Lv.<UlOv
1
St4 ^ Dist.;bct. Ohx^V^u
and
%A
f ir DC*TH OCCURS *WAV FROM USUAL R E S I D E N C E G I VC FACTS CALLED FOR U N DE 1^ " S PEC I AL INFORMATION" \ \ IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD 0« STREET AND NUMBER. )
Oj^y\.<x. )
FULL NAME
itx
rx/.yxj..
si;\
PERSONAL AND STATISTICAL PARTICULARS
COI.OR
U)ivoLi
DA'IK <»»• lUK in
AC.K
%
I Month)
(I)av)
(Year)
MEDICAL CERTIFICATE OF DEATH
DATE OF DKATH /O
vjIaa^q
(Month) K
lb.
(Day)
(Year)
) I'O I .
5:
M.intfis
S
Da I .V
HI\C.I,i:. MAKKIKD. WlDnWHD OK I)F\()R(KI) (Write in scH-iri! ilt>iij.'ii.'if ion)
HFKrHIM.AOK
(Statr or Country)
NAM1-; OF- FATIFHR
RIRTFlPI.AlK OF- F-ATHKR (State or Country
MAFDl^N NAMH OF MOTHKR
niRTMPI.ACK OF- MoTFn':K
(State or Country)
'X
I HRRHBY CKRTIFY, That I attended deceased from
vXu^Ol i^- 190 '( to LLv.-i.x3u. .1.(0 190 H
that I last saw h -.t ^ v\ alive on LAa^v.-q 1 V jgo '4
and that death occurred, on the date stated above, at ?) XO. 0 AL The CAUSrC OF DKATH was as follows:
DURATION Years
CONTRIIiUTORV
OCCri'ATFoN
Mouihs 1 Days
Hours
duration (Signed)
Years
Mouths
f^ays Hours
Rfsidfd ill St\ti I'muiisi-o O Yrai .< -^"^ Months i
190^1 (Address) 2)S I 3a.vUjUv Bl
M.D.
?^^9'?i^J'^r°"'^^'^'ON only for Hospitals, institutions, Transients, or Recent Residents, and persons dying away from home.
Former or Usual Residence
i\i\.
When was disease contracted, If not at place of death?
ftew long at
Place of Death? Days
' "l;,^!ii*^ ^' ^'•'^'•■f:i> f'krsonaf. i'artfcii.aks akk trik to tuf
llhST OF MY KNOWI.KDC.K AND IJFMKF (Informant \i y\yC^AjLcX Cd . J (iAhVA V
^Address
:i4i
UXlAAyUAj dl
pi.^E of; bfriai. or rf:movai.
l^-^'I^of BiRiAL or REMOVAI, ^ T90H
UXDERTAKKR \ Vj . U \w,<n^yVLVV ^^"^
(Address
""' "'~rtaVe*'cl7sF*Ap nTrxH"."*"?'** **" ^"-^^^''^ supplied. AGE should be stated EXACTLY. PHYSICIAN -inl H 7 - OF DEATH m pla.n term,, that it may be properly claimed. The "Special Information- sons dying away from home should be ftiven in every instance. mat.on
8 should for per-
I
d . .Mi
\f
^'1
■«
•1
!||
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
H«Kir(l of llcjilth-F No. m T^-^Jw^ H& I' Co
REFER TO BACK OP CERTIFICATE FOR INSTRUCTIONS
/)((/(' Filed ,
ij[ 190'\
Registered JVo,
10*16
duJv-u Peputy Hearth Officer
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of Death
( 'Q. S. StanOarD )
PLACE OF DEATH: — County of
-P
City of UuXOL/WOj CJ^CUXA'vu CV.Qv
(No.
St
Dist.; bet.
and
(IF DEATH OCCUHS *W»V FROM USUAL R C S I D E NC C G I VC FACTS CALLED FOR UNDER "SPECIAL INFORMATION" \ IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. )
)
FULL NAME
Vj /CLfov^ok LU
\JJ\.^r\j
PERSONAL AND STATISTICAL PARTICULARS
s};\
riojui
COI.OR
IjO'I^u
DA IK o|- HIKTH
AC.K
/
MEDICAL CERTIFICATE OF DEATH
DATK OF I)I:aTH ,0 h
.JL .10..
(Day)
r\A.v
(Monlh)
(Year)
/
I Month)
!''■(( >
tl):ivl
.^/.mt/is /
(Year)
Am A
SINC. I,K \!AKKIi:i) WIIXiUKI) OK I)I\( >kr)-:i) (Writr in M)ri;il <l(sii.rnittiim)
lUKTHPLAOK
'St.it' or (."oiiiitr\'>
NAMI-: OI KATIIKK
lUK'llll'I.ArK <)»•• I-AIUHR
I state or C'oiintrv)
MAIDHN NAMK <>!• MOTHKK
inKTHI'[,ACH <U" MOTHKK (State or Cojuitrvl
I HHKIUiV ClvRTIFV, That I attended deceased from
— to
190 that I last saw h ~ — alive on
190 T90
an<l that death occurred, on the date stated above, at M. The CAUSH ()!• DI-ATII was as follows
DIRATION Years Months Days Hours
CONTRIIU'TORY
DURATION
(Signed )
)V</rj Jfont/is
IqO
(
Address) LL . a.
oceri'ATioN (Vu
f\f>iiir(f ill S(jn ridih isi'o
5 'I'ti I .
Ar,uif//s
Dcvs
Special Information only for Hospitals, Institutions.iranslenls. 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
rnr: auovic statkd pkksonal rAKTioii.AKS akk tkik to thk hhst oi- MY k\o\vm:i)ok and hhi.ihi--
a. IT)
(I
r\rW«:^SS
<XV-vo
;^M.ACE OF buriai, or kkmovai.
ini)f:rtakf:r
^■\<l<lrcss
DATK of BiRiAL or REMOVAI,
JX ... 190H
'^l
u. i , a
-jl\\X
^' ^' rtrJcArsF^Ap^nPrTS""*"?'** ^" ^"-*f""> «uPP'5ed. AGE should be «tated EXACTLY. PHYSICIANS should «inl H • . c I '" **/"'" '*'•''"•' •^^^^ '' '""y *"" properly classified. The "Special Information" far per-
sons dyinft away from home nhouid be ftiven in every instance. ^
L '^:
-f4 it
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
Hnjtnl (.f Utrtlth-I" No. i«; S-F^J^^H&p Co
0 jT
ow(rvAA^
10 0\
Deputy Health Officer
Registered J^o,
1032
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of Death
( "Ul. 5. StanDarD )
fU
'Na VC
PLACE OF DEATH: — County of 0/CL"r\; O^uX/W^cuic.c City of C)/CL^.; 0 A^Oy^x^M^^^x
\X
()0(H.W.to_l:.St.:
Dist.: bct«
and
/ IF Dt*TH OCCURS AWAV FROM lllSUAL R E S I D E NC E Gl V E FACTS CALLCD FOR UNDER "SPECIAL INFORMATION ■ \ \ IF DEATH OCCUrt>«CD IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. /
FULL NAME
:Yv-rvsJ.
DATi: OI lUK 111
PERSONAL AND STATISTICAL PARTICULARS
<3^
„<x.
I
J JLAr
I Month)
(Day)
(Year)
MEDICAL CERTIFICATE OF DEATH
DATK OI- DKATH
(Day)
(Month)
(Year)
ACK
I ^ Win < ^ Months y. \
Da vs
SIN(.I.i:. MAKUIKI)
uii><)\\i-:i) OK i)i\< »Kv i:i)
'Writt in Mninl dcsij^nation)
lUKTFIlM.AOK 'State or Country^
NAM!. OI
i-atiii:k
HlRTMPI.At'K <)»•• 1-ATHKK (State or Conntrvi
MAIDKN KAMI, ni- MOTHKK
lUKTHPI.ACK OI- MOTMKR (state or Country)
I HPtRI'HV Cl-RTIFV, That I attended deceased from LL^cAXi l.X I90M to vU.AxCL..l.b..
that I last saw h ^^i-^v alive on
1 niicui I
I90H
l.i.
190
'i
and that death occurred, on the date stated above, at IX-^"^ 4I M. The CArSB OT DICATII was as follows:
\J -AAJL^VVV^'V^XXAA^
DIRATION Years
CONTRIBUTORY
Mouths
Days
Hours
OCCri'ATlON
%
"JLo^
£) 0-<-C^lj4.A.VM.iUi'
Resitird in Stiti /'> am /wi)
)'f til V 1 l/.'^////N
DURATION
.NED) UJ rrru \l7\
(SIGI
}'ears
cyy\j
^^ 190 H. (Addresf
Months
Pays
Hours M.D.
SPECIAL INFORMATIO . .
or Recent Residents, and persons dying away from home.
Lvss) Ld:uX.^^.Q m CKO.|.vt.
N only for Htkpitals, Institutions, Transients,
Former or
Usual Residence ^
hiiv
THK AHOVK STATi:i) I'KKSONAI. I'AK Tlcr I.ARS A K F. TRVF To THF
iihST OI- Mv kno\vm:i)<-. H AM) nHi.ri:i-
(Informant LU rVVA.) . \l /\. Os^VAATA^^CA^
(Address
<X-^yAyCL VX) .
Wfien was disease
if not at place of death ?
contractei^
Hew lonq at ^'^ Place of Death? H Days
I'LACH OF m-RlAT, OR RKMoVAI, I)ATi;,of lU r.ai. or KKMOVAI, ^-M/lfVAOA/S^^CC-CV-^-x- I ^^'^^^^^^^^^^ \% I90H
^Ad.lress !i.^.'l.l....>4^^
^' "■ TtaVe^^Ji^irsF^Ap nTri'r •**7''' **" ^"'•«f""y supplied. AGE should be stated EXACTLY. PHYSICIANS should !«^1^^ . OF DEATH in pla.n term*, that it may be properly classified. The ''Special Information" for dt- sons dyinft away from home should be ftiven in every instance.
- '-
mi
f'n'
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
REFER TO BACK OP CERTIFICATE FOR INSTRUCTIONS
Hoard of IlfiiUh- »• No. !S *^E^ H*^!' Co
I)((fe Filed f
A^Xl^ 11
100 "A
Registered J^o,
1 0.'^8
Deputy HeMvh Officer
DEPARTMENT OF PUBLIC IIEALTH=City and County of San Francisco
Certificate of Beatb
( Xa. S. StaiiDarD )
— County of O/CUvu 0 /L-CL^v^^A^c^City of CjKX^Vu 0 X^<X/>ax:.^s.<l-C c
PLACE OF DEATH:
(No.
Sos'iiiuJ^
\X^\)
St.
\
Dist.; bct.^' OJi.rLvw.ql^ ^> \. and
A.^^>
CI
(ir Ot*TH OCCURS AWAY FROM USUAL R E S I DE NC E Gl VE FACTS CALLED FOR UNDER "SPBtlAL I N FOR M ATIOH '• \ IF DtATM OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STRt-ET AND NUMBER. /
ai
li
(<)
FULL NAME
'\Xkjy\j. 0 <X/mj \Ltv.A,jL:y\:
SKX
DAT!-: oi- lUK rn
ACK
PERSONAL AND STATISTICAL PARTICULARS
COL
(5;^
""Vli^.-
'SA
<Mo!ithl
'"^ I JV,/;,v
\^
1.
(I)iiv)
Mouths
(Year)
Da r.
MEDICAL CERTIFICATE OF DEATH DATE OF DKATH ^
(Day)
I go
(Year)
SINC.l.K. MAKklHI)
\vii)<)\yKn OK nivoRiKi)
'Uritt'jn S(x-ial «Usivr nation)
niKTMFI.AOK 'State- or Country I
I i
i:
y'
NAMH OF FATUKR
HIRTHI'LACK f)l" lATHKR (Statf or Country^
MAIDKN NAMK o»- MOTHKR
lURTin'LACK OF MOTHKR (State or Countrj)
VAw/W^CX^
(Month) J I IIHRHRY CICRTIFV, That I attended deceased from
— to :■
190-——
that I last saw h •• - alive on
190 190
and that death occurred, on the date stated above, at I ?v AJ M. The CArSR OKDJ'ATH was as follows:
-Q.^
— ^"^ \ I
r
DURATION Years ^ Mouths Days Hours
CONTR IBUTOR Y
0^
vl AJl
w
i.
'*
>JkjUL
vtx
duration (Signed)
Years
AlfoHi/lS
Resided lit Sav /'i nii, isr,} I ( )',-,i i ^
Days
Hours ^AJ.<^. M.D.
^>A/q, 1^ 190'^ (Address) (pOb d^Ottuy. dl
PP
f^^^'fi'-J'^f^^'^'^'T'ON only for Hospitals, Institutions, Transients or Recent Residents, and persons dying away from home.
v../////.
/',n
Former or Isuai Residence
When was disease contracted. If not at place of death?
How long at Place of Death ?
Days
''""\k^J^-r*y.^'■«'.^ '•"'■'" »"»^K^'>NAI, I'AKTU ri.AKS AKI! TKIK To TH H HhSr OF ^V KNO\VI,HI)<;kaNI) HFI.IKF
(Informant
(Aria
ress
10b
(J
(Ow/Cx^^
p
FI.ACE OF-^BIRIAI, OR RKMOVAI. DATK of Ht-RiAi, or REMOVAI. INDERTAKKR oL/L<OCr>-
/ 7
^ t K ^
HII
<;■
I90H
(Address 1 0 ^
JCrVk d^^c^
rH
^' B* Every item of Infor
state CAUSE OF DE «on« dying away from
^ri-'r. •*'7'.** ^^ '^-'••^"'•y supplied. AGE should be stated EXACTLY. PHYSICIANS shauld EATH m pla.n term., that it may be properly classified. The "Special Information" far a.r. om home should be given in •very instance.
♦ ■ 1
r
> %.i
>
d
1 1 'I
m
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
I'.o.M.l ',f n< :i!t!i- I- No. K t?^'^-'^- I'mS; J' Co
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
/)(f/(' Filed J
H IDO'i
Beglstcred J\^().
1 0*59
M Dcp'.-, •■'■ ■„, Officer
DEPARTMENT OFPUBLIC HEALTH=City and County of San Francisco
Ccvtificate of Beatb
( tl. S. StanC»arD )
i Oil) -^ ^
PLACE OF DEATH: — County ofv.'/Ou^x^ 0> v<X. >^c^ui^City ofCj/OLA^ ^ KXXyy\.Al^<y<^<:^i)
No.
l^'i
OAy~w<X'
St.; ^ Dist.; bet.
^
md X C^xAj
(IF DCATH OCCURS AWAY FROM USUAL R E S I D E N C E G I V E FACTS CALLED FOR UNDER "SPECIAL INFORMATION" "X IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. /
FULL NAME
sj;\
PERSONAL AND STATISTICAL PARTICULARS
rjn ji I COLOR
*\\i{ oi iMK 111 jr\
M-.ntli)
A<.!-;
H^ r,.,„, S
(I):i\l
1 /,.;////<
(Vf.'tr)
Ay^w^cLcueJo
MEDICAL CERTIFICATE OF DEATH
DATK oi- I)i:.\TII
It.
XL
/>,n^
-^iNt .1.1-: M \K K n:i)
\\ IDi >\\l-l) OK DIXoRiKI) ^^'' it'- in ' <li -i;.MMtiiPii I
lUK IHI'I.ACK 'St.itL- or Coll lit r V
1 \ IIN-.K
lUKTIlIM, ACK o)- 1 A I' III-: 1<
MAIDIIX NAMi: Ol- Mo'lin;K
Mikinpl.Aci-; Ol" Mothi;k
'•^t.it. ■,] Co\intrv)
'Hcr]'\-ii(»N(gy) ^
RfFiilfif in Still I'l ,111. i^rt) A
a)ay) (Year)
I IN<:ki:HY CKRTIFV, That I attcMi.k-.l .IcHX-ased Tr^n
3-'^ 190H to. La-\a/CL 1.5^ iQoH
that I last saw h^'i alive on LLwQ ^ iS 190 H
.111(1 that (kalh occurred, on the dale stated above, at M. The CATSI': Ol- Dl-ATH uas as follows:
DCR.ATION Years Months Days Hours
^fonf/^s /)ays Hours
1 M K .A 1 1 () .\ ; , ars . Mon ilis Days Hours
f)rRATI()N Vcars
(Signed) lU. Li. .L) c^^.^xJ\X^^lu m.d.
U^vQ.n T90M f\ddr<-ss) il^\jilJU^.(DJ<in
EC^AL Information only ' " ^ ^
Special information only tor Hospitals, institutions, TransienJ^ or Recent Residents, and persons dying dWdv from home.
31 )>„•;.
1 /.-»'///.
Former or Isudl Residence
Wljfn wa« disease contracted, If not at place of deatli ?
fioM long at Place of DeatI) ?
Days
rin. \Ho\j-: nt \ n- i. i-kksoxai. i-ak ncci. \ks \ki: thd- t. . thj.-
IJhSI Ol- MV KX0WIJ:I>C.K AM) UICI.IICK
J'l^CJC OI; lU KI^I, OR RKMOV.M,
rNi)i:RTAKKK \.\j.\J \J^i-^\\yY\j^^ 'H K,
HATJ;;^.,! ]U uwi. or ki:m()\-ai,
l^ I90H
{■
N. B.-
Ttrt^c'rir^rUf nTri-'r**'"."''' "' carefully supplied. AGE nhoulcl be statc.l RXACTLY. PHYSICIANS «houId VI A '\* «» Dr:ATH m plain tcrmn, that it may he properly classh'ktl. The ♦'Special Infformntion" for dt- sons dyint away from home Hhould be <ilven in every instance.
m
\
t]
-if) ■ »i
«!
i.,'
*
I
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
H.):ii.l nf HiMlth l-'No. 1^ 1*^^^^n&PCo
RCFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
'; »
b
I)(f/r Fi/cf/,
L^
1.1
100 H
Registered ^''o. ^ Q40
Deputy Health Officer
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of Beatb
( "CI. S. StanDarC> ) PLACE OF DEATH: — County ofO/<X/>\. 0;vcxa^.^^l^cc City of ^"^'^CUV^ 0 /vxXoa^v.,Aye c
Wo.\
i.
