;-

> /

i . )

t

I- \

*

f

\ ,

> '

V I

I r

, .'

( .

\

' \ /

I '.

|l

I '

I '

„>

A-

% -

\

/

/

^ ■ V _

■^ ^CAL 2-38C 1 ^

1 KOLL NO

j

1
J

1

i

-

1

4

11

\

-^^-=-' — ^^ - - - - - --..->.-- J .

■

■

=

■ I

s-

LOCALITY OF

RECORD S

SAN FRANCISCO
COUNTY

S AN FRANCISCO
CALIFORNIA

HEALTH DEPT

M I CROP I LMED

FOR

THE GENEALOGICAL SOCIETY

OF SALT LAKE
C A L I FORM I A

C I TY

UTAH

j^

DATE

APRIL

1

1975

PH OTOGRAP HER

CAMERA

NO ^'=;

MAX JOHNSON

RED J

I

RECORD

CERTIFICATES

VOLUME 2031

Y EAR

1904

)U

» I

♦ ..

X

'•)-.*Aj:v>^v'-,

P^i

EGIN

4
I

I

f

• •

I

..^•••••'

.^. » " • "

^ FEB8 i«0>^ ^

i»l.^f..waA. pew*' -•-•'*'•

fl/ P.

iiber H'

El)M()NI)(i()l)(^!lArX,

) I, OUDtrt

By-"

DEPury.

I

i

WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD

.,1 II^;.!lh I- N.^. !. •ft.'^^^^tr 155:1' Co

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

Dale Filed ,

hj \

100\

Be mistered J\^o,

3a3i

1

vcoo

Deputy Health Officer

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco

No. IHS

Certificate of IDeatb

{ *a. S. 5tan^ar^ )
PLACE OF DEATH: — County ofO/CLY^ J-^^O, ixo.^ci Qty ofCj-O-AT^ 0/vxx.-\-^C.^<i. Cc

/ ir DtATH OCCURS ^WAV FROM USUAL R E S I D E N C E G I V E FACTS CAILED F
V IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NA_M E I

FULL NAME

St.; ^ Dist.; bet. G A^^ vcJ l.Ui and ' I

-OR UNDER "SPECII^L INFORMATION ■ \
NSTEAD OF STREET iAND NUMBER. /

^ n } u

A

li A I ], ^ U lilK III

PERSONAL AND STATISTICAL PARTICULARS

Cf^

U. mil

11

(D.'iv^

/?

A' . I-

/',M

•^iM ,!,i- M \u\< n:i>

u'l In t\\ ]■ I » » iK It ;\< ii-T i: t)

iiiK rnri. st^-"

(Stat. I.; '■ .mill

A 111 Ik y I

p.iK I'll I'l.ArK
<»i I \ rin-k

a. , "

\a

M MI»KN N \M 1
m- Moilll-.K -^

cLttrwcfuX'

JUX

Jn

Jus-A.

I'.iR iiiri, \t*i:
t>i %T<»riii.K

-•• 1 1 .11 t". Ill Hi I \'

I M I I TA 1 ION .

(v..

^'

);-,i

Ar,,,'//'

/hi

Tin: M'.n\ I' ^ r ATi:n fi-KsoN m, rxKriiti, \ks ah )•; tkik m rm-
in%sTi>i 'IN KN<iui,!,i)",i'; AM) i;i'i,n,i-

MEDICAL CERTIFICATE OF DEATH

DA Tl.; nl- DMA'CH J)

U-t^UZt. 1^ /Qn\

(Mofithi 'I>;iv) (N"f,ii)

1 HlvRIUJV CIvRTll'V, That I alk-iuU-.l .U-iH-ascd from
CLl^q iS iqo , to a-dAl XH upH

4 f

> I ' f

Up

tlial I last saw li '. - alive on

and that dt-ath orciirrcMl, on tlicdalA- --t.iti'il alnivi', a

M. Tlu- C.VrSi: <)1- I)i;.\TII was as folh.ws:

Dik \ rioN

) 1 </; >

CoNTkllU'lN >RN"

Mouths

Diivs Hours

S ...i^'_'^ I

3-1^

»...,., }'(t/rs Qt Jf(>>///is

NED)C,3). ^^^xtU^
,o l f AiMrc-ss) Ss'X'ivJ

1)1 RAT ION
fSlG

/hivs

Hours
M.D.

0^'.A>-»i^U.; ^t

Special information «nlv for Hospitals, Institutions, Transients,
or Re»ent Residents, and persons dsinq awdy from home.

Former or
Usual Residence

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

HoH long at
Place of DeatI) ?

Oa\s

'i,Aci': oi- nrKiAi. or kkmdvai

DATK (.1 Hi I'i \i .)! KKMOVAl,

I N I ) J : K T A K !•; K VJ ^\XX>\} ^U. LL A '. ^

T90'*

IN. B. Hvery Item of inf.,rm,tion should b.- cnfcfully Hupp!'. mI. AHr. hHouIcI be stated HWCTLY. PHYSICIANS Hhould

Htate CAlJSli OF DLA TH In plain tcrmn, that It may be properly classified. The "Sputial Information" for p«P-
«nns dyinft away from home should be d;iven in every Instance.

WRITE PLAINLY WITH UNFADING INK

;|. :,Mh

^i, l!^;:!' Co

THIS IS A PERMANENT RECORD

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

Dufr' Fi/rfi, y^tc^v I

IfWi

Bniisfered J\^o.

203^

o'i

V^ Deputy Health Officer

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco

N

Certificate of IDeath

( 11. 5. StanDarD )
PLACE OF DEATH: — County ofHo.^ si JU>jy\/:AA.C^ City of H Om; ^ KOjYs^^^l
o Ul5 LlaA.1 St.; X Dist.;bet. ^ I tO-^tr^ and ^ <X^^

/ .F DtATH 0CCURS AWAY FROM USUAL RESIDENCE GIVE FACTS CALLED FOR UNDER "SPECIAL INFORMATION" \ (^
V IF DEAtJh occurred in a hospital OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / J

FULL NAME

lid

a^

PERSONAL AND STATISTICAL PARTICULARS

- I , X

(.<

UA 1 1-: < M lUKTIl A ^

\ < }•:

bl

M.uit

)

Davi

0s. M.,>i!li^ C\. J^

/>,!'.

U i ! M i\\ 11 1 t >R 1 'IX'i )Ri- 1 I)

\\i !!( i ti *' irial lit -i^'li.il ion)

^!.,i.. I li I '• 111 nt! \

1 A 111 l.R

luk rHi'iAiK
ni- I \iiii:r

^ t I t ■ • •'. t " \ ! 1 1 t * ■>

M \iiu;n n ami;
()]■ .Mt»riii;K

lUR rmM.AC!-:
(ii M(rriii''.R

i ^ia!i , u (.'ounlry

d

e 1
In

Aw VCU J -t\AXV)

y^^

/\'r:-;-ff'' •" Sil>r /

11 H-. AH')\'l", STA TI-: D PKR-^nXAI. I'A R Tl i " r 1 . A R S AR l*. I" K T l-l T* »

iu>riii MN' RNnwi.i.Dt'. J-; ANi> i'.i;i,ii;i

III 1-;

!liifiii inaist

lis [AjXxl 6fc

^V>Xs

X'l.h I'-s

MEDICAL CERTIFICATE OF DEATH

DATK Ol- Dl.ATH I'

(M.mtli)

(Dav)

I go

(Vt-ar)

I III'IRIU'.V C 1:RTI1'\', riial^I attoiukMl (Ucrascd fnun

axkfc

Q

1 1 1 '^ , 1 nai 1 aiU'iuuMi ii

that T la'^t ^a\v h

190
alive <Mi

JJLi ..\j

it)0 H

in<l that diath iHHurred, on t he ilatt. ^ta!t.<l almxr. at llob

AISI-; ORDi: A

^ • M. Thr CAISI'! OU, DI.A III \vt- a- tuUows:

K^^VX^fr^ VCLA V 1

Dl'R ATION \ Years ^ Mouths
CONTkllU'TORV

Day

Hon

/ s

DTK AT ION
(SIGNED)

^

)'t'ars ^ J/oi///is /^avs Hours

*^K. d^i M.D.

Special Information «nl> for Hospitals, Institufions, Transients,
or Recent Residents, and persons d^ini a^dv from home.

Former or
Usual Residence

Wlien was disease fontrarted.
If not at plareof deatfi ?

How lonq at
Place of Deatti ?

Ddvs

l'I,ACI'; 01* lURlM, <)R K!.Mii\\I,

m €.Lv>^t

>\rU.'i; I'a HiAi, <M Rl'MOXM,

I NDI R lAK i;K

(Address

W^lX I TQO'

IS. B. F.very item of infopmiition should bsr carefully supplied. AGB should ha stnted RX4CTLY. PHYSICIAiNS should

state CAUSI: Ol' DLATH in plain terms, thnt it may be properly clussified. The "Special Information" for p«ir-
Rons dyin^ owny from home should he given in every instance.

'?SjS

WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

'111 1 Vo :^ ti-'^>S.i: lUtP C,

l)((h' nfefl.MizkA.-

n)(r

JRo^istcred .A^o.

0

L

Deputy Health Officer

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco

Certificate of IDeatb

( 11. S. StanDarD )

PLACE OF DEATH: — County of

\

%

CXJ.

City of

e^\)

OJ

No.

St.;

Dist.; bet.

and

/ IF nrATH OCCURS AWAV FROM USUAL R E S I D E N C E G I V r FACTS CALLED FOR UNDER SPEC
i IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREE

F + n '^

lAL INFORMATION" ^
T AND NUMBER. /

FULL NAME

SKX

PERSONAL AND STATISTICAL PARTICULARS

I'l il,i >K

\)\oL

\

DAI'i: I >1- iilKI'll

\< .!•:

I7i<

1%

!l)av)

)■(■(;» t

^

M'liHi

X

/

VI

ar

I hi 1

>^I\< 1 I' MA K K II- n

wi I )i iw i- n ( iK I) :\'( )i',t' 1' I)

^ S\'i it: 1 n -SK i.il '1< -li' naliiiil'

luK rm'i. \oi-'.

>t:ili ii! I "i iiml ! \

NAM J <M
} \in IK

TUK riiri, \t'i-:
oi I' \ rii I'k

\! XIDIN XAMJ-:

(•1 MornHR

lUR rniM.An-;

(Ii Mu'nil'.K

(UHT I'A liOX

<f\^^'XKOj

A'

V,;;,' /■; ii Ihf.u'd

IV (II 5

yr,>iif//s

ih.

Tin- M'.ox'i'. STA'i'i':n i'I'-r^onai, r NKfirn.AKs ar}-: ikri-:
in;s 1' ni- Mv K.N'< •\vi,i;i)(',i<: and in;i,!i:K

i"< I I'll 1'

f liifDinirmt

^ (5? (1

'YY^^XLK.^xXj

fA(1.1rf«<«4

J AJtn^^A.^'W WO-X

MEDICAL CERTIFICATE OF DEATH

I) ATI', (M- Dl'ATH J?

Ox^aI:' 'h^ I go'

(Moirth) 'I)av> (V<-:ir)

I IIERlUiV Cl'iRTlF'V, Tlial I aU(.'iiiK<l 'lt.Hias(«l from

— — — ————up -to — ""190 "

that I last saw h - — alive nti — — —— up

and that ikalh ncnirred, on tlie <lati- stated almvr, at
M. Tlu- CAISI'Ol" DI'.ATll was a^ follows:

IH" RAT ION }V,/;s-

CONTRIIU'TORV

I )r RATION ^ Ytars

Montin

na\

Hours

.^fonths

Pav

(SIGNED)

'\

f-f

/t.

.i

«i^

Hours
M.D.

19.

oH (

Address) OXAnA?vO--^^ \jOM

Special INFORVIATION f>nly for Hospitals, Institutions, Transients,
or Recent Residents, and persons dyini| away from home.

Former or
Usual Residence

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

flow lonq at
Place of Death

Oavs

lil.ACH (»1' lUKIAI, OK KI'.MoVAI

in "

DAXI". of I'.IHIA

I, 01 K1-:N!( i\ A1

rSDKKTAKl-K Uk/O^ V US An^Ui-y^^^ .

T90H

(Addresf

rS. B. Rvery item of mformntion should be cnre?ully supplied. AGB should be stated KX4CTLY. PHYSICIANS should

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

WRITE PLAINLY WITH UNFADING INK —

;ii-. I

No :- t'-r^arS^: liS: 1' I

IXile Filed , U^Clt^r^MJ

K^ \

10 a

THIS IS A PERMANENT RECORD

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

2034

Broi,sfef'cd J\^o.

DEPART

puty Health Officer

DEATH: — County of^^a

Lie HEALTH=City and County of San Francisco

Certificate of IDeatb

( 11. 5. StanDarC> )

'Tu ' J V

City of U CX>^ J,\.CL vxxn.

No. ^ ^ X^-^

4-

St.;

Dist.; bet.

and

FULL NAME

.kXxxaJs

\JLcL

v^roKcet

■rt

4

■ 1. X

PERSONAL AND STATISTICAL PARTICULARS

fl.

i»A 11. «>i ink ill

\ " . !•;

! 1

Muiithi

D.iv)

5 ■--.,■

n

14

an

Jh!\

<!\<,1 }■' MAR ]<!)■'. I)

W\ \n >\\Ki» < >K I) ;\i i!--! i; I)

I W- il! in ■•- ' U -iL- iiatmn )

Hli

■St.

,^

1

L

MEDICAL CERTIFICATE OF DEATH

DATK <»i Dl.A'lH 0

(Moiitli)

(Vcar)

. Day!

I Ill':Ri:iiV CI'.RTII'^V, Thiit r altt. ii-U-il .krr.i^cil fniiii

190 to — — — jfp

that T last saw h — alive on icp ^

and that (k-atll iHHurreil, dii the date -taU-.l ahove. a*; -
~^~ M. The CATSI-; OI' DI-.A'PIl wi- .i- follows:

^jj^^,.^^

N V \I 1 < 1!
I A!'1!1;k

I'.iKfii I'l, An-:

()!•■ 1 Alili: K
' Stat I- 'ir I'tiluitlN

MMDKN NAMl
Ol" MuTIUtR

UTR'niPLAeK

i>I NKiTlll'lK
I Slati ..I t'oiuUl

hCLc^r

lo, a.^L

r

^

.\f,i,ll/lS

Ptn.

Tin" \!'a>vi*. sr\'n:i> phrsonai, i-akiutlaks ar>-: TRii': r< > rm

Hl-.sr ni- MV KNoWl.l I)!',)-; AND lUCUllCF

(It

Adilrfs*

%

H^^ IX ibcrWv><vN^ dt

i

^l.v.OyVU.. ■. -

DT RAT ION )V<//-.s- Moiiihs

CONTR lI'd'ToRV

Pay

//.

'//; \

DTRATION

)V«;-

Pars

(SIGNED ).L^&A\-^V . /xJb LO- iiJUx>XcL
noU-h'V^ j^oH (Ad.lress) Wurv\.iA,^ ^. ^ >

M.D.

cuycfc ^0

SPECIAL INFORMATION only fur Hospitals, InslittMi^iis, Transients,
or Recent Residents, and persons dvinj anav from home.

Former or nn r 'i F, ' Hov» lonq at , »

Usual Residence M^5 la Jt'&AA.vaK ' piare of Death? C <^ (\.:.. D»vs

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

PI.ACK Ol" HTRIAI. OK Rl'.MdVAl,

I)A'n:..t" Hrui.xi. <»r RHMOVAI,
U'tLfc 3^ 190H

(Address IQl'?^ "^i C^Ldjl^^ D^Ojtx LLv^.

IS. B. Rvery Item of information should he 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 p«r-
nf>ns dyinft away from home should be £iven In every instance.

|s)RM 31

^n

ss.

m

m

1-4

M

15 O

I M

K
H

Sq
O

za

o

I— I

Eh
O

H
OQ

o
o

>

lU
CO

o:

STATE OF CALIFORNIA Local Registered No. .<'.yv.^.

3D(^p^rtlnetlt of ^lublic Henltfi

VITAL STATISTICS

Af flDAVITS rOR CORRECTION Or A RECORD

City or
Town of.

W^»

.. of.

^ r-

ll'V

22 ' ' -thj^ ^en

(Name of Affiant)
Calituriiia, bein^ tirst duly sworn, deposes and says that she is

-^ *-

J-

A.l.:rt.i<i

Coiint\ ot

Julius ...Fxad Brockwoldt " [X^f^l '"

(If relate 1. spi ■ • • It. r-— 'f frynd or gUipr>vIs<'. so &['i^ql^

the City I'i

on the.

. .V*j*.

;iN stated in a rertifieate of

wi

th flu I.ucaj Kegi-tiar loi the City of .

. f September 19 04

day or a ^^

I filed In- Porter . anjd :l;i..t.:.

/ death ) ■ (Givu name of I'hysitian or Midwife for Birth — Undertaker for Death*)

County of ■ ■ " N FF A N.GlHCiX California

r-irtifl^j

19.

04

on the ^.s. w day of

That the following tarts set forth in said certihratc are not correctly stated therein, to wit;

Pull name of decadent

w,.

:f father

li, • ;,tHai>' upon her own knowledge ^tate^ the true facts to be, and the changes necessary to make the record correct

T^nHl name of decedent- Julius .Fr^HiBockwoMt

Name of father- Jacob H. Eocfewoidt __

are. as follows;

T

y
u

h.

U.

O

( Affiant) ^^

( Address)^.C.4:...lr.¥ InjL?: ..S t

Subscribed and sworn to before me t\ih...^..y^^^ day of

»-• I

u

SiAir or C M.n oRS! \
CfMintv of

N.it.nv Public in and for the Coun^4flf.*^....ft ..'..>....SS%* <Wjalifornu

^ZZao

( .Name of Alll.iiii )

he

s Aiiait.'.-

Calif.. rnla. being first duly sworn, depos.s and says_that^ has kriowledgey,^ the facts hereinbefore alleged and that the
said tacts as stated therein are true.

(AlTiant)

(Addres|). ^.x2. C^G
Subscribed and swuii, to before me this.v^.../. day of^^^

I , . ^ ...l- , 1 93 j[;^,,rv Public in and for the County of Sr^te of California

•F.,r ,,,11,. tin,; ,,i ;i inuiia^f rntincsifp. in raic lii'itnnrrs where n.-.',.^<ai y, llic word
■justiri-," It... miy i... i,n..; J spclully t'.v way of suhstitullon througlmut this blank.

•were married." "marriage," and "minister." "priest." "judge" or

! : I:

Two

INSTRUCTIONS

iTr

inncipal artida\ir

.( ,; H'

<H1J\- Ji

niii a,

wi^ write plainly u,;,.- black ink.'^'' '''" '"' '''' ^'''"'^ '■■-'■'" M.nat

1^ ith

•*• N'o clmnu'. can .e made in a cert,T,,„. ,

maU changes that will l.-avc In,,,,,, ..,,, /^' ^; '"'"'-'•''■ ''"■ ■'■"c • > :^ :r. ■ ,K, :,, ,,,

' ]( rU ■ ■ , in,., ,n the ccrtilicat,. '

' ■ It the onjrinal certfficite to be

• '-al Reg.trar. on the <;„h of each month '■"^■""""'- ' 'n«inal cer.i.ica,,- .

ppr

ilea:-

Othe-

f'j acre-

.I'd \vi:;
affidavit
"rwardcc

WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD

REFEH TO BACK OF CERTIFICATE FOR INSTRUCTIONS

/)((

tv F}h'il}ui&A>\Kj

U)0\

Fie^htcred >N*o,

'^\^*.

i /

Ow^VA^-

Deputy Health Officer

DEPARTMENT OF PUBLIC HEALTlI=City and County of San Francisco

PLACE OF DEATH:

n

No. I'XSc.

Certificate of Beatb

( 11. S. Stan^al•^ )
County ofCjCO^Yx; J /vcL-^^-e.^.^t^City of '^ -^^^"^ -J Axx^-^cv.^c^

St.; 3. Dist.; bet. ^ J^sA^ and A.<XX.Ka_,-> ^ )

/ IF DEATH OCCURS AWAY FROM USUAL R E S I D E N C E G I V E FACTS CALLED FOR U Ad E R "SPECIAL I N FO R M AT I O N ' ' \
V. IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIWE ITS NAME INSTEA* OF STREET AND NUMBER. J

FULL NAME >0^^^J^

H C

PERSONAL AND STATISTICAL PARTICULARS

■IS A (.Ol.OR

I

j:x)

^l,+

- TV<_^^,

n \ ii: < »i I'.iK Til

f^

M..nth>

\i

n

I>av

Moilln

M%

'X'^:

\ car

/>,

-. I \ ( 1 1 • M \ !< !< ! K I )

\\ \ I M I A I-. I » < iK 1 >;\i III ! I)

I Wi !!( Ill >-. H 1.1 1 (li -11' !ial ii in )

luimiri, \cv.

Slatt lit i". iiint I %

I \ rii ! K

• ii I \ rmtk

^' • ' • I It It ,11 nt ! \

M \ ini: N X AMI-:

isiH'cuiM, \rj-:
(If. M(.rni:K

I vta'' ' il i'l iitilll \' I

J AxLcrvAj-
MIxut

1

(1 \

1/

)i'C !

MEDICAL CERTIFICATE OF DEATH

uAi'i-; « u Di: Ai'n

axivt

igo \

Mental' I Day) (Year)

m-Rl'lJV tl.RTIl'V, That I atteii«U-.l .KcrMsc.l fn.m

tli.-it I last saw h-iA; alive on C'_L.^^xt: ^\ n>o

and th.it death tKH'urrcd, dii the datt.' stated ahove, at J
iX M. The CAI'SIv (>!• DI.ATU was ■a< foll-.wsj

C O N T k 1 1 U "1" « • k \' O/CU A \.CXVv-VA^ cLsJtt. J <>t \

Dik A'l'ION ^ Yt-ars
CONTkllU'TokV

i()0 r.Xddre^s) 13^^ uLl

Mini I /is , /^h\:jl Iloh

I Xk AT I ON' )'rv?;,v Months IH />./rA //iv/; n

(Signed) ^X A. rC.u ^^0 .. j.\ ' M.D.

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

A'C df'' III V,i;, /■

M. nil,

I I.! S

rm: \novH st \tki) pkkson m. par i iiilaks ark Tkii; to tiik

lU.S'!' nl MV KN«»\\I,J in ,}•, \N!) P.l" IJI'.F

(^

f Fn f >• inaiit

'^wAa.x:^

r

.s 1^5^

^iU.^^^v <jt

Former or
Usual Residence

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

How lonq at
Place of Deatli ?

Days

DATi; o! P.iRiAf, c)i Rj;Mi)VAI.

i;i,ACK OI" lURIAr, f)k kp:m<)\a!,

r M ) p; K i- A K V. k MX/V>vX^ i ll O-C^^-vX; ^v K,K

N. B. Every Item of inJofmntlm should b.- cnrcfully ftupplied. AGE fifiould be stated EXACTLY. PHYSICIANS should

state CAUSE OF DEATH in plain terms, that it may be properly classified. The "Sjiecial Information" for p»r-
s'lns dyin£ away from home should be A'lven in every instance.

WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD

,f !!■ 111! !i F No. 1^ ^■^?^;"- li^l' ^''

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

llcdistcred jYo.

i^036

HU^jLA^ dUL\KM Deputy Health OfTicer

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

PLACE OF DEATH: — County

Certificate of Beatb

( 11. S. !^'tan^arD )

\ ^ . A ^

oiQ/Ouy\j vj .^vxX'^^ocAl^cc City of O.ccav 0.*

/v a, vv

No. \'^TH

r\

(^

St.; 0 Dist.; bet. 0 KAJ^

^^rrv^cAJl

and 'J

Li^c \

)

/ ir DEATH OCCURS AWAY FROM USUAL R E S I D E N C E G 1 V E FACTS CALLED !^0 R UNDER "SPECIAL I N r O R M AT I O N ' ' \
V IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. J

FULL NAME ^Ivvyv

W

^.^Y^

Ibx^rvcLuui c

• J". \

PERSONAL AND STATISTICAL PARTICULARS

N

DA n. < II lilRlII

\i. K

IM.mtlit

• 1 >il s- I

^1

/>,n

\\ \\ - ' . . •:i! .!« -it' ii-il imi )

BiK in ri. Xi'K

'->t.i' ' • ■ -iii \-

.vxoo<L

k

X \M 1 ( M
1 \llil.K

HIK 111 I'l. \iH
< )! I \ ni I'.R

NI it" I i! i( lUIl! I %

M M1>1 N NAM 1-:

(ti M<triii:k

I'.ik rnrLAi'i*,

<•! %!<>riii-:R

■^I.l! Pi !'• .11 lltl \

OkV

\ f

?

A

0

( »i I ', 1' \l li >N

h'riisri! ill Still I'l i; III ntii O T. t/if/»

1/..,///

/',/i

Till ^ i'.< »\ !■• s r \i"i:i> i'KR>^< »N \i, !■ \Hrn*ci. XH'^ ARi: TRri-: to rii i%

P,l>r »>! MV KN< lUIJ'.IX.l-; AN!) iu.i,ii;i-

MEDICAL CERTIFICATE OF DEATH

DAI'H ni Di; \TH >^

'J

1

D.iv

I !II:R l-;i'.\' f i: k'll 1*V. That I aUcntU'il <kHHasc<l I'mm

a

IqO H

1»/1 \ to

tliat 1 la-^t -,i\v ll alive nti .\..y.-A. 's . t<)0

ami that <lt ath iHHUirt'il, «>ii tlu- datr >>tatiMl ahnvc, at UJt>^
' M. Tlu- tWrSl-: <)1 DI". A Til was a'^ follows:

LaJvxLv^O^i:^ J W -<^v\^-£.^^

Vf

Jy^

) '( \i I

Dik \ri()N

Motifhs

IIo

lit s

<i^'\^X4XA^

/',

i\\

I In HI s

DrkA'l'lON )'ca)s < .]f,y>i//i.s

(Signed) i /\^ix^^^^ OS ^..<r>x.,L4>'-^^. ' ' .^t v^^ M . D .

a-t^vt %C) ic,nM fA.l.lnss") 9.U DC- Lcxj

Special Information »nH for Hospitals, Insfitulions, Trdnslpnts,
or Recfnt Residents, dnd persons dyinij .may from home.

Former or
Usual Residence

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

How lonq at
Plar e of Death ?

Days

I'l.ACK «>1- lUKIAI, OR KI-:M(>\ \I.

a

INDIRTAK 1"K

DAi'Fof Mi RiAi, or RHMoVAI,

T90

Ci,

fA.l.!

^51 oLtU/x. Vi

M. B. livery item oV inlf.iriniition should be cnrefully HuppHecl. AOB shoiihl be HtJited fiXACTl.Y. PHYSICIANS Hbould

«tntc CMISr. or DIIATH in plnln terms, that it mny be properly classified. The "Special Information" for par-
son* dyin{^ away from home Nhould be (^iven in every instance*

WRITE PLAINLY WITH UNFADING INK

I)

fffr /^y/rfI,V^z)i<Ah^>\j I

/.96>H

THIS IS A PERMANENT RECORD

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

2037

J^eo'/\s/r/'rd A'^o.

VMwO

.K^ Deputy Health Officer

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco

Ccititicatc of ©catb

( tl. 5. 5tan^ar^

PLACE OF DEATH : — County ofO<X'>\; O-VO;

Citv of ^XX^ru g /V>cx.^^ec4 c <

. > i ry\JL<X>v Cj/0^^»^' \i^.A.>-^ -v-^< ■
No. 1 5 D ^J (VV^Uc ^.. ' ' St.; t) Dist.; bet. and

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

FULL NAME

V/"Y>^vjJb (J^XX/y^JiKj

PERSONAL AND STATISTICAL PARTICULARS

l> A i i 111 ii; i<

,XX^

Ul.(.._l

a

M. Iith'

(I)av

\< .i-;

On '

--IN" 1.1 ■ MAKKll'Ii

\\ I 1 H i\\ 1- !) I iK IM\ « >Rr 1-: I)

Wi iti 111 -.iH'ia; (U -it/is.iliiiui

^ ;.»,/// '

> < ar

/>,

lUUrni'I, \r]'

\ \ M )■ < »r

1 \ 111 1,R

, ; 1 1 : K-

M MDK""^ NAMi:
or Ml I 11 1 KH

niRTin»I,\i I,

<}]• M<»'i'm:i<

' --tnt' 1 I '. Ill lit r\

I ). r r 1' A TM >N

U CXa-v O.Kcx

<"^ I. s^ f"^

1)

(\

<Xc*^^

1 1

4

L

-C'U y >

^r^j^/yy^JUuuhj

t

h'ttntfit III ^i!" /'i ilui i^fi) rA, 5'

5

^r,,„ii,^

Ihi

iM xHovi-' ^ r xrii) I'l'iRsoNAi, I'AH lu 11. \Ks xHi-. TR! J' To rni-:

lU'.'^T ni" MN KN< »\^■M'.I)«■.1^ AND FU", I, n'. I'

(Iiifoniirmt

T>

MEDICAL CERTIFICATE OF DEATH

ATi: OF DKATII _y

Dav' I Vt-ai <

I M.mtli*
I Ili:U!':n\ (I'.kTIIV, That I atUMiiUil ilt( i-ri-^i-d frnni

— — — — — -— I^ to — — ——————— Itp

that I last saw h - alive on ~ — -~ iw"

and that dt-ath ncrurred, on tlu' dati- stati-il aliovi-, at —

V M. Tlu' C\\rSI'; Ol' I)i:.\TiI was a- follows:

I )r RATION )V<7r,v

CONTUlDlTokV

DTRATION ViiU

M OH I /is

/hi]

I /on I

^/o)li/l.s

/hiv

NED ) LyurrUA^O.vfc.Uj. dulLcxAoA

/ /I'N > s

M.D.

(SIG

OxUj: so r»)oH (Addn-ss)V^ra^rraA^ , . .

Special information only for Hospitals, InsmiH^ns Trdnsipnh,
or Recent Residents, and persons dvini awav froni home.

Former or
Usual Residence

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

HoH tonq at
Plare of Dedth ?

Days

ri,At'H Ol" p.iRF.xi, <>R ri:mo\ai.

r.NDi.H'iAK i:r

/€L/>'

'vL'WJlAj

fX.Mnss laOH OT

F)AI"K..f 111 KiAi. i.r K1:Mi>\'\I,

©^ X 190H

wV-nL^ U^ V"\w

IM. B. Rvepy Item of mformiition should be cnrefiilly supplied. A(JI. shoiil.l ha stateil EXACTLY. PHYSICIANS should

state CAUSE OF DI:ATH In pinin termM, that it may be properly classified. The "Special Information" for per-
sons dytnft away from home should be ftiven in every Instance.

WRITE PLAINLY WITH UNFADING INK

,1 .,r n. :i!

\ Vu 1^ t-X ^:-^^ lift I' C

Dff/c Filr>l, \L'/C.t<rlHL>v

I

V)(n

THIS IS A PERMANENT RECORD

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

]i('o'/\s/ef'ed jYo,

Deputy Health Officer

DEPARTMENT ()F PUBLIC HEALTH=City and County of San Francisco

PLACE OF DEATH : — County of *^ i<X-.v 0 ."va
NoiV.! VJ Lt aLO-v' ' St.; Dist.;bet.

Certificate of "0eatb

( "U. S. StanC»arC> )

Jl ^ A ^

> vJ.Mx ^ ^ City of 0/Cuy-u JXXX.^^^<^ e c

and

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

FULL NAMEO'^^^^^

.vv\.>

PERSONAL AND STATISTICAL PARTICULARS

t'oi.oK \ , A

I » A ! 1(11 lU K i II

'l<

M.iiii h i

.S^H

\t .1.;

T

m\<. l.l" M \K1< I 1!)
W I ;!< -11 , : lb -ii^natioti)

luirni IM. \' 1

-?

tit )V4

SL I )

MEDICAL CERTIFICATE OF DEATH

DATK <)l- DHA TH /A

(Ml null I

I)av> iViai

I 11 i;i>J I{i'.V Ci; kTI 1"\', That T atU'!i'U-«l iltMH'.isctl ffimi
up to ' — ~~

tliat I last saw h

alivi- on

'Icp

*^ >va

N XMl- 111
I- A III IK

111 I \ : III- K

M X ! Ill- N N \Mi:
III Ml I'i i I I K

Mil' • II ri, \i' I-;
»i MMiiii: K

-!,it. -H 1 .iU!ltI\

}Ooj\X<nj<r \c

I V I \.

TTU ^>^C\

0

ami that death oinnirretl, on the dntv stated al>o\«,', at
~ M. The CMS!': Oh" DI-.ATIi wa- a^ follows:

I )!■ RATION )t(ns Miuith

Pav

IIou)

c oNiuimroRV

)'iar

:u>>>it/is

/hjv

//on,

I )re I lA I i< 'N U

l\r tjr-! I II Sill/ / I i' III i^i'i)

C4t\/A

) I ill .

V/.M/Z/r?

/),/!

!! I \ r.i i\ 1 s r \ ri i» im-k^on \ i, rAK'ricri.AKS ak i: ik r j-' I'l » rii i-

lUslo: MS K M i\\ lj;iH -K AM) Hl-iUHK

Ca"LcLL<X; >1rW\'

<Xj W'Y\r\'y^^M > V

Xi'.iIk

3l\MCi

"ti\» 0% \i)/CMOLa.vuJL vod.

Dr RATION

( Signed ) UrXCTrA^^ '.^d^Au. cixLou% M.D.

//C!t I T()nH f Address) WH.<rrXjt^^ UI|a.<^..

iT!

Special information onH for Hospltdls. Institufibn^. [r.insipnfs,

or Recent Residents, and persons (f)iiij .iwd> from home.

former or lO 5 5 P J How lonq at

Usual Residence ^ OJfiJLCij'w/dj VXJjU PJare of Deatli ?

U

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

Days

IM.AC)-; (U* m RIAI, OR K|.;MnVAI,

i>\n*..r niRivt, m ki;M(i\Ai,

r M 1 1 i< r A i; i : k NrCL/VVVXG -J 'v^c^A.^^

N. B.-

-livery item of informntlon shouhl be ciirufully 8upr»Iie<l. AGE shf»uld be stated EXACTLY. PIIYSICIAINS should
•tutc CAliSi: Ol- DIATH in plnin teriim, thiit it msi> »»e properly clussifled. The "Siiecinl Informntlon" for p«r-
Kons djln^ uwuy from homu Hhotild he given in every instance.

«m-

IU:iUh I- Vi,

WRITE PLAINLY WITH UNFADING INK

'ii; HSil' Cn

l)((h' ri/rr/,Vctj:r^-l\j

llWi

THIS IS A PERMANENT RECORD

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

2039

Jlro/s/r/'ed A7a

Deputy Hcallh Officer

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

Ccvtificate of IDcatb

"U. S. GtanDavC j

0 Q^ A ^

PLACE OF DEATH: — County of CJy<X^v J V<X ^ \ <- 1.^ ^ City of ^ cun^ JAa

^ A '" '

N©

m

tuLl)

\ I

HJ>\AACt

St

Dtst.; bet.

and

(

IF DEATH OCCURSUWAY FROM USUAL R E S I D E N C E G I V E FACTS CALLED FOR UNDER "SPECIAL INFORMATIO
,F DEATH OCCURRED ,N A HOSP.TAL OR .NST.TUT.ON GIVE ITS NAME .NSTEAD OF STREET AND N L, M B E R .

N)

FULL NAME

xXXAJO^yy^

c

til.

1

PERSONAL AND STATISTICAL PARTICULARS

1) \ir. I >1 !,!i; I'll Y

M. Mill '

5

i i \

A t . !•;

^h

^ I

M.n:lh

An >

-^I^< l.l- M \ K l< 111'

W 1 1 n i\'i I ' 1 > < >K I 1 ' \i f '. I'D

' \\; it, '11 -11.;: .li -• na' i. .'1 I

lUK'llll'l, M"

ol^^uuL

C<r

--U

\Ml ■»;
\ 111 IK

iUKIIi li. \* K

<)i i\rm; K

M\;i)i:x NAMi:

or Mo'l'lIKH

( u- M«>riii-:R

I --, 1 , 1 1 1 lit i ■ 1 1 u n 1 1

n\Tr\iii»N r^

u

.-n

L

-I

CCrLA^O^^v

r-^

\

I \„v

V A

I < ,1

■ a>t

5

.^f..,Hh'

I hi 1

I'll I- MUiN'I-* ST \ ll-It fl-HSi i\ \I. I' UrrfiT!, \KS AR I" TK!'!'" TO I'll I-;
Hi:sl' <)l- MS K N« lU !,1.|M , 1-; AM) I'. 1 . 1, 1 1: 1-

( 111 fii' 'nanl

x.i.iK-s \X'X s^X^CkXXjO^^ry.As'^f^O^ C)X

TOO s

(Vtar)

MEDICAL CERTIFICATE OF DEATH

DATJ-; Ml- Dl'.A'I'H jJ

Oxkl

(MoiiflO l> in'

I ni<:iU-;HV CI':k ril'\', That I alU-iuk-.l .UHv.Kf.l from

a^Wt It !./.'■ to d^^xt ^ T<)oH

that I hist saw h -• < . anvc oil O-X^vV ,1. ', y<p

ami that (k-ath (ucurroil, on thi> <hitt.' statc-il ahoxL-, at «• 3v
M. Till- CAISI-; <>h' I)l{\ril \va^ a^ follows:

1).- RAT ION
CoNTkllU'TOkV

)V(7;s M on ills

Hav

Hi

out <

1) r U A T I () N
(SIG

t'iirs

NED) LU. vJ

Months I />.7r

//ours
M.D.

U/Ot I looH (Ad.lrc-ss) lllO g^CctUA. J. I

Special Information on'y for iiospiidis, institutions, Transients,

or Rt'itnt Residents, anJ persons d)inij away from fiomc.

Former or

Dsudl Residence'*.^

I y I I ^\ How lonq at

MAXCtCcL >^<-CKacL Jl»idrc ol Dcatli ?

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

i

Days

iM.ACi-; Ol' niRiAi, OK ri;m(»\ai.

I)\Ti:-i!' I'.t HiAr, or Rl':Mti\Al,

TQO '

fAildicss

HHb Yrv

A.^4. C<^-V\

IS. B. Kvepy item c.t' inforiniition should he Ciirctully supplied. AdT. K^iould be stated EXACTLY. PHYSICIANS should

state CAlISr OP DLATII in plain terms, thnt it mny he properly classified. The "Special Information" for per-
sons dyln^ away from home should be feiven in every instance.

lir-

WRITE PLAINLY WITH UNFADING INK

\{. .' :i'. I ^<

'i;^ I'nSll' c,

Dff/r ri/r(/,h.<^)uX<>\j

■^

Dep

ino'i

k% f^ffi

THIS IS A PERMANENT RECORD

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

:040

J^po^isfr/'prJ .A^o.

t3i

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco

PLACE OF DEATH: — County of^O/^v yi K<X

Ccvtificatc of IDcatb

,, ^ ^

y]K<X , ^ City of O^Xj-ysj Jxo-^vC , ..

N

J (rlA/fvw

„ 2) 1 % - I aI St.; 2» Dist.; bet. J OXA^r'yyX' and "Vl^ CUv-v^A^m- ^

FULL NAME oL O-AvoO) 0

PERSONAL AND STATISTICAL PARTICULARS

1 < tl,» >K \

^yudx

i> \ ii' < •! r.

CxJyj

0 IvCtx

M,

3^

: >;t\')

1/, »/'//.

3L"i

S ( ; 1 !

/^,/l

-,!X. I.IV MAR I- 11 :i
W I 1 11 '\ ! I 1 1 iR I I ' . i in

Wiit

niK ' II I'l, \i 1'

-1 • . ■ ' ■ mi N

I l\<X\.>vOL<L

VXXVuCa^

MEDICAL CERTIFICATE OF DEATH

1).\ 11-, < '! I»l. v III J)

M.,nllfi 'I>:iv> (Vt-ari

I ill'Rl'lSV Ci'R'ril'N'. Tlial 1 attrinK-il <lr(Hasf,l itoin

)x^ a.0

AMI (H

\ i li I.K

lURI'lii'I, \i I-,

''' iiiiiiin %

M \I1>1%\ N \M i:
Ml Miiiin K

lUR riiiM AC1-;
111 M<»rni-: H

( >. 1 r I' \'

,o\A C

I I

J.uJL(a./\m

Krsidf.l I'l S,nl I

l',! I

K.) \runfln '. ( /'.'

Till MioVK sr\-n-I. i'FK-oN M, l'XI<ri<Tl,\KS ARK TKlH Tn THK

i5i-:>r ni- MS isNi iu i,i:i)( ,)■, AM) lu'.i.ii.i-

( lllfii; m;ml

^t

A I IqOt to aJCyVAj OU I()0

that T last ^aw ir alivron O^^ ■ s-' -^ l.p

ail. I that (k'.ith . .(•cu rred, ..ii thf <lati- stati-«l ah.ivr, at
" M. The CAl SI-; (»1" DI'.ATIl was as follows:

I )r RAT ION

)'i:ars

Moulhs

CONTRIIHTOR

^V vlAAXX>-\.<Jt -if

Pax

Hour

-o

I )r RATION ^ ,^''''^'^'^

(SIGNED)

/^//

^'s

li

H

M.D.

■ \

* t

SPECIAL Information nnly tor Hospitdls, institutions. Transient*
or Rfcent Residents, and persons dyin;) away froii home.

Former or
Usual Residence

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

How lonq at
Plareof Death?

Days

ri.^CH oi- lURiAi, «iR ki;M(»\Ai,

^^^<^^

,1

'CX

K i:m»»\ \i,

Pi. B.-

«t»t/cAUSE OF DEATH in pl,.!n terms, that it mny be properly class.t.eU. The Spe.lai Information *or pT
mnn9 dyinft away from home should be 6<ven in every instance.

i

t

Li

WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

/)(//(' riicii , yA^LdjJuv> V

ino\

lla^Lstered -jVo,

*>

041

dUL/v-u Dep

/~. e*T -* ^ .J

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco

PLACE OF DEATH: — County of ^ ^Xnt^ ■J Ax^
'♦fo. VLlU^ W^ V^tu. ill: H. Wv' . '\. \ St.;

Ccvtificate of Bcatb

( tl. S. StanDarD )

^ ^ ^ ^ City of 0/O<.^'\j 0 A.<X>\.Cla.,

■^

H)

Dist.; bet.

and

)

I w -i^.. iiciiAl or e; I nF NCE r.lUE FACTS CALLED FOR UNDER SPECIAL INFORMATION \

( '^ r/rCATH"o3c"u%r.r.;*rHo's^p"T'AL o"r fN^.'.TJV^o'^O^V.'^.Tl NAME INSTCAO OF STREET AND NUMBER. )

FULL NAME

av^

PERSONAL AND STATISTICAL PARTICULARS

n \ ri: < »r hik i ii

Vlv^

V

.vxt;

"I,

ID

1 ',,1 '//

/',/i

^ ' \i 11 M \ K K I 1
Wn'.

lUKTH J'l, VC!"

*-; • . ■ 'i uinU

N \ M i ( M
J- A 111 l.K

A

^ ^ cjbv^cJi

x<xci<.

iMK 111 ri, \t'i\

( »I i \ I 11 !• K

M \ h>i:n n wn:
(»i Miiriii-.K

lUK I'll i'l, AC I"
iH MnTlIl-.k

oi cri' A rio.x

1-

c1

o

Oa^^<x>^ ' vc

.hJLLcc yvcL

MEDICAL CERTIFICATE OF DEATH

DATH «»l I)i;Aill \

\!. Mtll)

iKivt

(Year^

4

I III-;kin'.N' CI'.kTll-N, That ! atttMiik-(l (Iccasc.l Innu

I I I % IS I . I > 1 V 1 , IN J 1 1 • ,

\ , 1 . f

T()OM

that 1 la-t vaw h .' alivi-on "" ! ^"^ ^'- ^'>«

ami that dentil omirred, <>ii tlu' datr -talfd above, at I-IO
;M. The CArSI{ Ol' I)I:A'I'II was a< follow

III I

)\vs :

-k^CrVMXV

DIRATION )'ruis

eoNTKiiurokV

DTRA'I'K >N -. )V'/'

Hours

MiUitJi

Pav

NED^ 0 'a. Ob-OXfc

rsiG

M.D.

1% H, (' %
N only lor flospitdls, Insli

SPECIAL INFORMATIO..

or Recent Residents, ami persons dvin-i dv^.iv fro;ii liome.

litutions, Transients,

J",,/

^^..,lt^n

/hi

Till- \Hnvi.- ^rxTii) rHK>-i)\ \i, r\K ruri SK-- \ki riuH to phi-
liisrm MS KNOW i.i:n<;i'; wn i;i:i,ii;i-

; Info- nianl

( \<Mr'

U^

rt

D 0-^vaX<X.I'

l-hA^llAi

Former or
Usual Residence

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

How long at
Place of Death ?

Days

ri.ACH Ol- lURIAI. (>K RKMoVAI.

i)\'iT:.)t lui-tiAt, (.1 k1';m(>\ai.

TOO'

■J , ,, [^ i *cp «hniilil be Rtnted F.WCTLY. PHYSICIANS should

IN. IS.— Every Item of inif.,r„.Uion «h„uhl b. cnrefully «"PP'- • „^,^f;X7laBsmei? The ^Special Information" for p,r-
•tote CAUSE OF DEATH in pliiln terms, thnt it miiy be properly ^.lassiticu.
lions tlyinft oway from home hHouIcI be given in every instance.

i

I

WRITE PLAINLY WITH UNFADING INK

(^

Dfffr hlli'd ,^"6

iXxsaMA;

in()\

THIS IS A PERMANENT RECORD

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

llroisteird ^'o^ 2042

£crv^l^vvu Deputy Health Officer

DEPARTMENT OF PUBLIC HEALTH-City and County of San Francisco

Certificate of IDeatb

^

^

^

PLACE OF DEATH:-County of^^<X- ^ Xc..x^..< Gty of ^^^^ 0/.C^-v.^u.

St.;

Dist.; bet

and

f4€>. ^'^^ *^WCrVC^VLU ''^ '^'^ ' "^"^ "h' „,^=?i^^lrF r,«r t^crrcArtED roR under 'special intormation' \

\

FULL NAME

tCVv

Mluv

>^i:\

PERSONAL AND STATISTICAL PARTICULARS

i < 1 1 .1 • K \

(V

1 I •

IOlU

lLi.a..

M%

\'

,1 .}-.

-:Nt ,1.1

at

\ 1 .1!

n,t

(Vt-arS

UiK I'M'" ^'-^

NAM I 'M
»• \ ri I 1 K

HiK rnri. \rH
Ml r \ rin-K

■Slut. ' i nil

Ml MMllll-K

i;m.' rni'l, MK
Ml N' I I '■ 1 1 K H

■ - • : . 1 (.'.illlitl %

ri' A timn

A',

MEDICAL CERTIFICATE OF DEATH

DATH OF DKAIH j . ^

1 lll{Ki:i'.V C!;RTII"V, That I .iUcii.UmI .UHnavcl fmin

: ; -t >*'\ ,.^nH t.) C)-^t^ ^^ T(,n K

tliat I l;i-t ^:iw h -. -Hvr Mil ^^ i '- ' ^ ^'P '

;,„.l th^.t drath ..rrurn-a, <n, llu- -Intr stated alH.ve. at IC H5
M Tin- C \r<l' Ol" Dl-A rn wa^ a^ follnsss:

j^:

0 A.vy^.^v.c •^<^-

I

■\/,.j,f/n

/>,!

T,lv\lM,VHSTAT!Un.KR.oNX, 1.AKM.M_;,XR-XKKlM<rKro THH

ni'-r Ml MY KNOW i,i,i>''. 1-: am> i.i-i.ii-t'

DrUATIi »N

SIGNED

dxMX

Mouth.

Pay

KJ

AL INFORMATION only for #nspitrtls

VU.%m4

//ours
M.D.

= 4

or RctenI Residents, and persons (l)in<| away fron home.

Instilutlons, Transients,

former or s *> f -

Usual Residence ^ ^ ^

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

Lliv

Hov^ lonq at
Place of Death ?

Day

(Infii- inant

XUlrt'^

\.

l'I,ACK 0\- lilKLM. (»K RKM«>\ AI,

datUj')*' hthiai I.I ki;m<'\ai.

' <3 ' ~^ ZTaGB ehould be «t«ted RXACTLY. PHYSICIANS should

„. B.— F.very item of information •hould b. cnretuHy f"PP«'=^- ^^ ,y ,,«,emed. The "Special Information" for p.r-
state CAUSE OP DEATH in plain terms, that -t may »»e proper y
nnnn dying away from homo should be given .n every Instance.

!l' Mil '.^ Ni

WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

2043

JUtIm-*

.^rx.^ 1^' Deputy Health Officer

Jlrf'is/i'j'rd J\''o.

DEPARTMENT Of PUBLIC HEALTH^City and County of San Francisco

Certificate of IDeatb

■a. S. 5tanC>arC>

J? (\,

-^ ^

PLACE OF DEATH:-County of ^ a/>^ J ^vcc^*^^* City oid<^ JA.a..vc.^....

No.

's'> ^

St.;

T

Dist.;bet. C^AJ

JLcvL^^^^ and Ax->vl^

t^

( ^ --^^i^^Jr^v. -J^i^^t :^v^f^^-i-^}^^i^^ ,;^^-: s^^EEi-No^-eEr ■ )

FULL NAME

PERSONAL AND STATISTICAL PARTICULARS

lO.kd.

Mi.lltll !

'i);

)V,-

1/

■, ; \, 1 r M \ k K 111)
\\ 11,1 I iK l)'^■l ''■ 11'

\\ I n ' 1:1! 11 -.iL' n.,; ■

.^

1UK'"n 'M. N" 1

I A I II IK

lUK 111 ri, \ri-:
(»i 1 \ ni 1: K

-,• ■ ' r, .nut! \

(ii Mi»rm:K

HIR'nilM, \< 1:

<>r N^iiini". K

-^ M etc

MEDICAL CERTIFICATE OF DEATH

DATl-; 01 niA TH li \

I III'IRI'IIV CI-:rTII'V, Tliat 1 aiu-n.Ua .kcca^cl from
'^jLM. Vi upH to ^/cit: I 190 H

that I last ^;uv h ■* alive on ^ C w igO ^

an.l that death nccunvd, -ui tlu- .late stated ahnve. :-t 4
>T. The CAl'SI' Ol" nilATH %va< as loUn%vs :

V

\

Cx^oiiyw

A>Vt'

t I

DT RAT ION

)■ -/v

.l/o.'i/Zis /^tns 10 //<j///.s-

» >.-

. 1 "^

v

■T

4" ''^

coNTRir.rroRV

I)rR\ri<>N )V</r.v .Vi>>,'f/is

X.

fhivs

SIGNED)

:|

'>'>x^-^

flours

M.D.

l<»n

^t f Address) l\ H b JLtAAJ^C^kt "

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

r,'

I

1/,

.■„:^ 1

l>.'^

)K CI I'A Tit tN

Tiir xnovr-TXTini-KR.nvM.rxKTirrKXKSAKKTKrH T<> thh

lU-sT 01 MV KN«>\Vl,l-.lH'.l-; AND lU.lJl.H

(I

\iMrp«s

5X0 ' ^i

^ d

*

Former or
Usual Residence

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

How lonq at
Plare of Death ?

. Oavs

rLACi". »H- in KiAi, OR ri:m<>\ AI,

^

I

DA I

I.MAI 1.1 k1';m<)\ \i.

let ^

rSD.RTAKKR ^C^CcL^ WxLt^l<^k4M

IQOH

;a.i.1!. -

, TT TTf. ^sould be stated RXACTLY. PHVSICIAIN8 should

IS. B.— Every item o? inWmation should be ca.eH.lly f "PJ* "^;'- „ ' ;H>classmed. The •'Special Information" for p.r-
•tate CAUSE OF DEATH in plain terms, that .t may >^ P^"'^^*^ '

state V#^kUi5i, Kjr i#i---i 1 .. •■■ t - ■ . l«ot-»ice

sons dylnft away from home should be given in every Instance

• a of HiiUh 1- N

WRITE PLAINLY WITH UNFADING INK-THIS IS A PERMANENT RECORD

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

2044

-t"^*'^..n^iT

H Officer

Be 'Mistered J\'*o.

\ \ ^ Deput. -^

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco

Certificate of ©eatb

PLACE OF DEATH: — County of^ '<XmJO,^.<XA ^ity oi

No.

4 (1^ l' ^ 14

St; -~ Dist;bet.

and

( '^ --^^^c^uR^v -°"ti^^t -?^?^^^ .;^ .^s p. ,

..S.DENCE O.VE .ACTS CAL.XO ^^^ER ^ ^ CC • AL^ N ^R M ATK, . •■ )

K Y\

FULL NAME

XCX'

CL*

\

PERSONAL AND STATISTICAL PARTICULARS

1 1 \ i 1* til r, IK in

■>iat

Ihis

MEDICAL CERTIFICATE OF DEATH

DA XV. <>1' DKAIH JJ

iDav'

I (JO .

,Vc,U '

1 iii':ki-:r.v ci-rth-v, Thai.i auiMuK-.i .Urriisni

lolll

1 1 )1T

H'l' rni'i. \i'H

that I last saw ll ■' alivi- mi
a„.l tl.at <ivalh ..rcurrrd, .ui tlu- -1 at. .tat.-.l aln.vc, at
M. Tlu- CAT SI-; Ul" DI'ATI! was as follows:

flav^o^-cL

I

I- \ 11! l.K

!'IK rni'i.ArK
«»i 1 ArilKK

-,' i< I III I'l i\5 nt t N

M MI UN N \Mi:
Ol MKini-.H

HiH rI^'f,A^]^
(>i \;<>rin".K

! vt:itt oI riilUllI %

CONTKinrToRV

Months

DiU

'S

/lours

UJL^..<:^ ^

OkxX^ . -^

( HIT J'A'I'KtN

^5

DTRATinN
(SIGNED)

n,jv<

IJouys
M.D.

■ .i - I V

..t r^

I()n

SPECIAL INFORMATION «nly for Hospitals Institutions. Transients,
or Recent Residents, and persons dving m^s froii fiome.

K,-:Afd ill V,(>' /

■I' /...I t

)'i a ' »

M,,„!ln

I

Of)

11

I 1 Ti I . . ' t n ; I n t

\<l<lr("^H

J^J^

31

Former or y

Isnal Residence i

V^tien Has disease rontraded,
It not at pla( e ot death ?

As fi J How lonq at

VirUUv^ at Place of Deatli

Oavs

(IccL

/CL.-»-x^O.; ^ ^

nAl'lii; r.nuA!. Ill Ri:M<t\AI,

i ' 1

I'l \il-- nl- lUKIAI, OK H1;M«»VAI

TQO

■ 1 ' ■ ,. , .pp ^H,.,,tl be «tate,I F.XACTLY. PHYSICIANS should

!S. B._F.ver.v Item of Information should b. cnrofully f"n»> '^ " ^^ ;^,y '.^^^iried. The "Special Information" for p.r-
«t«ti. CAUSE OF DEATH in pinin terms, thnt it mji> nc p

if

WRITE PLAINLY WITH UNFADING INK

THIS IS A PERMANENT RECORD

REFER TO BACK OF r.FRTIFICATE FOR INSTRUCTIONS

10()\

DEPARTMENT OF PUBLIC HEALTH

Mes^fsfcrrd JS^o.

204

City and County of San Francisco

-^ v'^vCl

PLACE OF DEATH: — County ofOa^OA^O.

No "i QCL^^ IWUvv.- St.: Dist.;bet.

(

Gcvtificate of IDcatb

\ ^

< City of ^'^'^'^ O.h^cc^vcc^

^c

\

L^O

' '^?^^v^:^:^ — ^^^ ^^ii^^^^-^^-^^^^ :^^i: s^^-^^-r=

and J'^>-

TION" \
ER. /

)

m^

iQ\' /D

FULL NAME \my^

'lvcn'>xo.<^

\ : \ V

^_X. i\

i> \ 1 1: ' '!

PERSONAL AND STATISTICAL PARTICULARSv

mr^i. ^^--'

5.

'i; I

-.ivi I r ^'

Ji I l_ : 1 I l-I % '

N \ M 1 II
1 x lis l.R

I'.iK rui'i, A<1%

M N I I>1".X NAM 1-,
(»| MnTHl.H

iUR Tiiri, \ri-:
ni Miriin: K

oiHTl'A'rinN

1 1

MEDICAL CERTIFICATE OF DEATH

DATl-: i>l I'LATll -^ . I

I IIKRKHV CI^RTIl V, Tliat r.Ur.i U-.l .Uhh a.c.l fnm,
Vt\<t \^ iqoH to OJjJp^t ^Ci T.)oH

tliat 1 la^t -aw h • aliN^ -mi t- -*- ) >

^,,,.1 that .U-alli nrrurre.l, nn tin- .late slatcl above, at H
LU M. Tlu- C VI SK OF DKA'ill Nsas a- follow^:

1 1 ■ ^n

DIRXTION y"^rs Moulin ^ Pays

Hours

nr RAT ION y^'%^

(SIGNED) I

.][, tilths

/hw

f fours

M.D.

V.,'i' /

(. /VM

lU'.^r »)1- My KNONSl.l'.IX-''. AM) l.!.I.'l •

\

f Infii: matit

\juyvaji

o-a

.\AjJyw

fA,i.iT.-% CJ/CWw

axx/>^ IX^W^^rv^^

J
i.:)l

SPECIAL INFORMATION only for Hospitals, Institutions. Transients,

or Recent Residents, and persons dyini av^rtv from liome.

Former or
Usual Residence

Wlien was disease contracted.
It not at place of deatfi ?

HoH lonq at
Place of Deatfi ?

Days

I'l ACH OI' lUKIAI, <iK Ki:M"V \

1 S-

rNDl'.HT.

1^ X

.cv>^'

TQO'^I

1

(T>

— " ' "^ ; T"! TTr Hho.ld he «t»te.l r.XACTLY. PHYSICIANS should

^. B._Bve.. U.„, oV ......nntlon «Hcn.r.. H--^^^;^ ^^ ^^ pt L.. c.„«eWled. The "Speda. lnfo..„«t1..„" fo. p.r-

.1 ^ .-*i!«i iW- ni-\TH in pltun terms, tnni n ■•■"^

«nn, dyS„4 oway from home should he ^nen ni every

m

^

1

r.....r. .MK THIS IS A PERMANENT RECORD ^Wm
WRITE PLAINLY WITH UNFADING INK — THIS 15 M rt

"^"'^^ ..c.p TO BACK OP ^..^...r^Tr rOR .NSTRUCT.ONS

,! ,.t" III :i'tli 1 ^"'

,-^^*^'%i.i\f<vc„

REFER TO BACI

Be <^i stored J\''o.

046

l)((le /v7^>r/,L)ctM>?-A, I -^'"^^^"^

"Lxr^^-^ Ijl^xhj Deputy Health Officer

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco

Ccvtificate of Bcatb

( XX. S. GtanDarD )

PLACE OF DEATH: — County ofOcL^-vAJ

v} . VOLA'vX^^ACt) City of C )/CV>v 0 X O.

St,; \ Dist.; bet.

No. Cs6bv V,<X/>A; M WC-X^' " ^.cilill RESIDENCE GIVE FACTS CALLED ►i

- ,. DtATH OCCURS ^^^'^ ^ , ;« ° "^^ ,^3^,V,'^,i: J,^ f^! ST^.^UT.ON O.Vt .TS NAME .N

and vJ.>ULt'V\

C^IlED rOR UNDER ^SPECIAL .NroRMAT.J>N'. "J

u<:)

(

IF DEATH OCCURRED II

FULL NAME

si:x

PERSONAL AND STATISTICAL PARTICULARS

v.*»»I,(iR

STEAD Of14tREET AND NUMBE

A^ \jcrvw^>vi\

I '

j_

I) All". <»» r.IKTH

xr. 1-:

I Mi.tUhi

I Dav

/%5H

oL' y.ai^

lA

Vtarl

I hi ) V

\vii»< '\\ in OK !)!V.)Kri-:n

iWi ;t> ni -'"1.11 '1< -luMKt;.)!!'

lUR rniM.Aoi-:

f st:it<- >! i.'.i-;nli V

NAM J <•!
1 A'l li KK

lUR rin'UAri-:

nl lAPintK

M Ml U.N' NAMl-

oi' MDrni-.K

lUK rm'i.Aci*.

n! \!t lill l-'.K
(St. a. 'ii CdUtilry

f^

aur UaJ^^o-

MEDICAL CERTIFICATE OF DEATH ^

DATH «)l DEATH J ^ .

I lll-KlU'.V CI-RTIFV, That LatteiuUMl .Ucca^cMl from
Clu.q ... 190S to ijtj^^C icpH

that 1 last ^axv h ^'^ alive on t.^)^ ^' Kp'i

an.l that .U-ath oocurrcl, on the date statr-l above, at 1 1^0
OL M. The CAISI- OF l)l-:ATn was as follows:

^^(^

t

XlU^j

1)1' RAT ION )V<7/-.v ^ .Uofi/Zis

/)</r.v

//oil PS

<^\p

VVC^-Q^^^S t

t

Mt^tiths

ni'KATloN I '^^ Vi'ors

Pavs

'rw\i

(SIGNED) ^ ^- ^ a

Hours
M.D.

.trVc^s.'Lv.O.A vcx

(Kcri'A rii>N

•u

n ,

i' n

)V,.'.

M,nifJn

/).n.

ruV v,M.vrSTXTriM-KK<..NXl,PAHiU-,I,AKSAKKTRrH TO THK
' HKSt'». MV KNoWU-noH AND nHl.lKl-

(Iiif.Minant

< \Uill

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

Former or
Usual Residence

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

How lonq at
Place of Death ?

. . Days

ri.ACI-: Ol- IHKI.AL OR RHMo\AI,

(Aaar.ss, bll U'CC^x. M\.U1.^ llx>

DAI To! I'.i RIAL or R1-;MoV\I,

O'ctr I 190H

I

.. , .,,F «Uould he stated RXACTLY. PHYSICIANS should
SN. B.— Every item o? Infort^Btion should he cn.cfuny -PP^-^; p^perly classified. The -Special lnfor.„Htio„" for pT-
state CAUSE OF DEATH in plain terms, that it may ne pr»p*;r ,
«on, dyinft away from home should be given in every instance.

'4fi£*-J«.c^,

i
I

.It" 11: ,::!]

WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD

"" . lu-vl eu REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

\. ■

lie i:! isle red JS^o.

Ajl/v-u Deputy Health Officer

DEPARTMENT h PUBLIC HEALTH=City and County of San Francisco

\

No.

Certificate of Beatb

( 11. 5. i?tanJ>arD )
PLACE OF DEATH: — County oi^CK/y^ Oxcu-^vcv.; ^ C^\^J nf U<x.-rx^ J

City of *^' O^^rv vJ /UO-'W/C u^

D-'Tr^xtrWalL'Ku:'Cj/a',\Lwa\u.' .St.;

Dist.; bet.

and

(ir iJeath occurs away from USUAL R ES I DENCE give facts called for under "special information" "X
IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. /

FULL NAME

'L>A.^^\JU

PERSONAL AND STATISTICAL PARTICULARS

iX

iMl.Ok

u^

4

i> \ri: III i;iR rii

A< . }■;

\J

I

^\

1

3.1

M.iih

I tar)

Ih

^IXt.I.l-: MAKKIl'K

U • ;;' Ml - . -ii' ' • .til, Hi

'UK T!!!'!. \(*1-:

i \'iH i:r

lURTIir!. \«K

<ii- I \ rn Ik

• '■ 111 nt \\

111 Ml tTII hi^;

niui'iii'i, \ci%
ill- ^;l•^^l•■. K

< !il' I I' \'l' It iN

v] oX,K.\^^

"VA;

(11

^ AJUL a.' X ^ ^

^

MEDICAL CERTIFICATE OF DEATH

DATK nl- 1)I:aTII

i Ml. nth)

I

igo \

fl)ay) (Year)

I ill-: k i:i'.V Cl'KTIl'^V, That I atlcii<UMl .Ktxasccl from
\^k ^.L um'i t.. APct 1

I(p

1 90 "i
that I last saw li . ahvc on ^^-^\yX; ^b ^^p '

and that death ocrurred, mi the datf -^tatt'd ahovc, at "i
•A M. The CArSF*: ()!• DI'ATII was as follows:

Jj A^Crvw-^4x,A^X ■

DC RATION

}\ar

in

t oNTkim Tory >

Hours

v^vXO„ ..

1)1 RATION

(Signed )

i\^\:

TQO

Address) b^b QxCtt.' S

Hours
M.D.

AV ,/.;'

'^fnith^

I hi

1 in. AH()\J" STAT I'!) I'KKsoNAi. i'\K ri<Tl, \RS AKI" rKri' in THK

m;sT ni Mv KNi >wi,i:i)c,}.; AND rn:i,i);i-

In!

Special Information only for Hospitals, institutions, rranslents,
or Recent Residents, and persons dyinq anay from fiome.

y r- o 1' I ! ' How lonq at

Former or
Usual Residence

Plate of Death :

Days

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

I'l.ACH <»|- lUKlAI. «iR R|.:M«i\AI

nATi-; -it I'.i RiA

I ill Ri:M(t\ Al,

•Nni:RTAKi.:R OvO. 0 OAv'i'^H/ ^''«C Lt

A<l(!ii

N. B.-

-Kvery item «V informatiofi «»houid b.- ciirefiilly supplie<l. ACJfi should be Htntecl EXACTLY. PHYSICIANS Hbotild
state CAUSE OF DEATH in pliiin terms, that it may be properly classified. The "Special Information'* for p»p-
Rons dyinft away from home should be j^iven in every Instance.

m^^

't »

II

^KR. '

WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD

l;.>at<l

:;;th r X(,

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

/)((/(' Filed ,

^ctxrv>-xAj

100\

lie ii isle red jYo.

2048

Deput '■ - - - Officer

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco

Certificate of IDeatb

( "U. 5. StanDarC* )

PLACE OF DEATH : — County o{yjiCur\j -)ao

%

^, ^ r^

" V " ■ City of VJ i0^y\j 0 AXX^-^ X.C oci. c '
( Na oL 0 ^ -^ 1 I . ' . ', St.; S" Dist.; bet. ^ W CrUKXXxl and 0 Crl^Lryrw

(IF DEATH OCCURS AWAY FROM USUAL R E S I D E N C E G I W 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 «W>VU4 \yx\/>\JvO.\cL (j/Orvy>\A.<lt

PERSONAL AND STATISTICAL PARTICULARS

roi.oR \ 5

I 1 , \ ;/

I'-
ll >:iv)

^

9. M '2

A( ,1.;

b! .■.,,,

i/,.,//A>

\ ( ari

/),;

SIM 1.1" M \U U II' I »

U I i I. >\\K1» OK li!\ I "Kv 1 I)

* I"

I

I VuXhJ

N \ M I . .'

I A 111 IK

lUR III IM. ACK
m 1 \|in-:R

■--l ;it I III < '( i\! !lt ! %■

oi- Mol'llJ.K

iMRi'mM.Aii':

' '^t:lti )1 i'ltUIitl \

h^uixL

:1 Q^

-: f

MEDICAL CERTIFICATE OF DEATH

DATIC OF DKATH

6x{^'

1

SO

(I)av)

/go

I Ill'.kl'l'.V CI'.R'ril'V, Tliat I j^tciiiU-d (IcHcasc.l frniii

dx|^

10 npH to OJL^^t; ^0 T()0

that I last saw h A/'Wx alive on QJL^^^' OC up .

and that (Uath niMnirreil, on the date <tatL'<l aliove, at O-oO
LA., M.^ Tin- CVrSIC 1)1' DI'ATII was as iollnws:

DC RATION

U jJ\jy^Xy(Xyyxx,i

Hiri'A rioN J( 0

)V<?;-.s^ .I/o/jZ/js H /.)<?r5 Hours

CON T R n u "r () R \' LlAXAr^-/oJC &. j^^-^^^axJuo^c^, .

DTRATION Yrars Jfouf/is X\ /hns IIouis

NED)|.^.Q7lCLC.U^J-

i<)oH (Addnss) "il^ LxL-du -^

(SIG

M.D.

\

SPECIAL INFORMATION only for Hospitals, InstituNons, Transifnts,
or Recent Residents, and persons dyinij away frou home.

v,/// /■/

M.nifin

/),n

iii). \i'.(»\-i': s rsii!) i'j''RS' >NAi, PAR rirn.ARS aki-; Tur j: r< >
mcsr oi- y\\ know i.i.ix.i. wd r,i:!,n:i''

0 i^ 9

[it

I j:

(Inf

Former or
Usual Residence

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

Itow lonq at
Place of Death ?

. Days

I'l.ACl-; Ol lURIAI, OR RKMtA'Ai

x)ULt

DXIT,"! J'ti roAi, .11 RlCMuVAI,

T90

Ct'.

INDl-RTAKKR UU. ^ . VJ JLLfi.^

fA.l.lross 11^ \iy\, (JJUUA-liA; Ut

N. B. Rvcpy item of infopiiintion should be cnr-efully supplied. AGB should be Htnted F.X4CTLY. PHYSICIANS should

state CAIISI: OI' DM ATI! In pinin terms, thnt it mny be properly classified. The "Special Information" for per-
sons dyinji away from home should be feiven in every instance.

I

1 1

♦I

Bonn! . f lie ,1 Itli r Vi) I -

WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD

.^-^r^^oc.,., REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

-r. !U<s:l- (',,

Megisfei^pd .jYo,

'^049

L,^^!., i:>eputy Health Officer

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco

f4©.

PLACE OF DEATH: — County of ja-yx

4-

Ccvtificate of Bcatb

' . City of ■J'Cf~'^' ^''^-'C*^'*^

J 0

^'\y\jy\JXQ <Xr\\xXxx^ St.;- Dist.;bet. and

/ ir dVath occurs away from USUAL R E S I DE NCE give facts called for under special information" "\

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

FULL NAME

0

.fyxmAj UynX'

Xo-r

PERSONAL AND STATISTICAL PARTICULARS

'A

h

■< !l < iR

I n

Li,

fX^

C, CI

M..nt'

> tar

Ai.

1 1' M \k k ii:ii

A I !> ( »K \> '.

■ 1.1 -M -.ll .l.-K

lUK in I'l. si'j".

1)

'X >"vo,C

(

X \M1 Ml

I \ I'll IK

M \im:\ NAM I

(i! Miirill'K

ii!R rni'f, \ri-:

111 MmTIIKH

< uori'Ai'ii i.N

A

MEDICAL CERTIFICATE OF DEATH

iiAi 1-; I >i 1)i;a ill

c\

^ct

^M(.!lt1l>

Uav

(N'rrii

I II1;In1':I!V C'i:K'ril'\', That I att. n.lr.l lUcrasc.l fn>ni

uoH

U)0

I i l( )

6ct I

that T last saw h - alive nii * * ' up

ami that lUalh ocru rred, mi tlu- ilatr state-il aliovi", at 0
M. Tlu- CAISK Ol' Dl Ai'll xva-. as follows:

Q

H

^

1

W^xr

I

V, V

ktrKnA^^^Cr >v

'0

K^O. ^vo

-4 ,-.

/,/•■,/ /^' V,f„ /

yhnilln

Ihn

rni: aishvk stai'i: r> pkksiixai, v xhtuti, vk^ .\ki ikii; in in i-

JU'lSTiH'.MV K Nt »\\ 1.1 III, !•; WIi i;i ill-

flufotiiiniit vJ-X-vCXvX*

\,!,i,-,... RM"i oxa-vu

%

I )r RAT I ON Via I

CoNTkllUTORV

Dr RAT ION Ycafs

' a

J/o>///is

Da 1' ?

//

OH) V

(Signed )

Mouths

Ck

Par

A.hlri-ss) 111 '^io.n.^jl

//ours

M.D.

Special information omy (or HospifiiK, InstikiUons, Transients,
or Recent Residents, and persons dyini awav from tiome.

Former or
Lisiidl Residence

When Hds disease contracted,
It not at place of deatit ?

HoH Jonq at
Plare of Deatfi?

Oavs

Pi.ACi-: <»i I'.tRiAi, OR ki:m<«\\i,

I < , ,

UATi: >.; n

190 ,

Imiaa^o »\j

IS. B. Rvery item of informntlon shnuhr b.- cnrefully Hupplitil. AGF. should be stated EXACTLY. PHYSICIANS should

state CAUSE OF DEATH in plain terms, that it may be properly classified. The * Special Information" tor per-
sons dyini away from homu should be Jiiven in every instance.

h. -Nl^;*^-

WRiTE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD

l>...ar.i t n :, th I N .. *^Y^~. v,:^\-(., REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

,(rv'-.'-o i^-' vu Deputy Heairh Officer

Itegistered vVo.

2050

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco

Gcrtificate of IDcatb

I 11. 5. 5tnn^ar^ )

^

PLACE OF DEATH: — County of

^'

1 U ^' JV '

h

City of ^ CX^^'

4

No.

nd J ^ ^^ ^^ ' '

^ ' St.; S Dist.;bet. OlDcru>a\xi

/ IF DtATH OCCURS AWAV TROM USUAL RESIDENCE GIVr FACTS CALIED FOR UNDER "SPECIAL INFORMATION ' \
V IF DCATH OCCURRED IN A HOSPITAL OR INSTITUTION dlVE ITS NAME INSTEAD OF STREET AND NUMBER. /

.^ N

FULL NAME

0

0

<X\.Kjj dj . U C^ A C

I

PERSONAL AND STATISTICAL PARTICULARS

1. \

Jl

J

r « i! i;!K rii '^

J)V

M..iith' h

D ^ y

/>,n

W I 1 >( 'W 1- I » I iK ! > 'X't >!• r i: 1)

BIK III PI, Xi'J'

iStnti i.T I ■. Hint • \

ci

Cuw

vi

s

<X

N \ M I 1)1-
1 \ I II IK

nil: I'll PL \>K

> i: I \ III i-:h

■ ■ r (.'i It! Ill I \

MEDICAL CERTIFICATE OF DEATH

ii A ri-. I >i i»i; A Til

N't Ml

M..iUli) D.iV

I lIh:Ui;r>\' l i; KTU-'N', That I att<--n'k-<l ilnx-asiMl li..iii

.. ; - 1 \i ^..„ lyo'i t«» Cvclu I I(;0*1

tlial I last "-aw h ■■' ■ ali\c nn w i^u Ti,o

and tliat lUath m mirred, on tin- dati- ^tatru alxtVf, at O. I U
...'. M. TIk' CAl SI-; Ol' I)i;.\rn was as foUnws:

1)1 RAT ION

}'itir

Miniths

Pax

I lout

CoN'Ikll'.I roRV

MAI i»i;n X w! 1
OF \!(>riij:i

^ VI A

f L(xr

^ 1 /

lUK ruiM. Ml-;
• •I Mii'rm'.K

I HAll-A riON

A'

s,;,/ /

)'

1,

/ hJ \

III 1-, AI'.OX'K ^^TATl-'.T* l'KR<()V \1. 1' \R lirr I, \RS A HI-, rkl}-:

> Till

I AT, KN'iiW

1 lllf..Mli;|!lt Sj ,\^<X^

rxd,h,.s ass a ^ S Ub lW,

nr RATION
(SIG

lV(^rs-

NED ) VL- <^. Uj.U

X

p V- «»^ 1^ I

I^ax

/fours
M.D.

I I/O

SPECIAL Information only '<»'■ Hospildls, institutions, Transients,
or Recent Residents, and persons dyinq <iway fro-n home.

Former or
Usual Residence

When was disease (ontracted.
If not n\ plare o( death ?

How long at
Place of Death ?

Davs

>.\ i L I)!" I'.iHiAl^ II' kl',Mtt\'AI,
X TQOS

PI \CH oi- mkiAi. OK ki;m(i\ \i,

w J P

r N I ) 1 •; K T A K i: K U /CX ^-AA.^x-tA.' "-J^ -N^^^o

IS. B. fivcrv item of informntion «hm.UI be cnrefuliy .supplied. AGR should he stated EXACTLY. PHYSICIANS should

state CAUSK OF DEATH in phiin terms, that it may be properly classllfled. The * Special liOormation *or per-
sons dyln^ flwny from home should be (iiven in every instance.

t

,( II. ;i'th i V

WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

i',.-v i- I

/),f/r riJcd , U/elcrA>4J

.Hi I

lOO'i

Rrof'.sf ('/'(' f/ jYo.

O

o;>i

KJS <Xu^

'\ V-i

rv

^

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco

Ccvtiticate of S)catb

! X\. 5. 5tnn^.u^ )

PLACE OF DEATH: — County

ofQ/CX^ 0 AXXavC^UlCC City of CJcu-yv ^ >^<^

N«

0
'\k^.)^\.\: ' St.; Dist;bet. ^3.CuH.^\< and cUwi.C'

/ IF DEATH OCCURS AWAY FROM 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 STREET AND NUMBER.

A

A

FULL NAME

il

L

r

^V-w »

PERSONAL AND STATISTICAL PARTICULARS

A

1

■« >i < Ik

n

It \ IH t

Kill

C

u

:!;i\-

\". I-

to

M \ 1 ■ ! . n ■ 1 )

Ul I X t\\ 1 I > I
' \\ I Itt 111 -

[ f 1' i

X \ M 1 It
1 \ I 11 ! I<

M \ , I iix NAM i;

iUK ri! 1*1, \r I'
111 \:< t rii IK

- : ' ! i Milt I \

\

A

elv

:(T^

^U

V\ >^ 0 XC

Id

r^

(\

V

t ll. I ', 1

"■""'(Lt.

A,<A.

V

THi' \nr»vr. SIX II. I) i'i-'Ks(»\ \i, r AK ri'i !,Ak> \in: I'kn: to tiik
H!--^r<».^^ M\" K Nt i\\ i.t i>' . I-: WD in;i,n: I-

unit V ^ C\ \ \ C^. '^ kJ A^K^KXj^Ka ,..

i 1 11 1. .> m

I 1

MEDICAL CERTIFICATE OF DEATH

1) \ri' ' l! Ill'ATII i: \

%

Miiiilh

/ 0<^

V.,.i1

I II P: 1< l.l'A' r i; k'l'I l"\', riinl I ntU-mUd dc-ciasr.l fn'iii

i*^ 4 : I

, ' i i.,(i 'i to V ^\: . i(p \

that 1 last saw h ali\f on w -. - ^ iqo

.iiul llial lUalll nciairrcMl, on tlu- ilale -tatnl above, at '
.\[. Tlu- C'Al SI', Ol' |)i; \rn was as fnllf.ws:

nik \ lit >N )V</;a H

CON Tkiiu rokv

Moiitlv

Ihiv

llou

rs

l)\'\< \rn)S

}'t'iirs

M^Nl/lS

/hiv

I

Signed )

i.U-4l^'

1 1 it lit s

M.D.

'N,-

KiO

Aa.in-.s) 5 IH \|)la4.frt

I \

Special information "iH for Hospitals, InsliliifiiHis, Transients,
or Rctrnt Rfsiilrnts, and person'* rtvin) awav fron liome.

Former or
Usual Resident e

When was disease fonfrarted,
If not at place ot death ?

How lonq at
Plare of Death ?

Oavs

IM ACl-: <)1' lUklAI, <'1C R1:M(i\\I,

) \'i'i' ..:' i;: Hi \i -1 !•: i;Mf t\ ai.

■ N I ) i: R T A K iv R H u 0 ccdLdU^>v M u ^.M. aKtt^

IQO

fAd.lti

^^as^

1

N. B._,:v..,v U..,n ,„■ ln!,..„„..l„n ,h„ul.. h. .„ne»..Uy supplied. ACE .h„„l.l b, H.a.edl fiX*CTLV PHYSrClANS ,h„„M
HtHtc CMISI- OH nriATH in plnip term,, tha. It p.,.y he properly .lo,»lfl»d. The Specnl ln!or,n,.t,..n »ur p.r-
Bt)n« dyint owny from home Bhoiild he ftiven in every inntsnce.

WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

J )(!((' Filed . U.cl.^iMA^ 1

V,)()\

Bcillsieviul J^o,

'Wvf • ^'•'•m

M

j^^K^KA -iJ->M Deputy Health CfHcer

DEPARTMENT OF PUBLIC HEALTH =City and County of San Francisco

PLACE OF DEATH: — County of

Certificate of IDeatb

11. ili. t?tanDav^ )

City of C' <X,^^ J /v

^r\j vj . wp

C\

A

■^

TS[o I [^iX X.^a - , — ' , St.; i Dist.;bet. JCr^C--.. • ' . and OA.v'

• iP DtA- • '.AV FHOM USUAL RESIDENCE GIVE FACTS CAtLED I^OH UNDER ' ' <^ P E C 1 ft L INFORMATION ■ \

V IF DEATH OrruRRED IN * HOSPITAL OR I^JSTlTUTtON GIVE ITS NAME INSTEAD OF STREET AND NUMBER. /

^ .1) r 1, ..

FULL NAME 'X^cUv\.Cn U, Ix \ . .

PERSONAL AND STATISTICAL PARTICULARS

\ -\

ll,. ^

X

A

a^v

4

r^J: a

Ht »\ 1- SI" \ r

I'l-' U ' t >X \ I. r \ I: I

\K-, \K]: iKi 1 I "• I'll I-:

If 1,1 1,11

1 11 1| I 111, ml 1

JUs

wv-v.

cL Lc

. IIH <

\^ocM5^^iv Ot

MEDICAL CERTIFICATE OF DEATH

> \r >■ I M 111 \ ill V

■ • iI);iV

i\'.

I II1;KI.I1\' t ! Kill-N', rii;!' ■ "m.lctl <k'f<a-^fil Ipuii

ibiil I l;i-1 -.iw

1

i! ' ' till

^^Ji\rX ^H

y^

\

;v'

itioH

li;0 H

111 i lli.r '

d M.

1i I Ki'll I K-'il. I '11 1 ill t':l'

!;<• C \1 >-l: < >1 l>I- A'

• tat I'll :iiiii\t.-

\\

|( )!li i\\

M K A ri< >N

I I >N 1 K

(>i<\ '-J

// /

Mi^nths

iKix

1 A ^ 1

(Signed ) U. > ^^ '

M.D.

■J^ '^D

.,nH ^ (

gp^^l^j_ ify^FORfVIATION on'^ ''ir Hfispihils. InslittillonN. Tninsienls,
or Kt'irnt Ri'sidfnis, .mil pfrsons (Uin'i rt\*.iv from \wm.

Former or
Isudl RpsHli'nif

When was discisr <ontr.i(f('d,
If not al pldifol dpdil).'

Him Imiq .it
Pld< (• ol f)i .illi .'

Od^s

PI, \»"i: < •! IM 1^ 1 \!. '
\ Ni)l- K I'AKHK

\l.

M \'i'

- I< 1M<>\- \I,

N. II.-

' 7T ,. ., AfiF «h.» .1.1 be Btnteil HX^CTLY. PHYSICIANS bIiouIcI

-!;vcr.v item o»' inform,.t!on .houl.l h. cnre»»lly «u,»,.I.e I. ^^J' '^^ " ^^'J;", t^,,^ ••Sp.d,.! ln?ornn.f.on" for per-

HtuU- C \lISf ; OF Di: ATH In pli.m tcrmn, that !t mny be p^opcrI> U..sh,»,ccI. I

«of». tlyinft Hwny from homu nhoultl be ftiven In every inntance.

c
o

M

WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD

Ai REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

Dnh- Fi/rf/ ,\J zXy(AT<Aj 1

VJr)\

Iic^ish'fcd J\'*o,

a053

1

^

c

Deputy

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco

Gcvtificatc of "5)catb

PLACE OF DEATH: — County of ^^^

City of

^

No.

A

/%

(

u

St.;

Dist.; bet.

and

^•y rROM USUAL RESIDENCE give facts called por unocr " special information \

r^DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME I N STCAB OF STRCCT AND NUMBER. J

f D E A T

FULL NAME

^ : \.KMJ

PERSONAL AND STATISTICAL PARTICULARS

I li.i )K

^ t \ K '' n ! t

\

N S M 1 III

I XTiil K

t! %■>

M 1 ■ ! \ 1 1 ■

. I ni 1 K

ir A rii 1

n

rin^ % !!mn*h s'r \ r K n iT K - 1 >N M. r \ K i ! 'I t \

l;| - r I n MN is Ni >\\ 1. I 1 »' . 1'^ \ \ 1 > Hi ; I.l 1 . 1-

^-^ULu XJUv\^wtrv^ 'V*^ K-

\ 1< 1 IK

V V

I i; I'n rn !•

MEDICAL CERTIFICATE OF DEATH

\ ri

M.,r

/(JO :

! lIl^KKIiV Ci:Rril'\, Til. It [ atU!itk-.l tUHxa<^LMl fmiu

— l^p to " Tip

th.it I la->l -Mw h ~~ alivv on " Kp

ail.l tliat ik-alh orrurri'd, on t he <laU- '-tatt.-il ahovr, at
- M 'riu- CAl^K Oh IM: AIM \va< a^ folh>\vs:

u

s^ ^aX^N'n- >'"''^CX.

CON ruiiir i'Hkv

'/IS

/hi

I! u,

DTK ATI ON

-->

'li

/hn

SIGNED ) JV. ^

>VO->

//ruj s

M.D.

JtnX^

,^X

\i)ry%

Special information »«'> t'»r HosplhiM, institutions, rransients.
or Rcient Rfsiilenfs, ,inil persons dsin'j .i\*.t\ fro;n liome.

Formfr or
Usual Rfsidrnre

When wns discasp contrartcd.
If not at plare of deatt) ?

How lonq at
Place of Oeatti ?

Dav*

iM \ri

I ) \ I

r /A) , ,

1, r

I QO

Ad.h.-s bH'b I a /.A. .

L

^^""^^ .. , -^c I, ,..1,1 Ko Bfnteil HX\C Tl.Y. PHYSICIANS should

,. „._nvery 1.1 n, oV inf ,.n,i.,1on should b. carefully supplied. ^^^;;^'^ ^^.:*^'^^J:>:\^,,.u.l Information" for pT-
«t«tc CVUSI or DIATH \n pl»1n terms, that .t mny be properly Uass.t..U.
IS dyin^ inviiy from home should be given m every instnncc.

nnn\

c
G

WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD

! \..

!;\.r r.:

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

n^fjH.

M

DEPARTMENT OF PUBLIC HEALTH

Jtf'(f/\s/('r('(/ 'jVfh

City and County of San Francisco

Ccvtificatc of IDcatb

■A

Q

%'

PLACE OF DEATH: — County of '' ^ City of CJ.<x-y-v 0.V.O

IVo -I ' St.; i Dist.;bet. l^U^ and l^t(

/ IF DtftTH OCCURS AWAY rROI* USUAL RESIDENCE GiVE FACTS CALLED FOR UNDER 'SPECIAL INFORMATION' \
V IF DEATH OCCiiRRjn in A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. J

FULL NAME

.c

LcLa; LoJ

kJYXJL '^^ t '^K. j^-'

PERSONAL AND STATISTICAL PARTICULARS

■^

X^

~> I

• \ i r

I;

\i I

r >t \ R u ! r ! I

I \ I I 1 1 K

II r

111 M' . . ;, I K

' r II 1 K

•■ i' I r \!i( iN

A'

A

rv>x

\ >s

'w^. U

(\

\

Ll^v^^'^^.

u\lL^.l.

L>VQ

■^

in-:"-^T « ii M \ ; iM .1-: \ M> Hri.ii:!-

I". !•> i'

I II !• I- inriiit

(

H

MEDICAL CERTIFICATE OF DEATH

It

I IIKRHBV Clk riFY, That I it

1 1 1

. il I rum

'/

that I ]avt V ,w h

alive nil

iii'
I'l-

;inil I !i;it lU ilh I H-iMi rrt'd, < n t lu- i

\T

latr >>tat(.'(l al>n\"f. at

Thi.- C \I SI" Ol' Di; A'I'I L was .m folldws

A

DlkArHiN )V<//

t'(»N'rRIHl luRV

i/,.//-^

/h

I] •^

1 lom <

I M K A r 1 < ) N
I SIGNED )

Months

Par

l<)0

\

//itlll s

M.D.

h n 1 . A

SPECIAL INFORMATION ""'^ '"r Hi)S(iil.ils, Insfitufions,
or Recent Residents, anJ persons (hir.) .ih.iv tmn tiome.

former or
Usiidl Residence

Wlien Hds dise.isp ronfrarted.
If not at place of deatli ?

ffow lonq at
Pl,i( e ol Dcith ?

'ransiriits,

Days

PI. \i I I 11 I'.IKI AI. I iK M l.M< '^ '^'.

U

' ^

\

r^ «

1) x'n i' I'

Is I

AKiVAI.
TC)0

m

INDKKrAKHH

"""""""""■■"^ TTT n ,1 A(iF should be stnte.I RXACTLY. PHYSICIAINS Khould

B.—Hvery it. m o^' i„form,.t1on nhonl.! I.. c.reVuMy supplied. ^'^1'^^''':"'^^^^^ Th, "SpccU.! Infor.nHtion" tfor p.r-

stnte CAlJSi: OP DII A TH in plain term., thnt it may be properly Uoss.t.cd. I

son, dyina away ffom home Hhould he ftivcn in every instfince.

&■-

^•

i~

c

G

WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD

•

REFER TO BACK OP CERTIFICATE FOR INSTRUCTIONS

i

l)nh FHp'I , \Ji^

V. X

ll)0\

Jici^isl ci-vd v\Vy.

2055

XoA V , Deputy Hesith Officer

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco

Gcvtificatc of Bcatb

11. i?. !^'tnn^al•C^

'V I

m

PLACE OF DEATH: — County of

City (A^^O^-rxj ^KO

N

().

xl

and

, v^ ^ ,■ ' , St.: 1 Dist.;bet. "^ OJ\h.y <. ' , and •■ ■'

/ ,» otATM ,, r ■ AWAY rROM USUAL RESIDENCE GIVE FACTS called for under '^--cial information \

I ,r DEATH /, MRtD IN A HOSPITAL OR INST TUTION GIVE ITS NAME INSTEAD OF STREET AND NUWBER. J

\ 'y

FULL NAME

\ /

.U\.L.V

PERSONAL AND STATISTICAL PARTICULARS

A.

o /

L

L A.'^ -

^^ik_- -^

\W\ iii

niRTIl v\. \i H

fit ! \ rin K

nA ;i

(^

' i I i I iv

L^

A, U-O

\ I I« 'N f l)

d^L

m

^ /

L

^.-^

^^

dL

Tin N I'.i »\'!.: V r \ r 1" I > ri-' i< SI t\ \

i;i:-.r»»iM\ K Ni .\\ 1. t.j " ■ ' ' ^^ ' ' '•'

j I !, \K-. AKK rKi I' ■'■<» ■l■^"■■

fi

1,1,-. 1 » il M N

OCYSJ

I \<\.

^1. <^X^,^vvX^'

MEDICAL CERTIFICATE OF DEATH

DA ri-: i

;>i: \ iH

! );l v>

/Or)

1 II!{RI'I'.N' t"i;Rril-N, Thai I atU-ii-kil .k'» i a>^e<l IniHi

tn

^■4

II,'

A

•hat I li^i ^iw h .. alivf di! '• ■

ami that df I'li < .(a-urrc<l. lui tlu- daU- -^taU-.l alxivi-, al O
' M, TIh- CAISI' or |)i: ATI! was as foll<i\vs:

111 RATION ' )■"?/
(.ONTRllU i'* >I^V

J/(-;.'//V.c

/ ></ ]

//,///

[Ir.

1)1 RATH >N

(SIGNED )

)'.'<ir

Mruth^

K.

K I

/>(i\< tk \ I Ilia s
M.D.

I < lO

Aildrt-ss)

HftH

SPECIAL INFORMATION «nb '"^ Hospitdh, InsfitufiinN Iransienfs,
or Rercnt Residents, and persons dvinq <m.iv from home.

Former or
Usual Residence

When was disease fontrarled,
If not at plareof death?

How lonq at
Plaf e of Death ?

. Davs

I'l.ACH OF lUKI \!, <»R Kl-MiiX AI,

i

1 1 ^

ni,.;rtaki.k Uw'>^.CtiU^. I^^cUUv^

^A^t

^ , u ,,,,. ....fullv Huppn -.1. AGF. HhruMcl he «tnte.l l.X ACTLY. I 1I>S!UANS should

IN. B. !.vcr.v Item otf ir.formi.t -on Hhoi.I.I b. ...fcVuHy f"t*'»"' „^„.,crlv cluW.tficd. The "SpccM.I lnform,.ti-,n" lor p«r-

«t«tc CAllSI. or DI \TH 5.1 pli.ln Icrms. that .t mny he propcrl> .Ium.

son, clyinft owoy from home should he Aivcn In every instance.

>

h
^

c

G

J*^

''^.

»^^.

|i

WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD

Ml) IS.

:'.v\

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

Ddfr Fih'ii , \j <;^u)<t~U\j 1

iy)()\

Ih'i^ish'fcd J\^().

2056

.<^ v,^\^

Deputy

V^ i » I *_» ^. f

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco

Ccvtificatc of iDcatb

PLACE OF DEATH: — County of^<Xi\ ovccvvcc^ec City ofO^X^v

n\

'Sxo

No.

f

I

St.: 1 '^ Dist.;bet. " ^ ' '■^'^ ^ and cLrv^v''

USUAL RESIDENCE GIVE facts called for under

/ IF DtflTM orCURS AWAY FROM USUAL R E. Sj I U t Wt^ t G I V C FACri, i-BUi^tu ► ■-■ r. u f'. u c r,
V IF DtATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF S

S='ECIAL INFORMATION" \
JTREET AND NUMBER. /

I

fO

FULL NAME

H

^CX...

PERSONAL AND STATISTICAL PARTICULARS

»iii.i>k ^ ^ ft

rrv

o.

M A R k :

(

hi

C> Ctx^

\ K M 1 < U

lUK I iiri.At'K

Nt \ ; 1 .} N N \M 1-:
II' Ml I III Ik

HiR I'liri Ai i:

<•'■ m<»!im:r

\l!i >:

(

0

c

^'

Tin \H<»V1 -^T \ TI n i-KR-^MN W. l'\K 11' I ! \ K -■ XKi: i'Rri-.
lU->r»»l MS 1. Ni »\\ I,i;i" .1. \M' 1.11,11!

To riii;

( I I! fi i: tllii Jit

^d

X'ldl t-.s

ou

I , ' I

iX

0 a.<v->->^lJ-o^^^<*-

MEDICAL CERTIFICATE OF DEATH

! Ill : 1 \Tii

Uct^ 1

I ii!;ki-;i!\' c! krir\', 'rii;r ' 'riiiU'.i .i(ri;i>..i.-«i \v>n\

i

t

A . u >

til. it I la^t -aw h -- alivi- imi

aii.l tliat •!< I- 1: Mciirr

J \I. 'Iht CM SI'" ()1" I)I';A'riI was a-- rfill.iws:

IcjO

aiiM' I'll ' i 'v*'

■cil 111) 1 1u- ilatt statt.Ml ahtni-, at S>

0--%

DTK AT ION

C<)N TKinrTORV

Dl'R A'PioN

y'tdj s

.3^

Moiii/rs H

/>ii\

Hours

(SIGNED ) dU . U. ViJ

Pays

)<x. c.^^

I lotn s

M.D.

SPECIAL INFORMATION ""b f«r Hospitals, Institutions, Transients,
or Rrrcnt Residents, dnd persons d^inq .may from home.

Former or *^"** '""^ **

Usual Residence Place of Death ? n,.vs

When was disease contracted,

If not at place of death ? __«

I ; 1 ■ in A I -

t' ^t

i'l ACK or lUKiAi, (iR ri:m< •\ M,

i:M" >\ ai,

TQO'

Atldl f'i'^

• I, I 1 h. ..r.fullv ,.n.„ii.<l. AOB »l.....l.l h« «t«t.H EXACTLY. PHY.SICIANS should

N. B. fivery item oH* ln^:»rin;it

HtntL CAUSE OF DEA . .

sons dylnft oway from home should be fe.ven .n every instance.

c

G

H,,-,^

WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

;th 1- V

♦ »

/}(//(' Filed , \iy /^lijyiy^K: ^

!f)n\

Bcslisfcred J\^o.

2057

^trv.c^v/i

\>^ Dep

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco

Gcvttficate of ©eatb

A

11. 5. StanDarC^

City of Ucw^YV 0 AXX

^

PLACE OF DEATH; — County ofv a^^ ^

0 mo

*io ^^ Xh/ry\XXrY\) UUMi -' St.:" Dist.;bet, and

/ -r OrftTH OCCUMS AWAi FROM USUAL R E S I D E N C E G 1 V C FACTS CALLED FOR UNDER SPECIAL INFORMATION
( ir DEATH OCCURRtD IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER.

> \^^-. ' ^-

)

FULL NAME

OuAaX^ .

PERSONAL AND STATISTICAL PARTICULARS

M I LclU

s^

"^

I'

M^ i-

! > < » k

HI!

' St

X \ M 1
i At II

luKr

« »l

K

M MIM Ml

I ■' Ml 1 in IK

ufK rm'i, M'K
'ii %!!iriii:H

•ill r \ri« IN

H5 .. S

0

A

A',- ,A-,^ : H S.'i; /

rin" \r.< i\'i* ^r \'ri:i>

ni> i' <)] MV KN<

, I J. \K IIi'lM. \Ks AK

! WD ni;i,ij:t-

*Kri-: TO Tin-:

(In f'i- tii'tut

MEDICAL CERTIFICATE OF DEATH

\ ri; < >i in: \ TH J/

Muihh)

I ili;i^ i:r,V C1{RT1FV, That
LLcCQ -^ iuo'3> to

t 'iO i.,oH

that I last ^a\v h '■•-' alive on ._■-,.'. I90 1

:in,| that .Icalll -.(MMirrcl. <>ii tin- date -^tatcil ahovf. at H H.

^

M 'rile CXi'^'!'" ('L^Dl.ATII was as follouv;

H^ 0 ^' .

YX-O

, i "S

A^A^WvXr^

4

nr RAT ION )'(;;

coNTRir.r'roi

Moulin

/><7)s 1 1 Oil y

n 1 K A T I < ) N
(SIGNED )

I. ■

liirs

jrnuf//.<i

IhiV

'i'

I lours
M.D.

X.l.lres.) U-4A/VV^0,A^ ftp CH^M. J„O.J

SPECIAL INFORMATION <»"') *''r H ispitais Institutions. Transients,
or Recent Residents, and persons dying away from liome.

■ IxXA/UAvt

Death

Ddvs

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

U,tl,

I'L \CV < n IMiyAI, (»K KKMi |\ M-

U l-Mt >\ AI,

INDllK TAKlsK

-^

Addit ss

IN. B.-

'*!

' TT .^p should be stated RX4CTLY. PHYSICIANS should

-Every item of information should h.- cn.otuU.v suppi.e ^J^Z^^^A, The ^Special Information" for p.r-

state CAUSE OF DIZATH in pli.in termn, thot .t m»y be properly Uass.t.ea.

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

s:

wwntpg-

.i%^

^

II

^%ik

WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD

,,! !l. .ilih 1- "-

luv r <•

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

Dah' /'^ifr(/ ,\^ zk^>-^K' X

lt)0\

JiCiiisfet'cfl v\7>.

2058

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco

Ccvtiticatc of Bcatb

PLACE OF DEATH: — County ofwCtiv

Tr\

^

City of '.OAA^ v].va.iv^

V

(\,

a

No.

f -,

^ ,. St.; -^ Dist.;bet.M t wO ^-' and^nU4.4-

/ ;r OtATH OCCUPS AWAY FROM USUAL R E S I D E N C E G . V £ FACTS CALLED FOR UNDER '■•"'" ^ <^ '* "-j;^ ''^.^^f^^ '° "' )
( .FDtATH OCCURRED .N A HOSPITAL 0« INSTITUTION GIVE ITS NAME ,N3TEA0 Or STREET AND NUMBER. J

4 r-

FULL NAME

^l [La^u

4 I ' ^^'-

PERSONAL AND STATISTICAL PARTICULARS

St 1 ! . t > K

t °% *

M Mt|< tl"!>

A

%

HVi

o

i r-k

ii • ' • 1 1

\ r in K

^.k 11 '^

ill NfOTIllR

. i Ii i:h

I . Ill lit 1 N

A-

"^^

Tnr MinxH htatkii im-k-hx m. pah nrt :. xk-. akh ikts: t- • ini

l;i-^r<.i MS lsN<»\\ I.l J>< .H \"^I» J^l- '••'

(Illf ,; ni;iiit

A.«.>^..

-U.

\

\ %

MEDICAL CERTIFICATE OF DEATH

\ '' \ I

ii lu: \ 1 n

f

ii.is-

! I!!:K!;1!N' t i:k'ri I'N', Tliat. l attc-ii.Uil «UHr;i-.cil frnni

il,,,t I ! . I; .ilixt nil Cn^l. -"wUviL^ a.cv

an.! that thalh ■.<. arrvMl, .ui tin- 'late -tati'.l ;,1h.vi', at
^ M. Tilt- (' \l ^l^ Ol- I)! \TII wa-. a- t"f)!l<nvs:

-!(

CONTKIIUTOKV ^

Months

Pays

1 1 1)11) <

1 1

Ur RATION'

(Signed) J C

Mo)iths

Pays

M.D.

V.Vl\,

Special information ""I^ ''••' Ho^PiMs Inslitutions. Trdnsients,
or Recent Residents, and persons dvifii) dw.iy from Ijonie.

Former or
tsudi Residence

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

HoH lonq at
f'Idce of Death ?

Dd>s

J. I \oi' ni- IHRI AI, ou ri;m«ivai
r.NI.l.KTAKKR VwO.^^C'wU- ^^ O

i»A ri; ..; Hi v.\ w <•• k!:m<>nai.

TOO

N

(Atia

H's^ <k.H. w

/0-/W'

"-* — i— ^ ,. , TTp „H„i,u| be sti.UMi liX4GTLY. PHYSICIANS stiould

N. B.— r.vcry ftc,„ o* i^V^,rm„t!on shoul.l be cnrcfuHy -r>»> '^ ;. Z]^^ f;;^ dosslfled. Th. -Speclol Information" for pT-
Htiitc CMJSF. OF DEATH In plnJn terms, that it m«> >- '* ""^'^ ^
«nn, dylnft nwoy from home should be gUen In «very .n.tnnce.

c

G

SSgiM£Z^^^

L

I

WRITE PLAINLY WITH UNFADING INK — THTS IS A PERMANENT RECORD

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

1 N.

I'-.-v !■

Jifo/sfr/ if/ .jYo,

2059

Deputy Health Officer

DEPARTMENT ot PUBLIC HEALTH==Clty and County of San Francisco

Gcvtiticate of IDcatb

^0

PLACE OF DEATH: — County of ^^arv

J ^

\ n

< ^' City of d/Ow>\. J ;uOl > V c.cA

Ml

?4i

,j^tv l.^«^ku ob(v4>v-^"^ ^^

St.:

Dist.;bet.

and

/ , - orATH OC-URS AlWAV FROM USUAL RESIDENCE Give F«CTS called rOR under "special INroRMATION' ^
( ,r DEATH OCCURRED IN ThOSP-TAL OR INSTITUTION GIVE ITS NAME INSTEAD or .T«CT AND NUMBER. J

FULL NAME

\.(1Xm

)(rr\xSJ

u

PERSONAL AND STATISTICAL PARTICULARS

LL', '.

(\

I . li nik in

a^'

b

N \M 1 Ml

I \ rn IK

if ^

'\^y\j fllD crv\>

< »1- MmTIIHK So il

luu rniM, \( V,
(•I \;(i'nn:K

(T)' W\' >N PTn '

LtA-v

^^

uu

T!!!- \nnVI- sTXTVH I'KR-oNAl. I'XK'lUr

r.AKS AKK TRVK Tn nil-

(Iiif(.nn:i!it i '

CQ^ J C^^-^

.U.I.... 3H50 ^ inl!.^ "t

MEDICAL CERTIFICATE OF DEATH

DAlli ill- I>i; \ IH

Ni'.lit

!!:ivl

1 II I:In I". I'.V CI'.KTIIV, That T atlLMitUd ilf.r;i«>.<l Inuii

that I last -aw h . ahvc on t</'

atiil that lUalh occurred, <»ii the <hitv -tateil alu.ve, at H
\\ . The CAl'Sh; (>!■ hl'.ATII \va>- a- fn!l,.uv:

Co ■ ■

a>.

1)1 RAT ION

I 0

) N r R I r. r T <> R N' LxX^^-C^'TL^Cr^^ vO^M^\>^-<i/

//(!///'?

A C

DIRATION
(SIGNED ^

IcX.

Vrars

Mn*llll>

Pays

T«in

f AiMress) '

M.D.

>. <, A

SPECIAL INFORMATION only for Hospitals, Institutions, Transients,
or Recent Residents, and persons d> in] av^ay from liome.

'^X.C > V V.

Former or ^

Usual Residence J

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

How long at
Pldce of Deaff??

Oavs

i-i.ACi-; OF nrKiAi, « ik •; iM' 'V \i,

X ['K of ncuiAr, or Rl'Mn\\I,
% Tqo'

at

(Ada,... iHlli ^^\.^-^^^'s\.

!N. B.-

-"- ... AnB should be stated HX VCTLY. PHYSICIANS should

-livery Item of informnf.on should be ^nreVully f"nP •;^^- ^.operly classified. The "Special Information" for pT-

«tate CMJSF: OF Dl:ATH in plinn terms, that it m.«> be pr< p y

;in. dylnil oway from home should be felven In every .nstnnce.

c

G

M

WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD

1, 1 V.

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

mm

'\, Depuc h O^ -

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco

Certificate ot IDeath

"Cl. S. '-•tanJ.irC

PLACE OF DEATH: — County of

■X

"\

n

City of ^^CU^rv '» \0

^i.

No.

^

A

Aaaj

and Al C

(

St.; ^ Dist.; bet. M I U^^QAm^A;

^.. orrun- -^Wfty FROM USUAL RESIDENCE give facts called for under "special .NrORMATIOM' "\
.,,.M nr-uRRED .N A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBCR. J

'■^'^ A C' ^

n

FULL NAME ^ h^o^

PERSONAL AND STATISTICAL PARTICULARS

rs ;

u

%;. h\

I

'N

I

dct>v

1

u.

N \M
111 K

lUKrniM, \ii:

mt I r \ r 11 )N

(\r '^

C^y\A)

t-

] r

ml

> 1 r> S

I \. !.;!.-■

i ()\l,l^.v1 ^^

MEDICAL CERTIFICATE OF DEATH

I! XlK < >l l>i; Alii

4

I IIKki;n\ I IKlll-N. That r :ith!i.U-.l .Ilh t ,i<e<l I'r.

nil

tliat i last saw h ali\t "Ui ''

and thi* ilraili (iri-urrr.!, i.ii tlu- <latt- vtatr.l aliove. at
M *riK- C \l SI-; <»1* hi:. \ I'll was a^ foll.nss:

, J r^

ri . "

„^A

/-S - - r^

CnNTKIlUTnRV vWu>-

Mo^iths

r-v

/>^7r

i_, VA.-

Hcii^

Signed ) Lo^^toa^

Ho Ills

M.D.

SPECIAL INFORMATION wN *»r Hospitals, InNliftilionv. rr.insifnts,
or Recent Residenis, and persons dvinq dwri% frfiT, hnmp.

Former or
IKii.il Residence

Wlien was disrasr i nntrarted,
If not at plare of deatti ?

Htm lonq at
Place of Deatti ?

n.iv^

PI.A01-: >tL' r-i K 1 \i, < >K K i

c^LoJuu^:

\

DA ri

_Q^.

-s'

i:m<>vai,

'4
TOO ',

,. , >nF s'v>uld be stated I.XACTLY. PHYSICIANS should
N. B.— Hvcry Item of Inform .tlon should be cn.etully f"Pr> -d ;^;J;^,^^,^^^.,f.,d. The ^Special Information" for pT-
•tau. CAUSE OF DLATH In pli.m terms, that .t may he P^''P^'"y
"n. dylnii away from home should be felvcn in every mstance.

c

G

m^

•r*^^-

1 .

WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

«« ■**»*^

uKl- c<,

{\

\_'

Ifff/

Deputy Health Officer

Ju'iji sfcrcd JVi),

2061

DEPARTMENT OF PUBLIC HEALTH-City and County of San Francisco

Certificate of iDcatb

1 1

PLACE OF DEATH: — County of C

No. oL L v^*^Lu. ^

(IF DCATH OCqunS AWfiir FROM I,
ir DEATH dcCURRLD IN A HO

O.

4

V - 1 City of O

St.;

Dist.; bet.HllU^C

O

vXOAXand

\

i n n ' .

USUAL RE S I DENCE GIVE facts called por under special information \ \

SPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. J U

FULL NAME ^ Lclt\

V I

PERSONAL AND STATISTICAL PARTICULARS

fi i ' '1.' 1^

\ I VI

/''^

>^

L

5

H

rk, -

A

r^

il W I wS.

^ IVct

MEDICAL CERTIFICATE OF DEATH

I

K.iv

/ f>( '

lint I 1
tiii| I h ■

i,,.j'v to • ^' "^t) I r.ioH

' y h alivi- nil W " V l.,n" .

h ' Hiurri-tl, on till ilatc statril ahoM-, at -

M. Tlu- t \

i<\ Dl \TII \\;.

1)1 UAl'loN )V</r

C( iNTklin I'f >KV

A/o>ii/t

fhiy

Ili'Ul

t^

Q-vcvcec

I'l \> }■

' . ^i ' 1 1 1 ( 1

;• K I II IM, \i-

» ri- \ ! h IN

V

l

^a L

\j

I HI' '>

1.!

\< i\\ 1.1 "i' <

I Pt.R^oN \I. I'XRTh I I. \H'^ NNi; TKrH k' I
i\\ I.KIii.K \ A

"-?

Cj (^V <x^<i^

\.l.ll.-.v

)^K/VVw<b'V"^-^'LjL CoJL'

Dl l< A in »N
SIGNED

J/-

'///I

LC

M.D.

! I in

f AiMn--'-) HOX

a.A_0 1 W i

Special information »"'> '"f Hnspildls, InNfitufions, Transients,
or Recent Residents, m\ iirisims dvini -i^''^ '"'" '"•"""•

Former or
Usual Residence

When was disease (ontratted,
II not rif plare of death ?

How lonq at
i'ld« r of Dcitf) ?

Days

rxnKk

aki;h Lo^OU-aX

^l

I QO

>

^

Aa.h.s^

k^ \j<xjy\j

•WNL-

N,

H._,..,,, Item nV into.m.f.on should b" cnretully MuppI.e I. '^"':;,7' '^' ^^^^^ t,,^. -SucciHl Intormr.tion" for p,r-

HtiiU CM SI OP DliATII in plain terms, that it may be properly .l»s«.t.ed.
IS <lyina i.vvay from home should be given in every inHtnnce.

noni

c

G

i^wmwip

■

1 ■;'

1

i

i

;

i

'I

1 ]

1

WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD

"v -. ! r . REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

% Deputy Health Officer

Jfr<j/s/rrr(J A^o,

2062

M

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco

Certificate of IDeatb

cap

4

PLACE OF DEATH: — County oi

City ofClXX

• , 'I

No. V

.ouC

StU

Dist.; bet.

1 r ! r A T H f I

r i) ( A T H

»./,*v rHOiV' USUAL RtlSIDENCE GivF F'lrT*; «- a

(?RED IN AHOSPlTSL OR INSTITUTION C, IVE 1^ NA^/l

and

FT FOR UNDER _ _ i A L INFORMATION" \

A I NSTFAD Of STREET AND NUMBER. /

A

^

tl

FULL NAME

/U-c'

PERSONAL AND STATISTICAL PARTICULARS

h

LCUU.

X

^.

>

'V

b

1 M \k

1 ' >

1 !)

A

il ».K

>N

in

1 1

(1)

y

u^-

k n

Nf.il,;!

,„ S,ni I I

111 I \H()Vi' ^ r \'! rti vvM

HK--^ r ni MS I. Ni p\\ !,1

\ R< \ w K iH I 1-: I ' » I 'I •

^

MEDICAL CERTIFICATE OF DEATH

;i; 'i_-IliU'il (It ( < I

iN .a;
-I'll t II Mil

I (111

lie

;il|i I Ilia'

hi R A TM »N
i;(t\Ti; iiirToRV

III R \ rh 1^

\ 1 --. 1 { ( » !

Ml- (latt

lu: \ r

c &=

•i| a I )( iVf a'

a^ fnll.iu^

M^h

t

'UC'

/>./rs

Ihuys

•r^\

IhlVS

Signed • L^X-cmJ^v J ^u5.Uj JjlJUMx^

l^ in

M.D.

SPECIAL INFORMATION •►n!\ Jir Hospi
or Recent Residents, and pfisoiis dsin'i .mnv from lioftip.

als, InsfituTiohs,

tnrmer or s f ^,. . 'm' ,

I'sual Rfsidiriip ^

When w,is disp,)sr ( ontr,ufed,
|[ not at plare of deatti ?

tfrm IniKi <if
PIhi c lit flcifti ?

[idH'^icnts.

n,)vs

•1 \CJ- » Il V.\ V 1 \I, "

\X:

1 QO

I NI)IJ< I \l- 1 i;

\-Mi' s"

'^5ivy>v

SCSI-'

N. B.

, TT ;^pp Hhm.ia l»c stnte.l HX^CTLY. PliVSICIAN>i Mhotild

r> item oif inf..rmut loii shoul.l «'^ oi.-u>ull> svippli^u. • • . .. , y,,^. -SiKciH' liiformit i.ii" tor p-r-

U- CMISi: or DI ATH in pl»in terms, that It mnv he properly .Iuhs.UcU.

"fivt-r:

• tote w ,»,.,.- -,. - . . . »„„,.„

mnnm dyinft nwny iVom h«,mu should he ftivcn u, overy .n«t«nce.

c

G

t;«:

WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

t 1

](ri>isfr,'(ul JS^O.

mm

Deputy Health Officer

DEPARTMENT OF PUBLIC HEALTH-City and County of San Francisco

K^*U^

Ccvtificatc of IDcatb

■a. 5. t?tnn^ar^

PLACE OF DEATH:— County of av

s

CU^CC City ofw

N<,. ^\Xc\,^^ LcrWW'

St.:

Dist.; bet.

and

^ ( ir DEATH OTu^, & A' » V TROM USUAL RESIDrNCE GIVE FACTS CALtED ^OR UNDER "SPfCIAL INEORMATION \
1 V ir DEATH OCC4jRRID IN A HOSPITAL OR IN' ' ' _, n O N GIVE ITS NAME INSTEAD O? STREET AND NUMBEH^ /

FULL NAME

--^

■4-

PERSONAL AND STATISTICAL PARTICULARS

^\

n

^ u I

^

n !>

4 1 lavvct-<l

0

K

(n^^^xU ^^^

OA^cLo

MEDICAL CERTIFICATE OF DEATH

li

r

lllMl I 1;

ail'!

^\\ 1

I I ill

r 11

N , ,'I 1

:-t. ll t 1' III!

I(,0 H

1 UO i

M. Tlif C X

■ ' ' ' : ■ id a hi >\'«.', at
il l>i: ATM wa-^ a- fo!]^ u-

//.

M 1

%•' nil iJ<

IM, \r>

.1

0

I

I<.N(^'

ni>i

u! MV K Ni iW I.llttU-; \M» i;i l.:i :

ri » I'll I-

\>M'

mi'wvxsj

^

vvxs-.4x^

/>

n'v

O

//I'l/rs

M.D.

\.

SPECIAL INFORMATION ""l^ J'lr Hrispitals, Institutions Iranvirnt
or Recent Residents, and persons dvin) ,ih.iv fnvii linmr.

.U^

Former or
Usual Residence

When was disease confrafted.
If not at plare of death ?

How lonq at
Plare ol firaft) ?

I)avs

I'l \v'K or Hi U ! \i. < >i^

\ 1

Xlv. ^v^Yvcv.

ti i\ \i,

I qo

rNlU- K I'AKl- '<

(Ad.lr.sv oU'

^'J

I 'T I ' 1

'~*'"'~'"'"""~~""'~~"-~'"— """'"■ Tm IlTd \nF. shouia be stntecl KXACTLY. PHY.SICI ANH «houlcl

N. B. !;vepy Item ol" inV* >rmBtion should b." ciirctully siippii<-«i. ' L.^^ii?!^.! The "Suecial biforiii:itHHt' lor p«p-

«t«te CAllSr or DEATH !n plain tcrmn. tb„t 5t m»y he properly .lHH..t.ecl.

son. dylna nway from home should be j^iven in every instance.

s

9

■f

c

(

r

■•pa*'

^

i

« ,

WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD

RErER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

Hiiai ' if III Mil IN.p 1' '5--v:'3r|;^5 liS: I' r.i

^

/)/(/(' F//('f/, L/cL(rlK.^s 5>

HJfn Eeg/sfr/rd A'o, 20G4

d^\^ov_xs Xvwu Deputy Health Officer

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco

Cevtificate of IDeatb

( XX. S. StanDarD )
PLACE OF DEATH: — County ofU-O/^W J K<Xm/lA>U^ City of C)xXa\; O \.a tvC^UK^
No. li 51 0 (ruMrnPy\: St4 4 Dist.; bet. 1 kJX) and ^

(IF Dt»TM 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

>!.\

!i \ ri: 1 ii i. IK III

PERSONAL AND STATISTICAL PARTICULARS

^

4-

M. nth

.t

MEDICAL CERTIFICATE OF DEATH

KATI-, (•!• Dl'. \Tn

\

i nav

Ac.H

1/

/'.n

^IN«. !,l MAKHII-.I*

\\ \\n (Win I >R I»l\( iRi 11)

Wilt' ; !i -I II ' ' ' - : s.' ii.it ii ill '

■^t -• 1 I >; < '. iuntr\'

^

L>xa

t

■1

I- ATI! i:k

i; IK rii I'l, \i}',
»>i I \ rin-K

ist.i!, I.: (oiinttx

%! \II»1"N- NAM I
ni- MnlHl R

lUR llllM.Al'l-:

Ml M(»rin.;R

' St.'itr or (.'(Mint 1 \

' l\c Vq aiv i^ \x >T > \ a r

^

IL'tt

(Month)

3

'l>avi

(Year)

I IIl':ki:r.V C1;RTIFV, That I att<.Mi<k<| ilcnased from
V^X-l^t aO iQoH to ^'tt; ?>

i(p*(
T90 1

that I last saw h OYi alive on C 'ZXj 'h

and that death occurred, on the date stated altove, at \

U. :M. The CAI'SH Ol" DliATII was as follows:

nr RAT ION )'iU7rs

CoNTRIiU'Tol

A f Of ///is 3. /)(iys

11 out

\\ LLojCLl Uj \>0-"A,c4vvXtA

^i\\A^U^vl

t\^vlLa

\i<>jysJXKK^OJ

\

C/AJ^Lc-^-vd-

ot'CII'A TIDN

Kf'^niffi in Sail /'> ,i h, i ^r-t

)', ,1

.1/.

..*////' 2,

/',n

Till' \HoVH STAT1',I> I'KR-^nNAl, 1' AR PliT I.A KS AKI-: TKIK T* > 11 IK
Hl>r Ol- MV KNOW I.l.Ix.K ANDiilLn'!

(Infotiiiant

^HWq

\

niRATION

(SIGNED)

]'tars Atou//is 1 0 A/vs'

J ^>

Iloui <>
M.D.

^/tfc ^ i<,o^ (Addrews) lUH 0 Q^<Ur>Vu ot

icyt^

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

former or
Usual Residence

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

How ionq at
Place ol Death ?

Days

1M,\CH<>I HlRrAl, OR RKMoXAI,

i)ATi-;.)f lUHiAt. <»r rj-;movai.

Udarcss . 1 OS' 1. A} I'U^AUt^X .J.

N. B.— F.very item of inWmi.tlon should be cnrefully supplied. AGE should be stated EXACTLY PHYSICIAIN8 should
state CAUSE OF DEATH in plain terms, that it may be properly classified. The S|>ecial Information for p«r-
8on« dyin^ away from home should be feiven in every instance.

i

I I

WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD

•th f V.

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

^

J)ff/(' Fi/f'f/, L,I^tcri.^^' ^

If^O'i

Be<^isfere(l JS^o.

2065

<^v

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

Cevtificate of Bcatb

PLACE OF DEATH: — County ofJa-^v 0 Vavvcc^co City of Oa^ 0 ;v<X>\ c uix^o
jVfo 1 Ul V a CU St.: 5^ Dlst.;bet. X\.-)\A.> and 3.3^.<i

/ \r DEATH OCCURS Aw»y rpoM USUAL R E S I DE NCE give facts called por under "special information \

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

FULL NAME ^.V^ a ^v

Ka4X

PERSONAL AND STATISTICAL PARTICULARS

>

n

iR \

U^

1 1 I'^du

:^ /^■ L—

/tS5

\ t ! :

^H

]■ M \H l< I»

1 \

LI

Lr^^

V • ^ V Ca.

IlIHTIII'I.Ai 1
(St;it«' or t'om I

X \ M 1 I »!

1 \ III 1 K

lUK 1 II ri, \r )

M ^ I 1 il N N XM I
»>! Mi»SHi;i<

lURI'lII'I. Nri*.
<•!■ MMfMHR

' St.ii' 1 >i i'l Hintt \^

V>X'

.0

u ^^^

vav.A>iAX'r\)

. 5

1 , .7i

M. uth>

iHcrr A ri<»N

■\-\\r M'.<(\-i* ST \ri n iM'-!<'^nNAi, tar ricn, \k^ ari-, rRii-: r<>
1,1 --r ui MS KNDW i.i'.ix'.i'; AM' ini,ii;i'

/'.M

(Iiir<i!iii;iiit

^Qx^

JC\XX^

\.l<ll.ss

A

H,'h\ UA.CVOLA^^-fi-">^

X<5

MEDICAL CERTIFICATE OF DEATH

DA ri-; ' >i iii;aiii i \

l^'ct

(M iiitlii Davl (V.:ii>

I Ill'lKlir.V C1;RTI I'\', That I .ittrinUd «K(r.isc»l fnnn

that 1 la-t ^aw \\ -^S) ahvf on *^ ^ ' lyoH

and that lU-atli .HCiiirt'<l, on thi- <lati -tateil almvv. at H

i^^lj M. Thr cwi'si-; or hh; \rii ua^ as rnii.-ws:

V

DrkAI'loN O )'t'ins
i( )NrR I lUTORV

< ^ '

MiDiihs

Par

Hour

DT RAT ION
(SIGNED )

)'( ay$

M,>)it/is

I

/Vfr>'Vu<X^

^1 ^

/hivs

I Ivios
M.D.

l(>n

H

A.hlrLss) SIH UXX,LLvV^.a.'^"'

Special information on'y for Hospildls institutions, Transients,
or Recent Residents, and persons dyinij .m,iy fro:n home.

Former or
Usual Residence

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

How lonq at
Place ol Death ?

D,<\>

» WW (i! Hi RIAL i>i R I Nil i\AI,

IQOH

ij^ H

.. 1 4nP =^r„,l,^ ha stilted RXACTLY. PHYSICIANS Hhould
,f 1nfo.n,.,ion should b. cnrcfully Hupph.d. ^^J' f " '^i'^,,^! /'^ ,nf<.i.nuf.un" for pT-

; OF DliATH in plnJii terms, thnt it m»y be properly cluH»i^i..il. int. , .»c

IN. B. Bvery item nV

• tnte CAlISn _ . . ^_„^^

lions dyinft iiway ?rom home Hhould be fe.ven m every instance.

^WJW_JJPUP1

mfmmmmmm

WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD

:,<,) iif Hi :i!ll! I

No ; ^ -f*^^^ IS.t I' O

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

Dftfc F//r(/, L -[rlcrAMAj 3

jorn

Jfeo^i.sferrd J\^o.

20G6

\

^

cLtv V- -.VI Deputy Health Officer

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco

Ccvtificatc of E)catb

( XX. S, SranDarD i
PLACE OF DEATH: — County of a^^ A/X nxCUXM) City ofU>a^A; J ^X>Ct/VLCA,A/CMi

No. 3.HD

4-

-v<X^^q\fc^x St.; i Dlst.;bet. ^txXWULtm. and^KLLO^y^k )

/ IF Dt«TH OCeflWS •WAV 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. Aj

FULL NAME >ta-^-v ■■ V.lci^C\d

-•l.\

PERSONAL AND STATISTICAL PARTICULARS

1 N

HICL^..

IL'vJii

MEDICAL CERTIFICATE OF DEATH

DATl-: I >I I>I. Al'H

1

Let

!»A*I i; Ml HIK in

lU

4CS

\i .]•'

*^ IN '1.1 MAKKH 1>

WllM t'A »• It < »H Iix . r. 11)

U ! It. Ill -... !.i' ill -iy n.it i.'iO

H

L^ va^^

HIK rnri. \t"i'.

iSt;i!i 1 i! 1 '. uiil' \

N \M 1 t »1
I ■ ! in K

lUK riii'i, \»*i.:
Ill 1 A rii!:k

■->t I ' • lit (ill"!

<»1 MolllJ K

lui' I 111'!, \ii:

't| Moflil K
->taSi .! t'liuiit I \

vtVv>\ Ll^u^cl
' \ \ ^' A

iVtatl

(Month) n.tvi

1 in.RIJ'A' C IlkTII'V, That I atftn.U.l 'IcfLiiscd fn>ni
\t m 190 i tn U'ct^ 3. icpH

\

A

tlial I last saw h -^^n alivt- on V. tAi X up M

iin! that (k-atll iHi-iirrt'iI, (»ii thf datr statiil ah<ivr, at ^
U M. 'I'hi- C Arsl-; (M* l)i;.\ Til was as follow^:

LIcmJIx L^vbjVO ^^OU/^i

coNrkiiuroRV

A/o////ts \ Days //o.ns

DIRATION }'fars

(SIGNED) ;>UU>

^

Mouths

/hiv

UU^y\ uw

/

<»i'r\i' \ rioN

fsf'itifi! Ill Siiii /'ill II. ' ' ) 1.1 1

rm- .\H()\ i-: sr \ ii ii i-kksun \i. j'\k ih n. \i'> aki; tki » r< > rii>-;

llI'lS'l'tM MN K N< i\\ !,) IX'. !•. AN|) lU I.II'.I

1 M,.iitl

' lufotiiirint

10 ^1\; H. CcxXK^

\.l.!i

1%

d^<XaA^oA^^

c^t

C)<ib "X ii|o\ f.\.l.ln-ss)'t>0"l IXVO-Ah/

A

.0^

Hours

M.D.

Special information mIv tor Hospitals, Institutions, Franslents,
or Recent Residents, and persons dying anay from home.

former or
L'sual Residence

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

HoH lonq at
Place of Death ?

Days

I'LAt,"!.: <>l- I'.l HIM, i»K Kl.MiiNAF,

INDJ.KTAKKK

DA TK lit lUHiAi. or H i;Nti i\AI,

V.' €fc 3 T90H

\(l<!i<>;s

in I

A

l\

ft >.

■\

rV

, .. 1- I AHF Khould be stated EXACTLY. PHYSICIANS should

tS. B._Kvery Item o^' Infor.nntion should b. carefully -ppl.ed ^J^^^^^lll^^^^^^ ..Sp,,j„, ^formation" W pT-

Btotc CAIJSK OF DEATH in pluln term*, that it mi.y be properly Uassmea.
son. tlylnft aw«y from home should be given in every Instance.

f !

t

WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD

!I. :!i); 1

l'.."vl' 0

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

l)(il(' Filed ,

V,

4

,\. 'h

l'.in\

]l('i>i,\lrri'il jYo.

2067

Deputy Health Officer

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco

PLACE OF DEATH: — County of

Gcvtificatc of Bcatb

itv ofO<X>X. J.*\_n^ > ^ ^ ! <}

City

0

U

No, N-^^<-

^. *w >

. >K

St.;

DE

STI

Dist.; bet.

and

\ / ir DEATH OCCURS *W«Y F R O P>$ USUAL R E S I D E N C E G I V E FftCTS CAllED ion UNDER "special INFORMATION ' ' \

' V If DfATH OCauRRtD IN A HOSPITAL OR INSTITUTION GlVf ITS NAME AO OF STREET AND NUMBER. /

FULL NAME

,1

"^JXXXxh

\ I

A

PERSONAL AND STATISTICAL PARTICULARS

if H / '

\' I

: : S M \ K !. I ! t i

i\ I I H i\\ 1 1 i ( I K

I ' I

I II

ItlH I'll 1'L \"J-;
I i! 1 \ in I R

M \II>HN N\MI

<ti m<>thi;k

lUK 111 I'l, \<K

>'i MMi'iirK

I'll' \ riuN

MEDICAL CERTIFICATE OF DEATH

i» \ ri-;

r\

1 llKkl-l!\' r 1:1nT1 I'N', Tliat I attituUil «kH-iavi-.l fnuii

tllal 1 la--t ^,ii\ li * ' ' ali\«/ nil

^

r

TikT

aii'l that iltatli > h ruiri-il. <>:' 'he dati- •-tatril alioVf. at '
M. Till- (■ \i>>l-' <»1" l>i;A'i"ll \sa- a- foUnws:

<?^y

V r 1 ,

iS\ XaxX Qv

v^.

1)1 RATH iN

I < (NTH 1 lU '!<ikV

) i iN

.)/i>////lS

/I

1 lom

\

/

/

S,;,, /■

\

\

'\ T ST NTH I) I'KR-,. >X \l, l'\KT|i'ri, NR-^ \KK THI l- I' » I

111 M\' ix\< >\\ !,i;i i< . i: \ n: > hi i.ii'f

III-:

In T'l-iiinnl

y ^1 ,

, I

I ) I K A '1 I <> N
(SIGNED )

^%

Motilh.

fhiv

^

M.D.

!<,'>

Special information nnly for Hospitals, Institutions. Transients,
or Reient Residents, dnrt persons dvini m,\) from liome.

Formfr or ^ , i

Usual Residence ^

When Has disease rontrai ted,
If not at piai e of dealfi ?

How lonq at
flare of DeatI) ?

f

Dh\^

I'l \cv or in RI \i, i>i< 1^ i

Ml

I) \

k i-;Mif\ \i,
TQO'

I ni)i;ktaki:k

m

VL

Addi <ss ob li- ■ i * ' ^ > ^'

^ 7\, ,. , AHF should be stnte.l n>:4GTLY. PHYSICIANS nhould

N. B. Every item oV inV'<.rm.ition »hmil(l he cnreVully supplied. a . ,„^^\i\^A The '*.Snecia! InformatM.n" for p»r-

«tHte CAlJSi: or DI:ATII in plnln terms, thnt it m»y he properly wlus«.*.eU.

son* dyinft owny from home should be given in every instnnce.

c

G

r

h

H

m

w^

WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

De

IfJO'i

u •^ .«v^

Me^isfercd J\^o.

2068

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco

Certificate of Beatb

"a. S. StanDtirD

(^

No.VC

PLACE OF DEATH: — County ofOCc^^ J/uOL-rxoUt^o Gty ofCj<X^^ J\<X >

v<"<.^ <" (

(

St.;

Dist.; bet. and

.„ -i - ---- ■• ■ ..».». ■^.-^ FACTS CALLED FOR UNDER "SPrriAL INrnRuaTin

.r DtATH AJCCURRED IN A HOSP.TAL OR INST.TUT.ON GIVE ITS NAME INSTEAD " STR EeJ AN D NUMBER

ir DEATH OCd^RS AWAY TROM USUAL RESIDENCE G.VE rACTS CALLED TOR UNDER 'SPECAL .NTORMAT-ON

FULL NAME

)

fWxA UriLL

-1 \

PERSONAL AND STATISTICAL PARTICULARS

MEDICAL CERTIFICATE OF DEATH

n '

• \ n ( »! i;!R rn

\<-i':

a

H^

M

\

.111! hi '

b

:):iv)

DATK ()!• I

)i;ATfI ^

ux-

%

•Dav) IViar

\r.>i'/n

x\

/>.,v

"^I^ ' ] (■ MARK F }•■.!)
\\ i IH i\\ I 1 . ( iK IMVt )!••> }:n
\\ I 1 1 ' ;n Alicia! i !t'-»i"!iat ii ill )

1 HKRHBV CHRTIFV. Thai J alien. led .Ic-rcasc-.l fm,,

^JLivl

that I last saw h •• alive on d^CVvt t< I

OX^-t

Ti)0 H.

lUKfm'I ^ ■! ^

N \ M 1 ill
I \ I II I K

HIHTHIM, Ai'i:
Of' FATHFk

M \ II>1:n NAMl

'ii m«)Th1';k

luk riM'i.Ari.;
<»r Mnrmic

iSiatf or (.Nuinli \

oi'crpATiox ^

n f

-CdcOu^^v

III

aiid that death ..ceurrcl, mi the date vtate<l al.ove, at IQ.'^O
) n *^" ^"■^' "^'v-S'^' nHATII ^^as ;,. follows:

\.\.^<A>

^J-^aX/w

K.<. > \_iX

U Uc , .^

DlkATlON )•,•,/;

C'oNTk iniTORV

Mouths

Ihn

I lOH) S

i)rk.\Tir>N
SIG

nav.<;

<ryv^rucr\)

Yeats ^ M.^)iths
NED) 10. b. C^ >X.Lo,. ,

1Xy\A ^H Tool (Address) L\Xa->%Xl4a. ^We

Hours
M.D.

Special information onlv for Hospitals, InsmuHons, Transients
or Recent Residents, mi persons dyim] aw,iv froii home.

) , ,;

M.niih^

\-\\v. WMwv. sT\-n:i> i-kksonai, i-ak irt-rt. \ks ari- tki j.- -lo i-in-

in'sTolYOJV KXdWi.l.Dr.H AM) IUI,[i;i-'

iifv.inatu OA/CL/>xJk Uw- Cj<:Jx/\'>Axta

Former or
Usual Residence

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

How lonq at
Place of Death ?

Oavs

(III!

\'lilrr>-.s

VA-^^>VV4U■\ <i

I'LACH ()I- lUKIAF, Ok RI-tMiiX \I, I n a Tl

Ha^'W

tN"i)i:RrAKi':K *

^: .1 Ri;Nf()VAI,
T9ON

^- **• Rvery Item o»' Infcrmiitlon should be carefully supplied. AGB should be stnted liXACTI.Y. PHYSICIAINS should

state CAUSE OF DIIATH In plain tcrais. that it may bs; properly classified. The "Special Information" for per-
sons dying away from home should be feiven in every instance.

n

f^l^

WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD

_««____^«___ REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

/)(f/r Filed

J DO

Ii0^isfer(ul vA7>.

2069

-^

X ^ \

Deputy Health Oflficer

DEPARTMENT OF PUBLIC HEALTB-City and Countj of San Francisco

Certificate of Beatb

tl. S. Stnn^arD

(^

PLACE OF DEATH: — County of Cl/CX^x- J a

.a.

^ ^

ly,

0

V City ofv^'/<X/7XJ 0 AXt

A

No.

r^i.

(

St.j ^ Dist.;bet. LcL4.t^..

'^'^^M ^T.j I L^ist.;bet. v^CLnlA.A,c and i^"

" f/nrl.!.^^'"' ""^"^ '^''^'^ USUAL RESIDENCE GIVE TACTS CALLED FOR UNDER 'SPECAL INTORMATION ' \
IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. J

FULL NAME

/w

PERSONAL AND STATISTICAL PARTICULARS

V

> \ n < 1 !

i)

ri ii ( Ik

MEDICAL CERTIFICATE OF DEATH

;ik ill

/loH

Month

Dav

/(JO

i \'t ill

M.nth

D.iv

S*i-ar)

lURTHI'!, \C]:

10

f HJ{RP;i>,V t'i;RTII-V. That I attiiKU-.l .let > ,s< .1 f nm

If)

Jj A. cL^

UJ

V \ ^T I ill

r \ in I R

lUk III i:. \r |.;
< H I \ III IK

St.il I lit I'l in 111

M Mill- N V \M 1
Ul- Mori! Ik

lUR nil'!, \i i;
•I \'ii||(ll<

■-■1 ti . .! ('i 111 lit I \

KxXo

*^^ » 190 i to . ly^d:. [

that T last < iw h -v' alive on ^ zX: I

ami that <k'ath nrcurrc'<l, on tin- daU stated alin\r, at
M. 'llu CAl>^H Ol" DKATII was a^ follows

190 i

\iLhJLAj\^<xX.

V

I

9

c'oNTRinr'idi

I

Months

< N' N / IaAaxOu Oyyv^AA,JSr^v\.oJL'\x,'C

'//; V

n

1)1 'RAT [OX Yrars

( Signed ) dubo ^1 1

Monf/is

Ihn

'S

i -4

/^

Too

X^UT>X^CV>\.

.%

flours
M.D.

i:

< M ,•! I' Aiinx

h'f'^iilfii III Still I I ,; II

Special INFORIVIATION only for Hospitals, Institutions, Fransifnts,
or Recent Residents, and person** dvins) hwh) Iron home.

)■,,,'

v. /////«

Tin* MU)\-i' ^ r \ii;i) !'».R--nv \i, k \ k Ifr I I, \ k s A k V. TKl). T" • rili:
HKsT «)! M)»:^js X( »\\ ij'iii ,!•; AM) Hr!,n:r

'W

Former or
Usual Residence

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

tloH long at
Place of Death ?

Days

rjL.\CK ni' nrRiAi, OR ri.:mm\\i.

f 1 1) fo- inaiil

J A4D»-^rJk L<rvuwvo

\.Mi

\V\

OX-vVvu c3 %

■X

%

\J\J^>-^iJ^

DAT!' -: n

Ni>i;kTAKi:kM il 0 <XxdLdL«/YV Hrw ^4U _,

xi ..I ki:Mi)\ \i,

•^ T 90 ' I

N. B. livery item oif informnlion should be ciiroifully »upplied. AGB shfuiltl be stntetl HXACTLY. PHYSICIANS nhould

state CAlISi: or DliATH in plnin terms, that it miiy be propi^fb wlaBsified. The "Spcciiif Information" for per-
sons dying away from home nhoiild be fe'ven in every inHtnnce*

^

^

9-

» .

^

!i 1

WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD

- REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

:f<\' r

Dulr Filr.l. ilctfrW.

liei^i.sli'ii'il J\'().

2070

.^ V A <.

Deputy Health Officer

DEPARTJIENT OF PUBLIC HEALTH=City and County of San Francfsco

Ccttificatc of E)catb

PLACE OF DEATH: — County of o^^^ vj .^.cu-*^ec4X: o City of Cj,cc^
No. I2)b Oa/>^ St.; 4 Dist.; bet. M rUAXL\.^r>% and Jb C^^^HXHA )

r .r orATH occuBs AWAY FROM USUAL RESIDENCE GIVE tacts called por under -special information \
V IF death occurred in a hospital or institution give its name instead of street and number )

Vcu >

I

FULL NAME

Cs

XooX^OL'

PERSONAL AND STATISTICAL PARTICULARS

MEDICAL CERTIFICATE OF DEATH

liAI'l-; I )1- DI- \ 1 H

Ll

I) \ I1-; 1

/1>SS

/(JO

(Vt'Mr)

\<^\-

\\ It-

H! K i lll'l \(' r

I \ 111 IK

sj W

V I- I.

i/nutiiin

I lIHR!;nV CHKTll V. Thit 1 atiLii.k-.l .ItHvascMl fnm,
^ - I go t<; — — — -

thai I last saw h

alivi' on

i<>o

TtjO

ati.l that .hath occurred, on tlu- .late staled aliovc-, at
" M. ThfC.\rSl{<)I [)1{\TI1 Nvas^as tullnws:

3r

i I LCL^

lUR III !■

I i 1 ] ic

<>! Mo'i'm K

lUK 1 ItlM.Ati;
«»F Mii'IIIKR

^ St,i; .iiiiili \

< H( 1 1' \ rn)N

/,v

DTK AT ION )V.//v

CoNTk IIU Tory

Mo II //is

/hiv

//<

uirs

I ) r R A r I ( ) N

iNED )L

SIGI

/^,/r

AjUV o

IL'/CAi ^ i(,n H f \, hirers) UrVfrVuiU) L ' '

flours

M.D,

SPECIAL INFORMATION »«!> for Hospitals, InstituHons, Irdnsienis,
or Recent Residents, and persons dviny awav from home.

,'(■ /

\r.,,ij,^

l>,i\

Till' \i'.« i\i' s r vn i> !'».• R-,(»\ \ i_ !• \H run \Ks xki; pri-h tc i iFii-:
lij.srtii M \- KNt >\\ i,i,i». ,!•; AM) iU':i,ii:!-

Former or
llsudi Residence

When was disease rontrarfed.
If not ^{ place of death ?

HoH lonq at
Place of Death ?

Oa>s

ri. \K'\', <i|- IM K I \I, ( >K H |.>!i i\ \

I 11 h 1- lU:i lit

\.1.1;

^.

,-vu ^ tv

-H

h \ n

O^t 1

K i;Mn\- Ai,

igoS

V I T (

\t

IN. IS. Bvery item oi' informiitlon whoulcl he cni<iifiiii>^ HupplK-il. ACT. shuilcl be «tntcil f.XACTLY. PHYSICIANS sliuuld

etnte CAUSF OP Dl A TH in phiin li-rms, thnt it irmy he properly claBRifiefl, The "Spcv'ml Informntian" for p»r-
«on« flying away from hoinu sluuilti he ftiven in every inntHiice.

♦ .

Ili 1

WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD

,.__,.,^___. REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

* *• ^*»'v

H^J' C

1

'C.t^yvMA;

trvoui

Dep

n)()^

Er(j/,s/r/'rfl A^o.

207i

cer

DEP4RTNENT 6F PUBLIC HEALTH=Ci> and County of San Francisco

Certificate of IDcatb

^

^T^

PLACE OF DEATH: — County ofOc

o

City oiO/(X,y-\j v .\ cx >

^-M f;

i- ^ V.t '^^ ->\.Lu, V. . ;. , ) V . \ ■ . St.; ^ -- Dist.; bet. ^ and

/ >F DfATH OCCUfIs AW4Y FROM USUAL R E S I D E N C E G I V E rACTS CALLED TOR UNDER SPECIAL INFORMATION ' ' \
V If DtATM OC^RRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER /

^n If P

FULL NAMEUj.L.Lico.>>A., Uuo --

PERSONAL AND STATISTICAL PARTICULARS

h It III Ik N

Iv

' ' \ r i: < >! i:. K 11

\(

'^

MEDICAL CERTIFICATE OF DEATH

DAi'K Ml- Di-: \i n ij'

/ (JO
1 V( ,11

I ^

^ I \ 1 , t r M
^\ 1 1 »< i\\ III'

IMK 'li i'l, Av" 1

^t;. ' . ! I . Ill n t I \

'> \

]

,cL<rtA

o

S \M I ( >I

I \ Til i;k

i

II ri, \i 1-:

\ III FR

I I i.lMll

MAII ii: V V \ M
<»i M((|-|ii.. k

inirniPi \(*!-;
'»! \;(ii'ni':k

I M:!!. ,T rt.uill 1 \

'^0

' Ml iiil li ' I ).i s i

I III-;RI:i;\- n,RTll-V, Thai I atltn.k-a (UHcascl fn.m
U;nS to 0^\X X'S up S

that I la-t saw h .. alive nn ^. . >.'\, i«p'',

and that «kafh <KHiirre<l, «iii the «lati- >>tritr.l alxivf, at 10. IS
M. Tlu- C^ArSI- ni- I)i;.\ril wa- a. folh.uv;

aiiu

\xy\j

O^vLLo.

1

y

Dlk A riON },,/;s

CONl'Kil'.r'IOKN-

nr RATION ),,/;v

Mouths 3lH Ihns Hours

Mofiths

fhivs

Signed ) u

.0

t Ml I' 1' \ r i> ».\

OA^vl

^w OJwwLu,

i

J U^|\.S %, \j Iqo'

AiMress)

IIoui s

M.D.

-Uwa^'

SPECIAL INFORMATION onl> for Hospitals, Inslitutions, rransients,
or Recent Residents, and persons dvinq dw,»y from home.

Kfsuied

ni .Siiu i i iiii

^I.nfhs

/■

'I'll I' \i'.n\!-' s r \ T) i> iM''R->(>x \i. !• \k rill I \R-, \Hi; I'krr: r« » i'lii-;
Hi>i«>i us KN« »\\ i.i;ih;i-: and iu;i,n;i-

f 111 r, 1' mniit

Former or
Usual Residence

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

How lonq at
Place of Death ?

Drfvs

L/Ui/vv'

A-, J

q,.\C}f. in- l!tRI\I, (ik ki;Mn\Ai,

DATI-; ,,! h

\\ .1 k i;m« (\ \ I,

IQO ;

N. B. livery Item of inforrriHtlon should be cnrclrully supplied. AGB should he stated RXACTLY. PHYSICIANS should

state CAUSE OF DEATH In pliiln terms, thnt it mny hs pr(»perly classified. The "Special lnforinntion" f»r p«r-
Ron« dyln^ away from home should be given in every instance.

f

!!■ !h IV

WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD

_^-^__-________ REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

0

Ddlr Filed , iL ' oLcr{>JU\) 3 VJO\

Deputy Health Officer

Registered JVo,

2072

1 "^

DEPARTMENT OF PUBLIC HEALTH-City and County of San Francisco

Certificate of IDcatb

11. 5. 5tnnDai*C> )

v(

-? w

PLACE OF DEATH: — County of Qa^v J \o ,

St.; Dist.; bet.

City ofOo^"v JAXXy>xt.ML<: '

Nt>. I lXcv "^ UrU/Yxl^^

and

(1, ^»., .^^.oi.*^ i^*,i« *IX1U

IF DCATM OCCU*S AWAY FROM USUAL R E S I D E N C E G 1 V t FACTS CALLCD FOR UNDER SPECrAL INFORMATION ' ' 'X
IF DEATH OCCURRED IN A HOSPITAL OH INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. J

FULL NAME

PERSONAL AND STATISTICAL PARTICULARS

XX..r-

^

i;x

\t \ , \

Qic^L

i < li.i >k

u.

k IH

MEDICAL CERTIFICATE OF DEATH

i>A T1-: oh i»i: \ IH

-'X I .

So

^ 'Xixfc

{ 1*1

/ i H

I i H

M-!llll)

1>:.'

X ' . 1,

Wl

Uiit. <u

Hik iHi'i. \r 1'

(\

X/^^\XX^

•"H

% \ Ml Ol

I \ 111 i;r

in Kill I'!, \i 'I-:

< • i I \ I H 1 U:

%T \ii)i N' %• \Mi-;

<>; \;iriii! k

luk rniM. Ai'H
<»i Mti'i'm''. K

' ^!a!i I •! I'liu lit 1 \

M

\

^I HKKl'IiN' (l-RrirV, riiat J attriuk-.l .kHHasc.l fmin

that I last saw h . alj\rnii O ^ 'i^"^' ^- * up >

and that death ' n^cii rrril, <hi thi- date stated ah«i\i-. at
^ ■ M. 'Jhe CM sK nl' |)i;\ril wa- a^ foII..s\s:

DCRA ri(>.\

)'tiirs

^lonl/is . t /^fU'^

Ilom s

^v>%.

L^C^O,

C>ajlLcx yx'^^

< »i t i i- VI 1(1

N ro

e:.

c(».\ ruiinTokV

Dr RATION
( SIG

Ycuys

Months

NED) lA). t). W>OLa./v\,

/CX/^O;

V^Aj tiO KjoH

:i

f A.ldrt-ss)

/?<n.T

0

I lours

M.D.

'VV\A-^ V^ VA.AJC

Special information only for Hospitals, Insfilutions, rransients,
or Recent Residents, and persons dving away from home.

r^ r»

Rf>iilfii IH Sii II I'lOHii'iii

M..,.'h'

J hi I -

Former or
1'su.il Residence

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

How lonq at
Place of Death ?

Days

III I AHovK sr \ !'i:i) !'KK'-'>\ \i, !■ xK'rim, \Ks \H j; iHrj-: 'r<> thh

HI-,sr(H-MS KNt i\\ i.i;ii(,l-; AN!) lUl.Ii:!

f I !i fir ni/inl

^

Ui,ACi<: nj- lURiXF. OR I-' i: ^ro\ \ 1.
I N n I K r A K }•; k sAAaAXm ^^

if).

HI \r ..1 R KMOVAJ,

^ ^ T90H

\i

/CC<:\

V

c^

d.lnss 2>bTX' iq tl

,%. ji. fivepy item of informntion shoulil b.- cnre'tully siippUcil. AHR should be stated f.XACTLY. PHYSICIANS Hhould

state CAlIsr OF DKATH in pliiin terms, that it may be properly clasHified. The "Special Information" for per-
son* dyin^ away from home shoiilil be given in every instance.

V

» i

f
I

WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

/)a/r rih'il , h^tAylh^ ^

lUO'i

Jfr'(f/\s/(>/-rfl JYo,

2073

Deputy Health Officer

DEPARTMEM OF PUBLIC HEALTn=Ci> and County of San Francisco

Certificate of IDcatI?

1 11. 5. *5rnn^ar^ i
PLACE OF DEATH: — County ol Cl ^\ VC City ofO<Xov 0 Vn i

. (Hi 4 n h ^ m :

No. ill \| ft.<mXatV>viN.u. lb>i St.; 1 Dist.;bet. O-XUriLCV.:; ;. andCtl

/ ir DtATM AccuRs «w«v t-ROM USUAL RESIDENCE GIVE facts called for under special information \

V, IF DEAT^ OeCUR«CO ^ A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. /

^ ^

FULL NAME

v-^.Lx.'>\o..

sHN (

• \ 11 ( li

PERSONAL AND STATISTICAL PARTICULARS

V I > I , I 1 1-:

g < , > , o

- \_'L

ox^fc

1^

>,i\

R01

MEDICAL CERTIFICATE OF DEATH

DA TK < ir !>i: \ rii n \

( Mnilth ) I I »;i s

•^I^.< , :.l* %f AR k II l>

BIKIfl I'l. \il*

'•^htf- .' '■ .mit'\

; k

-D

. I ni-:Ri;i;V niRTlI-V, That I attcn.U-.l ,hrr,i-~.<l In.m

tliat I la'-t '-aw h alivi- on ^-^-.^J- ' T<p H

aii<l that flcatli < h-cu rre.], cii the dati- stated ahnvc-, at '\
' >r.^Thi- CAISI-; (»1- I)i:.\Tll was as follows:

I \ 111 i;r

lUR in I'!, \i K

or I \ I II IK

'^.Llti i It I'l ilMit

M \ 1 PIX N \M1

I >i Mt I'l" 1 1 1- k

Hik ni iM, \ri:

» ir V.i ill I KK
(st.ii. ,t v'.iimti

HiM 1' \ IK )X

U 4i

I )r RAT ION }'riirs Mo>ilh^ fhiys

I lout V

DC RATION )V^/r.v

(Signed)

Months

/hi]

IIou

;v

^J

M.D.

\

€u

Cc > V V Ao. \v e ui ^ c

n»n

f A.hlnsv) Hb5

ft>\LaAi U^

SPECIAL INFORMATION only loi ll.is|Mfrtls, InstifulM, Trdnsienls,
or Recent Residents, and persons dyimj dw.iv from home.

Kr^idfil lit Situ /;,■',>;•

M.nifln

i>ii\-

Hi" \i',()\'i-: ^ r \T!'i» i'l- k--nx \i, I'AK'ri'.r !, \k'' \hi; rkti-: ii » r

HKsT «»!■ MS KN« »U 1,1.;|)<;H AX!) i!!;i.ii;i-

cLOUmj^\X^v^'^L

{ I n !i i: iiinnt

. ^

N,Mn.. 1^1 M rUnxla ^^ . > ^^^K-U L

:T1

Former or
Usual Residence

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

HoH lonq a{
Place of Death ?

Days

I'l.ACH OI* lURIAI, Ok RKM<1\ \!, | DATKo! Hiimai .,: RrNtn\-\i

0^

IS. B. Rvery Item of infornifitlon shoulfl be Ciirefully supplied. AGB shoultl be stnteil F.XACTLY. PHYSICIAIN.S should

•tote CAUSE OF DLATH in plniii terms, that it may be properly classified. The "Special Information" for per-
sons dyinft owny from home shouhl be feiven in every instance.

I ' j

I. .,'!)

WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD

' ^^ ••■■-^^ - '■■■ ' ' ' REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

I

"^ Officer

Ii.eijli,sh're(l J\^o,

^074

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco

Certificate of IDeatb

PLACE OF DEATH: — County of' a . , City of CJxx-w V\ o ..
No, ^3jy\XKXkM L^»XJl^J:^,^ , wCu Ol Ov ^t4 ' V u • Dist.; bet. — and

(IF DEATH OCCURS A\Ay FROM USUAL RESIDENCE give facts called for under "special INFORMATION'- \
IF DEATH OCCURR^ IN A HOsjpiTAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. /

FULL NAME

\j

k, y\A

- \

I» A

PERSONAL AND STATISTICAL PARTICULARS

HlK I

, ^V'

MEDICAL CERTIFICATE OF DEATH

DA ri-; I >i- Di.A'in

0

^to!lt^l

I);iv

(N\;il

l);iv

\< .!■;

1C3 '

/>„

i: ril PL \."l'

I fli:ki;i;\' CI;rTI1-\'. That I attLMi.k-.l .leci-ascd from

— : up to ~ —;■■■- . — -

that T last s;i\v li -~ — alivr on

■~ Kp
— Up

and that death occurred, on the dati' stated above, at —
^ M. The CAISI-. OI- I)1;ATII wa- a- tuUous:

X\M)- It)

I Sin I K

HIK in I'l, \' V

Ml- I \ III ! ■

M X :i»i:n; v \m j

111 Mill HI k

HIK 111 ri,Ai'|.:
Ml Mirnil-H

< Ki' I ■ rxi it iN

I) I k A T I ( ) N

CON TR IIU rokV

) 'I'iir

Mont ha

/hiy

I Ion I N

Is f ' .if if HI V.?)' f'l it II

M-iiilli^

t) IS

DlkATloN

( Signed >

^t 3^ iQoH

9?>

}r,niths

L^A.'<n^jl?v 0. \Jj U). dLtLoc-i.^

^ax^

fliiHI S

M.D.

(

(A(Mress) V<fUrv^JLN,^

m

Special information only for Hospitdls Instifuflolf^V Transients,
or Recent Residents, and persons dvinq away from Ijome.

Tin' \Hn\' ic ST \Ti'i> I'KKSMX XI, I' \k II. ri, \Rs aki; Tk
iu;sT of MS- KNM\vij;i>< .I-: x\i> I'.ii.ii;!-

i: r< > THI-:

Unf.itininl

Former or
Usual Residence

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

How lonq at
Place of Deatli ?

Days

I'l.ACK <>I- ni'RIAI, OR RlSruSAI
\ ^S ft A

I>ATK .if n

Hi 4

I 1 \ ■

C^

kl'.MoSAI.
TQOH

Si1(lu-s

N. B. Hvery Item of InformntloTi should hi cnrcfully .supplied. AGE should be stated KX4CTLY. PHYSICIANS should

atntc CAUSE OF Di:ATH in plain terms, that it may he properly cfassiitied. The "Special Information" for pri-
sons dyinft away from home should be felven in every instance.

M

I r

ipi

^.\

m

all

I. : :t'. I \

WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD

. REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

I' c

■S

7.9/9 4

Jlc^i sf rii>(l JSfo,

2075

DEPARTMENT OF PUBLIC HEALTJWity and County of San Francisco

Certificate of IDeatb

I 11. S. StnnDai'D ;
PLACE OF DEATH: — County of 0 -CU^w J ^\XX^'vc\A/Co City of Oo^-yv 0.^.<X>\^AULCo

Dist.; bet.

U%A/yu\^^>^'>^<x^\AlA^UA vv v^t.; Dist.; bet. and

f ir DC*TH OCCURS Ayw4\y from ^SUAL R E S I DE NCE gi we facts called for under special information

V IF DEATH OCCURReQ IN A HOtPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER

)

FULL NAME

^^Ow^AJU

\)X\/y\j

iXx.

PERSONAL AND STATISTICAL PARTICULARS

u

r

4

•<<i,i »k ^

r-

MEDICAL CERTIFICATE OF DEATH

DA ri-; I >i PI. A in 0

'&

i N'tat )

\ I . 1

l^

ok

r>a

M \RKIKI'

HIK rtU'l \.'l

NAM! «il
FA 11! ! K

lUH lli I'l. \. }%
11' i \ I HI K

-t.it. I ,t rtmiu ! V

MXIIH^V NAM!-:

Ill M<>i"ni;R

iiM- ni I'l, \r!-;
•>i %ti ii'iiKk

••^1,1! I I i'liimt 1 \

' >'-A ri>A riuN

^0^

^ I m{Ri;i5\ ri.;kTlI-V, That I ittcipK-d ,KH,,i.r.l from

c

i,pH ti. pJOfi 'X%

that I last saw h vy-'j-v alivu on

^

^i.^xt XL

and til

■I' lUau

1 iiccurrcd, nii tlu- date '^tatl•d almvi.- at

4- M. Thu CArSK Oi- |j|;.\TH wa^ a^ follous

K^<XSjk.K.£X. c

DCR.MION )'i'ui.

CONTRIIU TORY

Mont /is

/hjys o Hours

DIR.XTIOX

)\'ars

^f<>>it/l^

NED)\!Tl. d WUx>lAi

/?rn'C

(SIG

'VC\. ',. *,

Ilout s
M.D.

.Xddn-^s) S.S0O

^A^'U.

A%> '■,//',/ /;/ V,;m /'; ,M/.

M.,„ll,^ K_ o /)„,

Special Information only for Hospitals. Insntufions, Transients,
or Recent Residents, and persons dying av»,iv from fiome.

Former or
I'sual Residence

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

ftoH long at
Place of Death ?

PdVS

Tin' AH<)\'K '-r \ ri i» i'Kh^i »x \i, i- \k riiTi. \ks \r i: ih i !■■ I'o I'li i-
iiHsr ui MN' Is x< i\\i,i:!MU-: .\m> in:i,!!;i'

fA.Mnss is 0 0 0 x,\XA'ru:r\X 3a

;i,A<.'i': 1)1 iitkiAi, OR i<i;m<>\ \

XV>\AX.M ^ X','.

! ) \ !■

c ^ ^

\\ .1 RKMmXAI,
IQO't

rNi)i:KiAKi:R J^^-^JLaXli ^^

(Address ^ SblX' .H i

IS. B. Rvery item «»>' i ii form iit ion shoulil be carefully supplied. ACB should be statetl l.\ \CTLY. PHYSICIANS should

•tote C AlJSr or nriA TH in plain terms, that it may be properly classified. The "Special Information" for p«r-
Anns dyin^ away from homo should be ||iven in every instance.

WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD

,,.__^ I^E'^ER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

s- ■^. H\ 1' (■

10 OH,

Deputy Health Officer

JlegLsteird JVo.

;2076

,d La.

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco

Certificate of Seatb

< in. 5. i?tanCnr^ )

i "^ i Of?) ■

PLACE OF DEATH: — County of OO/n^ 0 .\XX/YVCX^C0 City of w/CU^v J ;u<X.'>^ o <^ <- <

« _j'

No, W VUUWU^' :L L ^ ^ C ^ • St.; Dist.; bet. - - -^nd

/ IF OtATH OCCURS AW«Y FROM U S U A L ' R E S I D E N C E GIVE FACTS CALLED FOR UNDER "SPECIAL INFORMATION ' \
V IF DEATH OCCURRED IN A HOSPITAL )0R INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. )

k

I \

FULL NAME

-I

d-

"^I'X

PERSONAL AND STATISTICAL PARTICULARS

Wu

> i i ( I !

(

MEDICAL CERTIFICATE OF DEATH

!) A ri; 1 !)• ni; Ai'n -A

V.zl

fMoiitlil

I
I):IV

\« . i:

■^ I ^ ' 11 ■> ' ^ '■ ' ■ F K ! '

\\\u 111 ri. \r)

'^\

K >

L!

a,

I lll{Ui:};V Ci:f<TIFY, Thai. I .ittcn.kMl (U'cia^cd frnm

tliat I la<t saw !i.?». >i\ a!i\{. on

-t,

IC)0

T<P

)vr, at D

ami that ckath nrrurrcd, nn the dati- stated ah«
^- M. The CAT SI-; ()!• Di; API! was as foIlf)wsr

LwvCo

AJ,^-kxxs4uui, IDi-

N \M I ( I!

1 All! IK

nil- riii'i.ACH
"I I \ niKk

--t.tr III r.,iinti

<n MOTH J. K

lUR'nil'I^ACH

«ti Miiriii:R

I Sl;it< u! t'ount I \

• »t V IP \ IK i\

Axxr l^^t

Uv

Cr'>\.q

Dlk.XTlO.N
CONTRIIUTORV

Mi^uiln

\
/hns

d-3

I lours

^ \

1f.>f////s

fhjv

\

/^fi,!r,

f'l itH,

'^XOL

r> I )v,,/

DTK AT ION

rSlGNED) ll) to. ^U tvU

^' '^ ■'' fA.i.iivss) s^imoxt

fliuirs

M.D.

[i)0

<■

SPECIAL Information nnn for Hospltds, institutions, Transients,
or Recent Residents, and persons dying away from home.

Former or
Usual Residence

M.nithf

/)./!

Ill" \i'.M\'i-: '^r \ri-i) I'KRsnx \ 1. r NKTii'ti xk'^ xki jk! i: ro thi-;
iu:>i' lu MS K N*i iw i,i;iH .M and iu;i,n;i-

K 1 1! fii; ina til

.u

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

\Vl ^5 1^ S HoHlonqat

f H LUaMIxXXiULC UOJu Place of Death ?

i UxJu

Oavs

i'i,Ai-i; ()i- lURiAi, OR ki:mo\ai,

A

^

OL/>'>u

\jOa

1

X^ Jt

IS. B. Bvery item of inV'.>rmnt!on should be carefully supplied. ACJE shi.uld be stated RX4CTLY. PHYSICIANS fihould

Btate CAlJSn OF DEATH in pliiin terms, thnt it msiy be prf>peply classified. The "Special Information" for pri-
sons dying «wny from home should be ftiven in every instance.

I i

"J

I

WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD

- REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

" -•■ !;^i' V-

4* -P

^

^-vcv

M

Deputy H

h Officer

liegLsfercd JS^o.

(4

DEPARTMENT Of PUBLIC HEALTH-City and County of San Francisco

Certificate of Scatb

PLACE OF DEATH: — County of a rv J Xn , „< -_ Qty ofUcv^v J Axx-^'X.c c --

No.

I I

I s

F,

^

n

St.; 3 Dist.;bet. Hi I v and 'K 0

ruRS AW*V TROM USUAL R E S I D E N C E G I V E FACTS CALLED POR UNDER SPECIAL INFORMATION
OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER.

)

FULL NAME

( J

A

Xaj^

KKJ^AAj^T^^KX)

PERSONAl AND STATISTICAL PARTICULARS

MEDICAL CERTIFICATE OF DEATH

n ATI-; < »i !)!. \ 111

A

D.is-i

IV. al

X' K

I II!:Ri;n\- tlirni-V. riiul I alten.UMl .Uirascl fn.m

t

i',<

»K nivjii

A

i

V ■' t

Xj^

A

tl1.1l 1 la^t saw It .»-' aliNf on

aii.l thai (It .ilh » k curriil, .»n tlic dali' ^tati-d alxn-f, at l '5 0
I

M. TIk- CAISH Ol' m:Aril was as rollnw^:

Ml I »l
III IK

nik ni !'i, \( K
< »r ] \ ni HK

^' • • ' ( 111 n! I

M \ I1»HN NA^1 1
<>S MOTHHK

Hik III !M, \i i:

il Mii:ill-K
"■i.iti 1 a t'liuiit 1 N

I >v*'(p \r;< r

0

(

u

K^

>

k

DIR ATION
C<'NTRir,rT

DIR.XTIO.N
( SIGNED )

Pax

II,

tifrs

},,i

IS

n\.

M,i>!lJlS

1)0 »^

/>,

/ I s

//i^N I s

M.D.

HK'

(A.l.ln-ss) it I'l iL^O.

SPECIAL Information onI> for HospiJah, institutions, Iransients,
or Recent Residents, and persons d)in) away from home.

rm-; auovk sTAii't) im-ksonai, tak iiiii, \hs .\ki-: tki. j-. r< >
lu-sroi MS K xi )\\i,i;i)('.H A\i> i;i;i,ri:i''

!•:

Former or
Usual Residence

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

ftoH lonq at
Place of neatf? ?

Days

fin fiiriiiattt

'XA.^^aX^^

<X/"v^

> L, . V '

\.M

)A I'l'. ,)!' I'.rHiAr,

I'l, ACi; ol- HfRiAi, OK ki-;movai.

I ni»i-:k rAKJ':RVyyVCUi. «t' V Ja^ ,v .

I

KHMiJX AI,
TQO';

IV. B. F.very item oi inf(»rmation should be cnrefully supplied. AGR should be stated HXACTLY. PHYSICIAINS Hhould

stntc C.AlJSr OP DHATH in pliiin terms, thnt it miiy be properly classified. The "Special Information" It'or p«r-
fions ds'infe away from home shouhl be 6,iven in every instance.

«

WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD

t 11, ,:ili I \., .- ':■- '^ ~.^ i;^,!' r.,

Ihilr Filv,l. PctXov S

REFER TO BACK OP CERTIFICATE FOR INSTRUCTIONS

^mmfmrnfammnmin

I !) 0 H

0 ^

Jlr o' /,<:/(> /-r (I jYo,

J^o?8

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco

Gcvtificatc of IDcath

No.

PLACE OF DEATH: — County of

AtV ofC)

\<X/Vc^^«.>ax^t) City of-'<Vvu O/UX-vxCv^^r ^

4

Dist.; bet.

and

; - ^- • 1 -vw-w, j^iiju, ucu ^ ana

/ IF DFATH OCCUBSlAW«V FRO|| USUAL « E S I D E N C E G I V E FACTS CALLED FOR UNDER "SPECIAL INFORMATION ' ' \
V IF DEATH OCCUl^RED IN A>lf<OSPITAL OH INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER /

FULL NA[V!E^<XAAKxX^\j

-^

v ^

-l.X

PERSONAL AND STATISTICAL PARTICULARS

;

V

I' \ I 1 ' il HIK 111

\< .H

WlUnw ! 1 1 Ilk : I \ I i

I: \

N \ M ! t 1 1

r \ I'm H

MEDICAL CERTIFICATE OF DEATH

DATK Dj- I)i:.\ I'll \

L*

r<}n

IV. ai!

t

/',/!,

•Ml Hit 111 I):t\i

I IIKkKBV CI;RTIFV, Thai I atU inU-.i .UH.asci fn.m

I ( )' )

that I last saw li alivt- on

ailil that (kalh mHurrfil, mi f hr A.\\v ^-tatid ahiivi- at

It/)

f\

lUK ill PI, \V

• »• 1 \ in IK

M X IDI'N" N \M
111 MMlinK

nils I'll IM. AC IC
<»i Miiilll'R

■ ■*! it 1 -A I '( mill \\

M. The CAI SK (»1' DlXlil was as follows :
.K-X^t^K^ix^^tL Orv^jLevN^-oslb lix-^-L^vVLJ%xt'a^

i-v L;

\ -<^-

Di k \ rioN
c<>.\TRinrT()k\

Dlk ATION

M,>uths

/hn

I lout \

Yra

r<

M nths

/hivs

( »iA' r r A III »N

/■

,^

MwO^Lu.

f SIG

NED )Ur\^xJl^ J Al^.U) dULL<X/vudL

//(>urs

M.D.

X

( A . 1 ( 1 r.ss ) L.tr\..crvUlM

t:

SPECIAL INFORMATION only for Hospitals, InstitufioWs^ transients,
or Recent Residents, and persons dying away fron tiome.

Former or
Usual Residence

aa

<A.XX,A,^

4 t

HoH lonq at
Place of Oeatti ?

1/, -,'//-

Pnv

Tin-; \Ho\i-: sr \ri- r» 1'i-;rs»»\ai. i- \h !"hm"i,ars a ri; rRiK to I'li i;
lusi'oi' .M\' K N< >\\ i.r.ix .1-; AM) in;i.n:i-

(Inf.Hm.nU M lUyC^VJUL WOw^A^-rxLlX^ '^

Davs

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

nxil^.tf Hi M!Ar. Ill HKMOVAI.
^ ^ ^^ TOO H

I'LAOK OI- nrRIAF, OR RHMOVAI

I N I ) i; R T A K 1.; R U ^OJJj-YVjb \ I J^^"^ ' ^ * > ^ ^

^. B. F.very item ni liiformBtion should be carefully supplied. AGB should be stnted F.XACTLY. PIIYSiCIAINS should

stutc CAUSE OF DEATH in plnin terms, that it mny be properly classilfied. The "Special Information" for p«r-
finns dyin£ away from home should be <iiven in every instance.

I

y

■uli

^i:U

1

'■*^^M

}

i

f
i

1

1

WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD

'!.('!!. 'Ill I N ,

\'.S.V I

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

Dn/r /'V/r./, L.el(rUc\; Z

U)(n

M^cc<i

Begisfered JVo.

20?9

\Kj Deputy Health Officer

DEPARTMENT OF PUBLIC HEALTH-Cit)- and County of San Francisco

Certificate of IDcatb

( 11. £. 5t^n^nr^

r>f«.

PLACE OF DEATH: — County ofd/OAv J Axxoo^cvAci City of CjOla^ o Axx^^vcc<s r« <
U>Vt\XU.^%CM. UwCVdl-M^^l Dist.;bet.

K<X.

and

/ ir DtATH occurs/Way rRoii USUAL rIESIDENCE give facts called for under "special information- \

\ if DfATH OCCURRED IN A S|<OSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. )

FULL NAME

I tax.c4va >v':^.

PERSONAL AND STATISTICAL PARTICULARS

^ r< »l.< iR \

<X.U

rf

MEDICAL CERTIFICATE OF DEATH

i> \ ri-; < M- !)i;a III 0

i» \ ri; ( ii i;iK 1 11

/^i'i

I>:i%-

Jjj/vt

M..:iUri

'! , ,

/ (JO ' I

\' . I,

/',

: I i>

WIIHIWI

I Wt itf ill

lU!; ;•!! ri \ 1

1 lll';ki:!;V CI':RTII-N', Thai I attLMi.U-.l ,k.,-,.asc,| frniii

I (/) t< ) 1 iff)

that I hist saw h —

alive oil

Icp

and that (h ith ( icciirrtMl, mi *J\v <la*( sfati-d aliovc at

M^. Thf CArS)-: OI* hl-.ATII was as fo]|,,ws:

CH-<L<; > ' ,\.o

VJ-\,MKX>U. vDi\A^Ay»%C)

I '

VAMl (.1

f- ^ 111 I i<

ni k I' 1 1 1'l, \i' J^

< tl 1 A 111 I- H

^1 .' ■ ;

M \ • •

N \ M 1 ,

!)!' RATION

CoN'I'KIinToRV

} 'rtir

Moutfn

Da

rv

lloi

Its

>: '.:■ 1 i II i.k

iUKriii-i,A> i:
<M M<iiin:R

I >t*it< 1 ,1 ii milt I

< »< I ! !' \ r Ii i\

1)1 'RAT ION )',iirs

(Signed ) Lox^crvw^^

6x>

%

'iriuu/is

/hiY

3-H rqoH rA.i.lriss) UA-'

XLUx >

, A

M.D.

0-yUA>6

SPECIAL INFORMATION onlv li»r Hospif,ils, InstifiKians, franslfnfs.
or Rctfnt Residents, and persons dyiti) dwdv frnm home.

f\f Itlfii III S'i'tf /'iiniilu'ii

V.>ii//n

Ih

'I'll H ^isovH s'l'M"!-;!) i'Kksov \i. 1' \ K lu r I xksaki; ik; i; r<> riii:

liu

Former or
Usudl Residence

When was disease contrarted,
If not at plar e of death ?

HoH lonq at
Pld« e of Drafh ?

Days

I'l An-: oi lu kiAi. (IR ki:M(.\Ai, I \)W^.,,\ i'.' I \i. Ml ri:m(.\ai.

I !l fill iii:i til

\j:f\Ary\jJ\M

\,l,|n.ss --

^

NDHRTAKI'K J\JLaJLX<-JL H. UC <X C^O, ^V

I

M. B. Jivcry item of inforination shouicl be cnrefuMy supplied. M\T. should be stntetl F.XACTLY. PHYSICIANS nhould

«tiitc CAllSr or ni ATH in plnln terms, that It mny i»c pr«»r>'-'»'ly clonsifled. The "Special Informiition" for per-
son* tij inji nwtiy from home Hhoiild be ftiven in every instance.

i

n<.:n,

I h I

i:K r ( ,,

/J(^/r /'VAv/, ^^

1

WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

w

bx.K^y-^

u Deputy

h Officer

DEPARTMENT OF PUBLIC HEALTH-Cify and County of San Francisco

Cevtificatc of ©catb

I XI. S. 5tan^ar^ )

4 ^ ^ ^

PLACE OF DEATH: — County of C\a>X' 0 Va,ixci4CoCity of O/Ct^YV ^KKX/yxcuic^

No.<

1U\' 'Lacaivt '^Ji...Vci St.; H

Dist.; bet.

and

( IF DEATH occJbs 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

FULL NAME

lai!

VC\.LlXi

i

v.v.

'<dL

(\\

oxju

PERSONAL AND STATISTICAL PARTICULARS

It \ i 1. « li

1

a'

11

\\^

n \

Dav

3.C)

L

MEDICAL CERTIFICATE OF DEATH

DATi-: . ii m; \ III _ , ^

iNfotith) I)av> (V.ai

I ni;Ri;i5\' CI:RT11-\-, riiat r att.n.k.I .kc^a^d fn.m

that I la-t saw h X>U alive on iL ctT ^1^

upH

■^i \ i; i- 1 1 [1

ri

x )

in '.' I'n ;■! n .■ k

I \ I'll t K

iuk r H iM, MI.;
')' 1 xriii'K

M A N>!:X V \Ml-

or M<>rin;K

lUKIFI I'I,AC1%

'>! M<.rHi.;i<

o.tirA 1 KIN

Ix

(X^\. J .Vet ^ VCMLCMi

1^tk>\,

<X\

kUi

ami that <li'ath occurred, on the ilatr stated above, at b
^ M.. The (*.\ISI{ OF m;.\ri! was as follows:

Mlcur J (^-wovA^ ^ d.

^

Dr RAT ION* )V.;;s- 3, J/,>„///s L Days

to N T R I n l" T <) R N- A. . .„ N ^ \Xr7vtXv^,v<i a. AVCL;

DC RATION
(^SlGNED )

//o

ID S

(1)

)'iiirs

i(»o H

\)

(A<l.lress) '^1 Vj CKtA)4,il 8t

SPECIAL INFORMATION only for Hospitals, Insmutions, Translrnls.
or Recent Residents, and persons dyinq dwdy fron fiome.

/\ri.lr,i : ii s,,)> I'l ,!ir

'\^

t

) \/-^„'//-

H

/).

(hi fi)* niiiiit

Tin: \Hn\}' ^r \rj'i) i'kkson \i, pxk rn'ri, \hs aki; TKri-; I'u iii i:
ni:sr oi M\ K \(>\\ij.;i)<,K a\i> iu:i,ii:t'

Former or
Usual Residence

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

HoH lonq at
Plare of Death ?

Davs

IM.ACH OI- in R[ \I, (IK

U^

\i\)\Ji:L^-

K i:n'i >\ ai.

l)\ri.ii.' Ht KrAi, (ir KKM«»\AI,

iqoH

rxDi-KTAKi-R LolVXOU" ^^ L^xoXMi,ni

(Address '^, .U/CLO^ y\iA4

IN. B. F.very Item of information should be cni-efully supplied. AGR should be stated EXACTLY. PHYSICIANS should

stntc CAUSE OP DEATH in plnin terms, that it may be properly classified. The "Special InforniHtion" for per-
sons dyin£ away from home should he ^iven in avery Instance.

«

}•„.:, u] ,.( !i, ,11), I V

WRITE PLAINLY WITH UNFADING INK-THIS IS A PERMANENT RECORD

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

t.£^.^^

^»:r?^;!!&l'Oo

ySXi 6

190H

Jieo'lstcred A''o.

20H i

DEPARTMENT OF PUBLIC HEALTH-=Ci> and County of San Francisco

Ceitiffcatc of Seatb

( tl. S. Stan^arD )

Am J) Q^

PLACE OF DEATH: — County of'"^CL-.v OK^^xcu^Oiy of Oxx^ J^UC^^vCc^ec

No.

a ^ D. L CU :.. L ^ V C A X St; I 0 Dist; bet. a 1 ^<i and 1?,aA

( " .■^/•;\°'^^^''^ *^»^ -"o« USUAL RESIDENCE GIVE facts called for^nder "special information N

V IF death OCCURRtD IN A HOSP.TAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STR EET AN D NUMBER )

FULL NAME '\'C^^^^JL^

L

PERSONAL AND STATISTICAL PARTICULARS

-•IX A * I COLOR

€U\XA>LL

I'Ai}-: ( ii luk I II

w.

rX>

dLsL

M..iithi

A<,K

5i

I>;iv

1/ '»/'^>

( Vear)

/OOH

/ hn.

*^IN<.IJ- MAK1<II !•

U MX >\\ l-;l» OR l»;\ I t'-M |.|,

lUkPHPI, \C}-.

^I.lti I IT I (1)1 lit t\

\ \M 1 ( U
1- A Til l.k

MIR rillM, \CV.

f»i. I \ri!|.;K

I stall ur I'liiint 1 \

mahh:n' namk

<>1 MoTIIKR

nTRTiipr.Aci-:

I Stat! i II I'ouiit I \

MEDICAL CERTIFICATE OF DEATH

DATK OF DICATH , A

(Motitli) ,i,;,y) ,Vrart

- 1 II1';RI{BV C1':RTII'V, That J atten-ld decease.! fnuii
I 190H to U/ct; I np1

that I last saw h A/A^ alive on U-^vt ^^ j^ ^

an<l that death occurred, on the dale ^ta(c<l above, at Si

yj M. The CUSI- ()!• DIvATH was as follows:

.KKJ-

Dr RAT ION 3 Years L .Voui/is Days Horns

CONTRIiUTORV LL\.aX^-c^lL ALcr . ^^J.AM)^vUi

DIRATION

">

)'rars

'^fouths Days

iytfc 3 ic)oM (Address) 153)0UUild*

(Signed) V'^J'cclx.a

Hours

M.D.

oiiTPAIK

Special Information only for Hospitals, Insmullons, Transients,
or Recent Residents, and persons d>ing away from home.

rm: \movk stai"if) i-kksonai. p\u iui i. \ks aki: ikih to tiii-;

III-;ST ol' ,MV K NOW i.iix.H AM) lu;i<I i; I'

Former or ' K . y - J , . 1 V How ionq aX ,. ^,, *a
Usual Residence iP-'UU AKJt<UAX LoJU. Place of Death? ^^ ..

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

Oiys

I'l.ACK Ol- IITKIAF, (»K KHMoVAI, I DATK ..f Hihiai, or KHMoVAI,

n

fill fonna tit V-.A./^./OU

(A-Mr«-.s

(Xaj^ C

V

I- DIKIA

f Address . .31 "^ U J /ZkKhXlX 3i

I90H

INDICKTAKK

N. B. Kvepy item of inform«t!on should be cnre?ully supplied. AGE should be stated EXACTLY. PHYSICIANS should

state CAUSE OF DEATH in pinin terms, thiit it mny be properly classified. The "Special Information" for per-
sons dylnit away from home should be 4iven in every instance.

t

WRITE PLAINLY WITH UNFADING INK —

n.-.M^i of !i, :iiii, !■ No is t-^^*^,, i:«ti'0<,

4^ -p

THIS IS A PERMANENT RECORD

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

.\J 3

100\

Registered jYo,

2m2

^^■/VA^A^l.^

«l

DEPARTMENT OF PUBLIC HEALTH-City and County of San Francisco

Ccitiftcatc of Scatb

( XX, S. Stan^arD j

PLACE OF DEATH:— County of^ct^^ "^ \ 0L^vc^4/:cGty of ^cl^ 5x<x

^ V C K. C^ -co

No. bOT

0 ^

-V

oU^vr>Vu St; 3. Dist.; bct]aXlJ<5\/>v\X]u and d CUXXXAVLlAiKs

f .r nl'' °*=^"''^ •^•^ ^"O*- USUAL RESIDENCE GIVE facts called rOR UN^ER ■'SPECAL .NroRMAT,ON^\ ^

V IF DEATH OCCURRED IN A HOSP.TAL OR INSTITUTION GIVE ITS NAME INSTEA^OF STR EET AN D NUMBER )

FULL NAME

^U^^-y^^Oj

mLcl/H

<X/rLcu)

--1 \

PERSONAL AND STATISTICAL PARTICULARS

a

i» \ ri'. <i! i;iK in

X < . »■:

•M..iithi

1

(l)av)

i

MEDICAL CERTIFICATE OF DEATH
DATK OF DEATH //A

I

Ik

rgn

(Month) (Day) (Veat

5o )-,.■;

yr,„ii)is

3

i

Vc:u

Ihn-

\^.K.

I HI:RI':HV C1.;RTIFV, That I attciKkMl <krca.sed fn.m

H t.. €\/^ I

^^.Q i \(p'

^

up\

i

» I

Ul It. !!!

lUkTiUM, xrj-:

(Stati iir t'liiiiitrx

\ \\!l' Ml
I A III I'k

lUK rillM, At K

< ti- I N I'll Ik
(Hlat« .IT r, MHiti %

M\!I>J;N NAM!-:

<>i .M()Tiii.;k

liikTni'F.Ari-;
'»! Mi>'nn:K

I stall III I'ouiit I V

.it :..ll)

.>w

<i

A

>cv. va ■>\j

I

?

that I last saw li-t.>>A alive on U/ot I icjo H LO

atid that ikalh <irciirre<l, on thi- liaU- state*! above, at S
' Uw :M. Tile CAISI-: Of- I)i;.\TII was as follows-

i

DTK AT ION 4 )'t'ars Miuiihs

C { ) \ 'J' R I lU 'T ( ) k \' ' 4\. ^.\

Days

Hi

ours

cT^

I ) r R A T I ( > x

)\'ars

V-v

.'Sfi^fiths

Days

■\

Rfsidrii ill San I iiiiiii-iit ^ ),,! i ■■ ^ '^Jinitli^

( Signed ) LI. ^-^ L uxU.

Ij/./ctj I ic)oH fA.hlress) iDDH L)Umj^ 5tj

>tifufWns7

Special information onlv for Hospitals. InstitufMns, Transients.

or Recent Residents, and persons dviny dH.j> from liome.

I hi I

Till.; AHOVI-: sr \ I'Kf) I»KKS(1NA1, I'AKTKI I.AkS AKi: I'KI !•: TO THJ-:

HKST ()!• Mv KN<)\vi,];i)c.i-; AM) ni:i,ii:t.

(Infotmaiit

^.-1.^

Former or
Usual Residence

Wlien was disease contracted,
If not i\ place of dcatli ?

How lonq h\
Place of Oeatli ?

Days

IM^ACK OI- niKIAI, (»K RHMoVAI, J DATI-of Hi hiai, ..r KI-;M(nAI,

X.l.hcs^ Ho^X si^ A.VkX/Cnv'VAj i.Jt

/D

T90*<

N. B. Kvery item of information should b- carefully supplied. AGR should be stated EXACTLY. PHYSICIANS should

state CAUSE OF DEATH in plain terms, that it may be properly classified. The "Special Information" ior par-
Hons dyin^ awny from home should be given in every instance.

t»

WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD

Board (if II ■ > \ '-' zf '-. Ik's; 1' Co

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

Re^j/sfcrcfl jYo,

2083

<vvcA N ' I Deputy Health Officer

DEPARTMENT OF PUBLIC llEALTH=City and Connty of San Francisco

Ccitificatc of JDeatb

PLACE OF DEATH: — County ofUCL/Tu J^-XX/^VCUl.CCiCity of 0<X^V J .^^XX ■»VC-Ci''

No. 'liH?5 >l/lc''v.v,'cL'^.. St.: b Dist.;bet. I'^'v.'^. and V\ U

r IF DtATM OCCURS AWAY FROM USUAL R E S I D E N C E G I W t FACTS CALLED FOR UNDER SPECIAL INFORMATION' \
\ IF DtATM OCCURRED IN A HOSPITAL OH INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. )

FULL NAME ^6^Kxyy

\)

n v

t

uavu

-(;\

i>.\

PERSONAL AND STATISTICAL PARTICULARS

MEDICAL CERTIFICATE OF DEATH

tTlol.

kill

fU(

.0^

Month)

\( . I-

^1

1>,I\ I

1/ ,,'1:

\ . .1! i

DA'Pl-. nl Dl'AIIl

I'ct

1

Dav)

/on I

(Viat)

-9

w riH i\\ I' I » Ilk 1 1 ^ I
u ■ •

lUK nil! ^>- )
"'^tit' . .1 1 . ,11111 ■ \

)w

OJxM^o

^4

4X/v>v<x.i

A k

iMoiitll)

I i!i-:Ri:r.\- ri;kTii\-, That i.ittcu<k..i .u«t:isi-,i f,,,iii

that I last '^aw h *>> >- . .alivf on nL C\^ X lip '\

iikI that (k-ath occurred, on the >\n\v <tatii| aliovc. at >.
^-^ M. The CAISI' i)V !)i; ATll wa^ as follows;

N \M1 ( II

I- \ ill i;k

p.iK rii i'i. \( i<:

MM i<i;n' N \M I

Ml MoTHHK

niK ruri, Ai'K

ill MtiillHR

' -' :' I -l (■( III lit! \

I >i>- IT ATIDN

nri-i\ri<)X )•,,,;. Mouths Pays

Jh)i

lis

COXTRIHrT

..\jQy-^-v\, <.