}JL
>\sK<xXj K.^^\\.^\.al: St.;
Dist.; bet.
and
(ir OCATH OCCURS AWAY FROM USUAL RESIDENCE GIVE FACTS CALLED FOR UNDER "SPECIAL INFORMATION" \ IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. /
FULL NAME
J\XX.^r\)
si:\
DATK OI- lUKTU
PERSONAL AND STATISTICAL PARTICULARS
C<)I.()R \
ll'>Ajk/
M..iilh)
ACK
bS
Yrai
<I)ay)
^/>»lf/l^
(Year)
Pii ys
MEDICAL CERTIFICATE OF DEATH
DATE OF ni
UwAA/
(Month)
r
•I t
II ■■
SINC.l.K. MAKKIKI). WIDOWKI) OK DIVoKi'HI) (Write ill sfK'inI (K'sij^iiatimi )
BIRTH IM.AOK
(St.'itc or Couiitrv)
NAM1-: <)|- FATllKR
HIKTHI'I.ACK OFV^ATHHR
• State or Ci)uiitry)
MAIDKN NAMH Ol MOTIIKR
IUkTni'l,At'K OI MOTIIKR (State or Country)
(Day)
(Year)
KRI'HV CI{RT1FY, That I attended deceased from
Qv\d I90H to LAa-a^. I.hl i^S,
that I last saw h •.*.-< i^ alive on LMwA^Q 1 H T90';
and that death occurred, on the date stated above, at 105
.0 M. The CAISH OF DIvATH was as follows:
..<X
^^
M
►CCI'I'ATIOX fd . ~? 0
DURATION ' }'ea/'s ' MoNi/is" Days Hours
coNTRimrroRY >J!ir^J^.Ar)nJ>.^..0>.c:^
DURATION ^ Years Months Days
( SIGNED )"^,.^J/OAJkJl^i cDjJuUttxj LLc^O, IH iQO*\ (Address) U', 8. Lv.vJjl/vJL W.CH^^
Hours M.D.
.^ IH iQo*
ecPaTTnr
Rf^idfd in S\in /'i iin, i^rn
) 1 III
M.uifhy
Ihn:
THl", AHOVK STA'n:i) PHRSONAI, I'A KTICn.ARS ARK TRl'K TO THK HKST OI- MY KNOWI.KDCK AM) IIKIJ1:F
informant \K^ (j . LL- Vj
Ji/^r>JU^^.<^.
Jc OK) {y<4^vt txt
(A.l.lress
Special information only for Hospitals, institutions, Transients, or Recent Residents, and persons dying away from liome.
Former or -V ^ P f How long at
Usual ResidenceO Oyyu JAxx^vuCA-^Co uxq»iafe of Oeatli? CLC Days
When was disease contracted, If not at place of deatli ?
PI.ACE OF BIRIAI, OR RKMOVAI. I DATK of BlKlAI, or REMOVAI.
r.NDKRTAKKR Hk . \J T V - oLJ J^^txt
' U. i CL
(Address
^' B* F.very Item o? infformation shoulil be CHPe?ully supplied. AGE should be stated EXACTLY. PHYSICIANS should
state CAUSE OF DEATH In plain terms, that it may be properly classified. The "Special Information** for psr- sons dyinft away from home should be ^iven in every instance.
m
I
•'i
("■^ulJ^
r
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
Jloai'l of llr.-ilth I" No. i^
n& I' Co
RCFER TO BACK OF CERTIFICATt FOR INSTRUCTIONS
iXtfe Filcil, (jLa^^va^ la I'^O 4
"^ ' '^ - Deputy Health Officer
Ee^lsteved J\^o,
1041
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Ccvtiftcate of 2)eatb
( la. S. StanDarO )
% J t % ^
itv of £J v) CPv\XKAaJ(.xv
(No.
PLACE OF DEATH: — County of
(IF DEATH OCCURS AWAY FROM USUAL IF DEATH OCCURRED IN A HOSPITAL
City
St
* ♦t
"Dist*; bet/
"and
RESIDENCE GIVE FAC OR INSTITUTION GIV
FULL NAME
'ACTS CALLED FOR UNDER "SPECIAL INFORMATION" "N E ITS NAME INSTEAD OF STREET AND NUMBER. J
^\.^' O
PERSONAL AND STATISTICAL PARTICULARS
^KX A _ : I COI.OR N A
^maJ.
kx
DATK ol- IIIKIH
.\<.H
0\.
MEDICAL CERTIFICATE OF DEATH
DATE <>1 i)i:atii
(Day) (Year)
OiLith)
L
• Month)
3 rllS...
(Day) (Year)
J^t^ Yra,s h
Months
Dii r.v
SINC.I.K, MARklKD \VI1)«)\VHI) OK DIVOKiKD (Write in scxMal <l<si>.'natinn)
KIKTHPI.AOK
(Statr or Countrv)
VAMK ()|-
fatmi;r
HIRTHIM.ACK Ol" FAPIIKK (Statf or Cojintrv)
MAIDKN NAMK, or MOTHKK
HIRTIIPLACK Ol- MOTHKK (State or Conntrv)
XA'AJrU>
VCr^U->v
, ) V.
d
(^"y^M-U-^-v
I HHKl<:nV CI'IRTIFV, That I attetidcd deceased from
— to
190 to 190
til at I last saw h alive on 190
and that death occurred, on the date stated above, at '
M. The CAUSE OK DIvATII was as follows
.'^.«<L/*w/-vv^ft<.:'V^^ L\J. .^tA-a^-w^cL,
DURATION Years CONTRIIU'TORY
Months
Days
Hours
\y
•«
i9|^cxv iL- i. a
OOCrPATION
Rrsiitfd ill S(jv f'l ant isro
cars
Mouths
Days
DURATION ^
(SJGNED) UtlOl-^ A.U^XxJkAA.
I iqoM (Address) (ibcr->M)XA^J[^ ^.A..
Hours M.D.
SPECIAL INFORMATION only for Hospitals, Institutions. Transients, or Recent Residents, and persons dying away from home.
Yrai
M.niHn
Da 1 .
TMK AHOVK STATi:i) PKRSONAI. I'ARTICrKARS AKK TRIK TO THH IIKST OK MV KNOWI.KDC.K AND BKMKK
(I
nfonnant \l /UCXa^C^ V' • IA • oUjLA.rtr\.' (Acldrcss X>-U \A.- C^^ dU
XX/\hv^
Former or Usual Residence
When was disease contracted. If not at place of death ?
How long at Place of Death?
Days
PI,ACE OK RlRIAr. OR KKMOVAI, I DA'i;K of Bi RiAi, or REMOVAI,
iL. -^ a'
UNDERTAKER
(Address
^' **• Every item o? information should be carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should
state CAUSE OF DEATH in plain terms, that it may be properly classified. The "Special Information** f©p per- sons dyin£ away from home nhould be ^iven in every instance.
S\
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
I
lU.anl of Wealth K No. in
H& P Co
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
Duto AV/^v/,XL^^ 1.1 IDO'A
0 oLx/v-u Dep'^jty Health Officer
Registered J^o.
104
o
DEPARTMENT OF PUBLIC HEALTH-City and County of San Francisco
Certificate of ®eatb
( "a. S. StanOarO )
%
PLACE OF DEATH: — County ofOcL^^ 0.>vOLVLCc0.cc^^City of ^€U>X/ 0.\xx^^i:iA><i.
cc
^No. 3 b Cn^vUrixxCLi VI. <: CJxX/vuxLr VcStv; ^ -^ v Dist.: bet.
and
r \r Di*TH OCCURS *W*V FROM USUAL R E S I DE NCE C I VC 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
SK.\
DATK «)|- lUKTM
PERSONAL AND STATISTICAL PARTICULARS
I COI.OK
u-
a^Mr>v
VC
±JL
MEDICAL CERTIFICATE OF DEATH
DATE OF DKATH
a(;k
iM(iiUh) K
\^
Vrun
%
lb
(I)av)
Mont//.'
(Vt-ar)
(Month)
1
(Day)
(Year)
An.v
SINC. I.K. MAKUIi;i) \VII)»»\VKI) <»K DIVORCKI) ^
• Wiitt ill ><(H-ial (li'si^natioti)
HIK TflPKAOK (Slatf or C'otintrv)
NAMK or
fathi;r
RIKTm'I.ACE ^)r- l-ATHKR (Statf or Coutitrv)
MAIDKN NAMK OF MOTHKK
rtrthplacf: of mothkr
(Slate or Countrv^
^I HRRERV CI{RTIFV, That I attended (leceased from
^^ 190 "i to .LUaa- .1.1 190 H
that I last saw h A. S. alive on
^<\- \^- 190H
and that death occurred, on the tlate stated above at ^ 3) C A M. The CAUSfv OF DHATII was as follows:
^ "^ - • -- V/CXA^<lA./-VX^cr^v\.rCU
f\AJL
^^y\J
Kd
'CC^JL'<ry\j
DrRATION 1 Vearp^ AfonU^s ^ay/ Ho, CONTRIBUTORY L<X^^..dLA./lX^ i /a..vlA,Ajrv^.
Davs
Hon
")
c^-v
cLo,
M
OCCIFATION O
Rfsidrd ill ."^u f'lan.isrit
T^
) V-,,-
1A. ,////,
DURATION ^»^A^ ^Mouths
(SIGNED) y. bU. Vjtfti^ M.D
^^ rqoH (Address) (9 Ob OAvtU^U 3l
« ^^^ D uK "^f^^'^'^T'ON »"'y 'or Hospitals, Institutions. Transients or Recent Residents, and persons dying away from home. 'ransients.
/)(/1,v
J
HKSTOF Mv knowi.fdc.f: AM) iu:i.n:F *'
(Infunnam \. & Am^OLA.v(6-C C, K
Former or Usual Residence
When was disease contracted, If not at place of death ?
How long at .
Place of Death? I Oays
.'I, ACE OF niRIAI, OR RKM
e
I)ATF:of HcRiAL or REMOVAI, ^'^ T90I
li
t
i
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
'f
2?V:.
, •
Honnl of llialth- I- No, !«; ■5*er':St'3ri5 ){& I' Co
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
I ,
l)nh> /vV^^r/, UwA^^^-O^^^ 11
WO'K
dv^r^-^'-'^-o
Registered JsCo,
043
Dep jvV Heafth ?
■j.
DEPARTMENT OF PUBLIC HEALTH^City and County of San Francisco
Certificate of ©eatb
( 11. S. StauDarD )
PLACE OF DEATH: — County of vJ CTWXrry^wOu City of VJ Crvy^^CTYlOyOu
No.
St.;
Dist,; bet.
■and
f IF DEATH OCCURS AWAY FROM USUAL R E S I D E N C E G I V E FACTS CALLED FOR UNDER "SPECIAL INFORMATION • \ V IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. )
FULL NAME
PERSONAL AND STATISTICAL PARTICULARS
-:n (^
0X/»\X5j(jL
COI.dR
rVAAX
I>AIK OJ- lilKTU
Ai.l-:
HS
)V:,V
1
H
(Day)
1A';////>
fVear)
MEDICAL CERTIFICATE OF DEATH
DATK OF DKATH
(Day)
sA^<-^WQ
(Year)
10
A/r.
sr\C. I.K MAKKIHD. WIDOWIID OK DIV( »K» Hr) tWritrin social (Itsij.'iiatioii)
OJXXXX/CL
J«'l
i
lukruri, \ok
'Slate or I ■' Hint !■^•
NAM1-, ol I'A'IIU'.K
IUK'n(l'I,A<K 0|- lATHl'.U 'State or Cimiitrv*
m\ii)i;n NAMi-;
•)I MOTMKK
UTKrifl'LACK Ol- MOTHHK (State or Country)
occri'ATioN Qy
(Month) ^ I HI<:RI<:HV C1:rTIFV, That r attcMia^rck'ccase<rfroni
■ 190 to •
that T last saw h
alive oil
190 190
an.l that death occurred, 011 the date stated above, at M. The CAUSK OF DI-ATH was as follows
vJ -^-A^\JL<r>AAiA^
CL/>X' vj 7VXXy^ry^x:.o^a o
1 f
1)1' RAT ION Years CONTRIIUTTORV
Mouths
^ays Hours
M
or RATIO X
ll
Years ^ Mouths Days Hours
(SIGNED )..\]/OL/cL O. "QLjvXXOL^*^
i^ 190 H (Address) O CTv-uirvv^^^ Cal;
M.D.
?^^9*ftK "^f^"'^'^"'''ON only for Hospitals, Institutions, Transients, or Recent Residents, and persons dying away from home.
'•i'.fd i,> S.I)/ /■'} ,ni, i-rn -^ )',-,i;<
M.,„lh^
n,n
hi: MIOVI-. STAIJ-.I) I'KKSONAI, I'A KTUf I,A KS A K I' TKD- T« » Till-
m.sT OJ- Mv KN«»\vi,i:i)c,H AM) hi;mi:f
Former or Usual Residence
When was disease contracted, If not at place of death ?
How long at Place of Death ?
Days
(Info: jn
I
( X.l.lrrks
T90H
'^- R' fivery Item of iii?ormHtion should bt
^Ji'^*^^' <>»^A^KIAT, OK KHMOVAI. DATK ,,f HnuAi. o, KKMOVAI,
r.NDl'iKTAKHK
(Ad(htss
^4
state C\IISF or nr ATM ! . . '"^ '="''«f""y f"PP'"=^«- AGF. should be stnted hXACTLY. PHYSICIANS should ««n. 1 -1 c T" '" **'"'" **^'''"'' *''«* " '""^ •'^ properly classified. The 'Special Information" for psr-
«on« dymft away from home should be liiven In every instance.
t
i'
';..■
I f
'if'-'
r
i\
.Ji
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
n. tnlnf n.tith- h No iii^^^H&J'Co REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
Dff/r FiJrd,
^ OsJi/\)^^
...1.1
lOO'i
Registered J^o,
1044
DEPARTMENT OF PUBLIC HEALTH^City and County of San Francisco
Certificate of H)eatb
( "Q. S. StanDarO )
(^
PLACE OF DEATH: — County ol'^OJW) J .>\^Cl/>\/xa«(. City ofOcVrvj dAXX/>vC-A-^<:u;
'No.
:i.:
.c^t^jcL..^ <]\: cr<i.^
^|vX<xl
St
Dist«; bet«- and
-v.n_. I ^^.j J ^_ u >a^' v^^^^v^.^. :>t4 .JJist*; ben- and -
/ ir DC»TH OCCURS *W*vl FROM USUAL RESIDENCE GIVE FACTS CALLED FOR UNDER "SRECIAL INFORMATION" \ V. IF OtATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. /
FULL NAME
SJO
Xi
DA'll-: «)l- lUKTII
PERSONAL AND STATISTICAL PARTICULARS
I COI.OR
N
K^-
ijL
^
<XKj
I Month)
AC !•:
So V,a,s ^
n
(I)av)
M.tHtfiS
r 'I H L .
(Vcar)
MEDICAL CERTIFICATE OF DEATH DATE OF DEATH
l.L,
(Day)
(Month)
A? ij
"^1N<.I,1-: MAKKIKD, UIDOWKD OR DIVDKrKI) 'Writiiii siK-ial <l«.-»;i>^n:ai<)n)
niKTMlM.Al'K
(State or Country)
NAM!-: <)|- FATHI-.R
lUKTHIM.AcK ni lAIHKR 'Statf or roiintrv I
MAIDKN NAMF <)| MOTMKR
i9o\
(Year) I HKRHHV CivRTIFV, That I attciKkMl <leccased from
^Jp^M 3^^ I90H to .LU,A^...l..(c itp^
1 111
that I la.st saw h ^.vS' alive on LCvs-<V ' 16' IQO '1
and that death occurred, on the date stated above, at 3- XC U-M The CAISIC OF Dlv.ATH was as follows:
\>J<\:^\^^rY\.^S<:L .vrXxkJvx^utXo
niKTiII'LACK ()!• MOTHFK (State or Countrv
oocrr'ATioN
Years Months
Days
v/VU^L/Lciyi^^ 6~
I)l'R.\TION CONTRIHUTORY
DURATION Years Mouths Days
( Signed ) Uj.- \j CvvJL^i^-'trvv
U. 190'! (Address) at.
Hours M.D.
ly^^i:.
Rfsidnl in San Fiaiiii.^ro W )'iuii s
U>>i/f//s
n,i 1 .>
'"" ».^"^^^'^^ STATKD I'KRSONAI. I'ARTICr I.ARS ARK TRFK To TUF llhsr Ol- MV KNO\\Ma)C.K AND HICIJKF
(Informant xL . o(d JOojJL
SPECIAL INFORMATION only for Hospitals, Institutions. Transients or Recent Residents, and persons dying away from home. '
Former or Usual Residence
When was disease contracted, ICl 4-
If not at place of death? \J..^ ^3j>.^
Days
\<1(lrfss ^l^
ii
PLACE OF BFRI.M, OR KHMOVAI,
INDERTAKER db /oJuLtX-'dL ^ Cc
(Address .C\Wq >ftVA^^x<L^.,:(r>A...B^^
'^^''"'<<>f HiRiAi. or REMOVAI,
190H
N. B.
rtflVe^^C^ir^F^Ap nTri-M".***?'.** ^" carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should !«- % r^ OF DEATH In plain term., that it may be properly classified. The "Special Information" for per- «on« dyinft away from home should be ftlven In every instance.
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If. . ,11.1 ..r llraltli- !•• Vo. K f'-^-a^^'. H& I* C
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
/)(f/(' Filed ,
^y\J<^\A
11
lOO'A
Registei-ed J^''o.
Deputy Health omcer
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of E)eatb
( XX. 5. Stan^ar^ )
No.
PLACE OF
DEATH: — County ofO/Cb^ru J AXX/>vC>c<l/CcCity ofC)<X/>^ J -^XX/vvytM^^i/c^o
0 VA.KX v<:^^
(
SU ^ Dist.;bct. b
\'
and
1
I F
ATM OCCURS AWAY FROM USUAL R E S I D E N C E G I V E FACTS CALLED FOR UNDER "SPECIAL I N FO R M ATI O N '• \ DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. J
FULL NAME
.CL;V-V<L iJVl'AA.4^'
^(m„)
Ni.\
1).\!"1" < >l lilKllI
PERSONAL AND STATISTICAL PARTICULARS
t'ol.oK
M..nt!i)
A (■.!•;
(dO
)■.,//
(Dav
lA <////.