\xxk'

DURATION )\'ars

(Signed) v

Hottts

V
I<)0

J/iif/Z/is /hirs

^X^UMXt M.D.

SPECIAL Information onh for Hospitals, Insntytlons, rransienls,
or Recent Residents, dnd persons dyinq nvtay from tiome.

'^ ^ v'-vv.XK-

f\/''ii!f'i! ! II ^.;>> f ) ii III nro 1 .>

U..„//n

Former or
Usual Residence

Wfien was diseasp rontrarfed,
If not at plare of deatti ?

How lonq at
PIdf e of Deatti ?

Days

'I'n I". \!!(»\'i" ^1" \ riu I'KRsoN" M, r\K TTii t \Rs SRI rKfj.;
iU';sT <)i MN isN« iv\ i,i;i»< , J-: and lu.i.n.i

(Inf-.n,.aiit Uj Ow^K- Jl^cLcL ' fUxhJV

1) rm-;

I'l.AOK <il- IHKIAI, OR KK>tn\\i,

Qllt

^ltLAN4±

IiXri'i.f I5i PiAi iir RHMuX'Al,

T90H

r.Nur.R iaki:r Ow ■ -J 0-Ca^V\,A^

^\(l<lr< ss I I 2)1

A^'^X

Pi. B. Every item of iiiformation should be carefully Hupplieci. AGE should be stated f.X4CTLY. PHYSICIANS should

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

I »

%

WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD

ll.alt!

"^. !1^1T„

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

I)(f/r Fihul ,

.0^-oU)

\

3 V)0\

Deputy Health Officer

ll('!di'^tci'('<l JVo,

2084

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco

Ccvtiticatc of IDcatb

I in. 5. StnnDarD i

4

ni

PLACE OF DEATH: — County ofvJ/aj>%' O A.<Xi-^cu<i.e(N City of 0 CL^v JA.o ,

i[

li^

^Na.VxT^l;uxiJ L>>\X;U5uUvvCH L C^^^^UulaA Dist.;bct*

and

/ IF DEATH OCCURS aAjAV FROM liS U A L R E S j D E N C E G I V E FACTS CALLED FOR UNDER "SPECIAL INFORMATION" N
\ IF DEATH OC'-'RI^Vd IN A HOaPITAL OR INSTITUTION GIVE ITS NAME INSTFAD OF STREET AND NUMBER. /

FULL NAME

t 1 fvil

UuV^

- 1 \

1 1 \ I r ' 1 1

PERSONAL AND STATISTICAL PARTICULARS

i 1

/

I M-.tlthl ll:i\ '

MEDICAL CERTIFICATE OF DEATH

iiA ri-; (ii- Di: \ rii ,

W I I 1. .w . I 1 ,

ii!K I'ni'i, \.' I-;

^\,S\I I ,• I . 11 III

X \ ^t i III

I \ ill i;r

!UK r II I'l, \' 1

< •: I \ III IK

■^t l! I I il 1 I Ml II

(ti MM'nii R

' ^! it 1 1 i! ('(Hint I \

I »t ( rp A'liox \

Cjv

V

^

i ^tl.|l'lil • . Kav)

I Ill-:ki:i!\- CI:RTII'V. That F atteu.U-.l .InHa^d fruiii

that I last s,i\s h alivt- <»ii -- jip

and thatdtath < xi ii t rt-il, cni thf <lntc statc-d ahovi', at
M. Th.- C \I -:• i>\ l»i':.\TII was as foll-.ws:

i r. *. N. '

A

{\

DIUATION }Vuis

CONTRIIUTOKV

DIRATION ^ ),,/rH

Mouths

Pa

J'V

I /oil Is

W

<X\M

I

(r

(SIG

(
NED ) \J^

m

Mrulhs

/hus

\trA\jUv

%v

dL

Hours
M.D.

'-1 0 k 1 '^■

U)n

\d<lri-ss) MrX^vuL^U Cn^

Special Information onb tor HnspiiaK insfitutfeiis, TMnsifnts,

or Recent Residents, and persons dyini] dWciy from tiome.

k,

/ ; t
II, I ,-,l TS -) )'l'll I

M.Hltln

Ihn

Tlir \Ht )\! -^1 \ I 1 n l'KR-< >XAI, 1' AKTFtTl, XR-, ARK TR t*l" '!"' » TIIH

)!i->^rni M, KNi »\\ i,i;i».;i.; AND hkijki-

( f n f()' ill

mt 0 yK^^

\J

X.Mrc.s ^XS \t

Former or
Isutil Residence

When was disease confrarted,
If nut at place of death ?

HoH lonq at
Plare of Dcalli ?

Days

I'l.ACJ" <)I- r.IR I \I, (»R RI"M()VAT, | UNll ' Ili|.'i\t

i:m<>v Ai,

I QO ' 1

INDl-.l

Ad.lit s.

^A>4. w«

IS. B. livery item of informntlon shoulfl He cnrefully Huppllecl. AGE nhoultl be stated RX4CTLY. PHYSICIANS should

• tnte CAIJSI: OF DEATH in plain terinM, that it may he properly classified. The "Specinl lnformati<m" for ptr-
nnns dyinifc away from home should be ^iven in every instance.

WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD

,._,_,..,^.,________ REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

J)(ff(' Filed

0

Registered J^^o.

3085

l<rU^\. a 7/y^H

Deputy Hoafth Officer

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco

Certificate of 2)eatb

I tl. S. Staiiear6 )
PLACE OF DEATH; — County of d\ 0 \a^\/CAulcoCity ofO<X>\; XVa>XCU^oo

No. -t \1 iWu^ liVviKciaA) St.,

(IF DtATA OCCURS *WAir FROM USUAL
IF DciTH OCCUKRCO IN A HOSPITAL

RESIDENCE GIVE fa

OR INSTITUTION GIVE

Dist.; bet.

and

FULL NAME

4

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

PERSONAL AND STATISTICAL PARTICULARS

Wrf\j

l

'\

yy\XUJ>^

• \.\ y

Ha

v(»I,uK

:> \ ! I < >! luk in

c w.t.

N!o!it)i '

M.V.

Dav)

M •uth

(Year)

/hns

MEDICAL CERTIFICATE OF DEATH

DATK <)1- DI.ATH \

Day) (Vt-ar)

^IN'l.l" MAkRIi;!)

\\ [III t\\ i'i» OK i>:\i iKi i:n

' Sfnti or CiMifitry

K

I- \ III l.R

nik III I'l. \v"K
ni- I AiHHk
' StMli- or c'diinti ^

MAIIU-N NAM1-;
ni Ml en IKK

lUk I'llIM.MI':

ni M<»rm-:k

( '^tatr or I'onnt 1 v

ccL^u-vcL

(

iMoiith)
I Hl'KI'UV Cl-RTII'V. That ] attcn.k.l .kacMstMl from

U \t aa 190H to t ot 3) u)oH

tliat I last saw h A-^T^ alive on WxA X up H

and that death occurrcjl, on the date stated above, at 1
LI -.M. The CAISI^: OF DI-ATIf ^va^ as follows:

^'^'^^\yJ\JLAAA^^^>^ \Xx^<,yyJL

Dr RAT ION

)'t'ars

Mouths

L

A.

0
(

r>

Day

/lours

r

c:^

CONTRimTORV C ..|^»iMxtl.frVA. .^.^^<tatx.ot^>^x^ I

DIRATION

} 'cats

Mouths

/)av.

Hon

rs

(Signed ) t:: . o Ci-Wlva. »v

d'ct ^ iqoH (Address) otHiWvM

M.D.

L

i

uOCrPATIoN

Kt'hifif III Sati ] luitii-ti

Xj\jywXK.y\x\

) fU! I

.V,

I III f ft S I I /hi 1.

SPECIAL Information onlv for Hospitals. Instit
or Recent Residents, and persons dving away from home.

ttftlons, Transients,

i
?-

>

THl-: M5nVi: STA I'JI) I'KkSoXAl, PA KTir fl \ KS AK l". TKl' K To THI'.
nnST OI-' MY KN<)\Vl,i;i)(.K AM) HKMia-'

Iiifiii ni.iiit

X.Klr.ss I'iOO NL^^^^^'U^^V at

Former or A n ill

Isual Residence ODuYK) \^%JL

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

How lonq at
Place of Death?

(I

Days

ri^ACK OK HIKIAI. OK KKMOVAI, I DVIKof Hi kial «»r KKMo\ \I

I (^ IK

I'NDHKTAKKR

cot ■ ^

t

190 "i

Athlre^^ ..Ibl. XlhAA^'U^^ . t

IN. B. F.very item of information should be carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should

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

fn

1

~

i

f j

'*

*l '

.

1 j

■^ \

!i'

1

f

■^^

4

♦^

I

t .

' i

ri

I

WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD

I. •,'!li IV..

i: \>.S^V C,

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

/^

Drf/c r//rf/,Kj-X..

r- , ^

r,)()

/i('<ji,s/('/-efl A^o.

2086

..V. V

Dep th Off -

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco

Gcvtificate of IDeatb

( XX. iv. GtanDavO j
PLACE OF DEATH: — County ofOcL-rv J \a Y\/eULeO City oiOo^y^ ^ AXX \ :

N«, Ul rdxal [jmiKo^yx^ Uw (s^s^. \ stt^. (• Dist.; bet.

-~ and

(IF DEATH OCCURS A^AY FROM USUAL RESIDENCE GIVE FACTS CALLED FOR UNDER SPECIAL INFORMATION" \
IF DEATH OCCURM^O IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. J

FULL NAME h/OM KjA^xJ^x ) ..

^1 \

PERSONAL AND STATISTICAL PARTICULARS

M

1)^1%

\^ .1

W 1 • ! . : -

HIH I'll I'l, \.l-

'S!:if I i.T ' ". ,11 111 • \

NAM|. »»i
FATIIHR

lUI<THI'f,Al"K
i' • I'HI'H

M \ I hl.N N XMl
III M<>!"m-:K

lUR rn IM,A<H
III Miiilll'lH

I -'tilt I ,1 ' , 'U lit ■

I ■ )

MEDICAL CERTIFICATE OF DEATH

DA Ti-; < ii 1)i;ai'ii 0

J. A I

• I V.1U /Q(}

M ,!illi' iDriv'* (V< ,11 ;

I III'MU'HV Ci;UTll'\', That I attrmk-.l .IcHtiisrd fmiii

— I9O to ■ —•. 190

tliat I last saw li ~~~ alive on _______ _ ^^^

aiif] tliaf (Itatli < ucii rrtd, (iii the- datr sfatiMJ ahovr, at
M. Tlu- CAI SI' Ol- 1)I:AT1I was as f.,ll,,ws:

^C\AaJ\J_ ^uX'j oSwVaL v-vJoc^ , vj XxXvc^vwcCIa, tL
1 ) I " k A 1' I < ) N } ?<7r.v Months Days

//<>/( I N

C(>NTl<imT()RV

DTK AT ION )',,!)

.)[.>>!( /is

/hiv^

/ /on I s

/

( K r ( I'ATH >N

Kf^H>l > :,< S,,, /•

),,//

M..,.>h

/,

( SIG

(I

NED)L<r^.<n<\iA; jAd.Uj duJl

<X/v>.dL M.D.

T(»o"\ ( Ail.lr.s.) V.0 U0-"VAJLM> ^-^1^- '■ •■

L Information only l«r Hospitals, Institftfiyns, Tr,

X looH ( Ail.lr.s.) L^VCTAjeA^ L/jiv^

SPECIA

or Recent Residents, dnd persons dvintj dwdv from home

Former or
Usual Residence

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

HoH lonq at
Place of Death .'

Transients,

Days

'in' .\nnVK HT \ IKI) I'KRsoN \|, :• \H IKMi, \H-. \KK fKlK i'< > 1*111';
lU-;sr nl- MS K V' »\\ l.l.Fx ,I% AND HI-l.lI.!-

„f,,.„umi L^<rX^-'YvAAA L-^ X

W ^'

f \.Mi.

T90H

I'l.ACHOI' nrRFAI, nk kI^M<.\Al, l»\l'l ,' IltiuAi, or kHMoVAI.

jS. B. Bvery item oi' informiition should b.- c.irctiilf.v siipplie«l. AGK should he «tnted HXACTLY. PHYSICIANS should

state CADSi: OP DHA TH in pinin terms, thiit it miiy be p-operly wlaHshicd. Thy '•.Specuil lnforiiiHli..n" for p.i--
fions dyinji uway from home nhould he given in every instHnce.

I 1

i

I

WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

nu)^

Jiro^/.s/crcfl A^o,

\

DEPARTMENT OF PUBLIC HEALTH

City and County of San Francisco

Certificate of Beatb

\i 'i

PLACE OF DEATH: — County of <Xi\ J\(X^xOuic^ City of^/a/vu ^ K/X/y^'dUl^:^

No.

;^^

C^^x

s^

(ir DtATH OCCURS AW»V FROM USUAL R E S I D E N C E G I V E FACTS CALLED FOR UNDER SPECIAL INFORMATION ■ ' \
IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. /

FULL NAME

\

^L' LLLcav>%. OLt^Xl

PERSONAL AND STATISTICAL PARTICULARS

1)1

il I >K

CLl

■t^

M .mhi

.0 l.t.
1% , n 1

l>;iv

\ < . »•;

IITRIII I'!. \«' I

9

H

/•■M_

I)

.A

\ (

:i

Cl>^ J >va >a e^.^<to

FAT 1 1 1 K

;| K 1 1 1 I I \ )•■

M \ IIU-N \ \ M 1
t»l MiilIll.K

ininiiff.An-;

i»l Mit'I'III'K

";^

_u '

u

^uLLOw > \ ci.

Hill' \1I(»N I * i)

/,'. ; f,;/ 11, ^ :ii / I .1)1, ■ < ■! (k^

1/

111 f(i' matit

I'm" \isM\i* sr \ri;ii i'KRso x m. r xkih i i, \ms ar i; rKiK r» • vwH

1U>1'<»1 M» Is Ni »\\ 1,1.1m .1. AM' lU I.ll.l-

>;tv) iVc.iI>

MEDICAL CERTIFICATE OF DEATH

iMi.tltJl' !»;t

I ili;ki:i;\ tlKTIlV, rii.it I atttiKUd din a-.r<l In.iu

lliat I last saw h L-a-w alivr dii W.'CA7 I u,o H

and that ikatli (icciir rcil, <mi tin- datt- •^tattd ahow, at A^
^V M. Tlu- CAIM; Ol- ni;:.\Tn wa- a^ f^,lI,,^^s:
J -CaJCk-A^XO^ULo-^V^ err tlvX "^MwWXV^

C< )NTK!inT< >k V

1 lour

(Signed)

IhiV

ly^s

llntns

M.D.

K

CV ahj "^^ . ^&A.Lj^>Ajt

Special information nnU lor Hospltdls. InstitiiHonv Transifiits,

or Rt'ienl Rpsiiicnh, dnd persons dvinj dHdv ffum homr.

rormfr or
llsudl Residfnce

Whfn was disease confrar ted,
If not at place of death ?

Hovi lonq at
PIdf e ol Dfdlh ?

Days

I'f.Al'l^ni HIRIAI. UK Ri:M<t\AI,

DSlI'nf Hi NIAI, mi K1;M«»\AI,

IN. n.

■f

•v.rv Hem o»- 5„f,.rnu,t!on «h„uld b. cnrct'ully supplied. Adf. «'i,h,I.I he Htutcd r.X.\CTLY. PHYSICIANS should
tiitv CMISi: or Di; ATII in pljiin termm, thnt it mn> be properly clo»«hicU. The "Spccuil Inlormntiun" for p.r-

noris clyini^ nway imxn home Hhoulcl be j^lven in every instance.

WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

Huat.l • III ili!t IV,. ■ :^•' 5r — :• I'S; 1' C

Dah' FiJah aeU-l^\. ^

/^^>H

Begi.sfi'rcd J\^o.

^^\ji

ft i^

\ ■ ' I

Deputy Health Officer

DEPARTMENT OF PUBLIC HEALTH^City and County of San Francisco

Gcvtificatc of IDcatb

PLACE OF DEATH: — County of

n

\. \ I

C(ty of

\ 0

y

No.

St.;

Dist.; bet.

"and

(ir DEATH OCCUR"; AWAV FROM USUAL R E S I D E N C E G I V E FACTS CALirO t^OH UNDER "SPECIAL INFORMATION" "\
IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. /

FULL NAME

PERSONAL AND STATISTICAL PARTICULARS

I x A T I < ij.* (k \

A

C J s.. )

^

MEDICAL CERTIFICATE OF DEATH

DA n; » »i i>i; \i 11 \

» \ : 1 III HI k

\i . 1

•^INi . ! r M \R l< iKIK

Willi -will < M< !if\-(»Ki'! f)

W' - . .

k

II

T , '/

J l^O

iV(-;ir5

/'.n

> Ml

I

lUK III

'St;it. .

N' \ M I < I'

1 \ III I I-'

liiK niPi.Ai'K

I , , 1 , 1- 1 1 I' l.

MX. Ml

III \;i I i i i 1 K

lit H III 1' I \| I'

111 Ml p : I ! ' \-

c

W> w<^l o

u

iM.infh' |);iv)

I iii;i< i;i;\' ci;i<'rn v. Thai i attcMi.u- 1 (k.ca-rd fi"ui

up til — up

lliat I la-^t ^aw h ~~~ alivf dii up

ami lliat ik-ath < iiaaiiTLal, mi tlu- dati.' stati-i] alniNi , at ~
M. Tin- CWrSf-; nl Di; ATII was as fallows:

hJv^'\A^<i '\J L^.

Dik \'rI^>^•

/ f(/; s

Months

Ihiv

Hon

rs

C(»NTkIlur(!RV

(SIGNED) U

I s

M'>ilhs

Pav

Arlilriss) ck-0-0 \j\

Hoii I \

M.D.

VA'NJOi^-

Special information nn^ for Hospitals, InstHutions, Iranslfnts,
or RcrenI Residents, and persons dving <iHiiy Iron fiomr.

I I I 1' \ I |i iN

QO\i Vci v^ -vvt

M,„,tln

l>

III I \".< i\ !■: -^ r\ i*i;ii !'»*ks«»\ m, tar iiiti xrs a hi-: tkih tu Tin-
ni>i' Ml MS" K \i »\\'i,i;r>< ,}•: and \.\ ui t

i' In I'l! fiumt

(L.

i a

rsrvxj:r'\>'^J^ Vjj^jvwwvtj

\.',i,,

Former or
I'sudI Residence

Wtien was disease rontrarted.
If not at plarc of deatli ?

How lonq at
Pfare of Oeatli 7

Days

DA'I'Riif HIKIA! 1)1 ki:M<)\AI,
\J^ 3> I90H

ii.AOi-; ni' in KiAi, OR ki;miivai.

IN. B. li

Uvrv Item of Informntlon should be corefully supplied. AOB «ho»Id He stnted EXACTLY. PHYSICIANS should
tntc CAUSE or DIIATH In pinin terms, that It mny be pr«.|>erly tiasmt'ied. The "Special Infoniuition" »op p«r-

unns fiyinft away from home should be 4iven in every instance.

■m?^

«

fi

•III

WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD

* J ,1

.1 t|. .;ltll I Vo I

^■— i: V.^VC

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

z)^^\>Ji\j

Ifu)^

licoish'j'cd JVo,

3089

I Deputy Health Officer

DEPARTMENT OF PUBLIC HEALTH-City and County of San Francisco

Certificate of IDeatb

11. 5. Stan^nr^

J? (s^

PLACE OF DEATH: — County ofOcLmjv'Axi

(^

^r\

No

, OS. ok. U '^

^_cc>

^

^ " ' ' City of CJ/CL^yv vJ AX^vxC^o. C f
St.; Dist.;bet. \ -^ and InvC^.

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

FULL NAME

^CLu/'v > A^

PERSONAL AND STATISTICAL PARTICULARS

m

|i \ 11 <

1

\' . I

\\\ I H l\\ I

iW,.,. -u

luk I'll

I- \l li IR

lUK I'll ri. \t-'

•'I

I I»;ivi

1/ ,.'/

/ T' H

MEDICAL CERTIFICATE OF DEATH

DA ri-; t ii I'l. V 111

Uct

, 1

[l.is-l

/ (;i >

I Mi.llthl

I II1;RI{I'.N ri:RTIl-\'. Th.if I itti-mltMl .UHHasd fruiu

L.

/',/

! II

A

•\\\

K

.Til!

M »•

( ii >;i 1 I I i I

(l)

"U

tlml I last saw h '.. alixcoii LA^^. \ i.,

and that iltatli ocrurreil, <in tlu- ilatc stati-il a1>n\H-, at
J M. Tlu- CAI'SK OI- DhATII was as follow.

Q^..

DlkATloN )V,//s Mouths lb Days

CONTRinri'ORV -^ w^..'; U. c.i

Hours

WW 111 I'l. A*' I
ill Ml ill ! 1 ■ K

1 si, ! • 1: 111 lit 1

I HI r 1' \ I Ii tX

(X/Y\> 0 )v<X>x.c.\-si-^c

I )r RATION )V.7rs

7\

J/,.vM.'

Ihu

SIG

K)')

1 It'll is

i\/XA^^ U ^ Vv:' --■' '.^ M.D.

A.l.lnss) llOH U/Q^V^U^; a .,•.

NED) LIvO^.U U

Special Information unl> f^r Hospitals, Insntutlons, Translenfs,
or Recent Residents, and persons d)inq .iwdv from tiome.

R,ui,-,i :ii '^.;>> I

!,,;/« I !/,.»'//■

I hi 1

111' \Hi)\|.' s r \ri'i> !'KH>-.nN \\, i'\H rici'i AKs AH J-; I'Krj-;

1U>T ol- MV KNtiWIJIx.l-: AM) HKl.ti;!'

To Till':

(Inf'i! iii;nit

L-yvwA > \.o^ Q j5L^ *

n A A

former or
Lsual Residence

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

How jonq at
Place of Death ?

Days

I'LACH c)i* nrRFAf. ok ki:MM\Ai,

n (%

NI)i:RTAKi;k ^1^ \) KTYK ,

HA ri: .i m wiai ..r rkmox- \i.

T9O

N. B.-

-Rverv item of 1n?orm«tion should be CHr«fully supplied. AGE should be stated BX^CTLY. PHYSICIANS should
state CAUSK OF DEATH In pinin terms, thnt it msiy be properly classified. The "Special Intormiition ' for per-
son* dying away from home should be given in every instance.

rr

i -^

¥-

\l

1

m

I

i

I

I

,t' .

M

WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD

■<i II. lit h I- V... ,: ■?" ITSr-:-.; Hf;.}' c,

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

Dn/r /-VAv/, i.ctcrW\' ?,

lOO'i

Iti-^l^ferrd J{().

,cvi^

Deowi

» I *. 1 ,<"^ i?^i-«

er

DEPARTMENT OF PUBLIC HEALTH-City and County of San Francisco

Ccitfficatc of Scatb

tl. t5. StanDarD

PLACE OF DEATH: ^--County of OxXA^ J/ua\LCv.sir ' Qty of O/Ouru oAXL^ v.CUl

Ne. V.L

It

Dist.; bet.

and

(IF DEATH OCCUR* AWAY FROW 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 /

(00

FULL NAME ^^

K^ i i . XX'

-■i;\

PERSONAL AND STATISTICAL PARTICULARS

MEDICAL CERTIFICATE OF DEATH

DATK ol- l)i:A Til

clU

u

rii

Ow

^

l).tv>

(Veai!

\< .i:

•-•M •.!' M\Kl<ir

W r I 11 • A 1 • I 1 Ilk' ! 1 V
W ; 1-

l>

III.-,

in 0

1,

luR nii'i, \«i'

N'XMl <!' ^
t A III IK

lUR 111 IM, XiK

1 »i- 1 \ ill r k

•-t;it' • \ i'. ,i;t.! ; V

^1

M \II»1;N N ANSI

i»i- M<»TFn:K

?

I'.IRI'II !M, ACi;

- ■ ■ ■; r. .\mt 1

\S

I Hl':kl':i5\- ri:KTlI-V. That I atUMi.lf.l .krtasc.l frnm

tliat T last snw h '■• ali\t.()!i nw'-*_'|v\. j^p

ailtl that lU'ilh ociurrcil, dii the ilati- --tatril ahovt- at I

to OX'JaI. a.% i()oH

M.

Tht- cwrsi-

Ol- DI-ATli was as follows

.X.

: ' t

, a.,...,v ■,:

-^

nr RAT I ON )V,//-A

CONTRIHrTOkV

Months

fhiy

Hon

rs

DTRATION

ymis

(Signed) J" ^■

J/i>////fS

vi

'■'■V

0^a\X

/hn

X) (

I lours

M.D.

1 1)0

(

X.Mn-ss) ultuU C-O Ic {SsiUt

if^ only for (To

Special Information only for ffospllals, Insmutlons. Transients,
or Recent Residents, and persons dylny dway Iroin home.

h'f : iiifi] in Silt! I

M.'rfir

Former or
Usual Residence

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

HoH lonq at

Place of Death ? 1 I

Dav^

rm Ai'.ov!.. sr \ri t) i-kus. »\ m, rARiHTi.AK^ aki-: pRri-; to rm-:
isi'sfoi- MS- KN( >ni,];i)i ,i; and i!i:i,n:s'

III f(i- n!;nit

C.(?,%.

\.;il;

Cau V C

J

0^

K<-^<XAJ

l.A.CK ()K lU'ttlAI. «)R Ri;m«»\ \1,

A- V :v

■CWO- > Wi

'\ ri; '•' Ht HiAi or KJ^NfoVAI,

T QO \

4 j} V ^

r\ n ^

IS. B. Every item ct hifc^rniiition should be ciirufully supplied. AGR should be stnted HX^CTLY. PHYSICIANS should

state CAUSi: OP DIiATH in plnin terms, that it may be properly classified. The "Special Information" for per-
sons dyin£ oway from home should be j^iven in every instance.

i

WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD

111 Mil !•' Xi). i -. K' -ar. i-i luS: !' r.,

Dfffc F//rf/, L otcrlMA) 5

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

/fU)H

liegis/ernd J\^o.

^^.Aji 4Jb\yu Deputy Health Officer

DEPARTMENT OF PUBLIC IIEALTH=City and County of San Francisco

Certificate of E)eatb

I XX. S. GtniiCarC i
PLACE OF DEATH: — County ofOoA^ ' " c Gty of C^ O. >^ U A.a >\ - v.a -^

No. vJ^'-yvtA.oJL

\iu

^-vCa-J

Stt

Dist.; bet*

and

(IF Dr«TH OCCURsOftWAY TR^M USUAL R E S I D E N C E G I V C FACTS CALLED FOR UNDER "SPECIAL INFORMATION" \
IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. /

FULL NAME

\J

1 i 0

j\.o..^-\ji\

« K

<^I*X

PERSONAL AND STATISTICAL PARTICULARS

^,

MEDICAL CERTIFICATE OF DEATH

I 'ATI-. I >i hi: All I

I

» \ n: < >i i;!R III

D.iv

\

.A, p. I

li

'Day^ iVcar)

cci>t be

ih

^FVi IK M \K R II'!)

"s 1 I It >-,V) \^ ^^^ | » ' ^ i i ^' i ] I )

W ; ■!. IM .,

"^! ' ; in I '■ 111 nt I \

I lIi;ki;i!V CI'kTII-V, Tliat r atUMi.le.! .lerrased from

that I last saw h a!i\A' on

Ttp

V\MI Ml
I NTH IK

lUR riiri.Ai}-:

<)! I" \'i 11 I'K

■^t ,<, , ,, (■ . unit! \

MAIi»i;x NAM1-;

<ii M<>rin:K

im< rmM,A<i:
«>i- %!<)'riii;K

'■-t >• ! t'lUHltl

and that <k'atli occurred, on tlu- ilati,- stati-d above, at
M. The CAISI-: OF I)I-:.\ 111 WIS as follows

as loiiows :

DIRA'i'roN )V</;

CONTRIIUTORV

nr RAT ION 5V<7r.r

( Signed ) LtrXxmjUu J.

Months

Pay

Hon

IS

/

< ^^'CV V XilON

\^' c.

rt

Mnnfhs

0

/\U'.

•s

I lours
M.D.

TO^'^ f Address) W^\.<rv\l^ C k s, w-^^

Mr

SPECIAL INFORMATION only for Hospildls, InsfltulWrN', Transients,
or Recent Residents, and persons ddni dwdv from home.

AV. ./(//•,/ /;; Si/ 1' / iiii. Ill

) 'ril I

Mi.iifhs

\'\\V. MUiVT-: STATl'D l'HR'^<»N M. !' \ K TIC T T A KS A K l! r R T I-! I'f » I'm"

i:i>r c)i- MY KX( iui,r;i)C, J.; wn i;i:i,n:i''

Former or How lonq at

Usual Residence -. , PJ,irp of nedtli ?

- ^ y '4-

Wlien was disease contracted, ''^ *b£n ' *^ J j n

If not at place of death ? S ti^v '^Cw-^^<C dJx^^iJ

Days

n

\ !,!'

I-^^ACK OF HI RIAI.UR RI-MoXAI. J \)\X^.l^\ Hikiai, ..i K^MmVAI,

IS, B. l-.vcry item of iriformntion should he carefully supplied. AGB should be stnted EXACTLY. PHYSICIANS should

Btate CAUSE OF Dl.ATH in plain terms, thnt it muy be properly classified. The ''Special information" for p«r<-
fion* dyin^ away from home should be given in every instance.

i i i

MHi

Mi (

H. ;ii.! ,,f irtallh I" X

WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

Registered J\''o.

I Idle Fi/eil, ly-ttcrlM.'v ?n

190 \

2093

^ » *

IT 6

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco

Certificate of IDeatb

( "D. S. StanOarD )

A

%

1

A

m

No. I bio

PLACE OF DEATH: — County oi"' Oj^^o v XOvvC w -cCity of ^aru vi^VcoNv^L^ui/C^
^fr-V^Ci lU^ St.; H Dist,bet. Stfv and btk

FULL NAME

SKX

PERSONAL AND STATISTICAL PARTICULARS

H^Xz-Y^aJL^ Oi-YNvCtA

IC kcti

MEDICAL CERTIFICATE OF DEATH

DATK UF DKATH

n A II-: »i!' Hik I II

A I . K

XX

)■

l/-.///>>

A%\

ao

» t ar

A/

fMonth)

(I)av)

(Yt-ar)

^rNr.!,!-: MAKKIKn

\\ in<»\yi-;i) ok ni\( iri f-o

•Write ill ^(H'ial iltsiiMiat i.ni )

c

h

I lU'KI-P.V CI:RTII'V, Tliat r attciKk-d deoi-ased from

.)...\\k IS' 190H t., Vzt X ,<pH

that I last saw hl.nnf\ alive on 0-£,^^ XT upH

and that death omirreil, on the date stated above, at ^HS"
'^y M. The CATSI-: ()!• DliATlI was as follows:

(?j\U

--Lrry-xyfy-N ^ ^

IURTm'I,Ai"l
( Statt I)! (.'( )ii n! ! \'

N" \MK «)!■■
I A III } K

lUKTlllM, XtK
Of- I-\rilKK
(Slat* ur t'ijiintrv

MAII>HN NAMK
OF MOTIIKR

HlkrHIM.Al'I-:
<>l" MoTHKK
(State iir (■(intittv

3'

AA

1

r^^vLCyx.

t\-

I) r RAT ION I }'t'ars Mont In Days

CONTRIinTOkV mX^a

Hours

XXAXX.XI/ »a..-uu:j

or RAT ION ^ Years b Afo/iths

(Signed) J.

&.(Jc..E

/^i7 VS

1

Hours
M.D.

(\

oi'cri' ApioNi

Rt'-iiled in San I'l atu isro #wiJk )V'(f'> 11 \t<<nHi- A 0 /'i/i

)XAAA_iA/

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

riiiv AHovK s'lA ri:i) pkksonai, parti(M'laks aki; iKri-; lo riii-;
HiCsT oj- MY KN<»\\i,i.:i)r, K AM) Hi:i,n:F

Former or
Usual Residence

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

How lonq at
Place of Death?

Days

(Informant

(A<l(lT-e

PLACH ni- P.l klAI. OK KI;M(»VAI, I n\Ti;of Hihiat. or KICMOVAI.

'O^H^Ux^Mi^ I ^^ ^ 190 S

(A.l.liess ini \f}WL4.^-^>uI^t

IN. B. Bvery Item of inffonnatlon should be carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should

state CAUSE: OF DEATH in plain terms, that it may be properly classified. The "Special Information'* for par-
sons dyinit away from home should be jtiven in every instance.

I f

WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD

»S*JL**'

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

':"\

hair l-ih'<l, ^'.cUlvX\) 3>

/,9(9H

Registered JSi^o.

2093

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco

Certificate of ©eatb

( U. S. StanOarD )

No.

4 ^ \ ^

PLACE OF DEATH: — County of OcLl\) w Va>vCv_4C{) City of C}<X>A; J >\>(X/-rvx^UU^<:)

1) A

5?) a. - \\U^, LU^

St,; ^ Dist.;bet. LLIa">'\X^

and

r ir DEATH OCCURS *W*V TROM USUAL R E S I D E N C E G I V E FACTS CALLED TOR UNDER "SPECIAL INFORMATION ' ' \
\ ir DEATH OCCURRtD IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. )

-CriKh^ )

FULL NAME

1

.I^^AXXj vl^\-AjCj(TrtCO\j

PERSONAL AND STATISTICAL PARTICULARS

SIX

Hll
4

t«»I.nR\

DATi; « i| lUK 111

\<.l-

C^.lxt

LUJviOc

M.iriihi

11

(Dav)

rl'^l

190 *1

(Year)

11

• il t

M.,rh

\\

Ih!

\V| I)( »U l.|> OK IHVi tki i:i) \

U'litf ill ■-. .cinl HeHii'iiiuii.ii i

Hiki'ni-i. \ci

Matt or ('.111 lit t \

FA I II IK

HI Kill I' I, \i ).;

'•I I \rni-:K

<H!,it« .If »\,||iiti \

M Mill's- X A Mi-
ni mmihi.k

i!ik iiii'i. An-:
••I M(»rm-;K
' ■-tat. 1.1 r.,iinii %

(]

IL LcL>^\,^^sA.<L

? 5

R)

MEDICAL CERTIFICATE OF DEATH

DATK (U- i>i;aih \

(Month) (Day)

I IIJ{kl{HV Cl-kTIFV, That I atten.kMl dcccascl from

-i--i^ iO 190H to (i//cfc ( ic^H

that I last saw h-2A) alive on 0-A^^%i 3)0 190^

and thatdiath occurred, oti the date stated above, at iQ,-50
^J M. The CAISK OK I) HATH was as follows:

px^TN^Utu ' a|xx JMx/dL h^juu^

DTRATION b Years Mouths Days Hours

CONTRIHrTOKV

yxSLOj\j!>

9 \

1 (

DIRATION

Years

iSfouth.

Ihiv

Hours

(SIGNED) dU, Mk dULOL/ru M.Q.

iy^ ( iQoH (Address) I no motdk^ dt

Special Information only for Hospitals, Institytlons, Transients
or Recent Residents, and persons dyinq away from fiomc. '

nccr PA r ION

h'f'-iitcit -11 S,;;/ f'l ti H, ni'i> OsO

) ,,;

MoDth}

/h!\^

Former or
I Usual Residence

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

How long at
Place of Death ?

I'm-: xHux'i-: sr \ rin i'kksi>\ \i, rAKi'iri i.aks aki-: tktk To th i-
iu;sT «n .Mv KN('»\\ i,i;i)(.i., A.M> ni:i.fi;i''

( liifotinrifit

y

Days

O)

I'l.ACH (H- HIKIAI. nk kl-MuVAI, | DATi: ,,f HiKiAf. .,t KHMOVAI,

190*1

I NDliKTAKKK

5 'CU-A.tjuL V U>

N. B. Rvery Item of information slioiild hs carefully fiupplied. A(JB should be stated EXACTLY. PHYSICIANS should

•tate CAUSE OF DEATH in plnin terms, that it may be properly classified. The "Special Information** for par-
sons dyin^ away from home should be feiven In 9\ory instance.

I;

bm

i

4^

WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD

I, .Mil !■ v.. i'. *•'• •«*. '--:■ ]\Si\' (

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

/)(f/r F/7('(/, vJ/ttxTAM/v S

/.96>H

llegLstcj'cd J\^o,

2094

)

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco

PLACE OF DEATH: — County of^ia .a

Certificate of Beatb

( XX. 5. GtanDarD )

m

f^ ^JKsJuyxXAx.

\X.A

L^ .VL-^v^

St.;

Dist.; bet.

City of^^Ou^Yx 0 /VCL/vx^CA^

and

(IF DEATH OCCURS AWAv FROM U S U A L ' R E S I D E N C E GIVE FACTS CALLED FOR UNDER "sPECfAL INFORMATION" \
IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. /

in I

FULL NAME

(M ^\' V

PERSONAL AND STATISTICAL PARTICULARS

XUJL

) \ I i: Ml lUH in

1^

M iith

:)a\

\i . !■:

^ I NT, I, I" \! \H k n !»

-\ ■ .-^ ■ M ^ . ■ ■ :

V\M1 Ml
I- \ I II IK

FUR ill II. MK

Ml I A III i:k

-i!.'! < I ,1 i'liinU! s

M \ litis N \M 1
Ml MMIIIKK

mi- ni I'l. \i ]■',

Ml Mti'llIlK

vt 1 1 , ii i ', 111 nt I

Mm 1' \ rn »

-^l-

/).!

S^ I

A^^xXX^

n

MEDICAL CERTIFICATE OF DEATH

I).\TH Ml- Dl-.AIH

l\ \ I

1

Monllil

(Dav)

fpo 1
(Year)

1^

HI'IKIU'.V eivRTll-V, That I attcii<liMl (k-ceased from

V„ CV I KpH to

p

T90

that I last ^a\v h t. » alive- oil \w/ /cX> 1

and tliat death <ic( urrerl, on tlu' date stated above, at i
LLjVI. The C MSi-: Ol I)i;.\TH was as follows:

190M

L ">'ru ylD x^^^\>

0

DIR.XTIOX )'tijrs H Mouths Days

CONTRIIirToKV

Hours

Dr RATION

)'tuirs ^ Months

1

{\XA\JX}

(SIG

19

NED) 10. vi.MC^trU.

na\

'S

/C^ 3L I()oH (Address) ^Xl

I loui s

M.D.

Kr ;,ii<' III ^'d'/ Fl till: f-i'ii

).ai

\J, „)!),■.

I hi

Till", ^HM\i: s r \ no pkksmna!, i-nkticii, \rs, akh TRri'; ro rnK
mtsT Ml' M\ K nmw i.ijx ,1; AM) I'.i: i,n: 1-

IiiFi -in-mt V-xy

AyWX> \JXKrr\j

\ fid toss U I"

't

SPECIAL INFORMATION only lor Hospitals, InstltHflons, Transients,

or Rerent Residents, and persons dying away from home.

^ n How lonq at
J.C\^<>Cs>x V<.>WA^ Place of Death? l Days

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

Former or

Usual Residence J 'C\^<>Cs

.c.t.

l'I,.\CK OF HIKIAI. OK KK-MOVAl.

DA PK uf IUkiaf, or R1-:moVAI,

T90I

A/V\^

(..

[N. B.^— Every item o¥ information fihoulil be cnrefully supplied. ,AGB should be stated BXACTLY. PHYSICIANS shoum
state CAUSE OF DEATH in pluin terms, that it may be properly classified. The "Special Information" for per-
sons dyin£ away from home should be given in every instance.

B

;■ \

I ;

fii

WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD

fil III. IV-, -t'^^^- l'^''^" REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

nuj'i

Regisfri'rd J\^o.

J^095

6s^\.^<j^ A H^ Deputy Health Officer

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco

PLACE OF DEATH: — County of

Certificate of S)eatb

i 11. tL\ Stani>arD )

Cj CL-Y^ 0 AXX )v<^<^,^t City ofOoy>\; OAxX^xCo:^.

C.c

No. iolSlA. ' ' St.; b Dist.;bet. 3.H tJv and 9^5 Liv )

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

FULL NAME

Lrvc

I'D'

AoiLTLn.ui.tc

%

u

JO

ft

-LMl

PERSONAL AND STATISTICAL PARTICULARS

• 1 \

ii »I,t iR

• \ 1 i: I ii 111 K III

^

t

|0„.

ac;h

--is< ij-: M AKi; n

HiH rm'!, \im:

"lint' ■>'. < I Ml 111 I \

's XM 1 < >! V U

Vt

I

ATIIIK p

hjXKA

\

1 ,

HiK Tiiri, All-;
f)i' i*\rm"H

' St;lt f ■ i! (.1 lUlit : %

M \! I UN N" \M 1

or Mttini-: k

I'.iu rnri,Ai-i-:

(Stntf I ii (.'tiitnti ■

I n {• ri'A'rii )N

^'Ct>\; ^Ks

OL

A"V^\A_.<.

/~\

\

^Ouy\j 0 H^<X>xe^<i'Cc

r,-,,-;

y/.-uf//<

J',:^^

Tin* \Hnvi' <r \rii> im* K'^onai, r \k i uti \ks ark rRiK to tiih

lyN" iW l.l.DCK AM> HI

i!i>r<)i MN lyN" |\^ i.i.iX'K AM> Hi;i.n.i

(Tuf'i'in.im

A.Mn

"ilS l)jt>v.'»AXrY\l- ].

MEDICAL CERTIFICATE OF DEATH

DAIl-: ol- Dl.ATH /

(Day) (Vtar)

] III-:KI;I'.V C1:1<TI1'V, That I attcn.k-.l den cased from

19^ 9. looH to iD.ci-

^■^ iqo H

that I last saw li a.livc on ' " ' l(p

atid that (U-ath nccurred, on tlic datr '-tatcd above, at b • J "O

>r. The CAISI-: <>l' DICATII was as foil

(1

( )\VS

^ .La„

o

itl

l,^'

.n^<xX L-c^^^a. > V

WCV.

1)1" RATION }'tiirs Months /)ays Hours

CONTRIlUroRV M\.<nr^w»L

I ) r R A T ! ( ) N
(SIGNED )

l()n

f A <ld re^.^ ) I ^ M AjlLocav VfeXd.^

I lours

M.D.

SPECIAL INFORMATION nnly for Hospitals, Institutions, Transiefits,
or Rfcent Residents, and persons dving away from liome.

Former or
Usual Residence

Wlien was disease contracted.
If not at placed deatfi?

How long at
Place of Dcatli ?

Days

ri,ACK Ol' nrRIAI, OR RHMoVAI. j DAXKof HiKiAi, or KKMOVAI,

0^ ?> TgoH

^.0-^

fAddifSs IXD^.

-unoi

N. B. Every Item of informBtion 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 p«p.
sons dyin^ away from home should be ^iven in every instance.

I 11

I

WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD

l'.,,;,r,l .,r Health IN- .- ?-^'5^^i) lu^ JM u x REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

Dff/r /'V/^'^/, U,^t^UL>v H

/VM.

V

Deputy Health Officer

Reglsicred JS'^o.

2096

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

Certificate of IDeatb

%

PLACE OF DEATH: — County ofOxXno; ^ hXXjYx/ZKA^A. Oty of Cj CL/rw 0 ;v (X

>\ C*A. ^

No. Ho I

(ir DEATH OCCURS A
IF DtATH OCCUHf

I

1 \ *

St.;

I ,

Dist.; bet. 5 *Llx'

and

klk

WAV FROM USUAL RESIDENCE give fact

RED IN A HOSPITAL OR INSTITUTION GIVE I

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

)

FULL NAME

PERSONAL AND STATISTICAL PARTICULARS

iMi()k

OlJ

e

mA:

MEDICAL CERTIFICATE OF DEATH

DAI'K ()!'■ Dl'.A'l'H

i> \ 1 1 Mi- luin 11

A<.K

^IN< I.l' MAKkl!''

IlIH PHI'I, \i'l'.

N X NT 1 <»!
I A 1(1 1 R

lUR riii'i.xri:
<»! 1 A iHi: k

■^t.it?' (ir I'l Hill! t \

MAII>I%N KAMI-
(»1 MiHHHK

MIR rm'i.Ai'i-;

Ml- MnTHi:H

( Slatt ( ir t'diirit i \

A

0

M, Mill

l),l\

\r.-,i!h

/hiv

I !»
11. .n'

IaA^

^ w

(Mouth)

\

(I)av)

/go

(Year)

1 UlCkliBV CI'.RTII'V, That I attended deceased from
lD<:l '.'. T90'- to ^itL^.. .^ 190 ■'

that I last saw h C . ■ ah\e on ~~" ~ " ' 190

and that death occurred, mi the date stated above, at

UWLoi

M. The CAI'SI-: t)l- Dl^TlI \va^ as follows:

DIRATION
C()NTKlI!rT(

/></)

)'iars Months . .. , .

Hours;

xk

KJ^ K^\0.

K.c^Ou

DT RATION

iNED) ^H

(SIGI

Yi'iirs MiOitJis

T<)0 '\ (Address)

Pavsi

Hours
M.D.

\} ^ '\ Tooi ^Address) 3^ b ' H IAv ) t;

SPECIAL INFORMATION «»nly for Hospitals, Institutions, Transients,
or Recent Residents, and persons dying away from fjome.

I HCri'ATIC)N

l\f I'lril J II StDi / ! 1! Ill i^i'ii
rni: M'.oVK STAI'KU I'KKSONAI I'A K I' IC r I.A R^ A K l, PR f H T« » THH

iu;sT (n MV KN'<»\\ij;i)i". }•: .\Nn luii.nj-'

r,-,n

^r,.,l//l'

/),n

(In

' Xl.li.^s \ o I

,.^

\1

Former or
Usual Residence

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

How long at
Place of Death?

Days

I'LACK 01 lURIAI. OK RKM<)VAI. I DATK of Ht kial or KKMOVAI^

T90M

I ■ N I ) K R r A K K R ^ CKrwX.yyy^t \ jb >v 0- v

(AddrcHs

N. B. Bvery Item of informntion should hi carefully supplied. AfiB should be stated EXACTLY. PHYSICIANS should

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

Wit

m

WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD

I'l I Vi

'-»: ?a: 1!\ !• (•

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

Re<iistere(l jYo.

2097

Xat^*^ \ju^ Deputy Health Officer

DEPARTMENT dp PUBLIC HEALTH=City and County of San Francisco

No. ^

Certificate of IDeatb

( 11. S. Stan^arD )
PLACE OF DEATH: — County ofvCL ^^ Jk<x .w^-^'^f City o{^^^^^y\^ Jaxx/>x4v^c<

i Xl^.- -. ■ St.; "^ Dist,;bet^JJAA,C4x^CUv^XX.>% andU^-J^A^ )

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

FULL NAME

3

cL

n

\ n . . ,T

PERSONAL AND STATISTICAL PARTICULARS

n\'n »»! lUKi H

Molithi

r%~

\<.\:

^\

J -.ui >

1/

> I ai

/',/).

Un»i »\\!- |t < >H IM\» if" ill)
^Wliti ill -«iiia' ilf'-ii'iial ii 111 I

f.iK rm't, \i"i'

\ r 1 n R

III Kin iM. \i }■:
III ! \ rm;K

■^!a! c . il roiuit I \

\!\ii>i;n* n\mi

Ol' Mnrm.K

HiK rn i'i,Aci-:

'Stale 1 il (,'( lUIlt I \

Oi'Ori'ATlON \/

"VX^V.X3u

0 wcrwvaj6

xxx^

VllxurV

\j Litrlu. ^cuIulI^^

i\

0

n

m

Mnnth-

/),n.

rm". AHn\i--. "-.I- \i!: I) rj^-RsoxAi, i'ARri<.M-t,AKs AKi-; TRrr: to thh
iu>r oi' MS' KNOW i,i;i)<',}<; and hi:i,ii;h

(liifi)' in.'int

r \<l(lr(.-ss

MEDICAL CERTIFICATE OF DEATH

DATK OJ- I)i;ATiI

(Yf.'ir)

(Month) a>a.v)

I Hl-:kI':i5V CI{RTII'V, riuit I attcmUMl .Uh cased from

T90 1

to

<»o ^

that I last saw li ^^-w alive 0!i L' /^ I H)0 H

l<p

atiil that ileatli occurred, on the elate stated above, at • v
UL M. The CVrSI-: ()1- I)I:ATII was as follows:

DT RAT ION

}'{Uirs Mont /is

CONTkHUToRV L.<lJl/v>->./CL.

/hjv

Hours

l^a ys

nr RATI OX ~ Yi'dK "h Mouths
NED) |04^\Wm, OId

)}<^ 'h looH (A.ldress) lOl'i OX\MxA; Ot

(SIGI

CLhJu<c^

Hours
M.D.

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

Former or
Isual Residence

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

How lonq at
Place of Death ?

Days

PI,ACK OI" HIRIAI, «)R KHMOVAI,

^L-h, \i\- HI Kl\l, OK K h.

I)An;of IM KlAl. or RKMOV.^I,

N. B. Bvery 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 dyin^ away from home should be ^Iven in every Instance.

\ll

♦:

J

u

Boai'l .!' II'

WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD

w^VCn REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

r v<

I )((/(' riic<i ,

d^^

MwA^

Deputy Health Officer

Ite^isfet'cd A'^o.

2098

DEPARTMENT Of PUBLIC HEALTH=City and County of San Francisco

Ccvtificatc of Bcatb

{ "U. S. Stan^ar^ )

(^

No

PLACE OF DEATH:— County of C'ay>x-^ ^o. .- '^^.c-' City ofC)KX/>A; J^va ^vc^.c

St.;

Dist,; bet.

and

(IF DEATH OCCURS A\JtAV FROM USUAL
IF DEATH OCCURRED IN A HOSPITAL

RESI DENCE GIVE FACTS CALLCD FOR UNDER "SPtCIAL INFORMATIO
OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER.

" )

)

\

FULL NAME ^'

SKX

MA-

A<1K

PERSONAL AND STATISTICAL PARTICULARS

V

M.>:itjr

!>,i\

M,.n'ln

fV< arl

/lay

sIN»;i.K MAKkHin

w \\n tw j:i» < »K i);\'< iRi i i»

HIKTHPI.ACl-

' Stuff or I'liimt i %

lU

OJxAaJLcL

NAMl »»l
FATllKR

itiKruri.AiK

ni- 1 AlUl'U

' Sl;i'> • il r, ,nllt ' \

A

M

I

MEDICAL CERTIFICATE OF DEATH

DATK 1)1- I)1%ATH ,A

(Month) (Day)

I HI':RI-;HV CICRTH'V, Tliat I allciKled deccasea from

O-rt > UK,H to O-Cfc 3

igo .

(Vt-ai)

[cpT tn \,/i\J\i Zi 190 H

that I last saw h l- alive oil

and that dt-ath occurred, on the date statecl above, at IC
M. The CATS I-: <)!■ DI-ATII was as follows

190

t

J<x,<iXvv.c LLtc.^'

1)1 RATION

\\

MAII>l%N NAMK /\\
111- M(>TI11';k ' l'

iuR'rmM,Ari«:

ni- Morni'.K

I S{:it<' 'ir eouiit T \'

J\

^

lO.^ I

I t ^

OCCri'A Ti

Years Miyntlis

CONTRIIU'TORV fcX'»vV\A^

nr RATION _ Years

Days /lours

Mi>nt/is

(Signed) J. TO. U<x-'v\, JiCUiA-v^l

f^avs

Hours
M.D.

00 *H

H)0

r

LuJku gyPM^ul

Special information nnly tor Hospitals, Institutions, Transients,
or Recent Residents, and persons dyiny away from liome.

Kr- iilr<l III S'liii /'i ,111, /■> Il

M.»illi<

IhlV

TUF, AKovK si\ rin i'KRsonai, j'ak ricri.AKs aric trch t<> thh
liiisT oi- MS' KNOW 1. 1 1)1 . 1. AND in;i,n"j"

(Info-iii.int

Former or q . 1 SL Wn . . W®* •«"<• **

Usual Residence »il n Qk) '(XKhAAJTY^macc q\ dtaih

•• Days

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

PI.ACK OI" IHRIAr, OR RHNfoVAI,

(Ad.lrcHS V^^l Njr\>UiA.A,.Cnru dl

N. B.-

-Rver-y Item of jnfopmatlon should be cnrefully supplSed. AGE should be stitted EXACTLY. PHYSICIANS should
state CAUSE OF DEATH in pinin terms, that It may be properly classified. The "Special Information" f©r per-
son* dyin^ away from home should be given in every instance.

J

lioani ,,f n. ;i!tii !■■ n;

WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

l)(fh' Filed, L'd

.tr\A,co

/L>ckM^'

H

u-u

7.9(9 M

Officer

Registered JSi^o,

2099

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco

Certificate of IDeatb

( "U. S. i?tanCar^ )
PLACE OF DEATH: — County ofU,<X-A^ 0XXX/->vCA.4f^. City of 0 'O-^'^ J A^:>-^v<i.cA. C,t

N

o. 151^ ^iyiojvk...t

I

St.; ^ Dist.; bet. \ I Xix> and I % X^\i

( \f Dt«TM OCCURS AWAY TROM USUAL R E S I D E N C E G I V t FACTS CALLED FOR UNDER "SPECIAL I N FO R M ATI O N ■ \
V IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. /

FULL NAME

\

\ f>^^ IaJU '^

n

)/Ou\.t^JJ

^i:\

PERSONAL AND STATISTICAL PARTICULARS

^4'

DA I ]• or !;1H ill

I

I

+

> r- I

W V.

il):tvt

\ < . J-

\>,

.car J

/>,n

sFXt.I.F MARKI!-!'

\\F in tsv)- 1 • Ilk i);\i •'■• I i;i>

' Wiit. in -..( lal '1< -it'll. iti. Ill)

lUH rui'i. \*"i-:

' stat« <>i 1 ' >■! lit ! \

N \ M 1 < • I

1 A Til j;k

mKTlll'I.Ai'K

Ml iArm:R

!Sljit«' iir ii iunt ;

NTMhlN N\M1
nj Morm.K

lUK rupi.Ari-;

nl- M4t|in;K

I'St.iti' 111 ifiuntry

L T

Is

frUJ

'(Ji^^

.>VXXa^^1X

4^

MEDICAL CERTIFICATE OF DEATH

DA'IK Ol- 1)1:ATH

(Vt-ar)

(Month) iDay

I HI':ki;r.V CI;RTII"V, Thai I atten. U-d dcccasea from

w ctj I 190M to L ctj 3> T90 H

that I last saw h J^'^"^ alive on \J t.Xj .' 190

and that ik-ath nccurrcd, 011 the date ^tatt-d above, at 1^0
V,: M. The CUSI': OF DHATII was as follows:

(^A

h

n '

i^

1

(H'cri'Ai'H)N

M.'iilh,

Ihiv.

TIM* MinVl-, SIATJ:!) I'KRSoXAI, I'A K'IF'.M- I. \ RS AH i: TRlH TO THK

lucsr (»j- MY KN" >\\i,i,i)( ,}•; ANi) Hi:i,n:5-

(111 f' I- ma lit

MYU5L^ilJd' I

I )r RAT ION )'iar

CONTRIIU'TORV

I )r RATION ^^ Years

(SIGNED)

Month's

H

Days

Hours

.}r,.)iths

/^ays

Hours

.>^.'..'wOU

M.D.

\

190

H (A.hlress) H^b a^\.tljl/v Ol

Special information only for Hospitals, institutions, Transient^,
or Recent Residents, and persons dying a^ay fro'n fiome.

Former or
Usual Residence

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

How long at
Place of Death ?

Days

rr.ACK 01* BCRIAI, OR RI-MoVAl,

DA IK of niHiAl, 01 R}:m<)\AI,

U^CA- 'i T90H

Xwa^ ^ . sj

INDKRTAKKR yVVA-A^VA^ w. \J ^'&>.X/CKj>u^

(Address SOS \rh.4rvJL<x Lbusl..

^n

IS. B. Every item of information should be carefully nuppliecl. AOB should be stated EXACTLY. PHYSICIANS should

atote CAUSi: OH DEATH in plain terms, that it may be properly classified. The "Special Information" for per-
sons dyinft away from home should be j^iven in every Instance.

saaass^ssnassm

1'

N

i

i

WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

0

H

lOO'A

JRpgistcred jYo.

SlOO

TO

DEPARTiyiENT OF PUBLIC HEALTH=City and County of San Francisco

Certificate of £)eath

( 11. 5. t5tan^arC» )

PLACE OF DEATH: — County of Oo.^rv v1k<X VwC^.^ :rCity ofO/CX^rv 0 AXX^vue^^ - <.

I k n 1 fi , , ^, <;♦. ' ni^f'KoK 1dAJ\) and I

No» 5 01) \| toXo '' :>' St,; ' Dist.;bct. bA_^ and

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

FULL NAME

vl^-d

\ \\^ ^ T

V i WN^

■-• \

PERSONA'- AND STATISTICAL PARTICULARS

A i'<>l.<iR /^ \

D All-. I H I.IK I'll

Ucfc

Miiiilhi

Dnv

A5 5

MEDICAL CERTIFICATE OF DEATH

DAii; <>i iti'.A in jA

Month)

5

/go I

(l):tvt (Year)

\'

siM.i,}.: MAKkir;»

U IIH >\\'HI» < »K Ii \ • •• It) "\

' Yi-ar I

/hi

W I

niK riiri, xcv.

(Stiiti I i! I I illllll \

\ \ M 1 I »!
I \ III IK

lUK riiri, \^ V.

< H ! \ I I! I- k

-l' • . . ' I 1 111 t.t 1 \

M \ nii:N v \Mi.;
(»i NKiinKK

luk riiri.Ai'i:

<>l- Mn'I'lli: R

' Stati ' i! I'l 111 lit 1 \

<»i crrAi i«)-N (^

I I N

K.KT

r\^

'^xa/CL»v

\

I lll'RIvHN' C'i;kTII"V, That I attfiiiU'd «lt(xasc(l from
iL^^ X upS to Uc^ /b TtpH

tlial I last ^a\v li '* alut-on w /tL X KjO H

aii<l that (Uath > Kcurrcil, oil tlu- ilal*.' statt-d abovf, at •
0. M. Tlu- CAISI-; ()!• !)i:.\TII was as follows:

CL^-xM

-vM, VM

DT RATION )\'ars Mont /is /hns \X Hours

CONTRIHl'ToRV LO^X-iA.-^-'VYvO^ cu^vvC^

n

I )r RATION )'i'ays ^ Afouths Pays Hours

M.D.

(Signed)

/ tat > iU ."lui.s

lo. Q. ULLx

(

X

,\.l.lri-s) S3 I vbo-UJ-QL/ul

A'

1 ',.'/>,

/

TMi': MM»\K HTAri'IM'KK'^oVAl, l'\KI'I«"ri,AR-^ AHi; IKl I-. T< > Tlllv

HHsi'.iF MN Is Nt >\\ l.r Ix^l-; AND nil.tHI-

fin T'l: ninnt

Special information only for HospUdls, Insmutions, Transients,
or Recent Residents, and persons dvinq away from liome.

Former or
Isual Residence

When was disease contracted,
If not at plat e of deatli ?

How lonq at
Place of Oeatli ?

Days

0^ 5

PI.ACK OI- lURIAI, iH< HI;M<>\AI

N. B. Kvery Item «f Informntion should b,- cnrcfully KupplJecl. AGR Bhoultl be Htntecl RX4CTLY. PHYSICIANS should

•tntc CAUSr. or DKATH In pliiin tcritm, thiit it mny he properly classified. The "Special Information" for p«r-
lions cfyin^ iiwny from home Mhouid be ^iven In every instance.

»-'T-

.^^nskM.

WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

J>„/r Fi/n/.V^X-^LK "i t!>OH Brgis/rrrd A'o.

"l^vA^ioL^ Deputy Health Officer

DEPARTMENT dp PUBLIC HEALTH=City and County of San Francisco

Certificate of 2)eatb

^. 5. j5tanDarc>

4. «}

i

(^

3'

PLACE OF DEATH: — County oiUia.y\^ ^ K<^y\/:^UL^i^ City of^^<Xy>v 0 A,<WvcuU!x)
No. Ol^^ LLU.A:Atx\. ^ J A.li v^ StA' ^ Dist.;bct. and

/ IF DtATH OCCURS AWAY TROM USUAL R E S I D E N C E G I V E FACTS CALLED FOR UNDER SPEC
V IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREE

lAL INFORMATION" ^
T AND NUMBER. /

FULL NAME

Cf\AX' \hxKkx^X/Yy\J

PERSONAL AND STATISTICAL PARTICULARS

ri lit »R

DA I 1. Ill I UK III

jJ(vUJ6

\!miU1i)

I):.v

\< . i'.

k

lUvC it.

4 fart

/hn

■ \\ ; it. i ti *.,, i;i 1.

iniriMii'i. \(' r;

■~.\,iU ■ ,' I '. ill III

I

Ayd-^^w^>^-XL

y

X^^^v\^^cc>v

1 AIH IH

luK I'll ri, \ij-:
i >; 1 \ ri! I R

(Htlltr iir I'ouiltf A

M Min.N N ami:

luurni'i.Aii-;
<n Moim-'.H

1

I,

? '

Cr\ou .

{J XK/YYX/X'y^

in C\]

ATION (jNp A

1

u a

hs

\f,,ntfi(

l>.

iiii; M5nvH ST ^ nil i-i- rsonai. i'\r i iri i ars ar k iKri: m riiK
i',i-:s'r oi- Mv K N< >\\ ijix.i', AND iu;i,ii:

1 11 f' I- niaiit

MEDICAL CERTIFICATE OF DEATH

DAi'i; » ii- Di'.ATn

19^

iMiiiiDi) (Day) (Vfar'

I IIICRI-IBV C'I'.kTII'N', That I atternktl <leicast'«l from
^" I(p — — tn " " ' ' ^(p

that T la«»t <a\v h alivi- on ~ — Kp

aiiil that dtalh tnH'iirrcd, on tlu- «lati- stated abovf, at b-oO
(j M. Tlic CAISI'; Ol" DI'A riLNvas as follows:

(J
1) r k A '1" I ( ) N ) Vrt;A Months

Days

/fonts

CONTkllU TORY

DTK ATION

)\'iirs Afotit/is

/hlY

SIG

NED ) Lt^.cr>\x^^ JaD.UO. oLila/ruL

iO

r^

Hours
M.D.

ii^'ct) 3^ igoH (Ad.lnss) Wx^vUA^ t/,f s

iO^

Special information only \w Hospitals, Insfitu^o^s, Transients,
or Recent Residents, and persons d\in,i .iwdv from home.

former or ^i ^ v ^

Usual Residence ^ "U^UwA^oJoc -^^Vu

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

How lonq at
Place of fleafh

Days

I'l.Ari: ()l- IHRIM, '>K r!;m<»\\i.

i)Aj;i. ..f P.I Hi\i, .,1 ri:m<)\ai,
w/CAj 5~ 190H

NDKRTAKKK LIvOUO \, Ui . \JlLl

N. B.-

-livery item «.*' 'informntion uhoiil.l be cnrefully supplied. AGE should be stated EXACTLY. PHYSICIANS should
state CAUSK OP DEATH in pliiin terms, that it may be properly classified. The "Special Information" for per-
sons dyin^ away from home should be It'ven in every instance.

-J^te

m

I

■

I' r<

|i,,;ni! .'■ ll.-ilth I- N

WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD

"^^nlJS:! On REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

3103

n

/)i//t' Fili'il . U c.Lc-^-'

Eegisteipd J\^o.

Deputy Health Officer

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco

Certificate of IDeatb

( xa. 5. 5tan^al•D i

No.

PLACE OF DEATH; — County of^'C:^^^ J/vXX.>xCULOo City of CVoy-vv J AXu-i^AXiAixL^M)

0 cru

St.: S Dist.;bet. S/v.'Ci

and I

Jtl

/ IF DEATH OCCURS AWfiV TROM USUAL RESIDENCE GIVE FACTS CALLED FOR UNDER 'SPECIAL INFORMATION" \
V IF DEATH OCCURRED IN A HOSPITAL OP INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. /

l\

FULL NAME

A

.0

^\i

PERSONAL AND STATISTICAL PARTICULARS

!» \ 1 1' I ii i;iK 1 II A

M.. nils'
\< .1'.

\\\ I M .\\ 1 1 1 ( iK ! > ' KD

Wt-- ■■ -..',' .>. - . . .,: .,11)

-KAjtx

HOH

» I at

TyVv^iA

lUK I'M '■! \'"K

X \M1 I tl
1 \ 111 IK

lUK !H!M.\>K
<)I- 1- \ 11! Kl<

■^t i!' < I' I'l Hint! %

M MDl-.N N* XM J

<»i- .M<>rm;K

HIRTIIPLAi 1-;

<»!•■ \!tirin;K

I'^tati <>l t'i>unt1\'

niTll'A rH>N

KX/YXTs vol ^ J \AyY>^JU

MEDICAL CERTIFICATE OF DEATH

DA I'l-: < >i i»i:a Til

(Day) (Vtar)

(Month)

I Hi;Ri:r.V CI-KTII'V. That J attL-mUMl <lccLasc(l frniu
i9/C±- X i.pH to 0/ct; ^ TCP H

that I last ^a\v li -r^' alivt- «)ti V CAj 3 up H

and that (Uath ncnirrctl, on the dati- statt-d a1)<)vc-, at O- O 0
y^ M. The CAlSh: Ol' Hi: AT 1 1 was as follows:

DT RAT ION

]'('a)

Months

CONTKIIUTORV 'Wa'UL

Davs

I lours

\\X/<.'

KT

f^

N, •>■ /'llllti

'- ).,!,.

A/, III f /is '^ /hn

rni% Aii(»\|.* s r \ri:i) rKKsoxAi, v\h ii<ri. \ks mo; ikii-: to tii i-
iii>«r oi- Mv KN-< i\\i,i:i ><.)•: and iu:i,ii;!-

l!

( XiMicH^

I )r RATION ^ )'t'iirs Months Pays

(SIGNED ). 0X<^ ' ' . ^JlOvLl^V^I

il'ct '^ icoH (Addrc-ss) 46H ' 'b.V<t rit

I lour s
M.D.

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

Former or
Isual Residence

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

How lonq at
Place of Oeatli?

Days

Ai.'}<: <)i- HiKiAi, OR ri;m<>\ \I,

DA'p: of Jit K[AI, or RKMOXAI,

Gt% H T90H

f N I ) i; R r A K I-: r \JK^\^XSL^ L LL^rocLtsjLo. ' , ' u:^
fAddrt-Hs obb \T r\AuQ>Q.A>^r>x "u^

IS. B.-

Kvery item of Information should he cnrefully supplied. A(IF. should be stated BXACTLY. PHYSICIANS should
state CAUSE OF DEATH in plain terms, that it mny he properly classified. The "Special Information" for per-
sons dying away from home should be ^iven in every Instance.

•I

WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD

„,„,.,fH. aUh IV, .^^^^^.li^VC, REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

Dff/r Fih'fL ^/cl^

c\> H

^

n

-H

cK^u^Ayo

\

'A

pu

Officer

Ree^isfr/'ed J\^o.

DEPARTMENT Of PUBLIC HEALTH=City and County of San Francisco

Certificate of IDeatb

( 11. S. 5t^nDar^ i

J? ^ ^

^

PLACE OF DEATH: — County oiOOmj J.VaA^^c<A<:<: City of ^ ' O^^ 0 .\xvvx/a^,^L/t^<)

I

"Wo.^^

XK.k C 0-vll\dloJj

^0\Xl4 -l C)-vi

St.;

Dist.; bet.

and

/ tr DEATH OCCURS AW*y Ff4oM USUAL RESIDENCE give facts called for under "special INFORMATION" \
V IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. /

FULL NAME ^

)

PERSONAL AND STATISTICAL PARTICULARS

!> Aii' < >' ';: K

A< ,1-

\\JI>nwKl» <»K l»

I \ nil R

u! I \rm-R

'St, it. nt

M MDi; N N \M 1
ni MOIlIl.k

I',! urn I'l. \rj-'

(stnti oi Cnuiit 1 \

oi'cri'A rioN

\!,,nth

L\_

!»..\

,1'iL

I Year)

/',/.

I --4

MEDICAL CERTIFICATE OF DEATH

DA ri-; Ol' Dl'ATH

(Dav)

k

fMotith'

(Vt-ar)

I lIMkl'r.V <.' i:kTI l-N', That I atttiuU'l dti-L-ascd from
^X^ XI upH tn JL ct ^ 190 H

that I last saw h X>V alive on V//cfc X T90 H

ami thai (K-atlt < k cii rriMl, cii tin- datt- stal^Ml ahnve, at b- I 0
OL M. Tlu' CArSI-; 01 I>I. A'l'll was as follows;

.KAf^X'

Mouths

DrKAl'ION )V./;s

^f A

CON T R 1 1 U "I' 0 R V 0 &>V,<5'*\) U4 w...

/)avs

Hours

\'

<l^

" ),,ns -^ ^r.iKtli'

I), I

Tin- \Hovi-: sr \ II r> I'H'KsoNAi, r\K lUTi.AKs AKi: iKi J-: r<> vnv:

lU-lsr ()! MY KN<>W1,HI)(UC AND HKI.IHK

( 111 fot inaiit

C(?.%.e,ic.

\<h\r

H

,<kX

nr RAT I ON

(Signed )

CM

)'raLS

A n nil /is

Pavs

o i()oH ( AiMrtss)

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

Usual Residence ^ w A JNXOA/Vvu

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

Hew long at
Place of Death ?

1

• Days

I'l.ACH <)1" m RIAI, OR R1:M<i\AI, j DA'lJ'.uf P.iHiAi, or KlvMnXAI,

//ctr 5" T90H

indi;r

fAddres. ISXH C

YSj

SS. B.— ^Iverv item of information nhould be carefully supplied. Adl. should be stated EXACTLY. PHYSICIANS •hould
state CAUSE OH DEATH in plain terms, that it may be properly classitied. The Special Information tor per-
son* dylnft away from home should be given in every instance.

r

i I

I

1^

_,WRITE PLAINLY WITH UNFADING INK

THIS IS A PERMANENT RECORD

/hf/r' riled , U-ci.CrlOA; H

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

100^

Bogistei'cd J\'*o.

^i-vxx^

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco

Ccvtificate of IDeatb

( Ta. S. StanJ>acCi »

PLACE OF DEATH: — County of Vcv "ix >-■ "^Cv ,

0^

<3J D (MO

% , t * "I I

Dist.; bet.

City of "^CXA^ 0 \.CV. > ^

md

vCK- vv>4.r'' ^^ Str— Dist.;bct —and—"

/ ir DEATH OCCURS AWWAV FROM USUAL R E S I D E N C E G I V r 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 >tHLL^

PERSONAL AND STATISTICAL PARTICULARS

-■! \

j
I

a tl.oR N

I» \'i 1 III l'.' K III

\«.H

V!

^

o^u

\! ,nth

■ 1

I>..%

4l ,

i < .1!

/'■M

U I IM >\\KI> < »K 1 1!\( I ! ! ; >
' \\l itc in ^1). ;;i ! h -ii' :.

niKriii'i. \«'i'

CSlat' .>r •'■iiniii \

A

"n

o *

N \ M I < » I
I AT!! IK

lUK THI'!, \i v.
Of? FATIIKH

•■^t I'l 1 if ("mint 1 V

M MI>KN NAMI-
nl NKiTHHK

lUk 111 I'l, Ad",
m- \t«.rniK

'stati 1 1! Ciiunt!

Vt>^t|\'- It

M

()ccri'A'rn»N

UAvo
U kxXA

Kfsitifit ill Siitt /'i,in>

.Kyyx

5 V,/

1 ', nf/n

Ihs

■nil- Miovi', srxrii. i'kk-,m\ \i. p \i< rif i.ars aki-: tkcj'. 'i«' riM-
iii-.HT c)i- MV KNt »\\ 1.1!" -i-; '*^" in'i.n.i-

inf..;,„:nit OU-t^VVh-M

U 11

, I I

.1 1

,C^S_„

MEDICAL CERTIFICATE OF DEATH

i»A I'j-; <>i- Di: \in

fMomli

(Dav)

(Year)

I n I'ik i;i'.\' CI.RTII-N', That I attciukMl deccasoil from

O^^vt. Xl I90H to

tliat I last saw li W>\ alive on

X

(^

iL'c*

i{)o H

and that (U-ath uctMirred, on llu- ilate stated above, at o
\J M. The CM SI'! Ol" DI'iATlI was as follows:

I ) r I-; A IM ( > N ) 'I'iirs Mont /is 1 6 /hiys Hours

CoNTRliU TORY ''t<^<->^A^<>-^^ Vj vX^'X.O-^^Ui

DT RATION

/hi\

\ I iw.> ^^ ]'tars ^ Months

(SIGNED) i. \A. U;u^ULcu

iDcfc ^ TooH (Address) "t^b dxU^tK; dt

Hours
M.D.

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

Former or

Usual Residence -^ ^ » ^ ^

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

■ , How lonq at
/OA^UwU. .J I Place of Oeith? > ^ Days

l'J,ACH <)!■ IH KIAI, HK KI;M<»\ Al

DATllnf HiHiAi, <.i KJ%M<)V,M,

I, B — Bvcry l.cn, .i n,fo..„Ht1on .houhl be ca.ufully .uppHecl. AdI. Hh.ul.l be stated EXACTLY. PHYSICIANS »hould
.tat/cA "st: or DIIATH In pli.m terms, that it may be properly cloH-lflcd. The "Special Information" for p.r-
«on« dying away ifnm home should be a'ven in every Instance.

\i

'8S^^

WRITE PLAINLY WITH UNFADING INK

liJO\

THIS IS A PERMANENT RECORD

REFER TO BACK OF CERTinCATE FOR INSTRUCTIONS

i 1

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco

Certificate of Beatb

ofCj/avu 0 VOL-WCUlCOCity of \J<Xmj 0 AXL/VLyOUiyCM>

PLACE OF DEATH: — County

M

Nb

m

. JX^t^xck ubch^vd^^tx*

St.;

Dist.; bet.

"and

/ IF DCATH OCCURsUw^Y FPOM USUAL R E S t D E N C E G I V E FACTS CALLED FOR UNDER "SPECIAL INFORMATION ' \
( ,riE*TH —----" .- • MO«.P,TAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. J

OCCURRED IN A HOSPITAL OR INSTITUTION GIVE P

FULL NAME

TV

■-ix

PERSONAL AND STATISTICAL PARTICULARS

r< >i.t iR

'^rioL

I) A ri; • >! luK 111

,A

10 ct

A * . »•;

Hi

I > I \

V,. >////•

» carl

/>,

mS'i I.J' M \H U 111*

W! IH )\\ I 1 » » Ik 1 ) ;\ I iK . ID

I W ! ill- 1 11 ^' Ml. I i . li -U' Ii.it 1' 11 I

HIKTIII'I, \t'!

■-! iti '•: 1 ' .11 nl '

N \MK Ml-
I AT II I- K

lilK lliri. \i J".
OF 1 ArillH

i St;iti III I'lnint' A

M\ mils' N\Ml-:
(M \!<i!Hi;r

lUK I'lllM.Aij;
Ol- MO'lllI-.K
(Stnti 111 t'liuiilt V

1^ -L

\>.

I
I'

«HA'ri'.\'l'lc»N 9 ft .

Rf^titfil III So I' I 10

III. : I It

^^,,l

M.nilhi

fhl

Tin M>..)\ 1 ^r\ 111) I'KKsONAl, I'AKTUTI.XK^ \\<V. TKIK TO THH
Hl-<rt»l MS KN» >\\ I.J'.IM'.H AND iu;i,ll'.l'

i\\

( \ihlu -s

MEDICAL CERTIFICATE OF DEATH

D.\Ti-; oi- Di:.\Tii [C\

I Driv

(Year)

fMi.iitlO

I III'lRIir.V CIRTII-V, Tliat I attended tleccasc«l from

— — — — — i^o tn -■ I9O

tliat I last saw h : alivt(Mi • — -— - -^ icp

and that dcatli octurrc»l, on tlu- date stated ahos'e, at
M. Tho C.XrSI': Ol' I)1;ATI1 was as follows:

1 ) r K A r K ) N ^'^'•^ .'^/out/is /hns ' Hours

coNT k I iu"r( ) K V J.Ajuru^^v J|t>urn^ jux^:1a.^^ ^.ctr

DIRATION

( SIGNED ) LtfUn^XN?

&

Ytiii

^

Months

Pays

ct

Tt)0

H (Address)

ss) Ur^UnnJtM V\y

Hours

M.D.

Special information •>«'> 'or Hospitals, InstifutikV, Transients,
or Recent Residents, and persons dying away from home.

^ , 4. (hi pi' ««^ lonfl «»

, J 0\Aj N I lO^'CnrV. UXl Place of Death?

Former or
Usual Residence

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

Days

i'L.XCK OI- lURIAI, OK RHMoVAl.

Cxi

DA'!>. of IliiUAl. or KHMoVAI,

^ct H 190H

N. B.-

-Hverv Item o* Information •hould be cnrafully supplied. AGB •hould ho stated BXACTLY. PHYSICIANS should
rVatc C\U8E OF DEATH In pintn terms, that It may be properly clflsslfled. The "Special inform„tlo„- for psr-
«on« dylnft away from homo should be felven In every Instance.

I;

:N

.%\

I

m

li

t:

li

1 • . ■ I h I \

WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

t-.^"^?^:-, 1)5. IT

2106

Xfr^_v^ "LtyxvM Deputy Health Officer

DEPARTMENT k PUBLIC HEALTH=City and County of San Francisco

Certificate of "2)eatb

( H. 5. StanDarD )
PLACE OF DEATH: — County of' 'CV^^ J \o avcc*- City of "'O.nv J v^O-

^-.^X

VVC.Ul^V<;

NoH^^

/-Uv-^<lOcrLt.\X) SU R Dist.;bct. U VTU^I and

ir DfTH OCCURS AWAY FROM USUAL R E S i D E N C E G I V E FACTS CALLED FOR UNDER " S^fCJ^AL J N FORM AT

(

rF'DEATH^OCcJRVED'.N'I'HoTprTA: O r" 7n ST ITU T . O N G.VE ITS NAME INSTEAD OF STREET AND NUMBE

5'

ION
R.

)

FULL NAME

LoJI k.L^A/Y^Jl i CrwA^JL

PERSONAL AND STATISTICAL PARTICULARS

4

^

Ml i;iH in

.L 7\uil

/Ibto

Miiiih

\i,j-;

al

/'„'

-iM.II MARK II It

w i iH »u i; i» UK I »;\'< iR. I i>

Wtitt ill ^iifial ill -u'l!;!!!' iM 1

^» • • ! < I 111 111 I \

Xol:

hJVA^

-v_

dL

^-hjiAxx/w^i.

I A III l.K

lURTII I'I,A('J-:

< i! 1 \ riu.. K

~.! i1 1 I It l< lUtlt I \

M \n»Hv NAMi;
(•I Moiiii; k

HiK riii'i, \i i;
<ii \tt»!iii;i<

I ^tnti I -', riiutlt I

« MAT I'A 1 I< >N

(

,/ Sitii it ii III IWii

VlLou-vxx:L

^ H )Wm^ -

M.,nll,

lh;\

Till- M'.uVl.' Sr \'n-,!) I'KHSON W , I'XRTK t! \Rs A R l-. i Rl}; To Tlli;
in;ST OI MS' KN<»\\I.I".I>(.I', AM> I'.IJ.II.I'

(III fi)i mant

MEDICAL CERTIFICATE OF DEATH

DA IF, oI- IH.ATH

III I

H

fMoiith)

iciv

IVL-ar)

I IllvKi;i'»V CI;RTI1"V, That I atleiukMl (Icroaseil fnjiu
YO^^-Xi 190 1 to ^'tlAJ H 190 H

€ot

that I last saw h '^A; alive on
and that <K-ath occnrrctl, on the date state<l above, at DoO
IX M. The CArSI- OI- DICATII was as follows:

DTk A'lloN -J Yrays \

lO

CONTKIIUTORV

Mouths

Days

Hon

r\

I )r RATION ,, )Vf/;v

|U

(SIGNED)

0

/C\

\ iryn

\.i<in-ss) o ^ U oUx^M^Q><x>dUDL^ < )t

Hours
M.D.

Special information on'y f^r Hospitals, Institutions, Transients,

or Recent Residents, and persons d>iiig away from liome.

^

Former or 1 n m "^^ >. . , ^U "•** '""' *^

L'sual Residence 'oub OMnM UX Place of Oeatti ?

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

Days

I'l.ACK <)!■ lUKlAI, nk R1;MuVAI.

DAIi: ')f I'.iRiAi, or KHMoVAI,

T90^

f

<Vcx/yv

\ 0 fi

"^11

. „f l„fo.,n„f.on .hould he cnrefu.ly supplied. AGB should »>« stated RXACTLY ^"Y^'CIANS should
SE OF DEATH in plain term«. that it mny be properly classified. The Special Information for p.r-

!S. B. livery item

state CAU

«f»n» dylnft away from home should be feiven in avery Instance.

I

\

M ,

Hi

m

m*¥

!|. .!'^ I "^^

WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD

REFER TO BACK OF CERTIPICATE FOR INSTRUCTIONS

l^c^ ijL^ Deputy Health Officer

DEPARTMENT flfp PUBLIC HEALTH^City and County of San Francisco

Ccvtificate ot IDcatb

-No.^

PLACE

\
(

OF DEATH: -County of Oct^ 0;u^^vcv^^ City of U^C^ 0 A.<V>xc^^ - '-

(1 % ^

^^

'wCH^. wW^.<XJl

4

St.;

Dist.; bet. —

and

-XJUQ WV. %^ I ^^^--^^ or^inVNCE GIVE FACTS CALLED FOR UNDER 'SPECIAL INFORMATION" ^

FULL NAME Ox^ax^^mx^

ivo c\j LLvkxa-u^

. 1 \

I \\<x.

DAI 1 . I M r.i K 1 11

PERSONAL AND STATISTICAL PARTICULARS

. \VA^'

/^

M.ituh

Dav

\ < • 1-:

i'^

) -,/'

» . ar

A/1

Wi; ). i-,\ lit « tR I I ,\t ii' ■ I' !)

X \ M I « »!
1 A III I.K

!'. I K r I n ■ I , A I F.
ni' I \ II! l-.H

M mi>i:n' nam I

{)] Mo'llli: K

lUK Tnri.ACi',

<)1' MDTIII'.R

i St;ltf I >I (.'tUllllI >

oi'Cri'A'l ION

■\^

ME

DATK «»|- DHATll i[\

tiCAL CERTIF

ICATE OF DEATH

(Year)

•Month) 'I>:«V'

I IIICRIU'.V Cl.KTII-V, That I atUMuU-d (kncastMl from

^jp

— • icp

that T last saw h

up
- aHvc oil

and that death orcurrcd, on llu- dato stat«.'<l above, at
M. The CAl SI-! Ol' niiATII was as follows:

f

" M . I 11

r\Aryy\j

nrRATloN )'rars

CONTkir.l TORY

.lA'z/Mv

/)a\s

Hours

Di; RATION
(SIGNED)

)V<?r.v Months

Davs

Hours
M.D.

fAddre

,.^yvUL^LA vJi(4

SPECIAL INFORMATION only for Hospitals, Institutidrts, Transienls,
or Recent Residents, and persons d>lng .iv*a> from home.

.aJ^'vAA.

"S'l a ,

M.HttIn

/),M

TnVM»)VKST>TKn.>KRSnXAI,l-NKIUM;i,AK^ XKHTKrHT«> TIIH

in:sT oi' M% KNowi.i.iM.i-; and iu-,i,n-.i-

(Iiifitiniant

0^X>ouu:>A\JO\M^

X.ldrf^H O'W

/(KjiAU

M

Former or

L'sual ResidenccU.\\Un'\;

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

yUOAJjb 0.0 3 Place of Deatli?

Days

IM.ACH ni lUKIAl, OR RHMoVAl.

O

i>.\ij. of p.! Ki.Ai, III ki;m()V\i.

0^ H 190H

(Ad.lnss 9s'i?>'\ QfTUAA,A„^r^ ol

N. B.-

^ .. \7 , AfiF «houId be stated EXACTLY. PHYSICIANS should

-Bvery Item of info.mntlon .hould be cnrefuHy «"PP'- • „^„^„^erir"lls^^^^^^^ The '•Special lnform»tio„" fer pr-

•tate CAUSE OF DEATH in plain terms, that it may be properly Uassmea.
son* dylnft away from home should be ftlven in every instance.

! 3

k ' |!

till

M

Il.^!th 1 ^

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

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

^1 A/O

t"?' -a-'.^li- luS: 1' I'

!)ff/r Fi/r</, ^/cl^rVC^u H

JOO'i

Bedisfrred ^'*o•

^'CVA.A,'

"it

Deputy Health Officer

DEPARTMENT ot PUBLIC HEALTH=City and County of San Francisco

Ccittficate of ©eatb

> 11. 3. StanOarO ;

PLACE OF DEATH: — County of

0

^

<X^^v,

txXX;

City of

v^oJo.

No.

St.?

-Dist.; bet.-

— and

-)

FULL NAME UlDOAvruxiv JXa-^uu

PERSONAL AND STATISTICAL PARTICULARS

>-!:\

^

rl ll,( >k

VX^O

ilib

I) ATI* » >t HIK 111

\< .l",

(lf>\

M , 1 111 h

1 ,,„,

aV'

H

, D.v

,U7

\ .1! i

b

1/ ,,,'/,

MEDICAL CERTIFICATE OF DEATH

DATK i>l' Dl-ATli ,p\

(Munth) 'I'=«y^ (Year)

I Hl'Rl'.l'.V C1:RTII'V, That I Mtteii.kMl ac-ccased from

- to ~ —————

190

that I last saw h — ™ alive on

T90
T90

"-.INr.l.K MAKHII'.U

\vinn\vi-i> t>K n \i>Ki*Kn

Wt it.- in -. . ial .1- '^Miatinti)

iuKrmM,Ai*K

I St:iti iir ifiiinti V

N \ M ! ( »I
I \!II1 K

niHIIMM, \«K
()l* 1 \ I'll 1-. K
(Htatt -I 1'.. nulls

M MIU-N N ami:
< »!• MO'l'lli: K

P.IK rni'i.Aii-:
Ml- Mirrill-.K

i ^tatc .1! I'ositlli V

(ucr PA rioN

an.l that death occurrcl, on the date stated above, at
M. The C.\rSI': Ol' DI^ATII was a^ follows:

yX>vvrv<XAxu

Dr RAT ION )'i'ais

CoNTRIPd'TORV

Months

Din

'S

I/out's

I)rR\TI()N )'t'iirs jr,>fi//is /hivs

//ours

K,is'-v\y^.^f"y\^ M.D.

(A. hires.) UoJuL

Kf^;.h.l :•■ -■r>' I :

) ■/•(,' )

Mn,i(/n

I-

THKAUnVKSTAT.MM.KKsnSA. PJKn.rjXK.AKHlKrK TO T H K
Hl-ST 01 MV KNoWlJ-.Di.H AM) hlKi,Il.»

^Iiifntniriiit

\.l.h

(SIGNED )

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

r «»rnr \ ^ Howlonqat ^

Usu!l ResidenceOoAV 0 A.<X.-vx :. Pia.e of Death ? SoncXAA... ^

Wlien Has disease fontrarted.
If not at place of death'

DATj; <»t lU lUAi. 01 RI%MOVAI,

A

pr.At'H «n- lUKiAUuK ki;m»>\ai.

T90H

r , , 1^ stated EXACTLY. PHYSICIANS should
:r;."n'i -ai «-"- "cne .h.,„K. h. .'.ven 1 > InM.nc

I

I

)-'

I ' i

I r

r

It

1^ 1

WRITE PLAINLY WITH UNFADING INK

THIS IS A PERMANENT RECORD

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

21 09

Lrv-c^ijUK. Deputy Health Officer

DEPARTMENT (IF PUBLIC HEALTH-City and County of San Francisco

Ccvtificate of Bcatb

( XX. S. StanJatO J

PLACE OF DEATH:-County ofC^Cmv J ;v.V..xx^ Gty of C^^^ ^^^XTT"
^ I

Sf'^ Dist.; bet. U CUYV M UAA, and

FULL NAME

CUvA-trvo

PERSONAL AND STATISTICAL PARTICULARS

i» A ri; < >i niH I'll r\

5S ,„..,. '-

M'\

D.iv)

'i I a I

/>,

MEDICAL CERTIFICATE OF DEATH

DATK «)1- Dl-ATIl

Dav)

(Year)

(MniitlO

in<:Ki:r.V C1;RTII'V, That I atlciukMl .leceased from
t bO igoH to %* "^ '^"^

slN<.l,i:. M \K1< 11 !>
wil)oWHI> <>K !>;''' '''' ' ^' ^
^ \Vi itr ill '.iM iai .1< -'iMi.itiin;

ll'^d

-1 I V

I'.iK rni'i, \i"i*.

>^tat I 1 1! t'l 111 nil \

NAM I- <H
1 \ in 1 K

A

BIH miM, \«K
(U- 1 AT III: u

, St it t 1 ii i'' Hint ! \

M \I1»1%N NAMl-
()i- Mo'l'UHK

lUK rm'i.At i:

4)1 MiiTlll-K
f Stati oi I'liunti V

that I last saw li X\; alive on ^' ^ ^ ^'P

aii.l that .Uath occurred, on the .late state.l above, at 5
CX M. The CAT Si- Ol- ni^ATII was as follows:

DIRATION IV.vr.v J/ou/As H /hivs Hours

CONTkilUTORV

h^KJ\sjL \jOJ\AiA^r>^^.ArYr>,XX^

( K'rti' \ ri< »N

.', .' ,„ V.fM I'l at', isi'n I U 5 '■

M:'nt!i<

Ih

ni-ST »)!■ MV KNOWI.I.IX.H AND l.IJ-n*

I \RS AR1-; TKIK TO Till-

(SIGNED) \JYUu.^<U ^J^^^ p

/fours
M.D.

SPECIAL INFORMATION only for Hospitals, Institutions, franslents,
or Recent Residents, and persons dviiK) away from home.

Former or
Usual Residence

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

How long at
Place of Death ?

Days

{Info- tnaul

^. i9

A.

f A<l<lr<"^'^

ioTkCs ojuuvik ^3fc

DATK .

6.

,f H! RIAI- or RKMOVAI,

/Ca> b 190H

rj,ACE OI- lURIAI, OR R1';MoVAI.

(A<

—"■"■""■■""■"■"■— """"TT T^ AfiF should be stated EXACTLY. PHYSICIANS should

:". dWnVaw«; «™". ho^-e should be llW.n y ln...nc..

I

ii^k:

w

'

V I

w

RITE PLAINLY WITH UNFADING INK

,1 i.f ih ,''i'i

>, 1- Nil

^^"^XiUS.VC

THIS IS A PERMANENT RECORD

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

Dh/c Fih'fl , UoLcX

sJlN; H

n)o\

Jici^isfrred J\''o,

9A10

h Officer

■? i De uf H.

DEPART^ENTOI^ PUBLIC HE AITH-City and County of San Francisco

Ccvtiticatc of IDeatb

PLACE OF DEATH = -County of 6,.^^ W..^.^ Gty of Oc^ J AX^c.--o

f

!K

^c i

and

<•.

( •' r;o7..H^o^cu%r;.;^rHo^s^y.**^ r.^^^^.^^^.^o^'^o./r.! name ..s...o o. s..... ..o ...s... j

FULL NAME H K^M^d. ^

^ V ^^.O. )

PERSONAL AND STATISTICAL PARTICULARS

JO

i>A ri; t >s I'.i K rii

\i .l•:

\\ ! In i\\ i: 1 > < »K 1 > '

\\ 1 lit 1 n -. H i,i ' li' - .