< » far)
/)<M,
MEDICAL CERTIFICATE OF DEATH
I).\TK <n- DIvATlI
15-
190 H
(M<Mith) /T (Day) (Year)
I ni<:RI<;HV CI-RTII-V, TIimI I attende.l (Icccased from
\M^
\*p
tu
S!N<,I,K, M.AKkll'l
\\ ri)n\\i-:i) OK i)!\'( >Ki i:i)
Write ill vooial lit-iviiatiDii) |
iiiK rniM. \ri-:
state or (.'1 mnti \
NAMI': 01 !• A THICK
P.IKIII I'l. Ml-: •»!■ lATHl^K
< State or Coiniti \*
A^VXLaLvXXj
^v.
liat I last saw h rV^^^ alive on yVA./%
■vJL iC
IC)0 -
I90M
and that <katli occurred, on the date stated aluive, at 0 ^ M. The CATSlv OI- DIvATlI was as follows:
• "^ ri'A'i'ioN
Rr.iifri! lit Sr.t' /'niu.i-.-n J^O )'rii i • - M,.):tJn
MAID); N NAM1-. or Mo'IMIi: K
IMK I*HlM,Al"l-: ol- M()Tni-:K (Stale or I'oiintrv)
DIR.VTION )'rars
CONTRIHUTORY
M<nit/lS
Days
Hours
Cj AA^cL/cL.«>^vAj
I )!' RATION (SIG
)'rars
jV>);////s
NED )\1 itojvt^^v ^XlLqX-vwLo
/)(7 rs
Hours
v<|x>v ^ M.D.
i^ iQoH (Address) "feO^ <0 J^ttiK. Q^t
Special Information only for Hospitdls, institutions, Transients or Recent Residents, and persons dying away fron fiome.
Former or
Usual Residence 10
ihi
Hil)&w<iva.ib!!,r:;vi,h;
Wfien was disease contracted, If not at place of deatfi ?
Days
fi
iin: AH(>vi>: sia ri:i) i-kkson \i, I'AKTicn.AKs aki- tkik to thf iiHsT oi- \\\ kno\\t,i;i)<;h and hi:mi:k
f \-Mress
^ SH
!N. B. H
ri,.VCK OF RfRIAI^ OK KKMoVAI,
I)\rHo! Hi KiAl. 01 Kl-:.MO\-Ai^
n
ni>i;ktaki:k Jo OJLciXc<JL ^^ Co
T90 V
Ad.hess ^Hb VjrtvA,/^^
s^-w, ^±.
Hvery item of information shoulil be cnrefully Bupplied. AGB Hhould he stotecl EXACTLY. PHYSICIANS should state CAUSL OF DEATH in plain terms, thnt it may be properly classified. The "Special Information" for o.r- «ons dyini away from home should he Jiiven in every instance.
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WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
H.unlof HcMlth- KNo .s*^^H&i'Co RCFCR TO BACK OF CCRTiriCATE FOR INSTRUCTIONS
Deputy Health Officer
Registered J\^o,
DEPARTMENT OFPUBLIC HEALTfl-City and County of San Francisco
PLACE OF DEATH
'No.
Certificate of 2)eath
( Ta. S. StanOarO )
: — County ofO;CL/T^ OAXWuCAA^ City of C)OL/ru JAxX/vv<i.c><ML<)t
5 ?) C) cL<JLh6\Xi.j St.; I 0 Dist.; bet. WLLA^Uvo and '^1 L.{SX
f \r OE*TH OCCURS AwAV rROM USUAL RESIDENCE GIVE facts called for under "special INrORMATION- \ V IF DEATH OCCURI^ED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. )
FULL NAME
PERSONAL AND STATISTICAL PARTICULARS
si-:.x Qo^ jj I coi.ou^
DATK Ol- lUKTU
)M^OJl
iMotith)
(Dav)
(Year)
MEDICAL CERTIFICATE OF DEATH
DATE OF DKATH
,15,
(Day)
nAa.^,1
(Year)
A(.K
V \ VliD > c^
Months
0 ^'
Da 1 :
SINC.I.K. MAKK IKD UII)n\VKI> (»K I)1\'MK( HI)
iWritf ill MK-i:!l (hsiiMiatioii)
MIKTHPI.AOK .
(Statf or Comiti v'
\Xax^v.o-^cL
(Month) C\ l^HKRHHV CICRTIFV, Tliat I attended deceased from
190 o to
that I last saw h -V-^J alive on
GU.^
190 H
^ 1 190 'i
and that death occurred, on the date stated above, at 3.3) 0 Uk. \l. The CAl'SK OF DKATil was as follows:
VAAje,
^VVU
NAMK OI FATHER
MIKTI!I'I<A(F: OI- l-ATHKK istatf f>r Country)
MAIDHN NAMK OI- MOTHKK
lUKTH PLACE <)1- MOTHER (State or Countrv)
(^
^ Jb'y^M^^^YWX/W)
O/cJlsi^j
DURATION I ^ea,r^ i^^^wXT^^^ CONTRIIU'TORV
oys Hours
i^jiXXjs
MfloAxXr Lcrvl
x^yy\)
ty^
DURATION }^ars Mnnths Days Hours
(SIGNED) MfWuuL ^aj3un\s M.D.
n TQO H (Address) 111 "^X^t^A^ Bjt
OCCUPATION
^^^^^y}^^OnfAIKT\OU only for Hospitals, InstituUons, Transients, or Recent Residents, and persons dying away fro.u home.
M,„ilh< " Dn\
Former or Usual Residence
When was disease contracted, If not at place of death ?
Now lonq at
Place of Death? Days
'''"V:;^"i.^^'*'' STATED I'KRSONAI. PARTICn.AKS ARE TRIE To THE IJhsroF MY KXOWI,EI)C.E AM) BELIEF
(Informant yCUWvJL/) LULvl/vO
PI^CE OE niRIAL ()R REMOVAL I l)ATl< of IJtKiAi. or REMOVAL rXDERTAKER 0&V<AJL/TV U /CXAX
I90H
jAiMress XH-S. '^ .,.\fi\«A.XLAA.<r:YV. ^..^t^^
^' "*~rt«V/cl'im2*A"JnTri?M" •*'7'.** ''*' carefully supplied. AGE •hould be stated EXACTLY. PHYSICIANS should state CAUSE OF DEATH m plain term., that it may be properly classified. The "Special Information" fsr i»er. «on« dylnft away from home should be given in every instance.
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WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
Ho;inl of Health- FN
o. i^
H&l^Co
REFER TO BACK OP CERTIFICATE FOR INSTRUCTIONS
Drffe Filed,
11 190 "{
Deputy Hf^afth Offioer
Registered J^o,
1047
DEPARTMENT OF PUBLIC HEALTH-City and County of San Francisco
Certificate of Beatb
( "Cl. S. Stan&arO )
J? (5} . \ ^
PLACE OF DEATH: — County ofCj/CU>v J/uX/TtCiAOCity of Cj/O^^nj J J\yO<jy\S:AJ^<U.
''0
^No.
D^!-^
oAXxxiCi
St
Dist; bet. and
/ IF DEATH OCCURS AWAY fROM USUAL R E S I D E NC E Cr V t FACTS CALLCD FOR UNDER "SPECIAL INFORMATION" V V IF DEATH OCCURRCO IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER J
^P J? -^
)
FULL NAME
\^\JLu
PERSONAL AND STATISTICAL PARTICULARS
U^la
DATI-; <)I- lUKTlI
Ar.K
tMotitli)
In I
(|)MV)
M.'ulh^
fYcar)
Ji
MEDICAL CERTIFICATE OF DEATH
DATK OF I)F:ATH
' ' I.b,^
(Day)
(Year)
A; I '.«
SIN(.KK. MARKIKl). WIDoWFD OK nn'oKCFD (Writiiij •^(K-iHi (lcsij.^niitii>iil
K^Ji-.
,a.
mKTMPUACK
(Stiite or Coimtry^
NAM)-: or
FATUFR
HIRTMI'I.AC K OJ- lArUKK
'State or Country'
maii>i;n namf
«>l" MOTHHK
niRTjrpr,ArK
OF MOTMHR (Statf or Couiitrv)
I HKRKBY CKRTIFV, That I attended deceased from
^ 190'"^ to ....UwA,.MX.....l.!b. 190 H
that I last saw h-^vn alive on VAa.aX3l \ b igo H
and that death occurred, on the «late stated above, at ^ M. The CAUSK OF ])1':ATH was as follows:
^^-^^^:-Aw\AX ^ ^JCOwt/od^^t^-v. fe..re.-OLAJL
U<Lf<:L.^ir^r^,jA,^.ry^
DIRATION
Years - Months ^ Days X Hours CONTR IIU'TOR Y '-i-^i/^^X/V^A^Jl<^^
DURATION Years Mouths
OV
P
occupation ^ . () A
(Signed)
k)., ^i. CJ I
n 190 4 (Address
f\f>idfd ill Sim li ii III isiit
) til I
.lA»;////.v
/hi
^^^,<i^^,^,^^^ORM/KT\OP* only for Hospitals, Institutions, Translfnts. or Recent Residents, and persons dying away from home.
Former or M |
Usual Residence dJxx/vUi/YyxUA^xj w>^x ^^ff or ueatli7 U Days
Wfien was disease contracted,
If not at place of deatfi?
u
How long at o Place of Death? h
THF. AIU)VKSTATi:i) I'KRSONAl. I'ARTICF I,A RS A K I". TRIF To TIIF IHvSl OF MY KNO\\l.i;i)<-,K WD Mi:!.!!:!.-
:}%
o
^'^'tf\5 '^'V^'^Io'' ''^ '<»^'^"»^-^I' I IMTFof HiR.Ai. or KEMOVAI,
INDKRTAKKR LvWAjtt^i^
(Address 0..(a lo. M'\A-/<5^'<L'U<rVx ,3:^.
N. B.-
-Bvcry Item of information should be CRr«fully supplied. AGE slioiild be stated EXACTLY. PHYSICIANS should state CAUSE OP DEATH in plain terms, that it may be properly classified. The "Special Information" for Dsr. Rons dyinft away from home should be t'ven in every instance.
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
Hoard of Health— I-' N'o. i^
H
1 I
M
fii 'I
fr^H&PCo
REFER TO BACK Oir CERTIPICATr rOR INATRUr.TIONA
!)((/(' Filed , LLooOL
Registered JSi^o,
1048
A.v^t va ioo\
M^ Deputy ' ■ fth Om-cr
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of Death
( "U. S. StanDarO )
PLACE OF DEATH: — County of OkX'^\; v) AXVYVCA^cxCity of O/Cuw 0 A/CWvc^.^^<.
(No. ^^t^r^L^w^xt^, 'db CH^KAial'. St.,
-^vvvYvv^t ^'^^>^i-"U^Ci.'... M.; — — Dist.; bet. r and — — ■
/ ir otATH occuRsUwAv moM USUAL RESIDENCE civc facts callcd ron under "special iNroRMATioN- \
V \r DEATH OCCUf^RtD IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. J
■)
FULL NAME
PERSONAL AND STATISTICAL PARTICULARS
<X<X/sLA.;
^i;\
flwL
COI,(>R
DAI i: «>l I'.IKTM
A<.H
lUvvi
M..ii\)i)
(Day)
V
oU
U-far)
MEDICAL CERTIFICATE OF DEATH DATE OF DKATH
^'\ 1V,„.
%
M.iulfis
at
Pa ) :
'^IN'.I.K. MARK IK I) WIDOWKI) OK niVoKrKI) •Write ill s<Kial •hsiti'nation)
niKTn»'i,ACK
'StMt«- or Coiiutrv^
NAMK Ol-
HIRTHPI.ACE/l I
OF FATMKR A
'State <,r Country) V ^
(^*""th) (J (Day) (Year)
I HICUl-HY ClvRTH'V, That I atteii.le.l .leceased from
. Ll^OAA^i IC 190*^
that I hist saw h
to >.. l.A^.Q,....l.L
o.- 1-^ 190 H
alive on V.AAA.CIL 1 V 190 -H
andthat death occurred, 011 the date stated above, at O. QLO ^^^ M . T h e C ACS \\ 6 V 1)1 < A T 1 1 was as f ol lows :
%Mr<lX^VOrcOj . O^ct VI )WtrC>Cu\ycL<^/C^
(d v3-v>A.lN^'du
S)
'1'
<XAA.
I) r RATION CONTRIIU'TORY
Years Mopit/is Days
LiXc<m.£rVA
Hon PS
r.\.^a^.7vx.
MAIDKN XAMF Ol' MOTHKK
hirthit.acf:
Ol- MOTMKR (Statf or Couiitrv)
occri'ATiox (^ n
_ 0 XKrv^^ <Xyy^
A font lis
Days
V'.
Hours M.D.
Rfsidfii in Sat) I'l a>\i iso '^\. Yrai^
yr,niiii^
n,t\.
'"'' HF^ST nr'^Tv'u-l!' !;»^K.^'>^"A'. I'ARTICFLARS ARl- TKIK To THK iJF.sroi. M\ KNo\V1.1-;D('.f: AND IlKMFtF
{rnformam UJ />>\; . \H\ - Xo-^^^^Lt V
DIRATION Years
(SIGNED) LUm\;.m- axx.^v^L\;
'"^ 190H (Address) LuLXc Cq. fe CML^^;!-
When was dIsMSf contracted, If not at place of death ?
Place of Death? 116 Days
i\iU
rc'ss
N. B.-
W^%L Co . iV) CHi.^vvt'OLi
190H
PLACH OF HIRIAI, OR RKMoVAI, DA'i;Kof H, k.al or RKMOVAI
JM, Qivv^ I (W...i t
INDKRTAKKR OX) ■ O. M / C<X <VAXi/ L<;
(Address
•tate cIirSE OP nTrxH I . carefully •upplied. AGE should be stated EXACTLY. PHYSICIANS should
««nr,i : ^ DEATH In plain term., that It may be properly classified. The "Special Information" far Mr-
«on. dylnft away from home should be ftlven in svcry instance. 'ormation rar psr-
'11
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WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
I!.,:Mfl ..f Hillltll -I-' No. U
-i^^^!^:
HJX:!' (V>
Dale Fileil ,
m
ifcrfcniw anv«r\ v»r v^cn I i p iv^A r R. r'Uli INSTRUCTIONS
11
lOO'i
Registered JVo.
1
Deputy Health Omcer
DEPARTMENT OF PUBLIC HEALTH-City and County of San Francisco
Ccttificate of Death
( Ta. S. StanOarO )
Jj 07) . -^ ^
PLACE OF DEATH: — County of ^'<Xa-u -J-'UXAveA.AAU.City of Ooyru 0 AXVyvca^-O-CC;
'No
.l\%
.<X'
St.; Dist.; bet U OU>x<L(r»\ji.;
and
( *' ?J'V** <'4'="''* ***^ ^"O** USUAL RESIDENCE GIVE facts CALLED FOR UNDER "SPECIAL INFORMATION • N V IF DEATHJOCCURRCD IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER )
{TK
FULL NAME ^J.■^L/yx<iJUy^^a/:^
If!'
\
♦
1 '^..iv
SK\
PERSONAL AND STATISTICAL PARTICULARS
COl.OR \
I
UoJuL
MEDICAL CERTIFICATE OF DEATH
DATE OF DKATH
n.M 1-; n\ lUKIH
Af'.K
I Month) \
I
(Day)
M.oiths
(Year)
/hiy.
(Month)
(Day)
i9o\
(Year)
^IN'.I.K MAKKIi;i). WIDnWKI) OK DIVomKI)
tUiitt ill s(Ki;il <ir«.i>.Miati()ii)
HIK rniM.ACK 'St;itf or Coimtry'i
NAMK Ol-
iatmi:r
niRTTIPl.AfH 1/
Ol- l-ATMHR <Statt' or Country)
I
<X/vN-^jui.
.^-(X'Lo
.o^a
I irrvRHRV CHRTIFY, That I atteiide.l deceased from
190 "-rr-
190
that I last saw h
190 to
~ alive on ~~
and that death occurred, on the date stated above, at - f /rhe CAl'SR OF Dl^^TH was as follows:
?wA..
Dr RATION Years CONTRIBUTORY
Months
Days Hours
MAIDHN NAMK 0|- MOTHKK
HIRTHPt.ACK OF MOTMHR (Slate or Country)
J
DURATION ^>V.7;'5 ^ Months ^ Days Hours
(SIG
NED)..J..-iE..ljQ.ljLLx^.
LLa^S^Q Q TooM (Address) Lfr*UfVaA-^\!Jv
-all iQo' iCIAL INFC
\i M.D.
^^^Jt^'^^^^^ORfAIKT\0^ only for Hospitals. Instituhons, or Recent Residents, and persons dying away from home.
Transients,
OCCUPATION
^^•"'tM in Sdn J't^tuisro I S )>«?;.
Mnnt/ia
Par.
"ll
'^"HK^T y^^^lvV:/^;!* T'HK^^OXAI, I'ARTICn.ARS ARK TRIK TO THK HKSrop MV KMOWJ^KDCK AND BKUKF
(Infonnant \J \y-^^UU^ M)XcX^<L/Cl^x>oJU^
Former or Usual Residence
When was disease contracted. If not at place of death ?
How long at
Place of Death? Days
(Add
ress
.oJLXju^ *3j:
PI.^CE OK lU-RIAI. OR RKMOVAI, | DATK of IUriai. or REMOVAI
IINDERTAKKR L oJlC/VnXx ^TK^XA^Ovvvj '^M.
i'O
(Address l.S.XH
m.
mm
""' "* .^t^/cll'sE'^OF dTItSI'^ *' '""•^"J'" f"'*'*""'*- ^"^^ •''""•^ **• •*-*'^ EXACTLY. PHYSICIANS .hould
«oni dyfn Aw«r from^ome ^i" M K •":.• "' '* """^ !*' '"•"''*''*^ classified. The "Special information- for p^r- • • u^'inn away from hpme should be (ivcn in svspy instance.
u
\
•If
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I.
I.
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f
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it i
[ UB^H^fl
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
M.iai'l.'t lltriMIi- I- No. n ^^OTJj^ »«: I' c'o
REFER TO BACK OP CERTiriCATE FOR INSTRUCTIONS
/>(//(' Filed ,
II
lOO'i
RegistereclJ^o. 1,050
Deputy Health Officer
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of Death
( Ta. S. StanCarO )
PLACE OF DEATH: — County of ^ '<^^^' ^ Axxaaxxa^cc City of 0/Ol^W; 0 A^O.yTva<..<:L/C.c
1, % , .. fl
'No. 0 Jc Vvr^<X'>\; dbcKL'
^'\.JL<xX:'
St.
Dist.: bet.
and
( IF DtATH OCCURS AWAY FROM USUAL R E S I D E NC E CI VC 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
Xa
V.<l/\^^A^O^'
SKX
DMK ul FUKTII
PERSONAL AND STATISTICAL PARTICULARS
COI,OR
'\jy\T
I Month)
XX /iHO
(Dav)
MEDICAL CERTIFICATE OF DEATH
DATE OF DHATH
AC.K
t)^ V.,n, \
.1 A -;////.<
ai
(Vear)
Da Ys
lb
(Day)
190 \ (Year)
SINC.I.K MAKWn:i).
wiixtuKi) OK i)iv()Rt'K[) n
Write in s<K-ial (ksijciiation) Jc
lUKTMPl.AOK •Stjitf or Country)
NAMK or- J ATIIHR
lURTMIM.ArK
Ol- FATMHR
• State or Country)
MAIDKN NAMK <>»•■ MOTHHR
HIRTHPLACK Ol" MOTHKR 'State or Countrv)
I IIRRKBY CKRTIFY, That I attended deceased from
LL^a a 190H to LL-^....l(o 190..H
that I last saw h'<^v-rx alive on LLv-a_^ lb. igo H
and, that death occurred, on the date stated above, at 9
^M. The CAUSK OF DIvATH was as follows:
vVx^^rv-v^ \
OO'u.v^v^vH., Q.
.^.
o-v<i,,<rvu^.<<%:
^.
-t.
DURATION Years ^\ Months \'\ Days Hours
CONTRIBUTORY
nccri'ATiox
fir.^ided in Sav l'tatiii<fo 10 Vfata
DURATION
)V|^rj
Months
( SIGNED ) ...UJ. , 0 (h C^4Jk.^./v>^
n -^
^>^^^^q 1^ IQOM (Address) V) SPEdlAL INF<
Davs
Hours M.D.
) "^-^^-Vyyvo/^x/. ..m
^fnllt/l.y
Dn \s
'^" nvJ-r^y.?.';!;^''^^''' •'HK^'^NAU PAKTICII.ARS ARK TRIK TO THK Ilhsroi. M\ KNOWl.KDC.K AND KKMKF
(Infonnant J^CV/V^XOw^W
D . D .^ . IfORMATION only for Hospitals, Institutions, Transients, or Recent Residents, and persons dying away from liome.
Former or ay "1 1 How lono at
Usual Residence ^ UU^vvi^^LU (Jl piare of Death? 10 Days
irv^ryv
When was disease contracted. If not at place of death ?
(Add
res.s
PLACE OF BURIAI. OK RKMOVAI, DATKof Hir.al or REMOVAI
.__tob_ mlZ^ I ulCx a
UNDERTAKER
(Address
YDL/^rrU^a Ik)
190
N. B.
rt«Ve*'crim^*n"Jnrfiu^**'7',*' **' carefully supplied. AGE .hould b« .tated EXACTLY. PHYSICIANS .hould !! % . ^ DEATH In plain term., that It may be properly classified. The "Special Information'* fer u.r.
«on« dyin4 away from home should be given in •x^ry instance.
i' ',1
1,
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41
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
lln:(i.l..| llcilfh— I" No. 1 1; TP^jH«R^3 Hffc P Co
¥
n
I
I
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i'%
( f
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(!
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
I)(ff(' FiJeil,
n wo'i
Registered J^o,
CA^
DerJ-^^^y '-J-^n'-*- Offlicer
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of Beatb
( TO. S. Stan&atO )
%
PLACE OF DEATH: — County ofO/CLoo; 0 AxxavCc<lc<- City of OxXAV J Vou>vCA.<iXU
No.
IH
'.^\.v<:>
St.; I Dist.; bctX
and
r ir Dt*TM OCCURS *W*V FROM USUAL R E S I D E N C E C. V t facts CALLtO FOR UNOCR 'SPCClJl I N FO R M ATIO N • A \ IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREEtIJiND NUMBER. )
u (■
FULL NAME
J..X;:>x^^ca\.j
UAJ
SKX
PERSONAL AND STATISTICAL PARTICULARS
COI.OR
1
yr
.<Xjl
I>\T1-: oi lUKTII
A OH
'Month) i]
11 (Day)
/iO.M
(Year)
Da ) .V
MEDICAL CERTIFICATE OF DEATH
DATE OF DKATII
LAaa^
(Month)
1
l.k,,
(Day)
i9o\
(Year)
SINC.j.K, MARKIi:i), WIDnUKI) OK DIVOKiKI) 'Uiitr ill sorifil «Usijf nation)
HIR rniM.AOK (Stiitc or Country »
NAMK OI I AT Mi: R
MIRTH PI.ACK OI' I ATHKR (State or Country
x^
I IIHRKRY CivRTIFV, That I attended deceased from
-^-^^^^^-^ l^ 190H to LUa^ Lb 190.H
that I last saw h'<^-.v^ alive on LLca^^X , 1 lu igo S
and that death occurred, on the date stated above, at \X, I 'o A; M. The CAUSrC OF DKATH was as follows:
•■'^jAJL>v;. S....o^-wiu>.AAAiZXa
fVVv<y-QL'
MAIDKN NAMK HCS OI" MoTHKR '()l)
Dr RAT ION Years CONTRIIU'TORY
Months
Days
Hours
DURATION Years
a. a
Months
Pays
inRrm'i,A(M-:
'M- MOTHKR (stall- i,r Country)
CCCiAAJ
Hours I (SIGNED) LI. 6J-^ A.AA,^Ov^^ M.D.
^<^ n 190 H (.Ad(lross) '^^'^ yiWv-^
1
a.
?^^?'ft'-J'^f°'"^'^"'"'ON only for Hospitals, Institutions, Transients^ or Recent Residents, and persons dying away from home. '
i^lAL INFORI
v^fca^l.L\^4'.
'HCri'ATlOX
. ^'^'''f^'f "I S<i„ / ,,in, i.u'it - }V,ns - yf.uitfis "^ /hns
' " nrJ'r^r7.'^-^J,V'''-'> l*»':«^ONA I. I'AKTICf I.AR S A R K TRCK TO TIIH
Hhsroi. MN kno\vm;i)(,k AM) Hi;iji;i-
(I'.fonnMnt O . \l l\e W^^Oth^
(Address l^i \cyJtwo at
Former or Usual Residence
When was disease contracted. If not at place of death?
How long at
Place of Death? pays
fi OH BURIAI, OR RKMOVAT. D.VlH of ntK.AT. or RKMOVAI, olu Gut^<l^. I vL-v^ \'l igoS
r XDK R TA K K R U <xXx/^<XX \^^Ux^.A/YVV "< Lq
(Ad.lirss IS'^H C) ^tv^L>|^^jt«ry:\^.....dl
"' "* rt7t7cMr8F*OP n7rTH",*''7V' **' carefully supplied. AGB •hould be .tated EXACTLY. PHYSICIANS .hould ^nnl H 1 / e T ^'"'" '"'""' **""' '' """^ '^'^ properly classified. The "Special Information" for Jr-
«on« dylnft away from home Hhoiild be Itiven in mvory instance. "^
^■(:l
'iJi;
'1
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ti
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1 .li
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
l; ,1-.'. ..f flea 1th -J" No >«. t-^^^^HS:!' Co
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
Didc /vV^v/, LIa^w<u^^^ II
100\
.>&-VC>CCi
Registered J\^o,
105-2
DP"^'-/*"*' '.'->-> I* ». r-. rrr
DEPARTMENT OF PUBLIC HEALTH-City and County of San Francisco
Certificate of ©catb
( Vi. S. StanC>ar^ ) PLACE OF DEATH: — County of LlLa>-> v<.d.<x City of
M3X>JkjLLvi Let I
No.
St.
Dist.; bet.
and
/ ir DtATM OCCURS AWAY mOM USUAL RESIDENCE GIVE FACTS called for UNDER "special INFORMATION V IF DEATH OCCURRID IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STRrrT AMn Miitiar.
FULL NAME
IK
SK\
PERSONAL AND STATISTICAL PARTICULARS
I
)
■)
^
mc^L
I'M K »>| ItlKlH
AC.K
J
1
KC\^<.
MEDICAL CERTIFICATE OF DEATH
'^VXcLO
.t.
Month*
is ......
(Day)
i Mo„!hs
^f
V
(Year)
DiJ 1 .V
DATE OK DHATH
1.
(Month) 1
11
(Day)
(Year)
"-INt.I.K MAKKIKI).
w n>o\yKi) «>k n;\»»Rt"Hi)
N\ riff ill <(KiaI iU«.ij»n:itiiiii)
HIk rilPI.^t'K St;ttt <ir Cmmti \
K<L<y\x>^\)
i^
I ni^KHnV ClvRTIFY, That I atteiulea (lecoasoa from
~ to
T90 — that I last saw h ^alivc on
^90 190
ami that doath oconrrctl, 011 the ilato stated above, at • M. The CAJLI^SK C)l< Dl-ATII was as follows:
\AMl-: n|- I-ATHKR
lUKTMI'I.ACK oi" I-^IMKK 'Stale .,r lNmntTv>
MAII)1:n NAM!" <»I MOT! IKK
lUKTMI'LACK <M" MoTHKK 'Statr or C«)uiitrv)
DVW,
\.A^>
DIRATION Years
CONTRIIU'TORV
Mouths
Days
Hour.
>vcrv<vrv\.
DURATION
Ytiir
Mouths
/hivs
ii
0_^.<x.yc>v\
*»
(Signed) ♦ 0, J.ix\.vo.. ..
Ua\0. tl Too't (A.Mress) \DxV.VU.Uci La..».
f fours M.D.
%
Special Information only for Hospitals
or Recent Residents, and persons dying away from home.
i, Institirtlons
fCrsiifnf in San /'rain isrn
)'rnt s
y^niifliS
Du r>
"",;,:^"r*^'^'' ^'''^'''J--l> »'KRS<)NAU IWKTICrLARS ARK TRIK To THK Ithsroi< MY KN()\Vl.Kn<*.K AND IJKI.IKK
Former or Usual Residence
When was disease contracted, If not at place of death?
How lonq at Place of Death ?
Transients,
Days
Ml
(.\<lclress
(Address
N. B. Every Item o? information should be carefully nuppiled. AGE should be stated EXACTLY. PHYSICIANS should state CAUSE OF DEATH in plain terms, that it may be properly classified. The '♦Special Information" f«r ••r. «ons dylnft away from home should be &!ven in evory instance.
V'
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WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
:it,! .,f Hr.lltll I- X<' I- •t>'^^^''-; li.V I' C,
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
/)((/(' Fi /('(/, (X.^v/cyL\^ n
lf)0^
Registered Js'*o,
1
Deputy Health Officer
DEPARTMENT OF PUBLIC ilEALTH-City and County of San Francisco
dcrtificatc of ©catb
( U. %. StnnI>arC> )
^ ^ J?
%
PLACE OF DEATH: — County ofvJ/O/w OAXXy^xccvtCt City of ^<^>v 0 Axx^ yv<^a.xl ti^
IVo
.5t m
OJ
CK-
|\AA/X.
St.;
Dist.; bet.
and
f ir dcatA occurs a\mav from USUAL RES I DE NCE ci VE facts called for under "special information' \
V IF DC^TH occurred IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. J
SIX
PERSONAL AND STATIST
FULL NAME
ICAL PARTICULARS
^jy\f>(\KX> vJLlo
(rirbny^v/)
aJU,
M-
i» \ 1 1-: < »i r.iK rn
\t.i-;
Y,ai
1
M,niths
(Vcar)
H
lilKl'lIl'I. Ai'l-: 'Slate or Comitrv
\.\Mi: oi !• \'i"iii;r
lUKIill'I.Ar
oi- i-Ariii'
state or (."ounli V
Ux\A.^ULdL
MEDICAL CERTIFICATE OF DEATH
DATH (»I- Dl.ATll r^
^Mdiitli) ,r (Day) (Vc-ai)
1 in':ki{l!V Cl'iRTll-V, That I attcu.k'.l (Iccvascd from
HW-U 1 t up H to CLuwQ_ L& i^o H
lliat I last saw li-A,^' alive on LA^Ays^ 1.1 loo 'V
and that .k-ath occurred, on the date stated' above, at '^ U. .^L TIk- CAlSTv ()!• I)i:.\TII was as follows:
DIKATIOX CONTUIIUTORV
) 'cars
MAn)i:N N\Mi: (^ a /Tv
oi- M()Tiii;k L 1| [V
HKiiii'i.Ar}-; X
»i Morm-k A y
State or eoiiiitryl Ij '
HI
OCC
Years
Mo)ilhs
.drouth:
'1
^
Diiys
Hours
1 )r RATIO N
(SIGNED) Ll>Ctivuav ^; . vi^ v.^^v^o^
\X<^X>, IL rcjo'i (Address) BtrXHlxX.'
SPECIAL Information only for Hospitals, Institutions, Transients or Recent Residents, and persons dying away from liome.
Days Hours
K^^u M.D.
0 dl'ft-dixi..
t. 0 ^ M J Ut^aXcvM U. V . piare of Deatfi ?
f\r>'iffif ill S,ni /'i ,!ih /m;i \[ )>-,// c
^rniiflf
n,i\s
'''"',';,>'!' '^■'•" ^'l'\!"l-I> PKKSOXM, I'VKTU-fl.ARS A R !■: TRrK T< » Till- l.l-.sl OI- MY KNOW I, i: DC, H AND HHUIKF
(1
b<j±^\niy(uX
V/>A^
'\^l.!r.-.s C>C)'i
/(n'>'VJL\x/
Lwa
Former or L'siial Residence
Wfjen was disease contracted, ^ ^
If not at place of death?
Days
n.ACH ())• HrklAI. OR R}:mo\AI,
DA'I"K<)!" IliHiAr. or KIvMoxaj,
TQOH
(Address
' . B. F.very item oil inltormation should be carefully supplied. AGB should be stnted EXACTLY. PHYSICIANS should state CAUSE OF DEATH in plain terms, that it may be properly classified. The •'Special Information" for D«r- sons dym^ away from home should be feiven in every instance.
f
m
I
41
11
1
I
¥ J
te"
I
' ♦
m
r
1-1 !
«!
^
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
H,,:,T-.l ..f II.:ilth ^ V Sn m ^-F^^iiir*' '"'^ 1' '
dLcr\^A.o iiLa>v. Deputy Health Officer
Registered J\^o.
1054
}
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of Beatb
{ TX, S. 5tan^ar^ ) PLACE OF DEATH: — County of 0 /CU^rv J/UXTL/CXaC^j City of 0/CL/Tu oAXXy-v vc.c<teo NoAt'i ^J(xYVyJlOx't\>A-0.' St.; '^ Dist.; bet. 2);v<L and H t4\;
(IF DE«TH OCCURS AW«V FROM USUAL R E S I D E N C E G I V E FACTS CALLED FOR UNDER "SPECIAL INFORMATION" N IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. /
FULL NAME OcLcAvKVv<ij 0 .>\x>djAx<:^ UJLrux.lvcv>>v
PERSONAL AND STATISTICAL PARTICULARS
OLv
DA'l'i: <»! KIK 111
V . 1.
\
\
^\^
■■u
yavv-
I);iv)
<V(;ir)
4t^
b
1/ ' v.-
X^
-IN' !.i: MARlvIi;!).
\\'!i)< t\\i-:i> OR i)i\'(>ri'):j)
W'l it' in >.<)ri;il (l<-ii.rnati' m )
lUKTII IM, \rv (Stilt. ■.! '•..:;;;lt \
J-ATHJ-.R \()n
MEDICAL CERTIFICATE OF DEATH
1 1 ATI". • »!• i>i;a TH
n
^kxAjc
Kx.O
w.Cuy'Y^-
lURTHlM.ArH
«)i" I \ riiHK
' St.Mtt (.1 ('> ^niitr\ '
maiiii:n \ami-.
HlRTllI'LA'/l-: nl' MoTHKR 'Slate or roiuiti \
OCCT
f<?cA
(Month) (\ (Day) (Year)
I lli;ki;HV Cl-RTIl'V, TliMl I attt'ii.UMl ileceased from
VlrVo^ Xl 190S t.) Caa^q. 1(q 190 h
tli.'it I last ^a\v h *w .>v alive on nJ^A^v-O. \^ 190 'S
ami that <U'ath occurred, on the date sta1e<l above, at v- o5^ LL M. The CATS]-: Ol" I)1:ATII was as follows:
DlRA'noN )'rais Mo>i//is;Wi'X fhiys Hours
CONTRIIUTORV
1)1 RATION
/?)
Years
Mo)ith>
Pavs
(SIGNED) ^vK.^'^l.(J)XV.vcLt LAxvQ \'-l T(,oH (Address) 1^^ 0 CrUl
Hours M.D.
t»v
SPECIAL INFORMATION only tor llospitdh, Inslitiitions, Transients, or Rrrent Rrsidriits, and persons dying away from home.
AV.,',,V(/ /;/ V,;)' / / ,;;-
1/ -////.
/ ',,■ 1
Tin-. AHovK ST \'i'i:n ckkx' »n a 1. y\ ki-ut i. \ k-^ a k 1: i'r i 1: r< > rii i-; m:sT Ol' Mv KNiiw i.i:i)(,i.; AM) in:i,n;i-
e
Former or Usual Residence
When was disease confrarted, If not at plare of death ?
HoH lonq at Plare of Death ?
Ddvs
ri,A(."i-: <ir iukiai, ok i.;i;M< i\ai.
T90H
KAIl-.o;" in KiAi. or R1-:M()\m^
rNi»i:R'rAKi:R 0 '0^/^vvt>rvjL^u \>J -K,.<>-'<V
(Address
IS. B. Kvery item of informiition •thoiild be cjii'cfullj MupplicMl. A(IF. «ho;iltl be stated r.XACTLY. PHYSICIANS should
state CAUSE OP DEATH in pljiin terms, thnt it mjiy be properly clossifieil. The ''Special Information" for per- son* dyin^ away from home should be (^iven in every instance.
? V.
w^
fH
I ■ ' t
fill
1 ''
I;
WW
■' '1. ■ ■ \
.V
I ^ *
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WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
llr,:,!,l ,.f II, , lit!) !■■ No ;- "?-r\ia^;. V.SiV Co
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
\l
IfJOH
Date Filed , LI.a^v.<xva.<iAJ
X<iAAA.^ \kjxy^. Deputy Health Officer
llc^istei'od Ko.