, ^

( Vt-arl

!i

lUK rill'I, \rj-'

vtatt < ii I '.in lit : N

r ATII 1^K

I'.iK rniM. \<'H

Ol lAllUK

-,tatt |>I i'lilUltlN'

MAIUl'.N NXMI-:
Ml- MOTIIKK

Hiu'rmM.Aci-:

C)|- %1( I ill I'.K

oiHTl'A TioN

MEDfCAL CERTIFICATE OF DEATH
UATK UH ..KATH iCS X H

! UI:RI;15V Cl RTII-V. That I atteiKU-.l <UHcase<l from
O-^-jAt a^ .90H to 'p'^^ ^ T90H

that I last saw h Jl^ alive on ^' ^ ^ ^^P H

an.l that . loath nrcurrcl, (Ml the date statc-d above, at 5"
Ol M. The CAISP; OF DKATII was as follows

J M'< v'l' in, .A 1 I 1 ^^il> rt-^

nr RAT ION >Va;-

CONTRIIUTORV

h

Months 11 Pays Hours

V^,^'VV^"V^A.^X4Mw<5'YV0

DTRA TION

)',uirs

A'

,.' , •! S.,-'/ /

) 'r,j I s

yr,;,fii< i I /''

TH,^^1U>VKST^TK,M.KH..>NA. PAKTUM^KAKS AK,- TKfK TO

iii.>roi Mv KN«>\vi,i:n<.H AM) ni.un.h

rm-

Months \ Pays
( SIGNED )Mfl\.aAXJ 1.1-6^'

_s_'-

Hours

M.D.

Xa.lress) lloi Qaa±Uaj q1

SPECIAL INFORMATION onb tnr Hospitals, Institutions, Transients,
or Recent Residents, and persons <l)in3 away from home.

Former or
Usual Residence

Wlien was disease contracted.
If not at place of deatlt ?

HoH lonq at
Place of Oeatl«?

Days

(Iuf(>!ina!it

A.Mi

DAllIof lURlAI. or KHMOVAI,
0/Ct^ r TQOH

rNUi:HTAKi:K

— ■ TT Tgf. ,!,ouI.I ho .tat.d EXACTLY. PHYSICIANS should

,. B.-P.veO. ..en. ^n„...^,0«n .houia he_^=_a..»u,,, ,u.^p..e... ^A^.^^_^_^ ^,_^,,,,^^ ^,, ,.,^^,., ,„,„,„,,„„.. ,„ ....

:r„rd"Taw°,' from h„™, .hould b. ftW.n In .v.r, -,„,..««.

; ii

^f

iii

t!

It

I <

\

> t

H.iiu

WRITE PLAINLY WITH UNFADING INK-THIS IS A PERMANENT RECORD

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

2111

ith r X

l',\ !' I'

Dafr Filed, ll)/cXM>--t>v H

U)0\

Be^Lstercd J\^o.

J<

if-h

'1 >-*, iOi

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco

Ccvtificate of Beatb

( Xi. S. StanDarD )

cto

m

PLACE OF DEATH: — County of^^^^

No. His

5 A^^^CAJ^^ City of U <X/>x; J AXc/wo^^<>D

-COV

St

.; 5s Dist.;bet.

and

AVclX

. O..TH OCCUPS .WA. .ROM U S U_A L ^ ^^lO^.C^^^^^J^^^^ ^^^O .0.^..0.^. ,-,%-- 'rN^J^^ER^^' ) ^

( - r/orAT°H"o^CCU%reO IH rHOSpTTAr OR ..SnTUT.O. 0,VE .

FULL NAME

PERSONAL AND STATISTICAL PARTICULARS

I < )i,i>k

0 J

1» \ 1 1-^ I !| l.IK I II

L

_\_

.tt

Kvci.

1^

/tit)

%i.,nl

\i;i-

^H

lb

/'.

^CLX cLil/XMJ

■^I^.l ir M \K H IKI>
Writi in ^'Hi;ii di -.i^niitiiiii)

lUKTUlM. \>-»-

<XA^ 1 ^L0LyYV/C<^<^<5

I- A 1 I! l.K

<»i. I A rill- K

--' ,1 , ,• 1 ■. Milt ! \

MAIhl N N\MJ
ol- MoTIIKK

Iuua;-

1

\

fvf i.lrJ III S,ni funhi'in Q \ ,,,/< o .

lUK rillM. \ri.

Ill Miiiiii; K

t K I 11'

MEDICAL CERTIFICATE OF DEATH
DATK <>1 DEATH A

(Months 'I>=*y^ t^^'*'"^

j hi.:ki.:I5V C1':RTI1'V, That I attcii<le<l .leccasol from

C)S\X lb 190H t.> li)^ "^ I^P"^

tliatllast.aNS h-L>V alive cm ^^ ^ ^ "<

an.l that death occurred, oii the <late ^tate<l al.ove, at 0
d M. The CAl'Sl-: Ol" Dl-ATII was as follows:

I )r RATION Years

CONTRIIH roRV

Mioit/is ^l /?<n'v //6»//;

., )V<7r.? Months

DT RATION

( SIGNED ) <*wM^^-^^ UaJAA^
Uct H u,oH fAddre-^^) (s'^'3w

/?r7t'

I-

Hours
M.D.

,-„H X,MiV..sTM. l>i-KU->XX..l-XHTUrLARSAK)-TKrH To nXV.

(Inl

iLdlxA^^xH^ 'o

f A>l<lit>^'^

iXXXAAj.

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

Former or
IJsual Residence

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

How long at
Plar e of Death ?

. Days

n \CF OF lUKIAI, OK RKN!o\ AI

%mx. ^

DATi; (if I'.iuiAi, (>! ri:mi>vai.

(A<l<li^'^s

__ I .. ■ Trv H<.ul.l he stntecl EXACTLY. PHYSICIANS should

11

#13

S Si

1

II

!<'

If, i
11

J'

P:

i

; i

,,f H« :iUh » N'

WRITE PLAINLY WITH UNFADING INK

, *.!:,-« ,^i Its, I' t .

I>

ate Fileil , \)fdjXAhj H

V)0\

THIS IS A PERMANENT RECORD

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

]l(>(iisl(>rc(l JS^o.

i Xjuxhj Deputy Health Officer

DEPARTMENTS PUBLIC HEALTH=City and County of San Francisco

Ccvtiticatc of Bcatb

PLACE OF DEATH: — County ofcl^<5U>^XXL

1

City of cMhC^

m

YVOA^it^

Ne-

st.;

Dist.; bet.

and

-)

.. OC..H occu.s .w.. .«o. USUAU R^S . OENC^vc^J^C.S c^;^o ^^^.« 3?:^^ri^n;M;^;;'''" )

(IF DEATH OC
IF DEATH

(CCURRED IN A HOSPI

TAt OR INSTITUTION GIVE ITS NAME II

FULL NAME

XOX.'

h \jiW\L.

PERSONAL AND STATISTICAL PARTICULARS

.-< li.tiK N

mJ

%

X

J. . .^Xjl

i>\ri '- M i.ii<

|i \ 4

M

\< .1'

u

It

lKi\ >

\l.,,ilh:

')

Vi-ar)

lhi\

IViEDICAL CERTIFICATE OF DEATH

I)\TH <)» Dl'.AlU

fMotftlO

rgo'i

1 m':Ri;P.V CI'RTII-V, That I atteiKlea (Iccoased from

__ . — — up to — —^—.190 —

that I last saw h :tr alive 011 ^ —,__:— 190

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

-.IN'l.l- MAKKn.I>

isiK rui'i, \*'v:

^tat 1 111 ' ■ M nn \

\

L

<Lo'UJ-^d-

:\a.LO

I'S

1 A I' II ).K

lUKTiiriAiK

oi- 1 \ nil K

MMI.IX N\M1

HiK rm-i.Aii:
()i M(i'nn*,K

( state I ir ("oiuiti y

.>ccrrATH>x(yy^^^^

'LojCL^'w^^

M The CVrSIv Ol- DIvATII was as follows

n xTxK/vx/cOL

DTK AT I ON )'<'^''

CONTRU'dToRV

A/onths

/hn-

Hours

nrRATiDN

(SIGNED)

(J

TC)0 \

Yi-ats Months

(Addri'^s') cL^O

/>«n'

Hours
M.D.

\\X^.<AX<» ^CL^

M,ni(h>

lh:v

T„KAHnVKSTATKnPKH.oNXUrXK.M.M^..AKSAKKTKlKTn
l',i>T «)! MV KN«'\VI.),I)'.K AM) 'aW''*'*

THl-:

VOuvyA-

SPECIAL INFORMATION only lor Hospitals, InsHtutions, Transients,
or Recent Residents, and persons dyiny anay from liome.

Former or
Usual Residence

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

ttoH lonq at
Place of Deatli ?

Days

UI.ACH ol- m KI\I, OR HHM«>\^I
I NDl'.KTAKKR

DATr. > • I'.iHiAi, or RKMoVAI,

jb ^<L^ »v vl^oXit aX-^-^?^-

— """""■"""— ■"—"■^'""TT r\ IfiB should be stated EXACTLY. PHYSICIANS should

N. ».---^ ••- -• -'^TA-vs^r;.: •: r;;^::;c. rrr.r:; ."Zr^. ..«.«.»-. xne ••8..c,.. .„.o..„..,on" w p.r-

state CAUf9t: iir- ui:.« 1 ■ k ^ Sn«t«nce.

::r;d,rg aVaT Tr:™. Hon.. «h„ul.. he .iv.n 1 , .n.t.ncc

p

'I

k

[■♦-.

« >

ll

WRITE PLAINLY WITH UNFADING INK

v)(n

THIS IS A PERMANENT RECORD

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

Duh' /'V/r^/A^ctJjaA. H

iuyvjuOi duia><i Deputy Health Officer

DEPARTMENTOt PUBLIC HEALTH=City and County of San Francisco

Certificate of Beatb

( *U. 5. StanDavD j

PLACE OF DEATH:-County of C^a^^ K.X^cu.0. city of^^nrv JAXX^e^

No.

u

and ^ ^

a 0 ?5 L0L\tH.O St.; 10 Dist-bet. ..FORMATION- >J

O.-.M OCCURS -- -C. U^SU.L --^f.-,-4--;-;| N^AME -X^rO. STR.eX ..O .UMBCR. J

IRE D II

(IF DEATH OCCURS A
IF DCATH OCCURI

FULL NAME

<>o^

PERSONAL AND STATISTICAL PARTICULARS

WoXx

i» \ d: ' •! liiK in

cfc

J

5

A

\' .\-

vix. ,i,r M \H ' n '

\\ I 1)1 »'A 1 1 » < '!< 'i >

W ! itt HI -I .. n ■ '■

HiK rui'i, \i'i-:

(Stnti I ii < ' >•' II' '

N \ Ml < > I

1 \ III IK

HIK III I'l. A«'K
<»! I xrill'K

^1 ,i! I ( il ( I n\ lit T ^

s ,

11

IH

■> ' a!

Ihn

!)

MEDICAL CERTIFICATE OF DEATH

iDav) (Yt-ar")

iMoulht

(A

I I1I';RI;15V Ci:ivTlI-V, That I attcndtd <UHcascMl from

IDtt 1

M MIil'.N' X \M1

(ii M(ii"m;K

H

0

ll^

lUR'nn'i.Ari-.
(>! %!(>rm;K

I ^tat< 'it CimiUt %

OCiri'A'lK'N

that 1 la^t -aw liA^Wi alive <Mi U/CA; H icp H

..,11.1 that .kath ..rcurrcMl, on the <late ^tatc-.l above, at H
CL M. TIh- CAl'SI-: (>l* 1)1- ATI! was as follows:

DTK AT ION )V<7/-,s- Monlhs H /?<7i',s- /A>//

eoNTRiniTOkV

/.S'

DURATION
(SIGNED )

}'tars .Uon/Zis

navs

riou

rs

iiGiNtu ) nr'^'-^-'i^^-^^ »^ ^-^^^^^^^ M.D.

I<jb H 'ic)oH rxa.iress) lSOiCkL^^^ at

SPECIAL INFORMATION only ^or Hospitals, Institutions, Transients,
or Recent Residents, and persons dying dv^ay from home.

Rr::df,> in X?" /><

)/, nr-'

\ [ A/.„ff/is X'i /^'''>

THK ^.-vK-T^TKnpKR^>NA. rAKT|.r..u<. XKKTHrK TO Tin-:

P.i;sT <)l' MV KNoWl.l-.Doh AND lU.l.Il.J

(In

I'Xddrt

i"lG?i L^xaIxo ot

Former or
Usual Residence

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

H«w lonq at
Place of Death ?

Days

I'l ACH OI- BIKIAI. OK KI;Mo\ A1.

Ii\Tl'. of HlRiAl, or KICMOVAI,

T90H

,. ■ .pp ahmild be stated EXACTLY. PHYSICIANS should
N. B.— Bvery Item «? Information should be cn.efully f^^^^^'t properly classified. The '*Spec|al Information- for p.r-
otate CAUSE OF DEATH In plain terms, that it ma> ne proper y
sons dylnft away from home should be ^iven in svery instance.

111

t ?*

h

I

4

I J'

f'

I rf"

P'

WRIT& PLAINLY WITH UNFADING INK

II. Mh \ V,

THIS IS A PERMANENT RECORD

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

I

Dn/r Filril, \l clt^oOA; H

l'.>0\

Jlcf^i.sli'i'cd •A''o.

2114

Deputy

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco

Ccvtificatc of IDeatb

PLACE OF DEATH: — County of

0;

No.

^ r^

• Vcv>^c^<i^ City of 0<xrr^ OXcw-vrov-^ ^
St . : Dist; bct.(XUX/v^m.uJ-Cr\.L \ and w v/ Xl C

(X\rs ^l^i\ I i(\a i\\

)

FULL NAME M-OavyuxIxj U^cx-o.

M.

PERSONAL AND STATISTICAL PARTICULARS

"^ ft V nl.t.R \ . ^

+ .,

C »-vXX

|( \ M' I 's

\^ .V.

i 1

<v.

I). I'

V, I ■/'

"\ 1 .11

/>.■

^p . I r M \k k 1 1 P
\\ I iK .\\ r 1 1 < >K i» i\"i •

HI!.' rn 1M. \i'l"
>^' • • < mil! \

I All! IK

HIKTin-l, \»i-

(II* i\rm-.K

tIiIi ..I I'liiini

M \ ! DI'N N NM I
i>l- Mnl'Hi; H

lUH rin'i.Ai'i*,
(li \!iirin",K

i Sl,(t( < il t'ouiil

ij AXJUr^>-<><^

MEDICAL CERTIFICATE OF DEATH

I llI'lKl'ir.V Cl'lRTU'V, riiat I attends. l <UH».ase<l from

- to -

til at I lavt saw h

I9O — ■
~ alive oil

T()0

up

aii.l that .Icath ..rrurrtMl, on the date stated ahove. at

- M. The CM

J\J

i)\' l)I':.\ril %va-« a^ follows:

AAJUX.4JI ci (iL ' f^ \t

^'>vO^

I

\ni^

OAXA

liX/YVOrYV

i

\

i '

1)1' RAT ION )''iJr

C(>NTR!1U-T()RV

Months

Pay

Hours

nr RAT ION

)'t'illS

( SIGNED ) Lc\Xn<\-»A'

c,

Jf(>N//lS /hiVS

^'

'\^

(0

Hours
M.D.

V 4, «V1l

SPECIAL information only '"^ Hospitdls, InslltulWiH, Transients,
or Recent Residents, and persons dying away from home.

ni'CI TA I 1< 'N

A'

,; )' ; I il III

)-,,<

M.iiith-

I hi 1

lU'srol MV KNOW I,l-.I»*.H A\I) 111,1,11.1

(Iiifii!in:int

Former or
Usual Residence

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

How lonq at
Place of Death ?

Days

'LACK 01- IHKIAI, «>K kl.MoXAI,

DAil, 'it IM itiAi, nr K):Mn\AI<

0^. H

(A(Mi- s^

igo

H D S ^ o-\A><,

... ~ AfiF shoulil be stated RXACTLY. PHYSICIANS Hhould
:'".' "nl «w.y «ro-n horn. -houl.. be ftiv.n i y ln...n«.

i I

J.

11

I .»

jl

' I

■•■■•maMMi

WRITE PLAINLY WITH UNFADING INK

,,.1 ..f l!.n!t!. i ^ ■

t^.t^^^,ns.v

Dttlr rih><l , \iJct<rWv' H

mo'i

THIS IS A PERMANENT RECORD

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

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

Ccvtificatc of Bcatb

m

PLACE OF DEATH; — County

of^C^^v 0.,^v<X/>xx^vCi/coGty ofO/CL/>v JXxvyv.^^^<ucx)

No

M

ChClK^Aj

.<xl)

St.;

Dist.;bet.

and

)

0 ft ^ iPvi -

FULL NAME

.VXX/vyj

XXX;

PERSONAL AND STATISTICAL PARTICULARS

D Ai i: or I'.i K 111

i'< M.i iK

.Uivdjb

,Cl\)

r\^^

Month

[1.1%

\« .K

ST ,

■» I ar:

/>,

siM.i.i: M \u!< n-.i> -.

Wtlx »\\!- I » I tic 1 » ;\i i!' .• !; t> ^ \

I \Vi it '■ i n ^> » ia ! lU -U' ii.i! '> ■!! '

niKPiU'iNt'j:

(Statr "'' ' ' iin! i \

Month'

,A^X<X

NAM!- <>!
FATin-.K

P.IK THlM.AiK
<>I- I Arill-.K

(Statf nr (."iMintrv'

MMin'.N NAMl-
(>1 MOTHKK

OJVX'

coK^<Y^^^^

MEDICAL CERTIFICATE OF DEATH

DArF, Ui I)1:A'1'H ,, ,

% 5 igo\

(Day) (Year^

^^ I ni;Rl-:BV CI'-KTM-V. That l atUMukMl dcciascMl fnuii

tltat I last.awh-tV alivf on ^ '^ ^ ^QO H

aiitl that .Uath nriurrcl, en the <latc stated ahm-e, at I
CX M. The CAT SI-: Ol' DI'ATII^vas as follows: ^

DIRATION Vti^ts Months H fhiys Ifoms

CoNTRIF.rToRY

I )r RATION

) 'iW'S

lUR rill'I.Ai I',
Ol- Mo'Iin'.K

(Stati i>i i<unit ! V

orci I'ATloN \{

^(Wx^\W\-

V

(M

U,.*////- ~ /'

TnKXHnV,-STATK,>1-KKSnNA, rXKT|.rj.XK.AKKTKtK TO THH
lilCST ni MY KNHWM.lx.h AND l.l-.I.H.l

\i r\jux>vou

vj CrLcur>>v

( SIGNED )U) A. ^OO^'

0^ - '^

J font/is /hirs

Hours

CoH^ r Address^ qilM^WJuJidfc

SPECIAL INFORMATION only Jor Hospitals, Institutions, Transienls,
or Recent Residents, and persons d>ing away from tiome.

c\A>cr>-

. Days

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

• IirRI\I<<)K KHMoVAI, I l)A'IJ-;..f liiinAi. or Kl-MOVAI.

(A.iar...s l'h'h\ QrriMMiA.-to^ Ot

N. B.-

— -"' ~. Tr.F should be state.! EXACTLY. PHYSICIANS should

-F.very Item of Information should be cBreVuHy -PP^'-'" "^^l^^tL^^.S,^. The -Special Information" fer p.r-

state CAUSE OF DEATH In pliiln terms, that it mn> be propeny

son. dyinft away from home should be felven In every .nstancc.

in

ft»-.

I

i!

m

■-.^mdittmt

WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD

Hi. mUIi

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

Ih

f/r Fi/rf/, UcIMjOA; H

IfJO'i

Be^i.slered J\^o,

2116

Deputy Health Officer

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco

Cevtificate of S)catb

( XX. 5. 5tanDnvO )

m

PLACE OF DEATH: — County of^^a-vx^ J.^^XA^cc^c^City of^l<X^a. J ^^o.m.<i^A^o

No

.at

.K^.><.¥LUs

Ch^t'VvJtxx

St.;

— Dist.;bet.

and

/ ir DEATH OCCURS AvLaY 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

PERSONAL AND STATISTICAL PARTICULARS

SKX

iiA ii; < 'I III Hill

/Us

\t.i-:

Si

M.mthi

J

1);.V

1 '

I '-

s|\» ,I.|* M \R k n.I>
W I l»< t\\'l It Ilk iMVi iKi'l-:!)
Wiitiiii -"nial ilr^iinuitinti)

lUR THl'I. \»'|.-

i Stati 111 > I ii) nt ! \

\VcxhKUL6^

I)

^

LOLW3^x:y1">-^'-<i-

J±.

N WU < »1
I- A 111 l-.K

luu rin'i. All-:

ni- I A III i; K

' Si;t( . I ii I'liilllt r\'

MAim'N NAM!-;
(U' Mol'Ul.k

luk riii'F.Aci';

(>l Mn'riii:K

( St.itt lit V'i>\Ullt \'

? p

V^C^

\ ^

«H A ri

'AIION^

/'\J'Ji^XAJ\y^

Rffittf'if in S,7ti /'i ,1 in nt i> ^ )ii!i'-

,^^X3JulA/>^-^.^«*-'>^

Af.i)if/n

/>.;

rni- \Hr>vi-: sr \ ri.!» pKk^<>N \i, i'\r ik iiaR'^ ari; TKri-: to thi-;

Hi:ST ()I- MY KNOW I.l'ix.l-. AND lU.MlJ-

dtif')- maiit

6. J. (JXdj^A-^ciycry^

XC1

MEDICAL CERTIFICATE OF DEATH

DATH ()!•■ Dl'.A'Ill

l/QAj I /goH

fMoiitht (Day) (Y«:tr>

I II1:RI:P.N' CIvRTII-'V. That J attendi-d cU-i c-asi-.l from

IJokl) CivU I90H in U-CAJ I U)0*i

that T last saw h^ < >^ alivt- (mi L <^Ai I icp H

ami that iKath omirrcd, on the date statt-il above, at u- oO
CL M. The CATSI-: ()!• Di: ATII was as follows:

(^A-Ujoctx^-vh^ UK.<rL<X.'%AXXAjtAji

DTK AT ION

}'iUt/ s

MoniliR 10 Pays Hours

1)1' RATION

(SIG

0^

)\\iys Mofiths X f^avs I lours

NED ) i . Ob. Ua,>\» J iOJ:U^JLkL

M.D.

TC)0

(A.Mn-;s) Q% ■ \kkKSLM IO0^^VLla6

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

Former or ^ 4 w ^ •'"^ •**"' ^* 1 a

Usual Residence U/a^>a; J -aXVMXAwA^i^ Place of Deatfi ? »U Days

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

V N I)H RTA K i: K VA • Ia) . \| fUX^cWw- \ Lc

jS. B.— Every Item of Information ,houI.l b. cnrefully supplied. AGE Bhould be stated EXACTLY PHYSICIANS should
•tate CAUSE OF DEATH in plain terms, that it may be properly classified. The Special InVormation for p.r-
sons dylnft away from home should be feiven in every instance.

m

111

* «

I

WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

(■- ^7.:: 115:1' I'.,

I)(f

fr riJi'<l, iD.cttrWu H

rJ0\

Ji('o^is/e/'C(i ^\7>.

21 1

\H^

Deputy Health Officer

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco

Certificate of 2)eatb

^

?ri)

PLACE OF DEATH: — County oi^CLy^u 0 ^X).^xculx^o Gty oiO<X/y\j J Axx^>AyC.Uiycx)
No 1 5 5 0 ^ 1 a t^^ itxM. St.; ^ Dist.; bet. ^ and

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

FULL NAME

PERSONAL AND STATISTICAL PARTICULARS

• All; I >! iu Kin QC^

JjlXt

KaXX;

\r :i!

I

I las '

A«,F

SINi 1 i M \K I-
iWriti- ill ^

lUK rui'I. \t"K

•St.i!> ■■! ('iilIlUlS

^

'i ■ .1 !

/',/

} !>

^

» \ I II J K

b

I'.iK inri, Ari".

Ol- lATHI-R

' "^tnt«' or Ci ill n!

M \im:x NAM I
n|- MoTHHK

iiiK Tiii'i, \» i-:

Ml- Mnriii: K
' "-tatc 1)1 t'mmt I \

-<fV"r.^^XX

orvTl'A'noN

■" 1,,?;. % M.~ii!U- \

Jhn

rm- .\i?(»vi: sT\-n.r> rKR'-.)\ \i, INK IK II. \Ks xki- rKri-: t<> tiii-;
iu-;sT «n" Mv knmw i,i:i)'.i: anij in.i.ui

niifii!lll;int

\^

<XKA><A

\.l<lr.

/vxl^

MEDICAL CERTIFICATE OF DEATH

DATK 111- 1)1:aT1I h \

(M.dltll 1

I lli:Hi:r.N CI-.R'ril'V, That I atteiicU-il dtCL-ased fmm

i9^ :3k

iDavi (Year)

tliat I last saw h -^A^ alivi' oti

Tip H

and that dentb nrcurrcil, nii the datt- stati'd ahnvr, at C>
\J M. The CAT SI-: Ol" DI'.ATII was as follows:

DTK A rioN
CONTRir.ri'ORN

DTRATION )V,/;-

(SIGNED) \A. (IIdAI fU J/CxxX<x ,a m.d.

)'t\irs^ Mont In 10 /><n.H' ^^ !lour.<

Mouths

Days

Hours

Special information only Jor Hospiys, institutions, Iranslenls,

or Recent RcMilents, dnd persons dving away froin home.

Former or
L'sucil Residence

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

HoH lonq at
Place of Death ?

Days

HI \I, <>K ki:M< >\ AI, I I>A I

INllllK TAKI-

..! l',t in.u III KlvMOVAI,

y-t^

N B — fivcrv i.em of information should be carefully ^uppll.cl. AHB «houl.l be stated F.XACTLY PHYSICIANS should
ItateCAlISI. OF DIdATH In plain terms, that it may be properly classified. The ^Special Information for per-
son* dyinft away from home should be a«ven in every instance.

WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

2118

Ihf/r Filed , IJJ.'tiJ.xrU-iA^ H

ii)(n

lU'!^ I sic red jYo.

KJU^

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco

Ccvtificate of "Seatb

H. 5. 5tanC>ari?

^

Qn^

Ne.

PLACE OF DEATH: — County of^<V>v ^ Jyoj^x/^^JU^ City of C3<>^^^ 0 X/CX/wca^i.<^
^ilL iWoodL St.; i 0 Dist.; bet. - — — and ^

F«nM USUAL RESIDENCE GIVE FACTS CALLED FOB UNDER SPECIAL INFORMATION ' ' \
" - TT AND NUMBER. J

( IF DEATH OCCURS AWAY FROM USUAL H t » I U t n. ^ IL u . » t r«v,,o ^j V« V . « =T r . n n F ^TB E E"
V IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION OlVt ITS NAME INSTEAD OF STREE

FULL NAME

'^TcL

JLvou ^^X/CU'

a^xoJu)

PERSONAL AND STATISTICAL PARTICULARS

1

» ' . r I ii !;: K I I

IG

\i .1-:

U i i M .W 1- I > < »K II"'

Wilt. Ml -. M i:il .1- ^

HiK'rmi. \«'i-

>--l ' . . .1 I . !l' 111 ! \

M.),'li

Ik

1)

1 Sill IK

lUK rill'l, \i !'.
< ti I \ 11! 1- H

•^1 :it t I iT ( I I'll lit I %

M \ ii>j:n n ami-;

<ii MtiTIIj; K

niRTnri.M 1

«»|. M. Ill I IK

I HI ,,: ,! »(iu lit 1 \

»HH'» r \ I It ix

1

1

AVi'./'i'i/ /!» Si.'" 1 1 it III

Y.

s

\J..iil!r

la /-

Tin XHUVl- sf MID l'KK^..V\l, !• s K I' Ft T !. A K - A R !• TKIJ-: To Till-

lii-srm Mv KN' iw 1,1 I"' J- ^^" Mi.i.ii.i'

In fn: numt

x^Ap<y<xjy\yy^^K>

VHr... Le^j[K^^J^a.<i

MEDICAL CERTIFICATE OF DEATH

DATK ol- Dl.ATH j|

(Moiitlil (Day) (Year)

I If ^;I^: !■. r.N' Ci:kTI!'\', I'hat r altet»<kMl (UtxasLMl from

that I la-t saw ll-£>^^ alivi- mi SiJ ^CA7 I i,pH

and that death -icciirretl, on tlu' <latc state<l abnvf, at o
vJ \r Tlu- CAl SI-: Ol'" dp: A Til was as follows:

UJ-UAJtA^tL.K^

I )r RATION

)'t'<l>S

."Sloulhs

Davs

Hours

CoNTKIIUTOkV C^rY\.XX^'\^^jOLK^^r>r^

DIR A'PK »N

Ycat s

Mi^iths

Ihiv

Hoi,

; V

( SIGNED ) LUUKjuL M ll XcL^A.<mX>u^^ M.D.

Special information onlv <«r Hospildls, institutions. Transients,
or Recent Residents, and persons dying ,iv*.iy Iroin liome.

Former or
Usudl Residence

Wficn was disease rontrrfcted.
If not at place of deatli ?

HoH long at
Place of Death ?

Days

I'l.ACK Ol mKlAI, nK KHMoVAI,

DATJ'.of HiHiAl, or R1:M(»VA1,

0^ H T90H

O AXxXa./CX/'-vn^
ni)i:k lAK! u vXIaaT- ^— w- -I J,

N. B.-

-Bv.ry iten. of information .hould be carefully supplied. AGF. should be «.nted F.XACTl Y ^"YSiCIANS should
•tat« CAUSE OF DEATH In plain tcrm«, thot It may be properly classified. The Special information tor p.r-
Hon* dyinft nway from home should be ftiven \n every instance.

V\

pMa0^^

I

I

I •

ill

WRITE PLAINLY WITH UNFADING INK —

Dafr /v/rv/, U^ctVinX' H

IfHJ\

THIS IS A PERMANENT RECORD

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

Registered jYo. "- * * ^

DEPARTMENT Or PUBLIC HEALTH=City and County of San Francisco

Ccvtificatc of E^eatb

0 (^ A ^

PLACE OF DEATH: — County oiOo.^ ^KCXA^^<^^ City ofOxXAV 0 /v<x.^>x.c^<^o

No

JIHS VJt

J t iXtJ^ Ua>X St^ ■ Dist.;betJll^'c'.\VCV<^ ■ and 1 aJ

J JK) ^.J^^ \J \^^ ^\J ^/— ^ ,,-,,*l orcinFNCEGIWt FACTS CALLED FOR UNDER "sAeCIAL INFORMATION ' \

( " r"o;iT°„"cc"u%rcV,"r„o"s^p"Tit o%'?:?,',?u"4';'"vr,4 name ,»s...= o. st^..t .no «u«a.». ;

FULL NAME

^VJ, I

•J X

PERSONAL AND STATISTICAL PARTICULARS

DA IK I >1 lUK fH

\ t . \-

\^ I IH i\\ Hl» »»H l>i\
Wiitf in ««iciiil «1« ^1

lUK 1*111'!. \i'l-

/',/

I »

0 1 '' ' ^

NAM I <»»
FATH 1 R

lUUrm'l.ArK
• U lArill'.K
^« iff or I'ount 1 V '

III N!i (I'll 1 K

lUK riM'i.Ar »■:

(»l M«»rilKK
I ^tatc III riitiiit t \

< Hi I I'A rH)N

bwu

kriAfii III ^ii" I

I ,1 I' ' ( 'I

>» )-.;

\r.,tiHi'

Ihn

VnV MinVKKTMl I'rKK-^nNM.l-Akrirn.AKSAKKTK! K T< > THH
jij-sT ni- MV KNOW 1,1 i'*-»'. "^^i' Hi.i.n.i-

1

v-^

^ cC'-^

11

ri

1

(X/v\,4."(:

' i

i

4-

MEDICAL CERTIFICATE OF DEATH

UA 11-. « >1- lil'.A 111

(Month)

I>av

(Year)

I III'RIP.V CI-RTIl-V, That I atteiKlf.l tkHiasctl fn.iii

to . V

0.^

1

U)0 » to V^'V'L' t> 190

that I last ^aw h '. ahvcnii L'ct -^ I90 ^

and that (U-ath (uuinrccl, nii the- dati.- <tati'<l above, at 1 I oO

H

>

M The CM SI-; Ol' Dl'.ATII was as follows

V^'X^^'\..<X,w,^A.A^fr ~v V.

^.A^^LA- ^- '.' : ^-C^

DlkXrioN Yi'ais A/oiii/is Pays ^

ay (?

_,. z,^kXjl J<X.<il^^ ^>xl./..

Mo)itln /hns M) Hours

i

or RATION
(SIGNED )

)'rijrs

Afoul Ms

/hns

r

ttWKx/>x^ ^^

„u

Hours
M.D.

1

I()0

(A.ldnss) ^iol ' t Itv. Lv-a

Special information only '«r Hospitals, Institutions, Transients,
or Recent Residents, and persons dvinq away from home.

Former or
Usual Residence

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

How lonq at
Place of Death ?

Days

IM.\CH Ol- HrRIAl, OK RiCMnVAI.

8 /Ow^CA.4X/^«:-kNj^ . t o

fAa,i,..s. \X\ ^^AAjU-^^^

DAri'.iif in KiAl, or RliMoVAI,

U'Ci* 5^ T90H

■""■"■""■"""'^ ... ^ ,. II I APF .hnulcl bo Rtatetl fiXACTLY. PHYSICIANS should

Bon

s dying away from home should be given in every instance.

m

Hi

II

»,

WRITE PLAINLY WITH UNFADING INK —

i'di 1 ^■'•

,'U\ \ ' ■>

Ihffr Filc^l, y tLcTVt>v H

ion\

THIS IS A PERMANENT RECORD

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

Heciisfered J\^o,

^t:^-^^

X'VA-i.

DEPARTMENT Of PUBLIC HEALTH=City and County of San Francisco

Ccvtificatc of IDeatb

PLACE OF DEATH : — County of '"'rv^^J J ^ o„ . x <: tc

C ^

- '. City oiOjX.^^^ vJAXX/vx <-^-

A ac

No

m 4 1

UXhX^ JL ^ V , ^ ^ ' St.; Dist.;bet. —

RtD IN A HOSPITAL OR INSTITUTION GIVE I

and

JXLifS -'^ '^ - ' ,,c,,a, RrSIDENCE GIVE FACTS^CALLED FOR UNDER "SPECIAL . N FO R M ATIO N ■ ' \

( " rF'|;:.°"occuRr/^^-"° "--^^^^ rR'?NST'Tu';'o";"aiVE its name .nsteao of street and number. ;

)

(\

FULL NAME

N

PERSONAL AND STATISTICAL PARTICULARS

li A I !■; «»| lUK III

St .J-

uo

/ i.

ID..'

m.

\'i .^^ I

n,'

•^IN'i.I* MAHRD-.H
\\ I I K i\\l 1 » ' >K ri!N< >Ki' 1".I>
Wnti ill -'( Kii ,lt -ii-HiilMii)

ISIK 111 I'l, \iT
' Stat' 1)1 I 'i it!!)ti %■

N \Mi- « n

1- A I'll IK

C

1^ TWA -\^(K'y\xjJL

1 I ' I '^

lUK riii'i.Ai}-:

OI- (A I' I IKK

I St.il I I il i'l Mint ! N

MAII)1%N NAM)-;
(»I- MoTHF.R

lUH rniM,Ai'i-:

nl-- MnTIIKK
<Statf (il CuuiitiA

AX IXAjl

\. X )

a

(M'v:ri'A rioN 3 p

Kr hUd III X;;,' /'/ /''■ />'-'

^tcJL^

n

0 ) >r? ' >

M,<„tlr

■niK NH(,VKvTATKPi-KHS.>VX...'AKTirr!,ARSAKKTKI-KT.)
IU>r »»l MV KN»>\Vl,i;i)<'K AM) Fu-.i.n-.f-

Till-

l.x.'..\..'-x\

/90 k

♦ Year)

MEDICAL CERTIFICATE OF DEATH

DAi'i-: 111- i)ix\ Hi X

f Month) (I>:iv>

1 iniKiil'.V CI'KTIl'V, That I attcii.U.l <Uh cased from
^WXu IH up^ to vJcfc 3 TooH

that I last saw h A.>>^ alive 011 U ^ 3. up H

atnl that dt-ath orcurred, on the datt- stated alx.vo. at ol
OL M. The CAT SI-: t)l- DMA'PH was as follows:

V

DTK AT ION Years

coNTKira lOkV

Moutin

/hns

Hours

nrRATION Yt'iirs Miniths /hirs

( SIGNED ) \l\- i)- --JO^Wl^^^U^-^
Ijct ^5 r()oH (Ad. Ires.) dt

Hours

M.D.

SPECIAL INFORMATION «n'y f«r Hospitals
or Recent Residents, and persons d>ing away Iron home.

'Il\<!L^UO
ospitals. Instiiiti

Former or y S^ \^ N®** '♦♦"fl ^*

Usual Residence ^^u 1 AxX/^vMl\A.c^ ^ Plare of Death

When was disease contracted.

If not at plare of death ?

Days

l'I,ACK «>l lUKIAI, <)K KHM«)VAU

DXriliif BiRiAl. or RHMUVAI.

19^ r

1 90S

..I %.r\= oUnt.ia k«« stnted EXACTLY. PHYSICIANS should

IS, B. ^Rvery item of Informal

state CAUSE OF DEATH In p

son* dying nway from home should be ftlvcn in every instance.

I
f

It

I;

I-;

WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD

REFER TO BACK OF CERTIFICATE FOR INSTRUCTION3

.-• f»» V

Ih I \

Dafr /'V/^v/Al^t<jX^V H

HJfj'i

Be^istercd J^o.

J?

l<^v.^ Xa^x^H DeP^^y Health OfTicer

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

Gcvtiticatc of !Deatb

No.

PLACE OF DEATH:-County oi^O^ O.X<X.vc^ ' Gty of ^^CV^ 0 X<xp..A^
7l'> \trrVJU St.: ^ Dist.;b€t. if>-^ and Oa,*XU,\,

FULL NAME tO/YYvXA HL

PERSONAL AND STATISTICAL PARTICULARS

I' I 1,1 I K

^^.

W<XA4

\< ,1-;

\\ !|i< .will '
\\ T 't" ill

a

) .

H

:!!>

! »

/goH.

(Year*

MEDICAL CERTIFICATE OF DEATH

HA 11. <•! i>i;ath /A

I n i:R I'.I'.V CI:RTI1-V, rhut r attcn<UMl .Idc.i'^c.l In.m

^ ^ - ,,w-)3. in ID/Ct H IC)oH

that I la^-l ^aw h ^-WValivt- nii '^ '^'^ -' IgO ^

aii'l that -kaih icciirrcd, oti the date <tato.l a1...vt-. at ^ '^''

M

Tin- CAISI-: Ol' DI-ATIl was as follows

in' I ^.•|•

t • \

iC^yU

.<X. W

d^

N \ M 1 < > !
t \ 111 \ R

rue rni'!,A« H

<•• 1 ATIII-K

M \ IJtKN N \M!

LKcu

lUKTniM, xr I,

<»! MMTHKK

I St;(t« I If (oiitJti \

^"^uU.

(Mill'

Hf iiU'ii 111 ^>i>i

41

M,i„lh

I-

HH^T ol MV KN..WI,1-,I»«.K AM> MLiM

»\JkX T T N.-'W^

S'M!i'>-s

X5 MriA.^Q.^^^A.^i'^v^

ClouJU ^aJXk^UUl W£Uj^Xd^

lit I< AI'loN

CONTKIHlTokV oU-OCLXOJU. >t ^^ -^

u^ .

(v

t

Months Day^

K.WA^V^'w

/%

I louts

M.D.

nr RATION
(Signed )

SPECIAL INFORMATION o"''* '"^ Hospitals, Institutions, Iransient*,
or Recent Residents, and persons dvimj «*»a> froni home.

fA.i.inso iDSy/aA;u>ti.^Bx<la

Former or , a u

L'sudI Residence ' <^w ^

When v*as disease contracted,
II not at place of death ?

IRUAUiA^vl

(Vwo-^

Days

l'i,A(:K OI- HtKIA^dK KHMOVAI. nA^lK ..f Hi kiai, .a ki;M«.VAI

Tf>oH

rNI»l',KTAKl.K

iA^..^V\.» ^i ^<

A.Mn--

^1 Qfy\A.4>a---,^

.^YX

N-4

■^— — I , .(..r „^i,,uit| be stnteil F.X4CTLY. PHYSICIANS should

1^. B.— Every i.«m of Iniormnf.cn «houhl b. ^""^^^''^ uTmri e pr-.^rly clo.-lflcU. The •'Speci..! lnform»f.o„" fer pT-
•t«te CAIIHI OI 1)1 ATH in plum terms, that it mii> »w pr<.peri>
'on. .lymft «w»y from heme mHouI.I be feiven in every inntance.

y
1 1'.

i, 1

;.i

3 .

I.

i

PH ,,,

Id

i 1?^*

I! -

WRITE PLAINLY WITH UNFADING INK-THIS IS A PERMANENT RECORD

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

PI OQ

H5s; 1- r,

llU>-^\.'

lOO'i

Bc^istrrcd JVo,

■L^v^lc^ Deputy Health oncer

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco

Certificate of IDcatb

PLACE OF DEATH:-County of^C >.^ XC..vc...oGty of ^^u.^.^VC^— <-^
' ■ A , . ( St.- ^ Dist.; bet. 0 C^^vCyW and ^ CAX^

C IF DtATt' "-""oatn IM A HOSPITAL OH I N STITUTIO '^^ Uiwt

FULL NAME

.:.^ : >>xcyvv" K \J . ^

lU !

.o.^

PERSONAL AND STATISTICAL PARTICULARS

I

1. \ 11 « >i niK 111

Mmsthi

\' .j:

5H ,.

\vii>«i\\i:ii MR ii \ 1

niK niiM XT

I \ I I I I !.•

1UK 111 I! \' M
» >l 1 N 111 i.k
■-.till 1 1 riiiinlrv

M \ 11 UN V AM I"

»»i Mt»iin:K

lUH 111 ri. xi'i".
Ill Mttiiii: u

< nrri' Ai'ION

i : »

rn

(XhK^JLC

(\

n

^

xl. ^

0

MEDICAL CERTIFICATE OF DEATH

1, A ri-: I ti I'!' \ I'H

I I

,ct,

: Month 1

a.
n:iv

(Year)

I ni:in;r.V CI{RT11"V. That I attcn.UMl .UHva^d fn»m

190

'-\

t.)

0^ ^

Ti)0 H

lip

that I la^t saw h ' .in\^- •'»

iml that .hatli nrcurrcl, on the .late "^tatr.l above, at \

Q

M. The CAl'SI-; (»1' KI-.XTIl was as follows:

^^

-xt

V J^

niK \rioN

(SIGNED^

)"( i/rT

^

Months

Pays

i.C.^Vu ^

Hours

M.D.

)

TQfl^ (

Ad.lress) ^IH%^MKL&A.^C

) ViJ /

M.„ttli<

n,i lA

TnK^,u>vK.TvrK.MM^..o^^^P^KTHM^.,^Ks^KHTK^K m Tin-

in:sT..!- MV KN.'W I.TIM,!-; \M) Hl'.M'J
IiifnMn:nit

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

Former or
Usual Residence

When was disease contracted,
If not at place of death .'

How lonq at
Place of Death ?

. Days

l'I..\CH 01 151 KIM. OK K1;M<»VA!,

A4 UVO--^ ^

INDl-KlAKl-

DA 11: of HiKiAr. <.r Kl'.MoV.XI,

iD^ H T90M

,„,Ls Ibl OlrVx^.^cr>x. t\L

.,,0 1U

^^^g^^a.t^mmmmmmm^immmmm^i^^i^ii^'''^'^'''^'^''''''''''''^''''^''^''^ ... tatcd FXACTLY PHYSICIANS fihould

,. -^-^^-;-^^;;^a^. 1: -;:^:^ ^^t :^x:^J^^^ th; ''spec,. in.o.„-uo„'' .0. ....

f

5)

i-

I
7

til

11

i'l!

,11

WRITE PLAINLY WITH UNFADING INK

Mill •-.<: II. :ilth I N"

■*•»-■«- ---i, i;\ r »'

If^O^i

THIS IS A PERMANENT RECORD

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

Be <! isle red J\^o. 2 J -^3

Ihfte Fifed, ly^tcrUtK. H

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco

PLACE OF DEATH: — County of ^ Cl-^^

Ccitificate of Bcatb

^

City of^3,/CL/>^ 0 AXL/VL-eoMiXi

'fi^X^

kXA

SX-VuCi

ChiAvlL

Dist.; bet.

and

L^ ^^--*'- Y VAi y V^ U-\L/( U^'N-X-A^ V/ ^"t ,.'^oV»iirn for UNDER SPECIAL INroRMATION- \

FULL NAME

A

PERSONAL AND STATISTICAL PARTICULARS

1 ( 1 1. 1 Ik

1

.a

ll

I Mi.'itll'

,qoH

» 1 ar

\t .1-;

l'^

>1\< .1.1', Nt \K 1-. II 1>

W I 1 H i\\ 1 I > I »K I »:\ ' 'I" ' ! I'

lUH I'Hl'I, \>'l-

St;it. . i! I ' ilinl I

NXMl <M
I ATH IK

lUKTHlM.ArH
ni l-ATHI-K

■ll,!!! 1 I' I'l iimt ! s

M \iin;N N \M I
(>1 Mnl'IIKK

HIH rill'I.Ai H
<>!■ MoTIII'.U

I '^tiiti lit ("oinili X

MEDICAL CERTIFICATE OF DEATH

i)\ri-: (H di.atii

n

/,f

4

(Day)

TQO

(Vt-ai

H

I ni:Ri;P.V CI-RTII-V, That I atteii.U'.l ilccciistMl fmin
cLJaIj 5 i.pH to iD^ H icpH

^d.

fKD H

ttiat I last saw h ^>ri Mlivf on ^'^-^ ^ ^^O

aii.l that death occurrc.l, on the .late ^tati-.l above, at
lJL M. The CATSK OF DHATII was as follows

Dlk Alios Years

CoN'i'KM'.l TORY

) V</; s

MoiitiK ^ I Pays J loins

Mouths

/>,/ls

I lout s

M.D.

DIRATION . ^ ^ A

(SIGNED) %. i UaX^ ^

\j/^

(HiTI'STinN

tsr uifd III Siiii I

• 11,1 • .1

)'/il I

1/,.;,'///«

/),n

T,n-A,..,VKSTVTK,.,.KK...NM rVKT.;;,;;VKSAKKrKrH To TM,.:
Dl-.M- ol MV KNOW l,i:iM,l-. AM' l.l'l.ll'.t-

,„„„..« \XXdAA/v^^ fo(SA|vdQl

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

How lonq at a q

Plare of Death? a*^A Days

Former or
Usual Residence

?

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

I'l \CH ot HIKIAT, OK HI.MoVAI

I)A1 Ui>} 1^' KiAl- «ii KIvMoVAI,

iD^ 5- T90H

rN!)l-:KTAKl-:K

'""■""^■"""■"^T n^ AGB should be stated EXACTLY. PHYSICIANS should

atlon .houid be CHr«*ully suppi.ecl A^pB « ^ ^^.^,.^j, ^he "Special Information" for p.r-
4TH In plain terms, that U may be properly ciassiticu.

IS. B. Every Item of Inform

*„♦. CAIISF OF DEATH In plain terms, tnai ii mi., — k- ".-•
::„. d"nl .w"^ from horn, .hould be ftlv.n y .n-.-nc.

=«

••
y

?

i I

,1 , t II. ;i M

WRITE PLAINLY WITH UNFADING INK

rj()\

DEPARTMENT ^ PUBLIC HEALTH

/VMJ

THIS IS A PERMANENT RECORD

REFER TO BACK OF CFRTIFICATE FOR INSTRUCTIONS

City and County of San Francisco

Ccvtificate of Bcatb

1 X\, 'Z\ StanDarC* ;

i

■v,

m

PLACE OF DEATH: — County of CV^wXa >xce^

Chy of C' .<X >x J A a >vc c4. <-

.9

±

1^-

\

. , nr.-^ ^ i o o I J ( .c. St.: I Dist.; bet. dJA^^-cn-vAj and

No. 1^:^ tVCOLOO ,,=,,A1 BESIDENCEGIvr r.CTS CLUED rOH u4ct. SPECIAL INrORM.TION--)

( " rr'r-X"cCU%*Pro\"r„o"s^.yTll: r"-:"Tu"o';.".,VE ,TS name ,.STE.0 ». street .»» -.UMBE,. .»

FULL NAME J U^ -^.

( I

V.

■)

PERSONAL AND STATISTICAL PARTICULARS

^KoL

:iA'ii: < ii 1.: k ill

X < . 1-;

M. nth

\-h ,.„,

C

!':

M..„'h

L

\ : A\

IhlV

• \\ 1 it. in vtit ii 1 1 .•

■^t:it . . ' I ■' 111 lit 1 \

.11 )

•^ \ \t 1 I I!

1 A III l.K

niK 111 !M, \t i-:

«>!■■ I A ill l.K

(Strlti lit Ciiilllt 1 \

MAIDKX NAMi:
ul- Mni'IlHR

lUH i in'I.ACl",

(ii- \;» till I'lK

"-; it ■ . ! idii lit 1 'v

\J

\ I

IxJLA;

( »., r 1

\ 1 I'inA ft

' MEDICAL CERTIFICATE OF DEATH

DAi'i; <)i- nr.A.'i 11

^rX

')

IQO I

( Wat-

I lillklU'.V CI'.RTIl'V, That I altcndcl (Uctasctl Iroiu

i<p to -— r— — ~ lip

tliat 1 last saw h :ilivi- <>ii ~" ~ Ttp

aii.l that <Uatli ..rrurre.l, nii the date stated above, at — "
M. The CAl'SIC ()!• DI^ATII was as follows:

0 u

I )r RAT I ON y<'^^f^

CoNTRIl'.rTORV

Mouths

Pax

Iloitrs

nr RATION

(?0

) V<7/>

}[,<)! ths

nav

(SIGNED) JAXxLiXcek 0. UXVu^ ■

I fours
M.D.

*^'WCU

M,<lltln

rnUAnnvKSTATKn.KK.nxA, pxKT.r. ; ^ ;. H s A K ,.-, r R r H r. > r n .■

HI.STOI MS K^•<)\Vl,l.l»<.^. A^M> in.I.H-.l

I Iiifot tiiaiit

f Sd.lrt'Sf'

VxJUL

'-M

.^tr-Tv'

.t

Special information *»nlv for Hospitals, Institutions, Transients,
or Recent Residents, and persons d)in:i nwdv from liome.

Former or
Usual Residence

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

How lonq at
Place of Oeatti ?

Days

PI.ACH <>1 lU KIAI. OR R^:M<»^M.

Cj/CX/'^k^o

DAl'l .>t Hi HiA!. or R1';m<)VAL

190

rXDKRTAKl'.R V • ^

XXa^^-v d 0-C V

■-■—-'■■''■•'■'•''■■'■■'■'"'''''"'■■''■■'■"'"''""'''''^ .. . A^F »ho..l,l he Rtnted EXACTLY. PHYSICIANS should
,S. B— Every Item of Information .hould be c«r«fu.ly supp .ed ^^^F;;^;" '^^^.,,.,j. y^, ..g^eclal Information" for p^r-
Ktate CAUSE OF DEATH In plain terms, that it ma.v he proper y
lnn\ dying away from home should be given in every Instance.

I

i

I

RITE PLAINLY WITH UNFADING INK

Ihilr Fil(>(l, VxLe^^y-^^ H

lOOH

THIS IS A PERMANENT RECORD

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

PI ^^

DEPARTMENT OT PUBLIC HEALTH=City and County of San Francisco

Certificate of Beatb

1 Xl. 5. 'I'tnuDarD )

Q^

No. V;

PLACE OF DEATH-: -County of ^CV^ix<v>-^-^-C;ty of CW.^ J /..x/Y^^^

FULL NAME

i| UIK I H

- 1 \

It \ 1 1.

\i .K

-IN. i ! M \k h i '

W 1 111 'W 1 1 I I >K I I

\\ !i!. in — ; ' '■

|;ik llll'l \i'l'

\ \ M 1 I >1
I \ ! 1 1 i H

P.!K 111 !•!, \fl'
1 >| ! \ III !• K

S!:(t ^ ■ 1 . nut '

MMltl'.X N\MI'
<>I Mnllll K

iMi; rniM, xri:
Ml Ntdriii'K

-I il . . i! 4 ( i\l!ltl %

< M rrr A'l ION

PERSONAL AND STATISTICAL PARTICULARS

rt>i,<>k ^ ^ '^

UJJkAiji

,n

i 1.1

! '. >

)

MEDICAL CERTIFICATE OF DEATH

I) A I'l-; t »i I'l: \ rn .

i 1 I -

M. .'.nil'
I Hi;i^!;i'.V CIRTIIV, That l altcmk-.l .Ucea^cd ftuiii

u,c:t^ ^ I wo . t.. " TOO -—

lliat 1 last saw h alivt nii ~ I 'P

an.l that .Uatb .KHurri-.l, m, tin- -lat.- staU-.l al.nv.-. at
M. Tin- C.\rSI-;,()l' DI'.Alil was as follow^:

M , 111

a..

i

'i (M^Mxl ' \

y

,,! R.\ri(.N Vr^irs M'^»lhs Pays Jfours

UrRATloN
(SIG

0^

)'iiirs

Months

/)avs'

K.<X^

I lours

M.D.

'1^-1 ^

I ( )'">

AV /' ^ :ii ''-><> I

) > i<

M.oilh'

n,i\

■IMIl- XHnVKHTATKlM'KK..»NAI PARTirri XK- XK
I'.l-ST (H MV KNOW 1.1. lM,h \M> I'.l, I- 1 1 • 1'

i: IK IK i<> rn H

( 1 11 f' II ni.'int

>,/W

SPECIAL INFORMATION »nl> lor Hospitals, Institutions, Transients,
or Recent Residpnts, and persons dvini) dv*,iy Irom l>ome.

Former or
Usual Residence

Wtien Has disease contracted,
it not at place of deatti ?

How lonq at
Place of Deatli ?

Days

1M,AI-K <»!• mjKIAI, OK 1<J:M«>\ Al.

I r

1 NiuK r

)ATI'. Ill Hi Hi.^l. til Kl'.MoVAI,

— — -^ T^ Itf «hnul.l be *.tate«l RXACTLY. PHYSICIANS should

state CAUSr or DIATII in p ...n erms, th« jt m»> »»; P '

;r c;;iVroU;. ;:^- -.; ;;;;ouM Hc .^en .« eve., ^n...n..

u

,111. :0th 1

WRITE PLAINLY WITH UNFADING INK-THIS IS A PERMANENT RECORD

REFER TO BACK OF CERTIPICATE FOR INSTRUCTIONS

JfUJ^

Jiro'is/r/'('d jVo.

^^ Deputy Health Officer

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco

Certificate of IDeatb

I u. 5. StanDarD )
PLACE OF DEATH: -County of'^ O.^. 3 ^<X WCV^COCity of

I

No.

. ,,1K,

f -k

w

■St.; 1 t Dist.; bet. J

A.' ..

and -

■)

FULL NAME

h

I ^ . \w^w'UW

U I

PERSONAL AND STATISTICAL PARTICULARS

t't ii.i ik

i < I.

|);iv

%< .1-,

-^iNi . i.i" ^: *> K 1 1 n »

V\IIi< »\\ 1
Uiitt ill -• . i . .

"-.I. it.

N* \ M 1 I > I A'N

I- A I iii.k ,

luK rni'i, \»H
(H I \riii-:K

I ^t:lti n !!t I \

M Aim' N N \M 1'
<>l- NHilHJ-. K

lUK rill'LArK

I A^tril' III i'omiti N

1

K<x'Vv^'-<^

MEDICAL CERTIFICATE OF DEATH

IiAlK ()! niiAl'H

( Months

(Day)

(Vcitt)

I Ill-.RI-P.V Ci:kTil-V, Thai niUc-n.U-.l .IcTiastMl fmni
that I la<t ^aw h alivi- oil ''^ ^ • up

aii.l that <Uath ocrurre.l, en tile .late slated above, at O '-■

Xx

M The CArSI-: <>1' Dl-ATH Nva< as follows:

w^

A

\ l.T^

't i

0 ^A

'» ^

k A\ H

U

-1'

A:

t ,

4'

LoJUvVL-V^o^t ■JxJ^'^d.

]

\ .

O^u,

1A 1/.'//

/»,M

<H.'Cri'A llON

T^KA,u.vKSTATK,M.KK.ox^. rxKT.rr..xH. XKKTK.K T.. Tin-

l',i:sr «)!• MV KMiWI.l-.lx.h AM) J'.IIJ 1 I

(ITI'

DrRA'PiON H Ytars
CONTKIHITORV

Moul/is

Day

Hon

; A

1)1 RAT I ON

)V(;;a

Months

/hivs

f Signed ) \I " -cxxu -^

flours
M.D.

iiJ.<£t S iQoH (Aa.iress) 3^-^^S>u>-

" SPECIAL INFORMATION only for Hospitals, InstiluUons, Transients,
or Recent Residents, and persons dyinq dwdv from home.

Former or
Usual Residence

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

How lonq at
Place of Death ?

.. Days

I'l \CK OI' lURIAI, OR UKMoVAI.

\\.\\-

1 >.\ri". (it I'.S KIAI, 111 k I'.M* »\'A1,

nxtxhlLu. "^ . :>v.w^ ,

— ^ ——4 7- ~ Tgb should be stated BXACTLY. PHYSICIANS should

.. «--Hve..J^o.^.>.^:.on .h^ ^^^^;^ ^-^t ,..,,eH. classified. The ''Specif, .n.o..«tlo„'» .0. p..-

;r;d!fn'r«wa' frL ho.e should be ,We„ In .v«r> Instance.

\!k

WRITE PLAINLY WITH UNFADING INK-THIS IS A PERMANENT RECORD

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

11 rr

1 vn 1^ ^;:Sir-

[u'v!- c,

Be^isfcred JS^o,

o-i o^

l^^vo Icx^ Deputy Health Officer

DEPARTMENT OF PUBLIC IiEALTH=City and County of San Francisco

PLACE OF DEATH: — County of ^ A '^ • '

Cevtificatc of IDeatb

' -^ ' ■ City of ^ iW-VNiKArO^ >v , .

No.

St.;

Dlst.; bet.

and

(

' --^:\^:- -v'^:^^^ o-?;?f,?„=4=:'o,;er4 ^-m" -svr;- ,.%%%T;:rr:.*rr' )

FULL NAME

,<r\A>^

^^rVMr '

!,\

PERSONAL AND STATISTICAL PARTICULARS

A

n\

1

K.

I li i;iK 1 li

M..!iiU>

\l .1-

u .....

>.','.

\f ■ti'h

> I ;u

/>,/!

'A I \\>. ill -.,, i;i I il. -U-!',,ti.i!l i

MEDICAL CERTIFICATE OF DEATH

I, A iK < '1 ni'.Ai n

!):i\-

(Year)

f Month)
J lll'.RI-r.V CI:RT[I-V, That I attciKltMl .k-tvasfd from

to — — ^ 'Up ""~

— 190 - —

lyo

lf\0Lh.V<^ck

' 1 , '. ' ' 1-:

at.

\ ,

X \ Ml . »l
! Alii Ik

niR riii'i.Aii-:

^' ' I ', ,ti nt 1 \

iti M<»*rm;K

r,ik in I'l. \* 1-:

' .1 \!t If 11 IK
1 Slati; .11 ».'iiniit ! ^

11

\ % . .

M

J -v..

n.Cl'l'ATION

• \r,nith^

Ih-

in-sT 01 MY KN«>\\i.!;iM->-. AM> D-.i.ni

<I-; IKIK TO THK

(Infii-inntit

that T last saw h .^- alive mi
and that doatli orcurrcMJ. on the .late stated alcove, at
M The CM Si' Ml- I)l-:ATn was as follows:

DO . I i

I )r RAT ION )'t'iirs

CONTRlIU'inRV

Months

/hivs

Hours

DT RATION
(SIGNED)

Yea

H

Months

\^

f.\,l,lrvss)N iV-OCl

I lours

vt\j M.D.

SPECIAL INFORMATION ""!> tor Hospitals, Institutions, Transients,
or Recent Residents, and persons dvimj awav from fiome.
r », «r How lonq at

Wtien was disease contracted.

If not at place of death ? ^ ___^

ri.ACi

•: (n lu Ki.\i, Ok ri;m"Vai

I) ATJ; 'jf li! KiAi, 01 HKM'»\AI.

T90H

VJct S

M.HRTAKHK Wvv^^^ lU^-^^UKto^^

0-\.^ tX>w>

(Adi'iK H*-

b ^^ ) Wo^^tj vw ..'.L

.. , .pF should be stated KXACTLY. PHYSICIANS should
N. B.— F.very item of in?orm«f.on should be c«rafully «"PP '^ ' ^^^"^ classified. The "Special Information" for pT-
. */r AllSI- OF DEATH in pliiin terms, that it maj l»e propcny

h'
it*

WRITE PLAINLY WITH UNFADING INK-THIS IS A PERMANENT RECORD

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

2128

„,... 11.,.!. h IV.. - -■^;^«?^ H^rcu

Ihffr Filed, 1 tlcl-es ^

100\

Re<ii^l('red JS'o.

1^^^^^^ "l^x^ Deputy Health Officer

DEPARTMENT OF PUBLIC nEALTH=City and County of San Francisco

Ccvtificatc of Death

( tl. 5. StanDarD )

PLACE OF DEATH: — County of '^

City of^ CX

I'.

r^

• ^ _ \ \ ^ \.^^ wC

No.

^ tk lU

I * St • Dist • bet* " — — ~" ^^^

((fri '^

FULL NAME

\ I ' I w

^1 \

PERSONAL AND STATISTICAL PARTICULARS

ri»i.<»k

^lY

, I

ill 1 U i'- I I 1

M..iith>

1».<%

\| H

I car

/',

r M\KHti;i>

\ 1 1 1 " >H I » ;\ 1

1UK I'lIl'I. \>'»*

I n

-^k

MEDICAL CERTIFICATE OF DEATH

DA ri-, t>i- ni.ATii X

M-nth

h I

(V(.-i»r)

I in-:Ki;i'.V Ci-RTII-V, That I attciuk-.l .k-rL-ascd from

— — — i(p

■ . ■- Ttp

igo

to

tliat I la<t saw h ' alive on

,,1 that .li-atli occurrc.l, <.n thi- -late stati-.l above-, at
M MMu- CAISIC OI" Dl-ATII was as follows

ai

JXH. . . wCC .

N \M 1 < »1

I \ 1 n 1 k

lui- rtiri. \i}-'
ct: t \ I'll i:k

- • It. .,» I'mllltt V

M \ii»i;n namj:

»)1- MolIlHK

nil' Till' I, \iV.
Ml N;itiiii,H

I '^tati 111 riiuiltt yt

(uHTrA'l lt)N

Rf fdri! ni S,iii I

f-,n »

1/, <•///•

l',|-,-,T i>l M-, KN..U l,i;i".F'. \Mi 1. 1.1. 11. 1

I

H^^t<Jf

Q^ ^W.

Uw-A-

U A^Ok/ctL*.

1,1 RATinN )V;//v J/on/Zis /^<n'S Hours

roNTRim TON

I )r RAT ION >*"^''^

Signed) V^ V^ a-xia*

Mouth.

l\ivs

NED ) Ux^rAXlA, J.\^--UJ. Xl' A- - '^..

Hours
M.D.

V^' ( u,"

(A.iaris^) Uh^trrAjA^ vU^^MU.

" SPECIAL INFORMATION only f«r Ho^^Pital^. InstituHok. Transients,
or Recent Residents, and persons dying dv^Hy from home.

A
\ .

Former or

Usual Residence « - »- ^

When was disease rontracted,
If not at place of deatfi ?

HoH lonq at
Place of Death ?

Days

(Inff)' tn:mt

Kj^XM^-^JlSJ^ ^ tA

%^

A-Mit-H-^ ■

I'l \CJ' <»1' mRlAI-<»H Kl.MoVAl,

D,\Tl'ii!* HiHiAi i>r R1-'M<)\'AI,

lU

ct t

190

3,.:i..-,.<kkM-*-^^'^-

(AcMi.s^ WW

Qfiv

AAA-'

-^4

^-.^— 11—— — ^— ^■^'^"'^^''^*'^*™"**^"*'"^ 1 I K f t I EXACTLY PHYSICIANS should

state CAIJM- Wr Mir.« » aj^.h !n averv instance,

son, dyini away from home should be ft.ven .n every

m

w

11

4'lf

t ■«.

WRITE PLAINLY WITH UNFADING INK-THIS IS A PERMANENT RECORD

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

n,:,;th l^No ..-t^-f^gJtiiHM'* .

Da/c FiJ('(L L/el^cKKU\; 5"

rjo\

I{e(^isl('rc(l jYo.

Deputy Health Officer

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco

Ccvtificatc of E^eatb

"5^

m

PLACE OF DEATH: — County of Cu^^ ^

\^

City of ^'/0./>^ JJXCVrv c:^ v

No. l"^ '

V' r"l-occ%%-v,':r.o"/r.t o^"pi^^4=:";r,;!

1 Dist.;bet. LoJv'

and >JC

V„- i

TS*CALLED FOR UNDER "SPECIAL I N TO R M ATI O N ' ' \
TS NAME INSTEAD OF STREET AND NUMBER. J

n Un

FULL NAME^^^^^^^^^^^^ Ua^^a-U^CXv-v J^J^CAJ

PERSONAL AND STATISTICAL PARTICULARS

roi.ok \

. \ 1 i • il lUK I II

\i .V

•^INt.l.l* MAKHIl.l)

U I IH i\\ }:i> i»K ItlV«tKri;i)

\\! i!. ill -i.cial (1> -iL'Iiatioll*

as

(Day)

V.ar'

/>(/! *

^

NAMl Ml

I A I in: K

d.

\ [i

MEDICAL CERTIFICATE OF DEATH

DATK «»1 UHATH , A

U 1 »

1 Hf'RI'HV CIRTIFV. That I aUeii<UMl .hi ra^cl fmiii

that I last saw h -tA' alive nn "^ '*P

an.1 that <leath occurre.l, on the- .late statcl al...ve, at U-HS'
.L M. The CATSIv OF Di'ATIl %vas as foll.ms:

A

lUKTHIM.ACH
01 I AIHKK

stilt, ,,; i',.unt:\

M\n»i;N NAMl
01 MoTllKR

I'.lKTHlM.All",
oi- MoTHl-.H

iStatf i>r C.xuittA

A>•^;(/c^/ III Silil ! I •:>'.

o

A.'^^ '

n^^A lIvwCUUlOv

y

r.

yr,.,iHn

/),n

iiKST OF ^lvLK^■<|\\ i.i:i)«'.K am) i5i-i.n>

nnforinanl

\)\R.\'nos

]'tijrs Mont/n

CONTRIIUTORV \k^x)(k/^ts^

/^iivs 3b Hours

DTRATION

Yiixys Mouths

\\\ ^ t i Ci

(SIGNED) UJ.^Aj "J^^-^^^^ V^\^-v

Pars

yc

1

I()0

Hours
M.D.

'SPECIAI INFORMATION only for Hospitals. Institutions, Transients,
or Recent Residents, and persons dyiny away from home.

Former or
Usual Residence

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

HoH long at
Place of Death ?

... Days

1M,ACK <)1- lUKIAl, Ok KKMdVAI,

iJ.A'rK of Hrni.^i. fir KKM<)V.\I,

1 90 I

^»^*

ISDI'.KTAKHR

(

QLw'.

jl

' ■ TT TTf should be stated EXACTLY. PHYSICIANS should

^, B._F.ver. Uen, of ,nfor„.ation should he carefu... supplied AGE « ^^^^^.^^^^^ ^^^ ..g^^^,^, ,„,o,^,tlo„" for p^r-

state CAUSE OF DEATH In pin.n ^;•"^^; ^JT" ;',^";% nst.nce.
son. dyinft away from home should be fe.ven .n every msta

i

i

m

it

WRITE PLAINLY WITH UNFADING INK

11. ,;ni I ^'

/)n/r Fifrrf, kJ^z^jAm-K, 5

I !)()"{

THIS IS A PERMANENT RECORD

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

V-AwN^O X^OVKJ fc^

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco

Ccvtificatc of ©eatb

PLACE OF DEATH: — County ofO O

No. *^^ I: -^

^'i'.

,-~i , s c\ '^^ '" "i.

n

m

City of ^ ' ^^^ ^ ^^^

. *>^

u>

-V

, • ^ St.* ' Dist.;bet.^^^) - ' ' ^^^ .^

)

w

FULL NAME

) I

■ ) : \ I

Ui

PERSONAL AND STATISTICAL PARTICULARS

JX'T>XO.A

11

|» x 11 III I, IK III

A< .1-

I » /~T

.%!■

5 v.;

|);iv

1/ -iif/i-

\ ' ai

-^INt.l,!'*. MAKHir.n

wiiH »\\'i-i> t »K 1 > ;\ < >i' i 1 I)

' Write in «-<>i iai ilt -ir n..!ii.n i

HiR rm'i.Ai'i",

(State <»r Ciiuiitrv

\ wii; «»I

I A 11! I'.R

niR in f'LAiK
«>i- I- A riiKK

S!:i! I f i! I'l 1)1 Ilt I %

I .CLAXi

MEDICAL CERTIFICATE OF DEATH

DA I'K <»!• I'l-. \''"

/go

(Yvar)

^4

y

.

/^

^

Nt Mill's N xMi-; A) f\
<»I Mn fHHK y

lURTIIIM.ACK
OF Mi.llll-.R

f*^t;(!i . >i Simnlr\

<H vTi'A iion(1]\P (J

kr^Hinf 1,1 San liiiii'i^'-" '-Al)'." _

T.n^XM.>VKSTXTKl..'KR...NAKrAKTICIMARSARKTKrK T. > THE
in:sT()l MY KN«)\Vl,HI)«.h AM) Hhl.H.H

fin

vJ^YnXcO^

W'\,^<X''Vv>»

ixx-tixh.-

! ll!:ki:!'.V Ci:i<Tn-V, That I attcmU-.l (leceasc-a fnmi
• ; ,^H to . iD'^ "i 190 H

that r last saw h alive o„ iD'ct H up^^

a„,l that death «h eurrcd, on the dale stated above, at U H5
M. The CAISIC Ul* DliATII was as follows:

nr RAT ION >Va;-i

CONTRIIUTORV

Months /hns 1 1 //ours

nrRA'noN
(Signed)

iqO

}Wirs .)roN//is •A fhivs //ours

4 I '-^ \uu^s^ M.D.

A.hlress) Hbl U/CUvv mLuU. Uan^

(

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

Former or
Usual Residence

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

How long at
Place of Deatli ?

■ Days

ri,ACK Ol- IHKIAI. OK RKMOVAU

HATi: of HrKiAi, or RKMOVAI,

I90H

Q

„ ^ ,PF should be stated EXACTLY. PHYSICIANS •houid

^. B.— Every Iten, oi l„fo.«,atlo„ .hould be ca..fu..y supplied- ^«J^^ ;;;-„.,„,,. The -Special lnfor„,.tlon'' for p-r-
* * r-Aii«F nF DEATH In plain terms, that it may "c p

I 111

ill

III.:'

,111 I

WRITE PLAINLY WITH UNFADING INK-THIS IS A PERMANENT RECORD

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

04 m

\,<

t..t*^"S4-' lUSil' Cu

0

,VA^ Deputy Health Officer

Re^isfcrcd J\^(h

fi—^ •>

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco

Certificate of "E)eatb

( II. 5. 5t«nn^arO j

J?

(?!

No.

^ r^ ' - - r;tv of* ' CLz-^v Oxn 1

PLACE OF DEATH: — County of ,aT ^

( 4-

' ^ St.- ^ Dist.; bet. V,l,<XCYV-ft VA.. and ;^

V IF DtlktM OCCURRED IN A HOSPITAL OR INSTITUTION GIVE :, 0 ^ ^

)

FULL NAME OvAC^<XC 0 a^xct:

x; :

PERSONAL AND STATISTICAL PARTICULARS

! Ill lilKlll

K I I I . I I 1^

V'

• Day)

It 111

\^ .V.

■^IM , 1,1- M \ K R n'i»

\\ ; i>i iwi .1 1 I •!< I) ;\ I •!■' r Ki) "^

\\ ■ It. m - .. Ill' <1' -iL''i,il\iiii I

■t--

MEDICAL CERTIFICATE OF DEATH

DA ri", til' Df.ATH

iM.iitth)

il):iV>

I go

(Year^

V->

I HI'RM'.V CI;rTII'V, That I altcn.lol .k-tvasc.l from

M^+ t

to -^ ^

L

c.^

r^ ' 11

HiR I'uri. Si")-: Q

^Inti ')l « '• in lit ! % '

\M1 1(1
\ ill I R

»_t„^ .

lUK 111 !■!, \» l--

< ii r \ III i;r I

--' i' . \ 1 . 1, nt 1 \

MAIUKN N\MK A
ni MoTIIKH \ \^ ,

lUR ruri.Aci".

Ml- MolllI'H A

'Stat, or t'onilti \ I \

t O.^w^wtj

1,

J L' ''^-

Mirri' A rmNrVYx

•t

r?

r * I

,^_ yA„>'W

rt

■^1 » i c

Is'f I, hi! Ill Siiii I I <i

}f,,iif/i-

Ihn

Tln-^m,vKST^T.u..M^K.n.^..^•AKTU■^^AHs^KHTK^K m TUH

l!I>r <U %U. KN<>\\l,i:i)>n-. AND hl.Lll.t
.I,if..nnMnt J AXdULKA.^ ^^r

that T last saw h *■ ahve on ^ ^' ^^P

an.l that death <.0(urre<l, .... the date .tatcl above, al 1 "X^
LI M. Thf CAT SI'! Ol' ni:.\ Til was as follows:

I )r RATION >>'''^

t ONIKllUToRV ^

Mil)! I /is

/Via

J Ion I s

(SIGNED) 0.-3 JlDO/vus^'J

/hiv

Uct

T()0

f

A,l,lrrss)Tbl U O-Ua

I /ours

M.D.

X<l.*_<a-

"special information on!> for Hospitals. Institutions. Transients,
or Recent Residents, and persons dying away from liome.

Former or
Isual Residence

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

How long at
Place of Death ?

. Davs

I'l.ACH «)I" lUKIAI, OK KKM<.\ Al,

DXri'.i!' I'.iHiAr 01 K i;M« )\AI,

T 90

(\

%.

(A.1.1.L HH-tJi UJJLU^ u^--^^

— ^—^-^-^^^ i^— "^T"^"^"^"'"""^''"^"'^"''"^"^^"'^^^^ ... t t I FXACTLY PHYSICIANS should

N. B.— Bve.y i..m of i„Wn.,.lo„ .houl.1 he cnreiuHy -uppl^.d ^^F;;;;";,^,.',,:;; Vh: 'S.-^i;! InSor.na.t.n" for pT-

..».. CAUSE OF DEATH In -''""""••:;;„" „.r.,y in.«nc..
■on. .lyint uwoy »'»"' h""" «''""''' ^' *'""

1^

if

I

1

'«*

WRITE PLAINLY WITH UNFADING INK-THIS IS A PERMANENT RECORD

, , REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

Registered jYo.

, f,i i,i IX.. ■ - "^^-^^^ii V'^y '-' "

l;,,;,ri1 I ■ H<:! 'I li I ^" ■ *">■■> ^

Ddfc Filed, ^'.cl.ci>-t>\j 5

IDO'i

Of *\o

i ^ Deputy Health Officer

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco

Ccvtificate of IDcatb

PLACE OF DEATH: — County of

V

i(

,-->

- ' .. " ' Chy of^' O. ^■^ iKCXJ^X-^

No. ^

. o

n

St* H Dist.;betAfiKa.^->vO.>^ and ^JjAM^wt )

•^1*2 t..,= V...rn rOR UNDER "SPECAL , N FO R M AT.O N • \ A

F STREET AND NUMBER. • \J

'J I

(^■^

FULL NAME 0 ivt>v o

lav.

A

i I

V I

PERSONAL AND STATISTICAL PARTICULARS

Cm.c,

roI.OR \

.. V

^l

I ! \ 1 i; < ii hi K i 11

\< J'

M

1 1 1

/'.,'

-.|\i ,|.l- \1 \K 1< 111)

U 1 I >« i\\ 1 l 1 I >K ! I ;\t il-' !
Will' : 11 -I .< 1,1 1 11' ^U' !i.i; .

lUK rin'i. \t'K

•^t;it( . ' I 1 .11 ni I \

N \ M 1 ill
I A 111 l.H

\

MEDICAL CERTIFICATE OF DEATH

DATH OF 1)1:AT11 ' ^

i Moiitli I

(Day)

igo

(Yt-ar)

I III-Rir.V ri.KTII-V. That J alUiuU-.l .loH-asc.l from

to €ct X.

that I la^l-^asv li - alive-..,, ^' - ^ ^^ I

:n,a that .Kalh occurred, o„ the- datr ^tatc-.l abnvc. at \^. 10
Q M. The CAI'SI-: (»l' m;.\'ni was as follows:

n

J?

A \

<)| » A III IK

' "^tiitt 1 1! l"iiiint 1 ^

M MDKN NAM1-" 'N
(»l MC)Tin-:K

Hiu'riii'i.Aci:
<ii Mo'rin-K

I '-t.iti iir (.'<)\niti \

<«irr\TioN

^ r

' 1

\

0^4.0,0 ^' '

.ca

k_rx'

3

DIRATION y^-ors } Months \5 /hiys

C()NTRIl''l TOKV

I Jours

i ,

I )r RAT ION

(SIGNED) UJi»^

I/ours

M.D.

^00 y ^,

h'f-„/nf in S.nt /'■'"'■"'" ^ ' "'

M.^iith

I hi

SPECIAL INFORMATION only lor Hospitals, Institutions, Transients,
or Recent Residents, and persons dvinq away from liome.

Former or
Usual Residence

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

How lonq at
Place of Death?

Days

I'l.ACK OF nt-KI^T, OK KHM<'\ Al,

jiXll ..! lu K!Ai. ill KHMOVAI,

igon

tS. B.

^^^^.^^^^— ^^H»"i— ^''^'^*^^™'^^ . I FXACTLY PHYSICIANS should

state CAUJ»E Oh UtiA •"'"»' Ajven In every Instance,

son, dylnft away from home should be fe.ven

nTm^mm^~

RITE PLAINLY WITH UNFADING INK

l)iili' Fih'<i . CJ.cX^^»-^^ ^

lUO'A

THIS IS A PERMANENT RECORD

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

'^^ ^\^

Dep

1 1

f^m%^^

DEPARTMENT OF PUBLIC HEALTH-City and County of San Francisco

Ccvtificatc of IDeatb

I tl. 3. StanPatC )

: (X\ Si ^^

PLACE OF DEATH: — County of ^^x^ ^ ^^ty oi

No.

V\

loi

\ ' I ^><i'\v'.»'. St.; Dist;bet. ^^^ ^^^_ ..^^.e-At .NroRWAT.oN' \

I I

FULL NAME

kjjKl^. ■

i> \ 1 1 '

PERSONAL AND STATISTICAL PARTICULARS

I UXXa ■ -

UIHIII

/ ^

M..nlh

\ I ^ !

)V..'>

W n M iN\ 1 I > t tK DINc I'- ' 1 I)

\\l ill -11 -iH i.i ' (1< *iv 'I, It i' 111 '

A Y\ q

1 »:i\ 1

T ,:ii

V k.

■» C:!!

/';

MEDICAL CERTIFICATE OF DEATH

DATH t»I' Dl'.Al'H

M.mlli)

(Day)

{V«-ari

1 iii-RlM'.V Cl-.RTirV, That I attcn.lol deceased fnmi

to '-

u>o

llIR THI'I.AiK
• state or Cuiiiitrv

1 \ I II IK

1 ii 1 \ 111 FK

■ I nntt % I

M \ ' 1 UN N \ M K

• ii M(»iin:K

iMR riiiM.Ari..

Ill MoTHl-.K

0

(J

T9O A

that I last saw h .. ■ alive on ^9©

a„d that <leath oreurre.l. on the date .tate.l above, at
M. The CATSi: OV DI'.ATil was as follows:

nr RATION

(SIG

Ycors

Months

Pavx

r

.^

NED) vO H I VCXMiA,*^^

LJ.dt. 'h TooH (Addnss) SC^SD^^v-

//ours _
M.D.

( )t rr 1

■ATloN 9 I

hCf^iiifd in Siiii I I ..

ka r

)/, ;'• ,1

n

ni-ST<il- MV KN<>N\ i.l-rx.f-. AM) I-M-'ll

flufn-matit VD M iVoA^

■ c^prCIAL INFORMATION onh for Hospildls, Institutions, Transients,
or Rercnt Residents, and persons dying away from home.

II

Former or \ \ i
Usual Residence Uw^.

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

tiew lonq at
Place of Death ?

Days

)\ii: .)!' JUKI A I. 'ii K i;m< >\ Ai,

IM ACK ()!• HIKIAI, <>1< KJ:M<»\ AI,

\ilillr^>

^^^^„„^,„— — L^i— i ■— — FX4CTLY PHYSICIANS should

state CAUSt Of- UtAin h ^jv-n In every instnnce.

son. clylnft oway ?rom home should be fe.ven ^

I

I H-;<!th 1- V"

WRITE PLAINLY WITH UNFADING INK-THIS IS A PERMANENT RECORD

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

, 1^4^rv::^■ i!5^i'«--,

ino\

JiriSisfri'od Xo,

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco

Certificate of IDeatb

11. iT'. StauDarD )

PLACE OF DEATH: — County of

h

^0,

City of ^^<^^^^ '^"^

(> .

1 I

No. S ^-

4 C* . '^ DUt • bet. l^ ' ^"^ '

^ ' ^*** UlST., Dei. SPECIAL INFORVATION- \

)

FULL NAME

^t-4XA^-K>cA-OL K\)<x/:^

f

PERSONAL AND STATISTICAL PARTICULARS

( ■ ( 1 1 • I K

■,,,■' ^ ■

1 I i! !.; K 1 11

M-, lit hi

li.c.

■»■< ;i!

\t l".

-;\« .i.i".. MARK n'i>

U IlMiWKD OR 1)1\< 'H- 1 l>

W"! iti ill -.xi;!] (h -il-IKltl' 11 '

H lloJv^A^wd.

MEDICAL CERTIFICATE OF DEATH

(Yearl

Month) "'•'>'^

I IlI-Rl'liV eivRTII-V. That I aUeiuk-.l lUTca^cd from

f, ^5ct S

lip

! H

luuriiri, \v'K

\ \ M ) ' n
1 \ III Ik

niH riMM, MK

<»I ! \ 111 KK

-• ', • (-..nnti

(>i Mi)Tm:K ^ il

lUK IHIM, Mh",

It! Miiriii: K

(Stat.- ' 'V ( oiitUi y

M

f\

1 (1

^

1

I«;0 I

that I la'^l -^aw h .£A> alivr on ^- ' ^ ^^^

,„a that -Uath nrcurrc.l, nn the date stated above, at "V I U
' M The CA^SI^ oF DKATIl was as follows;

I )r RATI ON >'''<7r.s-

CONTRIIirTORV

Months

Pavs

J Jours

or RAT I ON

(SIG

♦

)'t'ars

.iroNf/fs

Pa vs

i.

Hours
M.D.

T()0

(A. hires.) H%^vjX£_

«5PECIAL INFORMATION onlv for Hospitals, Institutions. Transients,
or Rerent Residents, and persons dying away from tiome.

r\

- •\!,<iitln

fhn

lU-sT (>! MV KNoWM-.D'.H AM) lU.I.H.l

LkxxxjLju

IS'^jS obcr^^^xX-^^-^ -^^

Former or
Usual Residence

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

I'l \CK <)I- IMKIAI, OK Ri-MOVAI,

>^' ■ ;\ ,

tfoH lonq at
Plare of Deatli ?

Days

DXll ,,' I'.iHiM. Ill Kl%MOVAI,

T 90

\

:A(l<h(ss

— ^— — ^— — — — FVACTLY PHYSICIANS should

^

WRITE PLAINLY WITH UNFADING INK

1 . . * ' t 1 1

!)ff/r Filed , w'/cto'lMA. b

/.96>H

THIS IS A PERMANENT RECORD

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

0| or;

^'k.'.^<M

Deputy Health Officer

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco

Gcvtificatc of Bcatb

11. jT'. St an Da rD

^

^ \

^

" a.'YX) ^

No.

PLACE OF DEATH: — County of

'-T-C ^^ooj— ^1 ■. St.; '^ Dist.;betA;/anrv

' ' /.o^TH%cp...*v.:v..o. USUAL RES.DENC^^^^^

V ,r DCATH Occurred IN A HOSPITAL OR .NsrnruTioN GIVE

i ^.O.-^ vo^ ^r City of CJ^a^ J^^^

and J^UXnoyK-

1

Kuub^

eNCE a,V. .ACTS CA.LCC, -B_ UNOER : -JC - «. J -OR M AT.^O . ■■ )

FULL NAME

)AX

PERSONAL AND STATISTICAL PARTICULARS

( i >].' 'k

A

\

a

1 I •! nik 111

fXnX

If.iv

AHH

, )■:

U.

1/

/'

--IN' , l.K %! \R m 1 !•

W'l it- 1!) -I, i.il .!■ -■:•

III !'l. \i'K

\r\ „

X v'v^^^

MEDICAL CERTIFICATE OF DEATH

DAfK nl- I)i:\Tll I p.

I'Month^

(Vrar)

I Day)

I II1:r1.1JV Cl.KTIlV. Th..t nilten.lca ikTcasea fnmi

tlmt I last <awh^..- alive nn ^^ "^ ^^P "^

a„a that drath occurred, nu the .late stated abnvc. at

ID

CL ^T- 'II"-' <^'-^^^''' **'' i>l^\'l'l^ ^vas as follows:

\ \ M 1 Ml

I Vi II IR

lUK in IM, \CK
ni 1 \. ! H 1-;H

MAIDl.N NAMl
nh MdTIIHK

mK'rmM.Aci',
OK n!uthi:k

'Htati- or Ciiunlt \

(\

<X.C<TU'

\ ^

ns

\

J^^<XMJU ^^

i ri'A'noN _9 j\

kxAAajx

\ ', ,;

1/ ,','/!

hi:-.'!' n|- MV KNuWl.l-.IK.l-. \^" H1.1<n>
(Iiitonnant \J3 ■ KKJX. - ^

DIRATION 3s )V(/;v
CONTRIl'd rokV

Mouths

Ihi\

'V

IIOHIS

DIRATION
(SIGNED )

Yrars Mouths

Pav

Hours
M.D.

Ik)^ L Tc)oM (Address) bo^UX-<X>UM - ^

SPECIAL INFORMATION only for Hospitals, Instiludons, Transients,
or Recent Residents, and persons dyinq away from fiome.

Former or
Usual Residence

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

How lonq at
Ware of Deatli ?

. Days

|i N "i

T90H

(,

N. B.

^ I FXACTLY PHYSICIANS Bhoulcl

State CAUSE OH Vi\.^ 1 n n h ^Uen in every instance,

sons dying away from home should be given .n e e y

i

I

I

I ;.:ih I N.

WRITE PLAINLY WITH UNFADING INK-THIS IS A PERMANENT RECORD

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

t- -w i4,> I'lS:!' C'l

Be^isfered jVo.

01 *V\

\ Deputy Health Officer

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco

Certificate of Beatb

I I ^

PLACE OF DEATH: — County of 1 iVoxcUcc.x^o

City of

3 C 1

No. OLcxXl

St.; -

Dist.;bet. "~

and

)

JU ^^ OVL.,V^^^CX. „ro.,^VMrrr,vr rACTS*CALLED rOR UNDER •SPECAL .NTORMATION' \

/ ,r DCATH OCCURS AV^.V TROM USUAL « ^ f ' J^^.^JV^^^^' "o", v^",;! NAME .NSTEAD OF STREET Ar.D NUMBER, )

\ IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ^

FULL NAME ^v"ootv v.L

PERSONAL AND STATISTICAL PARTICULARS

\

, K ill

14H

M,,iithi

iiO ,

M \ K i< I J ; I »

W I 111 i\\ I i ' < Mi I>I\'< >K 1 J- l>

\\ ' in in -' I sal .li -if n,il ;> iii i

MEDICAL CERTIFICATE OF DEATH

DA 11-*. *>1- 1)1, A in

\

u

(Yt-ai )

r Month) 'l>-''y'

I lll'RlU'.V C1;kT11-V, TliMt I atU-iukMl <U'iH'ase(l frmn

r.iH rni'i, xi"i'

sfatt .It I ^ .unt 1

\ \ \n til

1 \ I II l.K

I'.iK 1 n I'l, \* K
1 ii » \ riii-.K

■^1 iti III rimnti\

, 0

1

i

^

MMlil-N NAM!'

«i| M.trilKk H

HIK rillM.Ai i:
111 MiUlll'.K
'^i:ii. Ill I'liiinlryt

^,

clA\j ^ ^ '^

r,-.,'»

yr,n,ili^

/',/!

tK iTI'A ll«)N

AV^ /<//-</ ill Sail I'l.ni. ,

Ill-.SI-or MV KNMW l.1.1>''l'. ^^1' I'l I'l'

( Infiit mini

up to - i<)0

that I last saw h " alive- (in ^'P

aii.l that <Uatlt nccurre.l, on llu- .late stat^.l al.nvi-, at
M. The CAT SI- Ol- Dl'iATIi wa^ as follows:

nr RAT ION Vans

CON ikiiH rokv

■Von f /is

Jhiy

Hours

DlRAriON

i^

Vfars

M, III I /is

J\„»w N W.J

/^avs

(SIGNED) ^ --. - , ^

iD^ ^ I.,oH ^AM.lr..HS^ IIKAXX>

flours

M.D.

y

"special INFORMATION only lor Hospitals. Institutions, Transients,
or Recent Residents, and persons dyin) dway trom home.

Forfflff ar
Usual Residence

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

HoH lonq at
Place of Death?

Days

I'l^ACK i)l- lUHFAI, nu KI-.MoVAI.

!)AT1". I)! r.i Hi.xi <ii KI'.MOV.M,

T9O

y,ct

tn2 frvu. \A.-o-\t.<i' « ^

^—^— ——— —■#■—'— ^"""^"''^''^"^'''"'^'''''^^ , , L t t I EXACTLY PHYSICIANS should

""•/.Mn^Lny "'™ hi. Should He ..v.n I y .n...nce.

I

1

w

RITE PLAINLY WITH UNFADING INK

THIS IS A PERMANENT RECORD

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

/),//(' /'V/fv/. Jct<AM^ b

LAv

IfJO'i

Bc<^istcred Xo.

Of •^^

V

-I •f-N nffi«,

No.

DEPARTMENT 0^ PUBLIC HEALTH=City and County of San Francisco

Certificate of Beatb

< XX. S. 5tan^ar^ )
PLACE OF DEATH:-Coun,y of^O. .x -^ - > ■ ^cc City ofOa^ 0/^^ - -.
• "> ■ 1> s K - i , , - - , St.; 1 Dist.; bet. O-O.^X^UP'^^ and ' OJaXA-A.

(57^

)

FULL NAME

a

i .. I

PERSONAL AND STATISTICAL PARTICULARS

i

i

M n! h I
0

•. arl

U ! It- in -. I. ial il.^iufiiatitiii)

HIK S'lllM. \i'l%

^' 1 Hint t \

\ \MI* OF

I A riij.K

HIK lliri. AiK
oi 1 \ 11! I'.K
-itatt I il I'lPlUlt I \

M \I1»1'N NAM1-.
<»1 MoTIIJ'.K

i;iK 1 iii'i. \ri-:
^^t.iti .11 ('uutstry

nm I'A riUN

MEDICAL CERTIFICATE OF DEATH

DA IK ' ►! Dl'.A lil

3

Dav)

(Vtai >

iD.ct

I lll'.RIU'.V Ci:kTll-V. Tiial 1 attciidcl acH-cascl fmiii

that 1 last saw h .L.-.,xa\\\v on w.. Cw ^ I90 \

aii.l tliat <Uatli ..rrurrcl, uii the -latr -tati-.l alM.ve, at
.M. TIk- CMS!-: Ol- DI'-ATIf was as follows:

Xx^'

nrvwt<uvXu I

rVYX, ^MJ^C^w^^>^^

)Vin

M.iitli-

Ih.

TMK XHUVKS. XTKlX-KKsnXAI rXKTj.rj.AKsAK.: TKt K H. THH

lu-sr or Mv KNo\vi.i;n«.K A\n Mj-.i.n.f

(111 I'' p- ;nant

r\(i(iit-«»«

it

Ur RAT ION Viiifs

CONTRIlU'TokV

Months

/hn

I lout

nrRATioN

^

Years

M out lis

Ihiv

( SIGNED ) J . ^. ^ O-dJr^rv^

J Jours
M.D.