105^
^
DEPARTMENT OF PUBLIC nEALTH=City and County of San Francisco
Certificate of Beatb
{ XI. 5. Stanc>arC> ) PLACE OF DEATH: — County ofCJ/OAV J ;uX/>\/OUlCC) City of C3/ayru 0 AxXox/Ci^vA^o NoA^D'i Ulxor\\X/^vtAAA-tX' St.; ?^ Dist.;bet. 2)Kxi> and \XX-\3
(ir DEATH OCCURS AWAY FROM USUAL R E S I D E N C E G I V E FACTS CALLED FOR UNDER "SPECIAL INFORMATION" \ IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. /
FULL NAME C<iAA^<xvcl.' 0 AX<LiLA.vc4^ UJlruxJ['VCL/>'>v
PERSONAL AND STATISTICAL PARTICULARS
oJU
C<U,uK
Lixvlji
A 11. 1 11 iiiK rii
AT, i-;
4?>
!V,;
t
ai
m.-iv)
I/..////"
MEDICAL CERTIFICATE OF DEATH
DAIl", < M" I)1:A'1'1I
n
(Day) (Year)
(Month) I ni;ki:i?V CI^RTIFV, That I attendod deceased from
vTyvoA^ x^ 190H to Ow^.^*^^ lb
■xt
l\iy.
-'INt.I.i:. MARkli:!), WNioWKI) OK I)[V< »Kvi;i)
Wiiti ill <i)ci;(l (li>.ii.']i;it i' 111 )
vXMI' OI-Wn
•atiii:k ^Qil
luk rniM.AiM-:
'Stall- ur (.*oniitr\'
rV<xiva'>TV'
r.iK ini'LAO}-: oi" i\rin--.K
St.Mtc 1)1 r.niiitrv
maii)i:n XAM1-:
ic)o H and that di-ath oceiirred, on tlie date staled above, at \. oS"
lliat I hist saw h '^ >>\ aHve on
a
NI. The CAISI' OI" Dl-ATH was as folhnvs
1)1 KA'I'ION Years MouthsW'X Days
CONTKIIUTORV
Hours
>..• MCTMKK (T\
V^^'
V>Y\XX/'W
iiiK rii I'l.A'/i-:
ol' MoTlIKK ' Siatf or eounti \
\
:cii>ATi()x (T^ . K
I >r RATION ^ }V<7r.v
Mouths Days Hours
Signed) OV.VIil Ob. xyx^^^xLt) m.d.
i
SPECIAL Information onl> for llospitdls, institutions, Transients, or Rerenf Residents, and persons dying away from home.
AV' • uU'd / II San I'l i! '
) 'I'd I
^l.:lfh^
h.
Tin". AIIOVK S'i'A'ri-I) i'HKsi »NAI. I'A RT IT r I. A R S .VRl". TKri-: T< ) I'll )•;
m:sT oi- Mv K. Now 1,1. 1 x,}-: .wd iu:i.ii;k
k\^^
' \<l(lr<-ss
Former or Usual Residence
When Has disease contracted, If not at place of death ?
Hov^ lonq at Place of Death ?
Days
I'l.A*.!-: (>I lURIAI, OR Rl.MoWM,
n\ri:.)f HrKi.Ai, or KKM<)\AI,
T90H
(AcKltfvs
N. B..
-F.vepy item of information should he cin'ofuMy supplied. AdF. Hhoiild he stated FiXACTLY. PHYSICIANS should state CAUSE OP DEATH in plain terms, that it may he properly classified. The "Special Information" for par- sons dyinjj away from home should he ^iven in every instance.
■H
I ;)i
* .!,
I't
J
' i\
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
It.Mid ..f Hciltli ]■' No. 1=; t-^«-«.->, H<<t J' CV)
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
mp
Dff/e Filcfl ,
C\..V^^>^->s^>0
li
190\
Regi.stcred J\''o.
i 055
Deputy Health Officer
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of Beatb
( XX. S. StanDarD ) PLACE OF DEATH: — County ofC)/0^\;OXxX^rUMw^LeoCity of O/CLAV O AXXAOX^CA. a^
No.
io^l
<^^\y'y^<Xj
H
1
^tl-
St.; "^ Dist.; bet. I /V^^TO and C) A^A\j
ilDENCEGIVE FACTS CALLED FOR UNDER "SPECIAL INFORMATION" \ IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. /
FULL NAME
PERSONAL AND STATISTICAL PARTICULARS
VMlcJu U)J\Aix
I) A ri'", ( 11 IlIKTII
(Mr)Mtir!
AC.H
S'l
)V,
ID.MVI
.1/.-;////.
I ■/car)
/',n. s
MEDICAL CERTIFICATE OF DEATH
DATJi ()1- DlvXTH /O
(MoiiDi) r (Day)
I IIl{RI-;nV CivRTlFV, That I atkii. led deceased from
- to ~— — T-rTrrr-rrrrr
(Year)
1 90
SINr.l.K. MAkUIl'.I) \\II)<>\VJ-:i) OR I)I\<)K»i;i) ^
'W'litriii social ilt^itMiatioii )
Mi
lUkTui'UAri.;
'Statf or ComitrN I
NAMJ- 01
i"A'nii:K
Hik rni'i.ACH
01 I'AIHF.k
' "^tatc ()T- Coiiiitrv
MAIOllX NAM)' 01 MOTHJ-.K
liikrin-LAci-:
oi" MOTHHK
(State or Coimtrv)
tliat T last saw h ^^ alive 011
190
T90
and that death (jcourred, 011 the date stated aliove, at ■ ~_ M. The CArSP: ()1- 1)I<:aTII n-^is as follows:
1)1' RATION }'rars
CONTRIHUTORY
Months
Days
Hours
oceriv\Ti(,x ri) , ::? 0
DI'RATIOX Vrars Mouths Days
(SIGNED) J. \Jj.U).XJLcL/>v<3L U\^VA l^ 190H (Address) LvurvMA-^ U
//ours
Jih) M.D.
Special Information only for Hospitdis. insdiufi
or Rpunf Residents, dnd persons dying away froin home.
Rf'tdrd ill Sail /'i <; in m-,i
)",„
M..iith-
/',
Former or UsudI Residence
When was disease contracted, I 'f not at place of deatti ?
Hovv long at Place of Death ?
nS, Transients,
Days
•nii: XHovr: s-|-\ti:i) i-kksonai, I'VRiicri.Aks Akj-: rkti- i-o tin-
Hl.SI Ol- MV K N( I W 1,1: 1 )(•.;;; AND \W.\,\V,\- (IiifnMiiant \; iVv^
'\.Mrc.^ bOl \l rLc/>V>VOuOt)
DAI'Hof P.riuAi. «.r RJCMOVAJ,
%
I'l.Arj-; Ol- iMRiAi, OR ki;m()\ai,
rNDl-.KTAKKK (fvD . J- OxaJKA/^^Co
T90S
fAdflrt-ss
N. B.-
-Hvery item of information HhouIJ be cnrefully «uppliecl. AdR HhouftI be stated EXACTLY. PHYSICIANS should state CAUSn OF DFATH in pli.in terms, that it may be properly claHsified. The "Special Information" for o.r- Rons clyin^ away from home should be ^iven in every instance.
!' ll
1
i
141
I
i
1i itJii
1:
ill!
4' ij
i
.1 >
I,
r
H
/
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
lioilKl nf lit ;il|)i I" Xo. 1
'*^^'*?
S^'}-.*-. HvSiI' Co
Dfffc n/rd , LLL^>L..oQ:fc
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
\%
I!) OH
L^
Reglstei'ed J\^o.
I ^^n
Deputy Health Officer
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of Beatb
( "KX. S. Staii&ar? ) PLACE OF DEATH: — County ofVJ/Ouvu ^J/u<X/>vcA^a/cuo City of CJ-CL/tu J A/Cl/>a./Ca^<^o No. UT Uldo St.; X Dist.; bet. XaAJkA./>^ and VJ Cr(J\
( '" °"'f^l°ccuRs Aw*v rpoM USUAL RESIDENCE give facts called for under "special information- \
\ IF DEAjTH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER )
FULL NAME
'^:^:\.>
>i:\
PERSONAL AND STATISTICAL PARTICULARS
(^ ft , ^'-I.-'K
^'^r^XxXjb
I> \ I !•: < >!• UlK'llI
\f. !■;
iMoiitli) /|
) V(/)
lb
(Day)
Mouth ^
fVcrirl
fhn
^iNt.i.K. M.\kuii;i)
wiiM >\\ i;i) OK i)[\( »R»i-: 1)
'Writ.' ill M)<-i;ii .K sij,'ti;iti..ii)
HiKriiiM, \ri-:
'Statf or Coiiiili vi
NAMl-; ()!•
iATin:R
HIR rill'I.ACK '>!• l-ATMIvR iStiitf or (.■()initr\
MAII)i:X NAMl- <>I' M()TlIi:k
HiR rin-i.Ari-; •»i- M(»tii);k 'Sl:itc or Country)
(3f (1
MEDICAL CERTIFICATE OF DEATH DATK OF I)1-:aTII r^
^^^^-^-^-o n. j^o'\
f^""t'i^ (J (Day) (Vcar)
I HHRIUiV CJ-RTIFV, That I attended (IcccaseTrfr^oni
'^ 190I to ^^-^-^ n 190 S
tliat I last" saw h -r^^.' alive on LLl.^ H t^q M
and that death occurred, on the date stated above, at S.3 0
'Ip^r- '^*li^' CAISIC (.)!• I)|{ATn was as foil.
)ws :
CS^jtxXA)
K.^Y\^
J? Oj)
1)1 RATION Years
Mofitin Days
I /ours
Dl'RATIOX
{ Signed )
)'cars
out /is
OCCri'ATlON
AW^ /;/ ,V,7„ rt,!)t, !-r,, — )■,,;/- ^ M.^iitli, \ 1
Davs
-\^<J^Jf^
//on
rs
M.D.
f ^^?'fi'-."^f°"'^'^'^'ON only for Hospitals, Insfifufions, Transients or Recent Residents, and persons dying away from fiome.
'""'.;, ^J-r' Vw •';'!". V'"'"" ''»'-'<^<'NM.l'\RTICri,ARSARI-. TRCK To TIM-
iii-,si oi- \\\ K>:<»\\i):i)c, K \\i) mi-:mi:f
(lMf');inrint
Former or Usual Residence
Wtien was disease contracted, If not at place of deatti ?
How lonq at Place of Death?
Days
' \'l.lr.
loO'l
^
''''•\iii'l,*''"J^'''^'^'''»l< 1<i;m.,VAI. I)ATK,,f n,K,,,. or RKMOVAI,
INI
)i.KTAKKR LoJUJUrVv"y^A/Ou Uw^vAxilo Co
"' ''■ Itrt7c'l\rSF^OP nTrTH" "^^^^ '^^ carefuny suppliecl. AGB nhould be ntntecl BXACTLY. PHYSICIANS «houId •in. civfni „ ^'^f "^A^" '" •»'"'" f*^'-'"«. th«t it may be properly cla««iiiied. The "Special Information" for per- sons cl>ini away from home Hhoiild be feiven in every instance.
t
1 1
li'
\\\
TA
PS
i i
I
/
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
*■!!?>'
)t";it(l of H<;ilth »•■ Vo K 'f-si: ."*./'"'♦ Mi"^ 1' Co
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
Ihffr F/7rf/, [X^^x^yu^ \l mO'i
Begistcred J\^o,
< 057
,<rVA.-^--o
>^{
N
Deputy Health Officer
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of IDcatb
( Xk. S. Stanear^ )
PLACE OF DEATH: — County ofOcL^^; vj;LCU\vCAXLao City of d/O/ru 0 ^L/O/vurx^^ e-t o. \^'KaJLc\AXa\^
(
St.;
IF DEATH OCCURS AWA
Dist.; bet.
iUAL RESIDENCE GIVE facts called for under "special
IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREE
"and
FULL NAME
lAL INFORMATION" \ T AND NUMBER. /
S !•: \
PERSONAL AND STATISTICAL PARTICULARS
DAii-; (ti liiKTn
\'.i-;
1
U
null I
) Id )
5-
'I):tv)
.1 /.->////>
\x
(W ,11
/',/]
HINCI,!- M \ K k I i;i). Wiitciii x.iiial (1( si(,^i);(tioii )
x^y^
'St:i!' '.• ''nititrv'
N'AMl' <)1-
F \thi:k
lUR'IMIM.ACH f)|- I-ATIIKK
'St;it> <)1 ("nnilliv)
maii));n xamk of mothhk
niRTUI'r.AOF:
'>!•■ MnTHI-,k
( suite or CduiiIi \ )
OCCrPATlON
[^ ] (J p |0
MEDICAL CERTIFICATE OF DEATH
datf: of DicATH r\
'^^-^^ n /(?r>H
( Mouth) J (Day) (Year)
m:KI';HV CI:rT]I'V, Tliat r atteM(k-<l deceased 7mm
l^ 190 H to LXm^ 11 KpC^
that I last saw h XV alive on CLlaXV H ^d 0\ icp H
atid that death oc(Mirred, on the date stated above, at 10-2)0
U. M. The CAISI^)!- 1)1-:.\TII uas as follows:
IM- RAT I ON Vrars \ Mouths H Days Hour,
CONTRIIU-TORV VIax^ccJLlW^ Ull
■!OXX\jy:
Lt\r
I )r RATION S Vrars .mouuis
(SIGNED) It). J . Ijuxiji^UX
^^^^-^-^ n i()o'-\ (Ad.itvs>.) UI^JUl\Jt^\^ '()b(S4.lvt
Mouths Days Hours
M.D.
112:
^P^^^'f^L INFORMATION only for Hospitals. Institutions, Transients or Recent Residents, dnd persons dying awdy fro.ti fjome.
■> ) .
'./ /
lA. /////>
'" n,^ ",V^'^. ^''' XH' I » 1' F k ^. )\ \ 1 , 1- M< I I . • r I, \ K ^ A K F; T K I I-: T( . Til }■• I'F.SI OF >,J^V KNOWI.l.Dt-,}.; AM) in- 1, 1 1 ; 1-
fii>f":"iriiit ds^-^rVLA^ VJj XxX>
former or [\ ^\ P 3 Hon long at
Isual Residence M kKaJSTYTsjO^ \JXXj pjace of Death ? P
was disease rontrarted, (v 0 (^ [)
at place of deaffi ? VJ CXJL^rywXK) LxXv
Days
When was If not
.\J^
^'i'i'<'«'^ ^J X^>-^AJL\aXX) L<U(Jt^^OvOU^ L<
TQOH
I'I.AC|:oF MrJ<lAI. OK '<»-^'"VAI. I,An.:,.f p.rK.AK or KKMOVAI, (Address 3 IH iD ' J <X>UuJl dl
I ndf;
N. B.-
-Kvery item of information hHouIcI be cnrefully Rupplie.l. AGR «houltl be stated F.XACTLY. PHYSICIANS should state CAII8E OF DEATH In plain terms, that it may be properly classified. The "Special Information" for o.r- Rons dymft away from home should be iliven in as^vy instance.
;r
i T i
•t
) ']
11
/
I
i.4
'^
mm
II i.
1^
4 1
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
H-Mi.l ..f Hiriltli I- No. !«; ■*-^''ra^.;, lK<;tl'Co
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
Deputy Health Officer
Bogi\si('i'0(l ^^r;.
lOi
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Ccvtificate of Beatb
PLACE OF DEATH: — County of vJCL^>\.) O^^vCl/^^/Caa^co City of O/Cla^ J AxXy->a.CA.<iXi c
St.; H Dist.; bet. db CK^J<XAydL> and 0 O-lA-tn-W
i AWAY FROM USUAL RESIDENCE GIVE FACTS CALLED FOR UNDER "SPECIAL INFORMATION" N IRRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. )
No. 0 dlD .a,^.»vvxl'
FULL NAME
SI
PERSONAL AND STATISTICAL PARTICULARS
'!
DA II-: ol' lUKlll
.\^.\^.
JJxVAX
/UCr\Ary\;
MEDICAL CERTIFICATE OF DEATH
DATH OI" I)i;A'i II ^-^
(Month) (V (I)av)
IH
il):i\ I
) III I s
Mnlilliy
a
/),/
SINC.I.i:, MAKRIl-l). WIDoWKl) OK DIVoKaIJ) iWritcin social rltsit'iiiiti'iii)
d
HIRTHl'I.ACK
' -^ritc or (."oiii'.trv'
NAM}; or
I-ATIII-R
niRTMl'!. AiK
Of I'ArnKR
fSlatf Ml rouiitrv)
MAIDI-.N NAMl-;
<>i M<»rm;R
IMRIIII'UACI-: Ol- MorilKR (State or Countiv)
occri'A rioN
f\t' idrd ill .S\ni I'l ,1)1. f ,-,i
XX/^X) O ^vXX^VVX^A^^CL/C^
(Year) I IN'RIvHY Cl-RTIFV, That I attcii.led deceased Yroiii
'J-^-^ IH 190H to CLaw^ 1.H 1^4
that I last saw h :^*V alive on LLa^/Ol 1 H Kp H
and that death occurred, on the date stated above, at 1^
^ -M. The CArSl<: OI' niCATII was as follows:
r f I
DCRAriO.X }'tU7rs C()NTRII5rT()RY
IMontln;
Days (0 Hours
\y\Jb
DI-RATIOX Years Mouths Days
(SIGNED) lO. d dvJjLx
UoC\^^ iS'iQoH (Ad.lress) ^ 3) ( ()b 0-Uj<t\xi^ Ot PEC^AL IN
Hours M.D.
?''^9^'S'- Information only for Hospitals, InstituNons, Transients or Recent Residents, and persons dying away froni fiome. '
) I'll I >
"" ^r..||fh^ 1^ //,;
THr. AHOVK SI-ATI-I) PHRsoVAi. 1' \ RTirr l.ARS ARi; TRD-: To TIN-
ifhsi OI- Mv KNo\\ij:i>(-,h- AM) in-:Mi-:i--
Former or L'sual Residence
When was disease contracted, If not at place of dcatfi ?
flow lonq at Place of Oeatfj ?
Days
f Iiif'i-iiiaut
U). a
M.d.lif^-;
S^l 'db Cru^KXVdL cjt
ri.ACK OK IirRIAI. OR RI-:moVM, j I)\Tl-:.,f liiKiAi. ,„ RHMOVAI,
rNi)i-;R'rAivi-:R
^^cMrrs';
SbT^- l^
^' "• ^'^^^y 'tern of informntSon should be cnrefully supplied. AGB should be «tfited EXACTLY. PHYSICIANS should state CAUSE OF DEATH in plain terms, that it may he properly classified. The "Special Information" for D«r- 8on« dyinft away from home should be jiiven in every instance.
\
f
I ;'
!;
«•;!
> t
.1.