ID.^t

T<)n

f Address) aos-bo^g/Yxtv^JUL^

SPECIAL INFORMATION only for Hospitals, Institutions, TranslenH,
or Recent Residents, and persons dyinq away Iron home.

Former or
Usual Residence

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

HoH lonq at
Place ol Death ?

Days

rj.ACK Ol- lUKIAI, OK RKMo'^ ^

DA ij: '.* nt HI

M ..I ki:movai.
• igo

-_————— , ^ ,, , 77p .sould be stated EXACTLY. PHYSICIANS should

.. -.---'>-'- totzr^n^:::^'' "^irr. •::'::^:t. J^U -..w... t.. ■•«,.«,., -..o..>...n-. ^ p...

state CAUSt ur ucrti" w ^Uen in every instance,

sons dy1n4 ov.oy from home should be g.ven .n every

3

I

J

(

^,:th FN

WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD

REFER TO BACK OP CERTIFICATE FOR INSTRUCTIONS

JJ

0

10()\

4.^, J^^l

Bp'> isle rod *jYo.

Of *>Q

' ccw

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco

Gcvtificate of IDeatb

i

(^

No. ^uti.y "X Urury\ti.i .' V 5 ■v,', v. l- r (

^

\

(^

FULL NAME axxaa^\x v<u. UlV

c'wO..

PERSONAL AND STATISTICAL PARTICULARS

ri»l,«iK

vVio

U

}"

H

\« ,i-;

1/.

/',/

WIlHi -K ! i;\»»Ki 1*. l>

(Writ. .ii I. -ii^iuuioii)

^!;ilt . it 1 • iillit I %

w/V^.

■\ '

I \ I 111 K

lUHl 11 I'i.ACK

<u I \ihi:k

^1 '. ■ ('iilltltlX

MMDKN NXMK
<i| Mt»Tm%R

iuKiiirL.\ri.:

<»l MoIHI'-R
iSlal< •>! r<»untt \

(0

Kj<r\X^-^^^ L'^CC^,'^

( 0

nil ri'Al li»N (T)

I

ll

MEDICAL CERTIFICATE OF DEATH

DATK «»!• 1)1;A I'll (^

(Month) "»^'>-' '^'^''"^

I I1I:R1';P.V CI;RTII-V, Thai I atU'n.UMl .U-ic-asctl from

i;? ' .. 190'. t.) V/^ ^ lyoH

that I last saw h - . alivc.n ^^ 2, I90 H

aii.l that .Ualh ..rcurre.l. mi tlu- dali- stated above, at
J M. Tlu- CVMSK Ol- DKATH wa^ as follows:

DlkATION Vinrs

coNTRiin rokv

(SIGNED) J '^V

Mouths

Davs

Hours

Motiths

/><jrc

H Tc,n

H (Address) uXuV^
ORMATION only f*"^ Hispitals,

1 1 oil Is

M.D.

0\o

kf.ntff i>' '^.Z'' ^

,^ 3H

lA^i/'/;

lh!S

T,n-xHnvKsTvrK.MM.K.<.NAi.rxKT.rr|,u<.xKKrK.K m thh

liFSTol MV KN«'\VI.i:n'.F \M» MI-.lJl.I

(liifoMiiaiit VJ . V ,

,T»

n

fA.l.li.'ss VaX* M

Cv-an

SPECIAL INFORMAT

or Recent Residents, anl persons dying av^aj- from home

Former or ^qXI « a
Usual Residence 0 aJK. '>-'>rs,i^

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

Institutions, Transients,

How lonq at
Place of Death ?

Days

()\ I K Ml in iM XI ..r KKMOVAU

IM.ACK OI* HtKIAI, «»H KF,M'>VA1,

rSI>l-RTAKHK UXM^ ^ V^' '^

I90H

? 1

■■^^■■■i^B^—"^^"^"^"'^'^""*^^"''^"'"^^^^""""""^^"^""""""^^"^^^^^^ I, I I H t ted BXACTLY PHYSICIANS should
:r.''H"„?.Z from h„,no ,1.o„.d be f.v.n in .-,., in.t.nce.

r

I

J
I

R

i m

WRITE PLAINLY WITH UNFADING INK

,1 ..1, i- v., ; ; ^fi"^**^^;; HN I* I'^-

Zz^/^' Fi/n/ , L.'C^>W-^^ ^

If^O'i

THIS IS A PERMANENT RECORD

REFER TO BACK OF CERTIFICATE FOR tNSTRUCTIQNS

Of «^n

Me (filtered ^\o. <^ ' '

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

Certificate of Beatb

PLACE OF DEATH:

'^ - J /wCu-rV/CL4C0 City of 0/CX/>V 0 \.<Xtvx^^AXU)

-f ^

County of Cl/n^ J /V0.^V/C^C^ City

No.

oa

(

iV i st« "^ Dist.;betM^^^iuV>v<vm; and ^O^OWYVO; )

FULL NAME

PERSONAL AND STATISTICAL PARTICULARS

m

1 111 K 111

0

VVJU

10

/ boJ

\t .I-

b^

?. ,,..

as

/',!

W I ; II A 111 » >K I »'\< »K(' K l>

\S ; ,:. .u ' .1 ;;il <\- -• vnatmil •

X^

vUxl

MEDICAL CERTIFICATE OF DEATH

DATK <'i' i>i:ath

1^

5

Dav)

(Year)

>. I in;Ki:i>V CI^RTII'V, riiat I atten-Uil .Icccased from

that I last saw h ^^^^ alive on ^ '^^ ^ '9° ^

an,l that death nourrcl, nu the date statr.1 above, at bAu

' M. The CAT SI* Ol* DI'ATII w.i-. a^ follows:

lUK riiri.Ai'j-:

Stntt < n t ■' .lint I \

1 \ III IK

lUK I'll I'l, \i }■;

«M I \ 1 II IK

'-^t itl I 1', I'l lllllt ! %

M \ii>i:n' n ami:

i»l .MmTIII-.K

HIK rniM.Ai'!'.
<t| MolllKK
I stall nr i'«)uutr>

1)1

IC^L^acK^^CLt

Lkkjb

\\j

«KCtl'AlH>N ( k! 4_ I

Rfiilfif ill

V,;,, //,,'/,"/•"• » \ ' "^ ^

lU-.ST ni- MY KN«>N\ 1-1 l><>li AND Ml.l.M t

(Infiit manl

e.

Adtln—*;

HOI

oJ ^^t

U J^^Xi sJ

Cj-jL'V-s-a^Aa.

DIRATION

}f.>>iihs

ill K A 1 I* '•> ' ' t'at s
CONTKMUTOKV ^^J^.^|^

nr RATION ^ )V</rv ^ -■'^^'^^^

&, U.,

/>^rv.v

//ours

nav

/loii

rs

(SIGNED) yxrrvxM

M.D.

lUd, ^

t

T()0

(

Address) \l% ^hjQ^^ U. .' .,

SPECIAL INFORMATION only for Hospitals, institutions, Transients,
or Recent Residents, dnd persons dying away from liome.

Former or
Usual Residence

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

HoM ionq at
Place of Oeatli ?

Days

IM.ACH OJ" lU KIAL, t»K K1;M(>\ M,

'Hi

r N" I > 1

KlAKl.K VV. vO

DXri.ii! I'l 1 IM i>i Kl-.MoVAl,

T90

A,

A^ Yx. '• V

.,,,,„. s %\'^ 0' T^rUvAJtUrlt,

,. , 77, ,houl<l bo .lnM.1 RXACTLY. PHYSICIANS .hould
N. B.— Rveo ...n, o* ,„,,...n„,lon .h„u..l be c...u(,.M, -UPP -I. A^f. . ^,__^,,^.,^, ^,. ..g^.,,., ,„,.„„„..I„n" lor pT-

..-.c CAlISi: or DIATH In p ...n ""••• ''"•'• "'^t .„.«„«.

""„';-.;:,»„««; *-- h„,„e »H„„... be »«v.n > .n.t.nc.

I

f

4

I

t it

WRITE PLAINLY WITH UNFADING INK

:i n

'/otxrl>-U

^. b

7-9(^A

THIS IS A PERMANENT RECORD

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

p< to

Bco'i.s/crrd Xo.

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco

Ccvtificate of !Dcatb

( XX. 5. 5tan^al•^ )

PLACE OF DEATH:-County of^^^ iMx^x^v^Gty of Oxv^v J/v^x^c.^^

0.

T«^.4lUX\.A.-rxi Ut '

, ^^ ^ ^4 N V ^ t o \ St.: Dist.;bet. ^ ' and

*^ TX>v JV. V, , orcinrNCE GIWE FACTS CALLED FOR UNDER '■SPECIAL INFORMATION' \

( '^ ^"o7AT°H^OCCU%*Rro\;"rHo"s".rT'lt 0^'?^?f.?J;^0^'^C^7Ts NAME .NSTEAO OF STREET AND NUMBER. )

f)

FULL NAME W^

/cxxva^

-IX

PERSONAL AND STATISTICAL PARTICULARS

.1 l:,K III

V

A.'r

\t.l-;

-r,i ,1.1 \t AK l< 11" I >
Wiiti in 'iijcial lii -n'li.it i' n

Ii.\

.1/. >i'/i

i I ,1!

fhlV

MEDICAL CERTIFICATE OF DEATH

DA ij', «•! in.Ai'n

' MnlUll'

(Day)

fYciiri

I lli:Ui:r.V CI;RTII'V, TUm l .ittin.lf.l deceasetl frntii

\ ■ ^ ..^ to vJ /CA/ 5 i(p H

up

that I last ^a\v hA<'»N alive «>n

190

W .

lUK riiri. \c]-.

V • , • I '. iimt I \

I A III I.R

H I R I 11 I ' I , \ » * J-:
Ml I \ III \ H

-•\ ,' ' ' Ti 111 lit 1

%! MDl N NAMl-:
itl MmI'D) H

luk riii'i.Aii',

tMii. .1 t'onntivl

dtcKvkkcrVrN

^1 .< p '^

\v.

1)1 ri PA IION Jl

n \- ,, I 1/../////

/>,;i ^

Tin-: \H..vis sr\rKD i-kh^.-nxi, i')'^ ':|:;',!:\'^
in:-.r<»i ^^v knuw 1 i-ix.h and hi, 1,11. i-

i 1 n |. li m tut

<s \Ki, I Ki K r<> THJ-:

au.l that <U'at1i nccurred, <.n the .late state.l above, at -
J M. The CAISK or Di-yril WHS as follows:

vj

K.

LxX^.C'^^"v^^tr>"v^xx;

a i^crrvvou^J^

nr RAT I ON* r^<7/^

coNTkiiurokN'

.)/tU////S

Ihns

J Jolt I

Vctirs

A

1)1 RAT ION
(SIGNED )

0/ct L ,00 H 0

A7l'S-

Hours
M.D.

SPECIAL INFORMATION ««!> •"•■ Hospildls, Institutions, Transients,
or Recent Residents, and persons dyinq awa) from home,
i-„«»»r nr HoH lonq at

When was disease contracted,

If not at place of death ? ^ .^_^

DVTi%"' I!' HIM -I ki;m«)Vai,

CMiixA

I

rNDKKTAKKK U^>^^i^^ OQ^VCUaIo XA

190 H

'— — — — — ■"""""""""■""■"""TT r^ AOF HhouUI bo -tnte.l RXACTLY. PHYSICIANS should

N. B._,.vcr. Itcn, of I„for,„..t1on .houl.l he cn.a^ully «upp .e • A .r h ^^^^^.^,^^^ .^^^ ..^^^^^,^, ,„for„,«tlon" for pT-
. #„ r\ll«r OF DtATM in plum terms, that it vnny ne prnp»^ ^
:rn; ..>CoZ .rL hn,„. ...,.ul.. b. ftiv.n In .v,r, .-..-nc..

I

m

1

i

WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD

- c^^'^i.iKS.irn REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

ii i N'

I)Hlr riled, i^,ct<rt^^ b I'^O'i

l^cru./^ ioLA>u Deputy Health Officer

DEPARTMENrOF PUBLIC HEALTH-=City and County of San Francisco

Certificate of "Death

( XX. 5. 5tanC>avD )

PLACE OF DEATH: — County of

\1jUjJG-0j

City of

H pi

CkK.^

No. -

St.;

Dist.; bet.

and

M USUAL RESIDENCE GIVE FACTS CALLED FOR UNDER "SPECIAL INFORMATION" \
M USUAL HtaiUt..^«-t K. .....r NSTEAD OF STREET AND NUMBER. /

/ IF DEATH OCCURS AWAY FROM USUAL H t a 1 U c --• «- "^ ^ • - •- ^"--^ « A M V .
( fr DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME .

FULL NAME

-;4-

'■i

V.

!> A 1 i: I 'I luk ill

PERSONAL AND STATISTICAL PARTICULARS

i(iI,<»K

>1

yvyy\yC-

,170

M.ti'h

A< , 1-,

■-1M.1 i; MAKkH !»
W I 1>' >U i;i> I »k I >IV< tK*. K I)
Will! in -1,1 I, i' !■ -iKHttli'JJJJ

1/

\ ( ;il '

Ih'.V

St, ill (ii ( 'i 111 nt ! \

N \\!1 III

lA 1 n i;k

lUk 111 ri, \^ v.

( il ! \ 111 IK

■^1 l! I 1 i! I'l lU till \

M Mill- N N WIJ;
(i| Morill'K

liik riiiM, X( 1-;
til MMTm'K

' Stati Ml Cnuiti ^

I HA I 1' xrioN

A

0 '?

A

a

\ V

^^s^

rll I <■

\J.,n!tn

/',,

THH Mi.,VKSTXTH!.I'KK^..NAI.PAKlM-I,AKSAKKTKl i: To TIIK
jil>T ()!• MV KN<>\Vl,i;i»<.K A\I> lU.I.II-.f

I I nfi )! maiit

(^vJLm y^JLJ^r\\jr\yoJ<> h^JJ^ > '

r

I \(lilr«'^"^

MEDICAL CERTIFICATE OF DEATH

DA 11', ol- DllAllI

A

\)r^

U

(Vf.u

fMonlh) ">;»y^

] 1II;K I'I'.V CI'iRTII'V, That I atteiukMl <lci cased fn>iu

— — — — ~- 1()0

~ \ip

to

that I last saw h alive on ^9°
aii.l that .Uath ocrurrcl, uii Ihe .late <tate<l above, at
^M. The CAISI-; Ol" 1)1 A I'll was as follows:

I )r RAT I ON YiUirs

CoNTRllU'TORV

Months

Pars

/Jours

DIRATION

}\'(jrs

Jfoh'/Zis

Pars

(SIGNED) oU'CL/\>V<A-

U/CXj '^ l()0 f A.Mress)

Hours
M.D.

SPECIAL INFORMATION onb tor Hospital, Institutions, fransients,
or Reient Residents, dnd persons dying away from liome.

Former or
Usual Residence

When was disease rontracted,
If not at place of dcatli ?

How lonq at
Place of Death ?

Days

J'l.ACK ol- HTKIAI. OH Kl.MoVAI,

1- UTKIAl

SO. m ^

i»\ri:.>t Ht Ki.Ai, o! Ki':Mn\-Ai,

ifA

U.t,t. b

/A) „ .-^

TQO

■n

.. . -,,f, ^u„,.i.l he stilted FiXACTLY. PHYSICIANS Bhould
N. B._r;vcr.v Item of Information •houl.l h. .a.e^u.l, .upphed ;;;f;^«^X,.jj, j. ^hc- ••Special Infor.nHtlon" for p.r-
atate CAUSE OF DEATH in plnln terms, that it may l»e pmperiy
*nn. dying away from hom« nhould be feiven \^^ «v«ry Instance.

• n.nlth i

WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

fir *9H,^

-- ii.S. r Cn

I !)/)'<

Bcilistcrc'l ^Vo.

Pi 10

i^rvxv^ dOAHoji Deputy Health Officer

DEPARTMENT t)F PUBLIC HEALTH=City and County of San Francisco

Certificate of IDeatb

( tl. 5. »3tan^ai^ )

PLACE OF DEATH: — County

of LLL Ow vwi-xi^

City of VL <X_/

Y\X^

St.;

Dist.; bet.

and

/ ,r DEATH OCCURS aWaV FROM USUAL R E S I D E N C E G . V E r ACT
( ,r DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE I

TS CALLED fOR UNDER "SPECIAL INFORMATION ' \
Tb NAME INSTEAD OF STREET AND NUMBER. /

FULL NAME

<

i

rl/'YXA.^./YVil CNA^ U\-a: '::

PERSONAL AND STATISTICAL PARTICULARS

1) \ ij; 111 lUK III

^.xx^

M. mil »

1 ) I \

\«.j-;

-.(

\c~

1/,,;

» I ai

r>,

sl\( . I.J' M \K l< IIP
WliM >\\ I- 1» < •'• I > ^ . 'I-' ! i»
Writ- ;n - '

liiR riii'i. \i*i-:

st;»?' ■ ■! < I 111 tit t \

Owh.^OL

A

I

NAM I ni
FATH Ik

lUk rHI'I, AtH
Ol- l-ATIIllK

'St;it»- »>r i'liuilll V

M AIIH-.X N \ Mi-
ni Mi>rm.K

lUK l'lll'I,Ai'l%
ni Mnrm-.K
(Statt m t'lniiiti %

\

• trri'AllON

"n s .

) , ./

]/,iif//'

Ih!

Tin- MM,VK^rxTKnPKK-^.)NM,i-AKnrri XK. xkv.tkvv. >•> vui:

HHST nl MV KNOWI.KIXVK ANI> I.I.IJJ-I ^

(Infotjiiaiit M I WVAwA-,AJ v. . -J ^. v-s»

^AED!CAL CERTIFICATE OF DEATH

I (JO
I Day) {Ytai>

nAl'l-: <'l I>KA I'll /' \

(MontlO
I HRRiUJN' Cl-.K'ril'V, Tliat ! attfn<U-<l (leccastMl frotii

_ u/) to —^— up

that I last saw h alivu on

190

an

,1 that <U'ath occiirre^l, on tin- .lati- .tatcl ahnvr, at
— M. The CM Sli Ol' Dl". ATI! was as follows

or RAT ION V'^i's

C'oNTRlHrTORV

MoHihs

Days

J lours

J/,>>!//lS

(Signed). Oa.\axxa^' > - . ' ' ■ -

DT RATION >'',//5

Hours
M.D.

!f)0 \ (

SPECIAL INFORMATION »nly lor Hospitals, Institutions. Transients,
or Recent Residents, and persons dvinf] <twav from home.

Former or \ 1 ^ . ^
Usual ResidenccVJXXA-A)

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

(1J>L,

i^ How lonq at
KSXXj PIdre of Death ?

Days

IM.ACH Ol- lUKIAI, OK KI-.M'tXXI

rNi)i':RTAKi:K >^ ■ -

I) \ 11

iU.cl

M .,! m: MOV A I,

' ( T 90 ' I

0 a

^4

-o

IN. B.-

.. , Thf Khoiild be stated EXACTLY. PHYSICIANS should
.Kver.v iten, of in?.>r.n«.1«n should be cn.eH.lly -PP'-^' ^^^^.^^ ..assifled. The "Special Information" for pT-
«tate CAUSE OF DhATH in pinin terms, that it mH> be proper y
^i". d>fng away from home should be given in every instance.

-T^f

I

•hi

t
I

w

RITE PLAINLY WITH UNFADING INK

11, ,:t)i r V.

-t) H&r *.■->

I)alc Filetl ,

y^Lhj b

IfJO'i

THIS IS A PERMANENT RECORD

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

^^

- jjuty Health Off^

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco

Ccvtificatc of Bcatb

11. 5. jTitanDcnrD )

PLACE OF DEATH: — County ofCJ/a/-^^

J?

(^

X/QA^.

'. City ofCJ/CC'^^ o/N

ex.

St.; 5

and

^

RT 'I Un 4 ' ' ■ > -^ St.: ^ Dist.;bet. u^''0

No. C<b \ 1 -^-. ' ,,<=,. 1.1 RFsTdENCEG.VC FACTS CALLED rOR UNDER SPECIAL .NFORMATIOM- \

( " ^.^rE:Tt,"occ^^;To^^^Ho"s^■TlL oB'fNSn^JV'o'N^o.vE .rs name .nsteao o. street a.o .umber. ;

FULL NAME

r;J<xxL4_x

PERSONAL AND STATISTICAL PARTICULARS

!i A II. < 'I lUk I'll A ft

I

iiiilh

4

\ 1 . 1-;

•-IN".!,!'', MAKKIi: 1>
Utiti ill -..riMl (1. sJ|rnatio!i)

I'.iU THl'I, \>'I"'.

lSl;iti ii! t Dimtl N

m.iv

■»»;tr I

fiti 1 A

\

\^

I go \

(Year)

MEDICAL CERTIFICATE O^DEATH

DATi-. «»i i)i:\in I A

• Month) "='>'*

I invKl'iHV CI'RTH'V, That ! atlcn.k-.l (l..i cased from
lL)ct. -i lyo . to G^ 5 TcpH

in f '

that I last saw h . ■ alive on ^ ^^ ^' ^^P'

an.l that .Uath n.Hurrc-.l, nu the .late state.l above, at i^^
I "^, . M. The CAISI-: Ol" DI'ATH was as follows:

,A^

V

NXMI iM
FA 111 l.K

I'.ik riii'i, \» I-:
• »i 1 A III i:k

' SI. ill' ( i! I'l iimt r\-

M \1 !ii:X NAMl'.
(>l Ml ('I'll !•: K

lURI'UlM.AOK
Ml M«)!H1-:R
' -tatt lit I'dUllt 1 %

m

\ '-

.o [

U

tn rri'A riDN

!V,M

M.,iitli'

/>ii )

T,,HA,.,VKSTXTKn)-KKSnNAl.rU<TirrLAK^AKKTKrKTn THH
HKST <)1- .MV KN<»\\ 1,1 l)(.h AND l.l-.I.H'.i

In

I)lk,\'l'l«>N )V'/''\^

CDNTKnuroRV

Moulin 'i /-''/i A Hours

DTK. XT ION
(SIGNED)

Afoulhs

)'rtirs

/hiv

Hours
M.D.

Ki"

(A.hlress) X "b ^ b Vjj /VUyO>/Y\t UA

"iiRt

SPECIAL INFORMATION ^ »or Hospitals, liMUfulions, Transients,
or Recent Residents, and persons dyinq away from home.

Former or
Usual Residence

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

How ionq at
Place of Death?

Days

I'l.AOi: ol- lUKIAI, nK KI:M«»VAI<

n\r!%i)i liiHiAi. or K 1-'.M« »V.M,

190

w

' ~ ~. Tr.F. should be stated F.XACTLY. PHYSICIANS should

„ of informBtion should be cnre^uUy supplied. ^;»' '^^^ , .jj^j. The "Special InVormation" for pT-
SE OF DHATH In plain tei-ms, that it may be properly wiassm

N. B. Every Item

WRITE PLAINLY WITH UNFADING INK

1!, A-\h \ V,

^ l-i.> luSci' c

Dfffc Fih'il , Uct<r\>-iV b

100^

THIS IS A PERMANENT RECORD

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

01 Id

Br<^ isle rod jYo. -^^ » f-

1

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco

Certificate of IDeatb

( tl. S. StnnDarD

[\

PLACE OF DEATH: — County of

'X

4

%

o

City of 'J<xjy^ J>^'

No*

t -—-, \

\

^

Jo^yxKXO^^ ^.^ '

St.;

Dist.; bet.

and

FROM USUAL RESIDENCE GIVE fact

J/,\r DEATH OCCURS AWAY FROM U 3 W « I. nti»iww.-w.
\.\ J^d^ItVoccurrcd in a hospital or institut.on give

TS CALtED rOR UNDER SPECIAL INFORMATION ■ "N
TS NAME INSTEAD OF STREET AND NUMBER. /

FULL NAME

\JLXL

■^

PERSONAL AND STATISTICAL PARTICULARS

ftlo '

u

\w I

I

I.A : \. « •! lUK 111

\ t . »•:

1 I' \1 AK K 11- 1»

\s ijM iUKI» OK i»r ■
Wt iti i !! -iHial i\f —

lUR I'lll'l, \s'l'.

vt ,'. 1,1 ('.iHiitr^

I Alii IK

I'.IK I'll !!. \rl
I ti 1 \ I'll J'K

stall 111 I'liiintrv

MMIU.N NAMl.
<»i MolHKK

ink IHIM.ACE

»»i- M»»iin:R

(Slatr or l"< i\int ! ^

M..m^r

).,n

Dav

\'\

Star)

/','

MEDICAL CERTIFICATE OF DEATH

DAiH «»i ni'Ain

*^A_AJ

Month)

iDav)

I (^0

(Yrar)

I lIl':ki;P.V Cl'RTII'V. Thai I aUciukil «k'(xasL-a from
: , , + :^ .yoM tn ^t^t H U)0H

that I last saw h alive nii - ^ ' l^P ■

anil that .Kath .Hrurn-a, ..„ the .late stale.! al..)ve. at ^
Q^ M. The CM SI-. Oi" DI'ATII was as follows:

Ko. .

.K V ri'ATluN

h'f'litfil in San /'i u n, i^rn

)'ll! I

\r.intln

/hi

TllK.m,VKSTVrKlMM^KS.»NXl.I'AHTI;M;KAKSAKKTKri-;T.. TllK

iu;>T <»i' MY KN.»\vi,i:i)«.»-. AM> iti-.i.n-.i-

(liifoTinant

Ad.lr,.s 3l U).^^.^^.^.

DTK A riON

}'<(irs

Mon/Zis

/><n.v 13* Hours

Dr RAT ION

0

Years

Mouths

Pars-

Hours

-t, '^''

(SIGNED

SPECIAL INFORMATION only for Hospitals, Institutions, Transients,
or Recent Residents, and persons dyinq awa> from liome.

I . (O

Former or
Usual Residence

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

How lonq at
Place of Oeatfi ?

Days

n.ACK nl' HIKIAI, OK KKM'»V\I,

Qflfu

DA ri' o! !!i HIM or K i-:mi »\'AI.

T90

AdHrc.^ ^0 5 ^>\<nxU

5 >a\jINu.4

i

— — — — ^ — — ~T_ ,j j^ ^,„j^j EXACTLY. PHYSICIANS should

IS. B.— Every Item o? inWmetJon shouhl be cnr.tully -PP'-^. At.E « . ^^he -Special Information" for p.r-

state CAUSE OF DEATH in plain terms, that .t may be properly
^nf. dyhTft away from home should be ftiven in every .n^tance.

^

m

WRITE PLAINLY WITH UNFADING INK

! l!,a!t!i I v.> i^ •*>;*.,^;)H^ri'<»

pff/f rih'<l ,

b

100^.

THIS IS A PERMANENT RECORD

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

Bro^/sfrrrd ^Vo.

Deputy Health Officer

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

Certificate of Beatb

( 11. S. 5tan^ar^^ )
PLACE OF DEATH: — County of '-■ '

Jn.O^YVC.w. Gtyof^CU^X) ^>^KXXyY^^^<^<

y\.oX

St.;

(ir DEATH OCCURS *WAV FROM U S l ^ , ., ^

IF DCATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE

Dist.; bet*

and

..Cllill RF«5IDENCE GIVE FACTS CALLED FOR UNDER "SPECIAL INFORMATION ■ ^
F DEATH OCCURS AWAY FROM USUAL "5 ^ ' ?5.;;.^,^„^J V. „ " ,^5 NAME INSTEAD OF STREET AND NUMBER. /

FULL NAME

^ I

'^

A

PERSONAL AND STATISTICAL PARTICULARS

vri: I >i !UK I'H

\1. Ml h »

\< . J-.

, K t

.1

I>a%-

1/,,, '/,

» • ,il

/>,/!

HINOI.I* MAHKIKK

!UR rill'!. \tl"
"^tatt I ir <"in! n! ! %

NAM I- 01
I ATHKR

RiH rm-i, \tK
nt 1 A rm:k

St. ill i.t (.'onuti V

N!MI)1:n NAMl.
Ill .Mollli; K

lUUIMfPI.Ai'K
III MMIIIKR
(Stat. <<l CiiHUM

X

< irrri'A'rioN

■^ oJo^y^ULK' f >

/,'/■ /7f .,'■ /» Si'»' / ' '"

1/, ;•///

/>,

I'm- \!$«>vi-: SIX rri» phkn. »n \i. i-xh ii* i^i. ^^k-^ "»

lil'ST 01 .MV KN<i\VI,i:i)< .»•: A"^'' I'.I.I.II.!-

KK IK IK l«' l"'-.

f Ii)f')!iii:iiU

Ol . U) . Qnru^^vt<m>

MEDICAL CERTIFICATE OF DEATH

IiA rK 01- 1)1 ATII |'^

VZAj

I Moiitlit

Dav)

rgo

(Yea I 1

I III-:ki:i'.V ri;KTIl-V. That I atteii<UMl <kr<ase<l from

tliat T last saw h ^^ ' ■ - alivt- on

an.l that <Uath occurrcl, <.n thr .latr -^tatL-.l al.nvf. at
M. The CM SI-: Ol- Di: ATI! was as follows

190 i.

I)IR.\T1()N
CONTKIIU'TOI

) Vi// s

Mouths

/hirs

//ours

I \- wd-^-^-CxX^X^v- o ^ w

k I

DTK AT ION
( SIG

yittrs

Months

/hiy

Itouts

M.D.

NED) Uu. U)^^ ' " /D ' )%

SPECIAL INFORMATION only for Hospllals, Institutions, Translen
or Recent Residents, and persons dying away from liome

Q D * How lonq at

r

Former or
Isual Residence

-UYYVOTwd. V "1 ' Plate of Oeatli?6

kvas disease contracted,! f f ( H . « L

at place of deatli ? J A) 'V-A^OV v. . -. .. >

B«vs

Wfien was
If not at place

UI.ACK 0

I- lUKi-U, <»K i<i;m'<x Al.

Lyi-xhJlAA

DA'p". .)! I'.rwi.Ai. or Kl'.MoV.AI,
\J 190 \

.. . .^p „h„„icl be stated EXACTLY. PHYSICIANS «houl«l
IS. B.— F.very Item .S info.m«tJon should be c«re?ully f "»>n''- " ^"f^^ ,,assWled. The •'Special Information" for pT-
-tnte CAUSr OP DEATH in plain term., that it may be properly
^n". dyfnft away from home should be ^ivcn in every instance.

•w

WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD

,, n , N„ - f.^-^S^.nu'vlC-. REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

Ii('o-i.sfr/'erl J{o.

Of tf^

L^iwu Deputy Health Officer

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco

Certificate of IDeatb

PLACE OF DEATH:-County of^^<X^ 0 Xa.a - City of CVc^^ J.'vxvwc.^.
No ^Ol'a■ ith. St.; .^ Dist.; bet. 3 tr^U^^J-v-^' and (.b.C^^A.^.-'■ - )

INO, V ^ V. I 4^ W. '^^ r V ,,c,,., RFCSIDENCE GIVE FACTS CALtrO FOR UNDER SPECIAL INFORMATION' \

FULL NAME a ^.^^

dL

4 ^ ^

\ I

v>

I' t . ^ t

PERSONAL AND STATISTICAL PARTICULARS

i» A s H « >i lUK rn

^<X^v,

%!i.lltll'

Xt .1',

^3. ,v,...

U

' Diivi

M.oilh^

f

\ < : 1 1

/',/ 1 •

SINt.l.l' M.\kUIlI>

w I n< I \\ 1: 1 ) ( > K I » ; \ ( » k r 1- 1 )

• Writ' i n -■ .< i:i; .!■ -■ t'Hat ii ^ii >

I l\xXh./v.A

nikTHi'i, x*"!-:

' Stall (i! (*(iinit ! \

\\Mf.- Ml
1 A III KK

r.iH riiri, \y v.

<>! I \ IlII'lK
' Ni,,!. (It iDimtry

NtMDI.N NAM1-,
<»1- MOTIIHH

lUH IHI'T.Ai'l-:
<H MoTIN'K
(Stat« DT rnuuti\

A

?

(V

•HATPATION 0.0 1 t)

TllKMUn'KSTATKnPKKSONAI. rAKTUri XHsAKHTKlK JO THK
H1-;ST <»1- MV KNn\VI,j;i)<'.l% AM) r.i.i.ii.i-

MEDICAL CERTIFICATE OF DEATH

DAri-; 111- Dl'.Al'H

(Mouth) 'Day)

TOO

(Year)

I Illlkl.P.V Cl'lKTIl-V, That I atU'tKlcd dere.isi'tl from

to ®^fc ^ ^^^^

loo'i to SJ^Sj 3 IQO

: ^ <{\ ■

that I last saw h ^^^ alive on Ucl- ^. 790

and that .U-ath ocrurrcd, on the .late stated above, at i oO
' M. The CArSI'! Ol- DIlATIl was as follows:

Ur RAT ION

)V<//'X

Months

:(>NTKnU'T(>KV U/>v.k.^-^*

Days

J lours

Years Months

/)^/r,s-

nr RATION

(Signed) UJnnru ^ Aa '

l^.^ b — "^ ^A,i,ir,.<o 'lib Nlrlaiu

/fours
M.D.

Tqo

SPECIAL INFORMATION only fo"" Hospitals, Institutions, Transients,
or Recent Residents, and persons dving away from lionie.

Former or
Usual Residence

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

How long at
Plareof Death?

Days

n \CK OF HI RIAL OK KKMoVAI,

DXXl!"' liiKiAi, III KlCMoVAI.
1 J \ T9OH

(Ad.li rs< iH 0 H.

.. . T^p «H«,.!,I he stnted EXACTLY. PHYSICIANS should
N. B.— Hvery Item of information .hould he CBrefuHy -PP -;«• ^^J^^^ classified. The "Special information^ for p,r-
atate CAUSE OF DEATH in plain terms, that it may be properiy
sons dying away from home should be given in every instance.

WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD

REFER TO BACK OF CERTIFrCATE FOR INSTRUCTIONS

)'..:ii(l t.f H.-nltli !•' N'o. te t-?' ;-:w!tti} Jl^p Co

Dale Filed, M^X

crl>~t>u '\ IdO'i

Deputy Health Omcer

Registered J^''o.

2147

cL<m.>^ Jo/v^, "''Huiy neaitn omcer

DEPARTMENT Of PUBLIC HEALTH-City and County of San Francisco

Cettitfcate of ®eatb

( "a. S. Stan5arD )

m

PLACE OF DEATH: — County ofOa.-vx J A.<x/>^/iuL<i^Gty of Haa^. JA^O/t^C^K^o

(No. Lix JLcL^X^^^ Al' ^nI KlIo..

, St; Dist.;bct. and

I "^ P/nrl.w^''"''^ ***'' '^"'"^ USUAL RESIDENCE GIVE rACTS called for under "special information- \
V ^r DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STR eIt AN D NUMBER )

T)

L^

FULL NAME

si;x

^

PERSONAL AND STATISTICAL PARTICULARS

! COI.OR '•

tk

i'^

%.^

VAjUj^t .. .

v^ . '^ \ > \. '"V
DATI-: OI- I!IK IH

\«;k

v^ "^ 1-,.

^

lLI

^ (

(Dav)

M>>,ilh<

-Ctx

MEDICAL CERTIFICATE OF DEATH

DATE OF DKATH

(M(Mith)

fDay)

igo\

(Year)

1 H

fVcar)

A: I'.s

SINC.I.H. MAKUIi:i)
\Vn)(»\yHI> OK DIVOKi'Kl)
'Write ill mnial (le-^iL^natioii)

BIKTflPr.AOK
(State or Coiiiitrvi

NAM1-: <>!••

FA'nn:k

BIKTIIIM.ACH
ni- l-ATHKR
(Stat<- or t'imiiti \^

MAIDKN' NAMl
<)»• MOTIIKK

HIKTIIlM.ArK
OF MOTIIKK
(State or Comitrv)

OCCUPATION

^UUXT

1

0 I HHRHRV C1{RTIFV, TliatJ atteii.le.l .Icccased f

.a_i4Ajt;: ai .^-m - ^

190

to

that I last saw h -A. '- alive on

roni
190 H
^t ^ 190 1

and that death occurred, on the date stated al)ovc, at 5
M. The CAUSE OI- Dl-ATH was as follows:

efc: £.

0

U

U:

^

UXA.L(, Ll

•c<rvL<X'^^dL

I) r RATION Years

CONTRIIU-TORV

DIRATION Years

Mouths

Days

Months

(SlGNED).^>i^JL/\Nil;

^ij's^AJ^'^j^^^

Pays

y.clj b iQo^i (Address) 5HD 3x.d±k

Resided in Sun I'l uin isro

Month

/hn

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

former or -s^.y^i . How long at

Residence AO i H Oo^vux/) / .

Usual

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

Place of Death?

Days

1 hf; ahovf: .STATi:n pkksonai, i'artufi.ars arf; tkff to tuf
hf;st of my kno\\ij;i)(;k and ni:i.n;F

Infoiinant VXL^VN-^w^^On^^ d^. LUUU-^

.4^-^.

(A<1<1

rcss

.10 1 H

ci

I'l^ACK OF RlRIAr. OR RKMoVAI. | DATF of U.riai. or RFMoVAI,

(Address ^sS/l ^O

190

}Jl^\^'

Jl

^' ^' Every Item oi information should be cRPafully supplied. AGB should be stated EXACTLY. PHYSICIANS should

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

I

f

M

WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD

H...'ii<l ...f III lit li }• No. I- "^'f^^'^tj: H,S:1' Cn

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

!)((/(' Filed ,

AyAhj 1

i'

wo\

Deputy Health Officer

RegisU't'cd JVo.

f^

No.

DEPARTMENT OF PUBLIC HEALTH-City and County of San Francisco

Ccitiffcatc of Scatb

' n. 5. StanDarD )
PLACE OF DEATH: — County of Ct y\; J 'LCtvvei.c^c City ofO£:L/>v JA^Cutx cl4 '^ '.

"St.; 3, Dist.;bet. V vj

^ and L

;UF*5 AWAY FROM USUAL RESIDENCE GIVE FACTS CALLED FOR UNDER SPECIAL INFORMATION
DCC'JRRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER

FULL NAME JlXuU

PERSONAL AND STATISTICAL PARTICULARS

n.\ ri; <>i iuk \ li

(■(»i.<»R ^

a

Ll

4^

mAiu

' f

MEDICAL CERTIFICATE OF DEATH

DATi-: oi- i)i:atii

Month)

< 1 );t V I

(Vtai

I);i\

\<.i.:

na-

S!\».I,I-- MARNIi;!).
'W'iitciii social lU-si^'iiat inii)

^1

\

Statt or < "i lunt r\

NAMl ni
I A Tin; K

BIKTIi 11. AC}.;

ni- i-Aiin-.R

(State or (.'niitlt! %

MAII)i;x NAM],
<)1- MdTin-R

in R TUP I, AC" i-;

•M MnTin-:K
(Stal<- i,r C<iinitr\-

< »*'(." ri'Aiiox

AV.v/(/^'f/ //' Still /'t n III i.<rii

I JIHRHHV CI^RTII-V. That I atten.k-<l .lectasc-.l fn.,,,
that I hist saw h .:. ahvc on ^' "^ \

190 ^
T90 !

ami tliat (katli (uH'urreil, on the thiti- staud aho

\'«, at

!^ M. Tlu- CAISH OF DI'ATfr was as follows

LojtcUvruVvcct U

yvx^.c t

^ rs

{Lrrrx, !

iJ^At

L

I) r RAT ION }Va/-.f

coNTRir.rToRv ^a"^

Months ^1 /;«n.v

Hon

rs

UXK^x

niRATIOX

f Signed )

y'l'ar

.V<^f////s I 'i /)ars

TOO 1 (A.Mn-sv) lOl^'lS.

mYUvl

flours

M.D.

Special Information only for Hospitdls. institutions, Transients
or Recent Residents, and persons dying awdy from home. '

) rill

Mnlth'

r>,n

I'm-: MiovK sTATi: n i'i-'rsoxai. par ri(-i-i. \ks ari' trii" 1. > rm-"

HHST t)l' MV KN'<)\\l,i:i)(.l.: AND HI". l.Ii; !••
Infonnam LU PnA^ ^ll . ' ^

Former or
L'sual Residence

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

HoH long at
Plate of Death?

Days

(Address 1 I |Qs

0 ^-^

PI,\rK (II Hf-RIAUOR Ri:M()\AI. I DAT];.,; H! Ki,\r. or RHMOVAI.

1 1 '51 ^TYXa,^^,. ^i

T90H

rXDlCKTAKKR

'All{lrt's^

N. B.

-Rvery item of i.iformatlon should be carafully supplied. AGB should be stated EXACTLY. PHYSICIANS should
state CAUSE OF DEATH In plain terms, that it may be properly classified. The "Special Information" for par-
sons dyin^ away from home should be given in every Instance.

lif^

];^ ^1

m

WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

..I llt.lltll 1' Nu^ !■: *-?^S^ li&l'Co

'^ 4 ^

.<r^oc^

XKl

1V0\
"'^*- Officer

Re^isfei'ed J\^o,

2U9

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco

Certificate of S)eatb

( "U. S. Stan^arC* j

(?f^

PLACE OF DEATH: — County o{OxX/y\j OAwCA^oOLCoCity of Oct'vo J Ax»y>-i^ev4. c o

No. H n L,a.-.\ 'ib_<L-J LW-i' St.; *i Dist.; bet. 0 Ajtbr>v

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

FULL NAME^^vdxiGr J...c^

N"

1)

>j;\

PERSONAL AND STATISTICAL PARTICULARS

LillvcU

!) A ii: <»r itiK III

ACiK

i Ml. mil I

} V,.'

I»avt

M.-ut/r-

\ ta t

/'./

MEDICAL CERTIFICATE OF DEATH

DATK n|. nj:ATII

(Year

-iNi.i.i* MAKi<n:n

^tate or Cnmilrv

XAMl or
F ATI! !^k

lUk'I'HI'I.AOK
oi I \rilHR
tStati iir i'ouiiti ^■

M\II»i:V NAMI"
oi- MoTHHR

niR rill'l.Ai'K

«>i MMriii<:k

(Stati ill ^'oiintrx

Oi'CrPATION

Kt'Miir'd in San /iiinii>r

cc

(Month) (Day)

f HI'Rl-HV CI-:RTII-V, That r attemkMl deceased from

190' to WvC^ fo njoM

that I hist saw li aUve on '• .:^w J^yQ

aiid that death ocrurred, on the date stated ahtive, at ^'i -■-
-> M. The CATSIC OI- I ) I- ATI I was as follows:

is

Dr RAT ION )'rars

CONTRIIU'TORV

Mo Hi /is

rX.

/hj]

'S

I louts

Dr RATION

SIGNED )

) '('(//■

Mouths

Pavs

Vvv^O^v

b

\^

H)0

Hours
M.D.

Address) lOl^llaS

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

Y,a<

Mnnth^

/),,'

lin; \HoVH STATl'I) PKRmiNAI, l'AKTIOrf,AKS ARIC TRIK To THI-;

iu;si" 01. M\' KNo\\T,i;r)<;K ami Hi:i.n:F

(Iiifotinaiit Vl I LCXAAJ,

(Address I IT. U /Cb^rU M L L<,/

<LAj5

Former or
Usual Residence

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

How lonq at
Place of Death ?

Oij's

IM.ACK OI- Hj^H|\I, OK KKMoXAI, I IJATliof ISihiai, nr RICMoVAI,

t V
I 1 90

uldifss ill. M |\a^4,A.a

l'J,.\en OJ- lil KIAI, OK K I

r.Ni)i:K iaki;r

j^^ \ \j

N. B.— — Rvery item of informntion should he cnrefulfy supplied. AGE should he xtfited BXACTLY. PHYSICIANf^ should
state CAUSE OF DEATH in plain terms, that it mny he properly classified. The "Special Information" for per-
sons dying away from home should be given in every instance.

1

WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD

i;. ,;ii.! .,f IIlmIHi !• \.

^••■E7.-«^, li^I' (\,

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

4

IfJO'i

Bcf^Lstered J\^o,

;^150

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco

Certificate of S)catb

( XX. S. Stan&ar^ j

Ne.

PLACE OF DEATH: — County ofO a>v\C

3,t '

]

City of OXcr^L^^rvv. ^

XU^A.

V,'. . A r^

St.;

Dist.; bet.

and

f IF DtATH 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

M I \cu\A.i

It

PERSONAL AND STATISTICAL PARTICULARS

'1 \ n; < •! i:ik rn

L

' Month)

\| .1-

b5

S

l),i\

M. •>,'/!

I L

MEDICAL CERTIFICATE OF DEATH

DATl-; oi- I»i:\TlI ij \

(Month)

IQO i

(W-ai i

r>,i

S!\«,l.l' MAKRIHI)

wiiM i\K i;i) ( iR i)[\( i«.'ri:r)

' W'x iti i 11 -.(ici,! I <1( -iiMi.it i'Hi)

W

I

lUKTniM, \ri-:

i St;i!c ()i I 'ini uli \

f- \ 111 i k

BIRTHI'I, \< i-:
ni- i-Ainij<

iStaii (It riiiintiA

M \ ii»i;n n ami:
III M«»riij: K

luuriii'i.Ai'i-:

<>1- MnTll!-:K
(StMtr or (.Niuntiv)

^■;

(Day)

I Hl'RI'HV CI'UTII'V, That I ittcii.lol .icTcascd fn.m
190 to

igo

that I hist saw h :t ^ ali\c' on — _ ^

and that death nccurre«l, on the date stated aljove, at

%

M. The CAISI-; OI- I)i:ATir was as follows-

<Xy>^^V^^V<3 A.U^\A Lt A,AXC„0,

i> 11

K

1 >

Dr RATION Ytars
CONTRIIHTOF^V

Months

Day:

'S

/Jours

DTRATIOX

^ Oxu

■>%

;^

)'t'ars

Month:

Ihns

(Signed) L(r*urvuA;

li'/^l^ b TooH (Address) Ot«rcki.^nv

Iloitts

M.D.

K.O.A.

SPECIAL INFORMATION only for Hospitals, Institutions, Trinslents,
or Recent Residents, and persons dying away from fio.-ne.

' H CI i'.\ri().\

-^

xjlLcx

k'f-hlt'f III ^,ni / I I

I II, I ,',i

),-,/;

Mnllth^

I hi

0
-Jf

Former or |(1 -

Usual Residence^ '^^^: i^ad.

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

How long at
Place of Deatli ?

Days

TH !•: AMOVl-: S,T \'l'i:i) PKUSDN \1, PAR rriTI.AKS AKl", THfK TO TUl-
IU;si' <)| MS KNnWIJ.lx', !•; AND lU'.I.Ij;!-

' III f>i! 111:1 lit

V

\.i.!re^^ cL0JvJK.A4VL^*V ^0

l;iLACKr>I-- FlUklAf, OR kllMoVAF. I DATi;,,! Hriuu, m ki:Mn\Ai.
IXDKkTAKHR O CUVXAy^xXK . I \, A v.

N. B.— — Rvery item of ln?ormntion sihoiilil h- cnrefully Hupplieti. AGIi should be stated EXACTLY. PHY$»ICIAISS should
state CAUSE OF DKATH in plnin terms, that it may be properly classified. The "Special Information'* for per-
sons dyin£ away from home Hhould be (^iven in every instance.

< M

I

4

f

1

WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

.,f Htalth !•■ N.) 1^. t«'?'->ati<-£u>iu«tl' Co

N

Deputy Health Officer

Registevefl J\^o,

2151

^ ■ 1

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco

Certificate of H)eatb

( "a. S. StanDarO )

■r\

I

PLACE OF DEATH: — County of /CLOr^j v^^CV > vCUicoCity of ^^ ) a/>v 0 V(X vvci^i.<M)

A

">->

«?

*No.^Ja^\' v'XaX>vCl4C(.

(IF Dl
If

St.;

. OVul/^x- At . U

Dist.; bet.

and

F DEATH OCCURS AWAV FROM OSUAL R E S I D E NC E Gl VC FACTS CALLED FOR UNDER "SPECIAL INFORMATION"

DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE

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

FULL NAME

n

%.:y\> L.a.\.^. K'

PERSONAL AND STATISTICAL PARTICULARS

nw

:»A 11 < i| lURTll

\ < . I-;

1

(

Month)

S

) V,;

1

I»av

1/ -;///-

MEDICAL CERTIFICATE OF DEATH

DATK OF I)i:ATfl // \

(Month) (Day)

I HI-KI'I'.V CI'RTH'V, That I atteiidcl «leitascMl from

— to ——r——

rgn \

(Year)

/)<? ! ,

s!N<.i,i: ^fARH^•:I)

WIIH >U 1 I» <iK I)!\(>k(. 1:1)
Wtitrin --iK-Jal tif^ii'nation)

lUKi'II I'l. \i'I-:
I Stall 1 ir i.~i iiiiit I \

.K^

N \Mi: 01
I A 11 1 ):r

BIRTH PI, AOK
Ol' FATHKK

(Stalf or Cijuntrv

MAIDi: N NAM1-:
<>l- MoTIIKR

iUR'IIIPI.ACK
<>F MOTIIKR
' Slatf or t'oiiiiti \

that I last saw Ii

190
~ alive on

190
190

and that dtath «»rciirre<l, on the date stated above, at
— M. The CAISI-: OI" DI^ATH was a^ follows
A^\\X V ^^ V s^ cv , L K.c > \,

'\.CrY>^ Oa.^'j

I tX..A.<L

O^-w.

I )r RAT ION Yvars

CONTRIinTORV

Motitin

Days

Hon

rs

B-^

DURATION

N \

HHMPAIION j^ fi

(SIGNED ) LCfUnXJL>v J Jj.ly.dU.
ILi/ci 5 uyoH (Ad.lress) WtO^XtMUM^ ^

/}iiy

Hours
M.D.

SPECIAL Information only for Hospitals, Instituttdlls, Transients,
or Recent Residents, and persons dying a^ay from fiome.

utroi

^JL'v;

Isfsitifd in Siin /'i iiHiiM',

) I'll I

Montfn

Piv.

Former or
Usual Residence

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

How lonq at
Place of Death?

lays

tup; m'.ovk sta ri'.T) pkrsoxai. 1'\k rion.ARs ark trtk to thh

MI';ST Ol- MV KN«)\VI,i:i)<".H AM) HHIJllF

niiforniant

v_<^-\Xr^

^JUxj:)

V

A

U' ■'.

Addn

190

l'I,ACK t))' BIRIAI. «)R RKMnVAI, I DATHof HtKiAr. or RKMOVAI

(Address ^bll^' l^ tk il

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

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

•I

Id

'W

Iv'l

WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD

liMl-l of II. ;ill1l IN'.^ : t^*"^^;, Hv'«cl' r.»

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

P

o-ivwcA^ Xtv Deputy Health Officer

lleg Ls/c I 'c (I Xo,

'*^' J. t3'^

DEPARTMENT OF PUBLIC HEALTH-City and County of San Francisco

Certificate of H>catb

PLACE OF DEATH:— County ^ ^Ouy\, J \a.i

City of 0 CUy\;

:iv..

r> - /-N

No.

^.1,1

' ' ' ' St.; Dist.;bet. : "* and \ I '

/ IF DfATH 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

■I fUt^L^ LI

PERSONAL AND STATISTICAL PARTICULARS

-^^■\

I'l >l.( >k

^. 1 .
i»A ri; «»i liiK 111

At.i-;

'O

iLct

MiMithi

I)MV)

/%HH

MEDICAL CERTIFICATE OF DEATH

DATl" (tl- I)i;\lII

Moiitlii

I I)av>

(Vfar>

I m-kl-BV C!;RTH<V. That I nttfii.lcMl .kcT.ised from

toD.^ ^

Ik

^IN<.I.l" MAKKIl'.U
W i 1)1 i\\ JI» ok IH\( iKi'KIJ
^\lit( in -.iKiul ili-^i(.>;i:iti.iii)

M (lev,

A

IUK!'m'I,AOI%

St.'lti- ii! < '. )M lit I %

NANTI* OI

fa'iiii:k

lURTHI'I. \«'l-:

< •' I \ in Ik

■->1 it I ( ll ii Ml lit I %••

^fMI»l•.^,■ NAMK
'•i Mill' I IKK

lURllMM, \CV.

<»i MMriii.;K

-talc 111 I'oiiiltrv)

< 's rri'A rH)N

e

lip

tlial I last saw ll -2A< alive oh ' _ wl'

aii«l that (katli .icriirrCMJ, <>m thu date stated al)()ve, at
M. The CAl SI-; Ol- DI-ATII was as follows:

I(yO

df

LLl- ^

I ^' I

K^K^^OJs^d^ ' ' ^

W

-^v

1)1 R XT ION )'cays Mouths Pavs Hours

CONTkim'TORV

1)1 'RAT I ON

Years

LU,

I I

^o lit /is /hivs

f Signed) j.xKxi^Ui'i- Ja1/\<l'. • . ■ ,

V -..'.. n,o 1 f Address) Ai . frVU C-L'

Hours

M.D.

.<X.

A

Special Information only for HospiMIs, InstUutlons, Transients,
or Recent Residents, and persons dyin:) dnay fron home.

A'' /,//(/ /;/ Silll /• I ll Hi isi'it

) I'd I

M.nilh-

/'

'1HI-; \n«)\i-; s r xn; d pkr-^on xi, r \k ruti. \k> ak i; I'Kri-: ii » rm-;

IU%sr (Hi M%" KN<»Ul,i;i)(,|-, AM) lU I.U!'

Former or
Usual Residence

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

How lonq at
Place of Death ?

Days

(I

.ifoTinant M iXm^ ^IaXa^^' \I I L

'■\(l(lll-sH O O I

Uy\,\ n

M.ACI-lol- lURfAI. OR R|;M(»\AI,

JcrnrxaXi^ ^^-'

I) \ ll; of in HI u. OI R HM( )\Ai,

\

TQO

lNI)i;kTAKK K .,w CL' J

N. B. Every item oi informntlon should bv cjirefully supplied. A(IE should be stated EXACTLY. PHYSICIANS should

•tate CAUSE OF DEATH in pinin terms, that it may be properly classified. The "Special Information" for per-
sons dyin(l away from home should be (^iven in every instance.

1

ftA

m

WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD

H ..!!<] i.f Ifialth 1 N

Dfffr /'VV/v/, ll' ct^crlM.'

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

Kj 1

IOf)\

or

Begisfet'cd jYo.

2153

.Kj<A -Kx^xHj Deputy He

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

Certificate of H)eatb

( 'U. S. Stan&arO )

PLACE OF DEATH: — County of "^O^w ^\xX/wcUlt^o City of C) a/Tu OXxX/>xx:uik:x)

O

f'fo. V -UL-UuV^Uw'

^

k±

cl

St.;

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

! \

^

PERSONAL AND STATISTICA

I Cf>i,<>k

FULL NAME kt^noJU

L PARTICULARS

Dist.; bet.

FACTS

tZ ITS

and

^19

CrV'l<X r\.d

' \ ri; • 'I lUK Til

\< .!■;

a.

U

U Jkctt

MEDICAL CERTIFICATE OF DEATH

i>.\Ti<; OF i)i; A'lH i<"n

> h A .1

Moiitir

n.'tv

/ V

ID

'Mniitli

I
IDav)

(Vt-ar)

d.\

1 /,.;/'

P.

^IN< . I.I' M AK k i III

'Writ' in -.xial <li- ii/tiat ion )

'Stall lit < 'i HI !it I \

^ 1

XXMJ" <»I
1- A ill IK

lURTIIfl.Ari.:
<>I I'Arill'k

' Stall (It ('oiniti %■

M X IIM.N N AMI-;

'>i M(>'rm-:K

I'.iK'jiii'r.Aij-:

«»l NSoTIII'.K
( st:iti I ii i'iiniilr\

1 lli;Ri;i!\' C1{RTII-V, That I attciukMl .ItHHase.l fioni

to ... v.'cit b

TooH

that I last saw h

C^l

Tfp I

alive oti w vwv |(p

ami tliat ilcatli <i<HMirrc-(l, (m: the ilati- statid ahovr, at T ^0
^I. 'rhy CAISI^ Ol' DICATir was as folhnvs:

-f

n

LcLi-^

DIRATION }'(ars

CONTkfm TORY

J/.>,///is

Days

Fli

lit IS

C\ ^ r%

I)!* RATION )'rars

/hns

\j ^i.

M'out/is

(Signed) u. ds. Ux>v\.a

flours

M.D.

Special Information nnl> lor Hospitals, institutions, Transients,
or Recent Residents, and persons dying away from home.

I ti 'I 1' \ rioN

Kf-ii{rii III Sail f'l ii III i.sri} <^ I )'r(iis 'O

Former or ^
Usual Residence^

)JLu;vlL.Vi. ""*'""'"'

Plare of Dfatfi

Days

Mnillh^

n,i 1

'I'll!', Mtnxi-: SI" \ri;i) pkhsox \i, pxRiicf!, \ks .\r!-: rKiK to th )■;
lU'lsT ui MS- KN« >\\ij;i)(;i.; and Hi;i,n;F

f IllfoMllalit

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

ri i^cH oi-* isrKiAr. ok hi.;m(»vai, I nxq:..! ittHiAt. ..r ki-mo\\i

ro I 'I )

N. B. Every Item of itifarmntioti should be carefully Bupplivd. AGE should be stated EXACTLY. PHYSICIANS should

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

1

¥ I

WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD

n,.:i!.i <>{ n. ..;'!i i s

:, ,. ! ^ t-f^r^^ nSi. v Co

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

Dff

/f?OH

Registered J\^o.

airiJ.

.Cr^<-^v

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco

Certificate of 2)eatb

( XX. S. StanOacO )
PLACE OF DEATH: — County of a "vx- \' O ,

3,

\(

\'

:- -s. - L City of U/CXaaj 0 ;\.o. ,
No. I bib iH M l/at<rv>vC\' St.; 5" > Dist.; bet. 1 1 -tk and 1 ^ t

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

FULL NAME

11

(I

"rX'lvL

PERSONAL AND STATISTICAL PARTICULARS

XTVXCL

ii \ ri: < >r luk rn

a

a^^r

MEDICAL CERTIFICATE OF DEATH

DAT1-: <)i' i)i:Arii

lU

(Vt-ar)

M..m!

I >a V

\< .!•:

u n)t>\\i;i» « >k !);\( »rsi;[>

\\!if( ill -iii-ial <li "-it'iiat i'lii )

i • ai

fhl 1

ll^

luR riii'i. \v'i'

'■taf f I ir • '. iiMit I \

NAMK »»l
FATHKR

HIRTHIM, Ai'H
"I" 1 \ rHKK
' Stat!' i>r C()uiitr\

M N IDi: X NAM1-;

<•! M<>rm:K

HIKI'Hl'I,ArH

<>»• M(>'rm':R

' '^tat'^ I a ( , amtT ^

(^

(Month) 'D.ay

I iii':ri:i'.v ci;rtii<v, riiat i Mttciuit-d (Uar.isrd fr..in

^ 'C^j 5 i(,o' to ...L/'/Cai tS.,_

TC)0

that I last saw h

alive oil

.^

T(p

and that <Uath occurred, on the date staled above, at I
U M. The CArSl-: ()!• J)I{ATI[ uas as follows:

ft

DlkATlOX
CONTkllU'TORV

)'ears Months

ry^J^X,

Pa

r.v

Hon

rs

C\

CLTUX-'

^Dxt

nr RATION }\<irs

'Is

(SIG

Mo tit lis,

Pavs

Hi

I()0

ft-^-

ours

M.D.

1

nClTl' \l"li »N

%

'>

vdw

yi,nith>

/J.M.

Special Information only for Hospitals, Instllutions, rransients,
or Recent Residents, dnd persons dying dnay from home.

Till". Ann\-|.: SI" \ri:!> i-i- ksi »\ \i. rAKrii'fi. ars ari-; tri'k t«> rm-:
iu%srnt- MS K Nt »\\ i.i'iH ,!■; AM) i',i.i,n;i''

{Infi>'!nruit

lu. d

V-

A-t. I

%

Former or
Usual Residence

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

HoH long at
Place of Deaffi ?

Days

PI.ACH <)!■■ IHRIAI. OR RK^f<)VAI,

IV,'

.^

^^^ ._

fA.l.lKSS (, ;0L,A^'U<IXX_

Lt

K.

INDICRTAKKR

K/x^

\^i

r)ArKi.! H! Kivi. i.r RICMoVAI.

0

190

KJLuJ- ^^ W^^c ' v.i

fAdclrcss ^^ UyC^-YV \l UUt/^

^

■■^ VA^ ^' .-*^

N. B. Rvery Item of informntion ahouhl be cnreViilly supplied. AGB should be stated EXACTLY. PHYSICIANS should

state CAUSE OF DEATH in pltiin terms, that It may be properly classified. The "Special Information" for par-
sons dyin^ away from home should be ^i^cn in every instance.

^

-4o

1 1 L

1

m

WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD

l!..:ml ..f 11. .iltli- 1- Nil ; >; 1^'?^?»^>> Hft I' Co

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

/M/r> Fi/rf/Xj^A^>^l

IfJO'i

Registered JS'^o,

2155

^

C^^^-^ \J *— - v^ *

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco

Certificate of Death

( "U. S. StanOarD )
PLACE OF DEATH: — County ofCxx^v J;vcu>v<:uiccCity of 'Clvu J/Vcl vxci^-ayco
^*^ UXu, ^ Mn^C'TvUi L'^(yU\A.tal St.;— Dlst.;bet

and

A / ir DC*TH OCCUR^AW*V FROM USUAL R E S I O E NC E Gl VE FACTS CALLED FOR UNDER "SPECIAL INFORMATION" N
y \ IF DEATH OCCUPRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. /

FULL NAME

^a.d,M.tj

xx,\yoA

PERSONAL AND STATISTICAL PARTICULARS

SIX

^ i Lev

COI.OR

i ^ I

. yvL

.t^

DATl-: nr- BIRTH

A<.K

MEDICAL CERTIFICATE OF DEATH

DATK OI'- DHATH Tx

(Month)

(»av)

I go

(Year)

M.-iitli)

)■-,.■

3n

(Dav)

M.nilhf

(Year)

Da » .

SINC.I.i:. MAKKIICI).
WnxiWKJ) (>K DSVORlKIJ
(Writf in social (l<si«'nati«Jti)

lUU THPLACR

L

f Stntr (»r I'mmt! \'

I ATm;K

mkrmM.Ac'K

Of I ATIIKK
(Statt or (.'iMintrv)

^f A I r ) }•; s n a m k

«H' MoTMKR

lUKTHI'r.Ac'l.;
<>»' MnTllHK
(Statf or Countr\

OiCri' ATION 0

1

I IIICRKHV CJ;RTII-V, That r atteiiikMl <Icccase(l from

■'Ou^ iL lyoH to L/.ci H 190 H

that T last saw h C - alive on ^ '^"^. ' i igo

and that <Uatli occurred, on the date stated above, at S^ S 0

M. The CAl'Slv OF Dl-ATII was as follows

\JjuUL"0^v.,<rvvcw>VM sJ .oJCk-C^^c

A

f I

\ 1 \ M

DIRATION

'W

Mouths

CON T R I m 'T ( ) R \' ^ XJ<XsXh^<Z^^X.QJ\J

Days

Hours

vu:^.^.!

n n

\ .

OJ

A f^

I )r RATION

K^\^ ) . V

( Signed ) o

in /?
,1 KI

Months

Davs

K

IqO

f

Ad.lress) OJlu <\J:> ^

flours
M.D.

^

fl. I 4

SPECIAL INFORMATION only for Ho^itals, Institutions, Transients,
or Recent Residents, and persons dyini] away from home.

Former or tii ;4 ^ How lonq at

Usual Residence 0 56 U>a CA.Ct-r^vC^C; f* piare of Oeatfj ? i \ ' ,

Days

Kf>iiir<{ III Sail / iimii'i'o

)V,/

yfoiith'

t),i 1

THH AHOVK .STATi:i> PKKSONAl, I'A K lUl" I.A KS AKi; rKCH To TIIF,

HKsT OF MY KNo\vij:i)(iK AM) Hi:i,n:p

(liifornuuit

C.(].%.(!JUi.

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

rr.^ACK OF HI RFAI. Ok RFMoVAI, | DATl',..: p.. i.iAr, or RKMoVAI
INDFRTAKHR JuUCaJLU %L u\0/<X<X,<X N w

N. B. Every Item of information should be carefully supplied. AGE should be stated EXACTLY. PHYSICIANS ahould

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

WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD

.f II. .ilih 1- .V

.■(1. 1 5, ■!^*c■. '3;--i.;, luS: J' Ti)

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

2156

t

i

trVAA^c^locxu Deputy Health Officer

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco

Certificate of 2)eatb

PLACE OF DEATH: — County of

( U. S. StanDard )

-LJ^

'..^cc City oi '0. >xj J 'VXX>vc<-<i'eo

St.

Dist.; bet.

and

/ IF PE»TH OCCUHS *W*V FROM USUAL R E S I D E N C E G I V E FACTS CALLED FOR UNDER "SPECIAL I N FO H M ATION '■ \
V Up OtATH OCCURRED IN A HOSPITAL OR INSTI^TUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. /

FULL NAME

-— *- /^ ^

PERSONAL AND STATISTICAL PARTICULARS

Si \

Cdl.oK

I> \ 1 i; « >! lUK in

A<,i.:

I Mouth I

-I

MEDICAL CERTIFICATE OF DEATH

DATK OK DKATII i( \

JV,,-

il)av>

M.,vth

I "/tar)

/»./ V

1 HI'RI'HV CI'KTIFV, That I atteii.lc.l ileceascil from

to ^^ (a..

siVf.ij.: MARNtl.I>

\\ri)()\vi"i> Ok n;\-« M'i i;i)

' U't itr in -iH iai .!• ^ii' iiat iuii )

lUKTnpi.Ai'i':

•Statf or l*>itll1t! \'

^ 1

L

^ ' O^y^ v-Lv<Xix^

I9« ; to SJ f^Si te I90 S

tliat I last saw li i.' alive 011 >w ^J. j^o

an<l that death tKCurred, on the dati- stated ahovc, at b
^-L ^. The CAISF-: (»!■ DliATII was as follows:

Hi

NAMI-; n!
I'ATUHR

niRTin'i.Ai'K

OI' lAIUKK
(Statt- or Coiiiif rv

MAini X NAMl-

oi- M()Tiii;k

IUKTI!l'I,Ar|.:

Of Morm'.R

I state (ir C'ouinr\ >

IH'kATlON
CjUNTkllUToRV

YtaiR

A

.«k_'

Moytths Days

Hours

■\

v:

I )r RATION Years

(Signed) dx^

Months

Pax

•s

Hours
M.D.

Ai b iqo'l (A.Mress) 9,5 OH ubftUj-a/uci '

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

oOCri'ATION

) I'll I

.1/. .//'//.

/),)\

%

Till-; ahovr sTATi;n phrsoxai. I'AKTicfi.AKs aki", tkih to Till-;
in-:sT oi.' ?.iY KN<>\vi,i:i)<.i-; AM) in-;i,!i:i

(Informant UXC) ub '»^ ' ' - M,

x.i.ir.ss ISOH yberv.ih<L\,d. U ^

Former or
Usual Residence

When was disease rontracfed.
If not at plare of death ?

How lonq at
Plare of Death ?

Days

I'l.ACK Ol- IHKIAl, <»K KHMcHAI, | HATI-.f ISiMiAr, or KKMuVAI,

UAa, >x n vc/, L CVC'

%

K Ikjjj

INDHKTAKKK

V t

190 i

n <-»

v:\

N. B. Every Item oV in form (it ion slioiiltl be carefully supplied. AGE should be ntnted EXACTLY. PHYSICIANS nhould

state CAUSE OF DEATH in pinin terms, that it may be properly classified. The "Special Information" for psr-
sons dying away from home should be given in avery instance.

H.

M

i f
III .

J

WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD

! '"1 f I', iiih ! V ^^^;j^HSci'Cn ri:fe:r to back of certificate for instructions

/)/(/(' hailed ,

■h

n)0

Deputy He '" ^

Begistcj'ed J\^o,

2157

I

t -» ''\

DEPARTMENT OF PUBLIC HEALTIl=City and County of San Francisco

Certificate of 5)eatb

PLACE OF DEATH: — County of

i

^

A

."J

' City of * -"^O.-^^- J A.o
-(I

No.

' St,; 1 Dist;bct. ^UXAyv-vu,- and b '

(IF DEATH OCtUBS AWAV FROM USUAL R E S I D E N C E G I V E FACTS CALLED FOR UNDER "SPRCIAL INFORMATION" "^
IF DEATH (Occurred in a hospital or institution give its NAME instead of sTRi^T and number. /

FULL NAME

'^

.<r\_xA'

personal and statistical particulars

six or^ f\ '■ coi.ok

i

I> V\ \: « H- IMK 111 A

\

I *.db

.U

Af.j.;

r

II

i Da VI

M..,tlln

(Ttal

MEDICAL certificate OF DEATH

DAT!-: CM' Di: \TH ,. \

ilu

(Year)

a5

/',M

-!\<.i,T.: %fAKRii:n

W MX )\\ HI) (»K I»!\i il'i I, I)
iWiitfiii '■JK-ial ill vi;. 111! !■ ,ii)

C>

iMH rm-j.AOi-;

>!ati (If < (iimt 1 \

NAM I tn
lATllKR

HIH III I'l, \i H
'»! I Arill.R
' ^latt (11 r.)iiii( ! \

M \II>i;n NA Mi-
ni- MnilliOi

I U !■• T III ' I . A I ■ I ;
'M Mttrill-K
I stall .it I'laiiit I \

<)*■«■ I I'A in IN

^

O.^^ 0 VOL^'VC <^XL CO

^

b

(Month) (Day)

I in-;Ri;BV C i:RTrFV, That I attciuUMl .ktvasc-d frnm

I9O tn Ucij • Kp *

that I last saw h ali\r on joq '

and that death ocrurred, on tfu' date stated above, at 3i

U' M,

The CAISI-; ()!• DI-ATII was as follows:

nr RATION Years

CONTRriUToRV

Mouths ^ l^axs

Hours

DURATION

(Signed)

LL/^p^.>C^

h't iih.l III Siin I

I ii III I •III

) , ,1

M..>illn

xs

Years Mi > 11 ( /is

up t (Address)

/hiVS

Hours

M.D.

Jo.... I.

Special Information m\s lor Hospitals. InsmuHons, Translenh,
or Recent Residents, and persons dying dwd> Irom liome.

rhi

Former or
L'sual Residence

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

NoM lonq i\
Place of Death?

Days

111: Ms<i\!.: SI" \i'i:ii I'HHSDX \i, I'Xk III I I, \Ks Aki-; tkii-; to rm-;
iii>r<ii MS K Ni »\\ i.rix , i'. \>j) iu:i,ii:i'

(Dlfo'lliatlt

Vlc v-uCLo

u.

1 Nil.lii-,s

\^

^ x.^x<Ui\Xxu kXIj. I ' .

I'l.ACK ni- lil KIAI. (»R HKMoVAl, ( DXIli-' Hi him, ..i KKMOVAF,

%

I ndi;k'i'aki:r

ft

Aiiiiiiss- 3)C)5 M rW-rvLo- *■

T90

-X 4'

A,

N'. H. Every Item of informntlon shnulil h;: ciirofully supplied. ACin should be stntecl F.XACTLV. PHYSICIANS should

state CAUSE OF DEATH In plnln teriiiB, that It mny be properly tjlaselfied. The "Special inlfopmotion" for per-
sons dying away from home Khould be gi^c*^ i>i every instance*

WRITE PLAINLY WITH UNFADING INK

n-.l .>f !li-:iUh I' N'

I)(ffr Fi/e(f,\U(zk.^si>^\^ 'I

190 "i

THIS IS A PERMANENT RECORD

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

,{^\^^v^i

\hU

cpytyHeaJthO 3r

DEPARTMENT b PUBLIC HEALTH=City and County of San Francisco

Certificate of IDcatb

( "U. S. StanDar? )

^

iNe.

PLACE OF DEATH:-County of '$^0^ i^xx^vc^c* City of C)/CVY^ 0 AXX>v^x^o

.Ci\A/"a1w it Cr<L\v J O..,'. St.;

Dist.; bet.

I *^ i _k.. iicii&l ore; I n^NCE Give FACTS CALLED FOR UNDER SPE

and

CIAL INFORMATION" \
ET AND NUMBER. /

- - 1

FULL NAME Ox^%\^^^

i

X,

x<A

PERSONAL AND STATISTICAL PARTICULARS

^\c

si:x

DAI i; (»i- niKTii

AT, 1-:

\

(•<>I<)K \

jj.kcbb

/ ^

%!<iiit IS

OO YiiX)

(l)av^

\!.>iifh

Ci . ar

I)ii\

> IN (,1,1.- MARHIi:!).

V.Iix >\V1-',I» OR IMVoK*' i: I)

I Write in -II. ia; <l.-ii.'n:it i. .ii)

,C^

lUKl'Ul'I.At'K
( Stat<- or I'liiiiit I \'

\A\n. <>|
I- A Til l-K

MIRIHIM.Ai!-:
Ol 1 AI'UKK
(Statf or Count rv

MAlItl-N NAMl
f)I M(»riii: K

lUKrm'UArK
ni \nii'm:k

(state I '1 Ciiuntl y

MEDICAL CERTIFICATE OF DEATH

I)\ riC Ol" Dl-.ATH ^_ ^

4

(Month)

iD.iv)

/go 1

(Vear^

I ni:i<i:i'.V CICRTII'V, That r aUcii<!<.-.l .UuHasol from

O.dt

IC,oH tn iD^A" 3>

190

3» 1 90

that 1 last saw h ^*^>^ alive on v."^' ?^ T90

and that .Ualh orcurred, oti the .late stated ahove, at I

' M. The CAl SI-; Ol" Dl^-Vril was as follows:

^^

A

ij

XXY>xa

otrti'xrioN

) ,,j,

\fnlttll-

I hi

rin* v i'.<)vi'" >-,i' \ rKi> pkkson \i, r \k ruri.xks ari: ikt i-

in-^r Ol' MS' KNo\\I,i:i)C. H AN1> lUCI.tlCF

To Till'

(I

„,,.n,.anl NIXxO fcXJ<xKL-rKX

<x^y\Jw,

(

( \flclr(>-H

DIR.XTION
CONTkllU'TORV

. 0'^

^ •' \\j.^\Jo -

Years

Months

Pav:

>s

Hour

nrR.xTioN

"^

)'('(irs

Jfoff//is

)

,<x

/hir

(SIGNED) J AJU)jlA-vdfe"u. C ^

I lours
M.D.

SPECIAL INFORMATION only for Hospitals, jnstifutions, Transients,
or Recent Residents, and persons dyiog away from tiomc. »

Former or ^^^^^Y^^'^^''^ ^* _^ « How lonq at f

Usual Residence l>-^ '2>^x^^ hX*v Place of Deatli? liM:^^

Usual Residence

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

Days

I'l \CK <H' IHKIM, OK HJ-NfoVAl, I DXi'I'.of HiHiAr. or Kl-.MoVAI,

<x.i-

, n,h;ktakkk dUXLtu V «|^^

(Address Sbl^ ^ i^ tL 0 %

190 \

N B — Kvery Item o? 1„f.r.„v.tion should b. cn...'ully Muppllcd. ACIH should ^f-^^^^ty-^'^^'^^', . ^^^"5 '^':!^, f ""'**
Ttatc CAUSL OP DEATH in ph.in term., that It may be properly classified. The "Special Information for pT-
«on» dyinft away from home should be ftiven in every Instance.

n

WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD

1 11

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

Dfflr Filcif . iL /^tWv '

190\

Re^isfered JSPo.

;2158

<hV^O

Xxhu

^t6

put

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco

Certificate of H)eatb

( 'CI. S. i?tanDarD )

PLACE OF DEATH: — County of C)/Ol/>v^ 0 AXX>\Cc4C<) City of U/CUW J ^^XXa-l/C^U^o

ft)

N«.

nC

CrVA/^^M vbCHLK^.t<xl St.;

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

Dist.; bet.

FACTS CALLE
GIVE ITS NAME II

and

FULL'NAME '''^ -C>\\.u, J ,L\. d

>!:\

PERSONAL AND STATISTICAL PARTICULARS

J

hi

W-^ ■ .

i). kcU

r» \ I!', t »r- r.ik in

A«.i-:

MEDICAL CERTIFICATE OF DEATH

DATi-: oi- i)i:ath //>

il^^t

iVtar)

Ml. nth

ll

I

\) ^

tuRrm-!, M*).-

i State I ir C' ni ut i \

I)av

M..,'h

Am

,0X0/^^

f Month) (Day)

^1 lli;Ri:nV CI:RTIFV, That r atlc!i.!c-,MiMcascd from
O.CX; 2> looH to iD<*" ^

^=S

I90H to \^ s^'-J O iqo

tliat I last saw h A^^^ alive on ^ ^^ ^ Kp

and that <k-ath occurred, on the dati- stated above, at I I

S

M. The CAISI-: ())• DICATII wa^ as follow

I* 1

N \Mi-: ni-

I A IlIl'.K

lURrillM. \i' I-:
01 I VIIIJK

' state i.T I'ouiltl V

maii»i-;n x a m 1
ni- MoTlu.K

liiRTniM.Ai).;
<)t- Morn I-: K

(Slate (!]• I'miiit I \-

OiTt }• Xlin.N

0

w^A\,0

DTK AT ION Years

CoNTRIIirTORV

(j-C^u -

'^■S

&

Mouths

Days

Ih

oil IS

XJ\,Y^\,CL s

\

.^Ot^^XCL'

DC RAT ION

)V<//

1

(Signed ) J;

^'/tt- IqoH (A.ldress) bOt aX^lLt.\; ^t

Mouths

P ft)

Days

I Ion

rs

1

M.D.

/\i\i\li,f in S'lin i'l ii

lit 1^1' 1 1

),.l

Moiilh^

lht\

SPECIAL Information only for llospitdls, Instilutlons, Transients,
or Recent Residents, and persons dvioq JHay froni home.

r vTVVv<Mj,A.,.tr>v c)*b „ , . ft

Former or q n Hoh lonq at f

Usual Residence hAXT '2)Ax^*^ H-Uk. piare of Oeatli? li,f^^

^^ Days

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

Till-: AIIOVK STA'n-:i) t'HKSoNXl, I'AK riiM'I.ARS ARK IKI I-! T( > THK

in-;sr oi' mv kn<>\vi.i:i)<; »■; and in;Ln:t-

(n

1 f - . t ma n t M lV\4 W Vj fXsX^

/^XCl >%. ^\,

\<Mrc'

PI^ACK OK HlKrAr. (»K Ki:%T(>\AI, I D\T}-:..f II! HIAI, e.r KKM«)V\I

1 ^

,1

TQO

KNDi'.K iaki;k

N. B. Kvery item of iiifcirmatton should be cnrefully supplied. AGK should he stated RXACTLY. PHYSICIANS should

state CAUSE OF DEATH in plain terms, that it may he properly classified. The "Special Informntion'* for |»«p-
Ron« dyinft away from home should be i»iven in every instance.

•■'I

1 1

'r'l

I

WRITE PLAINLY WITH UNFADING INK

I Ihallh I- No. 1"; i-fi^^^ l'.\: i" C -,

THIS IS A PERMANENT RECORD

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

Dff/c nicd ,

ioLo-VM.;

K 1

100*i

Registered J\''o,

J^l59

DEPARTMENT ()F PUBLIC HEALTH=City and County of San Francisco

Certificate of 2)eatb

( Ta. S. StanCar? t

PLACE OF DEATH: — County of 0-'v\. J

'1

m

i "4 ■

City of O.OLAo^ 0 XO. .

No. SsSi cLow rL<„ , . .' ' . St.; H Dist.;bct. J.^.O„''vxf.. ■. and ^^' ^'.'.'^ '

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

FULL NAME ■ ■ > ' ■^.^:^^.?.^Jo^\oJ>\X^\^ JL. a . - . . ,v._:

PERSONAL AND STATISTICAL PARTICULARS

"' ^ I)

I) All-: or luK III

lOl.oK \

u

MEDICAL CERTIFICATE OF DEATH

DATK ()I- Dl-ATH

fl>av

(Vf.'ir)

M-iuh)

a(;h

li;iv

.^/...////^

rhiv.s

'-IN*. !,!•:. MARKn:i»

\\ iHi »\\ I'D <>K i)i\()Kii;n A

!f)i.

lUR Tiii'i, \ri-

; st:it(- 1)1 I'luiiitry

\ \M I- < >i
I NT 1 1 I.K

IURTHIM,Ail<:

<>i" I AT in: K

'Stall I •; I'mnitrv)

MAIIH-.N NAM I
t)l- MnTHHK

iuK'rmM.Ai'i-:

<'l MuTIIHR

I Statf iir t'dutiti vt

tK'Cri'A'lloN

<XhKxj

1

I HI{RI':HV CI-RTIFV, riiat I atUMi.U-.l .lercascl frnm

t. '(

I9O A

. 190 to

that I last saw h alive on 190

and that cU-ath orcurred, on the date stated above, at 'A oO

M. The CAISH OI' ni{.\TII was as follows:

LajvuK^mu^ ci

1

\Jf\h.^^r\\.^^:z a=Jw<io \

c

^X-C.\^-^

A wQ

A

^

DIRATIOX -^ )\iiis Months ' Pais

CONTRIIU TORY L-ixn^tAX a. <: JwA^vlC'

//

ours

h ^^

<Xjy

vcL

DI'RATION X\ )V<?;
(SIGNED )

[^

Mouths

Days

I lours
M.D.

HjO

(Address) 111 ^X£kJ

V.U

7^

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

M.>nth'

Iht I

Tin-: A Ho VI-; sr \ nn pkksonai, tar ifitlaks aric rRii-: in
Hi;sT Ml Mv KNt)wi,i:n<.K AND in:i,n;F

Tui-:

Former or
Usual Residence

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

How lonq at
Place of Death ?

Days

(Inf.irtiiant

CL/^ ^

«w I V ^^..

AM.

ri.ACl'-, OI- nrRfAI, OR RHMoVAI, I DATI -•! lu hial or RliMoVAI,

INDl'.R lAK MR

(Ad.li, s^

JUL -A

N. B. Bvefy item of Informntlon should bs cnrefuli^' supplied. AfJB should he Htuted EXACTLY. PHYSICIAiNS should

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

t

\4

¥

WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD

! X.)

r>i'.&i' Co

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

i

Ljl^ T

lOO'i

J^eof\s/e/'('fl jYo,

.'31 f >0

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco

Certificate of IDeatb

No.

PLACE OF DEATH: — County of

\'

city of

^^

St;

Dist.;bet.'

and

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

/^

C" Oft

*y

FULL NAME

A

U)

PERSONAL AND STATISTICAL PARTICULARS

V. \ ii: < >i r.iK ni

,'%

11' ct

IQ

I I v
^INt.I.I-* MAKU!i:i>

U'litf ill -H-ial lit-ii-iiatiDii)

a.:

}/.»,///<

MEDICAL CERTIFICATE OF DEATH

DATK «>F DKAIH , \

I (jn

(VtMI

n,

\

lUKTfll'I.AOl-:

I stale (ir Ciiiiiiti \'

NAMJ. «)l

I' A 11 1 }.:r

FnKTHI'I.Ai'K
ni- l'\!I!KR
'Stall- (It t'ciiint ! \'

MAini'.V NAMl'

ni .m()thi-;k

HiK rm'i.Ai'K

' Stall III iduntrv^

i)*'Ol TAllON

^

( I > ""l I

I Ml lilt h- <l»ay)

, I m:Ri:HV CI:kTIF-V, That I ittrii.k-.l .Icceased fn.ui

' ■ ' • I ♦

■ ■'• I 190 . t«» - ' up .

that I last saw h - alive on <■ . j t</> S

and that (k-ath occurred, on the dati- stated ahove, at

1

■;^M. The CAr:^!^ DF DI-ATII was as follows:

\\m\^

^'^ r\

n^^-

ci

DlkAI'ION
eoNTRIl'.rTORV

Months

/hiv

I/oti rs

nr RAT ION }\'ars J/,.;/ Ms

( SIGNED ) lC>UxJuiH. J^^a-
'- Iqo (Address) ki \j

Pavs

//ours

M.D.

Si

K^K K I

C WA >.A„

Special Information oniv for HospiMs, insmutions. Transienh.

or Recent Residents, dnd persons dyinj av»d) from fiome.

AV,\/(/?',/ > >l S,;t/ /'liill,

) ,

^/,:>lf/i

/>„•

THl \I',<»\K STXTl'I) I'KKSnXM, 1- \ KTliT !, \ KS aKK TKIK To TIIH

lU'lsT oi- MS K xi »\\i,i:i»(; !•; and in:i,i];F

i, Itifii:ij»;nit

Former or
L'suai Residence

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

tloH long at
Place of Death ?

Da^s

(AfUlrcRS

PI.ACKoi- lURlM, Ok HIOInVAl, | IJATI*,,*- FliRiAt or Ki:mo\ai,

A, Ml

N. B. Every Item of Information should be cnrefuily Hupplied. AGE should be stated EXACTLY. PHYSICIAIN8 should

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

$ )i

t! Ik

I

f

WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD

H 1 .1 1 1 !r I- N'o. I > t"^^-^^:, JUt I' Co

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

m

Da/r Filed, U^cIchUa; 7 10 0\

\.^\j<j<Js JlIamj Deputy Health Officer

Registered J\'*o,

a

DEPARTMENT (JF PUBLIC HEALTH-City and County of San Francisco

Certificate of Beatb

p

( TH. S. StanDarD )

^

PLACE OF DEATH: — County ofOxX/Vu OA.^t'-^xcUtoo City of 0<Xax» ^J /ucl/w/o^axmd
rN©XuwU^Wu^'\Xu UJl^^v^U.CU.c^St.; Dist.;bet ^ — " — and-~

A f \r DEATH OCCUfWB AWAY FROM USUAL R E S I D E N C E G I V E FACTS CALLED FOR UNDER "SPECIAL INFORMATION" \
1 \ ir DEATH OCCiLrRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. /

FULL NAME

L

. (X'U 1.

PERSONAL AND STATISTICAL PARTICULARS

C<)I,<)R

K f^Uli

DAii-: ()(■ iukin

1
(

Month)

4

Ic .

MEDICAL CERTIFICATE OF DEATH

DATK OF I)1;ATH

%

(I)av>

Month)

I Vtari

\ I . 1-;

) id I s

Dav)

Mnnlh:-

'■/.■;nJ

Da ]

^

siN(,i,K M.\Kkn:i)

iWiitcii! '-(icial di-^if Tiat i( m >

HiKrm'i.AOK

(State t>r Country

I

tCUUu/tO

I 1II:R1-;BV CIIRTII-V, That I attoiKU-d decvascd from

•^^q XL 190 'i t() ^^ ct ^ 190 H

that I last saw h . ' alive on ^' w\!; ' j^q '.

and that (loath occurred, on tlie dati- •staled ahovr, at
M. The CAlSli OI- I)I;aTII was as follows:

\ \Mj; ni

I A'l'Ill-.R

HiR'rm'i.At/K
<)(■ I Aini-:K

(Sitatt- or Coimtrv

NfAini.N XAMl-:
<>l' MOTIIHU

lUH'rniT.ACH

OF MoIHI-'R

(Stat, i-r Couiitrv

niRAriON )W7/-,9 1 Months 1 !hi\s Hours

CONTRinUTORV

DIRATION

(Signed )

Vcais

\

OCCll'ATIDN Cr^ .

Uj. \ . Wv^i

\ 190 H fA<1dre^s) Li^t

Miniths Pays

M.D.

Yy\JiLM^<:s\.

Special Information only for Hospitals, institutions, Transients,
or Rfcent Residents, and persons dying away fro.ii home.

Ni'siiiril III Sail I'l am nrn

) rai

M.nifli^

lhi\

Former or
Usual Residence

Wfien was disease contrarfed.
If not i\ place of deatli ?

How lonq at
Place of Oeatli?

. Days

rm: kmovk stati'.d t'Hrsonai, I'ARTiccr.ARs ari; rKri<; 10 tiik

r.IsST ()!■ Mi\J<N-(>\\Ij:i)C. H AM) XW.X.W.V

(Iiifiirniant

rAfl(1re<4^ V^JC'WA-Ax^^U^-W

kAM

I'l.AClC (11 IHJJIAr, OR RHM<»\ \I,

DA^jK..; H' HiAi. or Ri-IMOVAI,

I NDllKTAKKR

V

iN. B.—— Every item of informntion should be cnrefully Hupplied. AGK should be stated EXACTLY. PHY8ICiAiN8 should
state CAUSE OF DEATH in plain terms, that It may be properly classified. The "Special Information*' for par-
son* dylnft away from home should be feiven in every Instance.

3:

%

H •'! 1' X,)

WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD

•■^^^-' I'^^I'^''' REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

A

100 \

Registered J\^o.

2±m

Dale /'y/r^/,A/etxrUt\; T

Km^k,^ Ix^ Deputy HeDfth Officer

DEPARTMENT k PUBLIC HEALTH-City and County of San Francisco

Certificate of IDeatb

( Ta. S. StauDnr^ )

%

0^

PLACE OF DEATH: — County of ^^OJ^fK, J \/\y-y lou-^^o City of Oa ^a. J V<Vv\.cc4 co

Ng. . .U , XLV. R-t^ ub 5-4.1 vCtaJ; St.; Dist; bet. and

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

it

FULL NAME

CuW,».

V 1 f

^i;\

PERSONAL AND STATISTICAL PARTICULARS

L'nj.uR

(71-

.OJ
i>A ri: ni iuK rn

\\,V'

\

MEDICAL CERTIFICATE OF DEATH

DATl-: (»!■ Dl.A'lH ,. \

IL'ct

IQO H

(War)

H

5 ■,',/;

Dav

M.niii,

\ (MI

I his.

SIN<-.I,K. MAKKll-:!)

wrixnvKD or nivoRnr)

iWritfin socinl (li--i<.''!iati()!i)

HiK rm'i.AOK

'Stnti f)r CDUiitrv'

C

K.^r\j

/CUaJrCV>X^O

NAM! ni
I- AT H IK

lO^iL ^'

lUk 111 PLAr!-:

ni I \iiii:r

' ^' .\\' > < i ■, ,1111! r\-

ma!i>i;n n\\ii.;

<»1- M«)Tin,K

luirnn'f.Afi-;

<>l- Morill'.R
' Slati I ii ('i luiili \

tKAii'A'i ION-

IA a. VL^

(Mouth) (Day)

1 in;ki;nV CI;rTIFV, That I attended decvasL.l fmin

OjJfJj ^0 190H u. i)^ b r,)0 H

that I last saw h alive oti ^^ ~t t. 1,^^

and that dt-ath < HHurrcil, on thi- datv -^tatid aliove, at

V.'. M. The CAISI-: (»I" DKA Til was as follows:

Moil tin \ Pijvs IliUits

1)1 RAT I ON )'cavs

CONTRinrTOKV

L 1

I )r RATI ON

SIGI

Years

1) ^:

/Vl

'V

p

Hours

M.D.

^ b r.,oH (Ad.lnss) lol gx^tU.\; It

SPECIAL INFORMATION only for Hospitals, Institutions, Transients,
or Recent Residents, dnd persons dyinq away fron home.

-OVA-v^a

AV' '/(//./ If Sin/ / I it III f<ri> i ) ' 1/

^/.„>^/,s %% /)

Former or 1 « ^ 1

Usual Residence IclHn (J^Oj^ •

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

How lonq at
Place of Death ?

Days

Tin-' Ai'.ox'i-: ST XT! i» I'l- !^s( »\- \i, i' \ k iKT !. \ ks A k ! ; Ik I )■. i'l I rn i-

HJ-.sr Ol- MV KNi )\\ l.l.lX'.H AN!) in'.Ml",!-

1' In fi I! ma tit

ih

\A

lO^j^-y^j H^^ct'ut

fAililrt'SS

3.HH

V

<XX4 " '■

I'l.Ari-: or iuriai, or ki:Mo\\i,

M LOLiv<X' La.A
r M > 1 ; K r A k i ; k uId . vT • \JJLLji\AJi/y

1>A I 1; .: lu I ' M .,T K I-.M(i\AI,

i) -I

■i

190^

N. B. Every Item of inf.»rmHt!oii sHduIcI b.- cnrefuliy nuppllecl. AGK shoiilil be Htiiteil r.XACTLY, PHYSICIAINfi iihouid

state CAUSE OF DEATH In plnin terms, that It mny be properly clasnified. The "Special Information" for per-
sons clyln^ away from home Hhould he (^Iven In every inntance*

;?i

«

M

i

N<

I

1< i;i r (1 Ml

H( ;i!t!i (■ N

WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD

lU'vl' f

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

/hf/r riJr<l, 0<±,(AM^' T

JOO'i

llciiistei'ed J\'*o,

?aiG3

•jf

,CrV,'w^:! K.A.