■f
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
V.r.-jv] .f !!' ii'th- I" No ••• "^"'i.^?/^*' HS.I' C-,
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
Bogisfd'od J\^o.
' 059
cLci-ccvo kju\>-\j Deputy Health Officer
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of jDeath
( "U. 5. Stan^arC> )
J? (?T^ A %
PLACE OF DEATH: — County ofC'CL^^- 0/VCX^vC^si C^City of C)<X/>v O.h^CU^vCc^c^ Ne. 0.\JL^VcJk) ()bcHtix\l<x( St.; Dist.; bet. and
(ir Dt»TH OCCURS «W*V TROM USUAL R E S I D E N C E G I V E facts called for under "special INrORMATION " "\ IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. /
FULL NAME 0.t>viXcvcL«-
-)
•1 A
PERSONAL AND STATISTICAL PARTICULARS
i> \ ri- < ii r.ik Til
" 1
15-
'D.-iv*
\' .1',
3.^
/'(M.>
^OAX
nil;-'-:i;M v.-j-
F'ATIU: R
HIk rui'i.ArH '»i- fathi:r
'^' iti or i,"<)ni)tr\' '
maii>i:n NAMi-:
or MoTUHR
iJikiin-i. \<i-;
OF- MttTHi:K
! Stall- <jr (.'<iinui
' »■ > I lAlIoN
MEDICAL CERTIFICATE OF DEATH
' Ml null > [\ (Day)
I HI-:RI-:iiV C1;RTIFV. That I atUMi.lc.l .IcHiMse.l from VvOLvv_ '^ looH to LLum3i_ l"^
(Year)
■y ^ 190H to ywA^^s^ It KjoH
that I last saw h -»w/u alive oil v^^A-a^CL 'I
ajid that (U>ath occurred, cm the datt- stated above, at io (X M. The CAISK C)l- 1)I-;AT!I
was as follow^
I ) I ■ R A r I < ) N
}'<•(/;.?
CONTRIIUToRV O-r^^
M (tilths Pays
I/oitrs
DTRATloN
(Signed )
)'i'ars
Cb. LIa1..<^X3.
n
Xj^X) ij . \j
kVidf,! in S,ni I'iaii< '^»•'> ,JL Vj
?.
v^A^^o il> ic)oH rAddris<) i£^2) UxxXXx
:3JJlL22_L_
:iAL iNFORi
Pays
Hours M.D.
/'.'l.
rni' AHovK ST \ri:ii rKRSiiN \i. !■ \K ihii \k^ \ki- trii- ri • I'ni-'
in-;sT •»! 'iJV KN<i\\I,l-:i)r. h AND lU.l.lI'.i (It. forma nt Obj2^'>'^VM, ^ CC^W-aJL^A^
0 (p a
4
\.Mv.
SPECIi^kL Information onU tor Hospitdls, institutions'! Transients, or Recent Residents, dnd persons dying av»a\ from home.
former or "^rJ^^T^?^^ ^'^^ ,t; fioH long at
Lisual Residence vj <xJk>v/o^/-i^cxA^ ^-a-. place of Deatfi? H I Oavs
When Has disease contracted, If not at place of death ?
rLACl-: ())• lUKIAI, Ok K1-:Mi i\AJ,
CnLu Uv
^r^^
I)Arjj:(>f 15! i-i.Ai, (,r Rl-:Mn\Ai,
^"^ I90M
0
(Ad.
•^^ ^' f"'vepy item olf infurmHtion should h.- cnrcfully siipplle«l. AGK Hhould be Htateil F.XACTLY. PHYSICIANS Hhouid •tHtc CAUSE OF DEATH in phiin terms, that it may be properly classified. The "Special Information" for p«r- Bon* dyln^ away from home should be ftiven in «very instance.
If
■1
'I;
•:U.]
J .: i k \''
t I
U
; ft
11-
Ml. Mi
;• t
( r
it I
I I
• t
^M
r
I \.
m
fr'^r-^,'.
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
Hm:M(1 of II( :ilth I' V<
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
/)f(/r rilrd, LUaXX^^aaJj 1%
lOO'i
Jlrgi.s/crcd jV(h
1 fi(\0
tj-\A.A^
^
^fj^ty Hcahn (jffi
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of 5)eatb
( U. S. 5tnn^nr^ )
^ (^ J?
%
PLACE OF DEATH: — County ofO/(Vru v) AXX/^x<>L4C(City ofO/CUOO; OAXX/YvedX^c
I^.
iiu X
^A.sLi\>0^<LiSt.;
~ Dist.; bet.
and
rt /' ir DEATH occunaTAWAv FROM USUAL RESIDENCE GIVE facts called for under "special i n formation-' 'X J V 'P death occi^red in a hospital or institution give its name instead of street and number. /
FULL NAME
.^w^
Uv^Crur
f
Utu
PERSONAL AND STATISTICAL PARTICULARS
--I'.X
I) A ri'. < »i HI Kill
^' . }■:
M..Ath)
,aJu
UJJvctji
Avi
51 .,.., H
il);iv)
M.'utli
' '\'f,\\
MEDICAL CERTIFICATE OF DEATH
DA'ri". nl- Di: \ III
n
(D.iv)
11
/',
I vs
\\ !!« »\\i<: I) ( )« iti\i )Rri: 1)
' W'l it' ill -i.( ial (!(sij.Miiit i.ui )
luk riii'i, \<^}'
'Mill' l)T I Mllllt I \
|'ATiii;k
HIRTHI'I.ACK
«>i- i-ATm:K
'Sl.itc oi Coiiiiti \^
MAII)i:\ \AMl-.
"!■ M(»rin:k
inKi'iiiM.An-:
<>l- Mit'llll-.K
'-0
I Hi'RI'lJV CI'IKTII'V; That I .iltci.U.l .lc«xasf,l fm,,,
IvaXu ^0 up^\ to CX^-vq.
tliat I last saw li ^'^ ' > > alive on
(Month)
up\
ami that diatli occuircMl, on tlu- datr stated above, at S" v) 0
M. 'Ihe CAISI.; OI' I)i: \|-il was as follows
, ;n . •" • ' '"^ v.Yi vii, wi I'l. \iii \\^is as I OIK
A^A^-VN.
1
.'Y^^J L^uO-U.rlx^
A)
ct
1)1 RA'i'lON Years
CON'i'Kir.rTokV
}'i'll IS
Months
\l
Pays
J/oin
f\'f!lll'<! Ill Will I I ,1 II, I -I'll »■ )V,M» "^
DIRATION
(Signed) UJ. Xd . L<r^\X_
VA.\^txr; i()o'\ (Addn-^s) UJLy\'ya.Iv^
dPal Infor
Mon/Zis /hns
//ours M.D.
SPECmL Information "nly for llospildls, Instilulions, Irdnsients or Rerent Residents, ,ind persons dyini) dway from fiome, '
Former or llsudi Residence
?
How long df f'Idre of Oedfh ?
1/,.;//'//
/>.n
llir A)|()VK ST\ Til) I'KKSONAI, l'\l< IH TI.AKS AKl! VRl }■ Tn nil- lU.Sl (»|. MV KNUA\|,l,I)C.|.: AM) i!i;i,ii:i-
Onf>j;iit;iilt
< X'ldicss
Wfien was disease ronlrd(fed, If not at pidfe of deatli ?
Days
<i \^^C.
I'l.Ari- ()i- lURiAi. Ok ki:M(.v\i, I datk,;- hiiuai (.1 kj:muv\u
0 h) Op ^. %" ^
MMKM
N. K. Kvery item of infoniiHtion Khotilcl be cnrefully supplied. AGK should be stjited KXACTLY. PHYSICIANS should «tatc CAlISi: OP DliA TH in plnin terms, that it may be properly classified. The "Special Information" for par- sons dyinii away from home should be feivcn in every instance.
M
\ •
if
.1 .
w<-y
"I
» i
"
I :
^.
m
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
t)*""^"*.
j;n;,lrl of II. ;iltll I" N'o. H t-- » --i) ){& P ».
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
Dfffc Fi /('(/,
cLcrOu^
\i
WOH
Reo'istered J\i''n.
^ OG 1
Deputy Health Officer
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of IDeath
SI ^ J?
^
PLACE OF DEATH: — County ofCJ/CL/-^ 0A^<X>vc.c4.C( City of 0 Cu v\j U AXX/'VX'C^^ C
o
ncSRIpSIl^
■OM^'^A^^Cj^*^.'
St.; H Dist.;bet. (o
\\)
.-It!
and I Ot'
(IF DtATH OCCURS AWAY FROM USUAL R E S I D E N C E G I V C FACTS CALLED FOR UNDER "SPECIAL INFORMATION" \ IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. J
FULL NAME
a
X-^rV
si;\
PERSONAL AND STATISTICAL PARTICULARS
!).\ 1 ! Ml Hi Kill
\i
JJJx^LiL;
<X<.<^r-
MEDICAL CERTIFICATE OF DEATH
DATK ol' 1)i;ath
|\!Mntli
^
Ob r,„..
li
II):ivl
M »/.'//•
\%
(Momli) rt (Dayl (Yrnr^
I m:Ri;r.V CIvRTIFV, That I attcMidcl (Iciv.isc.l from
a^
/),.' 1
<I\i'.l.l" MARRIl".!)
WIIx >\Vl'It OK I>I\'( iKT I'D
(\\'ii!i in s<n.-i;i] i!< v'<.Mi.it imi )
lukruri, Ai'i"
'Stilt I (ir rrnint I \
1 H
NAM)-: or I'Aiiii:k
lUKIH IM. \iV. «)! lAriM'K
(St.-lti- (It I'dUIlt I \
^M II li.N \ \M I
<'i Mi>rni';K
I'.iRiin-i.ArH
oi' Moi'IIlvU 'Stale nr C'ouiitrvl
.0^<i
u
XXX
I I I I , I\ I , 1 1
190 H t
\^p\
OLCcr
V>U
lxXv>
that I last saw h I- i>\ alive on \J^^CQ ^ 11 190'!
and that <Uath occiirrcMl, 011 the datr "^tatetl ahove, at H VJ ^\. The CAl^h; ()!• 1)1<;.\TH wa>^ as follows:
1)1 RATION )-fars Man //is /hfvs J lours
CONTRir.rTORV
1)1 RAT ION Years
( Signed ) J. <i M
0 XOL v^ v<i.yUt^.>
Months Pays Hours
u^rw-w^x^ M.D.
Lww^Q ll loo'i (A.l.lress) I I 1 6 H iXcuJkjob
It
SPEOIAL Information only lor Hospitals, Institutions, Transients, or Recent Residents, and persons dyinij away from home.
M.nilf,'
IK!\
I III' AIJOVI-: sr \ 111) I'KKSONAI, I'AKriCl I.AKS AKl' rkri-- )•( > Til F
luvsr oi- Mv KNOW i.i-.Dc. H AM) in-:i,ii:i-
Former or Isufll Residence
Wfien Has disease contracted, If not at place of deatfi ?
Hovv long at Place of OeatI) ?
Days
I NDl.K lAKl-K LvV\aXC<X V,^^A V-C^_XA^V'CCV\jLV/i
l)\ri^)! Mi HiAi (.1 KI'iMOVAI,
'A.i.Ilr
N. R.-
^■i- il—i
-F.vepy item of informHtion should b.- cnret'ully supplied. AdK should be stated fiXACTLY. PHYSICIANS Hhould state CAUSr: or DTATM in plain terms, that it may be pr<»perly classified. The "Special Information" for par- sons dyin^ awny from home should be J^iven in every instance.
J
I'M
J I
m
1^
i
!!
:
4*
m
• pi
I
f ?
■m^^^
VcJ
1
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WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
*\>''*^%f
!!,.an! of ll< ;t!lli l" Vo. i '^ '^'t'^^jr^ "'"^ '" ^
REFER TO BACK OP CERTIFICATE FOR INSTRUCTIONS
mmmmmmmmmmmm
I )((((' Filed ,
oUcrLx^Vw^
A
ii)()\
ItcgLslcrcd J\i'o.
1 0G2
Deputy Health Officer
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Ccvtificate of IDeatb
( "a. 5. Stan^ari) ) PLACE OF DEATH: — County ofO/Oy-vx' ^Lh.XX/>^,/Ot^x:.cCity of ^'^^>v J /ucx^ x c>Aw<ixt
o
1
'Xa\j
'No.'XVX dJlXv/VAXvCcT^v \X\>A} St.; 5 Dist.; bet. IS XA\^ and lO
(ir ttATH OcAuBS AWAY FROM USUAL RESIDENCE GIVE FACTS CALLED FOR UNDER "SPECIAL INFORMATION ' ' \ IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. J
tl
FULL NAME
M ]\<x\^^.A^^ db /Cu'^vfc
PERSONAL AND STATISTICAL PARTICULARS
Ctx
:> \ I i: tu- I'.iK III
\<", K
(k.
lie
) '•(/; -
5^
3.5
iDayl
,1 /.;/,'//>
(Viar)
MEDICAL CERTIFICATE OF DEATH
DATli »>I I)I;ATH
(I)ny)
CL
9.3)
n,!
SI NT. I.I', MAKKIi:!)
\VII)( iWKI) OK I»:\i (l-Ti:!)
iWiit in ■^uriiil dt sii.' n.it ii >ii )
IMK'PHIM.ArK
fSt.'itt or Cmniti \ »
iATin:R
I'.IRTHIM.ACK <)I" I AIMIvR istatf or (."'nititrv)
M\ii>i:\ Nwii; • >i' m<>|-|ii;k
lUK rniM,Ai'j-;
<>l- MM'riN-'.K
< Slatf or (,"oujitr\ >
occn-A Tlox
I'Montlii i'l" 1 IIliRl'HV Cl.kril'V, That I attLMi.lfd (IcM'c-asLMl from
(Year)
190 '\ to vXw<3L n KpH
tlial I last saw h -^J^' alive on vA-VvXV ^1 H/D H
atul that iliath ori-tiritMl, on tht- tlatc statt'd ahovo, at O v> 0 V M Thi' CAISI' ()!• I)!-:aTI1 wa-^ as follows:
>LX/CV/vvfc -^^-^dX
I )r RATION Yrars Months 10 Days //out
C()NTRii;rT()kV
Ol>
t'>r\^>^'
Vf- ii/rif in S',n,' I'l ttvi i^ri) \
A'
)>,,•
^ \J.>,>lh<
I'
DC RATION )\'ars Months /\ivs //ours
iNED) M iIolW \, d/Ou^vvJk.t4u M.D.
l^t r()0^( (Address) 2.(0 S C)/CV>v VxXAXcy^vXv-C
(SIGI
SPECIAL INFORMATION only for Hospitals, Instifutions, Transients, or Rerent Residents, and persons dying away from liomc.
liii: AH()\ K sr \i"i:i) i'Kksonai. iv\Ki"irri, aks aki- rKn-: ro tmi':
lllCST ()!• MY KN()WI,i:i)(",H AND lUvI.IllK
'Iiifo-niMiit
X'W'
yVDoJvfc 1-cxjUkjtX)
Former or Usual Residence
When was disease rontracted, If not at place of death?
How lonq at Place of Death ?
Days
ri.ACK ()!■■ niKIAI, OK KI:M( t\AI,
DAI^of !?i KiAi, f)i HHMOVAI,
^0 T90H
(Address iH^'i \MU.^U<LA.'Xrv\ 3t
N. B. Cvery item f»** inlfor'niation uhoultl be cnrefully supplied. A(]B Khoiild be stilted HXACTLY. PHYSICIAINS fthould
Htnte CAUSI: OI' DKA TM in plnin terms, that it mjiy be properly clussiltied. The "Special Information" ?gp pap- song dyin^ awny (from homu should be i^iven in every instnnce.
"-1
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M
"If
(vtl
.^1
h
m
'I'
1 1
1
ni!
fi-:
•
III;
|l I
^1
I
l>i{
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
H":i!-1 of II. m1I)i I" No. i c, 1v'- ■!? ;i4i lUS: 1' C,
REFER TO BACK OP CERTIFICATE FOR INSTRUCTIONS
Uuu^^cx^^^^.^ \h 700^
Deputy Health Officer
Registered J\^o.
^ £~\ -/'» ^-*. I
S? f p c s • jr
nafe tife(t , \x
DEPARTMENT Of PUBLIC HEALTIKity and County of San Francisco
Certificate of 2)eatb
PLACE OF DEATH: — County ofUcu^v. J>v<X/>x/Ouu;cCity of O'O-'W JAX3.-^v<M,.<i.<^<i No.a^^'cU-p^vx^Urv IUk^ St.; 5 Dist.;bet. R ll and aoiJv
FULL NAME
PERSONAL AND STATISTICAL PARTICULARS
fl);(v)
Jx/^^'v<xAjl
DAii-: (II I'.ikiii
MEDICAL CERTIFICATE OF DEATH
DAll-; oi" DICATH
M..nth
\< .1-;
lb ;,....
5r
1A /////.
5.^
/',,■
^IN<.l,l', M.\UKIi;i)
uii)(»\vi-;i) OR nivoi-TiM)
'Writ" ill ^<)ri;il (]( siviialioii)
I IK riii'i, Ai'i-;
'St;if< or Coiiiiti vl
\\\tl. I)!-
1 A riii.K
l'.IKT[H'I,A("H <>l' lAI'IlIlK
'^t.iti or i'')uiiiiv
M\II)i:\ NAMI-
lUKIIIl'LACI-;
"I- M()Tmi.;k
'Stall- i.r Coiuitrx I
1)1"' ip \l-|n\
I HI-;RI-:I{V Ci:RTlI-V, That r attm.lol ,lccvaso<l fro, 190 1 t.) A^^ im h;oH
« I I I . IN i , I >
thai I last saw li ■^J\-' aVwv 011
II
MiM that .Icath .H-ninxNl, n,, tin- .late stated above, at S 5 0 -^^''O'"" ^'/^^'' ^"' '^'-"^''''^ '''■" ^^ follows:
-'^-^^-'tYvvt -^-A^diw*.
cr>v
A>Kx
cnx'i-Riur'j'oRv
/A;//
/,v
I) r RAT I ON
)'i'ai's
M(>)i//is
(SIGNED) m<XW Y 0<X.'yJi\Xu M.D.
.'VvJf-^
/'>avs
//ours
v-C
Rf^ulcl i)i Si/ii /'i in/, i-i ,1 \
)>.:;
C
or RccenI Residents, and persons dyinij ,iwdv from home. 'finsienrs,
!/../////>
/',,•
ifi.M (ii. MS K\()\yi,i;i)c,K AM) i!i:i,ii:i
'Info'iiiaiit
I
Former or Usu.il Residence
When was disease rontrarted, If not af plare of death ?