DEPARTMENT OF PUBLIC HEALTII-=Clty and County of San Francisco

dcvtificate of ©eatb

"U. S. StanDarD

J? iTJi)

.?

PLACE OF DEATH: — County ofU^X^ru 0 VCLAVC^^iyCoClty of C)<X/>^ vJ AXXy>^CA^<lo

^

Ne,

i^ OAirrv (fb 04..Wla IvSt.:

Dist»; bet.

and

/ IF DEATH OCCURS AWAY FROM WSUAL R E S I D E N C E G I V E FACTS CALLED FOR UNDER SPEC
\ IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION

GIVE ITS NAME INSTEAD OF STREET

lAL INFORMATION' \
r AND NUMBER. /

FULL NAME

M I Lojvu V . cL<X/V> uC , '.

PERSONAL AND STATISTICAL PARTICULARS

DA il-; (»1 lUKTII

L'oi.oK ^

u

M^

I.inthl

A(.i-;

-'i^ ,. t

1A.>/M«

^l

» t-a r

I hi

WIDnWi-:!) « »K i>i\( iRi} I)
iWritrin «-i(oi.il il< '-.i<..iial i.in>

lUK rui'I.Ai^H

' St.'it f or • 'on titrv)

\kaxj5^

Crv* ^ ^

MEDICAL CERTIFICATE OF DEATH

UAl'K OK DKATH li'N

fMnlllh)

,, I in-iklU'.V CI'.RTII'V. Til It I aUeiuled (ItHH-ascd from

%

TQO ''

)a.v)

iVt-at )

ax^Al.

iPctj 3..

i</i> . to ^ v-VJ v:> i(p

that r last saw h •.. ali\i oii C 6 Kp

and that death ncrurrcd, oti thi- datt- stat(.-d al»()\X', at
M. The C.MSi; (M" l)i;.\TII was as follows:

i\XA,*^-"

I

nIVA. ix,<XA.^< ,

\- V^ > wCL

h r.

^

0

fS s

luR I'l iM.A( i:
oi- i\iin-;R

' St :it I » il k' i in Tit 1%

M\n)i:x NAM)-: a

F.iR ini'i, \i'j-:

oi- MnriliCR

(Stat',' iir Coiiiitrv

n(,'iM I'A rioN

\ '

I )r RAT ION ' )\a)s
CONTRIIUTOKV

DT RATION Ycat'S

(Signed) o, ou'

Months

Pays

/fours

Moni/is

/hrv

l^'L.

Ilonn

M.D.

u

f«)n

(A.hln-s^) \%\ ^-t<XAA.

^

SPECIAL INFORMATION only for Hospitals, InsWutions, Iranslcnts,
nr Recent Residents, and persons dviny away from home.

kD4X/>-

h'r :,!r ! ni Su >/ I

I ,1 i.'i ;mi>

}y,!

M.nii;

i>,i

I'll i: \H»)\'i'. sr \ri-:i) i-krsovai, rARricti, \rs ari-: pr r i:
iu:sr «)i Mv Kx<)\\i,).:i)r. !•; and i'.i;i,n';i'"

I'l > I'lii",

(Iiifonuant

Ktr>Ay V^ c3C<X' ^-^ V C

?l

f Afldrcss

CL/A-wtA-^O

Former or
Isual Residence

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

r\

How lonq at
Place of Oeatli ?

%

Days

i'Xt^CK Ol'" IHRIAI, OR R1':Mo\'\I, jl)\ru,,: Hi Ki.u, ..t Rl':.Mo\ \l,

(i

CLA'AyU.'CrA

^^

\

11

lool

! '.. K.,'

(Address sLbblo \I iVvO^ wo *

N. B. Every Item of inforitiHtion should b.- ciire»'uli> supplied. AGE should be stated EXACTLY. PHYSICIANS should

state CAUSE OF DEATH In plain term*, that it may be properly classified. The "Special Information" for per-
sons dying away from home should be given In every Instance.

0

o*

I

"f""^

1$ I
I

^1

'1 i; 1

WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD

"/ \ i *'., REFER TO BACK OP CERTIFICATE FOR INSTRUCTIONS

Dff/r ri/rd ,

7

IDO'i

liro'/s/e/ed 'A^o.

2104

I

-Cruuv^

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco

Ccvtiftcate of S)eatb

( XX. S. StaiiPar& )

n

i

PLACE OF DEATH: — County of A "tAj J/UX^/vCUSyCO City of aw J AXX/wXlA^<^0

No. I o I ^ ^.y^ K^O^iijuu- ry.AJ

V

4^

^

^-a,x;

'i) K^<k.<X.Kju- Cs.AJ St.j i Dist.;bet. (laiycUl and --^-Q

(ir DEATH OCCURS AWAV FFtfoM USUAL R E S I D E N C E G I V E FACTS CALLED FOR (^NDER "SPECIAL INFORMATION" \
IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. /

FULL NAME

cCrXax

1. h -

..K.h

PERSONAL AND STATISTICAL PARTICULARS

•Ml. nth" .l):i\i

MEDICAL CERTIFICATE OF DEATH

DATi-: oi iii;a'i'ii /

'Month t

Dav)

rgo :

) .^u^

M.>„f/i'

iWvnx

r>,t\.

\vii)M\vj-;n OK niviu'.ti I)

'NN'r.tc in •«iiii,ii fh'-i^'iiatioii )

UA '■ .

liik riiiM, A*M-:

(Statt or Ciiiititrv

N\M1- <)!

I- A rn i;k

HiK rin'i.ACK
OI" lAiin^K

' ^tat'- or t'dtuttrv)

MAIDllN' NAMi:
OI' MOTiniK

niRTiiiM, xt^i-;

Of M( (THICK
ISlatf or ('(unitrv

oi'Cri'A TION

r

I IIHRI-BV CHRTll'V, Tliat I attc-iulcl dturascl fn.iii

Ui^-CLA4 ;: 190': In ^xAni 2)0 I()0 U

tliat I last saw ]i - alive on jJU'^.. i,p

and that (Icatli orciirrtMl, on the dati- -^tatt-)! al)()ve, at 10

>

W.L M. The CAT SI- OF I) HATH was as fol!..\s^:
%

I i <

u

1

A

nr RATION

}'i;ais

Mo'i//n

fht

rv

I /out s

CONTRIIUTORV

DlRATIoN

)'cars

-\

Mi>ll(h.\ o /?r/I',V

^

i i

(Signed) nHI. U. KJ ; -» - ,

//ours

M.D.

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

Rr.siiii'if in Siiir I'iidi,

i r,a>

M. ml li-

no IV

Former or
L'sual Residence

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

floH long at
Place of Deatli ?

Days

Tllf, MU)\'f: ST \l"in I'J'R^nN A !. PA K I" r< ' f I, A K - AK ]■; I' R f 1-

nf:sT of MV KNOW i,i;iH,i.: wn lujjf.i-

^

I'o TIIK

Itifonnattt \j<J

KJ

<X/^rsi\j

I

f Address

^

A

I UUl-

DAXi-: o! Hi KiAF. or Ki;mo\'AI,

T9O i

I'fACK OF BfRlAI, OH KKMo\AF

mo I:

^>St--'v*

IN. B. Rvery Item of informntioti shoultl be cnraV'ully supplied. AGR should be stilted EXACTLY. PHYSICIANS should

state CAUSE OF DEATH in plain terms, that it msiy be properly gftissilried. The "Special Inlrormation" for pap-
sons dyintl away from home should be Jiiven in every instance.

Nlii

I

I

WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD

ill!; l- N.)

11 Jff ^^»%^

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

D^f/r FiJrd, llJctcrLux; 1

100 "{

Begisfercd J\'*o.

;52165

.<n.>Ly^w^

DEPARTMENT Ot PUBLIC HEALTH=City and County of San Francisco

Certificate of S)eatb

PLACE OF DEATH: — County ofOcXy^^ I A^CL-rx^cuiXoCity of ^

i

^No.

\J

\> J.^<xrrcei V

^^^•^ '.'V. ^<l'v^.L.'A. St.; Dist.;bet. and

(IF DEATH OCCURS *WA!V FROM USUAL RESIDENCE GIVE FACTS CALLED FOR UNDER "SPECIAL INFORMATION • "\
IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. /

FULL NAME cLc^^v V<,)0

Ic .

--I

PERSONAL AND STATISTICAL PARTICULARS

'V

I' \ I'l-: or- lUK III A

4 I LoX'

M.mtli'

\ " . !•;

^I\r, 1,1*. M \KH ij.j)

\\ \ i>i i\\ i:i) < »R iM\< M<r i:i>

i U'l it< ill V. ,( i;i ; ili^ii' n:it ii in '

:>:iN

M.nif/n

MEDICAL CERTIFICATE OF DEATH

DAii-: oi' i>i;\Tii ,| \

( Mi.lltlll

(I»av

(Year I

I m-KIU'.V CI'kTH'V, That I attcMi.le.l .Itcvav^cl In. in

/»,,

i

lUk I'HPI, Ai'l-; 0

' Mati or ('iiimti \ ' jf

Xa

»■ X III i-;r

lURTin'I.AtK
<>1 l-ArilMR

■ ^l.ltc (H I'ninif I % '

M MIM.N X \M)
()l Morill-.R

lUKTlMM.Ai'l.;
nj- M«»rii|.:K

( Slate or I'outiti % 1

i

90 \ to s-^ V,V J i,p

that T last saw h v. alive on ^ -X "T: i,jo

and that <lcat!i (KHnirrol, nn the »lati- stated al)<>ve, .at v 15
M. Thi- CArSl- Ol' I>i;.\TII was as follows:

1

>veuXo \' \^ <,\.^c^

'7

.^

IHR ATION

CONTkllHT

i''-'

Ytixrs

Month

\

( ) k \' c)

m

ix^^^^tSw.

i '"IJ.

Pay

HoiitR

DlkATION :^ Yens Mo)tths

(Signed) ^l j ^xxxx

MJx.<U.JL<xA,'

Pavs

r\JLt

Kt'^iiiiuf III S,iii t'l n III I >i'ii \

t^Cl;

1 90

Hours
^ M.D.

Special Information only for Hospitals, InsmMHoBS, Transients,
or Recent Residents, dnd persons d)in9 awdy fro.n home.

! iiu

t;, M.„lh-

IK

Former or 1 y

L'sudI Residence "^ WL<Xu,

When was disease rontrarted, 0
If not iX plare of death ?

1

How lonq at

Pldif of Death ?^ > >i.(^i.J^Oays

I" 111'. AH(»\'i', sTA'n:n i'»-i<sn\ \i, p \k ihi i, \k-, ak 1; rkii-: lo rin<:
HiCST ni M\- iyN'< >\\ 1,1.1)1, i-; \M) ni;i,ii;i

f !iifoiinaiit

0

' Nildie-ss 0

^

a

PI.ACi: Ol- lURIAI, nR R|.:m«i\aI, j l»\l!;..( lit MiAi, or RlMnVM

.O^CcC \w€

TOO

y

N. B.— — r.very item olr ittfuf million Hhould b.« ctirtifiill.v Huppliecl. ACIli whoiild ho Htnteil HXACTLY. PHYKICIAN8 nhould
HtHtc CAlISli or Dl: ATM in plain terms, thiit it miij he p?"upcrl> cluimiiiieil. The "Bpeclal Information'* for pmr-
monn dylnfi tiway from home Hhonlil ht- ^iven in evory inHtnnce.

I

I

WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

Ddfc i^i/('(l ,

Be^isievcd JVo,

^1G6

Deputy Heclth Officer

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco

Crvcu) civ.

Certificate of H)eatb

PLACE OF DEATH: — County of^Ct'-rv JXOxCC^co City of'^<X/>x. J A.<X ^-..ci^^co

N^.vy ^AJl.

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

.ALi .'. . V St.; — Dist.; bet.

FACT
>EATH OCCURRED IN A HOSPITAl. OR INSTITUTION GIVE 11

FULL NAME

and

\llqA.u > K,

^ \ : \

i) \ri; i'l liiKTii

PERSONAL AND STATISTICAL PARTICULARS

foLoR A

MEDICAL CERTIFICATE OF DEATH

II I

+-

■^ / ',

Ai.l-

M.Milh)

5'

Dnvl

V,.,,/^.

Monthi

I>riv1

/go ,

(Yf.ii

I in-RI'lJV i.'i:RTn'V, That I atu-iitk-.l .li-.t-ascl frnm

V ^ 5 ,.^ H

1 ..A. . 190 . til

that I last saw h ' ■ alixt- on

/>■

^l^:•.I,l■. MARklJ'I)

u nM»\v}'i> OK DixoKi i:r)

I U'l iti ill -I H i.ii ih ^i^- iiMli'iii'

"-•tilt I I ii t, 1 >niitr%* '

w (

NAM) til
I'AIH I-.K

lUK 11! I'l.At'K
ni I \ 11! i.R

MAIUKN' NAMl
ni- MOTHKK

(Stalt or I'liiinti V

A'/' ',/,'//'(/ ,'// S', /;/ / I

%^

apJ that (hath orfiirrt'd, on tht- «lati- '-latifl aftovt', at
^.--. M. The- C'AI Sli Ol" l>i;Aril was as folluws:

lc)0

1

x<k

K^O^Kk

I )r RATION y^ )'tius^ MoHlhs

CONTRNUroRV .Ct\A

Pay

%

Lb

D

rvcoxa

DIRATION
(SIGNED)

i()n

rA.hlnss) 13.1 M I

/?rt vs

Hours

- -3

re.?

': §^

//out s

M.D.

C c

^^

Special information onh for Hospitals, Inslituflons, Transients,
or Recent Residents, dnd persons dyinj dway from liome.

Former or "^ ^'l

) t'li I

1/,,.////,

fhi

vnv. \m)\'V. HTsrin pkkson \i, i- \h i iti-i.AKS ari: i'kiI'; to in i-
ju;s'r oi- ?,n* knoui,i:i)<,i^^m» inijii-

(I

"?)

f \<i(i!<"i< ( 6 ^ \J

0UCUA<..C

Ai,

:5 H ffow fong at

Usual ResidenceO/O/^rv J/uOAxCAA^t Place of Deatli? ^^Xi^x.'.... Dms

- - ' ^ '

Wfien was disease contracted, p.

If not at place of death ? ^ ' <X-y\j 0 ^_<X/>vOUl/ao

T0O*i

l'U\i"K OI- lUKIAr, OK RKMo\ AI, j n\'ll ;<,f IIihi.u, or KICMOVAI,

(Atldress . .

N. B.-^F.ver.v item o* Inlformatloti ahould be CRrefully itupplied. AGR should be stated RXACTLY. PHY8ICIAINS should
state CAUSE OF' DEATH in plnin terms, that it mny he prtipcrly classified. The "Special Information** for p«i—
nrtnm dyin^ oway from home should be given in every instance.

i

;l

\4

|;-;ii.

WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD

f !I alih 1 No 1^, ^ ■^D'- H^^lOu REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

Drf

fr FiJe<L VdiAyXA) 1

cL^CrO-^*^

Deputy Health Officer

Be^isfererl Mo,

216?

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco

No.

Certificate of Beatb

( U. S. StanDar^ ,)

' • -. City of Cj/Oax/ J AX>. .

\
St.; \ Dist.;bct. ^O \ H ^ , and ^

(IF DtATM 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. /

PLACE OF DEATH: — County of 0<xov -J Xo

C r A M,

^'

(

FULL NAME

YY

Vri

W . ! - r !

-•I-.X

PERSONAL AND STATISTICAL PARTICULARS

A i idl.oR

DA 1 i; ()i IliRTIi

'J

u

n.

.%<*. K

«IN< ,1,1' M \KI< nil

n^'IDmu i-;i» (»K i»i\ ( ikii:i)
Writfin social di -.ipn.itin!!)

lUR'nipi, Aoi-:

I St;it( I i! < 'i 111 nt ! \

i I».l V

Mxiiln

\ cai

I 'a !

Alcd

NAM I-: <H'

I AT III-; R

lukriii'i.Ai!-:

iStatf nr Count! V

MNini'.N NAMI-

<>i- Morm-R

IUR'rH!'I,Ai"K

OF M<>riii.:R

' state or ('(lunt I \

MEDICAL CERTIFICATE OF DEATH

DATl-; «)1* Dl-.A'I'II

1 1 i

' ' r

(Month) (Day)

I^m-Rl-.HV C1;RTII"V, rimt^ I at-cn.U.I 'k-irascd fi-.iii
SskXa^ \L ryo ^ to . ll'/cfc b itpM

that I last saw h •'. ' alive (ill sii/cli ^^ Icp'l

.111(1 that (Uatli (KX'tirrcd, uii tlit- dati' statc(l abnvc, at l- lO
LL 4r. The C.XrSI' Ol- |)I:.\TII was as follows:

(Vi .-ii

C

<X\/CW%'V.'0^'V>'\XX,

<A

n

1)1 RATION H }'(Uirs Mouths

C'ONTUinrTOKV \jOJ\JV ^ \ K.X.

/hns

] ) la. y VA.

I/ON

rs

H

I )r RATI OX ^ >''<^r^ U<iN//,s- /)av.s'

( Signed

OXKrrYxx^^^,

orrti'ATioN

h'l'' iiii-if III Siiir I'l i:

ID^

1 icpH (Arhlrc-^s) 15

V NflflxXAjul il

I lout s

M.D.

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

)'rai

M.o'th,

Ihn>

VUV. Al{(»\ K ST X'I'I'.n I'KRSONAI, I' \ K r H' ( i.A K S ARl! IRtl-: To Till-:

iu:sr ui- M\ KN( »:^ i,i:i)<; K and iu:iji:i"

nnroiinnnt

Former or
Usual Residence

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

HoH long at
Place of Death ?

Davs

I'l.ACK <)1* IHRIAI, OR RKMn\AI, | DXri:.' I!?Hr\r. or Rl-MnVXI

/Y\X<X,

n

tNH)';RIAKI-:R '^^ tx.

I Addi i-s'.;

IQO

^VkA.t ,

N. B. Bvery item of InfnrmHtlon should bj oirut'ully Nupplieii. AGB Hhnuld he i«tAtecl BX4CTLY. PHYSICIANS should

state CAUSE OF DEATH In plnm tcrm*t. that it mny he properly claasiliied. The "Special InformHtion** fop par-
sons dying away from homa Hhould he given in ev«ry instance.

^

H^

A

WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD

!i,l of iicnUti I- No. I'; s'^ =^^^^ nsz)' r.)

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

If) a

DEPARTMENT OF PUBLIC HEALTH

BegLstei^ed JS^o,

^1G8

City and County of San Francisco

Certificate of S)eatb

City of

A

9ri

\_<X/>^<:aa^c>c

PLACE OF DEATH: — County ofUO/^r^ JXa tv
Ne. J AJl/^ VC Ki (J\jCy<LKa_nu St.;—- D{st.;bet. —and

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

FULL NAME

VVYV \

rVYv \JCrcc4CL

sj:v

PERSONAL AND STATISTICAL PARTICULARS

1(11, Ok

\<xU

II

HA ri" III i;iR Til

\ « . !•;

MEDICAL CERTIFICATE OF DEATH

DATH OF DKATH ( fX

■ct

iQo'i

(Vc:ir»

■-, h

^IM.I.I" MAKRfJ:i>.
iWritcin ■^•MJal dt -ii- ii;it u 'ii >

HI HI' HIM, \0K

' Stati i>r Ci itintrv

)V<n

Dav

M.>t,fln

f'h'i'\

t I a I

/>u\

\a ' '-^KjuL

(Mo!itls> <I)av>

I HI-:RI-;1',V CI:RTI1"V, TIimI I aUfntU-.l .Itrva^oil from

^ ..•^:, ,x. ■ •- U)0 , t<» ^^ u^' i i()0 1

lliat I List saw h ■ alivt- oti A. up

and that <U'ath Dccurrcil, on tlu tl.iti- <tatt'<l ahovi-, at ' oO

.'. M. The CAISH OF DFATH was as follows:

.1 , ,'^

LLcLA^Ajtx ^Lcri^OL^u 'J

•\yULKA

'\

N \\f)' OI-

I A I 1! i;k

HIR'lIII'l.AOK
Of- l-ArilKK

' State < ir ('i miiti %■

OI- MOT I IKK

liiRinri.At^'i-:

OJ- %i<tlIIHK

(Staff i.r CDimtrvl

0
(

v

(

Dr RAT ION

Viars

^'

.^/i>llt/lS

/\u

IIoii)

CONTkllUTORV

i • "t

y^w

iun'iT?!

J

^VCX

oriTl'A'i"ioN"y

AV,;,/,

DURATION 1 ii^/;-^ b .}r,>nt/is

Ihiys

(Signed)

U . k,-

Hours
M.D.

ll)0

(A.Mn

•s^) 15 \ j.tcLLA.S; jL

Special Information only for Hospitals, Insfltutlons, Transients,
or Recent Residents, and persons d)lnq dHdv Iron home.

Former or
Isual Residence

Ho*» lonq at -

Plareof Death? 4H Oavs

// >^! IJ I I il 11, '.-III I.

) '/il I

M nllh-

lh-S

\'\\V. AT50V1-: STATi:i) |M-R^M\ XI, I'XKTICri.AKS AK1-: TRIK '1<> Till-.
Hl-.sr Oi- MV KNOW i.j I)( .f; AM) p.i:Mi:i-

(Infn.niant U^Mr\X^'CL Vj '

Oiw\.cinX

N.Mn.s IIH^ VJcnJ^ oi

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

rijACK OF !U RIAL ok KKMoVAl/j IiAII'..* Mi imai. or RKMo\AI.

^ \ -\ "-

^NI»1^K lAKKR H. . i 1 *.

d O-CLL'^ '

(AdchcHS

S.05Jsn\>rrUxv^>v\^\i^ 'I

IN. B. Rvery Item oV inirof motion should hi cnrefully Hupplied. ACJB shouhl ba Htnted BX4CTLY. PHYSICIANS should

state CAIJSII OP DEATH In pltun terms, that it may be properly classified. The "Special Informiition*' for per-
sons dylnUt away from home shoultl he i^iven \n 'jvery instance.

i
I

WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD

,,f III nlth I" Vo. 1=, X"-!^ :=fv.;,>; ]>,f:^i> (_•

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

Dafr /vV^v^ U/ctX^

T

190 "i

Kc^lstercd J\^o.

O

169

'^^A^

0 n \ I

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco

Certificate of IDeatb

( "a. S. StanDarC* )

PLACE OF DEATH: — County oiUKXrrx) J VCu^vCUi/CoCity ofC Oa^ J Vcx. Tvc-^x^'a

o

,'0

Wo. loll LcxJl\X) St.; 'l Dist.;bet. IH.IK and \'.-

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

FULL NAME

CL\.C'tX^

(\ D?

cuVt '..

PERSONAL AND STATISTICAL PARTICULARS

UWV. «)!■ lURTII j^

m

I go

(War)

\r.K

(Moi

\

fh>

Uav

MiOlfll!-

\ (at

A/1.

•^ IN 1. 1,1' MXkuii'n

U ! IH t\\ TI » I (K It i\'< >R.- I' I)
' \\ ! it! in ■-III i;i 1 ill >-i;' !lat •< 111 I

^'W^

L

lUK riii'i, \oj-:

"-"tit I I ii < I mill I \-

I AT in; R

I'.ik'rui'i.AcH
oi- I Arm-tK

I strife or Cijinitrv

MAtniCN NAM1-:
')! MoTriKR

inurni'i, \( !•;
<>!■ M(»tiii;k

(State iir Ouunlt

< H(. ri' \ riox

MEDICAL CERTIFICATE OF DEATH

DATl-: Oi' nivXTH

-. ± ".

(Month) I Day)

pi HRRI-l'.V fliRTII'V, That f attendtMl .UhcischI fruiu
OjJ^ T 190S to L^'Ct b TQoH

that I last saw h -thj ahvc 011 vL' ct b up H

and that dralh orciirred, on the <latc stadd above, at O
LLm. The- CAl'SIC ()!• I)I:AT1I was as follows:

n n

nr RAT ION )'i'ars

CONTRIIHTORV

Months

Ihiv

//ours

DTRATION ^ VCi^rs .^ .Vou//is

'2

^

^^-y-d^-

^^y^xX wLj. A u^

Jl

(Signed )

/)(7VS

//,

!]

CrV^

ly.cfc 1 IqoH (A. hi less) H^b^

^

(Stirs'

M.D.

p.

A'^A.A'yv

SPECIAL INFORMATION only for HospiUls, institutions, [ransients,
or Recent Residents, and persons d>in;| away from liome.

f\f,i,h'ii ni Siift /'iiiiiii^iit

.1A.„'//>

/),/

Tni'. \H<)\'K s r \ 11: 1) iM'"Ks<)N- M. I' xKiji'i I, \ks AR )■, vuvv. I" > m \'.
iji-;sT <)i- MN KN'i>\\i,j>i)(.i-: ANi' iu;i,ii:i'

(Fnfii'iiiant U

0

^\ii,ii,sH 1 3) 1 1 L/QuitA.^ c)i

Former or
Usual Residence

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

How lonq at
Place of Deatli?

Days

T90S

PI,A01<: ol- lU KIAI, (»K KI:M(>\AI. I liAXi;-'! HiHiAi. or KIM<»\'\I

I N 1 .i:kt \ K ) : K U <XLt.rLtX N fXoAAyvuk

N. B. Bvery Item of informRtion should be cBrulfully supplied. MW. Mhould be iitnted HXACTLY. PHY8ICIAN8 should

•tote CAUSE OF DEATH In plain tefms, that It miiy he pr<»perly wlamiified. The "Special Informtition" for p«p-
fion« AyXnf^ away from home should be given In every inntance.

3

■i'\

II

iJi

WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

IfJO'i

DEPARTMENT OF PUBLIC HEALTH

Be^istcred jYo.

J^l7o

City and County of San Francisco

Certificate of 2)eatb

PLACE OF DEATH: — County ofO,a/>v J.'U3^-»xc^^co City of U,(Xa^ J A ->

/ ^ _ -= W

No.

Q

0

\ N

iSu'i Mf ^CC<irvA^d St; M Dist.;bet >^^X^ and

(IF DEATH OCCURS AWAY FROM USUAL R E S I D E N C E G I V E FACTS CALLED ^O R UNDER "SPECIAL INFORMATION ' ' \
IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME t^STEAO OF STREET AND NUMBER. /

'-^

FULL NAME

o..

S^^s»i^

PERSONAL AND STATISTICAL PARTICULARS

iiAii; iiF HiRni

\'. iiflit

MEDICAL CERTIFICATE OF DEATH

DATl-: oi- Iil'AlU

( S"t a!

).. \

\< .!•;

SINT.I.K. MARK n:i)

wrn<>\VHi> c»K n'\ I »ki )-;i)

(Writfiii sc)ci;i' ill ■~iL'ii:it ioiO

lUK riilM, \ri"

: Stati- ..! 1'^ .init 1

lA

» i-ai

/',.' ^,^

OJxKxxA.

0

XX/rw

r>

XAMI-: OI
FA Til MR

niKTIlI'I.Ai'K

• )i- ! Arm':K

IStati (it Cdiitit I %■

maii»i-:n NA Mi-
ni M()i'ni;K

HlR'rillM.ACK

(»i' Morm-.K

1 stall lit l'( iiiiit I \

UiiTPATlON Qp

i^ % il

u

iM.mlh' (Day)

I 1I1:RI';1?V C1-:rT1I-V. That I attt-n.k'.l .Unx-ascMl frcni

^ O" '1 ■ * ^ . ■

\l 1 . .. 1 90 ti> I()0 ■

that I last saw h . aUvc on icp

1 A

and that 'Uath orciirrcil, on tlic dali- ^tatt-d ahi'vo. at \ '
^l. The

r^M. The CAlSf-; OI" I)l':ATn was as follosvs

DrRATlON )Vars

CONTkllUTORV

Mouths

Hiix

Hon

rs

\jX

YVCX<Lou

I )r RATION )■<<//,? Months

(Signed) cxaaalkak Wk^

Pil vs

T<)n

(A.hlrt-,0 llIM

U)

^ Kj

^

//out s
M.D.

Uii ...

SPECIAL INFORMATION only for Hospitals, Institutions. Transients,
or Recent Residents, and persons dvinj anav from tiome.

A'

AV.>/</i"(/ II! ^,/)/ /

^ ) '■./ '

\':,lfllS

/',>^

Till-; AnovK ST Ann i'i-ksonm, !• \r iim, \rs aki; prii-; to rii i-
in;sT oi- MY Kxt )\\ i.iix .1-, vM) iu;i,n;i'

(IiifoTiiiant

ijo, a. ^t

A '-1

( \(Mr<-ss

150^ Nf^\a^^,

Former or
Usual Residence

Wlien was disease rontracted,
If not at plare of death ?

HoH long at
Plare of Death ?

Days

&

M,AOK 01' HI RIAI, OR ki.;mi)\ai.

i>\ri;..' niin\i ..i Ri-;Mt>\Ai,

Tf)0

N. B. F.very item ok' inV'ormntlon should lie ciir«lfuliy supplied. AOB should be stHted KXACTLY. PHYSICIANS should

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

t

\

WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD

!J,.anl (if II. :l!tn I' N'o. Is T^l

'.K r <■

REPER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

Drffr F//r(/, ^//

1

loo'i

Mo<lLstcre(l J^'^o,

2171

Deputy Health OfTicer

DEPARTmENT OF PUBLIC HEALTH=City and County of San Francisco

Certificate of IDeatb

( "U. S. StanDarD j

C) /QWX J O KjO^'-^/X jOA^C.^ CA t V of C ) ,<X.ry\i J

No.

PLACE OF DEATH: — County of "^ J/(X/Y>J Oy\xx.^wx:i^XLC<iCity of ^ ).<X.ry\, J \.<X/v^x^LA/ao

'^ ^ ' " M Pv \^i A V. c r . St.; 5 Dist.; bet.

^ UK^ and 'IC

(ir DtATH 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

x-

> .'., \j

/O

PERSONAL AND STATISTICAL PARTICULARS

^I'X

^'

«»i.<»K ^

nx I'U or lUHi'ii

A I ■.!•■,

0.

.Ctx-

/I'lH

M.itith)

n.iv!

M,»iffi>

MEDICAL CERTIFICATE OF DEATH

I) ATI-; <»i* Di: \ in

Mi.titli)

I):tvl

(Vf.-ii)

1 iIi:Ri:i;V CI-.RTII-V, Thatl atteniUMldecease«l from

V<:X

/),

•-IXr.I.I- NJ \RUIi:f>.

Willi i\\ j: n <iK i»iv< iRri:i)

iW'iiti in ^i>i-i;il (U'viy natiiiii)

HiR rm'i,A»'i.:

i state 'It t'l HI lit I %■

r

\jO

NAM!* <)!•

HATH i;k

RIRTHPI.Ac K

nr* FATin:K

(State or Counti \-

N! \n>i:N NAM1-:

<)!■ MnTllllK

lUKTm'i.ArK

n|- Mn'rH}.;K

•Stale 1.1 ('..null \-

i

alive nil

KpH

u .

VI.

tliat I la^t ^a\v h .;> alive nti ^-' ». up

aiitl that <k-atli occurred, on the «latc statc<l above, at '^l oO
M. The CArSl' ()!• DI'ATIl wa. as follows.:

t/L.'

niR A'riON H }'rars A/on //is ^ piiys

c ( ) N T R I in ■ r( ) R \' LL\X^'c^\-Jl<x,\/ y

.vn,*>v<x.

Hour

t

^y\j vjL^^Uou

^jlLo

V

nCCri'A rioN

K'''.'{i\f III Stiti I'liiiiim'ii O O ^ I ii I

tctrs

AFonths

Davs

I/i

)HIS

DTRATIOX 10 K..

(SIGNED ) \J. vj . M / iMVi M.D.

vi'/CA! 1 inn'i rAd.lrcss)H5l UaA\.M\i4A. LI

jS>^.

Special Information onlv for Hospitals, Insmullons, Transients,
or Recent Residents, and persons dying jwdv from home.

Months

/>,n.

THl-; AHOVK STAI'i:!) I'HKSOV^I, 1' S K I' I' ' I I, A KS A K I". TRIH TO THH
BKST <)!• MV KNOW 1,1 I)(,K \NF) I'.l ' 1, 1 1", !•

(Iiifiitiuatit

^\ka

dhK^V

N'i.ii.

5.15 m H KAXUMw-^rrV dt

Former or
Usual Residence

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

How tonq at
Place of Death ?

• Days

T90

I'l.ACK OF BtKIA;,<iR R1<:M(i\ Al, I l)VTi;.,f Hf KiAi. or RKMUVAI,

I- N I > 1: R r A K i: R > Aj . U L<ry\/W«\' X L 0

(Addrtss

'XA.A^^iryx, (,

N. B. Bvery item o? Information should be carefully suppllefl. AGB ahould be stated EXACTLY. PHYSICIANS should

state CAUSE OF DEATH in plain term*, that It may be properly classified. The **Special Information*' for psr-
sons dying away from home should be given in m\9ry instance.

r

r
♦li

I

tf

WRITE PLArNLY WITH UNFADING INK — THIS IS A PERMANENT RECORD

H. 1:11.1 i.f H. lilh

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

Dff/r n/rr/, iL'oUlj

MA;

/,9<9H

ResiLsfei'ecl J\^o,

O

173

-\

^^^Aj<^ dXvu Deputy Health Officer

DEPARTMENT OF PUBLIC HEALTI!=City and County of San Francisco

Certificate of £)eath

( "U. S. Stan^arD j
oiOCL'YXjJA.XX/yXQAJKl^ Citv of d

PLACE OF DEATH: — County

,>-u J -^xxAOX^cax^o City of u o^y\j 0 xc '

St.;

0

Dist.; bet.

and

(IF DEATH OCCURSAAWAV 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

iL

1

M

\. JV-cCtuii LAjiOj

:^,Mf I

l> »

PERSONAL AND STATISTICAL PARTICULARS

SKX

I • >I.i iK

i'ATi-: (»i lUKrii

' v^ --

M- nth)

MEDICAL CERTIFICATE OF DEATH

DAI']-: (ii F»i; \ in

/go

(VtMr>

i >a V

^1.

/(,

■-IN' .1.1" M \R U 1 I'K

'stall 11! iiiuiitrv

I N rilKR

ink riiiM, Ai-K
01 1 XlilKK

' ■"'tati or Cuuiltl V)

M\II>i:\ N\M1

t»I M<»riii;R

I'.iK riipr.Ai^K

OH MOTHKK
"^tat. .,1 roiitlttv)

< n'r\- p AI'K )N

^

Ojr\j 0 /V'O

X\

kCXA^aJ^

A.

y

(Nfontli) iDay)

I in;R!;i'.\' ri RTII'V. TIi;.t I attc-n.k-.l .k-ctasc.l fruiu

Itp to _— - _ j^^

tliat I last saw h ~ ali\(.' on ■""" — " up •

and that tU-atli <H-('urrtMl, ciii tlu' ilati' --tal».'(l alxni', at ■ "

M. Tlu- CAISI' Ol- IHIATII wa. a- follmvs:

U)\^

<10J\KkJ^^

%jS-r" ^^ sj -— - ^^ '^

u

CX'^

nr RATION

CONTRimroRN'

I >r RATION

)'tiirs

A/oNt/is

/hiv<

I Ion,

U^n^

J/,"////s

(SIG

:l

NED) o. i. \&KjajzM^<

(>)uXou>^-*,

I()0

(A(l(lrcsv)\J/

Days

(

Hours

M.D.

^OA^x-frti ^LAjq

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

Krsiiiri, III Sdti /'i (iih isiii

}'tai

M.-nth-

/)</!,

Till" AHOVH ST \ Tin I'KRSnN \l, I' XKTirn.A Ks ARi; I'Rri-; ro line

iu;sT «)!• MS KN(>\vLi:i)('. H AM) h];i.!i:f

{Infnnnant NMVxA do. ^^ U- U i) .

0 0^

Former or
Usual Residence

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

How lonq i\
Place ol Death 7

Days

IM.ACK (U- in KIAI. OR Ri;Mn\ \I. I l»\ri;..f Hi KMI, or RlCMoXAl,

,>\

o-w->%x, ■ '

\'Mi,

rL<xLc>vvxx vJt

^'dtu^l

IL^^ %

r N I » 1

; H T \ K 1 •; R \l ri J oAjijuy^ N K yS AXCU

inLQryuv:A r

(A.Mn

X/'N^tii^'u

loo'^

I

IN. B.

-Every item of informntion should be cnrefully supplied. AGK should be stated EXACTLY. PHYSICIANS should
state CAUSE OF DEATH in pliiin termn, thnt it mny be properly classified. The "Special Information'* for per-
sona dy!n£ away from home should be ^iven in every Instance.

1, >»;

f

I'
I

,J

WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

/>^^/r F/^^</, l/ct^rVlAj 1

irwi

]^i^ ! sf t> i ,'/] ^Yo,

2173

^

\K^

DEPARTMENT OF PUBLIC HEALTH=Citv and County of San Francisco

Certificate of Beatb

( 11. ti'. 5tan^ar^

A

PLACE OF DEATH: — County of J <X">% J VC^^ vcvCCcCity of -^Ctw 0 VCl-yvclA^Co

;i

+ \

^kLLCLu, '^WVLO^LuU-.l"'.lvC ' • St.: Dist.;bet. and

,' / IF DEATH OCcJbS AWAV FROM USUAL R E S i D E N C E G I V E FACTS CALLED FOR UNDER SPECIAL INFORMATION \

y \ If DEATH OCJCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. /

FULL NAME \a>,\^^ v^L

si;x

PERSONAL AND STATISTICAL PARTICULARS

CX

i< A ri; Ml niRTH

\r, H

.Rct^

1

MmIuIiI

MEDICAL CERTIFICATE OF DEATH

DATK of^ ni ATI! , />^

iL'ct

3

(I>av»

(War)

li.iv

t

ui ill i\\ I n ( iR i>i\'( (Ri'i'i)

' \Vi itr i u -H-ial i|. -i^iia! mu)

iuk riii'i. \('i-

^i.iti- lit ( ■. itiiit r\

.UA.<LcrVc;

I- Alii l.K

inurni'i, \cr
•>i' i-\rm-;R

'Stair .ir rutnitrv)

HrRriU'l.ACF
<H M()THI.:r
'^t ;t- MI Coiniti \

Nf.tith^

1 lI!{kHi;\' t IkTIFV. That I^attrinK<l .k-.H-ase.l from

, ' Uy tn C'tvt) ^ I()0 H

lliat I I i^t ^.iw h V. ali\t on w wv^ o joq .

and that <K- ith . xrurrt'd. on the date vtatt'd ahove, at

_ M. Tlu- C.\! SI-: OI- I)i; Al'ir was as follows-

I)I'R,\TI()N )V,/;?

CONTKIIUTORV

Months IH llavs //<

oil PS

\

-K, w r )

> ^<..

Kk

?

occr RATION rp

'-i/UT>^^<r>^X

DrR.ATKiN

( Signed )

)'<•<// 5

Afofilhs

Pa vs

S>

b . L<r >'vt-

M.D.

Ic)0

H

Addn-ss)

^"^'V^ix.ow ^,c

SPECIAL INFORMATION only for Hosplljls, Insfituflons, Transifiits,

or Recent Residents, and persons dyjny awd> from fiome.

f^r ,.lr.' ,:

I '> ,

(/ III! Ill i r il

) I'ltl

M,,l!lhs

Till- \iu)\ ].. srA'ri;i» pkrsoxai, I'SKiim. \rs aki-; tkii-: to tin-:

!iI>T ni .ajA- KNOW 1,1, lM,i; AM) Mj;i,li;i-

Former or
LsudI Residence

Wfien was disease contrar fed.
If nof at plare of deatli ?

Now lonq af
nuft of Death ?

Days

Iiifi)tm.'nit

\;,':,ss yJ6'>^*'x^

"YW^A^^V'R

I'l.ACK OI" in RIAI, OR KICMOVAI, | DAI

-4-Wunruu

lAI, OK KI'.MOVAI, I DATRof Hi KiAi. <.r KK,\H)VM

t'.M)i;RTAKi;R

fA.I.

^M *< i/U/OLXl'OL^VV

N. B. livcrv item «>»' information should be cnfefully supplied. AGE should be stated RXACTLY. PHYSICIANS should

state CAUSE OP DEATH in plain terms, that It may be prtiperly classified. The "Special Inlformation" top imp-
sons dyln4 away from home should be given in svery Instance.

P

CI

I

I

■

WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD

REFER TO BACK OP CERTIfflCATC FOR INSTRUCTIONS

)!..a!'l ..f H.alth-l- Xu. i «; ^^-^SKvJ-J) lk"v I' C. i

Dnlr Filcil, %^

1-Lhj

lf)0\

Ecgistered J\'*o.

2174

,<ru^4^

Deputy Health Officer

DEPARTMENT OF PUBLIC HEALTIi=City and County of San Francisco

Certificate of ©eatb

( tl. S. StanDarO )

PLACE OF DEATH: — County ofCjCX^^VJ vJAXXA-X^CxAx^cCity of C)/CX/>^^ J \XX/v\-/C>Ut>cU)

%

t

No. 1 1 0 '^ ■ > '^ ', v-L C. '. X'-^ '■ St.; Dist.; bet. V-Q-AAX<JV'^'V<„CL and Cj ,CVC\,cv -, ^

(IF DE*TM OCCURS AW*V FROM USUAL R E S I D E N C E G I V E FACTS CALl.FD FOR UNDER "SPECIAL INFORMATION" "X
IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD g/F STREET AND NUMBER. )

, ..V

r\

FULL NAME

' -..'...N,

-i

n

44.

PERSONAL AND STATISTICAL PARTICULARS

I'ATl-: nl- IMRTII

iV^.n

LL^rvAjbt

I Month) 1

n

;i)av)

Qr

(

A<.1-.

!V

M.,nf>l'

fS"»'ar)

Par

MEDICAL CERTIFICATE OF DEATH

DATK oj" ih;ai'h

y^t

(Year)

^\ IDitU j;ii i»K IHVoKiHI)
i\Viit«iii siK-i.il (li siwnatiim)

lUkTHl'I.Ai'l-:
'Slate or Cnunt ! v

N XM1-: ni
I ATMl-.R

H k rill'I.Ai'H

oi i'\rin-:k

'■^titt I,! (.'iniiitrv

maii»i:n' xxMi*
oi- .M()ihi;k

luR'niiM.ArH

•>» MnTlIHk
^^tat< or Count rv I

'Month I (I>av)

1 HI'IRI-I'.V Ci;RTirV, That J attcii.ltMl (lereasctl from

IqOM to '. . lyQ

tliat I last saw li '- alive oti ^- " iqq H

an<l that death occurred, on the dati' stated above, at

U^X.

.M. The CAISI': Ol' l)i:.\TH wa-^ as foll.nvs

.K,<J^-y\j o^^/KA^ CJJ^^;t^.,^ JJ^cuvhJ^

I>r RATION Vears^ Mouthx \S Days

coNTRinrToRV Ll^t4\x. \x.s,a.

»V ■">

Hours

KO

(Signed )

Pav

Ilou

f s

li'.ct. % igoS fA.ldress) llOl lJxX'ruHU^^. U

M.D.

i\xj

OAXlt

nCClI'ATlON

f\f^i,!r,i III Siill /'l ,Uh / 'i,i

SPECIAL INFORMATION only (or Hospitals. InsmuJIons, Iranslciits,
or Recent Residents, and persons dying aytay from home.

Mnllth- A 1 /''M

IHI-: A!ir)\'H S'|-\ i-|:i) I'KKSOV \i. |'\kT!i!t.AKS A k I'. TK! H r< » THK

in:sT ni MA' Kxo\\ i.i;i)..H ^xi) i'.i:i.n;(

1^ I

Former or
Usual Residence

When was disease contraf fed.
If not at plare of deatti ?

How lonq at
Rare of Deatfc ?

Diys

\.i.i

^V-ft-CLYA^CC

.1

I'KACK C»F m RrAT. «>K RI:M.>VAI, I DAIVKof HiKtAt. or KllMoVAI.
o4u. L\,t^^^: I ^^ 'i 190 4

I MiKk lAKKK

'A.l.lrcss

\..^cry\j

1

N- »• Kvery item oi ififormntion should be cnrelfully supplied. AGR should be hteted F.XACTLY. PHYSICIANS nhould

•tote CAUSE OF DEATH in pi»iin terms, thnt it mny be properly clossified. The "Special Information" fop p«p.
«on« dyitij^ away from home should be feiven in «very instance.

'"Mf^^

!!

II

11

It
If

i

11

ll

il

I

WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

luite Filc<l\ cUWv

^am^Ewmftnm

\

wu\

]i('oi,sfi'i-e(l jYo.

2175

•\.{ Deputy Health Officer

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

Certificate of IDeatb

( tl. 5. StanDar^ )
PLACE OF DEATH: — County of OkX^Vl- 0 VCl vx-" c -cCity of ^ -Oy^^- -' A OL/^ \ c c<l^ :i

No.

^\„N^^ "l

St.; 1 Dist.; bet. ^ ' ^ ' and M H a

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

FULL NAME

0.

^1^<X

S--V.

^i.Lu.

PERSONAL AND STATISTICAL PARTICULARS

IC

XaXJj

I' \ ri-: ^i\ iUK rn

\'.K

MEDICAL CERTIFICATE OF DEATH

11 1 I

Uavt

(Year)

I I1I:RI;I:V CI;RTII-\. That I attoii.U-.l .k-ixasc-.l from

^. .1/,'!///

ihixs

NX'iUi ill -^iicial il(^i>/iiati(iii)

C

N \M1- iH
1 A I'll IK

luKriiPi.Aii-:

Nt.ii 1 111 riiiint!

M \1I>I-;X XAMl
<>! MOIMIKK

inu rm-i, \cv.

"1 Mo'I'lII'U
(Stall ,! r..uiiti\

1'

f^

190 i tn W ,UV C np^

tliat I lasf -^aw h ..» aIi\L' oii v, cl. (, ^j^

aiul that iliath < ucii rrtMJ, on thi' <lat»- staliil ahovi-, al b
-^. M. The CAISI- ()!• DKATII was as follows:

^'X,*^^^.

u.a.

lUkAIIIIN )■<■,;;

t .

-^ I

JW<LOj 'v£> AAA-CcLo

n

1/

CONTRIIH'TORV

I )r RATION )rar

s

A/i'Hths

CX > v*.l\..?^ >

/hiv

Hi

'//; V

Months

7^

Pa

\s

(\

:^:l

0

\

Hours

M.D.

(nxlAM I A

Special information only fur Huspitd

or Recent Residents, and persons dvin'j cIhjv from tiome.

s, Ins"!

itutlons, Fransients,

! V(/ ;

'^

yir„iih>

/i

I'm; AJ5()\-j.: si' \ ri:i» i't''KS(»\ \i p \r rri'ii \rs a r i: rKi i: r< > rii i-:
nj':sr o].- My know i.i.di.i-. wn ui:i,i);i-

'Iiifii.inaiit

V

'^

I

\5

\<Miv^s $11. UrXjUlt^^uct

Former or
Isiifll Residence

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

HoH lonq at
Place of Death ?

Days

I'i,\i-|- OF IHRFM, OR RHMoVAI. I |.\TJ.;,,! Hi|.,ai ,„ RI-MoVAI,

NlHik'l

xkkrU^XaX'^a^ nTK^XM^ao^u h I <

190

A. Mi.

$aH ll

N. B. Rvery Item of informntion should !».• ciireltully Miipplied. ACf. h'k.iiIcI b« ntntetl EXACTLY. PHYSICIANS should

state CAlIsn OP DI:A TH in pinin terms, thnt it mii> »»».• properly classilfled. The "Special Information** for p«r.
son* dying away from homo should be given in s\ery instance.

;>

Hi

i

n

;5*i

WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD

REFER TO BACK OP CERTIFICATE FOR INSTRUCTIONS

/)a/r /'V/,'.^ iJclolK-Uv ;■

y.9^H

Jicgisfc/i'il jYo.

21 76

^1

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco

Certificate of H)eatb

( XX. S. StanDarD )
PLACE OF DEATH: — County of^ 'O^AO^ 0 Axx.-vv/CA.^coGty of^-<X/>v JK.<X>^xx^c^

NcS^l ^

(ir DEATH OCCU
ir DtATH OC

St.;

RS AWAv FROM USUAL R E S I D E N C E G I V r facts

CURBED IN A HOSPITAL OR INSTITUTION GIVE

Dist.; bet.

'T

0

and

l IK

:ts called for under special information" N

ITS NAME INSTEAD OF STREET AND NUMBER. J

"^ (I

FULL NAME : 'X-tvav;. -Kcu'>\,l-vU , . Au

r^-

< I'. \

PERSONAL AND STATISTICAL PARTICULARS

i>Ari; oi- luk I II

\t.i-

^XA^

u

(\

h

imomli •

);,!>

IhiV

M.int/i'

(Vear)

MEDICAL CERTIFICATE OF DEATH

DAI']-: 111- I) i:\Tn

/'„■

^IN'.I.I-: MARKIJ'.K

\vii)(»\vi:i» <iK DiVciRri;!)

lUittt in >i(K-ial <lt-ij.rnati<m)

iWKrin'i.Aoj.:

^^t^it. -n I'.mnti V

(Month) (Day) (Vt-ar)

I m:ki:P.V CIIRTII'V. riiat I attcn.UMl ,lc»HastMl from
^^ Ct; H r.pH An. V.zt.l loo S

tliMt T last saw h ■ alixc on ^ A-ccLa^i^c ct 'I j,p \

a^l that lU'ath (m rurred, im tlu' Mate statt'il above, at \

)!• DIvATII was as follows:

ami that death o( rurred, (
vi^ M. The CArSH (

I

iVja^ '

I A'nii;K

lUK'rni'UACK
<>! i\riiick

'Stiti OI CduiiIiv)

^TAII>1:N' NAMl'

"I .M()'riii.;K

lUKTm'r.Aci.:

*)>■ MOTIIKK
'^tatf ..r eciuilrv)

Ut^

CyH V^CLi

\ 1

\ r

IH UATION Vvars

CONTRIIUTORV

Mouths

/hi

/louts

,u , w \ w.L,i:wJ.

N _ ..^

J : w:

Mi^nths

/hiv

k_, '^ '

CL-^-X' nJ Xa

u-^t c

nrrrpATiox

^^^^^ A'r'iifr,f i)f Suit / i,ni,i^r,> — )><?/» •- M»iHi- *^ 1 h> \

I>r RATION- Ycius

(Signed) Jb&uKUui jlaxv^ ,

iy-^ % i.,nH (Address) Hiio mxx\.kii ^

//ours

M.D.

Special Information only for Hospitals, InslituUons, Transients
or Rftfnf Residents, and persons dyinq away from home. '

I'll !•• \iio\H srAi'in* I'KR-^oNAi, i'\R riiM-r.AKs AKi; I'Hri-; r< » riii-;

HHST OF Mi_K,N<>\\ I,i;i><;H AM) HKlJi;!-

former or
Usual Residence

Wt»en was disease ronfrarted.
If not at place of deatti ?

Now lonq at
Plar e of Death ?

Days

(\.Mri-ss 0'j,L. U^lVC'L

\-

CA.7^CL

ri^^CK OI- nrKIAT. OH RKMoVAJ, I I)Arj:..f Hiriaj, cr KHMOVAI.

M^rvy^ £. ' ' • I ^'^ \ 190 M

^- B- Bvery Item of lnlf<,rm«tion •houlcl be cnrefully «uppliecl. AOH shoulcl be stated EXACTLY. PHYSICIANS should

state CAUSE OI- DEATH In pliiin term*, that it mtiy be properly classified. The "Special Information** for p«p.
mr%n% dying away from home should be i^lven In every instance.

'■^^

n

i ■

H

ii

II

11

WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

IS.i.ii.l <.f Utaltlr-K No. ! :; t«^vM^^ H&i' Cu

IDCi

Registered JS^o,

2177

'

\r

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco

Certificate of Beatb

( U. S. StanJiatS )

^

\\

4 (5> i ■.,,

PLACE OF DEATH: — County of CX-va; J Xa v^.cuic^City of <X>v J X/X yx<i4^xi^^

N0.HIII . >

St.

Dist.; bet.

and

/ IF OtATH OCCURS *W»V FROM USUAL R E S I O E N C E G I V E FACTS CALLED FOR UNDER "SPECIAL INFORMATION" \
\ 10 DEATH OCCURRED IN A ^OSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. J

\

FULL NAME Ii

PERSONAL AND STATISTICAL PARTICULARS

^1 \

foi.ok

DA IK nr lUKTlI

A<;i;

\ 5

Alniith !'

J 'e'll I

^IN«.I,R. MARKIHn.

\\ n)»»\\i<:n or divorokd

(W'littiii social <Usi^^nati<)u)

JL'

. I)a\

^/..„//,.

^

\\Ajij

r

1 far>

Ihi \>

(Y.-ar)

'XX^Y

HlkTHPl.AOK

estate or Coiiiitrv

N\\tl' ni-

I- A I 11 i;k

mkruiM.AtK

01 I AIHKR

' Mate or I'ointfrv

maii)i:n namj-

•>!• MoTHKR

lURTHI'I.ACK
<>J" MOTUHR
(Statf or roiintrv

OCCl I'ATIOX

fy^sided III SiTH /'i a III ii'i'n

MEDICAL CERTIFICATE OF DEATH

DATK t)F I)1-:aTH , j \

(NfotUli) (Hay)

I HI':KI<:IJV CI:RT1FV, That I attemUMl .Urcascd from

• ' ' 190 to U ct \ n^ H

tlint I last saw h .■■■' alive on C Cl. j^q

and that dtath occurred, on the date stated aljove. at
^ M. The CAISH OF DKATII was as follows:

I )r RATION Years

CONTRIBUTORY

Mouths

l\n

llou

rs

DI'RATION

( Signed )

Years

'SFottths

VA.

d^xIfC l<x^^.o

190 S (Acldnss)

Davs

M t

i t. , \

//ours
M.D.

) ra I

M.nith-

Special Information only for Hospitals, insmuiioBs, Transieiits

or Recent Residents, and persons dying away from home.

Till-: AiiovK s'fAri-:i> pkrsonai, i'\u 1 umlaks aki-: tki}-: r< » iiik

IIHST Ol- MY KNi)\VI.i;i)r, K AND liKMJ:!"

(Inf.

H tii.int

\

Ao.lrc... HiUj. at >M-Ci\Jx6 lU .,

Former or
Usual Residence

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

How loRn at
f\vt of Death ?

Days

Vl^CV. nv lURIAr. OR RKMoVAI. | r)XTl- of Ht k,ai or KKMOVAI.

'\

__4 V.

^'ct

T9O

-i

INDIIRTAKHR J tL

N. B.— -Every item of fnforitifition should be cacefull>- supplied. AGE nhould be stated EXACTLY. PHYSICIANS should
state CAUSE OF DEATH in plnln terms, thnt it mny be properly clasnified. The "Special Information** for p«r-
Aons dyln^ away from home should be given in every Instance.

;?

■^Mi^:^

m

«r

^

WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD

REFER TO BACK OF CERTIFfCATE FOR INSTRUCTIONS

Hoard of II. nltli-- !■' No. is t-Si^ST^) ]',{<^V (*o

Dfffc Filed ,

290 H

Registered JSI*o,

Of ^

178

■^Kjuus dXAjHj Deputy Health Officer

DEPARTMENT (f F PUBLIC HEALTH=City and County of San Francisco

Certificate of 2)eatb

( la. S. Stan^arD )

PLACE OF DEATH: — County of Q<X>v O/b-CL^veccixo City of '<X>v J V<X/yvAM^/c<i
'No. ' :\\-,'- , ' St.; ■■■ Dist.;bet. ''■ ' " "^ * '

FACTS CALLE_ _.. _. _„

OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET

and

(IF DEATH OCCURS AWAY FROM USUAL RESIDENCE GIVE FACTS CALLED FOR UNDER SPECIAL INFORMATION" \
IF De4tH occurred IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. /

)

FULL NAME

-L

1.

4

1 .

s 1-; \

PERSONAL AND STATISTICAL PARTICULARS

j COl.OR

^

nAi'i; (»!• HiKTn

A<,1',

^

MEDICAL CERTIFICATE OF DEATH

DATK Ol IM.ATH

V^

(Vt-ar)

<U4
Month) jf

r,-,.'

iliav)

M.n,tl,

(Year)

/)(,' 1

HiNc. 1,1-:. MAKRn:i»
\vn)n\yi:u (»k i)!\«)Kri;i>

(\\'ritiiii soi-ial dt — ii'iiati'in )

HIRTIIPI, \i-!-:
(State or ('mmti v

XAMI-; <>i-
I AIUKR

FURTHIM.Afl-:
Ol- lATlIKK
(Stale or Coniitrv

MAIDltN NAMl
<»l MorHKK

i

h

Dts

f Month) (Day)

I III'RI-P.V Ci;rTII'V, Thai I Mttcii.k'.l .lect-ased from

U/) : to L Ct- X up 'i

tliat I last saw h ... ■ alive mi „ ^ A. », ij^

ami that doatli nociirrcl, on the date stated alxive, at l'^ SC
>, .M. Tlie C.MSi; ()|' I)l':ATir was as follows:

^wXCu^^^XDULoJL dJA-lv,

a

Ouy^

">

fQ

^

-cc

DrR.XTION Years

CONTRIJ'.rTORV

Months H Days Hours

^.

all

1 (^A.

\

DURATION ^ Years Mouths

(Signed) \xJUoouwcL cLouci

na\

\'S

//(

'ours

M.D.

HiRTHi'r.ACi-:

<>I MnrilKR
(State or (.'oiuitry)

(HCI'I'ATION

f\'f\ui/r<f hi Sav /'i itn, i>r,} U )'iU!i> -) .1/,i//,'//>

ly/tifc ^ T<)oH (Address) llO\Mll<XA.kU 't

SPECIAL INFORMATION only for Hospitals, Insmutions. Trdnslents
or Rcceni Residents, mi persons dying andy from home. '

/',

Former or
Usual Residence

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

HoH lonq at
Place of Oeatli?

Days

TIIH AHOVK STA r»;i) I' KH SON A I. I'A RTICf !,A RS A R IC TRrK T< » IF It-;

BEST <>i' MVyKN'ow 1,1 iH.H Axn isi'i. n;F

(Itifotntant

(\d<lress cS.

'^tolS

q .tl' ^H

PLACE Ol^ ^IRIAI, nR RKMnXAI. | I>ATi:.,! \Uui.m. or ki;MnVAI

r N I ) i: R T A K 1% k \j <Xkjjy\Xx ^ I Xxs^^vc >x u

(Address IS^H ^.b^^US.t<. .V

190 \

^« B.—— Every Item of information should be cnrefully supplied. AGE should be NtateU EXACTLY. PHYSICIANS Ahould
state CAUSE OF DEATH in plnin terms, that It may be properly classified. The "Special Information" for p«p.
sons dying away from home should be given in ^very instance.

f

W^

WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD

h ]■ V,). !=^

, -fV**^-*!*,

'j-IUS:!' Co

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

Da/r Fi/rrf,.t.dixAy</x^ %

100\

RegLslcrcd JVo,

^179

.tM,o<^

/vKi Deputy Health Officer

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

Certificate of "©eatb

( "a. S. Stan^arD )

PLACE OF DEATH: — County ofC'o^-^' J ^^a

f?m

^ a :^'

V

,i

■>\ciA^X) City of 'Cz-Yw J ..'vxX'vx'C^^'ao

:r

No, ULla ^ LO-W^vUi Xk SU Dist.;bet. and

/ \T DEATH OCCURS AWAY FROM USUAL R E S I D E N C E G r V E FACTS CALLED TOR UNDER "SPECIAL INFORMATION ' ' \
\ IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. )

1^

II

FULL NAME

\xXh.

->i'\

PERSONAL AND STATISTICAL PARTICULARS

\

jOCx.

^\^JJb

i> A ri-. (.! in R Til

\<.i-:

Month'

ic

! V-(/ /

I);i\»

^f >},fl,'

;i! )

MEDICAL CERTIFICATE OF DEATH

DAi'i-; ui in: \ rii A

(Months (Day)

p I IN'HICHV ti-.RTll-V. That I nttcii.lcl .Icrcascd fnuii

i\t

rcjo ^

(V«-.Mr>

to W CV b

■^ IN <!»•:. MAKKn:i>

UI IH >Ui:i) «)R I)!\( )«»•»'■ I)
'\\iiti ill viH-ial fU-ii'iiat iiiii)

luK riiiM. \i'i-:

(Stati <ii l•.,l^lt^^■

^; \ M } ( )i

1- A III IK

A

n

0

T(>0 H

that I hist saw h

1 90 1
aHvo ni! y,^^^

and that dtath ocfurreil, <>n the .hiti- stated alnn-e, at 5 S^O
^]. The- CAISI-: (U- I) i; ATI I \va> as follows:

\XAa

AXi

1)1 KAI'ION Vtuirs

C ONTK IIUTORN' '^J

M.^uf/is

/hus

Ifoitts

>

luk rn !'i. At'}-:
<>' I \ I'll i;r

stall 11! riitnitrvi

^t \iI)i;n' X \mj-
"I MoTlIHR

iHkrin'i.Aric
'•I ^;'•■|■m••.K

' st:ii. ,,t (■.Mint : \

u: V

A

A

fU

I M ■ R A T K ) N
( SIGNED )

) '<\J Is

Mo fit /is

/^avs

(^

I loui s

M.D.

jJX Y\,'>\.^

•"' ' I'ATIox ^

f\i' nit\t lit SiU! J linniM'

I'joi (A.Mriss)LCLu XLt) ibo^

%

Special Information oni> lor hospitals, insniunons, Transienh

or Retcnl Rfsldrnfs, jnd persons dvinq dHdv from home. '

M,i,i/h^

Ihi

'11 1; A!',«»\-i.: sr \'n'i) i'»''Rsi IX \!, i'\Kii('!i xr-s xri'tri i-; in » rn)-:
UJ-.sT OF MS- KXmU i,i:i)(;i.; \M) iij;i,ii;i

I'lf.i-nintit

XO

Former or , ^ ^

Usual Residence ' ^ * * ' ^

When was disease ronfracfed,
If nof at plai e of death ?

NoH lonq at
Ware of Oeatfi ?

Oa>s

■i, \( !•; < >!

A^O

(^

\'!.ln-.s \js^

h-

mo

^ ^t OL 5^*0. rA.<^V,CCt

IRIAI, OR ki'.%!(»\ \i, I ii\ir ■ n-

!NI)I:r 1 AK IK sJVJULsXu "H /I

I ^i "I R i:m< i\ \i,

' T 90 ^

IN. B.— ^f^ve^y item o? niformiitlon shnuld h.* ciiruuilly supplied. ACJK Hhoiiid be ntated EXACTLY. f*MY8ICIAN8 should
stntc CAUSn OF DEATH in pinin terms. th»t it msiy Ik- properly clu^i^ilr'ied. The "Special Inl'ormntion" fop p«f.
«ons dyin^ away from home nhouid be ^iven in ©very inntance.

>

I

m
I

1

I

k

■'I

WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD

M.iiitd (if HL.'iIth- I" No i<, ■^■t^'X.X; luti' Co

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

Dff/c Fi7('(I,\Jjzt(A>jO\) %

JfJOH

Rcgiste/'cd J\'*o,

•2 J 80

1

^0

DEPARTMENT dp PUBLIC HEALTH=City and County of San Francisco

Certificate of H)eatb

( "CI. S. StanDarC* )
PLACE OF DEATH: — County of O/CU^x. 0 >MX/Y\^cuccCity of Cj/Cuyx; J VOLWOuiyco

V

^No.

^ T^

4 I

Dist.: bet.

and

/ IF DtATH OCCURS AWAV FROM U S U A L R E S I D E N C E G I VE FACTS CALLED FOR UNDER "SPECIAL INFORMATION" \
\ IF DEATH OCCUhRED IN A. HOSPITAL OH INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER, /

FULL NAME

I

'^ {'^

SJ.

hxx\:A.^,.t

PERSONAL AND STATISTICAL PARTICULARS

si:x

\

DATH OF- lUKTll

A'.i-:

(*(iI,nR \ .

c

MEDICAL CERTIFICATE OF DEATH

DATK ()1- DKATH

.i^

.'^

Montlil

)•.•<;>.

lJ:i\ 1

U.'H//t>

/>,t]

^!n<.i,t:, MAKRii-;n

W II)<»\yi:i> OK I)I\'OKiKI> ^^
iU'rit<iii soiia! (It^i^/^nat ioti) I

.L

CC LC'

lUKTHl'KAOK
^Sliif« i.r (.'oiiiilr vt

NAM).; Of-
FATIIIIK

HIKTHri.AiK
<>l I ATin-:R
(St.itr or Cotititrv

MMDllN NAMl
Ol- MOTin:R

lUKTMIM.ACH
Of- MOTHKK
(fttatc or c'omitrv^

OOCri'A ru>N

(Month) (Day) (Year)

I HIvRI'HV Cl';RTn'V, That I atUMi.lol .kccasol fn»m

-■ • ■- -...,:.::::. up to

tliat I last saw h 7 alive on

lip

ami that lU-ath «)crurre«l, oti tin- (latf stattd alx.vo. at
— M. Tlu- CArSl<: OI' I)|.:aTII was as follows

I )r RATION }'(Utrs

CONTRIIU'TORV

Months

Ihn

I Jours

w

)'iars Months

nr RAT ION

(SIGNED) .. ■ ^ 1-b.ll

K/ol (A.Mrcss) .^

Ihiv

Houy%
M.O.

W,ob

\ \

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

Kfsidfil 1,1 S,;i/ I 1 ,11!

) nil

M<>„lh- ', t /),/

rm-; Afun'i-: s c \ri'n i'Kksonai. pah iii-rr, ars ari' pRrK i o rin-
HKST oi' MY KNo\\i,i;i)r, }.; and Hi;i,n:[-

1 !

Former or -\ . (

Usual Residence U 'CL >vtaj

When was disease ronfracted,
If not at plareof death?

How \onq at
Plare of Death ?

Days

(InffJtmaiit

UJ. 'i)\.

(A

<lil!r<s I I O ,,i.

'\, >w ,

-r .

CX\.4,'

ly.ACK Ol III KX\r, OK RKMOVAI. I DATl-,,! lU ,< , u. or KFMoV\I

.V ^ ,v I ^ f ' ' '

CLAV.LOU ^A^vLO.' LCL^ I ^^^^ t

rSDl-RTAKHR LL . Uj . V/l UXvt \. A v

190

(Addrr

^" B«— — Rvepy Item of information should be carefully ttupplied. AGB should be stated EXACTLY. PHYSICIANS Hhould
state CAUSE OF DEATH in pinin terms, that it mn> be properly classified. The "Special Information'* for par-
sons dying away from home should be given in every instance.

^J

ia«^'

WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

Ho.ir.l ..r II. altll- 1- No. ii; -^^^{■4'Si UScV Co

790H

Begisfercd J\^o.

O

181

.-(rvM^ V\.\Ki

I «

DEPARTMENT OF PUBLIC HEALTH^City and County of San Francisco

Certificate of S)eatb

( XX. S. StanOatP )

PLACE QF DEATH; — County oi^-Ojy>o 0 \XX WOL4/CC City of ""' CL/Vu 0 AXX.vu^u.-Ck)

No,tC

,0

^b^u^nj

0-^'

^W-H

St.

Dist.; bet.

and

(ir Dt*TH OCCUBSjUwAV FROMIUSUAL residence give pacts called for under "special INFORMATION' \
IF DEATH OCCURRED IN A HOSPITAL OB INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. )

FULL NAME

U

aj\,K

.MJv\,i_

PERSONAL AND STATISTICAL PARTICULARS

si-:\

kXjjojJJl

MEDICAL CERTIFICATE OF DEATH

DATK OI- DKATH n \

!) AT}-: ur-- lilK 1 H

\ < , !•

K

m

Jf\r

(Motitli)

!

I I

(Dav)

1 A »>//// 1

(■^■<Tir)

n,i'

¥.t

il)av) (Year)

SfXr. i,K. MARK I I'D

\vii»o\yi-;i> t>K i)!\MK(i;t)

Writ' ill social fU'si^nat ion)

h

HIRTHI'I, \i'l-:

I Stiitt OI I'oniltl %

V \MI- ni

I \ I n i;k

niRIIll'I.AOK

OI I \riii-:K

i Sl:it» (It I'oinili v'

MAFI»K\ NAMJ-

lURT IIP LATH
'H- M<)Tin-:R
(St.iti or Coinitrv)

I uUaj

dHXJ

A

|c\.!

M

(MontJO
I IIlvHI-P.V CI'RTII'V, Tliat l^ntteu.le.l .lt( rastMl fn.iii

tliat I last saw h ■ alive on >— ^-v i j,^

and that (U-alh ncrurre<l, nii the date stated above, at
M. The CAISI': OI' DIIATII wa^ :,s follows-

n

. Y

I )r RAT [ON years

CONTUri'dTO

nr RAT ION

Months

RV V l\utMUX->\.<i,*w«jL X^X^

Pars Hours

A

(SIG

VTION ^^ )'L^rs^ ^
NED) J. VA. m

Mont /is
/CU>jfc

Davs

/lours
M.D.

K' i I te t'l

•HCri'ATlON
Re

s.'fr'if ht Sin? /'i tiiii rWtt v9 U )Vi?;v

\J/qXi % iqoH (Address) LcUN^ VO . Ibo^ivvtoa

Afldress) LCU^
ATI ON only for i)s

SPECIAL INFORMATION only for ifcspltals, Instituflons, rrmsienh.
or Rffent Residents, and persons dyiny away from liomc.

l/.M/,'//.

/ill 1,

Former or
Usual Residence

When was disease contracted,

riii'; AH<)\-i<: siaiid pkrsoxai, r\R luri. ars ari-; trik to
in;sT <)!■ xj[v KNn\vi,i;i)<;iy^^Ni) in;i,n;i'

(liifomiaiit

•m-:

3iH-hUv ']{

ontra(
If not at place of deatli ?

How long at
Place of Dcatli ?

Biys

I'UACK c)I- lURlALoR RIIMOVAI, I DATHof HiHiAi, or RHMoVAl

( \ I (0 4- • ■ -

I XDKRTAKKR 0 ^KX/C^^C^ cL'-«wCVi ..:

N. B.— Every item of infnrmntion should be cnrefully Hupplieil. ACJB should be ntnted EXACTLY. PHYSICIAiNS should
state CAUSE OF DEATH in plnin terms, that it mny be properly classified. The "Special Information'* for par-
sons dying away from home Hhould be ftJven in every instance.

5

"I

*li

til

^5

Us t I

Wt ' J

i f 1

WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD

Hoar.! r.f n.:.ith - H Xo ;. t--r.^g;»^) H«v i' c„ RCFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

0

wo\

Regiatered J\''o.

^182|

cXMXXAJS

-• *i^-*,.

DEPARTMENT OF PUBLIC HEALTH-City and County of San Francisco

Certificate of ©catb

( tl. S. StanC»arD )

PLACE OF DEATH: — Coui.ty oiOcXyy\j

^

\ o

J v_

.IM'i

-City

J? ^

No. ilCi LA.^^ st^. 2^ Dist.;bet. oC<XA^xw>-v and -^

/ IF DEATH OCCURS AWAY rROM USUAL RESIDENCE GIVE rACTS CALLED FOR UNDER "SPECIAL INFORMATION" \
V IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. )

)

1^

FULL NAME^d

'"v:v\AA^'>x.

d.

\\

0

^ 1 : \

PERSONAL AND STATISTICAL PARTICULARS

A I COI.uR \ q

1

DA ri-; «»F lUK I !i

\< .!•:

T

iM.itith*

13

(Hav)

'S

) >.;

M.iul/t^

Pa

MEDICAL CERTIFICATE OF DEATH

fe 7

fMcmtli) (Day)

1 HI'Kl-BV CI-RTIFV, That I atten,le<l iletvascMl from
~~ ' ~— 190 — — to ~.

tliat I last saw li alive 011

TQO 1

(Year)

190

lt)0

Sixr.ij:. >fARHIKn
WllH)\yi.:i) OK DIVnKCKf)
'W'ritt ill s(K-ial <li sijriijit iun)

BIRTHPl.ACH

' Stnt I- ' ir I'liu lit IN

lA in i;k

lUKTni'i.ArK
<H' I AT in; K

iStati or Countrv

maii)i-;n NAMi;

<»!• MOTHHK

^l

0 uSi^^dL-

<-a

il

ami that <lcath occurred, on the «lato statc<l above, at
^ M The CArSH OF I) I- AT 11 was as follows:

O-vQu^^ A„W^ ^x»

cC.c.rs^rLx ^ .L n .,L

CrUXCX 4.U/>'>vc^

Dr RAT ION Years

CONTRIIU'TORV

Mouths

Days

Hours

<xlJlJ^Xcr^-AJ-Y\. \ I

^ J

Dr RATION

(Signed)

wv^

)V</;'.s _ M,if/i/is
(TrULK*

^U^

lURriri'LAOK
«>t- MoTMHK
(Stall or Countrv

0.. a

Kf>tde<f III Siiii /'i a III i -III

Da vs

Hours

jAvt- b iQoH f Address) KjAJ^^JLKh VX\ ,. r.^.

M.D.

-Mil.

f ^^9'fl^."^f*^"'^'^^ION only for Hospitals, lnslitutrt»is, Translenls
or Recent Residents, and persons dying away from fiome.

) 1,1 1

Mnllth"

I hi

TUK AnoVK STAT1-I> I'KKSONU. TA K Ih T I. \ R s \ R i' TRl I' T< > THK
HhSroFMY K\<t\\I,|^I)i; 1.; AM) HI'Mll'

Former or
Usual Residence

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

How lonq ^\
Ware of Death ?

Days

I Infotniaiit

wA^WO

(j

Ad'lri-ss

X\'h \J CkjCxX. V

190

^l.ACl.: ,„ niRm. OK UliMnVAI. l>ArK..! 11, «,A,, or KKMOVAI.

N. «•— f;;;/ »^7 ^^^^"/-^^^^^ H^ ....Un^ supplied. AGB «hould be .tated EXACTLY. PHYSICIANS «ho„ld

!I^1 H • ^ DEATH .n plain terms, that It may be properly classified. The "Special Information" for n^L

•on« dyinft away from home should be g^iven In every Instance. information for per-

mm

WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD

Hoanl .,t HcalUi K Xo. i^ t^-^j^^V.ScV Co REFER TO BACK OF CERTIFICATE FOR I NSTRUCTIONS

I

Da/r FiU'd, li^riJ^Aj %

lOO'i

KAJS (

Registered JSTo,

2183 I

>u Deputy Health Officer

DEPARTMENT ()F PUBLIC HEALTH-City and County of San Francisco

Cectiffcatc of Death

( tl. S. StanDard )

.1..^ ^ ^

(No.

I

J

PLACE OF DEATH: — County of ^-/CLav s3 rLCL^v<^uu:.>D City of ^'/0./vv J h^LAo^/Cx^XL^

_ 1 ii -?

/ ^ - St.; ^ Dist.;bct. A and '

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

FULL NAME^ ' ' -■'^- ^'y^/yy\^^^■^'\Xi.d..

M,\

i

PERSONAL AND STATISTICAL PARTICULARS

j COI,()R^ .

a

MEDICAL CERTIFICATE OF DEATH

DAi'i-; or liik iji

\(.K

UJ.Iv.l.

/Kf.nith)

1/

);„

(Hav)

M<iul/is

(Year)

Da 1

Va,

(Month)

7

(Day)

19^ 1
(Year)

SfXr. r,!-:, MARKIKI)
WrDnWKI) <»K I)JV(»Rii:i)

fWiiff'in siK-ial lii^i^naliiiu)

(St.'ltf l>! (■lilllltt \

\

I lIKKI-nV CHRTIFV, That I attended deceased from

^^-^-^-^-O ...0 icjo s to \Jsi^. i TOO 1

-^ 190'^ 10 N-.V'>,^ B. IgO

that T last saw h % alive on , ).v„^ .1 ! . ^^0

and that death occurred, on the date stated above, at S
M. The CAISI': OF DKATH was as follows:

M. The CAT

I

N \M1- (»|
I \TII IK

HIKTIII'I.ArH
ni' I AIIIKK
(State- or I'oiiiitrv

mai!>1';n namk
hi motiikr

HIK rmM.ACK
01 MOT HICK
(State or I'fMHilrv)

e

ft

DURATION

JJU RATION }ean

CONTRIIUTORY Or

)'t'^s ii Mouths h Days

I /ours

%..

^

J-V>\.

<->

I

y\.

J xhjyyxxx.^^^

OCCII'ATION

h'rhlrif in S,n> i 1 ani ix-n

) rii

\

n

DURATION Years 5 Mouths \ Days

( Signed )Jir LI. GxA^vy^AvMrw

y--ct % rc>nH (Address) blX" ID tlu ^t

Hours
M.D.

f '^^'fi'-J'^r^^'^'^'^'O'^ ""'y '"f Hospitals, Insritutlons, Transients
or Recent Residents, and persons dying away from home. «"Mcni5,

M,.„lln

I hi

VWV. AH()\|-, STATi:i) I'HRSONAI, P\ KTHf I,A KS A K F TKI F To Till-

HFsT oi- ,Mv KNOW I, j; IX, J.; and I!j:i ii<:k

Former or
Usual Residence

When was dlsea«;p ronfracted,
If not at place of death?

How tonq at
Place of Deatfi?

Days

(Infotiuant

w

V \

( X'idirs.s

IH^l

:l

a4v LLxm.

T90

INDHRTAKI-K (jId . J . OA^JkA^^^Vt Cq

(A<l,l.csH^ 11 'bl

'^lA.^ry

N. B.-

"^re^Cru'sE^OF d7;th1 \' "l"J'^ T""^"';* ''''^ "''""'^ ""' •*•'*** EXACTLY. PHYSICIANS .hould

™ ^I t ^ OF DLATH in plain terms, that it may be properly clarified. The "Special Information*' for «-L
•on. dying away from home should be given in .very Instance. information for psr-

flJ
fcl

l(

I

I

I

iiii

WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

i;'.:jr^! J Ui.-illh t S'u ;' *-r^^;)it.'vl' IN

I)ff/r riled, SL:

I

190 "i

Registered JSTo.

184

AXJ Deputy He ~:?h Officer

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco

Certificate of H)eatb

( •a. S. StanOarO )
PLACE OF DEATH: — County of O/Ct^w OXxXa-vCUI^co City of U/Ola^v; J .>vX3LA^L<M..CL/eo
^No. ^Sb a ^ UaA- St.; 5" Dist.;bct. (ADXXh,>>wA^<p^ and J (r(A.en>^

f ir DtATH OCCURS AWAY FROM USUAL RESIDENCE GIVE FACTS CALLED FOR UNDER "SPECIAL INFORMATION- \
V IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. /

)

FULL NAME

t

^<.<KX^, ri.

\JU

V»i. '>

PERSONAL AND STATISTICAL PARTICULARS

DAi'i; or- niKTii

MEDICAL CERTIFICATE OF DEATH

DATK l)J- I

t/Aluiiih)

\ « . \\

y\

5 ra

%

15

(Uav)

Minif>n

1

7 / C
fN'car)

fhi 1 ,

""" iD^

(Dav)

(Year)

siM.ij.', MAKHri-:n

(W'lilt in MM-ial (lfsi<.'ii;it ion)

niRTHlM.AOH

(Stall- «»r I'rtniiti \

NAMl- oi

fathi:k

HIK IIIl'I.ACK
OI- I APIIKK

(State i»r Onnntrv

MAIDllN NAM I'.
Oh MOTHKK

I'.iK'iin'i.Aii-;
OF m(»tiii:r

(Statf or Country i

A A

\ i I I

'Month)
I HHRlvnV Cl-RTIFV, That J attended .leceased from

^t IgoM to SJ..^. 1 i^H

that I last saw h ^ . ..alive on \J /^ T Too *1

and that death occnrred, on the date state<l nhf)ve at I

I
U; ^r. The CAISIC^F DI^ATII was as foll.ms:

(I

'-X}

Dr RATION

^

ars

\ 0

oJlyv-x/^ro

Rrsiiinl i)t San /'ihhiiu,' )'i,i>s

CONTRIin'TO

DTRATION H }\urs Mouths

1JJ(>>V J, XiDoAAMxtj

ths ^ Days Hon

<5-i^-i^. i^-t.<i.e<^^ e->:\. ...,C1.

rs

/hJYS

(Signed)

U/efc % igo*^ (Address) 1^10 J CTV

A^'Y^Xj

A

Hours
M.D.

+

„rf ^^9'fi*-, "^r°^'^?''''0'^ ""'y *«' "»^l'"«''*' 'nstitutlons, Transients
or Recent Residents, and persons dying away from home. -"^icnii,

Mii»th<

Da

Tin: AHOVK STAII-:i) PKKSOXAI, PARTICfl.ARS ark TRIF To THF
ISF'ST OF MY KX<)\VM-;n(*, f: AM) HI-.I.IllF

Former or
Usual Residence

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

How long at
?iixt of Death ?

Days

(Infotniant

(A.l.lres^ 35"(o /a- \\ kj^j CJ.fc

^.ACKOF BlMilAr, OR RFMoVAr. | HAI^^^of n.K.A,. or RKMOVAI,

'"^ " TQOH

6ct

D

rNI)HKTAKHK\lfTr ^ 0.y6u^^JU>rS^

(AiMr.-ss

Ti muLwrv^aP

N. B. Every item o? Information should be carefully supplied. AGE should be stated EXACTLY PHVKICIAMB u .^

.t«te CAUSE OF DEATH In plain terms, that It may he properly classified. The "Sp^clai Jormat^Lt^^ for :;'
sins dy.nft away from home should be given In every Instance. information for per-

li

WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

nn.'il.l nf lli-altll l- No Is '&'^^*^) liS^V Co

Da/r /v7^>^/, UyetcW; I

VJO'i

Reglstei'cd JSfo,

8185

I

I
I

if

KJUS

XHJ

er

DEPARTMENT OF PUBLIC HEALTH-City and County of San Francisco

Certificate of Beatb

( la. S. StanDarD )

PLACE OF DEATH: — County ofOa./v^ 0 A.<X >v>c.ulc^ City of O/CL^x^ J/VxX/>voui.<^o

No

.1)H^

, -^" St.; 1 Dist.;bct. H A.K> and S A.|v

i IF DEATH OCCURS AWAV FROM USUAL R E S I D E N C E G I VE FACTS CALLED FOR UNDER "SPECIAL INFORMATION" \
\ IF DEATH OCCURRED IN A HOSPITAL OR I N STITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. /

f^

On

SIX

DA IK n|. HIKTII

A<,!.;

FULL NAME

PERSONAL AND STATISTICAL PARTICULARS

1 COl.OR

Js.

,Cr

4-

li

Oct

M..Hthi

L^^Jii

<xX

t.

'TXw^xq

MEDICAL CERTIFICATE OF DEATH

DATK (tl- i)i:atii

o

i

\\

I
if

3 >!/ »

1/

\>vltn \

'Year)

Ihi\.

iiU

(Year)

sixc.m:. markiki).

WIDOUHI) OR IHVORiHri

i\\'ritjiii siirial tltsi^'tiiitiim)

n

lUK rni'i.ACH

(Stnti iir Country

I A 111 i;k

lUR rillM.ACK
<>l" I'ATHKR

( Statf or I'outiti v'

MAII)1;n NAMl-
ni' MOTIIKR

HIR rillM.ACK

oi' M()Th1':r

(Statf or Cotintrv)

<KCl ^ATH)N

C

OJ

u

%

(Month) (Day)

I I1I';R1:BV CI:rTIFV, That l attcii.W.l .Icccased from

^ ^^" ' 1901 to U^ ^ IQO 1

that I last saw h .. . alive on w cX t igo I

and that <leath occurred, on the «lato stated above, at io. '~< '^

V-:^^. The CAISIC OF DHATir was as follows-

( u

T

< 1

\

DC RAT I OX Years
CONTRim TORY

Months

Days H Hours

^m

I )r RATION

(Signed)

Years

Ulbo. QJlv.

'Mouths

A

Ihjvs

1 > V

\

OJlV--^^^ <->

t \ '^ * ■ • ■■•

U^ X TpoH (Address)"^ 10 0^ V) /l^^X^4^fr>X.3.1

Hours
M,D.

^^^9'^*- INFORMATION only for Hospitals, Institutions, Transients
or Recent Residents, and persons dying away from home.

Sin/ /■; II Hi isin

)V.n

M.nilh^

Das,

Former or
Usual Residence

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

How long at
Wire of Death?

Days

rm: ahovr stati'.d phrsonai, pAKTicri, \ks ark trck to thf
isi'.sT oi. Mv kno\vm:d(.h and HKi.ri;K

(Informant Xj'^^A^ <70t''%X^tX' uV, XX. l J

(A.l.lrcss

%H?,

-A

V^^^<^'>X'

Pj^ACK OK m-RIAI, OR RKMOVAI. I DAirKuJ Hikia,. or RKMOVAI,
KNDKRTAKKR QsD . O . \) I 1>(X<X4,<S,' V i

190 H

(Address .^.IT.JsJrLv^^V

4,

^* "*~rtaV/clT«;F^A"J nTr^M" "''?'** " ' cnre?ully supplied. AGE should be stated EXACTLY. PHYSICIANS should
iitate CAUSE OF DEATH m plain terms, that it may be properly classltied. The "Special Information" fo- «-J^
nans dying away from home should be given In every instance. "^

' I

I!

i

1

WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD

isoard of H< iltli- 1' N'o. [^ S-^- ar^J^r. ju^cl' ("r.

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

^

roo'i

Registered J\'*o,

O

rw

l)(ft(' Filed ,

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco

186

,A.A^ CX^iAXJ

Certificate of H)eatb

( in. S. StatiDarD )
PLACE OF DEATH: — County ofOOyYV vJA^OL/vvxivCL/e^ City of C\ol/yv' 0 7UXoa.Co<L<i^
No. T . .■, St.; H Dist.;bct. M te ■ and LCLCilvi

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

FULL NAME te±LkK>

)

rU^^AT..

si:\

PERSONAL AND STATISTICAL PARTICULARS

\\ )

DAIl-; oi- HIKin

AC, 1.;

! \

I .Motilh)

) ,a>

• Dmv)

A /,»////'

(Vrar)

n<i 1

'^ INC. I.I", MARUn:i)

w iix »u }:i» OK i)i\( (Kti.;r)

'Wiitt in >()iial ih-^ii' iiatii)ii)

"^

MIKTHIM.ACl'

i Stati- ■ i! ( 'i iiiiit I \'

NAM}" OI-
I A I Hi: R

HIRTHT'I.ArK
ni- l-ArilHK

(Stall' or ('(iiiTitrv

MAII)1-:n NAM}-;
Ol MOTHKR

BIK'iniM.Ai'K
<►!• MoTMHK
(Sl;iti- ur C<Mintrv)

PJ l^

MEDICAL CERTIFICATE OF DEATH

DATK OF DHATli

Month) (Day)

I ni{RIvBY CI'RTIFV, That I atteiuled deceased fruiii

■ ^- ■ 190 't to ...il//£^ ?i 190'^

that I last saw h ^. > alive on V ;tfc ' j^q i,

and that death occurred, on the <late state«l above, at

U >r. The CAISI^ OF DICATII was as follows:

~V>AZLlUll.k..% wO.,

DURATION }'ears .I/on //is

CONT R I lU TOR V vJ^.A^-^'vC-^

Davs

Hours

DT'RATIOX

(SIG

NED) -1. vJ ^jS

\JXyY\

A

ry

J/ont/is

/hiys

A.-.o^a-kx?

U/CAj i U)oH (Address) UaAM^tlifc.lria.

Hours
M.D.

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

OCCI TATIOX

R^sitlfif in Satt /■') iiiii ism I )'iiiis

Mniiffi;

/hi

Tin-: AHOVK STATl-D I'KKSOXAI, I' \ K TKTI.A RS A R }•; TR T K To THH

UKST Ol- MY k.no\vij;i)«;h and m:Mj:K

(Informant Uk^O^C^ \X ^^KXXXJuu

Former or
Usual Residence

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

How lonq at

Place of Oeatli? o^yj

ri.ACK OK niRIAI, OR RKMOVAI, j DATJ- of MrKtAi. or RHMoVAI,

190H

IXDKRTAKKR

(Address

Q

}:l

I'l.L 1 UA^iAWMm.. ^ K

^' ^' Every item of {nformRtion should bs carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should

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

1
I tl

n

1
; I

j

i! )

(

tl

I

J

' I

WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD

I'... I!.; of H. tlth ' 1' N'O Is t'^^V^_

nf^VCn

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

/)(//(' Filed ,

%

VJO'A

Registered J\''o.

2186

n

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco

Cevtiftcatc of Beatb

( tl. S. StanOarP )

PLACE OF DEATH: — County of- ^XX'TV vj Axxyvv>CAXL/c<) City of "^^Olav 0 ^,CL/wcc<L<i^

r\

fNo.

St.; Dist.; bet.

FACTS CALLE
OR INSTITUTION GIVE ITS NAME INSTEAD OF STREE"

and V

n

/ ir DEATH OCCURS AWAY FROM USUAL R E S I D E N C E Gl VC FACTS CALLED FOR UNDER "SPECIAL INFORMATION \
V IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME iNSTrar, " ^-"JliND NUMBER )

FULL NAME

IK. C

i'

W 'v.

si;\

PERSONAL AND STATISTICAL PARTICULARS

\\i

DAIl-; ul- HIU i li

.\<.i<:

J I-vaJIx

M^

MEDICAL CERTIFICATE OF DEATH

DATK OF DICATH

(Year)

M-iith

) la I

Dhv!

M,mffi<~

ear)

/'■

'^IN«', IJ.:. MAKRll-JJ
\\II)<(\Vi:i» OK l)l\<»Ri i;i)
(Write ill -(Kial ili «.ij.»iiat imi)

(M.iiilli) (Day)

I IIICRI'HV CI:rTII<V, Tliut r atten<U-.l ,k"cc-ased fruni

^- i(/3 ; to U.~tj i loo "^

that I last saw h a. . alive on *^ ' ' loo'i

and that dcatli omirred, on the date stated above, at

I

y\. The CAISI- UI- DEATH was as follows

^^

v.L..,..L,. , ..

lURTIIIM.ArK

I State I ir ("i miiti \

»athi;h

niK riiiM.Ai'H

'»! lAliniK
(State or Coiniti v

oi MnTHKK

Hikrm'i.At'K

(State or Cuniitrv

f 0 d n

'\/XhJ

^

-I

1)1 RATION

V

^'t'lirs Mouths

CONTkllUTORV •:J^'Vtv>vC.

Days

n

DIRATION

(SIG

NED) J vj vJS

Mouths

/hn

'S

\

Jy/Zk) i tc)oH (Address) \J/CU\A.<^tli^i.<i.a.

Hours

I fours
M.D.

?^^9'^'- iNf'ORMATION only for Hospitals, Instltufions, Translenls
or Recent Residents, and persons dying away from home.

OCCirATloN

Kf>idf<i in Sill/ / i,iN,;^,,i I )■(■(// V

M.xilln

/hi

' "Vi.^ni^^'^'-^''"^''''" ''»'«^<>NAI, I'AK ri.ti,\KS AK1-: TKI K To THJ-'
Hhsr nl-- MV KN,,\vi.i;i),,H AM) Hia.IlCK

Former or
Usual Residence

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

How long at
Plare of Death?

Days

(Itifoiniatit

:k

,A^I.ACK OK niRIAI. OK KHMOVAI. I UAT^C of ItrR.At. or Rl-MoVAI.

190 H

(Address

11

^<X^.<i>\

IS. B. Every Item oi? iiiformntlon should be carefully supplied. AGR should be stated EXACTLY. PHYSICIANR -h« u
.tate CAUSE OF DEATH In pl„l„ terms, that It may be properly classified. The ••Specl. Informs tll^^'for^L**
son. dylnft away from home should be given in every instance. mtormation Tor per-

{ ■ J

' -wri*?^'

I

I: «

I

ft

i

WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD

Hoatil ,if Ilialfli !■■ Xo "■. '^2T^!*K^ ^^^ j, ^.^

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

/hf/r r//rff,Qdj^

(\

\j I

ifujH

Registered J\^o,

.-CrAOA^

2187

I

DEPARTMENT OF PUBLIC HEALTH-City and Cconty of San Francisco

Cectiflcatc of ©eatb

( tl. S. StanC>arD )

PLACE OF DEATH:— County of^A.>v J.fUX->v0.i^M) City of H^ol/w J A..cX/>^.t,cA.c^

No.l .^.^^^^ ,^^t .., LI •■. St.: *i Dist.;bet.LC^u^vx\, and 0 cVt'>-YV(rV. >>

.,..T„ OCCURP.O ,„ . „03P„.L <,» ,Nsf,TU-T7oN -C.vV-iT; NAME .'n^T^o"" .tVe";'^'" 'n u'^B t '■,°"' " )

FULL NAMEV-tAAlAcy J^&Vq^Nvlfl^Qj^Q^^,^^^^ iv.ll.tt:

ll

SKX

PERSONAL AND STATISTICAL PARTICULARS
^ I Coi,(

X

-^

i n

K

I'A 1 i: < »i i;iK i II

A«.J-

U)lob

-rf

Miititti)

ij>^

lEDICAL CERTIFICATE OF DEATH

DAT!-; Ol-' I)I.;aTII

(I);iv

(Year)

}V,

/(

n):iv)

Mofillf

\ car)

I)ii\.

I IfHRHHV CI'RTIFV, That J^atten.lcl deceasecl from

-i\' i.i- MAKNn-:i).

\\ iiM »\vi;i» OK iH\(iR<'Kr>

'U'iit« in >H(.ri,'i] il» si^.tmti.ifi)

.^

BlkTIUM.AOl-.

NAM J. <)|
l-A rill'K

(^

^

Ac>^

0^\

J

I90 I to

alive on U/ct "I

o^^;Q'a ,

tliat I last saw h ■

iu4 that death occurre.l, on the date stated aljove, at
i) ^'-.I'l^*^-^''^'' ^^'' I>»^TII wai^as follows

190 1

90 H

Cu^ru J.\x:)uvL,c^c<ixOo

Hik riii'i.Ar!'
<»!• I A in j.;k
'St, It. Ill (.■(Mn)tr\

t »

1)1' RATH )\

^'''0 •^^'''|('^' -^^^'J'-^ ^/^'^^

^^^^ mjL^\jLAj^

M \II»I-:n NAM)-
01 MoTIIKK

HIKTiIIM.Atl.; A

«>|- M()'riii;K /TN y

I State lit t'lniiiti vl j w M
OIHTPATION

\

n-

:C'U rVAXL

DTRATIOX

(Signed)

) rars

'^ i<)oH (A.Mn-ss) Sna

5ft-<.t i

Hours

M.D.

t

nr?»'!^?'^'-. "^!r°"'^'^''''ON only for Hospitals, Institutions, Transients
or Recent Residents, and persons dying dway from tioroe. '^ansienrs,

) V'l/ ,

.\r,>nf/i;

Ih'l

iU'.Sl 01. MS KNOW i,i:i)(;h AM) in:i,IKK

'IiifiKDiniit

Former or
Usual Residence

Wfien was disease contracts.
If not ^\ place of death?

How lonq at
Place of Death?

Days

PI^CK OF ,H = ,^AI, OR KHMnVAI. I nATK,of H, k.^,. „r RKM<,VA,.

Uu«-^^'

'©;.

rNDHRTAKHR (AO . J . Mf iLk

X

o

1 00

u

I

(Address "^ n MyVv^uu.<rv^i:).t

N. B. ';^«'*yj*e»" o» Information should be carefully supplied. AGE should be stated EXACTLY PHVAIciAMa u .^
state CAUSE OF DEATH In plain terms, that it may be properly classified. Thr'S Jclai Inwl H ^. . "^''"'*'
ion. dylnft away from home should be 4iven In svery instance. »P*clal Information" for psr-

• li

fl

■m

i '

I

M

WRITE PLAINLY WITH UNFADING INK

)','.;ir(! of ir,;ilth 1- So. i< T'>*^^^^, p,S:i' (

THrS IS A PERMANENT RECORD

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

I)ff/r AV/.v/,.,Ec1Jmju I

lOO'i

Begisteved JS^'o,

2188

C^U^

Deputy Health OfTicer

DEPARTMENT OF PUBLIC HEALTH-City and County of San Francisco

Ccttfffcate of Bcatb

( tl. S. StanC>arC> )

^ ^ J?

^ PLACE OF DEATH: — County ofO /CX/vu 0 Axc^nxiA^OyCX) City of Q

^

/<x>A^ o \xx/vx/<tA.^/a^

N©

. 'tii:

L \\K^^

■ K

uu

T

,\ ^

St«

/ IF deaWh occurs away from usual residence gi

\ IF C^ATH OCCURRtD IN A HOSPITAL OR INSTITUTION

Dist.; bet.

and

IVC FACTS CALLED FOR UNDER SPECIAL INFORMATION'

GI

FULL NAME

I

0

VE ITS NAME INSTEAD OF STRE

CIAL INFORMATION" X
ET AND NUMBER. J

\ ^U'-

SK\ -^

PERSONAL AND STATISTICAL PARTICULARS

COl.OR

I

DAii: (ti- niKin

ACH

\J^

)r,n

iDav)

M..Ht/,!

MEDICAL CERTIFICATE OF DEATH
DATK Ol" ni-:A'lH if

;»r)

SIXi'.I.K MARKIi;!),
WIDOUKI) OK I)fV<»KCj:i)

IWiitciii s(H-ial (U•>^iy;!lati'ltl )

HIKTm'l.ACH

'State or CiMiiitrv

I- A 11 1 },K

lUKTHIM.ArK
0|.- I AlllKK

(State in I'duntrv)

MAII)1:n- NAMi-'
OF MoTHKK

RIHTHIT.Al'H
•»f M()Tin-:R
(State or t'oimtrv

occrpATiox

iilaxvL,...^.

(Year)
I n\iRMU\ CHRTIFV. That I atUude,! deceased from

-■ • ^ T90H t.) ii' cti... t j^\

that I last saw h .. aHve on ^ zh k ,_. .,

niid thtit <U-ath occurred, on the date stated al,ove, at b. I S"
.^ ^f- '^J>^' CAISI- OF DKATII ^va. as follows:

L

^4^

( I

Ml H ?

'^^f^^

Oj^

rx-i-v

-d..- '^..'^

'^^'^^'''^^^^^ yj'-^ Mouths ] nays Hours

J( »NTR I BT-T()RV ^XiJv.alum. Jilci^^ "1 .ii.. J.l. .

DlRATroX ' Years

-^K^K

A^V^JUV

r

Mouths

Havs

(Signed)

.UJ-C>xw„L^ v-A.- iXn i,.:'.c -

Hours
M.D.

^^ ^ TQol (Address) 16^5 J.^mXH; H

orfeTpn^i'.Mif-nJ'^nrP^'^fJ'O'^ ""'^ '"^ ""^P""*'^' Insmutlons, Transients"
or Kecent KesMents, and persons dying away from home. ••-nMcnis,

/\r. Miff if hi Siiti f't ,.

f

/',,-i

'"li»?-!!ry,^'^[^i^;,---rAi;-;;i;,:,;;-^ -- ■- . - ,■„,.

(Informant

i/v-tx/^xi^ mV

esldence LL

ridii

When was disease contrar fed, ^ i 0 J

ff not af place of dcaffi ? lLli.C<xl\. 5 id

Former vi i , u

Usual Residence LLfXLa \

How long at
Place of Death ? o

D«^s

O-U.-i

4:

r\d.i

ress

.^tx-

1

I X I ) 1-; R T A K K R N^A^US^VA^yX IV K^O

yn. dylnj away from h^m. ,h„„l.l he tiv.n i„ .v.ry ln»t-n« ^'■""""'- ^he Special Information" for p.r.

■J'

\.

inncnnce.

^

^!mm!i

1
I

I

1

f.

ii'im

m I

M

WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD

n^ ,f H. u,. , NO . ^mt^.n8.VCo REFER TO BACK OF CERTIFfCATg FOR IN3TRUCTIONa

Regisfered JSTo,

189

ckmjuu^ ^icVHj Deputy Health Officer

DEPARTMENT OF PUBLIC BEALTH-City and County of San Francisco

Ccttiffcate of Hieatb

( XX. S. StanC»arO )
PLAC^ OF DEATH:-County of Oa vx. J/^^vec^.^ Qty of 0^ w- JAXX^^veui^

m

^No.

St.

( "^ .°/rr*l,°*^''"''^ ***' '■''°'" USUAL RESIDENCE GIVE facts**c/
\ ir DEATH OCCURRCD IN A HOSPITAL OR INSTITUTION GIVE ITS N

Dist.: bet. \j C-LH

ALLED FOR UNDER "SPECIAL INFO
"AME INSTEAD OF STREET A

and ^^lL^xj

W

FULL NAME

J <XuJj UiAXJru,

INFORMATION" \
NO NUMBER. /

h

< I

HKX

DATl-: »>1. HI Kill

PERSONAL AND STATISTICAL PARTICULARS

i COI.OR

Ac.K

U.. kctx

J Vi/ * A

<I)ay»

V. <»////»

iVtar)

Hii vs

MEDICAL CERTIFICATE OF DEATH

V.Vl'H OK DHATH /A

(^fonth)

( Day) (Year)

I HKRHHV C|.:rT[FV, That I attemled deceasecTSoiir

>i|N<.l,l-: MARKIHD

W II)t "U i;i» (»K Dlx-nKiKr)

'Write in vorjal <Ii vis., nation )

niKPHl'I, \CV',

(Stati or I •. .iinti %

NAM!, ni
f- A I Hl-.K

:\

that I last saw h x. , . - aliv

to .

c on

0.^ H

190 H
190 H

atid that ck-ath .KHurred. on the date state.l above, at IXhO
^ %;./'"''^' ^'-^'^^^ ^'l; DHATH was as follows

1^

niKTm-i.ACF
ni- iATin;k

(Htiitc r)r t'omitrv

MAIIUIX NAMl-
OF MoTllHR

niRTHPI.At^K
Of. MOTHKK
(Statf or Countrv

r7\

u

.'w

^UL

DrRATlON Years

coNTRinrroRv

Mont /is

Pa)

'S

liou

rs

-^ >X ^V\LLV^

\J

DIRATION

Years

Mout/u

Davs

CLc-L

Hours
M.D.

JLLLr

occri'Ai i«jx

Rfsidfii ill S,n> f iiunisr,}

^^\JiJ^V\j\:'0^ ) ^<^.

) I't! I \

A/ollf/,.

/ >,! 1 .

(Signed )

^vtAj U)oH (Address) I'bS l^XOJvL

«r?''^9'fi*-."^'^0'^'^'^TI0N only for Hospitdls, Insmufjons Tmii«Ii.i.k
or Recent Residents, dnd persons dying away from home '"^'"""MS. Iransleiifs,

Former or
Usual Residence

(Informant \J fl . L^ . UCC^^.tu

When was disease contrac fed.
If nof at place of death?

Now long at
Place of Oealh?

Di^s

(A«1«lrcss b^O v'^UX^K

PI.ACH (»!■ IHRrAU OK KKM(.\ \l | i>x n- f ., ' ' ^

^ ^n.>u.\ \i, I DAI J^o! jjtKiAr. or RKMoVAI.

190 1

/I 1 M N- •

XDHKTAKKK IsD/oJUtxdL \<. Co

N. B. Every item of Informntlon •hoiild he cnrefully

•tate CAUSE OF DEATH In pl„I„ terms
«an« dying away from home should be ft

state CAimP np nf? ATM • i. ''«^"«ly supplied. AGE should be stated EXACTLY. PHVAlciANa u .^

D..TH ,„ p,„,„ ."- .H-IJ.;;.. .._^n;op.H, c,„.„.... TH. S^Jj, ,Zl^XT,::Zlt

WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD

I

cL{^vc^A> IxoM.. Deputy H

IDO'K
h O

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

Registered J\^o,
or

2190

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco

Certiftcate of 2)eatb

( Ta. S. Stati&atO )
PLACE OF DEATH:— County of 3 OyYv \ .yx^<,,.^^ Qty of a<Vw. J^'UX/vvcc^^
rNo.dC-'.d.';o^Oxxl._ ,;.',. St.; — Dist.; bet. — ^ and

FULL NAME

y

mnn^CLA '

I

PERSONAL AND STATISTICAL PARTICULARS

J r

I) ATI-: OF I'.IKTii

^

)n">vA.Ll

IL . kobt

iNfcintli)

AC.K

( 1

( Da V

Month

(Year)

f)

'a v.v

SINCIJ:. NfAKklHI)
\Vn)n\vi:i) OK DIVORCKI)
iWritt in sorja] dtsi^nation)

0

\

HlkTHIM.ACK

'Statt'or t'ountrv^

NAMK o|-
FATIIKR

niKTlin.AC'K
<)l" lATHItK

(Statf or Coiiiiti V

MAII)i;n NAM!
<>|.- Mf)TllKK

HIKTUPKACH
oi MOTMHK
(Statf or Countiv)

L/VNwCl

lOu

%

S\Ji\^

MEDICAL CERTIFICATE OF DEATH
DATE OF DK.VTH

•'tt b

<I)ay)

1 ilKRKHV CivRTlFV, That I atten.l.d .Icrcascd fron,

190 — to

tliat I last saw h ^ alive on --

(Month)

T9o\

(V'ear)

and that rleath occnrre.l, on the <latc stated above, at
Di; RATION Years Mouths

190
190

(E.^

Pays

Hours

\>i

j^

CONTRIIU'TORV

duration
(Signed )

ears

J\flfN(/lS

Id

/hivs

^^ 1 igo M (Address) C(r\^^^^\^ L . s ^

Hours

M.D.

«rf.''^9'f!'-J'^f ^'^'^'^TION on'y '<"■ Hospitals, lastituiroils Traiisl#ii»r
or Recent Residents, and persons dying away from home. '"^""nMS. iranslents,

OCCri'ATl<)N(^

- i

fsfsidnl ill Sail I'lam 1 ,n

) '/'(/ J

'^r>'iith>

Da

( ♦

B

IS

I

iJKM OI- >.n k Now I,I,I)(•,^; AM) ni;i,n:F ''n.

(lu fnununl \JfVvO J. H "^

Former or ,s .
Usual Residence t^s I ^

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

Now long at
Place of Death ?

Days

fArl.1nv;s ^ : I;

*..

190 '(

,cx,c

'AcMre^sLHCI. O/CL/C/v^OU

'»^%-i4-%x.Li.. uj.t

«on« dying aw.y from home should be given In ev.py l„,t«nre *^'""'"***- ^*** «P««='«" Information- for pr-

?!

i 11

I

I

i' I

f

WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

Boar.l of IU:iltli 1- Xo. u 1^-V^^%f, iiSi.V Co

WOH

Res^l^tej^ed J\^o.

2191

Dale /■'//<■> /,t<±isi^V^ %

DEPARTMENT i)F PUBLIC HEALTH-Citj and County of San Francisco

Certificate of Beatb

( XI, S. StanC>ar^ )

'

PLACE OF DEATH: — County of ^O.^^- JX<X>v^u»Xo City ofCW-ru J KayyyjQ.UL<A>

No.

^ w

K V ft

St.

Dist.;bct. . J^A.'OT\XX/'>xaA%' and <:X.CLO

( "^ .Vl^ll."^^""^ *'*'*'' ''''°*' USUAL RESIDENCE GIVE facts called roR under "special information- \

V IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD " STR EET AN D NUMBER )

FULL NAME ^l^^dX^^OL^yy^ &. yAixcLt

si;\

n\rj; nr iukih

\ < . i-:

PERSONAL AND STATISTICAL PARTICULARS

r

■)\

J V(/ /

1

a>:iv)

}/.»(//,

I L

(Vt-ar!

Da

\

/go

(Year)

\Vll»<»\vi;i) »iR I»!\ »>Rv i:i»
fW'iitrin siK-ial il»Nij.'nat i. >ii )

HIKTHIM.Ai'l'
(State or C«miiiIi \

MEDICAL CERTIFICATE OF DEATH

DATH ui- i)i;\'rn / a

feci ■:

(Month) (i,„y)

^ I HHKI-HV Cl-kTIFV, That I attemUMl .lercase.l fn.m

190 ■ to sJ^ A ,go h

that I last saw li U alive on sJ cl I loo '

a;nl that .UmIIi orciirrcd, on the «late statetl al)ove, at I I
^ M. The CAISI.; Ol' DIIATH was as follows:

» A riii.K

I'.iK rm-i. \(|.'
"I I \riij;k

I St:ili ill liiillltrv)

HlkTllI'l.ACH
<>»■ M«»Tm.;R
(Slalr <ii I'nuntiv)

CdxA><x>u^

A

0.-^vd^ \nUlN.€ui (Llc^lUu^^

^\^

K^

W .4

I )r RATION }\-ars

CONTRIIU'TOkV

AfoHtfys

/)ays

//on

rs

Dr RATION

(Signed )

) car.

^

Afif)U/ts

/^avs

^-^ '■ i<)0 H ( A<Mress)U Oa^LO-ti'

//ours
M.D.

„rf ^^9' M^. "^'r*^"'^'^''''ON only for Hospitals. InsfJIutJoiis. Transients
or Recent Residents, and persons dying away from liome. 'r-nsienis,

oVtM

TATION (Op

/\fsl,lf,{ lit Will AillUil^,•,)

) (1// N t; .\/,)ii//i

I),

"'m^J-iV^','-':''*^ '''"•" ''WHSONAI, I'ARTHM-l.ARS ARi; TKl K In TIIF

ithsroi. Mv KN.»\vij;r)<;H and iii;r,ii;K

(Inf„„„a,., M., U/OJI. ri^-V^^V* •

(A.Mr.-^s bbb ^MV4 di

Former or
Usual Residence

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

Now long at
Place of Death ?

Diys

190

VJ-ACH <.F ,n K,^, .)K RKM.,VA,. I 1.^7^- -f H, H i.u, .., R HMnVA,;
r.NJ.I-.KTAKHR M L- 0 A.<Xm p ^< L (.

. . *^J/.?', '"f'"-'"*'*'"" "h""!*! ht.. ..,re?ully «upplle«l. AGR should be stated EXACTLY PHVfiiriAMe ^
•tote CAUSE OF DF: ATH In pl„l„ term., that It m„> be properly classified. The ''S Jclai l„^ •f m^. •*•**"'**

«nn. dying oway from home should be given In every Instance. »l»ewlal Information- for per-

^1^

■

I

I

I

WRITE PLAINLY WITH UNFADIIMG INK — THIS IS A PERMANENT RECORD

REFER TO BACK OF CERTIFrCATE FOR INSTRUCTIONS

Dfffc Filed ,

>v

^

lOO'-i

Regititevecl JSTo,

2191

TO

DEPARTMENT OF PUBLIC HEALTIi^City and County of San Francisco

Certificate of 2)eatb

( 'a. S. StanOatO )

PLACE OF DEATH: — County of^<V>v J V<Vyvca.<iXo City ofO-Cu-ru 0 fUX'Yy^cx-^.^:^

^ . /in V

^^* " ^ ^ ''- ^- St.; M Dist; bet; n AAyok^XAxOm; and ^\Xk.OK

f ir DE«TH OCCURS AW«V FROM USUAL RESIDENCE GIVE FACTS CALLED FOR UNDER 'SPECAL INFORMATION- \ \ '
\ IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION G.VC ITS NAME INSTEAD OF STR EET AN D N UMBER ) 1

FULL NAME UJa11a.<Xa^ b. Qmxd '

A^i.

SKX

PERSONAL AND STATISTICAL PARTICULARS

( COI.oK

\

Mxi'i. <»r HI kin

\ < '. I-;

.^X^

<^i

)V<

// >

SINi.l.K, MAHRIIJ)
WIlMtW i;i> «>K FMVoRi Kr>

(Wiitf ill -iH-i.-il <lfs!j.Miatii)ii)

HIKTin'l,A(*H
(Htntr or I'miiilrv

3.

iD.iv

I l/<.>////

<x^vuxl

/ u

MEDICAL CERTIFICATE OF DEATH

DATK <)I- i)i;ath [C\

(Month)

*<

(I)av)

rgo

(Year)

i HIvKl-HV CI-RTirV, That I attcn«le<l .leceascd fruni

IV tar)

rhx V.

\

r\

up:. to Aw-CL i jgo\

that I last saw h .. alive on V^t. 1 loo'.

nuA that (Uath occurred, on the <late stated above, at I I

V

N" Wt 1 (>!•
I A 111 IK

MIR rill'I, \(F

or I \ rin-R

ist.ilt or Coimti V

MA^ll^N N\M1.'
<)|. MOTHKR

niRTni'i,Ati-;

'>»• M«»TIIHR
(Siat«- or Couiilrvi

:^ ^

I?

n

n
(

) ►

VA

11

aud

M. The CATSH OI-' DIvATlI was as follows

I>r RATION years

CONTRIIUITORV

Months

Days

Hours

DURATION

) ca}

Monf/is

Days

hJl^

(SIGNED) qU., i^. J. <..<XAlf: ,
U/CL '. T()0 H (Address)\J g/lAJstl

Hours

M.D.

f^^^'fi'-J'^f^^'^'^T'O'^ »"'y fo^ Hospitals, Institutions, Transients
or Recent Residents, and persons dying away from home.

)'<,iis t M,iii1h'

1 hi \

Former or
Usual Residence

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

HoH lonq at
Place of Death ?

Days

'"m's^;•u'^^^^■'K!>J^l;^:laHu^ '"'^ | ;^^^»<<>'^ nrR,^,.>R KHNfcvA,, I „x;n^, .,„,,„,„, ^^^,,,.^^;

(Iiiff>i))iant

v^

'oX.

' r V

JNIiKKTAKHR M v- ^JKOUU ^'^ V,A

190

N. B. Every item o? Information •hould be cHrefully supplied. AGE .hould be stHted EXACTLY. PHYSICIAIMS 1, . .
«tate CAUSE OF DEATH In plain term., that it m„y be properly clarified. The -Special InZmJtlLt^' f'*'!"
•on. dyinft away from home should be given In every instance. mtormat.on for per-

W
^

llli

I

li

'1'

^\">-

WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

I'.nriT.! ,,f ll.aUh I' No. 11 ^"ar-'^-J) liiS:}' Co

Ddli' Filvil, \:^

\

190 S

Registered ^'"o.

SJ92

^\^KJU^

i

i

71

T(l

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco

Cevtiffcate of H)catb

( XX. S. StanDar^ }
PLACE OF DEATH: — County ofO£L>\; J A.Oyvxouix:o City of H/CX-^v OA.O^>x<m.4.x^o

No.

n /■.

^

AL'"L.C > )

St.; H Dist.;bet. '^ "klx^

and

ii

I

(IF Dr*TH OCCURS AW*V FROM USUAL R E S I D E N C E Gl VC facts CALLtD FOR UNDER "SPECIAL INFORMATION • \
IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. )

FULL NAME

I^'LCli.

* I It.

V'^O

^n^ v5. C

PERSONAL AND STATISTICAL PARTICULARS

^i:\ ^^

n

1

I'Ai i; t)i iiiRTii

AT, H

Month)

a

SIN'C. I.1-: MARK 11. 1)
Wri>«>\yK|) (IK I»I\(»KrK|)
lUrjtrin siH-inl di -.i^»nati<iii)

(Dav

1/,,,/ /,.

.U

( Vfar)

/'<7I.

1 90^

(Year)

\

niKTHJ'I.AOH

(State- or ("ountrvi

NAMK OF
I'ATni.K

HIKTHIM.ACH
ni- lATIIHK
(Stal«' or Counti v)

MAII)1':n NAMK

lUKTlIl'l^AtK
or MOTIIKK
'statf or t'omitrv

[llcc

KKajuX.

MEDICAL CERTIFICATE OF DEATH

DATK (H- DKATH lC\

wa,

(Month) (Day)

I IIHRliBV CI'IRTII'V, That I attc-iukMl <lcHcased from

'ct7 ^ ,90'i to k).<:^ 1 icK)1

that I last saw h ^* aUve on L '^^ t> > T90'.

and that death occurred, on the date stated above, at H. IS
LL M. The CAl^H Ol- DKATII was as follows:

tX/Vx;

■^.tr^

'Xy^nuyy~\xxJ\

K, I

DTRATION A Years Mouths

Pax

'S

Hours

\\

I
I

Residrd in S,;,, /', ,int i-.n I i 5

nr RATION Viuirs Mouths Pays Hours

(SIGNED ) J . y da.\.cL . ^.Cu M.D.

lii/ct) 1 TQoH (Address) U KX^L/v^tl V J A.4.A.L<3U^ v ,

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

\J„„tln

/h,v.

niK ^HOVK STA III) rKKSt)NAI, I'A K I" KM' I,A RS A K !•; TKt K Ic » IHJ-
HhST Ul- MV KN«>\VI.I.;i><*, K AND IU>LII:F

Former or
Usual Residence

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

How lonq at
Place of Deatli ?

Days

(Informanl

Ud.lrtss So

^JjXaa.'

/VtrrvAj, jX)

PI.ACH Ol* lURIAI, OR RHMoVAT, I I)AT|;; of Hihiai. 01 RKMOVAI

INDlvRTAKHR ulf? , J OAA^

T9O •(

Ad.lrcHN liSl'X M )\\/^L^VCrvx.. ut

^' ^* Every Item o? informntlon should be cnrefully supplied. AGB should be stated EXACTLY. PHYSICIANS should

state CAUSE OF DEATH In plain terms, that It may be properly classified. The "Special Information** for per-
sons dying away from home should be given In 9\cry Instance. \

If
•41

I

. a

p

8

1

I

II

M

WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD

_^ REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

Hoard uf Health F Xo, -; •**- 'V^^i: i;5: P Cn

/)Nfr F/7r./, ^DctXt^. %

100

Q^-J^^J^KA

Ilf'o^Lsfc/'cd J\''o.

2193

Deputy Health Officer

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco

Cettiflcate of H)catb

( tl. S. StanOare )

PLACE OF DEATH: — County ofC^rLCA.<x

City of O/CucAXV-^^^Xa-aX^

fD

No.

St.;

Dist.; bet.

"and

/ IF ptATH 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

/>A.

r"\-tX.

PERSONAL AND STATISTICAL PARTICULARS

SKX

'\

A

i'< »I <)K

MEDICAL CERTIFICATE OF DEATH

DATK i)F I) HATH

M.mth)

AC. I-;

)■ ii>

l>.ivi

y/.»,ffn

( \ ear

Pit 1 .

Ml

(Dav)

iV(;ar)

SIN<.I,1* MARKIKD

I W't it( in -iK-ijil <li >«ij.'ii.i[ii.iii

lUR I'Hl'l, \rK

"^t it' ' .r ' ■..iiiitrv

i

■ Ml. nth '

1 JII';R1:BV CI-RTIJ-V, That r altcn.le.l deceased from
190 — to
tliat I last saw h ..."""" alive on ' - ^•:-.. ~

lt)0

aii<l that death occurred, 011 tlie <late stated above, at
M^The CArSK OF DI-ATIl wa^ as follows:

NAMK OF
FATHKR

lURIHI'l.AfK
Ol- I ATMKR

USlatf nr I'liimt I \

^T\^)^;^• wmi

lUKTHl'l. Xil-
<»!■ MoTHKH
(Stati- or Connltv)

oCOrpA rioN

Kfsidt'il III Siui It ,nii i>,-i>

1)1 RAT ION Years

CONTRIIU TORY

Months

Pa vs

//ours

DIRATIOX

f Signed )

\

) 'ears

Mont /is

/)avs

//ours
M.D.

iqo

(Address) CjXXy<l>uX/\%\X%\t (

}-,/

M,>nth^

I hi 1

Special Information only for Hospitals, Insmullons, rransients
or Recent Residents, and persons dying anay from liome.

'"',;, ^!IV^''^ '^''■'^ ■'■'•■'* I'HKSowi, 1>\K rrciI.AKS AKH TkrK TO THK
nh,M «)|- MV KN«>WI,I.;i)(',H AM) lU-I.n-K

flnfoMuant UuX^J^ ^M^U6 6-t^tlv

.

Formrr or
Usual Residence

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

Now long at
Place of Death ?

Days

^ACK OK niRIAI, OR kKMoVAI, j DATK of HrKiAf, or Kl-MuVAI,

190

N. B.-

-Rvery Item of information should be carefully nupplled. AGE should be stated EXACTLY. PHYSICIANS should
•tate CAUSE OF DEATH In plain terms, that it may be properly classified. The "Special Information** for osr-
sons dying away from home should be given in es^ry instance.

> -'

li

n
I

I

n

^ ^

I '1

WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD

IIvaU;i 1 X.i :- -^^"^^ lUtl' I'.i

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

Dafr FiJrfl, {.diAyJL^ %

/f)OH

Begi\s(crc(J J\^(),

2194

Deputy Health Officer

DEPARTMENT ftP PUBLIC HEALTH=City and County of San Francisco

PLACE OF DEATH:— County of

Certificate of IDeath

( 11. S. StauDar^ )

y '^ City of 0a/C7uo-^>vc>vlc Lev.

I t I

No.

St.;

Dist.; bet.—

-and

(ir DEATH OCCURS AW«V FROM USUAL RESIDENCE GIVE FACTS CALLED FOR UNDER "SPECIAL INFORMATrON ■ \
IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. /

FULL NAME

\^o.%\ ^

xo

PERSONAL AND STATISTICAL PARTICULARS

•1\ 1

It

i>A 1 1; < »i i.iK in

f\

C( >1.» iR

v^

MEDICAL CERTIFICATE OF DEATH
DAli; 111' DEATH

L

Itll

A' .!•'

I HEREBY ClvRTlFV, That I atteiKU'.l .iicrascMl fmni

(I):iv)

(Year)

\

t

\/..„ri, J^"i

/ ',1 I

N\ 11)1 lUI'D MR DlVi )K* }r>
'W'rittiti -iKial di^iiMiat ;. .11 1

J'

I'.iR rupi.Aci-;

(Htatc (It I ', ,\uUl \

NAM) ni
lATlI IK

TilU ill n, \i J.-
'»! I \ I'll I- R

iSlati .1? I'oiiTltrv

M MI)i:v NAMl-

<»i- mothi:r

inRiiri'r.Aci-:

<•! MoTIIHK
(Stale 1)1 i^^nmtrv

<KA rpATloN- ,/'

A'f'^nff'if in Siiti /■') innift'o

that I last v;aw h

T9O ~

alive on

tn

igo

and tlial (k-atli nct'urrcd, (tn llic datt- ^tatid ahovt', al
~^ M. 'V\u: CMS!" OF DFATII was as follows:

DIRA'I'ION )'car.s

CONTkim TORY

Months

Pays

J /ours

DrRATrox
(Signed)

}'cnts

.M,>Ht/lS

/hTV

rgo

( A dd rtvHs) U /a^CAXX-'VVviAvt

I lours

M.D.

SPECIAL Information only for Hospitals, Instituflons, TnnsleBts,
or Recent Residents, and persons dying away from fiome.

^'eal s

M<„it)n

l\v

THI, \HovK, SI A I If) I'KRSoNAl, PART fcr I.A RS ARIC TRIK TO THK
1U-,ST o|- MV KN«)\VI,i:i)<-,H \NI) ni:i,IKF

Former or
Usual Residence

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

Now I0R9 at
Place of Death ?

. Days

a

yj^, \CK OF BIRIAI. OR RKMoVAr,

nAXHfft Hi KiAl, or RKMOVAI,

ii-ct I T90H

^' **• Bvery Item of information sliould be CRfefuIfy supplied. AGB sfioufd be sttited EXACTLY. PHYSICIANS should

•tate CAUSE OF DEATH in plain terms, that it may be properly classified. The "Special Information'* for psr-
«on« dyinft away from home should be given In «\%ry instance.

i

i*H

tfrni^^LiJimS;

K>:

WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

Dafr F//^>^^ OcJ>t-v^ "]

IfWH

HegLs/e/'cd J\^o,

2105

1

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco

Certificate of Wcntb

( XX. S, Stan^arD )

4 ^

^

PLACE OF DEATH: — County of ^jOuyxj o \^.Ol/>vcul>co City of '^Ol^v vJAxXywye.^-<Mio

!]'

No. ~-.

,- :\ ^

^ ^

St.;

Dist.; bet.

stl

and

(IF ocftTH OCCURS Aw«v FROM USUAL R E S I D E N C E G I V c facts called for under "special information- '\
IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. /

FULL NAME

.tl

Ow.La\.C:^

"\

- L

PERSONAL AND STATISTICAL PARTICULARS

"^1 N rni,<»K ].

\

lO kdju

!>\ rj; or iuk i ii

\ I . !•:

I;
(Day

•,ai)

MEDICAL CERTIFICATE OF DEATH

DATi: (•!■ I)]:\TH

iDav)

3'' ~

U !IH )Ul.;i» » >K I)I\< »Ri I'D

I i

MUXX^Uwdw

I'.IK THHhAri'
' "^t.itt* or Ciiinil r

I A III IK

HIKTmM.Ai H
<>l" lAPHHK

'"^i ttf or roiiiif T\-

^t\Il)l■:^• nam)-

<>l MoTIIhR

niHrm-i, \ri.;

<»l M«>riii.;H
e^tatt ,,r Coimtl \

(UHTI'ATION ^ p , '

C' . t^*-\. d

I IIFUUIHY Ci:r<Tn'V, That I atteiidtMl lU'iAasod from

tli:it I l.i'^t ^.i\s li j^-^x ali\i'ni] ' T(p

aii<l that fh-ath nccu r rdt, oii tht- datr •-tatial n1u»vt', at li A'
^U M. Thi- CATSK (»!• hi; ATllNvas a-^ foll.nvs:
V^XfrAXcC M.LOtA\A^CrA^<X>MJ JAaJjuL^^'

C<.\.Cc>

DfR A riON

C'l >NTR IIU T( iRV

)'f'<ti

Months

I\u

I lout <

Mouths

l^avs

I )r RAT ION Yi-ars

(^IGNED) UJ. V^ni. W ^^ ^

11-'/CAj :t TqoH (Address) IbOl yl.<Hl*\X.^Av

//ours

M.D.

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

Rfitlfii III S,in /• I (I III I SI-,} I I. ) I'd IS

yf.nilhs

thivs

Former or
Usual Residence

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

How loHfl at
Place of Death ?

Days

THH XliOVI.' STATi:!) I'KK^OSAI. I' \ KTICri,AR8 .4RK TR T IC To THK
HHST 0|- MY KNoWI.IJX.H AND H1.:mi;K

Iiifi'iinant

X/Vw

4 5 ai\xw,€mu Bi^

N.l.llr.

PJi^ACE OF BrH,IAU OK KKMOVAI, | IJATJ^ of lli kiai, <.r RKMOVAI,

tt

If

t£tr

(AdiheH?

N. B..

-Rvepy item of {nformatton should be cnrefully supplied. AGH should be stated EXACTLY. PHYSICIANS should
state CAUSE OF DEATH in plain terms, that it may be properly classified. The "Special Information" for psr*
sons dying away from home should be given in every Instance.

5 y

31

It

lil

i I

I

WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD

ofHialtJi IN.. :-- '^•^'ac^jJU'vl' t'o

REFER TO BACK OF CERTIFICATE FOR INSTRUCTION3

il

\

^

lOO'i

Dale Filed , \jfC

1

DEPARTMENT l)F PUBLIC HEALTH

Reglstrred J\^o.

106 I

Off

--O-OOUi i^JCV^M

City and County of San Francisco

Certificate of 2)eatb

( "U. 5. StaiiDar^ )

PLACE OF DEATH: — County

of ^/CX. Vu OiXxXAox^LAXx^City of ^XXav J /uOl/vuOlaxx)

No. 3S4

^

St,

inocci

»TH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE I

FULL NAME >jix,C->->x<XA

; ^ Dist.;bet. l^-<X>V'k.l<.-yV and J

&U.Qh.

(If DCATH^OCCURS *WAV FROM USUAL R E S I D E N C E Gl VC FACTS CALLED FOR UNDER "SPECIAL INFORMATION" "S
IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. /

"On

\

PERSONAL AND STATISTICAL PARTICULARS

i COI.ok

M

MEDICAL CERTIFICATE OF DEATH

DATK Ol- 1)I;aTH

.1

DATi; t>I ]UK 111

A»,K

A

V

fKli.nth

K

M.ntlli^

(Vtai )

/),/

lU'iitriti "^iH-iai ih --ii.- iiat mii >

i\a.\/>^v.X<L

N'AMi: (11

HATH i;r

I'

Month)

Day) (Year)

,1 Hl'kl'I'.V Ci;kTII'V. That r attended .leccased from

j ■ . \<.p'\ to Sw^^CAl I iqo '

that I last saw h i alive on W'^A' ^ Kp '■

and that death ocenrrcd, on the date state<l above, at w
LL M. The CAISJv ()F DlvATII was as follows:

I'.IKTHPl.At'K
oi I A rill-: R
' ^t i!( ..! Cuunfrv

MAiniN' NAMH

"I Mother

I'.iKtin'i.At'K

<M- N5<)THKR
(Htatt i)r Count rv'l

I )r RAT ION ■ )'cars
CONTRIIU'TORV

Months

Pays

Hon

; V

orcri'ATiON

Resided in Sati liati, i^fn

! Ill I >

duration
(Signed)

^cars

nn ^

Mo>tths Pay's

L iqoS (Address) 3^1 '}^KKS<XA: Jt

W . sJ .

I lours
M.D.

Special information only for HosplUls, InstituHons. Iransients,
or Recent Residents, and persons dying away from home.

Mnufh^

I I J

l\i^

Former or
Usual Residence

b

f\

Lcw^

Now lonq it
Place of Death ?

Days

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

TUK ATun'K s'rA'n:i> pkk^onai, pah iiitlars aki-: tri'H to
HKST Ol Mv kno\vm;i)<',k and iu:i,n;i-

(Informant \I lUv^^ m>X^'^--^UL v-^XX^Q/VC VA.

r\<idrcss oHH

TlIK

) <XV4,4^ Ml

D\ri;..! Ml KiAi. or ki-:movai.

1 90 1

%,

UNDHRTAKHR

(Address Aiftipb V J ' '-VQ^^^.^O^A^ J i.

N. B.-

-Kvery item of informntion should be cnrefully supplied. AGE should be stated EXACTLY. PHYSICIANS should
•tate CAUSE OF DEATH In pinin terms, that it may be properly classified. The "Special Information" for psr-
•on« dyln^ away from home should be given in every instance.

- y

§■"1

w

i

I'" '

•It

J' '

p.

WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD

I i, i M h i- V>i

rE-'.i.;, !;X; P C,

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

l\ \

pfffc Fi/rf/. ^ <zL(r'KxA} S

IfJO'i

Begistered JSI^o.

;2197 1

-V

-V

DEPARTMENT OF PUBLIC HEALTH

City and County of San Francisco

Certificate of E)eatb

( Ta. S. StanC>arD )
PLACE OF DEATH: — County of <^ >^ ^ Vn -.acuj City of

C'<X >v J A ex. >\ co^<ro

No.

^ i .. ^^.ixvLax Sh; Dist.;bet. and

/ IF Dt*TH OCCURS *WAv TROM USUAL RESIDENCE give facts called for under special information- N
V IF death occurred in a hospital or institution give its name instead of street and number. /

FULL NAME v.^kkcv.,U W^x^c

)

SHX

PERSONAL AND STATISTICAL PARTICULARS

L.U.

DATi: oi I'.IHTH

^]lm,

(Month

\<.H

Ha ,

^!N<.I,l MARHIRD.

WIIM )\vi:i) (»k DtVnKiKf)

iUiitfiii sdiial diHi^'iiat imi)

ii)av

\; •>!'//

> I ar

/),;

HiK'rnjM, \oi.

' "^t.ltf lit i'l.Utltl \

FATHHR

HiKTuri. \cy

ni- I \ III (. |.;
(Htali o! ii.uiit

maiiii;n nam I

«>1- MOTHKK

i5ik rin-uAi'i-

<>! MofllKK

• State- or Cmnitiy)

nccri'x riox

<XhJ^^^JL/6^

iO

'1 — —

MEDICAL CERTIFICATE OF DEATH

DATK nl- I)1:a TH U \

(Motitlii (I>ay) (Vt-ar^

I HI'RI'I'.V CIvRTII'V, That 4 atteiKled (UucMSed from
1^ ■:. 190H to W/cX 'I iqo n

that I hist saw h '^ ' ■ alive on ^ ^^ • Up '^

and that (k-ath occMirrcd, on tlie (hitt- ^tatf«1 above, at
^ M. The CArSI-: OI" Dl'lATII wa-^ as follows:

I) r RAT ION )V</r.v

CONTRMUTnRV ■

Months ^ ' Ihivs

1

Hours

,<x v'Vcvc

DT RAT ION
(SIGNED )

Yiars Mouths w f\n>s

Hours

^^^^ Kfsidfd ill San f'ldiui-in iX )V<M^ \ Months ■ I h- \

THK AKOVR ST\ ri:i) PKRSONAI, FAR IMCl-I, \RS AKl. TRIK I' > THJ

HHsT <)i' Mv kn<)\vij.;i)(;k and in.i.iin-

; Signed) \ Ki) .\XtsX\jo^^- m.d.

IP/tjt I TOO M (Aa.lress) bl^ Ij^dUyt ^K

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

Former or t^f^^X L x i How lonq at ^

Usual Residence ^ ^^\JO,JYwJuy\)^ '^Plare of Death? A Days

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

or

nr.ni »M< M^ KNOW I,i;i)(,h; AND
(Infnnnruit Vl ^tv.^4'^JL'L L

KA^ > . C

f A'Idrcss

X'XH cLLcvW^ry-L.t

\

rivACK oi" nrKiAi, <»R rkmovai

i»n*I)i;ktakkk y\AAXA.A^

DAI'lio! Hi KiAl. or KKMOVAI,

QlWYvt

CV0^>nUAx4

N. B. E

»very Item of information should be cnrefully supplied. AGE should be stated EXACTLY. PHYSICIANS should
state CAUSE OF DEATH In plain terms, that it may be properly classified. The "Special Information" for psr-
sons dyin^ away from home should be ftiven In every instance.

=> -*

k

^l

* *l

WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD

" ' ^ '•:.-r^ ' Vi « REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

li)0\

Regtsfered J\'*o.

2198

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco

Certificate of IDeatb

( tl. S. i5tan^ar^ >

No.

PLACE OF DEATH: — County of v <X ^x \0 %vcuioo City of ' 0^>^' J Aouwca^ <^

St.; Dist.;bet. ^^ \ ^ ^' and ^•C'v. r * >

(IF DC«TH OCCURS AW»V FROM UT JAL RESIDENCE give facts called for UNdER special INFORMATION" A
IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. /

FULL NAIVIE ^Iu^xm^LIoj yX^cLcL^*)\

PERSONAL AND STATISTICAL PARTICULARS

I) \ I i . ii

i.lK 1 li

<.

V

:.^l

'1^1.. nth) X

I )M V

> ' . v.

70

) )

\\ii><»u J n OK mvoRfi:i»

W'ntt in »..(!;,] «1« si^tuiti.iiil

lUHTHlM, \C\:

"^t.iti i: I '. .11 lit 1 \

V \M J- OF
1 VIJI KR

lUR IIIPi. \KV.

< " I A I II i;r
'^t;iti <ir r.iuiitt V

>f\ii>i.:N' Nwn-

'»! NKiTllKR

JHHTlll'i, ACi.',

'»i' Mi»iiri;R

iStatf or Viiiiiii I \

f\'f" ijn! Ill \,iii It ,!n,

^

/ Q(y \

MEDICAL CERTIFICATE OF DEATH

ilk i

(Montli) il);i\

I III:R1;1!\' CliRTII-V, That I nitrmlt-d dtri asid fnun
L -^ - .. .\ It/) i to ^.- C ^ < i()0 i

tliat I la-1 ^aw li «v-' alive nii - ^' I90 I

Hid that iK-ath ncciirred, on Hn- tlau- statiil alM.vi-, at I

c

M. The CMS!-; ()!• IH; A Til \n a- as tollous:

K^ -A^w-vtlu

C\

Dlk A rioN

) liUS

Months

Ihiv

Hours

> \. O.. \

CONTK IIU TORN

DTRATION Yi'iiis ^ M.oitJx

^.tA..C ^\,

C\..

fhiv

SIGNED ):Ja.CU J U mYI ^i)<X\Xlti

iJ/ct I TooH fA.l.lrt'ss) UH'^ :3A-aXUa; 1%

I lours,

M.D.

) ,,,-/ » 1 'I Mi^uth^

/hi I.

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

rin \i!c»\K sr \ r»:i> ckksonai. I'\r i icmi.aks ark trtk to tiih

•H-.sT 01. MV KN.>i\Ij;i)p».; and mCI.IIvK

'liifotinrint

\.l.ir.s. lilD ^ Lo-yA_A at

Former or
Usual Residence

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

How lonq at
Place of Df atN?

Days

DAT

HiKi Ai. or R i:Mi)\AI,
TQO

PI.ACH 01 nrKIAI, <»!< l:iNt(»\AI

N. B. Bvery item of Informntfon should be cnrofully nupplled. AGB should be stated EXACTLY. PHYSICIANS should

state CAUSE OF DKATH in plain terms, that It may he properly classified. The "Special Information" for per-
sons dying away from home should be given in mvery Instance.

4-

Mt

j I

I

i

WRITE PLAINLY WITH UNFADING INK — THIS IS A PERIVIANENT RECORD

' ll..,!h \ X

> 1-. t-S'isTT'S^; V.ScV C,

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

\ .1

1^)0 "i

Registered J\''o,

2199

\>

I

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco

Certificate of H)eatb

PLACE OF DEATH: — County of " O >v J \xXvvcul/CU) City of C'/avv.- 0/UX^>vc<^'CU)

Op

I

No.

\

Hi'

t}Wxkkj6 llc:<,V^t

St.;

Dist.; bet.

and

(iriDtaTH OCCURS *wtav rnoM USUAL R E S I DE NCE give facts cal'.ed roR under "special information-
it DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER.

)

^

FULL NAME

\ \

\

■\\

KxkSJkj^'\ V

PERSONAL AND STATISTICAL PARTICULARS

i C<>I,<»H ^ *

<>I lUKIll

i » I

M..!ith

A<,J-

a^

4

\ • .11

/',/!

/go 1

(Vent

^IN< I.I M \kK ii.;i»
\^!l!t•i!l v.Hial lb — ivtiatiiill)

IURTHPT..AeR

ist;i!, ,,: I ',,initt

J A III i;k

''.IRjHl'i. Ml.;

"I I \ I in;k

'stall .,i (.Dntiti \

MAIHHN NAM!
<»r MOTJIKK

I

ct

n (A-

MEDICAL CERTIFICATE OF DEATH

fM-.tithi I Day)

I Hf';kl-:P.V CI;RTII"V, Thai j atttti.li-.l .Unascil from
l()0'i t«. U ^L' i JqoH

that ! hist saw h -^ ' ahve on ^ ^^ i- Tc)n'\

and that <Uath Dcciirred, nji the dati' stated ahovi', at *« <'
M. The CAISI-: ()!• 1)1':^TII wa^ as follows;

ULcva^aJ^jL VJ iXaXoi

C^JVAJ 0 -CA^b

Cs„<w > > Vrfftr;

"t

CO^'„.j

I

\

e

Li

Aa/vucx LcU.aoA.cl ,; 4X0

HIKTIIIM.AC'H
01 Mo'nilvK

'Stall or fouiiti

\ )

) ^t'

1

DIk.ATloN }'ri7rs

CONTRIIirTOkV

Months

/hirs

Iloi

Ht S

l.CL

LI

OV.

<— VwCX/W

ci

nr RAT I ox
(Signed )

^-. Years

Afttfiths

/hus

Hours
M.D.

^/Ct i 190 H fA.1.1n-ss)3l3. %Kx|aJ^X^ JwMjU

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

<»i rri'Ariox

Former »r
Usual Rfsldence

kjG.^i

1i M^c|

. [ 1 How lonq at

4 Plare of Death ?

Days

M.nitli!

-- Da 1 .«
K

^'^^v. ahovk st a ri-.D |'kks(»n ai, i- \KTKfi, \ks akk tkik to tm

JU:ST OF MV KNONVI.i;i)C,K AND HHMJU"
f\,l,lrrssH/ UJ djb

4

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

OArii^f)!' Hi Ni.Ai. or KKMOVAI,

/c^ l^ 190 H

n^ci-: OF Bi'RiAi, ok ri:movai,

d.i-cs. xx\ Ol^ CILLUju

im»i:rtaki-

N. B. Every item of infopmatton should be carefully supplied. AGB aiiould be stated EXACTLY. PHYSICIANS should

state CAUSE OF DEATH In plain terms, that it may be properly classified. The "Special Information" for per-
sons dying away from home should be given in m-t^ry instancs.

4-

WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD

! Ml) 1^

-sr ^wt n^l' Ci,

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

%

/hf/r /'V/rv/,. tc'^

.■A^ <y'^.^^j^/i (xX XX.

s

IfJOH

Bciji^fered jYo,

2200

Deputy Health Officer

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco

Ccvtiticatc of IDcatb

11. 5. SUin^ar^ ;

PLACE OF DEATH: — County of "' y\ J V'O-^vici.ccCity of ' a ^x 0 V<x>xc<^i^c

ft

No.

'

I ^ o^L *^U St.? ^ Dist.;bet O/t^VccLoj and LU^xJja^^vcg

(ir ot*TH occurs AW»v TROM USUAL RESIDENCE give facts called roR under "special information- \
IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. J

1 1^'

%

FULL NAME

PERSONAL AND STATISTICAL PARTICULARS

vjTlal,

CUl,MK

01 i veto

4—

I < 'f niK III

Let

M Miih

I>av

I

1

•-iv'.i.i' M\RHn:i>

\V I til i\V)' I» ( (k I»!\< »Ri Kl)

n

lon\

go

Vt-ni 1

^ _

MEDICAL CERTIFICATE OF DEATH

I>ATH ol- I>K ATI! i ^

'NfoiitlO 'I>av

I !II;KI:I'.V C'i;kTll'"V. That I attcn.UMl (U-rcast-d fr«»iii
C ct t 190H to ' ^ ' np 'i

that I last saw li ' alive- 011 Itp

and that d alh occurred, on the date -tated alnivc, at
- >I. The C.^rSl'; <)!• in; AT II wa^ as follo%vs:

U

<X^'>A

I ATIIJIK \

lL

,L-'^C^<^^\

,~s

HtK'IflPl, ACF

'»' » \rin:R

MA\i .11 i'.iuntrv

^t\^>^.^■ nxmi-;
<»i M«>riii;K

^

XV ^^^ n

I )!' RATION
CUNTRHU TORN

)Vtfr.v

0

A/il>i//is

/hn

Hours

V 1 A

Months

ni'RATION )V.//v

J\}r

(SIGNED)

i:

^. ^'C

/ /on I v

M.D.

v.

inKrni'UAOK

"I Moi'llKK
'StMtc- .,r CouiUiaA

I

.<x

A.V A V „

.u

r\.VrL^4

I , \ I

occri'A'noN

• "i-

,"\

{\i

UcL ^ TQoH f Address) \J<xK^^ytt iXld

Special information only for Hospitals, Institutions, Transf
or Recent Residents, and persons dving anay from fiome.

siYnts,

}v,.-

Mnllttn

I'i.lM

THi: AHOVK STA ri:i) i'KRSONXI, I'XKTIcri.AKS AKi: TKIK TO THH
H1%ST 01.* MV KNn\VI,i:i)(.l«; ANJ) Hia.IlCF

f Address

300%' ^b

-tAi cj;

i.

Former or
Usual Residence

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

HoH Jonq at
Place of Death ?

Days

IM \CK Of nrKIM, oK KKMOVAI, | DATKof Hi uiai. or RlCMoVAI,

C

rNI)i:KTAKKK mX). I l^*\J 1^^ H^. JC U.

(Ailrcss I 0 SI UTL^

t.r

^SL'^A-.to^ '» V

N. B.—Bvery Item oif Informntion .hould be carefully supplied. AGE should be stated EXACTLY PHYSICIANS should
•tate CAUSE OF DEATH In plain terms, that it may be properly classHTed. The Special Information for p«r-

«on» dylnft away from home should be ftlven In •\^r'if Instance.

/I

f

I

i^

WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD

RCFCR TO BACK OP CERTfriCATE FOR INSTRUCTIONS

/ / (ff

r> 1 Ik

Jfpo'/sfc/'rf

f^*»r^

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco

Certificate of Beatb

PLACE OF DEATH I — County of

n

4eo City of

^

T

. NCi.

NAM

St.; Dist.;bet. and

SUAL RE SIDENCE GIVE facts c«llcd roR under "spcci«l information' \

SPITAL OB INSTiTUTION r ' NAME iNSTEAr ' STREET AND NUMBER. J

FULL NAME

PERSONAL AND STATISTICAL PARTICULARS

,C

MEDICAL CERTIFICATE OF DEATH

(Vtar^

\\

A-N

//<>/,

RATION

\ MI-
NI* till F K

, ,1-

npLAcr

.'n'ri! JM^

Signed ^ <.' 1 K ,m >.^ ■

M.D.

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

A'f.liitUI I It SiJtr /'iiill

til I S

H yt.iuths KX An

I'm

; A Tun H s r \ r i:n i'Ku^«>x \

tl'S'I' til M 'wJ».Xm\\1,) 1). , K

Icrr.ARS ARH TRIK TO THE
u;MHK

Former or
Usual Residence

Wfcen '^is disease rontrarted.
If not a! place of deatli ?

How toRi at
Plareof Deatfi?

Days

'"^UL

PUACH OF Bl'KIAI, OK RKMn\ AI, | DATU ..♦ !!» miai or RHMUVAI,
pi I ^ I . ^ . I - TOO

rNJ)i:RTAKKK '^-<^-^-^- VXX<IA^ Cjp^J^L

(Address kH'^SA'^oXt

N,

^ ._, ^ a „ ...„„ii-H AGE should be stated EXACTLY. PHYSICIANS should

B. ^F.vepy Item of Information should be carefully supplied. AUD snouia o .«R„^ct«l ln»rt,.,««Hft«" *«,. «-,.-

_ , . . . ^ *!._» !«. ..«nv K* nfooerl* classified. I ne opeciai inTormaiion lor* psi»-

state CAUSE OF DT ATH In plain terms, that it maj^ i>e propeny ».■••»

sons clylnft oway from home should be given In •\tirv instance.

X-

f

fi.'f,

m

WRITE PLAINLY WITH UNFADING INK

H.

I X"

^5l!5.f

THIS IS A PERIVfANENT RECORD

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

D^ffr riled , kj otrU
J J

"kjcyvH^L

Deputy Health Officer

JRp^isirred JVo.

2202

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco

Certificate of S)eath

( 11. 5. !5tanDar^ <
PLACE OF DEATH: — County of '^XXorv JXxX/>vocAX« City ofnxXvvO.'LO- . . _ .^^ . .

No.

. ' .' . , U. ' ' SU S Dist.; betMjA.CC V\.CL > va. ^ ^. and LL ^<- l^'<i

/ ir DTATrt OCCURS AWAY FROM USUAL R E S I D E N C E G I V t FACTS CALLED FOR UNDER "SPCCIAL INFORMATION ' \
\ IF DC4TM OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. /

FULL NAME

xd

PERSONAL AND STATISTICAL PARTICULARS

I' \ 1 i. ' '! :.] k rii .*>PN

^

i ^- ^

V

M. nth

MEDICAL CERTIFICATE OF DEATH

DATi-: HI i>i;ath -^

I

il)av

IQoH,

:iL

"• I N « . 1 , K . M ,Jk N K I r I )

\vi III iWKD Ok 1 1:\ I >K'i 1' I)

iuk iiii'i, \t*i'

' "^!;itt I il < 'i ill 111 I \

N"AM|- (U
I AIM J k

ink in )'f. \( i-:
<•! i\iin-;k

"it. it I < i! 1 "i 111 n 1 1 %

M \ IIH: N NAM J
<il MoTin.K

lUk ruiM. xn-

' "'tntt .,1 1 imntt

< »t t r I'AIH ».\

0 (\

"N > Vv^

r

N

(i)

kXJxjXj^->\j

I t

i Month)
I HIKi;r.V C1:RTIFV, That I atteu>k-<| .U-ccasLd fnmi

H" ■ , " KjoH tn ^Ct. 1 KpH

that I last saw h ■ ah\f (Mi v, iip

ami thatck-ath (»( mnil, nn tlu- il;it<.' --ta't'l ahovc, at l I ..
>r. The C \l SI' 'M' hlMTIf \va- as follows:

^V.atXVLi^ I (X4 Iax

CoN'i KHUTORV

/hiv

//out s

)\ijr

DIRATION ....^.

(SIGNED) MiL-'Cd. M)

1

/',7r

L<X.Q ,

iqo H (Athlnss) UlOXJflOwV

M.D.

SPECIAL INFORMATION only for Hospitd.K, Instifutions, Frdnslents,
or Recent Residents, and persons dying away from liome.

//,;//,.'.,■, fiAVU )V(M* I M, tilths '^ /hns

I hi: \H0VK six til) I'HksoNAl, I'A k I* IT I" I. A KS AKK TKlK TO TIIH
lU.M'tM MS jvN< i\\ I,I-:ni .K^WD inilJIlK

anf..,,„.,„t Uj. m. \. V^.CutLi.\tc iw

\>\'\\.

51X ab<t>u-LdBt

Former or
Usual Residence

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

How lonq at
Plareof Oeatli?

Oavs

T90 t

1?I,\C h: ()|- in klAT, Ok klMoXAI. I DAir.i' lU riai or kl.;M<>VAI,

IN. B. F.very Item of informiitSon •hould be carefully supplied. AGB ahould be stated EXACTLY. PHYSICIANS shottld

•tate CAlJSn OF DKATH In plain terms, that it may be properly claaBh'led. The "Special Information'' for per-
son* dyln^ awny from homo ithould be given In every Infitance.

> —

^ .

I

I

I

♦I

WRITE PLAINLY WITH UNFADING INK

THIS IS A PERMANENT RECORD

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

I)fffr n/i'tl

ioo\

Be^isferpd JYo,

S203

«.,, I

f*%Cf%

ut;r

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

Certificate of ©eath

tl. S. Stan^ar^

No.

PLACE OF DEATH: — County of Oa.>% 0 vo , h^cc City of ^ ^ >^' ^KX^^^ <- <-AiAto

St.; I ' Dist.;bet. ' ' and

/ ir DE*TN OCCURS AW*v moM USUAL RESIDENCE give facts CALtED rOR UNDtR SPECIAL INFORMATION \
\^ ir DEATH OCCURRED IN A HOSPITAl OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. /

u

FULL NAME

.c^i^xA-a

?^

PERSONAL AND STATISTICAL PARTICULARS

Ll

I

d:

i
L

MEDICAL CERTIFICATE OF DEATH

DATi-; < '1 i»); \ rii

li'cb

(Year

A,

t *, < *i

iwi ) r>

J(

(TS

< ^vc^x^t

L

V \ %t I I ,(

1 \

(Month) il>;iv>

I ni'RI-lSN' rikTITN', riiat I attt-ntUd (UHA-asoil fr. iii

L e' I«)ni tn V ^. V O

that I hi'^f saw li ■ ilivt <>n

aini lliat drafli < H-furrt'il, on tin- ii it* -,tattil alnnH-. at
%T Tlu C \rSI{ or in \ I'll \va< a-^ follnws:

TtpH

1 ( )() »

\.

L^ A.'|Vi\u \ vCVAa.

'ink

it! \

M X I I ilN N \ Ml
•'1 Mi'lin R

"'I MfillllR
■^l ill 1 ii » (iiiii( t \

«>C(tI>N'li()N

Dl R A 1 h )N

f( >\ I'ls I in I't >U N

/',

/I I.

//«

)llt V

I MR \ ri« »\

Hav

r .

L

CL^U^"

M,<iith^

fhi

Signed )

d' 0 I. HI

//ours

M.D.

!ll\

( \.

Special INFORIVIATION «>nl> («»' Hosplttrfh, lnstituflo«s, Transients,
or ReHfBt RfsMfnts, jnd pfrsws dylif vmn tnm homf.

formrr w
Usual Rfsldrnif

Whfn Wis rflspjsf ctnlrwW,
If not lit pi* I ol ^afh ?

How lonq at
Plare ol Death ?

Days

THK AH<)\|.-, sr \ IIJ) I'HUhc iX M, l'\R I l« r I \Ns XKI! VK\ I". r< » i'lllC
HKsrni- MS" K NoWI.KIx . I ', !' iMI.IHK

fill

f..rnirn)t OaJL

PI \> I I u lU K i \ I,

Ml >\ V I,

La

rsni

IK L ^\

lAiltli < -.I

i» \ 4;i: ..: iiiHiAi .11 K i:m»»\' \i,

II ' I

^ 1 90 1

N. B. Bvery It.m of inf.,rmntmn should he cwr.fully m.p|.lle.l. A«ll -•» nhl ^"f »«•;• IV^OTl.Y. PHY«ICIAN« ,houW

mate CAlJSf: 01 DIATH In plnln term.. th«l It miiy l.r proiH"!* I..n«m*«l. I »u ,s,.<,ImI |„iorin,,iio„- fop ^i*.
mtinm dy\ng, away from homa iihoiilil he ftlv«n In •very lniit»n».«.

k

«

i

'ii^-fi^slE^-

9 I

i

ll

WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD

H.uir.l ul H- Mh i V

"^: 1:5.1' C

liuff Filc<f , L ct<rlj

>^'

//^/^>H

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

Hegisfrrrd J^o.

i

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco

Certificate of IDcatb

^ 4

m

PLACE OF DEATH: — County ofdxX^wJ \XX ^vcc4C() City of 0<V/tv J MX^^c^^co

N«.U^U.'^L(-^u^vtu wv .^^^.',V^A.vXl St.; Dist.;bet. and

■Zls *WAv FR<iM USUAL RESIDENCE G.vt facts called for under special information" \

' IRRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. J

)

(IF DEATH OCCURS
IF DEATH OC^UI

FULL NAME

j^

Zs\y\

\ i

%, I

PERSONAL AND STATISTICAL PARTICULARS

V 1 n

I I u^
i> \ ri-: or iuk rii

\

I 4 .

MEDICAL CERTIFICATE OF DEATH

i>\ ll-; oi i»i:\T!i i \

rMoiitii>

/ go H

(Vcar'i

r\ ^ A

Moil

\'-i-:

il I

l>av

1/. . ■/

» f:ir I

siNi.I.l.:, MAKUn-.n
\Vn»n\\ I-.!) UK I)I\< >!•( Iti
'Writf ill -•iiial il-'-iu' siat i« iii >

HIK i'Ml'I, \t"l-:

St.iti I i; I f lU lit I %

FA IH IK

niKTHri.MK

OI iAriii-:K

I St;)i( iir Ciniiit t V I

MAtlUlN' X\ Mi-
ni MmI'III, K

MIR i!n'r,At'K

111 MOTHHK

■ stati ur fNiuntrvt

I III'RI-I'.N II RTIl'N'. 1'hal I atleniU'il (Urca^ed frntii

T()0 H
tliat T 1n'-;f '.aw h i- ■ alive on V^ ^^? t I90 i

an.l that .Ualli <H»urreil, on tin- <laft' ^ta1t<l al)OVi', at > » 3.
\^ \U. Tlu' CM Sl{ or l)i: ATIl was ;js follows:

U\ ^

Hi.

\^ik

,4

<)( rri'ATIoN 0 (^

Kesiiifil ill Sim /iiniii^i'i) l ^ )'iuii s

])r k \i ION )'rdrs

C< >N1 KlItrToRV

nr RAT I ON -^ X''"''Jv

^ (I

(SIGNED ) -J , vj\ (

C 0 '^ Oi-A..

MiiHths

a'd

/>.71

) V

PiU

Ih

^in \

I lout V

M.D.

N only for H^s

SPECIAL INFORMATION only for fWspltals, Institutions, Transients,
or Recent Residents, and person^^ng away from home.

^r,nilhs

Ihi

rHKAROVI-- Sl\ri!) I'KRsoNAI, PA K TICl' I,A K S A K l'. TK T H T« » THH

iiRHT OI- MV KNOW i,i;n(,r: and nKi,iKF

(1

\JCxx.^\>^

' S'ld'C'^'; \w

Pormer or
Usual Residence

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

\J VA-,*^ ^ V tx. a_ w XT

How long at

Place of Death ? ^

Days

ri,A( K OF niKIAI, OR KKiloVAI,

iqJ'

fL^nXy^-UX

rXDKRTAKHK

(Address

I)A'i;4-:nf BiRiAi, or RKMoVM,

(m 4

^ lf)0 1

N. B.— Bvery Ite^ of Information .hould be car.full,. supplied. AGB .hould "^^.^^-^^^.f .^5[^^,^; ,„ ^"^^V^*^:!^. ••***"'*•
state CAUSE OF DEATH In plain term., that it may be properly classified. The Special Information for psr-
«nn« dylnft away from home should be given in every instance.

> ^.

>

h

^

J

f*

5 i

i i

\

WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD

n<.:".! -f !l. nMli

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

Dfffr /v7r^/, Jc^ot<riM^'

ID

IfJO\

Registered J\^o.

^

\_0\^ 0»«4/\M.

i-

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco

No.

Certificate of S)eatb

( xa. 5. StnnC>arD )
PLACE OF DEATH: — County of C' a. \^ -3 vVQ^w^Cvi -City of'~'.<x^v ,) Axi. vx-ci.<i,<m,
ll'X 'vJJ^,^<XcL^-V -^ St.; I Dist.; bet-U^LAA-'a^^n-Yv^ and' JJ-ClIL-'lu )

(IF OEftTH OCCURS AWAV ^R O M USUAL R E S I D E N C E G I VE FACTS CALLED FOR UNDER 'SPECIAL INFORMATION" "X i

IF DEATH OCCURRED IH A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. J j

FULL NAME

PERSONAL AND STATISTICAL PARTICULARS

I

X.£kj

■-i:\

MEDICAL CERTIFICATE OF DEATH

DAT]-: 01 iii:\Tii

Vw

iL:ct

'M.ititlr

\ « . J-

ilniv)

■\f,.n'ii'

\ '■A\

/hn

Uct

IQO 'i

iMotitlO (Day) (Vtar)

I ni':Ri:i5V CI;RTIFV, That j attemlcd dcccasccl from

wA/

^ IN". I.I' M\Kkn:i»
WIIx i\\ i;i> < »K Iil\i >K>' 1"I»
U'liti ill -.(.iial ilf ^is.'!sati(iii)

lUKrin-i. AOi-:

St.tti .n < '.111 111 I \

NANfi-; nr
I- A in i:r

niR Tiifi.ArK

nf- I AillKR
(State III riiuiili V

MAIDllN' NAMK
<'I MoTHKK

nTR'nii'i.Af}-:

OF MOTHHK
(State ur C«)tintry>

D^'cri'A riox '^

190' I

alivf o!i

Tt)0

til at I last saw li ■ alivt- oti V' %,v ' joq

and that deatli occtirrcd, on the date stated above, at O
1 M. The C.MSK (M* DI'lATII was as follows:

II

dlD (CXA.LULiU

in'RATroN

)'t'ars

Mouths

CONTRIIU'TORV jX^wLa.

Day

Hour Si

^ «'

\1\

nr RATION r^ yxsJrs^

VI r It.

(Signed)

JAj;////.

'j' , a. (&

fhlVS

//ours

M.D.

IQO

. -KJ Kr\A.jx^.\. y-j M.D

(Address) lOS' (0 0 K<X/v^ ^LcLa

Special Information only for Hospitals, institutions, rrawienti,

or Recent Residents, and persons dvinq away from home.

A't\-iifrif ni San /'i aniixfn

).-.//

Mnntln

fhi

I'll I- \H()\-i.-, s I' \ii:Ft I'KRsox \i. !'\RTicr I \k> AKi; I'Rn-: t<> tiih

IJHST t)l- MY KN«)\V1J'.I)C. H AM) HHt,Ii:i'

Former or
Usual Residence

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

Now long at
Wace of Oeatli ?

Days

(Infoimant

'^VV

LV , V

J

\d.irc«s ^ 1 "31 ^ jj .McOwxLcu-txxt . jti

JtACH <>l- FUKIAF, <»R RllNniVAI, I DAp;..! litHi.Af. or Kl-'MoVKI

t

h..b^c:L^

\jJoJui/>r^Xx

190

1AU«

I

N. B. Every item of information should be cnrefully supplied. AGB •hmild be stated EXACTLY. PHYSICIANS should

state CAUSE OF DEATH in plain terms, that it may be properly wlasslfied. The "Special Information'* for psp.
sons dyin^ away from home should be given in svery instance.

i

i*-«n>^

I

I

WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD

REFER TO BACK OP CERTIFICATE FOR INSTRUCTIONS

11 :»th— K No. i^ ■^5 -s '— , l;>.l'

I)

ate 'Filr^L Uct^l

0

.Hi-v^-v^

i

<x\^

v-u

IffO'i

Begisfried J\^o.

!806

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco

Certificate of Beatb

i

^

i

y

PLACE OF DEATH: — County of CL-^v J Vcu^vCA,<i.coCity of ^<X/>v 0.\xv>x^c^^

No. :^ ^ a^

x-Nx,.. ^ St.; Dist.;bct. ^^^^^^^^ and*^^

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

A)

FULL NAIVIE^^^^<ici U >\tc ■ ■ • ^MtlnAj ^ LaA^\L^

^

I

4i.

PERSONAL AND STATISTICAL PARTICULARS

had; < -I liik iH ,p\

r..i.,,R \ ^ ^

liUt

M.'iitl;

Pav

MEDICAL CERTIFICATE OF DEATH

DAIK ' >I- m \'l H

Mi.titli)

) ■ \'

/ on \

( Vcarl

A <.»•■,

n,.

>1N«.I,I' MAKI<!i:H

\\ r IM i\\ I !» ( Ik |i|\< IK( |.:i»

! W't iti ill ^. H 1,11 ill -.!).> Il;t I ii 111 )

J

d

"^ t . I ! I I 1 1 1 ■ I 1 1 1 1 1 f ! \

N'\Mi: <)!
I- A 111 J-,k

niRi'ii I'l, At }•:
fn lAinj'k

I St;it( f ii I', ,ii lit! V

MAIKl'N NWfl'

oi Mn'rm:K

ruK'in IM, \( i;

'St:it'- '■! (dtnitl \

f^ !)

.wcj.

I H!kl liN ii-kTHN. That I attcn.It <1 dtHeascd from

T'iO to W,C\J \ IQO

tliat I la'"! saw h alivt- on ' icfj

ami that di-ath <icaurn'(l, (mi tht- ililv -.tati-il ahuviv at ^ ^

M. ThfCAr^l- (M IM'ATII was as foil, .us :

^,Aa.<^ ' - . . i ■

-^

X . »

a

1

n I

\ < (

La m

M^'.

IM kXTIoN }'t'ar

C'< )N'ikl i;r"l()RN'

Months

Par

Hoi

urs

(^

I ) r R A T M > N

}'i'ars

^r 'fths

Pav^

(\

h'l iifr,' in S,n' I

(Signed ) CLAAi^-cAvoo L<xJUi^/\.c -,

\lf^ Id T(,o ; (A.Mrfss) 5lH nHX/

M.D.

<X^<r>\.

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

) lai s

Mnnfhs

Ihis.

Former or
I'sual Residence

When wa- disease contracted.
If not at plare of deatli ?

Now lonq at
Mare of Oeatli ?

Days

Tin.: An()\ !•' s r \ tin f i<i' son xi, !■ xini rr i sks aki% rRiK m thk
HKsr <n MN K s« >\\ t,i i»( ,i: WD iu-:i,ii;i'

Infi.tinniit V^

vvvL

\.M!

,<UL

190H

I

S-K OF mkl\r. Ok kHMoVAI, I)\T1^,,! !!. k.ai, or KKMoVAI,
jLqIa.cw'yx I ^^^ IC

INIilCRTAKl'k N-^dLuJ^.

N. B. Rvery Item of information should hi carefully supplied. AGB should be stated EXACTLY. PHYSICIANS should

state CAUSE OP DEATH in plain terms, that It may He properly classified. The "SfMclal Information'* for psp-
nrtf\% dying away from home should be given In svsry Instance.

\\

;-v]

I

i

i

7
j\ '1

11. ., », - 1/ V

WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

•^■^,^1 UK V C

1

U)n\

Eegis/c/rfl JS^o,

2207

<r\<.^^

L^-xj^ Deputy Health Officer

DEPARTMENT Ol^ PUBLIC HEALTIl=City and County of San Francisco

Certificate of IDcatb

( XI. S. Stan^av^

PLACE OF DEATH: — County of "<v^^ 0 X.CL wcMic^City ofv <x >^ vJ V<x ^vc^laxl^

>

'\,

W^

">- ^

.<X\l^^

Su

Dist.; bet.

and

r .F Dt*Tfc occurs »W4V rwoM USUAL RESIDENCE GIVE facts called for under special information \

V IF OeiTM OCCURRED IN A HOSPITAL riB i ly "STITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. /

\ \

).a l,\A_c

FULL NAME V'.a.LVv.cV. ^U»p\

n

K \

PERSONAL AND STATISTICAL PARTICULARS

DA n: «»r iur hi

A' .1'

^'

-tt

MEDICAL CERTIFICATE OF DEATH

DXTK < ij m x'l'H

Month

\\ Ml. i\\ I i> < >R i>n-i ii.'i in

\Nti!> in "-iMinl il«'«.ij.' iialHiu )

1^

%

r\

• St:i!« ( i! < "i milt t N '

0\K.

^^t.

Dav

Vi-ai

I Hinvl'.HN' «.' i: k'I'Il'N'. Tliat J attt'tliU'«l .1^ .X asrd fiDtll

tliat I Iri'-t '^nw li i- > . alive oti w '

aiiil that lU'atll (iCi'iirred, on tlic datr vtati-d ;iliini', at
lI M. Tlu- CXrSK OF hi .\TI! u : folh.ws

I ( )0

NANU'. «»|

I' A 'III i:k

^\ a.1

ix

I'.TRIHIM.ACK

• H I A rm: K

' St;il I- I i! ( "i Ml tit t %■ i

^

I k

MAIUHN NAMlA

OF motiii:r

DT RAT ION )'tays

Months

Pav

//outs

DT RAT I ON )'tars

Signed)

Month

fXMJNu

I i]

Was^.Wl<^^.c,>^

iuRrm'i,A( K

OF NfoTHKK
(State or Couiitrv)

(KariAiluN >

iij'Ct ^ iqoH (AiMress) O't \J /

1

//out S

M.D.

'>

la\M^ k ^A^

Special information ©n'v for Hospitals, InstHutlons, Translfnts,
or Recent Residents, and persons dying away from l«ome.

yfinitlis

t\j\s

I'm; \Ho\i.' sr \ I 1!) I'KRsoNAi, I' \H I hi ; \Rs AKi: I'RrK m thk

liK-^r (it MN K NOW !J;I)(;}^ AVp lUIJlF

A

In f' >' niant

\,l,li, -

ID QAAAA-^Ov

,t

Former tr , ^^ . -^ t . . M»* l«»l »!

Usual Residence

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

b 1 1 0 U \k4 AA.A. Cr^\^ Mace of Death ?

Days

PI,.\£K <)!' BfRFM. OR RIOfox XI, I nAT^-; of HrKiAL or RKMoVAI,

n j 0 I ( ( i 4

0 (Vv^c

INIHIR I AKKR M ' V _ ,

N. B. Every Item off InformHlion .hould he carefully .upplled. AGE should !*• .t«ted BXACTLY. PHYSICIANS should

•tate CAUSE OF DEATH In plain term., that It may he properly classified. The Special Information'* for psr-
sons dyinft away from home should be given In svsry Instance.

B <

WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD

Hoard of lk:,;!!i I- v.). i^ t-F'rssy^ jtf^ p C

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

Ihif, Fi/rf/,\)^JuLu^ (C

lf)0\

Beghfrrpd J\^o.

'^'•^ilo

^^>-e5

A^. Deputy Health Officer

DEPARTMENT OF PUBLIC HEALTH-CHy and County of San Francisco

Ccttiffcate ot Death

PLACE OF DEATH: — County of OKX^^yv o >^xx/vx>CA^e<)City of C'/CL/vyj J /vcx^wcva^^m)

V A o (\

No. aOb acL>^^ V-i.i llv. St.; 'C D;st.;bet. ^H .tlw and 3.5.tL

/ IF DEATH^CCURS AWAY FROM USUAL R E S I D E N C E G I V E FACTS CALLED FOR UNDER "SPECIAL INFORMATION ■ \
V IF DEA-^tk OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD J) F STREET AND NUMBER. /

FULL NAME

\)\

^^ULA

V n

V

Cl

PERSONAL AND STATISTICAL PARTICULARS

^<xL

ll-kJU.

I 'Air. (»r liiRTii

X' .1-;

^a

(Dav)

M.ntih^

MEDICAL CERTIFICATE OF DEATH

DATH <)l' I)1-;aTH

IQO \

(Year)

%

Pa I

^ IN'. 1,1-: MARRIHl)

w MM )\\ 1:1) «»K r)i\<>KrHi)

\\ii!( ill MH'iiil ilfsijrnatioii)

lUKTHPI.ACR

(State or rnnntrv

r\

<XV\.*.X^

•\

(Month) (Day)

^I HKRI'HV CKRTn-V. That I attfii.k-.l .IcMHascd from

^^ ci t igo'i t.) licfc ^^ ic^ H

tliat I last saw h '. ■ > alive on \J "^ \ ^^ •

atKJ that <leath occurred, on tlu- «latr ^^tattMl above, at ( I
U.J ^r. The CAISI- ()r DI-ATir was as follosvs:

.<X

XANtl-: (H-
I- AlIll.R

lURTJIl'I.AOK

OI- I-ATHHR

' >it:itc or L'liuntrv)

MMDl'.N NAM1-; A

Dr RAT ION

) 'ears

Mouths

Days

J /ours

n

IHRTIIIT.ACK
Of- MoTirHR

(Htalc >)v (.'ouiitrv)

claM^iM'^

ocrri'ATioN' ('^

ruxv

K^^iilfii ID Sail /■■; ,7;/r />,',) o'l^ JV'(?;a • M,niUis

CON T R I lU 'To R V ^ <XX\n^>3^JXr'\j

DURATION j^^-.?;^ Mouths Ihiys Hours

( SIGNED ) JD. ^1 nQV X^4Jv>v Wtt M.D.

SPECIAL Information ©my for Hospitals, institutions, Transients,
or Recent Residents, and persons dying anay from home.

ihi

THK AHOVK STAI)-!) I'KRsoXAI, I'A RTIiM' r,A R S A R IC TRrH Tn

ni.si oi. MvivN«)\vi,i;i)r,H and ijhiji;!-

fliif'.onatit J. Xy^ . V^^^JLt*!

0 ^

!■ 1 1 H

Former or
Usual Residence

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

HoH long at
Place of Death ?

Days

xd.irrss AC)b d/CUVw VO^IA ^

l'I,ACK OF m-KIALOR RHM..VAI, | DMi;.,! HtHiAr. .., RFMovAf
I NDl.RTAKKR vJj-CO'X.^'^^hj \<. ^

190

N. B.-

-Every item o? information should be ctirefully Hupplied. AGE should be stated EXACTLY. PHYSICIANS should
state CAUSE OF DEATH in plain terms, that it may be properly classified. The "Special Information" fop p«p.
son* dying away from home should be given in every instance.

^ il

WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD

N

-^

.'.! ,.f II. :,llh I' N.

■ ■v- -. 1U*>^ I' c

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

Dfffr F//rrf, L'ctHK

\) ID

JfJO\

Bp^isfercd A^o.

2209

^V<w^^ \^C\>

I

DEPARTMENT OF PUBLIC HEALTIl=City and County of San Francisco

Certificate of S)eatb

( 11. S. GtauDarc* i

PLACE OF DEATH: — County of

01

<X/yyr\^x^u^

<x-

City of

^No.

1^05

a)

KUs

u

\^-t

St.;

Dist.; bet.

and

(ir Dt*TH OCcdRS AWAY FROM USUAL RESIDENCE GIVE FACTS CALLED FOR UNDER "SPECIAL INFORMATION" N
IF DEATH O^jcURRED IN A HOSPITAL OH INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. J

FULL NAME

wJLws. ,\^ ^ JS^r\X(x.

PERSONAL AND STATISTICAL PARTICULARS

COI.OR

JUXY\XXA

i>Ari. or r.iKrn

A < ■. !•;

iJJxeLt)

(L>

MEDICAL CERTIFICATE OF DEATH

DATK Ml- DKATII (CS

t'ct

XX

Munthii

2.q

(I>av)

M.iuths

I Vc'U

I hi:

I)av> (Veil I

I IIHRI'I'.V CliRTri'V, That I attendtMl .kccased from
— — — i^ to

"^iV" .i.i' M \K K ii: n.
W'liM AS 1.1 » ( »K i)f\< »Ki i;n

' Wi it« i 11 -I iria) 'li sijJTuiti. Ill

1UKTHPI,ACK

St;! I t I il < *( III lit ! \

NAMI-: Of*

i'atiii.:r

niR IHI'I. ACK
fH" FATni-tR
(Slatf or Coiiiitt v)

MAIi>i:N NAMJ.-
<)l- MOTUHR

HIK'I'HI'I.ACH
«)l- MOTIIKK
(St:itf or Coimtrv

<K"Cri"AII()X

that I last saw h

alive on

1^
T90

and that death occurred, on tlie date stated ahovc, at

M. 'Idle CAISI-: OI- DI'iATII was as follows

VJa-nJLcw*^

v<^ » , V

n

Dr RAT ION Ytars

CoNTRIin'TORV

Months

/hns

//(

ours

Mont /is

I )rR AT ION }'rars

(SIGNED) Xk \XX ' ■
U/Ot ^ 190 H (AddressM

/hivs

Hours
M.D.

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

Rt'iiiril in Siiif I'l iiHcisf'ii

y'tiu .

M,»ith^

Ihiv

Tuv. Au<n-F. ST \Ti:n phksonai, parti«mi, \ks ark trtk t<» Tin
liHST oi' Mv KN()\vi,i;nr, H and hkmicf

Former or
Usual Residence

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

How lonq at
Place of Death?

Days

(Address

I'l^CE OI" nrRJAI. (»K RKM<>\AI, I IiATKrif Bcrial or KKMOVAI,
r.N-DlCRTAKKR ^J CAAJL^j ^ LAjJk-^tlX

IN. B. Every Item of Information should be carefully supplied. AGB should be stated EXACTLY. PHYSICIANS should

state CAUSE OF DEATH In plain terms, that It may be properly classified. The "Special Information'* for p«p.
sons dying away from home should be given in o\'ori Instance.

i

I

I
I

|j

I.

• I >

#»fip*-

vmam

WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD

' . "-7" REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

If^O'i

If P^j/sf (>/•('(/ v\V>.

oo

2210

I)afr /'V/r^/.UdL<rW>u ID

DEPARTMENT k PUBLIC HEALTH=City and County of San Francisco

Certificate of IDeath

PLACE OF DEATH: — County oi^ CL-s

P

^

City of ^o

n

No.

I Vw. V ^

St.;

Dist.; bet.

and w

/ IF Dt*TN OCCURS AWAv rROM USUAL RESIDENCE Give facts called for undep special information- \

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

FULL NAME

V^vYv

PERSONAL AND STATISTICAL PARTICULARS

\i } I ii Hi i< r

' -1

DIR A'rroN

C( iNTkllU TORN'

WEDICAL CERTIFICATE OF DEATH

i t <)0 \

I HKI<i:i?N CI KTIIN, That J ittni.h 1 .I.hx a^i-<l frnm

that I la^t ->;.u h • alivi nn ^ it>o

1(1 tliat iKatli ixaairrt'il, !■" ''m- dalt- ^tatt'cl alniw, al »

U^ ^M. Till- CATSI-; (H J)i:.\Tn was as foII,,xss:

I

}V.;

i^av

I /ours

) '<a r

Miinth^

nav

Hon

rs

DERATION

(SIGNED) H<<nXO\> vJclAAx. M.D.

''"^ (j I' y ^ *

SPECIAL Information only for Hospitals, InsN^yfions, Transients,
or Rerenf Residents, and persons d>ing away from home.

Former or
Isual Residence

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

How long at
Plar c of Death ?

Days

dress i5:3lH. alMiJ^±:«->v

ry item otf inform«tion .hould be carefully supplied. AGB «houid be stated BXACTLY PHYSICIANS .hould
e CAUSH OF DEATH in plain term., that It mny be properly glawifled. The Special Information" for per-

4
I

1

- '^>.r??

I

WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD

•^* -Sr.^; iiM ^■

//^//r Filed ,

l!)()H

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

JU'i^isf r(u'<( J\'*o,

flR

Deputy Health Off

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco

Certificate of ©catb

11. %, i?tnn^nr^

PLACE OF DEATH: — County of UO ^^

<i <^oCity of o./^\

'W

^ % -i^ CO

N<^

- W-C V^ ^\Am

w wrM-i

St.; Dist.;bct. and

FULL NAME ^l^^0<

1

PERSONAL AND STATISTICAL PARTICULARS

r. .1 t >k '

to.

KTn

Ll

a«;h

■-IN" . I.I M \K Iv 111

\\ I I'l i\\ I I ' « IK I ."

WTitf in •

BiK riii'i, N '1'

A

'11 nt ! \ ' I \

x-^c^ Li

NAMK «H
PATHKK

nikTHl'I,\rH
or r \ IHHK
>!,(t. , .r r(iiHitr\'

MAIDl'.N NAMi:
<)1 MoTFIHK

lURl'HTT.ACH
<»»•• NToTllFK
Stati ill ('(Mint T \

vllcxtl lo-

^

^

rv

MEDICAL CERTIFICATE OF DEATH

• F A'ill

(%t..lltlll '' ■

i IR TIFN". TliiiLj atteiKk-il «U-<H';ist'il fr<>tii

I- •■ I "\

<4

tlmt I

;ini1 1

lc,0

-1! I rpil. on tin

'ill ;iii<i\'t', ;it

M,

If c

-O^ >%.Cy~v"*'^v\-; y> J^<^

()F liKATII w.i--. a-.^ folln\ss :

Dlk A rioN
CoNTKinrToRV

DTK AT ION

1 ' 1 1

Da

vs

I lout

) \'ais

IhlVX

(Hori'A rioN

Rr^idrd in San I i ,ii

[Signed ) J . ^ A

Hours
M.D.

10 TQoH (Adclrcss)^

yfitvihs

lhi\

Tin: AllOVK STATl-n l-KR--M\Al 1-\HTI<MI,ARS AKH TRIH TO THK
BKST OF MV KNuwiji). 1 WD lUljFF

(^ (? ^ , 0 "

SPECIAL INFORMATION only 'or ^'•pttdls, Institutions, Transients,
or Recent Residents, and persons dying away from home.

Former or a o. i
Usual Residence ^ J *t

Wlien was disease rontrac fed,
If not at plaec of deatli ?

Q f \^ How lonq at

XUl^'v Ja. Place of Death ?

Days

l'r,ACK OF I^l'mi'' '*•* KKMoVAI.

DATE of 111 I'lAi (>! KHMnVAI,

190'

TEof I!

Oct

\.M

(5 » .. X' A Ihr should be stated EXACTLY. PHYSICIANS sliottlil

N. B. Every Item of InformBtlon .hould be carefully «"PP''^?- ^^^.^ cla.sified. The "Special Information" for per-

•tnte CAUSE OF DEATH In plain term., that It may be properly ci«.sii 1^

•on. dyinft away from home should be given In •s^ry Instance.

J

II

WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

Tin ft' I'l/f'tl , ^ c

D

i!f(n

Jiroislcrcd >jY(),

f^f^ 1 ^

A

Deputy H--^'*^ Officer

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco

Gcvtificatc of IDcatb

4 m

PLACE OF DEATH: — County of

City of 0<x\x; •I'vcov

Hi

No. iHC \.v^^..w; St.; 4 Dist.;bct.Hrt^<^A.06^x, and

/ .r DEATM OCCURS AW** TROM USUAL R E S I D E N C E G I V E TACTS CALLED rOR UNDER SPECIAL INFORMATION • \
( ,r"cATM IcCURRtO IN rnOSP T.: OR INSTITUTION O.VC ITS NAME INSTEAD O. STREET AND NUMBER. J

FULL NAME

PERSONAL AND STATISTICAL PARTICULARS

I) \ i 1 < il lUK 111

'L' >K

L

] I la.

MEDICAL CERTIFICATE OF DEATH

DAii-; <»i'' I)i:a'iii

U^

It

!):tV

/QO \

\' .}•:

[[. .

1/ , '/

/ >,i

^IN<". I,K M \KH ll'D

' U"! it- ill (It -ii-tuitii>n> I

LL' LcC<^"LA>4<L

lui^ : iiri. \.- 1-

^t ill 1 i! I 1 illtll! \

N \ M 1 III

1 \ rii i-,H

!!IR III fl. \(J.:

«>i' I \rni:u

(Stati iir I'outitt \

MAn>i: X NAM J

<»i- M()Tin;K

HiH iin'i. \ii-:
<ii Morm-R

< ^tati or I'ouiit 1 \

-C

J^

^^ n .

(M.Hltll)

I III:R l-;i'.\' C I:KTII"\, Tli.it I :ittiii«lt<l <k'.Aasc»l frniii

t.. v.. a'^' 'f 190 H

l</^

lliMt 1 last saw li

.•ili\ f i)ti

ail<l that death .icriiiri-d, «in tin- ilati- •^tati'd ahovr. .at
lL. M Tin- C'X'^I" <>1' l>l AI'll wi-- av follcws:

T90

DrkATlnN )V</r.v

CONTUim T( »RV

Mo'ilhs

l^ax

I lout

V.

.^fnntlis

Par

(SIGNED)

Hours
M.D.

\

!()( I

(A

a,in-ss) 15'i ^3,u.^AXhj .;i

OIH'TI'ATIOX ,.

.\r,,iiih>

jhi\-

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

former or
Usual Residence

Wlif n was disease contracted.
If not at place of deatli?

How lonq at
Place of Deatli ?

Davs

Tin: AHOVI-; sTXTin PVKSOXAI, I'AKTim.AKS AKl-) TKIK TO TIU:

iu-;sT 01 iu: KNOW LiiH. !•: axd iu:iji%h'

(III fotniaiit

0^

llo.

r

ri,ACKj>Vv-Mll<!AI, (AR KHMOVAI, | DATI'.'.! liii-iM ni KKMoVAI.

((

rNI)KRTAKi:R UnJX''

(Ad.l!fS»4 W/

^ , „ ,5^,1 inB should be «t«ted EXACTLY. PHYSICIANS iilioulil

N. B. Every item of Information .hould be coretully «"PP'- " ''** ^k- cl«MH.»tecl. The -Special information*' for pT-

Mtflte CAUSE OF DEATH In plBln terms, that It mn> h. P m-

•tate CAUSE OF DEATH In pi

sons dylnft away from home should be given In •y^ry instanc*.

> l«

I

i

I

'J^at

ill

■A

WRITE PLAINLY WITH UNFADING INK

i '!h i N-

^ --u.

DS^V Ci,

I)

ftfr Fi/pf/, \L/ Alt-Hs^^v 10

JfJO'i

THIS IS A PERMANENT RECORD

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

Re ^i sic rod J\^o, -^-wl o

1

^r\KKJ^

\>

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco

Certificate of IDcatb

PLACE OF DEATH:-County oi^ Ck^^ ^i X^y^^^^<^ City ofC-CL^v aAxx.>^A^^

^

V^

No. ^-'Xcv ^ Iav^ >vtu. , -1 ^ ■i- 1 V ^- - -3- '

h ( ir Dr»TM OCCUR* »wav from USUAL

' V If^ Dt*TM ©CCyRRCO IN A HOSPITAL

St.;

Dist.; bet.

and

RESIDENCE GIVE FACTS called for under ■special INFORMATION' \

OR inst.tutTon give its name instead of street and number. )

\

\

FULL NAME C amX

a"!

Kj CvA.'

M

(\^

'^

(x.Ctx'

\t ■ !•;

PERSONAL AND STATISTICAL PARTICULARS

1.! lUKTll (^

!>.'V

HS

D )>./

I • ,u

Da

•-IN^.I.K, MAKHIi:!)
(Write in ftocinl flrni^iiai {•n)

ill

O.^^' ^

lukrniM.xi'H

'Stall ( ir l"i niiit ! S

1- A 111 i.;r

TURTm'I.A(H

• >i I \rni:R

' State i»i (.'kuiU I S

A

0

^

t

MEDICAL CERTIFICATE OF DEATH

DATK ul- Dl'.ATH

i

iMnlltiri

!t:i\-

(Vt-arl

^

I ni'.Ki;HV CI'.R'rn-N'. That I atUiiilL<l (lt'<ia'^f.l from

•^v«^W

\

^t

fjo H

ifp

190'^ to

that I last'saw h !•• ■' alive on ^ Tip

and that .U-atli occurrc.l, on the -lati- ^tatc.l ahcnx-. at il H5
k.L M. Tlif CAl'SH OF DI'l.XTil was as follows:

n caJjolcc^l \jTl\X<-'Ov-n.

-^

.M-,

O V.