How long at Plate of Death ?
Days
I'l.ACl-: OI- lUKlAI, (Ik Ri;M(t\\!,
fA(i,h-.s 3.4^^ (hx- "^
^^ ^^ I90H
I'AIUi.if Hi lUAl, 01 K »;M(»\ai^
N. B. fivcry itc
Htr/JVusr'of n^XT^^^^^ '"■ ^••"'^•'■""> -PP"-«. AGE «houI.l be Htnte.l HXACTLY. PHYSICIANS
sons civfni « f I '" ',"'" ''"'""' *''"* '* '""^ ''" pr.M-rly duHsh'iecI. The "Special InV'or„u.llo„- f
sons dyinft away from home should be 0,]ven in every instflnce.
fihould for pur-
il
' »1
ill
f
^r
Ill
■f
M
f .
f
>
WRITE PLAINLY WITH UNFADING INK —
Hoard of Ilialtli 1" No. i> *•« ; tsr 2i4 \\Si.\' Co
n
1 )((/(' riled , LLu^^^AA^ I?,
IfJO'i
THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
Re^isteved JVo,
\ Of ).3
Deputy Health Officer
DEPARTflENT tfF PUBLIC HEALTH-City and County of San Francisco
Certificate of Bcatb
( "U. S. StanDar^ ) ^ ^ J?
No.
-y (fl?) J? (^
PLACE OF DEATHr-County^ofClo/.^ Jyv^x,:^e,Gty oiOo^ Jx<^v<^v^cc
X ox <tu (h C^^ WtlcLA > Dist ♦ bet J
/ IF DEATH OCCURS AvtAY FROM li S U A L R F qW" fU r r " "^^S^** ^ I* ^ and
I
FULL NAME U
Xi^v.
dc
vj
s !■: \
DVV]-. Ml- l;ik in
\<". j;
PERSONAL AND STATISTICAL PARTICULARS
i"'»i,<)k
M.Mlth
rill
MEDICAL CERTIFICATE OF DEATH
DA IK oi- I)i;.\TH
Ii:. \-
Vtar)
I m-RI-HV ClvRTlFV. That I atten.lcl dcccascMl frn„, 190 to ■ — —
aa
\\n»< m HI) Ok i)iv( >kii:i)
' ^^ ' " ""ial il< siiMiat ii >n)
MiK rni'i. ACH
' Slate or (• lint r\-
i
I
tlial r last saw li r alive 011
r-r:iQO - ~ 190 —
■ni'l that .Icath occurre.l, on the <latr ^tate.l ahcvc, at ~ r^'' 'T7"^"n^ '>'^ATI^vasa. foll.nvs
■6.
NAM J- <»! lA THlk
inKTiri'J.ACK <»l lATHHK
'Statr or t'ouiitrv
''IMIM.V NAM)
<•! M'>rin-,k
li'k riiiM.ACi':
<M- MorilKK
''^l;itr i.r C.Minti \
A\A^'<}
'AAXiX/ayv JV<r^
?!
ITkA'llON CONTkllU'TOkV
}'c'<7rs M,))iths
Pars
Iloins
I )I RAT ION
)'('ai-s
.'^finillis
Pays
' " *■' I'Vl'ION
'jmiL,
ICML IN FOR I
Hours
(SIGNED) LcY^^X/vO.^AL.oUi^,.vv<JL M.D.
SPE
v-v-tX
^
)V,n
^ 1/,.-,,'//- - /;,,
'InfuMnrml
I
yi^KN<.\\l,i.;i)C.H AM) Itl-l.IlvF
yv. 'I'l » riij-
When Has disea'.e ronfrarted, If not ill plat e of deatli ?
I'l.ACI': OI' IMkl AI, (»R k l.M()\- \l
I N i)i-: R r A k 1 : k UCvou^ H- • vfc. \)|UJL'
l>ATlj..f iii KiAi. ,,i K>:M()\-Ai,
!N. "— ^;V';''y 'tern on„fon,„„tlon nhoul.! I,. c.rcV'uIly supplied. M\V. s,,„.,|<| ,
«tnK CAUSr or DI.ATH in plain tc
.e state.l fiXACTLY. PHYSICIANS shoiiM
-on. .„i„, ,.„„; ;;■ ,„ ■ ::: r:,.;;:";;;.";-;:*,::;:: ;:;r::r" ^'"""''"'- "^"^ ■'*'-'■" '"" -"•• '»
r p»*r-
^1
«i
t
1 1
s
1
^!f
•i
h
! I
[•♦i
i
'
II
1 j 11^
i»
' .
^-
H"^'
f
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
!l..:n.I ..f FI. ilili l- v.. I-, f-^^^W^) HSc\' Co
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
Dff/r I'ihd, \Juu<x>^y^AXj \\ 100^
liei^isfei'ed JVo,
I ncvi
\A
Deputy Health Officer
DEPARTMENT OPPUBLIC HEALTH-Cify and County of San Francisco
Certificate of IDeatb
( H. 5. 5tan^arD )
PLACE OF DEATH: — County of C'/(X^\; 0/UX/'>VCAAC€City of C) CUVi/ 0XXL/Y\'C,v^/C<3
No.
•'CX^CL-r^ ^JXCV.ti.K'
St.;
Dist.; bet.
and
/ IF DEATH OCCURS AWAY TROM USUAL R E S I D E N C E G 1 V E FACTS CALLED FOR UNDER 'SPECIAL INFORMATION- \ V IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF ST RE eI A NO N UMBER )
FULL NAME
<X/vuJUj
"-i: \
i> \ 1 1-: oi- i;ii< rii
\<'. !■:
PERSONAL AND STATISTICAL PARTICULARS
COI.ok
Q?
'yVvCtx
JWL<UyvX/>v
Jx\r
MoiiDi
3
,V^
I go \
(Year)
3
t
0 i;.
ni;h s
\x
\ car)
/),
^IN'.I.i:. MARK II- I).
\\n)t>\v}:i) Ok DivoKn-T)
U'ritc in «)ri;il .!< -iLMiat i.>n>
iiiK rui'i. \rK
(Stiitt.- or Couiiti V
^^-V'
MEDICAL CERTIFICATE OF DEATH
DATK oi- i)i:ath r\
LWOL 15
I ni:Ri:i'.V Ci;RTn-V. That I mUcikUmI .loroasd from
— — 190 to - iQo
that r hist saw h ' — • alive on : — \ ^^^
and that (Uatli orciiried. on the date stated above, at
M. The CAISK ()!• DICATH nas as follows.
N.v.Mi-: III i-Aiii i;r
IMkTlII'l.Af}- '>!• lATIII-.R
'St;it< 01 Ciinti v1
MAlI)i:\ NAM}-
oi- MoTin-;k
I'-IK I'HlM.An-- OI" MOTH I -.R
'Stair I.I- <.-oiint!\ I
C' vu< cL-. ^ -.j
X 'VA.cr^^'
«•
M
IMRATION Years Mouths
CONTKIIirTORV
>"*-0-^-\Ji V'OL<a^ c . . Lv<r>>-^,
A-XXv^v Jt>vtjl>wvva
Pay
'S
J lours
DC RATION
)'(ars
.^fi^uths
(SIGNED) WumJiX; J.lc.Uj.XliLou
Pars
n rqoH
Ad.lle^s) \js\.-
Flours M.D.
^\JJA^
"' cri'A riuN
-<Jl^
V.'.v//,..
/',;i .
or Recent Residents, and persons dyintj away from home. Former or ^ Py^ J How long at
"'nrJTy.l^';^ •'"'■'* I'KK^ONM. I'ARTUTI.ARS ARl- TRIK T. . TIIK
H h ^ r 0 1- M N K \ ( ) \v\ 1 ■: I X ; }•: A N ! ) in-: 1. 1 h k
p^" ' '^ ^' '*» i, 1-. IM .1-, .\ N 1) JUM.IJ
I'sual Residence
When was disease contracted, If not at place of deatit ?
-A^ ""« ionq at .Ou(Mr>v or Place of Death ?
Days
190H
(\<\A
io»;,s
5-61
tPOAJLh^
3t
f Ad(hcss ^ H XH O <rCcLil/W "
V^
-'V^..,
^' "* TtaYe^'c i'l^virUr nTr^M" "''?'*' ''" --«''«f"">' supplied. AGK should be stntccf RXACTLY. PHYSICIANS should !o^^l • . 01 DEATH 1,1 ph.m terms, thnt it may he properly claHsified. The "Special InformHtion" for per- sons tlyinft «wny from home should be ftlven in every iiistnnce.
!l
it
i vl
i I
f.^
<^i
■-^-^ f
-■% « *
■y !V -'i^:i!>^'
r,
I .
#;
li
lal
^-«ji
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
)!m;,1.1 ..f lh:illll I- V<>. I^ *'-'_'5;^'i- I!S:l' ('..
Xtn^cv^i dOL^xhu Deputy Health Officer
JivgLstcred J\^o,
1 065
DEPARTMENT OT PUBLIC HEALTH=City and County of San Francisco
Certificate of IDeatb
( tl. S. StaiiDnrO )
QK)
PLACE OF DEATH: — County of 0/<X-y^ 0/)^O^%OL^ecCity ofO/CLA^ 0 AXV^-VCaAXI^
No, 11013, X'xdvt^vt St.; ^5. Dist.;bet.C)ae>vayYvvt>xto and VAXXU.
/ IF DEATH (|)CCURS AWAY FROM USUAL RESIDENCE GIVE FACTS CALLED FOR UNDER ■'SPECIAL I N FO R M ATI O N • ' \ -1
V IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / J
FULL NAME ^^JU.
o-ooo
^AA.
'i:\
1 ' \ I 1-, < .1- !;1K 111
Af.K
PERSONAL AND STATISTICAL PARTICULARS
COI.OR
^yUjUUr^^
H
(I):iy
i •: i
MEDICAL CERTIFICATE OF DEATH DATH ol- DHATH
' ' It
(Day)
Moiitli)
TQO \
(Year)
an
) -
H
M.'iilh \
\ t ail
/',;
-iNi.i.j". MAkun-.i).
\VII)t»\VKI) OK I)!\-()k( I- •)
' \V: it- ill - • ■. --i^Ml;il;..ii)
lilKTHlM.ArK (State or Conntrv!
O^A^a/Lo
I [ll':Ri-;nV Ci:kTIFV, That I atU-n.kMl deceased fn.m
~ '9° tn TOO
tliat I last saw h alive on
and that death occurred, on tlie dale state<l ahove, at - ■" j^' M. The CAISI-: OF DI'ATII was as follows:
1 \ rm-:K
r-ikTinM,\«K
"I" I AlUHK
(Stat( or Ciiunlrvt
oi- M«)j-in;K
<>^■ MoTm-.K
I'Voa^O^
djLX.
.\^A^.<rwQ
nr RATION Years
CONTRHd'TORV
Mouths
Pays
II am
MJlXj
DIRATION
'W
)\ars
Monl/is
(SIG
NED ) JAJxIx>vaxJi 0. Cou-
Days
,
Rrsi,
s!ifr,f ni S,i)i /'i (! II, f^.'it ^\
-VOj
\ lie i()oM (Ad.lre-><) icO^ C
Special Information only for Hospitals, institutions, Transients,
lAC^^/q, lie i,)oM (Addre^<) (cO^ 3-'«-vttjl'X) Cjt
or Recent Residents, and persons dvjng away from home.
r.
1 A /•'//.
/',/! -
Tin: AHovi-. sTA ri;]) pkr^on-ai, p xKTicri. \k>-. aki' vkvk 'j-o rin;
l.J-.sr (>]■• MV KN-<)\Vl,i:i)C,H AM) lil'Ml.l'
Former or Usual Residence
When was disease rontracted, If not af place of death ?
How long at Place of Death ?
Days
fiiif
o; iii:i!i
\<l.Irr>;^
I'LACl-: t)l* lURIAI, OR ri:m(.\-ai.
DATKuf" IM HiAl. or KKMOVAI,
(Ad
t
-5
■ ^' fivery item o»i iriformjition shoultl bs cnrefuily supplied. AGE should be stated EXACTLY. PHYSICIANS should state CAUSr OF DEATH in plain terms, that it may be properly classified. The "Special InforniHtion" V'or pur- sons dyinft away from home should be 6'ven in every instance.
^'^
' ''J
I
■Is 1
ii
!,»
ll
ti
m
i
1 1
' c
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
!l.,:ir.l nf IlinUli I'" No. i >; <?"r=r; •»;-*■; |u«tl' Co
REFER TO BACK OP CERTIFICATE FOR INSTRUCTIONS
JiegLs/e/rd A^o,
lono
d^jyu^^^ji doL/v-u Deputy Heafth Officer
DEPARTMENT OF PUBLIC llEALTH=Cify and County of San Francisco
Certificate of Seatb
X\. S. StnuDarD )
-? ^
^ Qm
PLACE OF DEATH: — County ofOcLA^^ J Axv>a^^:.^^<1/Cc City ofOcLA^ oAxx.
a
>VC^V<t''C^O
X^-XJ
No. 10 II MfU-vA.Ax<x. St.; .^ Dist.;bet. I 1 X^^ and li
r IF DEATH OCCURS AWAY FROM USUAL R E S I D E N C E G I V E FACTS CALLED FOR UNDER "SPECIAL INFORMATION" \ V IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. /
\J
FULL NAME
-^lA
IiAll-: ol- I'.IKIII
\«'. !•;
PERSONAL AND STATISTICAL PARTICULARS
I Coi.ok
a,
iM.itith) A
);■„>
(I):iv)
M.nilh'
\^y\
cLu/^v-'
\\,K
(Vrar)
I hi
MEDICAL CERTIFICATE OF DEATH
DATK <)I- DliATH
,1
(I)av)
CL
(Moiitli) A
T9o\
(Year)
\VFI)n\VI-:i) OK ni\<»Rii.;i)
\\iit> ill social (l<si>.Miali(>ii )
IllKTHl'I. \ri-: ^t.i'i 1,1 I'oimti V
NAM!' (»|' ••Allll.k
lUk IMI'l. \< 1-
*»i- iAini:K
'State (.1 Ciiuntl V
"^1 Mlii;\ N AMI-
Ml M()rin.;u
lukriiiM.An': ()i- M()Tni.;k
(State or Count! V
T90
1 IIf:KI<;i5V CivRTIFV, That I Mllcii<k'd deceased from '^^'-^-^ l^ up'i to Clvupi ll TC)oH
tliat I last saw h ■ ' alive on
;i!i(l that death occurred, on the dati- stated ahove, at '^ >r. The CAISK Oj- 1)!-:aT11 was as follows
'>II^\TI()N Years A/on //is /)ays
Hours
V'^w^-\..*.^:;>.-vw
)'cars
MoHt/is
C.C.^xm'..,.
/^a vs
<K"crrAii()x
AV' ,',//■</ /// S,;ti f'l ,: 11,
a
0^'>v<\.
diratiox (Signed )
iXwQ il i()oH (Address) 1 6 I U ^xv M Um- LLkc
Hours M.D.
Special Information only lor Hospitals, institutions, Transients or Recent Reslilenfs, dnd persons dyinu awdy froni home.
}V„'/ <
1 A ■/////-
Former or Usual Residence
When was disease contracted, If not at place of death ?
flow long at
Place of Death? Oays
"",;.V!V^''"* ^■'"'^■'■i--i> ''nksoNvi, i'\k rhTF, \Rs \\<v. rkii' To 'i-ni- lii-.si Ol.- MY KNo\vi,i:i)c,i.: AM) in: 1,1 1'.!'
' Iiiriiiiiiaiit
Wny>^ (/b. dLu/-.A^
< \.l.ln-.v ( 0 I i
Q.
I'l.ACK OI" lUklALOk ki:Mo\AI IMJl'.kTAKllk
^\d<li
DA li;,i.f Him XI, ,,, ki:Mo\Ai^
■ '^' Kvepy item of Informiition shouhl be CiircV'iilly siipplietl. \V,\', should be stiiteil F.VACTLY. PHYSrCIAINS Khoulti state CAUSE Of- DEATH in phiin terms, tl.nt it msiy be properly cluHfiiV'ied. The "Speciiil Informntion'' for p«r- nons dyini^ nwny from home should be jiiven in every instance.
t .
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It"
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WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
i;,„,i,l ,.f !li :ilHi \ \'<
^<» ••*«*,
i- nf^\' c.)
I)
((fc Fih'f/, LA.aa.1
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
1%
HJO'i
ifruvv^. A-e.vvi. Deputy Health Offif^-r
l{rgi.stcrc<1 J^'o.
i Of)?
DEPARTMENT OF PUBLIC HEALTH==City and County of San Francisco
Ccvtificatc of IDcatb
PLACE OF DEATH: — County of^'cL/^v vl\<x>v c< <i q< City of Cl<X>\' 0A.O^>veA^cc
N(
o. 5 VJ)lA/>v<V^.cl'
(Jil
St.; 1 Dist.;bet. Oacc^C5\' and VO>\Jl>
/ ir DEATH OCCURS AWAY FROM USUAL R E S I D E N C E & I V F FACTS C A H F D FOR U 4d F R "SPECIAL INFORMATION \ V IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTFA^ OF STREFT AND N U M B E f| /
FULL NAME
IVL
xxkkju 'h. Va/>\, Mil.
<X\.\-
si;\
\-
' \ 1 1 < i| i;i K III
\ « . V.
PERSONAL AND STATISTICAL PARTICULARS
\t-nth> k
n
t
r
'■ >S i^ >\< >\,^/'w^
MEDICAL CERTIFICATE OF DEATH
i» \ 11-. < II- i>i; \ in /^
f Month) ,V (Pay)
I III.1':I.I:N I I.K'ni-\-. 'IMiat I Mttciiik-.l .Icrrasr.l fi.-iii
t li.il I l.isf saw li ' ' ali\i' on
(V.'.-it)
U)0\
i\>.i,i:. M\Kkii:n
Wi
[!• ; a -. )i-i
liiK I iii'i.Arj-:
'Siiilf or Co'nili V
lA in i;k
i'.!Ki"ni'i,\(i-; '"' I'xrnr.K
'>t,i|. 1,1 ('(iiintrvl
MAIIU-.N NAM}-;
«»)• Morn I-; K
iiiki ni'LAr}.;
<>1' MOTHI'.R
' ' ir A 1 ION
Kf'-iilci III Snii I
I
Cl'^x,
ami lliat <1< illi occiincil, nil llir .lalt^fafnl ahovc at U '.^0 M. llH' <^^\|■Sl•: Ol- |)i;.\TII wa^ as follows:
Q^
0 AyO.
CoNTKIiU'iOKV
Mouths
> >> s
/^'/rv v> l-fours
/t)
DiR \ri( )\
)j'(;/.c Mouths
(SlG
NED) ^IH. lb. Lt/tivi
/hws
lion
Is
t/vM.X\
.\^<X >V^«L
Lltcq n i<pH (A.i.irrss) H(>li.> )Ai.ll>:.s. ' Vi
,<\ It T<)f
dllAL IN
1
M.D.
SPEd^AL INFORIVJATION "'I'v (or M(is|ii(,iK. Inslilnlinns, rninsienls, or Recent Rcsidrnts, and prrsoiis d\iiii| ,iw,i\ linm homr.
M..,,il,s
lK-\'
fornipr or Usiidl Residence
When was disease ronfrarled, If nof at pjai e of death ?
How lon(| at flaie ol Death.'
Days
I 11 1 \ HoVl.; s r \|-);i) IM-' kso\ \ I. }• \ R r |t I ! Nf- \!'! ri<' I- To Till' lll'.^T Ol- MS KN(t\VM-;i)<,|.: \\l. It, 1,1! I
InfMMiKiiit
.^LO<y>r^
^-
I'l, ACI-; ()!■ r.iKiAr, ok r i,\T( >\ \ i,
i
II, \l I', I >!■ lil K
Wv
IQOS
! N I » 1 : R T A K i-: R
^\(!.lt. -s
I> \ ri: m! Hi i-i \i ,,i R i;M( )\- \[,
r
•^* ^- Hvery item o»* inH'oi'nmt inn Hhoiihl be cnret'iilly Riippriecl. AGP; sho-.ild be stntcil l.\ AC TI.Y. PHYSICIANS Rhoiild
Htiitc CMISr or ni.ATM in |>lnin terms, that It mjiy be properly clnHHili'ietl. The "Speclnl Inltornmtion'" Inr par- sons (Ijin^ iivvny I'roin home sliould be 6'^^" '" every instance.
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WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
»>r
)l,,:iT.l ..f nr;i;t1i !■■ V" '- t-.-ix_^>i: Itftl" (V
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
\/)afr F//('f/, LU^qu^vCt \% /^V^^H
llcgLslcred JS'^o,
ior>8
Deputy Health Oflflcf r
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of Sheath
( n. S, 5tnn^arc> )
S! (^ J?
(^
PLACE OF DEATH: — County ovJfXrr^ J/ucx. \^-ev-(^c(. City of CJ/tX/>v. J /v_<x/N^tv<i,-ac
No. 5 'vh
.'iXAw'^vOu'vcC'
St.;
\
Dist.;bet. Jo^v^Cr\.
and W^AJl^'5
(ir Dr«TH OCCURS AWAY FROM USUAL RESIDENCE GIVE FACTS CALLED FOR U nA) E R "SPECIAL INFORMATiAn' \ IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAli]oF STREET AND N U M B E W. )
/-Of ^
)
FULL NAME LK JLd c [. M WoJx^^Jb^^ V<Xo^
si;x
1» \ . 1. < I! 1; I kill
\' .1-;
PERSONAL AND STATISTICAL PARTICULARS
ft t^oiok
■^xX'^
ll.
i^^^\^L
h
^
I —
MEDICAL CERTIFICATE OF DEATH
DATl-: ()!• Dl.AlU
\Xj^\
MMiilhl K
v,,/. l^./nH
) ^i**.^ .
: i.i: MAkk n;i)
WIImWHI) OK I)IV()K>):i)
^' • ■'■ ill voci.'i' \ -'-n.il I'.ii I
Iilk IHJM.ACK 'State or Coimtrv^
1 Alllllk
lUkriii'i.ArK '>i- i-\rin-;k
"lit' 'If C'i.UIltl\-
MAinMX NAMl- <'!• M()THl-;k
liik riirLAci-:
OF MoTinCk
'Stat'- or Tduntrv
ir Alli IN
iH
^MoiUli) ,J ^Day) (War)
1 III-;RI-:RV CI;RT1I-V, Thai I attcinUd .UvcascMl fn.m
LLc^o n lonH to . LLlvcl n too
UwA^^ 1 . up
and that lUalh orrurrcd, on the (hiU- stated alxiVL- at l^ ^i M. The C.\rSl<: C)I«' I)i:.\TII was as follows:
til at I hist saw h -^ '>x alive on
DIRATK^N ]'cars
CONTRIIUTORV
Moulhs /)a\s \X//ours
/\.0 ^ ■ C<L
I ) r !>: .\ T I < ) .\ ) V.7 rs JA V////.V /)avs I 'J. Hours
(SIGNED) \l/\ \ CtcJ'VtM-«>uHAj M.D.
LL^v^a ri T(,o'i (Adduss) HOb Cj-v»JXt>v> ^:i
a
)t
SPEciAL Information only for Hospifdis, institutions, Transients, or ReienI Residents, .ind persons (l)iny away from fiome.
/
in; \v )\'}-: si' \ I) II )'i-- kx )\ \i. i' \kihm- i. \ks ak i-; tr vv. to rii v. lii'.sp oi- >i\- K N. iw ij;iM , 1-. \M> i!i:i,ii;i-'
Former or Usual Residence
When Has disease contracted. If not at place of deattj ?
liow long at Place of Deatli ?
. Days
ri.ACi; ()!•' lukiAi, ok ki;mo\\i.
DATi:..'" Hi iMAl, or ki;M(»\-Al,
) y
IQOH
N I ) 1 : k !• A K V. k >V,*JLa^ V>? *^ ^- O'tLc
CLA.\J
(Address 3)0 5" VnXfr^-vtcyA.. LIa>jL .
N. B. livery item olt i n form :it ion should be cnreitiilly .supplied. AGB .should be stated HXACTLY. PHYSICIANS should
Htntc CAllSf; OP DEATH in pljiin terms, thnt it mj>y lie properly classified. The "Specinl Information" for per- sons dyin^ away Prom home should be given in every instance.
■■\\ •I
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I!. .;il.
Ilr.iUh I- Vo I- ■?
f^r^'\-
USi. V Vn
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
lir^istered J\^o,
10G9
Date Filed. CLa^o^vxiI) \\ 10(n
^rvc^^ XiLxv^ Deputy Health Officer
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of Beatb
f 11. 5. Stan Da rO )
of ^ ^ ^
PLACE OF DEATH: — County of^/CLA\^ 0 ^UX/T\.c>ui.cc City of vJcl/>v OAXX/yve^^XL^o
No.
J?
f IF DtATH OCCURS AWAY TROM USUAL R E S I D E N C E G I V E FACTS CALLED FOR UNDER "SPECIAL INFORMATION"
vv.<: CjKX'VcaJUA.c^St^^x.- Dist.;bet
land
IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE rTS NAME INSTEAD OF STREET AND NUfMIBER.
FULL NAME
)
PERSONAL AND STATISTICAL PARTICULARS •-l-X (^ A j COI.ok
i'\ n; ( n iwK rn -^ a
M
.1 A. >/,'//
%
I Ti-iir)
/',/!>
MEDICAL CERTIFICATE OF DEATH
DATH K)\- l)i;.\TH
(Month)
a)ay) (Year)
^i\' i.i; M\ki<n-:i). \\ii»< )\vi-:i) OK in\()K('i:n
' Wi iti in -ix-inl •!» s-'v it;it i'Mi )
HIR rill'l. \kM': 'Stati or i.'i iiintr\'
ia'ih):r
lUR rniM,ACK
' state oi OomitT vt
MMDI'.N NAMl- OI MoTlHiK
I'.IKIHl'I. Acr:
OI' M«trin-;R
fStat'- oi Cuiintrvl
oiATl'A'i'n )N
I HI'RiaJV CIvRTlFV, That I attcii.lcl .Icccased from
Laaa^o 190 1 " to LU-<v/Q^.n up \
tliat I last saw li -^^^ alive on LXa.a.x^ '"1 i^o M
aii.l that (Katli occurred, on the date stated a])ove, at I 3..0 V M. The CAlSiv ()!■ l)i:.\TH was as follows:
^
'S\
XA
'^'^WLry>,AJ\A>^iA.AryK
0^'W<i.
Rfsidrd in Sav i'lan. i '■,> \o ! - .m v
DIRAI'lON ]'i'ars Moujh!; Pays //ours
CONTkllU'TORV 9.<^>-oJLc
at ()ox<x^t
DIRA'I'IOX )\'ars .}roNt/i.s Pays Hours
(Signed ) vjX^)\jI/^^./qx Ml. \X'<x>v^ MD
J? ■ '
\\ rqoH (Ad.lrc-^s) toOb QJA^fctx\. 6t)
Special information only for Hospitals, Institutions, Transients, or Recent Residents, and persons dyiny away from home.
Former or ^-, I'sual Residence ->0b
M,.>,th<
na\:-
'\'\\v. \U()\-i.: s'l" \ri'. I) i'i<:ks( »\.\i. r \rii rr lars a r i'. I'Kri-; r( » rii v.
nKST OI- MV KNo\\I,i:i)C, H AM) I'.l , 1, 1 1! 1-
'i'>ro;,„,u,t VlfUvo 0. vi\ Qi\jUx^<:^a.-y.,.
Uddnss 3>C) b
0^^<X..\^\J\JlXj
jLl. How long at
CTL Place ol Death? I 'Y^ -ftjys
; disease contracted, 'I i 0
place of death ? \XJy\M/w^b^^''y>o
ri,AC};oi' lURiAi, OR ri-;mo\ai.
(jIdCtIu Vv'fe-^^
rNDl'KlAKKK
I)\'n-;o!' I'.nuAi. or Ki:.Mo\AI,
(Address
Tt~i M)Vva^v(„tr-i-o ai
^- '*• Kvery ittm olt information should bj .iircfully supplied. Ad'B should be stated F'.XAC TLY. PHYSICIAINS should
state CAUSE OF DliATH in plain terms, that it mny l>e properly clussiltMed. The "Special Information" for per- sons dyin^ away from home should be 4iven in every instance.
i
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!:- .:!!
1 ,,f Ilc.ilth 1" No. It.
•t^'-ar^; iiS:!' C
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
/)((/(' Filed ,
i
\%
IfJO'i
BegLsfet'od Xo,
^ OTO
Deputy Health OffT-f^r
DEPARTMENT OF PUBLIC HEALTH-City and County of San Francisco
Certificate of Beatb
( 11. 5. Stnn^ar^ ) PLACE OF DEATH: — County ofOCL^O; vLn^/O/TV/e^ULCCCity ofO.<X/vu 0 AxX/W'Ouiyeo
Ox/xti'
No. 5 0b Ox/xUt^' St.; H Dist.; bet. MU ^J^vOla^ and VyUKXXAWUXm.' )
(IF DEATH OCCURS AWAY FROM USUAL RESIDENCE GIVE FACTS CALLED FOR U rA> E R "SPECIAL I N FO R M ATI O N ■ • N IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAbJ OF STREET AND NUMBER. /
FULL NAME U^JL^cl^- Wvv^^JuxaaXkx;
PERSONAL AND STATISTICAL PARTICULARS
si:\
UcJlx
i"< »i,i)k
kllxjt.
i
^
• 'I lilKTIl
\JJ^K
Moiithi h
lb
\'.i-:
t V< .11 »
0
M \K \< ii: i>
\\ ID! )\\ 1,1) (»U lil\( (R'KI) iWiitfiii '■iM-i.il (It -i^MiMlioii )
Ml Ml ■ \
NAMI- (H !• ATII J- R
I!IKIII1M,.\>1-;
<)i' i-\tiii:k
"^!:it'- .11- roimtivl
<»i M(»thi:k
liiu riii'i.An.:
(Stiiti' or i'(»iiiili \ I
" - 1 I'A rioN
J? ^ (J
\ \\
MEDICAL CERTIFICATE OF DEATH
DATi-: oi- i)i;ath r\
(Muiitli) K (Day) (Yt-ar)
I 1II;RI;I{V CI;RTII-V, Tli;it I altended deceased from
^ (1
lli;it I last saw li l .. alive dm LA.Aa,<V 15^
and thai dealli occurred, on the <late stated above, at V.'
M. The CAISI'; OI- DIIATIF was as folic nvs :
Tcpi
DIRA'IION
)'fV7/-.V
Mouths
/hivs
Jlon
rs
(ONTRIin'TOkV
1)1" RATION
^Signed )
)\-(fr.<;
JA '////' s-
d . Uj . 0 cy^KLoJLxj
I^ays
/fours
M.D.
iXcCQ IS rpo'l ( A dd r. 'ss ) '^O'S UjAvcv/O^vxt ;.Vi SPECIAL INFORMATION "nH l')r Hospifdis, rnsfitutions, Irdnsienls,
or Retrnl Residents, and persons dyinrj dway from home.
rJIl' AUOVK STAI'l" I) I'I'KSox \l, I'\K 1*1(11. \k-> \K 1 HK.ST <il" MY K\< »\\ !,I l)i,i; \M) HI';!,:)
K II-: To vwv.
' Inf.,: iiiMiil
' Vl.lrc.v. 5" 0 b ^ Cs XJi\> ot
former or UsudI Residence
When was disease rontrd( ted, II not at plare of death ?
How jonq at PIrii e of Oeatli ?
Days
I'LACi: <»!• HIRIAI, ok RI'.MkNM,
DAIVK'-: i;- II \i ,,i k ):.M< »\-..\i.
I90H
^'. B. Hvery item oil* Jnformj.tJon should »>e csirefully Kuppliecl. ACIK should be stated LX4CTLY. PHYSICIANS Hhoiild
state CAllSr or DI;ATH \n pljiin teritiH, thnt it muy be properly clusMified. The *'Specittl Inforniution" for p«r- R^n* d>m(> fiwny from home should be iltiven in every inHtnnce.
4
'*.i
P'
' J
■I;
' i!
I!'
»ymm
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
P
'f
i
);. .;l!'
,f II. :illll - 1' V(
f^m ''''•'"'^.
■art.y^i- ]>f;^i> c<>
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
I)a/r riJrd, [Xa^<yj<J^ \\ 290\
Jfrd/.sfrred A^o.
1 0? 1
u Deputy Health Officer
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Ccvtificate af 2)catb
( XX. S. StanC>arC> ) PLACE OF DEATH: — County of U /CUcn^x^-v^OcJ^^AXi) City of ^ <XAi/\^<:x./-yy^JUy-dio
No. LCrVAy>\Lu, (J^>Ci-<U^xLcu.
^ 1
St.;
Dist.; bet.
and
/ IF OrATH OCCURS AW*Y FROM USUAL RESIDENCE give facts called for UNDER "special INFORMATION" \ V if DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. /
FULL NAME
si:\
PERSONAL AND STATISTICAL PARTICULARS
i> \ii-; < ii I'.iK I'll
X.'^OxJL
MEDICAL CERTIFICATE OF DEATH
DA ri-: ()!• Dl'.ATH
Month) A
C
V.)
I I
I go
(Year)
NUknthi
XX
1
<I»:iv
Mn'llfl^
;n )
n,!\^
^i"-«.i,r M\ki<ii;i)
u iix »\\ HI) i>K i»i\'<>Kri:n
' Wt iff ill wi„ i-,1 ,1, ^!;Mi;iti<iIl)
I!IR lllll. \r\-\ (St.M' • ' ■iiinli V
Ia^vaAj^
nKiiii'i, \c}-; X
>i- M<»Tm-:K I)
'Moiittil A (Day*
1 III'RI-r.V CI:RTII«'V, That I atU-ii.lr.l (ItTLascd from
to
1 90
lliat I last saw Ii ^"^ alive on
T()0
190
and that deatli oi^-urred, 011 the date stated ahove, at "" •"- M. The CAlSlv ()!• Dl-iATIl was as follows:
•I if
V <X/yvdL
NAMl-: ()!
i"A riii:K
I'.IK rill'l, At M <>1' lATin'K
•^t.iti- nr <'(iiinti V '
MAIDl.N NAM! f>I- Morniik
1)1 RATION )<ars
CONTRIIU'TORV
A.-A^>VX
Moil //is
F^ays
/louts
DIRATIOX
)\i1)-S
Moiilhs
Days
^K >\^0.
' ii'AriMN S)
h'/'idfif ill Siiii /'i iiin I 'f'o OS c\ )'rii i ^
dL
M., lllll'
(Signed) mttl/yx; ck. UOJ^ujtt
n I 5 fo'T
LLv.V/Q lb T(,o H (Address) (j/O.OvXX/^'vJywto \_,ckX)
Hours M.D.
SPECtJAL INFORMATION only lor Hospitals, Instilutions, Transients, or Recent Residents, and persons dying .iway from fiome.
rill \i!o\i: s r \ ii- 1. pi- kson - -, r •, k ricn. \ks ari, ri< r i'. i' » 111 1
lil-.sToI MV KNdW I.I.DCK AM) l!KMi:i-
niif.i; ni-iiit
V KNdW I.I.DCK AM) IIKMi:!-
\.Mnss \ \\ \Jx>V/Qu\XX^ VA\>-L
Former or I'sual Residence
Wfirn was disease contracted, If not at place of death ?
Hdvv long at Place of Death ?
. Days
HI-' lAi. Ok k i:m( i\a I,
i»Air,..; Ill KiAi. (,i i<r:M()\Ai,
190H
I M
) I •: K T A K i- kM I I 0 <xxiAx/vo \| iV mViLaviu ^ 0\Jli/>\'
i^' I*. livery item <>V* inVormiit ion Hhotild bj cJire»iiM.v siippliecl. A'JH kJv)iiI(I be ntnted HXACTLY. PHYSICIANS Hhoiild
state CAUSI: OP DIIATH in pljiin terms, that it miiy be prf>pcrly classified. The "Special Information" for per- sons dyin^ away from home should be ftiven in every inHtnnce.
t
A' 1
I
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^^,
»''i
«i(i
II
J
f
I
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WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
r.oanlof Hfiilth I-' No. i>
,t?!^J!*v
i; nfkV ('
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
Dfffc I'^iJcd, LL<wA^Q,>uv.<£t 1*^
(X./()-AwA.-A^O
l!)0\ Deputy Health Officer
Beg i tit c red J\''o.
< ^72
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of Beatb
4 %
PLACE OF DEATH: — County ofOo^/Vu 0 ^Oy^vo^Ci;