DrK.KTION Ytars

coNTRrr.rTnkv

Months

Pays

noil

fS

XXl«:l.C^ wQ.

I U'VLC

\j

:x I

maii)i;n NAMi-: i^
01 .M«>Tin:i<

lUK'ririM.ACK

<>l- NtoTHKK
(state iir I'oniltlN

jU1/0lA>^wI'\j

,tl

^\

1 I

I)IR.\TM>N
(SIGNED)

v1 uv.

Months

/hivs

0

1 1 oil is

M.D.

L INFORMATION only f*"^ Kyspitals, Institutions, Transients,

nCrii'A'lIOX

Rf^ith'il III Siiii I iitii'i'i

M,<iilli>

lh}\

TIIH AHOVK STATKl) I'KRSONAl, !' \ K TIC C I.AKS AKl- TKlK T< » THH

UKST <)i' Mv KN()\vi,i:nc.H AM) r.i.i,n:i'

(Infottn.^nt U . v} , (aD . \jLXX.4.AH.t

e pECI AL ..». — -

or Recent Residents, and persons dying anay from home.

i:«.™.r «r f, "\ X ' How lonq at

When was disease contracted,

If not at place of death ? ^^^^ ^_

Days

DA

C

h

I'l \CK OI- ni'RIAI, OK RHMoVAI,

(AiUlrt-s.s 3vbiob \I riMlAX^«Sr>

t ISiHiAl, or RKNfoVAI.

190

rV

'J . .. 77a age should be stated EXACTLY. PHYSICIANS should

o? information should be carefully supplied. ^ ' classified. The "Special Information" for psr-

E OF DEATH In plain term., that it may be properly ciassme

N. B.— — fivery ite

State CAUSE OF DEATH In p.« , i„«t«.iice.

son. dylna away from home should be ftlven In every Instance.

+ 1
^

a

5»

I

\

WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

DEPARTMENT 6f PUBLIC HEALTH

Registered A^o.

22 1 ^l

f^^-^

City and County of San Francisco

Certificate of IDeatb

( "U. 5. StanOavD )

\

PLACE OF DEATHi — County of OcL>^ 0 ^xx^^.

3'

QTI

_ ^ V

City ofCJ^o^^YX' v/X<xo\^CA^^c

1 , ^^ -^ 1

No. 13 iO Ll>v.v.c St.; Dist.; bet. - Ux

/ ,r Dt.TH OCCURS .wv r«oM USUAL RE SI DENCE G.vr tacts ^^'-^/i' ;°" ,7°" ^5"^^^^^^^

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

and VJ.U./^ c_

FULL NAME

1^.

^c'

X'>x

PERSONAL AND STATISTICAL PARTICULARS

^ i'<)I,(iK ^ -\

III

I> \ 1 !•: <»! lUk Til

» ^

jMotitli

\<^'.V.

\\ llx nVKD OK Ht\'« >Ki J i)

'U'litf- ill ^111 jal ill >-iLMKi! ii 111 I

liiK rui'i.At'i-:

I Statf or CdiiiUi V

1 )a V

M.xilh:

^3:

n

CrAjt^-^wt

MEDICAL CERTIFICATE OF DEATH

DATH OH DlvXTH |A

IQO I

(Ytar)

> > al

/'./

O-

%!. ,11th) 'Day)

I HRRFilRV C I-KTI I'"\', Thai I aUfiukMl <kTcascMl fruiii

iJ <ik: i \^p'- to wet; 1 ItjO H

that I last saw h ' alive oil ^ ^- ' Ifp

aiiil that ilcath (M'turrccl, <in the date stated almve. at u
M. The CM Si-; Ol' nivATlI was as follows:

T

\».

^ \,U_W,5

I \ III IK

P.IKTUPl.AiK
<>l I AIHKK

St III I i! I'liil lltt \'

M\ini-:N NAMl

«>i- M«»*riii,K

lUR TUlM.AnC

'•1 M<>rm':K

(Statu or Coutitrvl

U

1

I )r RATION I )'ears Months Paxs

coNTRinrToKV Ua.cU/^'^vwc s^ ^>uo

Hours

A^A-/^AA-^w^Xj

1)1 'RATION Yi-ars Months \ Pays

(SIGNED) J/V\Xr-^ iw M I Ux'vC N v-wA-

iDct X ino'l f Address) nOO.UjtUL|

Hours
M.D.

^

SPECIAL INFORMATION •>"!> ^^^ Hospitals, Institutions, Iransients.
or Recent Residents, and persons dying away from fiome.

Kt'^idrd III Sati i'loni'

,,i ' i L ) '•<? '

\/,'i/f/r^

/hn.

Tin: A!5(n'K STAil.H i'KRSnXXl, PAR lUl I. XKS ARK TRTK TO nih

ni'.sToi-' MY KNo\\i,):i)c,H ANp in:i,n:!-'

(Informant db X^"^A-M ^v • OU CKX'>-r^aAA.^V

1 \ f

A.l<1ri-.s 5v?3lO

"U

former or
Usual Residence

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

How lonq at
Place of Death?

Days

I'l \cy OF HIRIM. OK KJ.MoVAI, j nATi^ «>f HiKiAl. or RKMOVAI,
INI.KKTAKKR fojl/>Xh^ V U<JlLcX^

(Address

xo

)X

^ . .. IVH AGB should be stated EXACTLY. PHYSICIANS should

N. B. Every Item «,f Information should be CHrefuHy suppiien. classified. The "Special Information" for p«i-

state CAUSn OF DEATH In plain terms, that .t may he pro, e

sf>n« dyinft away from home should be felven .n every .nstanwe.

4

I

I

r m
r

-i

1.

WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD

t; ,.>r.l ..f II. ;ilt!> I N<

^.y--^.^^. ,

'SF-^. l^Sil- I'

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

Da/r F//r^/, i'ctcl

M.\ ID

ir^OH

Megisfercd JS^'o.

'2^

IF]

o^^^vc

^

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco

Ccvtificate of 2)catb

PLACE OF DEATH: — County of Aa,-vv -Vex, , . . .City of C O.^ J X^-y^JZ^c^
N„ 1 LL. V- St.! ' Dist.; bet. 3 CPuUmx, and OC a\VU t , . )

/ ,r Dt.TH OCCURS .».» rROK USUAL RESIDENCE GIVE FACTS CALLED ron UNOER -SPECIAL "•'"'' ""'S"'" )
( ,roc.T„ OCCURRED .N°MCSr.r,.L OR INSTITUTION G.,E ITS NAME INSTEAD Or STREET AND NUMBER. J

FULL NAME JxJ:XcU

>i,\

PERSONAL AND STATISTICAL PARTICULARS

^

ClX-<

u

4

i» A ri- < >r i;ii^ in

\< . (

^\J

a

'IM

f%-.:i' I

I
-^

Cla^uVLKxc i \

MEDICAL CERTIFICATE OF DEATH

DA ri-; <>i nCATH fn

1

(Nfoiith)

Day)

/go I

\\ \\u i\V) I) MR DIXitKn:!)

'X^'iiti'iii ".(Mi.il (It -i>.'ii:tt idti'

v.

r

^.'^vCV

,w

HIRTIIfl.Ai'K

(Statf or Ci»imtr%'

XAMl- <)!
1- All! 1 R

p.iRiJiri.ArK

<)l' I A 11 IKK

' Sl.itf ( It V'liUllt I \'

M MDl'N N \M 1
«>l MoTHHK

inurKiM.Ac-H

«•! MoTllKR
'Statf or Codiilrv)

,c

I III':RI-:r.\' Ci;i<TIl'V, That r aUm.lr.l .U-rcasiMl from

tn UcA.' "^ Ttp *^

that r last saw h ^.' alivf on ^ ct L Tqo

an<l that di-atli occurred, on the dati- stated al)ovc, at » •.
M. The CAI'SI-; OI*' l)I{Al'n was as follows;

c

dU^L^'5.^^ >

1

«>CCri'ATION

h'rM('iif HI Sdtr /'l it II, IM n

DlkATlON )'i'ars Mon/hs Pars

C ON '1' R I I'd "1" ( ) R N* U /OJt'V-UAwLcu'v' Xkas^'

I)rR\TI()N i'tdrs .V,>>///is fhivs

( SIGNED) U^lMa^cL ' . ■

(Address) S^ioO CjX.^i.L

J/ou

rs

^

ICJO

Hours
M.D.

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

! V(7/

Mnilthl

Tin: AHOVKSTATl'.n I'KRSONAI, |»A KI'IC T I.A Rs A K Iv TKri- To THh

p.iisroi' Mv KNowi.i; I )(•.)•; and ni;i,n;»''

(Iiifoniiant

Former or
Usual Residence

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

How long at
Place of Death ?

Days

I'l.ACi-; o! lURiAi, OR ri;m<>\ai.

I>ATi:uf niHiAi. or KICMOVAI,

T90

I NDKRTAKHK U^ w k,.

(Add 1 1

-,^Co

N. B.-

"•— ^ ^ „ ..J *GB should be stated EXACTLY. PHYSICIANS vhould

-Every Item of informatmn should be cnrefully suppiiea. classified. The "Special Informallon" for psr-

state CAUSE OF DEATH In plain terms, that It may h* jjope

son. dyln4 «way from home should be ftiven .n every Instance.

4

4

I

I

I

m

r

WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

I N.,

»'.■« "^n*.

'A 1 I

Bo<^isfefO(l Js'^o,

-v*^

Deputy Health Officer

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco

16

,<.v^^

No.

Certificate of H)eatb

PLACE OF DEATH: — County of '<^ >^ OAxxaox^ul^cc City of ^'A. ^v J /vxx^ v^c^Axui

St.; tc Dist.;bet/ -^XCvOla' and VVA O

TS CALLED rOB UNDER SPECIAL INrORMATION' "\
TS NAME INSTEAD OF STREET AND NUMBER. /

'*N

(i F Dt
I*-

• TH OCCURS AW*V FROM USUAL RESIDENCE GIVE FACl
DEATW OCCURRED IN A HOSPITAL OH INSTITUTION GIVE II

FULL NAME

Vjllv.

n .

PERSONAL AND STATISTICAL PARTICULARS

sj x >

- •!,< 'K

lL'. IvaJii;

I>ATK. (•! lUklil

a<;h

A

t

MEDICAL CERTIFICATE OF DEATH

DATK <>|- !)J;aTH

, tf.-iith

■OK )

■^IN'.l.K MAKHIi;!)

W|I)( i\\ 1, l> ( »R I>l\< tRt I I)

' Wt i!' i 11 -iH-ia 1 ,1. -it'iirtt ii.ti i

HfR ^HPI,ACJ;

»ATni:R

luk III rr \, 1-
< »i I \ I !i i.k

I S!;,|c (il « .jSIIUT V

M \ Iin-.N NAM J-;

"I- .M(>i-m.:K

HIKrilPI.ACI*
«>K MoTIIHK

' ^tatf or Cduiit t

'N

TOO H

' Month t 1 I >av) ( Vt-nt i

I ni{ki;nv C I:RTIIA-, Th.it I Mttiti.U-.l .krcaseU frnni

— — — — \ 1,J, , to — _______ — — J^^^J

tliat I I;i^t saw li alivt- on — ~ i«(0

aixl tliaf «liat1i < ^ , nireil, (Ui the date stated alxivi*, at
M. Tin- CAISK or DliATII was as follows:

U CCL\^V^-L<X\/

Mruj^X'

,11) .cl

Mn'ilhs

'Cfr

L

\

\^ :i

I) r RAT ION Years

CnNTRIHrTOkV

I )r RATION )\drs M-^u(hs

/>-/!s

Ih

uirs

/h

/rv

(SIG

Q<xx<x.'

?

NED ) K^tfU^^^VK, J .\b LU. XtlcAxA

Hours
M.D.

SPECIAL iNFORfVIATION only for Hospitals. InsHtotioirs, franslents.
or Recent Residents, and persons d>jng away from home.

«H CI i'.\Tir)X fQ\p

^\

M.»ilh^

Pa V.

Tin* \i!ovi.: sT \ rin i'Hrson ai, i'\r ii' ii.aks akh tki}-: to thh

HKsfcii MS" K N( »\\ 1,1 I»i ,!•; \NI) ISKI.IHK
flTifotmnnt wX/YxX-AA ' ' ' o.,.fi_

3ll NjHXcr^^

Former or
Usual Residence

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

How lonq at
Place of Death ?

Days

\.Mi

PLACE OF BfRIAf, OK HHMoVAI. I DAXi; of Hi rial or KKMOVKI

N. B.-

-Every item of Information .hould be carefully nupplled. AGE should be stated EXACTLY. PHYSICIANS ahouid
atate CAUSE OF DEATH In plain terms, that It mny be properly claastfied. The "Special Information" for per-
son* dylnft away from home should be given In every Instance.

«

I

•f«t«»:

^mms^.

rif^W

WRITE PLAINLY WITH UNFADING INK —

IliiiUh I V,,

■Ml-

Dafr /^V/r./,Uct^Li/v

THIS IS A PERMANENT RECORD

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

0

IfJO'i

]ip<^i.sfpi'Ofl jYo.

?2217

vv^ Deputy Health Officer

fF

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco

Certificate of H)eatb

1 11. i?. StanOarC^ )

PLACE OF DEATH: — County ofOCL-.^ ■''.'va

J?

City ofCcL^v JA^O_/->v

C <.- 0

No. U;uU^-vaX<xX ob.C4, \ v^ > X. ^ a \ . . St.; Dist.? bet. and

/ IF DC*TH OCCURS AWAiV FROM USUAL Ne S I D E N C E G I VE FACTS CALLED FOR UNDER "SPECIAL I N FO R WIATIO IN " \
V IF DEATH OCCURRED IN A HOSPITAL Oft INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. )

FULL NAME

>

X > >

-- 1 \

PERSONAL AND STATISTICAL PARTICULARS

111.

XXAJL

I>A !1-; <u iUKTH

11 11

MEDICAL CERTIFICATE OF DEATH

I)\ IK ol i»i-; \TH ,, \

' Vfi.iithi

Q
iDav)

(V.-ni t

?4

\t

\ < . V.

M;

1/..I/M

^

that I h\<-{ saw h

i:Ri;nV Ci;kTn-V, That I atlt'n.U..l .UMvasd frmn ^^

1./" tl

' ah \ c' Of!

iWct

\\titiin '^■Mial 'U -ifiiatiull)

lUKTlII'I, \('H

i st.iti III r. lunlrv

NAM J- oi-

I AT in: R

niK ^m'I,A(•K
"I■ i\rnKK

I St.ttt III ('nunt ! V

MAriUtN NAMi;
«>l- MuTflKR

lUU IIIJM,\tl.:

">i- Mnrm:H

'"^talf or t'duntt \-

dJiJb

ami that (U'ath luaurrcil, nn the datr --tatrd ahnvf, at

^^. tik- catsh of i)i;.\Tif was as foii-.ws

.K^S^^-^-^j O >">\.^r

hlKA'lTuX )'tuits

CONTkllU T()RV

,7/,M/M.v

/hi\

nu>

DIRATH kN
(SIG

)',i!)s \ .^/ont/is T /hi

NED) LiJ Q?. kje^'

Uct 10 T90H (A<i,iress) qaiMKa- >

Special Information ©niv for Hospitals instituMons, rransients.

oi'cri'Aiiox

A'r\/,ffif ill Sail /■') (ini i^i'i)

or Recfnt Rcsidfnh, and persons d)lng away from liome

M.nith'

Ih

HI-: xHDvr. ST \r 1:1 > pkksoxai, ixKiii'rr.AKs akk trfk to thic
n}:> T Ol Mv KN<»\\ i,i:i)c. I-: wd ni:i,ii-:K

Farmer or t\ Oi' Hon lonq af

Dsual Residcncf UXX/AAj g A,>(X/>^,Cc4 c c pijre of Ofatli?
When was disease conf raffed. ^ '^ A^t.-^w'>^Jui, t-o ^. ;.
If not at place of death ? -uj-VnJhlxv; Xvcnoiv ^

lU.ACK Ol' UrKFAf, OR RKMOVAI, I FJATK of H

T

Oiys

-CUCL

(III flit luaiit

Address

H03.

dtr

y /> ^ I "M'->" "'HiAr. or RKMOVAI.

(W.

IQOH

(Ad.Inss 0*5 D I 1/ - *

N. B.— Hvery Item of inforitiHtion should btf cnrefully Hupplied. AOB should be stated EXACTLY. I
state CAU8E OF DEATH In plain terms, that it may be properly classified. The ''Special In
snns dying away from home should be given in every Instance.

PHYSICIANS should
formation" for psr-

t

II

!t

WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD

l; irinl , ■ !!

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

Ddir ri/('<l,\j

'C

^ ID

lom

Rcgis/ered JS^o,

22t8

,{ru-<^.^

DEPARTMENT OF PUBLIC HEALTH-City and County of San Francisco

Ccitifi'cate of IDcatb

( 11. 5. StanDarO )

No.

PLACE OF DEATH: — County of ^CLox. 1\ ex .

* "f

Lo.^

VlX^w.

St.;

(ir DEATH OCCURS AWAY FROM USUAL RESIDENCE GIV
IF DCATH OCCURRED IN A HOSPITAI.OH INSTITUTION C

Dist.; bet.

City of ' /cx.^%! J A^tx.->

and J \<wV. Lc r

E FACTS CALLED FOR UNDER SPECIAL INFORMATION" \
GIVE ITS NAME INSTEAD OF STREET AND NUMBER. /

i'

FULL NAME

^.. \_

n

■-KX

PERSONAL AND STATISTICAL PARTICULARS

A

LclU

n A ri- t 'I 111 Kill

^

i

^1

vcL.

)l<

MEDICAL CERTIFICATE OF DEATH

DATI-; n|. Dl'.ATII

1 ,

(Year)

M.inilii r

A I , !■:

Tl

^IN<.I,I* MARRIi;n.

U li)*»Ui:i) OR I»!\'« »Rt' i; I)

\\'!it( ill vi)(j;il lit -i".'!!.!! !i itl >

FUK rifl'i. \C|.;
' St.itt or (.'(Mmli \

I I

D.iv

M.,iith-.

ir)

( Month 1 'DaN-i

I HI;RJ<:I'.V C i:kTIIV. That I attcii.U'.l (Ifccascl from

t *

1 90

to

>l.

^'^t

Ih'.X

S \ LCCw w^Jt

A

that I last saw !i .; . ^live on M-' CA,

ami that di-ath occurred, on tlic il.iti- '-tatcd above, at 0

I

M. The CAISH OF DKATII wa- as follow^:
1

fvX.<>-v-a '

V \M I- oi-

1- \i II Ik

i'.iKTHiM,\ri.:

'»! I X I'll I', K

■^1 iti 01 ri)iiiiti%

maii»i;n NAM1-;

<>i MuTHl'lR

IHRTniM.ACH
01 MoTllHR

( St;it< ol l."ouilt ? \

vj\ ft

Kfsidfii ,,i S,

4'

kCX s ! w

DTK AT ION Year Si

CoNI'klP.rToRV - '

Mnniln Days

a .

Wx<^

1)1 RATION ■ )\\irs
(SIGNED ) \

1-

Months

Pavs

C

^

\ L

rcjo t

(AfMn-ss) 51%\J rUnvLo^H S,

Special INFORIVIATION only for Hospitals, Institfltlons, TransifBts,
or Recent Resltlcnis, dnd persons dyiny away from liome.

)'itH •• .) ^fiiuflt'

Former or
Usual Residence

When Has disease contracted,
/},, M I If not at place of death ?

How lonq at
Place of Death?

Days

TH J.. AIIOVK STM'j;i> I'KRsoN \|. lARTUTr. \Rh A R I-! TKt H r< > VWV.

iu;sT Ol- Mv KX(»\\i,i.:i)( ,}.; AM) ni:Mi;i

fliifoiin.int

C<Lv.t.l -1 .

I'f.ACH <)I' HlKFAr, ciR KI:m<i\ Al, I DATHo! I!ti<i.\i, or Ri;M(>VAI

i'<x^

'W^

<k. ^<Xl'

^1

(Ad.Ii

a.51

^.

4^

m

190

I ,vih:rtaki;r

n .

AcM,,.^^ IQlU LX-

^-H

^ ccixX^cw>%d

N. B. Kvery item of infofmHtion should lu cnrefully supplied. AGE should be stated nXACTLY. PHYSICIAIMS should

state CAUSE OF DEATH In pliiin term*, that !t may be properly classified. The **S;>eci«l Information" for psi—
sons dyin^ away from home should be given In e\9ry instance.

m

^^ i.

t ?

H

I

^p

i

m

WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD,

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

mo'i

Ilvgi^sti'icd JS^i),

22J9

^

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco

Ccvtiticate of IDcatb

■CI. G. GtanC^arC^ )

J m

\ m

PLACE OF DEATH: — County ofHyCX/rv. 0 ^.a >vcul/co City of Ti/rvvu J A.<x >^.xva^ co

No.

St.;

Dist.;bet. .^.-^A

and

fH ti

(ir DEATH OCCURS »WAV FROM USUAL RESIDENCE Give FACTS CALLED FOR UNDfR SPECIAL INFORMATION \
IF DEATH OCCURRED IN A HOSPITAL OP INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER )

FULL NAME ^a

1

PERSONAL AND STATISTICAL PARTICULARS

UJ-ivdi

MEDICAL CERTIFICATE OF DEATH

it\ ri-; <>i DK ATir

I) A li; «>l IllK ! u

Ai .!•:

.Scs

^^

M.mtli

1, 1
I )a V

. I IIHRKin ri:RTII'\". 'I'll. It I ittt u.l. il .U(. iM.l fmin

1 » , .

C

to V_

I()0 1

-!"•' 1,1 MAkkllli

\\ I iM i\\ 1 i» ( ,K i»!\» >k« r ! I

\\ ; U ' ill ^c 11 i;t 1 ilt«.i J,' ti.i i '1'

n: N I fi I'l, \t'i;

strit. ,,! I ,,11 III, \

1 .\ 111 i;k

niK iHj'i.Ai i-:

<)» lATHKK

(State or Coil lit rv

M \!l»i:\- N \M},
"I MiirilJ-K

BIN rilF'I,A»l%

-lilt 1 If (till nt I

• 111 I I ' \ I ' 1 ( ( '

C'CXiv

((fp

L >

*^a \

tli;it T last saw Ii . ali\t on ^ i itjo

Mtid that (l<.'atli I iiTiirrcd, mi 'lie dati- statiil alinxr, at C oO

t 'I

M. Till- CM s|- ol 1)1 XTIf ua>~ a- follows

XCJL >\Aj M I Li. ^

Our\j

1)1 kVI'loN )'rais

TON TK 1 IUT< »RN-

JAM///'

Ihiv

Hours

0,1

?l

(

m RATION

\JC ' Ll I { )

<Xy\

V

:i'

hJX. > VCC4

SIGNED ) J V_ _^ ^

lL)/ci S TooH f Address) lt5 , Cl^xx>^t^^^

//on / V

M.D.

X

Special Information «nlv lor Hospitals, Instlfutlons, rranslenls,
or Recent Residents, dod persons dvinq a*»i»y from tiome.

Kf lillil If Sfiu / lilllil'

) III I

I M,<>,lli h />,n

iFii; Msnvi-; ST \ I I I. iM- R-M\ \i, I'SK ricri.AKs akic tkik to I' UK

HHsT (H MV KNMW 1,1 |H ,1. \N|) HHI.IKK

Former or
L'suai Residence

Wften was disease ronfrarted.
If not at place of deatti ?

NoH lonq at
Pfare of Oeatfi ?

Diys

anf,,.in,n» U >^w/V^-Cjt-'>'X^

t QoiiL'wA.

X.l.h.ss oS

";:3^'

i

ri,,ACH Ol' in KJAI, OH KKMu\Ar, I I)ATi:<'t m »iAr ..t K1'M*»VAI.

U' ic,oH

N. B.-

-Kvery item of InformntSon .hould be cnrefully supplied. AGB .hould he stated I^XACTLY. PHYSICIANS iihould
•tnte CAlISi: or Df ATH m plain term., that It may be pfopeHy classified. The "Special Information" for pmr-
nnnm dying away from home should be ftlven in every instance.

WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD

i(.:iiih :■ Nil - ^^^^^- nSiV c

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

7,9/9 H

B(\^isfere(l A^o,

.(: v-oUi oULaj^

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco

Cevtificate of 2)catb

( "U. S. StanDarO

i %

%

.4, "A ^'

PLACE OF DEATH; — County ofOxXAX 1 AX)L/>xcuLeo City of ^ <X/yv J ^UX > vca.<ico

No. ^ I S^; Hi iv,Ci.siL.t'>

"\

■^

Q

((

St.j b Dist.; bctAJ .\XO^a3<x. and J ^ ^ '\

(ir DE*TM OCCURS *W*V FROM USUAL R E S I DE 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

.\.<X VVLL

1^

UC "> ^ -V -*>•'

PERSONAL AND STATISTICAL PARTICULARS

DAii-: 111 liiu iH '^

Cl)l,«>R ^

MEDICAL CERTIFICATE OF DEATH

0

(Nfoiith)

7 0nH

(Year)

/ -

xr.H

31

)

1

(Day)

\l,>tiili

( V«-arl

/',;'

"^iNt.i.i' M \KK n;i>

lUiiti ill viH-jnl (Ic'-is/ii.it inH )

lURTUPI, Ai'l'.

' Slat' 1.1 I'liiiiit! \

LclX^w^ccL

y.r

I ni':RI';nV CI:RTI!-V, That I attcmled deccasea from
' ' - to ©tut.

Let' '] I./) to ^-CX- M r^o 1

that I last saw h .^^^ aUve on ^ ^^ ' up V

and that death ncciirred, on the dati' stated above, at 3
M. The CAUil': Ol- DIvATII was as fQlIows:

u

V »

FATIIHk

HIK IIIIM, \(1-:

<>i I Ai'miK

iStatt (II Coiiiiti V

mmi»i;n' na%!i;

<»!• .MoTHI'.K

\.

i

KK

t

I ) r l< A r ION ) 'rail Mouths Pays

C'ONTRIiUTOF-lV C/^Jk^O^ ^.>- w.&\:v

Hours

V\i)

lo...

^

I )r RATION )\ays Mouths /hiys Hours

(SIGNED) Aj . LL. M rl ^' \.v.^ M.D.

iy^ '\ TooH (Address) HH' '^Xd. H,

w\i

inKiiii'r,Ari.:

*St:it( (11 I'dinitl \

OCHTJ'A rioNi^ ft

()b !KX'<UU>cmJ^JI

Nfsiiirii ill Stiu I'lam i<t'o

O 5 ''(/ I V

1 A .;////<

/'.?

Special information only ^or Hospitals, Institutions, Transients,
or Recent Residents, and persons dying a»d> from home.

Former or
Usual Residence

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

How lonq at
Place of Death ?

... Days

'\\\v. AiW)VK sr xii'i) im-:ks()x \i, i- \k rrcri.AKS akk TRrn t<»

IlKST KW MY KXnW'MCIX.K AND lUU.IHH

Till-:

Itir-.tmiint 0>wJt h . UJ. xfriX/

f \(lclrc*^s

2)151 TTLuua^v 3t

I'J,4CK <»|. HIKI.XI, OK Ki;Mn\ AI, I DAIK.)! Ht kiai, (ji KlCMoVAI,

c<

IN. B.-

of Information .hould be cnrofu.ly -uppHed. AOH «h.u.c. »>«•»«»';;. f.^fJLY PHVS,CIAN8 .hould
E OF DEATH In plain term., that It mny he pru„erly wl«.«i«ed. The Speelal Information" for p^r-

-Every Item
•tate CAUSE _. _
«on« dying away from home iihould be given In svery instance.

i?l

m

>i

WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD

I

li.'-^i* (',.

REFER TQ BACK OF CERTIFICATE FOR INSTRUCTIONS

hffr /■y/('r/,x^,<ziJLt

\> 10

/^>^>H

]>('^isfrr<'f/ JYo,

QOOf I

^:^ ci^^vu Deputy Health Officer

F

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

PLACE OF DEATH: — County of

Ccitificatc of Death

City of < T

No.

Dist.; betJ llr»\tqtiiUXu ai

^ ^ '^ -^ OAi. St.; Dist.jbet.'i llfr^X^qt^iUXu and

(if DfATH OCCURS AWflV rROM USUAL RESIDENCE Give tacts called fob UNDE^ special /fNfOHMATIOlM \
ir OCATM OCCURRtJD IN A HOSPITAL OR INSTITUTION GIVC ITS NAME INSTEAD OO STREET AWD NUMBER, /

FULL NAME

-.%

PERSONAL AND STATISTICAL PARTICULARS

'Vl]\.v'-

iUI .« )R

\ \ II! lUk 1 I

(Mnntli)

rg<r> .

(Vtai>

\i.-\

\<.j-:

SIN. 1 i: \1 \H|< iin>

WII)» lU I'll ( iK I»!\i »R( J-|)

'Writ* ill v.irial (|i siiJiiat -'.11 »

lUK Tlf I'l. \i-j-
(SUitt- or finitit ! V

FAT hi: K

Q

KX^X

MEDICAL CERTIFICATE OF DEATH

D \ii.' 1 >i- ni: \ III

%

I ni:Ri:H\' ci k'ni-w riiat i nttfiKU.i ,k«,asiMi from

UK) , tl I W ' . T()0

thai I last saw h alivt- ri-i itp

ainl tliat (U'atli nccmrcil, mi tlu- dali- stati<l ahovi-, at

M. Tlu- C Alsl <>l I)i;.\'ril w

1*^ ;ts f r 1] h i\\ V

-^

\_U^

J^^x

>%.

%

0

."^

"X

luR riii'i. \» 1-:

'•!• I \ til IK
IStnt. ..! I i.imtvv

i

niK xrinN )'rars

C<»Ni'l<ini '!'< »I<N'

^r:>l/^!s

/hi

IIv

•If V

^

MAim:x Nwti T^

OF MfiTHKK li'

lUK I'lII'I, Ml-:

<'»■■ M( rr m:i< ,,

i^t.ii.^ .,1 >',,,n)tt \ 1 U ^^

'>("C|-i'A 11, ,x

DIRATION

Years

)/,>)Ulis

SIG

' ^ f ^ f

NED) V^<X\,VO U CC > -% V I'

,eix<X,N^

d.

ly.'ct) t T(,o

H f Ad.lri'ss) loOl

U) -CLA^I

/'f?rs Hours

M.D.

US, If

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

h'r'iittii in Siin /■'/(/»/( /'»'/>

) 'ra I

ytnttlU^

D,t\

TH].; AHOVK ST \rir> l>KR-;(>\A1. l'\K ril-fl.AKS AKi: TKIK To THK
IIHST <»!-• MA K.N'(>\Vl.i;i)(,H AM) lUU.IKK

I iTifiinn.int

\

.<X.<L/Q M-'^

\l rlvcJkjLJ

Jj

Former or
L'^ual Residence

Hhen wa<; disease rontracted,
If not at place of death ?

How long at
Plare of Death ?

Days

ri.ACK OI* BVRIAr, OK KHMOS AI, I DATK of RiRiAf, nr RKMOVAI,

V a

t

\<l.lrc!

3i% ^A--^-ix<L-A>o.u.. d;fe

4

igo

„,.„, .hould be ca..»ully .uppll.d. AGF. .hou.d b...«..d EXACTLY PHYSICIANS .hould
ATM In plain term., fh.t It may be properly clM.lfled. The Special Infoi-mallon »or p.r-

N» B.^— -Bvery Item of Inform

state CAUSE OF DEATH In p

monm clylnft owiiy from homo iihould be ftlveii In mvory instance

4

f i

WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD

ii. ,'t'. 1

' , V ; I 1 )

ii!

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

l)ufr Fih'il ,

3^trV>LA,^

cl^u-C

\; 10

1U0\

livgisl i'rc(1 JVo,

oooo

■•,»_.<—_■*

^^^

*enu*y Health Officer

DEPARTMENT OF PUBLIC HEALTli=City and County of San Francisco

Certificate of IDentb

"U, %. 5tanC»ar^

A

PLACE OF DEATH: — County of a^x . Xa^xO^co City of^a
PioX^V^L?^\_L">v:i .w,: * ' ' St.;'— Dist.; bet.

(ir DE«TH OCCUSS AAA< FROM USUAL R E S I D E N C E G I V E FACTS CALLED FOR UN
ir DEATH OCCURBEO IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAC

'^?

and

lAt INFORMATION- '^
r AND NUMBER. /

V

FULL NAME J^O-^v^vO-i

-IN

PERSONAL AND STATISTICAL PARTICULARS

• \ ri: I >! nils rn

A«.I%

vn\^

M .nth»

%

n,i\

MEDICAL CERTIFICATE OF DEATH

I Month'

U

Dav

IQO

(V«ar

I III-Ri;i;V C'l'lRTII'V, That I attt'H«lL'<l .U'.casKl from

(iO

t-)

•^INt , I F M \k K n:!)

\vr ;>< »\\ i:n tin i mv< »ki t t»

' W: ;!; in -in-ial di -ii,' n;it :-;.

lURTIIJ'l \.-i-:

X \ \f 1 I II
I \ III IK

H!K riiri, \oK
or I \ rni.-.K

MAII>j:n NAMi'
ni MUTIIKK

Ol' MnTllKK
(Statr or (.■i)iintr\-

,CL>X'

ktHLMv^\;

i()0 H

that I last -aw h • alivu on i«p i

an«1 tliat iKatli orrurrt-il, oti tlu- datr stated afMivo, at A
UL M. Tlu- (.' \r^I" ''l-" IM- ATII ua- a^ foll-nvs:

<)-<l.:ii

fQO

L^x^o i o. \ ^^cL

rv<SiA)4/ CA4x^txc4

IHRA rio.N
CoNTKIin"!

DIRATION
(SIGNED)

Mmiihs

)'ears

ORV U/L^\VoU>-iX

fhivs Hours

■<XA.^XX,4lJUi

Months

}'i\irs

■J , Lxoli^ '

/\ir

//oias

V

M.D.

A.l.lrfss)^100 LcJuXoV >VLa Jl

, InsWt

\j

I

SPECIAL Information on'v (or Hospitals, InsWutlons, Transients,
or Recent Residents, dnd persons dying dnay from home.

ot'Cl !• ATION 4

Former or V ^ ^ k 4
Usual Residence UMX^AXtO

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

How Jonq at
Place of Death ?

1^

Days

"^vk>v<^

'rm-: ahovf sta'!*i-:i) ckuson m, par rirri, \k^ ari-; i'kii: r<» i'"'"

HKsT Ol' MV KNDU I,i:i)i,l-; AM) 1!KI,I1-;K

(Infiinnruit

<L

A.l.ltcs.s I't'^Ll

JcrLcLt-A. JojUlU-^

I'l \VH OI-' lURIAI, OK K1:M(>\AI. j DA I i; of Ht KiAl, or KKMtn Al,

190 n

\(I(lI t •'V

„ii.a AGB should be stated EXACTLY. PHYSICIANS should

N. B.^— Bvery Item of inform

state CAUSE OF DEATH .

•9fi« dylnft away from home should be ^Ken in every instance.

I

.1

'fl

f i

'H

I

-1^

li^i

WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

.f H.alth (■ v., ^-^ »; ^1 I!8:I* *

/

fO + f

.\j 10

IfJO'i

Registcied jYo,

ooo

'^»5

.^r^^AJ^^

^>M--

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco

Certificate of IDeatb

"U. 5, J:>tanDarD •

J? T) -^ ^

PLACE OF DEATH: — County of Cl-^v J V<x>^Co0.coCity of JO. >v JX.<X'>vc^<> ' '.

No. V V i .. St.; '' Dist.;b€t. Uk^<AxJ\. and O.n.

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

FULL NAME

PERSONAL AND STATISTICAL PARTICULARS

^

^IiIclU

V,'( ll.l »k

a

.a'v

I> A n I It !;IK 1 11

M ,11th

n.is

\< .!•;

/go .

(Year)

/),

U li)i >\\ i;ii ( »K l)!\( »i.:. 1 l>
' Wi \\, j ti -,Ki;i 1 i.-U'llat \i 111 I

-A

lui.' i'lri'i, \i'».;

^t it. ,,! r,,iint!\

I A 111 IK

HiK riiri, \rj-;

'•I I AIIIIIK

' *^t ill 1,1 riiiint I V

MAMM'N ^\^!^■

•>I M<tTHHR

lUK'llIIM.ACI.;

'•» M<»'nn;K

nCtTl'ATiux

MEDICAL CERTIFICATE OF DEATH

1) \ IK 1 >i i>i-,Ai'n , \

i\!,.!Ulii (Day)

I 1 1 l{ K I", I!N' ri:kTI!'\', Til it I ;itt«i!iU-<l .Uriasc.l from

that I I.i«.t sau li :\\\\v nil I'p ■

ami thai ihatli .H-cuncil, (»ii the <latc staltil ah<>vc, at 1
UL M The CMS!' oi" I)i;.\TII wi-- a', folinu-;:

_ /u^^'^-'J,.

[floJvci

Q

DIRATION )■'</;

CoNTKUH TORY

M, 1)1 ills

Paxs

Hon

r%

I ^

.k„ > ' t

(SIGNED )

)V,//?

^^o)lllls

IhiVs

^ii^.

IIoH) s

M.D.

rx.hlrrss) lOS-b OfUXmX' VjH^<t

n

SPECIAL INFORMATION only 'or HospiUls, Instilutions, Twnsien
or Recenl Residents, and persons dying dwav from home.

't

^ ~s-%-\ ''

Isf^iifni III S,ni I I ii n

i III I s

M.nllh^

lhl\

rill', \i5o\i.: ST \ ri.D pkr'^on \i, rsK'iicri, xK'^ aki', thii-: r«> rm-.
iu-:sT OI M\ K M »\\ i,i;i)(,i-; \M) i!ii,ii:i-

Former or
Usual Residence

When was disease confrartfd,
If not at plar e of deatti ?

HoH long at
Plareof Death?

Days

i\

iif.Hniant \J . nI M. C<X/vA„l\.M

X.l.ll.'SS Jv I

w

'ysjysjx.

\

I

I'l Xi'H (H- lUKIAl, <»K 1:i;M«»\ \I, I DVIi: .! I!i Ki.M, .11 KKMuVAF,

iL'^t u 190H

%A.

4,

N. B..

iTlACI should be Btate.l EXACTLY. PHYSICIANS should
-Rvei-y Item of Informntlofi .liould be CBPcfully supplleci. « • . ., j y,,g "Special Information" for p^r-

•t«te CAUSE OF DEATH In pl»in term., that It mny be properly U««..iie
non. dying away from home nhould be given In every Iniitante.

I

A

f t

WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD

II

If

'W^*"

II. Mil I- X.

i:.*^!'*-

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

ht//' F//('ff, kJ <:^AJr{)

yJL\j 10

HJO'i

Registered JVo,

1

DEPARTMENT OF PUBLIC HEALTH

City and County of San Francisco

Certificate of IDeatb

( Xl. S, 5tan^arC^ ^

PLACE OF DEATH: — County of

City of ^J^X^^<^

No.

St.;

Dist.; bet.

_ — _ — ^^^. i>pisT.; c

/ ir DtATM OCCURS *w»v FROM USUAL RESIDENCE Give FACTS Ci
\ IF DEATH OCCUWRtD IN A HOSPITAL OR INSTITUTION GIVC ITS N

FULL NAME H Kvy U

and

ALLED FOB UNDER "SPECIAL INFORMATION \
"AME INSTCAD OF STREET AND NUMBER. /

)

LtLlXcK,\Xim

/

PERSONAL AND STATISTICAL PARTICULARS

■» "^ CKTs.

i»ii,<>k \

i I >l I; IK III

Ibc

Ml. mil

I>;iv

MEDICAL CERTIFICATE OF DEATH

n ATI-; I »r i>i: \*i n v

c

(iJav)

/go ^

tYe;u)

Ai.i.;

HfNni.i-; M \K k n:i>

w I iM »\\ III ( > K I > I \'< > i-T j: I >

'Writriu >-(i( uil di siiMial i< jii )

I'.Ik Tili'i, \t'|.;

;st;it' ..1 I mint! \ '

N \MI «»|
» ATIII.K

lUH lllli, \r |.;
<'l I \ I II IK

NJ AlliJ.N N \M|.;
<»l Miillll-.U

/>.

L

xL

I I11;RI;I'V tl kl'IFN', rii;it I alU'iuUil <U'i-i-asr,l from

' lyO t»> I<P

that I la-^t saw II :" "alivt- «>ii ^ ~~ '^ '
ail.l that .K-ath orciirreil, on the <latr statnl ahnvo. at
M. The CAISK <>!■ I)i; A Til was as follows:

I )( RATION >'''</;■?

CONTRIIUTOKV

.1/, I >///.'.<

/hjvs

HoHt V

JhtM

IHRTm'I.Ai'l-.

<'» Mnrm-.K

' St:i!.- 1)1 I'dUIlt I

in'CI I'A'riON 1

nr RATION

(SIGNED) ... - p

Ilott) S

M.D.

Lo

qI

Special information ""b '«r HospitHls, InstituHons, rran'»ifnts,
or Recent Residents, dnd persons dying av»d> from home.

h'rsiilfil III Sini I'l a III I Sill

) '/ 1/.

Monlhs

/>a'

TM)-: \M0V1' SI* \ll.:i) fKUSON \!, 1' AKIKTI, AK

i!i;sT <»i\J^iv KNnwi,|.;i){,i-; AM) m:i,i»';F

s AKi: TKIH TO TMH

X.l.lrc.^ &V . V. i \JirY^\jXx.Ku

Former or
Usual Residence

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

How lonq at
Ware of Death ?

Da>s

yi \CV Ol m-KlAI, OK kHMiiVAI. I l»AT|.;... H. KiM ■> KKMMVAI.

N. B.

^ „ , .^F should he stntecl EXACTLY. PHYSICIANS .hould
-Rvery Item of Informiitloti •houltl he carefully supplied. « • * ^.,_,-|||ed. The "Special InformiHi.in" fof ^r-
•tote CAUSE OP DEATH In ph.in term., that it m.,> he propeHy U— mc
-on. dylna «w«y from home whoulU be ftlven In sv^ry instanee.

I

!*i

:.l

I

t
#
I
t

•I

I

t

r

w

RITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD

/h/fr Fi/('f/ ,\^ cLcr

10

IfJO'i

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

t^^o^ I.V., Deputy Health Officer

DEPARTiyiENT OF PUBLIC HEALTH=City and County of San Francisco

II

Certificate of IDeatb

PLACE OF DEATH: — County of '<^ ^^ ^

{\

No.

.^ V

.^.a/^xA^v4,^City of "■ ^ >^ J XO^Yve^^c^
.... . . St; b Dist.: bet. ' I iVo^dA^cL and :A^v '

/.r or.;. .M.;... r.oM USUAL « ^ S . DE NCE a, v. r*CTS c«.|^. o ro. u .^^^

V ,r Dr.TH OCCUHRtD IN * HOSPITAL OH INSTITUTION GIVE ITS NAME INSTEAD

FULL NAME

PERSONAL AND STATISTICAL PARTICULARS

1*1 ii,i »k

\

U Iv^t

:» \ 1 i: i i! 11 K ill

\ ' . I-

M.

1 '1 %

H

•-IN' i.r M \k K ii:i»

\\ 1 1 II i\\ I I » ( iK i»;\*i »'• I !■■ 1 1

I N\'i it! HI -. Kill tit -u'liat !■ .Ill

Jx^vaM

HIK rill'! \i'l-

lit I ^

0/(Xyv J AcL>-

NAM! M!
KATII J K

»'.1K nil'l, XT).-
ol I \ 111 IK
' "itatt 1)1 iiiiilit I V

maiim:n nam I
oi" .Mmi(ii;i<

I'.IH IIIIM.AI i<:
Ml- Mnrill.H

C^tati III v'lnmti \ >

/Cf's/if/'if 1)1 Siiii /'l il n, i^r,i

C V

K n

\

\\AJ^

■t'w . ^^ua

bfe

)■,,;;

%/,,., I fn 1 H /'

riii: \it()\i.: sr\ri',i> i-khsonai, i- \h rut i, xk-- aki: tkik i«> i i'
in<;s r <>i- mv kn<i\\i,i,i»(. jc and hi: iji.'

(liifoTiii.-mt

■^iXv.' ^' ^^^..u^ l^cXl.

\<h\\>

Xb

jJLaM.^

MEDICAL CERTIFICATE OF DEATH

DATH (>i iii;Arn

fi.d

(M..mlO ">''^' '^''''

1 III-RIBV i! RTII-V. Tli.t I ntlciplr.l .li< . •- -1 fn.iii

,hatlla.t.awh--- al.v.nn ^^ ^.t w IcpM

^,„a t1,;,f .U-all, ..rn.rrcMl, n„ the -lat. ^lafr.l ahnv.-, at S.BD
d M Tin- CAISH oF DHATH wa^ ..-^ ioll..us:

DIRATinN )'<.n>

CONTRII'.ITOKV

DIKATION ^ >i^^^^^^^ -'^""'^
/SIGNED) b. ^\- ^J C'.-^U'.

Months IC) A/ is

I lout s

/hiv

,C

Oob

(V.

It) ,„oi (A.l.lr.ss) Hlb':^i)Lt<Lj-

Hours
M.D.

QprCIAL INFORMATION only for Hospitals Inslifufions, fransipnfs.
or Rcreni Residents, and persons dyinQ -iv^-iv from tiome.

Former or
L'sual Residence

Wlien was disease rontrarted,
If not at plare of deatti ?

IM.ACl-: <»l in KIAI. OH

How lonq at
Plare of Oeatti ?

Oavs

,^fe-^^.

crlxf L

r N 1 ) 1 . I< I' A K V. K ^ J )-4A^'>

.A.I.I..- PsW'ol

MM\\i I iiAXK'it HiKiAi -.1 hi;m«>\\i.

ID a

190I

*^ X.CA.^A^

(K

A,ALA^A„0->>^

■ ' "■ T* ItF .HouI,! b« «t»te.l i;XACTLY. PHYSICIANS .hould

f l„»orm„tlo« .hould be cnre?ully -uppHed. ^Oh^^^ ,,.„,f,ed. The "SpccIhI InformHtlon" tor pT-
OH DEATH In pinin term-, that .t m,.y fj= [» »

N. B.-^— Kvery Item ni

state CAUSE wr- uc«in m m»">" • ; , iH.tance

«nn, dying away from homi, ahould be given In -very ln«t«n.

« r

!l

;l

• ii
I'll

■ ^)|

• ill

ifl

I

1^

'^%MC

WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD

H.nUh I

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

Offfr /-V/^'^/X 'cX.trVM.^j ID

ino'i

lif'oisfrred J^o,

'^226

cc.^ "Liux-M Deputy

DEPARTMENT Of PUBLIC HEALTH=City and County of San Francisco

Certificate of E)eath

( XX. S. StanDarC^ )

PLACE OF DEATH: — County of

City of

Wa:,-.o.

IStK

' . v ^<^KvXa_l St,; ^ Dist.jbet. and

( ,r DcaTM occults awy r«oM USUAL R E S 1 DE NCE G. vt tacts ^\'->,%^';f» " "^^^ J:,^";^^'^^^^^^

V ir DCATM OCCUHRCD IN * HOSPITAL OR INSTITUTION GIVE ITS WAME INSTEAD OF STREET AND NUMBER.

)

FULL NAME ^^t^

td-cK;.;.^.

^I-IS

PERSONAL AND STATISTICAL PARTICULARS

+

^

\jxXx

<] nil: 111

l\.

io

ion ,

(Year)

5

■-INi IF M \K k Iin

liIR rHPI,ACK

1 l»

IC)

^/.>llf/l

%

/I.

MEDICAL CERTIFICATE OF DEATH

li \ {)• t il i 1], A I'll l{ \

VL - ■ I

1 lil'kKnN' C1,UTII'\, riiat 1 aUAiuk-.l .k-(< a^r.l from
- ion'' tu L tfc %

tfiat I last ^a\v li 1 .ilivu on

an.l that <K-ath ,H-(urrr<l, . m \hv -lair statc-l ahnvr. at
■\^ 'l<),^. (^WlSl-; Ol" l)i:.\'ril ua- as follows:

Up H

I I c

_\

CL>

V'

j;va

\ \M 1 < >!
I \ 1 II IK

lUk iiil'i. \rK
«»i I \rin;K

stitt 1,1 i*i»unli y

,'^

Ujttxv ^Ick:41k

-i

Dl k.X'iloN }\-t2rs

CoNTKimToKV

.1/,';///m-

/hi]

I lout s

MMI.l \ XAMI-;

< •! M< I 111 i;k ' ^

^X > > vo

vUxUlvU\_^\

I'.iH rmM.Aci.;
<»i Nt<>'rm-:H

' Stat, c.i t'.iinit!

OiHri'ATioN 0

Ni'liii'l III Siin J iiliii:^i'i

v.t

1)1' RATH IN
(SIGNED )

M "/i/i^

Ihiv

//ours
M.D.

^.

r()0

1 1

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

n

1 1) \h'iiifi^% f><'^

former or i lu n

Usual Residence 1 1^ ^

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

How lonq at
^^OAXnx I Place of Death?

Days

t\ r HI r i I Iff . ^ii n J f II It I . • I ' • « i . , .. ■ -

I'm-: AH(»\}.: si- xn-n pkkson \i. I'XKi'im.AKs aki-: tki"
Hi;sr «)!■ MS' KN()\\i,i.;i)r, !•, and in-;i,ii:K

H TO TIIK

( \\AAAA,^^ry\.

;, .CFOF HrKIAI,<.K KHMmVAI. I I, XM;I^ "MM k i.,. .,r KHMoVAl,

111)! Qf%V^UtA.c

fNDKK r

(Ad.li

"-^ .. ^ A<ri .hould ba .tate.l i;XACTLY. PHYSICIANS should

N. B. Every Item ol' Information .hould be carefully supplied. ^^^ c|.,.|fled. The "Special InformBtlon" for pr-

•tate CAUSE OF DEATH In plain term., that It may ^^ pr-op^-'^
-i..t_* « K««- .h«uld be ftlven In •s^r^/ Instance.

•tate CAUSE OF DEATH In plain term., tnat n .""^ ," " ' .
ann. dying away from home should be given In every In.tanc

i
f

I

i :
11

. Ml

^^

<u

WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD

^- -3 -: 1!M' <•.

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

A

0

l)<ilr Filvd , \^ C^.rl^'v IC

^t J.

U)()\

le^isl (' I (•<! ^n.

K

e^^x'

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco

Certificate of IDeatb

11. t5. StanC^arD

PLACE OF DEATH: — County of Cj<x>^ J ^c^^xc^c^City of L <X^v J xcc>

xc

Id

. c-^KC.

St.:

No. ^ • V ^ V, C^"w^ > x-1

(ir DEATH O
ir 0CATH OCCURPICD IN * HOSPITAL OR INSTITUTION GIVE I

Dist.: bet.

and

..ciiAi ore: inriMr F riwr rACTS CALLED FOR UNDER "SPECIAL INFORMATION \

r DEATH OCCURS *^*•v FROM USUAL RESIDENCE give eacts ^*^lle° ,^,stead or street and number. )

FULL NAME

^ 1 \

PERSONAL AND STATISTICAL PARTICULARS

rt

,L

11

MEDICAL CERTIFICATE OF DEATH

(V.-Mr)

CI

lit— U'li,

IK I'HPr, \C\:

lilt r \

NX Ml- ni

I AT in: R

HIKTHIM, Ai*K

"1 1 \riiKR

' ^1 it i I ,: Oinuiti V

M Xnu'.N N AMI
oi MnTllI-.K

IHR JIll'i.An.:

»u M(»riii.:K

Xj

ns

^

I

c

\
I

t

'M,.ntbi 'i'^'^'

I ni'Ki;i?V t HKTirV, I'liat J attcn<U>! .Una^it! frntii

Ii)<l'1

thai Hast ^axv h--..- alive <.n ^^^ ^ IQO «

anil that .Icatli .H-curre-l. mi thi- .laU-tati-.l ahovc. at I I -^ t

^f. Tlu- CATS I-: OI" Jil'^AI'I' wa^ as follows:

DC RATI ON r^'?'

%

^ X^OlH.

M on I lis

fhu

J /ours

)RV LLc^xix NXx-^xi

DT RATION

r-1

.1

' 'VM

A^ i^

l/,.','/^

c

/>,/!

(SIGNED

l/UXl''

ii-^ct

%i

M.D.

I < )< >

A,1.1r...s)LK^Ux^>V^ ItpQ^^t.r^

ncci'l'A riuN

A'/ /'(ftui in San /'ianii>i

a

).uil ^

M, tilth '

iKn

SPECIAL INFORMATION only for Hospitdls, Institutions, Transients,
or Reient Residents, and persons dying dnay from home.

, 11 I , ^* How lonq at ^j

Former or 5 [ j 'j-^ tj/cta,ar^^' ^ I Pla^e of Death ? A

Till- \IU)VI-. sTATin I'KRsoX M. P\R lU I I \K< AKl! TKlH TO I IH'
Iii;ST Ul- MV KNOWI.l.DCK AND lU'I,!!'.!'

(Iiiftitniant

IAxaA;

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

Oavs

k > xK'vxiru.r^A^

ri.ACH (

I* lUKIAT, OK KI;M"^'AI,

(^ IQ tl i . Ul/AVLoleAH

1^ 0 ft I

I ni)i:ktaki:k

(Address

!» \TI' .>; nsKiAi. >>t KHMoVAl,

UrCt 10 190H

vj <^vvUXi'

0 01 Vl3Ax4A;C}t I '

'* u ij h stated EXACTLY. PHYSICIANS should
i„?.>rm„tlon .houhl b. carefully supplied. J^^^jZasf^Micd, The "Specl.l Inform.tlon" for pr-
»F DEATH In plain terms, that It may .»>« fJl^;'*"'

N. B.^— Every Item of Inform

State CAUSE OF DEATH In p.«... - -. i„-t«Bce.

•on, dylnft away from home should be ftlven m every msta

• i

1

iMl

• I

I

WRITE PLAINLY WITH UNFADING INK —

}!-.n.!..f Hi:, It], FXo. - '-"^"^i^ ]>^]-Cn

ludv Fiioii^ y,

THIS IS A PERMANENT RECORD

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

10

190\

Hegisterecl A'^o.

3328

DEPARTMENT Of PUBLIC HEALTIJ-City and County of San Francisco

Certificate of IDeatb

( 'O. S. Staii&ar£> ;

PLACE OF DEATH: -County of 0 ccov t vo. >.c.i o City of C^

0 (K M. (^

>. n ^h^

f .r DEATH OCCURS AWAv TROM USUAL R E S I D E N C E o ■ V E PACTS r!f.;^ ^ ' ^n<^ ^OJxKK^X ). )

FULL NAME AuJ

^oOx/rU^yK

-i;\

!.

PERSONAL AND STATISTICAL PARTICULARS

i>A 1 1: oi luk'ni n

.CJ..U

cl,

M ,ii!h

A<,i.:

1

1 |);l\-

yt.niUf

rgn

(Vt-ar)

< ^■<•:ll

n,l^.

iWi It. ill s,„-,,,l (It vis.-iiati..!i)

■^tati o! t'ljiinlrx

NX Ml- <>|'
I ATHIiK

''•Ik rilfl.ACF

<'i 1 Arm.;K

iSl.ilc (,i i'.miitrv)

^f\!I)l■:^' N\Mj-

'•I MoriUvK

niKTin»r,Ari.;

(Stillt 1,1 l*()Ullt!\ 1

oiiTl'A riuN ^

(^ % %

oui.

MEDICAL CERTIFICATE OF DEATH

I HHRiaiV CKRTIFV. That IalU.n.Ic..l.kHxasc.l fmm

^-^^^ K/l'^ to t'ct 1 ,,^^

that I last saw li .*..'.. alivimi W' ct 1 icjoi

.'M.i that diafh .-c-urre.l. ..„ the .late stated ahnve. at

Dl'R AIIOX
CONTRIIil'l

)iais

Months

or RATION );,//.? Months

i\u

Hours

\-XX^tKx/v^/-vxJL

CrVCu

(Signed

I

IhlVS

//<uns

M.D.

I C)0

(A.Mress) 3R b ' 1 t^

vuXcL'-rxdL

A'fMif/\f III Sun I'laiii: ,1

?^^9'fiK "^^O^'^ATION only for Hosplfdis. (nstiluNons rranslfnf.
or Recenl Residents, and persons dyln^ dway \xm home. 'ranslenfs,

.; / »

Mnlilh'

/i,n

Former or
Usual Residence

When Has disease fonfrarfed,
If nol at place of deatli ?

Now lonq at
Plareof Of ath?

Days

f \-I.lrfss

2>'i I cLxx^A^cyt^nx/

'X

-\',

TOO

I.SS I ^'\

N. B. Rvery Item of fnform«tlofi .hould be carefully «u„plle,l. Afli; hHouIJ be utate.l RXACTLY PHVAiriAMe ^ . .
•tute CAUSE OF DEATH f„ plain term., that It may he properly .i«..lfled. The •'S^,|.i |„fo"I 'T. ?^^, "**""'*'
■on. dylnft away from home •hould be given in every Instance. »Pecl.l Information for pmr-

«

;

f w i

if

t<\:

-mmf

WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD

A

.^n^x.KJi

100\

REFER TO BACK OP CERTIFICATE FOR INSTRUCTIONS

Registered ^'o, ^329

l)((fe Filed ,

i

DEPARTHIENT OF PUBLIC HEALTH-City and County of San Francisco

Ccvtiffcatc of JDcatb

A ^ A %

PLACE OF DEATH: — County of^^a n» ^ \ A wcuixu) City of ^'OLOv J \a >^ ^^4 co
No. Ic^b UL.. v_ St.: > Dist.; bet. ' '^ aVh.c4.<v-^^ and ^i^ ^U^. ^ ^ t

f "^ ?yj** OCCURS *WAv 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. ) ij

FULL NAME

a

\

K.

PERSONAL AND STATISTICAL PARTICULARS

i>\ ri; «»r hik i h

\<'. I-

I

C

4-

MEDICAL CERTIFICATE OF DEATH

(0

Rdh

'ATotitlil

'IhlV^

I m-RI'in CI RTIl-N, That 1 atttn.K-.l ,K-,Hnsc,l fmni

1 if

tn

^IVrW.l^ \I \kR IJ I>

UI I M (\\ I ! ( « »k' ! 1 : \ c 1 1 in

•\\'ii?f- in -iM-i;il il» '.i r lilt ' iiil

l ^X

that T bmt saw \\

\\\\v on

t>1 (0

t .

Tt)0 *i

T()0

and jliat «Ual1i oiHiii '■'■I "ii f br ilntt- ^t.iti il alinyt' at S

V

fuRfiii-r, \ci:

■-' ,'. ,.r I ..niiti %

J A I'll IK

luk riiri, \CK
f »i I \ I irKR

'St.ir. .,T r,,,iiif\'

'i^tntf or ( •uitifrv

invT r A ri» >x

AT. Tin- C \1 s], OI DiAril ^^;,< ;,^ foI|,n\<

a

n

/O s '\ ^

niRATION )'t'ars^

^

CON'IR IIU 'r< »R\ U '

IIoui \

/ n

li

%

Co

AJ

XX. o

L

(^

I M I A

DIRATION
(SIGNED) H'tH)

7s

^frulhs % I\ns X Hours

(A (\ ^H^v M.D.

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

IV'iM.v ,"S Minillly

I hi

Former or
Usual Residence

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

How loRf at
Place of Death ?

Days

THI-; \nn\K.*. STATHD I'KK'^nNAl, I'ARTIcr I,A KS .\R !•: TRTK TO THl-:

iu;sT (»!• Mv KNowi.iix ,1.; wd Hi-:i.n:F

(ho \

(Info; inriflt

fA'Mit-.^ H%\0 ^ 1.1

tli

ir.ACK Ol- IHRIAI, OK RHMOVAI, I r>.\ri<,>f lit rial nr RKMOVAI,

^.'

'^A^CL,

ft*

% u

I901

I ni)1';ktaki:k U , AajL^H^L^^

^.

N, B. Rvery Item of infofftifitlon should be carefully supplied. AGB should be stated EXACTLY. PHYSICIANS should

state CAUSE OF DEATH In plain terms, that It may 'e pfopeHy classified. The "Special Information** fop psi*.
sons dying away from horns should be given In svsry instance.

.11

fl

*

i

WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD

Board »f Hc:.Hh -KNn i. ^y--x^^:]\S.VC,, REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

/)ff/(> Fi/rff, V/zkM)Ji\> U

licgisieTpd JVo,

2330

Deputy Health Officer

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco

Ccvtiftcatc of IDcath

PLACE OF DEATH: — County of ^^a

City of ^ ^^ '

' ri

(I (Ml

No. 11 11 St4 Dist.;bet. ' and

(ir DEATH OCCURS *W»V FROM USUAL R E S I D E N C E C I V F r*CTS CALtrO FOR UNDtR SPrClAL INFORMATION" "^ A
IF DEATH OCCURREt> IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / V

1 I \

FULL NAME

J \ '

•-i.x

PERSONAL AND STATISTICAL PARTICULARS

HA ri; < »F liiK 111

\ < : H

a

Miiiillii \

11 w .

%

MEDICAL CERTIFICATE OF DEATH

1) \iK <- ii !>)•; \'iii ^

\

wm»»\\ i:r» or i»i\nk( j.:f»

(Wriff

i !1 1-1 K!;i 1 ,1, .-iir ,, , t i, ,1, I

A

I'.IHTHI'r.ACH

strife or I (jii Tif r %

HAT J I Ik

FUHI'IifF, \< I'

Ol I \ in JR

I St;il ( I if ('111 lit t \'

•>i Morm.K

I'.iK rni't, At f-
'•I MornHK

' Stall i,r Coiilit rv

II 1 I i'Al' [( »N

f \

1 .1

I

\

I HRRHBV ( hRTir-V. That I ;ittc-ii.l<

t liat I ]: ' ' ' % ;ili\c on

aiiil lliat flcalh i imi rrrd. nii the da' • -

<V(:t|i
Ui rased jmni

di

U

M. 'I'Ik- V .\] <\' «»l Di ATII u.is as l"nl!,,U'

IS r ft

"^ <X<A.AA^Ol

i i

IM R A'llnN

I ( 'NTR I Id '!"( iRN

l>rR A'l'H tS

T/, n//,,

/lir

//,

tut V

) i'lir

/>,

/i^

fL

n

Kf-iili'f rit Sini I

(Signed) AJfvooi.u LL^oxi^^ . ■'

Uct) iC iqoH (Address) II OH U^>\,y U-

M.D.

Special information onlv (or Hospitals, iBstltutlofls, Transients,
or Rfcfnt Rfsldfnts, and persons dying away from tiome.

! I s .A

Sr.mth^

IC

I hi v.

Former or
Usual ResideKe

When was «ls«Be contracted.
If not at place ff deatti ?

How lonq at
Pfaceof Oeatli?

^s

Tm-; An<>\F. s ia i i i» i'KR-.t)\: \i, r \r iicri.ARS ah v. prtk t<> riiR

HKHT Ol- MV K ^••iWIJ.IX',!.; AMi I'.i: 1, 1 IC h'

dttfo; iiKint

^J O^K

(\'\.\\

Til

\

u

KXJjy\y

y\j

^

l'I,ACK OIJJl'HIAf, UK Hi;Mc»\ \|, | l)\!

A

t

ri,ACK ORBIBI

(NKKKTAKHR MW J -'VCLLa.

(A.Mmks

HiKiAi, i,r KKMnVAl,

KJJUU

-H

IS. B. Bvery item of Information should bs capefully supplied. AGH •hnuld bo ■ti.tetl nX4CTI,Y. PHYSICIANS should

state CAUSE OP DEATH in plain terms, that It mny He properl|r classified. The "Special Information" for par-
sons <fyfnft away from home should be ftiven In svory instance.

1 ;

Ii

^

r'

r

r

I

i

* #

WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD

RrFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

f llialth- I" N'o i; t-?^^-, H*;:!' Co

Dafc Filed, ll xImmA' 11

1

Bfgisterefl X^

;233i

J2^^>u Deputy Hcr^f^^h Offin#*r

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco

1

.d-MwA^

\j

Certificate of IDeatb

A

PLACE OF DEATH; — County of

^No.

St.;

— Dist.; 1?et.

City of\l<xyva. y < >\x:

and

^tO'v\

(ir DC«TH OCCUnS ftWAV rWOM USUAL RES IDENCE GIVE rftCTS CAILCD row UNDKR "SPtCIAL INFORMATION "^
IF DCA7H OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. /

FULL NAME

\N.^

PERSONAL AND STATISTICAL PARTICULARS

\\\^

\ r\ '

MEDICAL CERTIFICATE OF DEATH

HA Tl" < »r i;lk I

\<.l':

M..?.nr

iintO

1 HKRI ^ • i- RTIIA. That 1

wriK»\\ Kr» nR i>i\

i Writf i II -i^K ial ili-iiu t

(*^t;i ■ ill III ? V '

1 i»

. \ . t I

n

V

\
1 1 I

> ^

1

ruR rm-r, \( K
■ -1 1 N rii f !-•

~.t ,ii t 1 ir (i 111 III t \- 1

• «: Mf»rriKK

'''^tal.- iir (;^u^!ltr^

he rl;

M 1 he C \i <'

\X\\ w

I on

"(I lire. :i<('(| f \, \\\
- Iqn
Tc)0

1 ollows :

>th

iM

non>

c ()NTR ir;i 1 ( »m"

nr RATION Years

M

{ Signed ) ^A.\J[ /\ . jujlax>v>

M.D.

SPECIAL INFORMATION only for HosjMUH, NsllNHfl»s, Tra«le«ts.
or Recent Residents, and persons dying away from home.

>' (i i>

Rr^idr.f /,' s.:„

} r'a I

A/,»if/ts

Pa 15

Hi-;-, r I ti- M V K V( >\\ i,ri>t

mint

M. n.ARS ARKTRTK TO THK

i i I.IHF

Former or

Ikiial RfsicitBCe

H len was disease contrarfed,
If not at pixe tf deatli ?

How ioiiq at
n^-eof Death?

kys

CX.I.Ut-v

I-I.ACK OI- BrRTAT. OR RKMfn'AI. I DAD; u! BrRr^i ..r RKMOVAI,
IN'DKRTAKKR ^ ■ C3 . sJ fr-tijtOCw

^oS' Qna<rW:^tr>^uAa, iiT I

(Adcln-

IS. B. ^Bvery Urn .»f In formation •liould be carefiilly supplied. AGE .hould be .fated EXACTLY. PHYSICIANS ^Miild

•tate C M'^r: Ol" DLATH In plain terms, that It may be properly clii««lfied. The "Special Information** Im* |Mr-
mt^nm dj In4 away from home should be given in every Instance.

I

I.

il
■■'I

l)|
ill

WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD

i{.ar,i.,f II ,itii IN. ^^^^ n.M < REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

1

n

Date Fih'd , \J x^

^'U^.KJ^

toAj-C

y\) \\

WO'i

Be^islered JVo.

2232 \

M

De

T r%m^^

f% w

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco

Certificate of H)eath

( "a. S. StanDarD )

PLACE OF DEATH: — County of^'<X-^nj JAXC^wCWLCCity ofO,CV>">^ J AXV>TwXM^ t<.

No

.1^'^

u 'n^^'XV K s.

St.; ?^ Dist.; bet. S hAo and ' 1 LI \

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

FULL NAME

.CL^

W-

yj^wCLJ

V n

six

PERSONAL AND STATISTICAL PARTICULARS

MEDICAL CERTIFICATE OF DEATH

A

1

n »

U.Vvxt

DA'll-; <)!• lilKTII

A<.H

)■,-,/*

i

li

airiv)

yhnilln

DATl-; ol' I»1-:\TH

~\

H

(Month) (Day)

4 ilHRI-BV Cl-RTH-V, That I attc-iKlcI deceased from

TQO

(Year)

Ih!

siN<.i,i:. MAkKii;i)

wrDoUKD OK DIVokCKr)
tWritfiii "Social cU'^ii'natioii)

lUKTm'I.ACH
' st.iti 'ir <.*(J^ntr^•i

N'AMI-: iW
FATHKR

^

\

J I

li)«t

">

.«*»..

190 H

to

/ct

10 iQoH

that I last saw h ^- ' > alive on \L /ClL 1 ' jcp i

and that death occurreil, on the date stated above, at
aJ= M. The CAl'Slv OF DJ-ATH %vas as follows:

\{

HIK IHIM.ArK

Of- iATm;R

'Stall (ii Cinmttv

-Vi^d ' I'^xxvl

n

nr RAT ION

) ean

&

CONTRIIUTORV Uv*%./CX.i„^v.:Lv -r >

Months \ Days Hours

M\1I>j:n NAMh

"I .m<)Thi;k

HIRTHl'f.Al'H [\ A

OF MOTHKR 0 /T) A^ -^

(State or Country) -< | il

. Cj/cuaoxxxj Ouc«^i,L^L

OCCUPATION A

DIRATION

Mouth

IM K.Aimrs ) ears iMouins » t )ays

(Signed )..n.V). vlAAXA.C'>%Jki^.

ILi/ct; i£) rep H (Address) \5H - jlsjd^ 't

Hours
M.D.

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

Rrsidfd III S.ni }'i o I'l isri}

KWV, AHOVK STAPH!) I'KKSONAI. PAR P IOC LARS A K 1-: TRIK TO THK

lucsr OF MY KNn\vi,i:i)c,H AND HF;i.n;F

Former or
Usual Residence

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

Now long at
Race of Oeatli?

Days

Informant uId . UvD

( \<ldrtss

X\\

L<:L<:Lu

AS N

PLACK OF lURFAI, OK RHMoVAI. I DATK of Hi kiai, or RKMOVAI,

rNi)F;RTAKi-:R i:w'>vUL^

N. B. Every Item of information •hould be carefully supplied. AGE should bo stated EXACTLY. PHYSICIANS •liould

state CAUSE OF DEATH In plain terms, that It m»y be properly classified. The "Special Information** for p«p*
sons dying away from home should be given in myry instance.

1

I

WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD

i;,.:i!.! .,f Hi ,ilth 1- X.

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

/)a/r Fi/rff, l'.cW>^U^ II

IfJO'i

Begisterorl J\^o.

2233

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco

Certificate of Beatb

A

( "a. S. StanC>ai*C»

PLACE OF DEATH: — County of ' <X/>v J VO^>xcuLc^City of ^^aXvu J JV<X/-nxiA^<U)

fNo.

4-

Q

IIU OLa/'>xu,o., V. St.; " Dist.; bct.VJ /OArnXL^-cu^

(If DtATH bcCUBS AW»V FROM USUAL R E S I D E N C E G I V E rACTS CAtUED roR UNDER "SPECIA
IF DEA-i>< OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET

and

X'V

Mviv-

FULL NAME

OJ\M/OJ\JJo VDKO-vui^'

3

PERSONAL AND STATISTICAL PARTICULARS

I) A n; t -I uiR III

UjJxaXk

^ V
1 Ml lit

,1

t

MEDICAL CERTIFICATE OF DEATH

I) \Ti-: oi- ni: A'lH

it, ID

Month)

(!)av)

(V.;ii»

i I):i%

\<.i-;

H

1/

U IIniUi.:i» nk Ii!\nKri;i)
'Uiitf ill Sdi'ijil (If^i^Miat ii»!i )

,U LCtot'^-^cL

lUR rni'i, \t'i.

' St;i!f 1 it ( 'i 111 lit I \

N" \M!' <)!
I- Alii IK

inKIHIM.AClC
"I I \ I' 1 1 IK

^t,l!i U! riiUIltlV

MMDJ-.N NAMH
<>»• M()TIII;k

niRriipi,A( K
<»|- Morin-tK

(Strii. or tNjiuitrvi

orrri'A Tiox

, I nf':Ri;BV CIIRTII'V, riiat lattcndcl (Ucta-d from

OX^t 15 i9nH to ^^ct. IC igoH

tliat I Inst SMSV h ■■ nlivi- nn ^ -'.. i(p \

and that lU-.ith iHriirml, kh tin- date <fati(l alimu', at U J* A,

M. Tlie CArSK Ul- I»i: ATI! was as follows:

C>v^

y

DrRA'lION

hniths «*'l /^avs

coNTRimroRV IpOjuxxX} jo. •.«
nrRATroN

//(

ours

(SIGNED)

}'t'(rrs Miniths

/yavs

IIou

rs

M.D.

15 it^i (A

^r^iifnf ni S,n> / i ,i ii, isi'it '^tj )V,;r5 ' ,1A**//'/;,v ^ /^flv.

Special Information only lor Hospitals, Insmutlons, Transients,
or RecfBt Residents, and persons dying away from home.

Former or
Usual Residence

When was disease contracted,
If noi* at plareof death?

How long at
Place of Death?

Days

Till.; AHOVK, HTA'ri'H PKRsoX Al, 1' \ R f U' I' LA KS AKi; TRrH To TflK
HHHT C)|' MV KNn\\I,i:i)<,H AND HI'.I.IKF

I A./CX.-'VXAA/a-nrv.

PLACE c)l nURIAr, OR RHMnVAI, I DATK of Hikiai. or RKMoVAI,

(0 ^ (0 t

:r LkxxNXiU AdA. J;

190^

ini)i;rtakk

(Addriss 1

N. B. Every Item of ln?ormntlon •hould be cspafully •upplled. AGB should b« stated EXACTLY. PHYSICIANS slMMlli

•tate CAUSE OF DEATH In plain terms, that It may be properly classified. The ''Special Information** for psp-
sons dying away from horns should be given In svsry Instance.

:.l

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

Buanlofll. ^ - _»^-- };^ I' Co REFER TO BACK OF CERTIFICATE POR INSTRUCTIONS

y^ Deputy Health OfTiccr

Regfste/'''ff A

it.

2234

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco

Certificate of H)eatb

( "CI. S. StanDar^ )
PLACE OF DEATH: — County of CVAx J

\\

No. b

St.: ^ Dist.;bet.

City of 'CL

.OJLMy^j

V 'X ,

and

(IF DEATH OCCURS AWAV TROM USUAL R E S I D E N C C G I V C FACTS CALLED FOR UNDER "SPECIAL INFORMATION Vi
ir DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. /y

^

FULL NAME

>

ll-iYV'viJ II OA-VX^iv

1 "

PERSONAL AND STATISTICAL PARTICULARS

sJX

m<xli

r< ii ( >R

MEDICAL CERTIFICATE OF DEATH

DA TH <>i ni: \'I'H

l»A I )■; »>l lUK III

M

le

/o<>

\ « . »•:

lURTniM \.-i-

\^ , 4 ^. .

CKo^vL

N XMF OF

F A ri!i:R

4

HIK ill I'l.ACK

n»* ixriiitK

' "^lat* 1 »! k' I m lit 1

MAIDHN NAM J
<>I- MOTUHR

niKTm-LAci:

HI' MoTin.R
(Slate ur tNuuit i \

(HH'll'A'lION I C

'-%

. I

w

^-vct

1 HHRI-nV CKimrV. Ih .' I ittin.U-.l <U-«h;is«.-iI fi..!ii

that r la<t saw h i''\' in lt)0

ami that <li-at h I »C(in rcil, (iH t hi < latr ^tati'il almvi-, at '
y], Thf CAISI- {)]■ ni-ATH was as f, ILus;

T)IR ATION

C nNTRinrToRV

DIR ATK )\

Signed ) lL^-FxX

.l/,>n//;s

/ ht] 1

I/oi,

»•?

1 r

fhiv

I lout s

M.D.

C'^

IQOH (Address) lO^S^ TKoAwkd '^

La^vo^o ^ ^ •'^

Kfidril in Siiti /'ttiitt is/i> o \ J ''<" '

Special information onl> for Hospitals, Institutions, fransients,
or Recent Residents, and persons dying away from home.

.\r, tilths

ihi

Tin: \!U)vi' sr xri-n i'krs(»nai, par rici'i, xr^, \k |.; trtk to thh

HI-:ST «»1' MV KN'itw I.lix.v AND BHI.Ii;!-

Formcr or
Usual Residence

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

How lonq at
Ptare of De atli ?

Oavs

'Tiifiirmaiit

LLdULXx

A

ri^Aci; 1)1 lURFAr, MR rkm<>\ai.

DAIi;»it" ISsHlAL or R}:Mi>\ \l.

TQO

ini.ii;r'iaki;r

i

^. B. Rvery Item of Information .hould be carefully supplied. AGE should be .tated EXACTLY. PHYSICIANS should

state CAUSE OF DEATH In plain terms, that it may be properly classified. The Special Information*' for per*
mnnm dying away from home should be given in every inatance.

rfr

i

WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

Ihf/r Fih><l , IL'c

^'Lo'Ima;

u

lOO'i

Eegislered J\^o.

2235

)f

Deputy Health Officer

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco

Certificate of H)eatb

( "a. S. StanDarD )

,4

PLACE OF DEATH: — County of -- O/^v J \.<X^XCU

ity of ^ <XfS\} J A,<X "rx c «.

City

0 c '.

No.

and

(

^^\.\.u^ St.; 5 Dist.;b€t. 3/vcL

IF DEATH OC^UnS AWAV mOM USUAL R E S I D E NC E G I V E FACTS CALLED FOR UNDER "SPECIAL INFORMATIO

IF DEATH Occurred in a hospital or institution give its NAME instead of street and number

:- )

FULL NAME

- 1. \

PERSONAL AND STATISTICAL PARTICULARS

(.■<>!, OK \ 1^

\

V{^

I;

MEDICAL CERTIFICATE OF DEATH

ni

UxU

l'\ ri; ^^\■ lUKTH

A'.K

I Mhiith

I

\\\\n »\vi.:ii ( »K nixTiKii:?)

U'litc ill -^(K jal il(>«it.'!uiliiiii )

LI.

!0

Dav

1 /,.)/,'//

Vtar)

DATK OF DlAlll (/"X

vL '.cX)

ID

(I)av)

(Year)

A

Stall ii! I'lUMUl %

NAMi: ()I
FATin.K

HIRTIII'i.AfK
Ol- lATMHK
i. Stall- or Cuiiiitrv

MA!!)}.;x XAMK

oi- N!()rni:R

HI RT HIM, Ml-:

<>i' Moim-.R

(Statf nr Country

C^CU-YX; J

I m^KI'lHV Ci;Rril-\'. That I attciKhMl (UriasL-d fmni

KpH

UOA^. IL 190H to L/'tti It

that I last saw h ^- > > alive on ^ Iqo'i

and that dt-ath omirred, on ihv dati- stati-d al)ovt', at \
M. The CA^i^Iv t)l" J)I:ATII was as follows:

rV->\; y^xc

I )r RAT ION )'tar

CoNTRira TORY

Months

/hi

IS

//on

/ s

}'i'ars

n

/h7y

DTR ATIOX

(Signed) ytrVv^r^ 0. d^ .cCc

iy.cfc 10 icK^n (Address) 3H (p ^ S ,tL ^t

I lout s

M.D.

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

A^a.

,.ci

Rf^idrd ill San Fi lunisrii'' I4 )>«fit b Mi>mh^

Pa 1

TIM-: AHOVK STA ll'.I) J'KRSON Al, PA RI'mLARS ARI". TRt K T< > TIIH
ItKST Ol- MY KN(>\VI,i;i)('.K AM) BlUJlvK

Former or
Usual Residence

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

How lonq at
Place of Death ?

kys

(lufotinaiit

C3/OJvX>^

(\.1.1

IfSS

Pr \CK Ol" ntKlAf, «)R RI;MM\ AI, I DATi: of Ht kiai. or KlCMoYAI.
INDl-RTAKHRNfTC 0 <Xd,4^YV n( ll y^AXOxL U ''

N. B.— Bvery Item of Information .hould be carefully supplied. AGB should b, stated BXACTLV. PHYSICIANS .hould
•tate CAUSE OF DEATH In plain term., that It may be properly classified. The Special information for psr-
sf>ns dying away from home should be given In m^%rir Instance.

I
I

!

n

..11

'n M

I "I

I

WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD

t ii, , ,)l I V . '•••■«r.^HS:I' (■

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

Dnfr Filed. XJ

hj II

lOO'i

liegistcved jYo.

2236

rsr

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco

^

.rv\

Certificate of H)eatb

PLACE OF DEATH: — County ofC Ci^v J \a ur , City of^^'O^^ -' A "i >> CuiXt
No. ^'I'X d'C'^t'-v..-. St.; '^ Dist.;bet. I b XK' and \'\ L^^

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

FULL NAME

PERSONAL AND STATISTICAL PARTICULARS

k

r< «! I ik

olU

f

L^

i>A ri; ( >r luk rii

\< .!•;

l!

MEDICAL CERTIFICATE OF DEATH

DAT!-; «>i ni: Alll _, \ II

IC

(Year)

( Mnlltll

I HlvklClJV t IkTIl'V, That I atti'iKk'd <kTiasc«l from

i9ct It

I i;f )

tn

II . t

b

WII)« i\\ I I» UK I)!\tiRil.;n

'\\lit( ill s,»ii;il ill -.ij.'Il;iti'i!i I

/),/

e

lUR I'Ul'I.Ari"

■^t i! I 1 iT I I illllt I %

XAMI- <)|

FATin;K

JUR IH PI, ACK
<" I AIUHR
Stati ii! (.Niuntrv)

mmiu:n NAM1-;

<H' MOTIIKR

HTKIHIM.XCH
«>l- M(>Tm-;R
f Stall- or t'uunlrv

<>»rri'Arit).N

Krsiiffti III Siiu f'l i!Hi isri

tliat I last saw h ■ ali\i- <>n ^

atid that lUath occurred, on the <lat«.- stated above, at I A aO
M. The CWrSh! Oh' DI^ATII was as follows:

c

h

" i

<X,Lc

W

o

I ) r K \ ri < ) N ) 'cars X Mouths Pa \s

CoNTRIin'ToRV

Horn <■

1 ^..'

nr RAT ION . >''''"'4v^ Mouths

(Signed)

Pays

trK'Tu J UjLUXcaJHX

AV

Hours
M.D.

^-' ^ • (Address) 5Hlb' nA.k d.t

) V'(M

b

SPECIAL Information o"''* for Hospltdls, institutions, Transients,
or Recent Residents, and persons d>ing ana) from tiome.

M.,>iih \ \

/',/'

THI-. \!u»\i.: sTxi'ij) I'KK-^oNAi, r\K riiM F, \Ks AKi; Kiuv. r<» rm-

Hi;ST Ol MV KN'dW IJ.IiC, K AM) liKl.Ii;!"

Former or
Usual Residence

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

HoH lonq at
Plare of Death ?

Davs

nnforinaut

f \il(lrt's»i

c

I- IHRIAL OK Kl':>f<)\AI, I DATKof Hi RIAf or Ki;M(»\ Al

lO

dLi/^Aj O^txfct bbAvcl:q U'

f.NDllRTAKIvR w

(Ad.lnss XHuO

Ul/i.MrAX

fl „ is.H ARE should be statecl EXACTLY. PHYSICIANS should

x;'s" „";t.': ";:: .h':^ rrr't n'o*;""':; c........ th. -sp..... .„»o..a..o„" .o. p...

N" B.— Every Item of inform
state CAUSE OF DE
«on« dying away from home should be fefven In every Instance.

if
(ft

ik

I

il

I *

\\

i

i

•

WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

n<,,:t!i I Vi, It, t"t^— ■ -., n^kp Co

l>(ih' Filed , ik^ctcAjUAj

II

U)()'\

RciiHlcveil ^^a

2237

1

in^A-^ cLc_ V 'A

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco

Certificate of ©eatb

PLACE OF DEATH: — County of a-.v - ^ :

No. ^ I C^ ^ ,<X.L L ^ V ^- St.; I Dist.; bet. L' -CcU.-Crv^ and Xux:

( ir OEATM OetUPIS AW*V FROM USUAL RESIDENCE give facts called for UNfctR SPECIAL INFORMATION" \
V IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. /

City of ^ ^■"•^■' ^ 'v a ^^ c ^_^ n

FULL NAME

\CL ^ V

PERSONAL AND STATISTICAL PARTICULARS

■\

■%

r« u,« iK

' \ 1 1 I 'I I.MMll

^

LI

' M..iith

\{

MEDICAL CERTIFICATE OF DEATH

1) \ II- n|.' r>i; A rii

TQO \

\< . 1

II

M,n,!h-

/»,;

■^|N< .1,1 M \k k n I)

w \ iH iU I I > t (R i»i\i »i.' I ■ I r>

|\\"ti!( ill v,„i.,i .h-ii'iiiit i.iti '

X >XQ

HiH rm-!, Ai'K

I stati III roiinti \

NA.Ntl <>l
1 All! IK

lUk rui'i.ArK

OF lArilllk

(Htatf -ir l*nuiit ! y

M XllUN NAMK,

lUK iiipi, \( i;
"I Mnriii.;K
I St.iti ,,r Count! %

(j <X>v 0 "vet ^^ ^ ^

f\f,,,ith^ 'Day)

I III-'RI'IP.V C'l-.R'ril-N', That I atten«k-.l .li.r.ist-d fmm
^., Ct I K^o'i tn ^'.ct U Kp I

lliat I last saw li '• • > alivr .iti ^ i«P

and that (Ualh < .criured, on the <lau- stafi-d abovf. at I
La M, The CAlSF-; OF hi;. \ Til was as follows:

n

5

la

a

Dlk.XTION Yans .Mi^uths ' fhiys

Ct>NTRIHrT<H<V n\txt>^^^lN.d„^AL

Iloilfi

nr RAT ION

(SIG

\TIo\' )'i'ays Mi^utlni

NED) b.W- d^<Xf^^ v\.Lo^v

Pax

M.D.

.^HLO)

(\

Lo^tL

« »» lip XT ION

t^fsiilftf ni Sii>i / I iiifi I I, I

IL^^L il TooH fA.l.lr.sO l'^3.% V<^K^C>. 3.t

Special information onl* for HospUaK Insntutions, Transients,
or Recent Residents, and persons dying dv»d> from home.

)',-,n^ i

{ M ,„Hi'.

[ J'

I III: snovK s'i\i!i> i'I';rs<inai, pakihti, \rs aki-; tkii-: to thh
Hi'.sT oi'" Mv KNOW i,i;])<',i-; ANP in:i,n;i'

Hllfii; lualit

-^

\ 1 (

Former or
Usual ResMencr

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

How lonq at
Plaf e of Death ?

Davs

I'I.\CF«)F nrKFAI, OK KHMo\AI. | DA TK of Hihiu. ..t KHMnVAI,

0^ I X

^<Xy^r\.>

I go

,. ^ AnB should be stated EXACTLY. PHYSICIANS should

N. B. Fivery Item of InformBtlon should be carefully supplied. «« ^,_--|f|,d. The ^'Special Information" for p»r-

•tate CAUSE OF DEATH In plain term., that It may be properly wlas.me
•on« dylnft away from home should be ftlven In ^yry Instance.

i A

r

I ,

ill

4: i

WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD

>tii,a;tii i \.) 1 "^T aC'^; H^tr (■(,

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

lU(tr Fili'il, ^d>ts^^ !!

l'.)0'\

Mr^i^tci'cd JS^o.

2238 I

(yoL>oo

VK^ Deputy Health Officer

DEPARTMENT OF PUBLIC HEALTH-City and County of San Francisco

Cevtificate of S»catb

"CI. S. Stan^nr^ )

A QD

4?

PLACE OF DEATH: — County ofO-CUno; v1,\xwvC4^<^ City of Cixx^y^, Jx<x^/vxXvuL<v<)

\

No. I

\

St.; \ Dist.;bet N I La<,C > and J <X4.i/

r ir DE*7H OCCURS AWAV TROM USUAL R E S I D E N C E G I V t FACTS CALLtD FOR UNDER ■sPECIAL INFORMATION \ \
\ IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION r. I U r ITG NAMT nuc-rc-.r. ^ r- c.--».-,-,- J j!

IRRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER.

i>A ri; < ti luk 111

A< ,1.;

FULL NAME

PERSONAL AND STATISTICAL PARTICULARS

/^vuuvcac

II

\

rlH'i

N'ollth

MEDICAL CERTIFICATE OF DEATH

I) ATI-: III i>i:ai II nA

10

'f>nv

(Veai)

be

)

\viiH iw I- ii , »k i>[\( ti;. 1 r»

HI k run. \c\:

I^AX.^

^

:M..nth

I UI'RIUiV CliRTfl'V. That r attcnikMl <k.,-,asc-<l frmn
tliat I last saw li nWw on

icp

i(p

and that tUalh norurrt'il, (in tin- dat*.- stali-d alxnf, at 'I
LI M. The CMS!' Ol' |ii:.\ TII x^a^. as fnl|,,ws-

\ \

NX Ml- «)|-

katiii.;r

Mik I 111'!. \. J.;

' »i I \ 111 Ik
~^t.it. ,.' I , ,111)11

O&vl

L'-v

M\n>i N N\Mi: A
' »i M( (III Ik ' ^'

ink riipi, \< i-;
<»!• MMiinik

(St;it< of Coiilltl

H

KuyxJX)

•i r 11

Dlk.XTloN }r,i/

i'os'i'n liu rokv

nruATfox )',,// V

e,

Months

Ihu

//oh

fS

Months /hns

0 \ ^

//om s

M.D.

(Signed) LcrVcrva>v
ly/CAj M KjoH ^\dd riss) Lcr\^rvaA4 iL'fV--^^<.

Special Information only br HospUdls, InstifuHons. Transients,
or Recent Residents, and persons dvini] hhciv froii home.

f''f -h,'. in S^ni I' I ti

{

M.xitin

/hi

Tin; A ISO VI-: s r \ i 1. 1» i-ciusi »\m. i'\k ri<i i sk-- \ki-; rnr j-; id tiik

JU-:ST ()1 .MV KNOW I J- 1). ,1. WD m 1,11.1

niifMiniant

X'Mi. V

U. oJjt^rCrt^

Former or
Usual Residence

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

NoH lonq at
Place of Death?

Davs

■^n\j

t

i'i,AOK ni- lu kiAi, Ok ki;%t(i\\i, | J)A

" ' ' .K4 ^ A ^ *> C I ^^ '\J

W: of Hi HI

Ai <.! Hi:\f<iv.\i,

'^ T90H

9,

''A.Mt. V.V

''^- B. Kvepy item o? InforitiHtion should be cnret'ully nupplied. AGR should be stated KXACTLY. PHYSICIAINS should

•tnte CAUSE OF DEiATH In pliiin terms, that !t mtiy be properly cles«ified. The "Special Information'* for per-
son* dyin^ awny from home should be 4iven In «\«ry Instance.

Ill

I

«st>

I fl

4

WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD

'-»-^

;. n^ ]' r

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

Regi^lrird v\>>.

2239

k

A Xw^-u Deputy Health Officer

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco

Certificate of Beatb

I "U. S. 5tanC»ar^ )

i

(^

S

No.

PLACE OF DEATH: — County of Ouro o Ajx^vcaaco City of V/a>v 0 A>o.>vcaA,<^o
• 00 ^ ^

St.; io Dist.; bet. L^*-0 ^ >^^a; and L<l.A>vt\ala'>

/ ir DCATH OCCURS AW»V rPOM USUAL RESIDENCE GIVE facts called for urtOER SPECIAL (NroRMATION \
\ ir DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEA^^ OF STREET AND NUMBER. /

FULL NAME O^XCt 0 d/Y^x'v'^ ' '

PERSONAL AND STATISTICAL PARTICULARS

MEDICAL CERTIFICATE OF DEATH

DATK <>1 nKA'l'll

'! lUKTIl

rv^

u

A < . I:

il>nv

M titft^

Uob

Dav) N(M!)

"-IN '11 MARKinn

Wnt' 111 --iM-ial ili'-ij^iiat ion )

mRTHi'i, Aij-:

^t iff 1 )i (*i iniit I \

NAMH ni
FATIIIK

HlR'iii I'l. \rK

<>i I \ihi:k

' :^t.i!. ii! roiuiti \

M Mill- N NAMl-

<>i Morm-.R

IURTH!M,AiH
<H MnTiIKK
(Statf or Coniitr'*

M -ith!

I niCRi:H\ C'l.RTIFN', 'Dial I .ittrfi.ltd ikHxa-^cd fmiii

4

that I la'-t saw li ■ '■ alivi- otl Too ',

(ii.l that (Uatli (>(H-urreil, <»ii tlie daU- *.tati->l alun-c. at
M.^Thc CXI si; (>1 I>1:A'I'I1 Wa^ as 1. Mnus;

IXR XTloN

XL I C\ >^ ^

ma^o C

CoNTKIIirTORV t. '"^^

DTRATION

. SIGNED ) Uw. L • ^t

J/,
,1

rc \

fhivs

Hours

,iA'»/Mh

/^avs

OiClPATION

A'fst'itftf iv Siin /> ,nn lu'i*

^

/Ct) 11 I<>oH (A.l.lrrss) uJj. L.

'\\

//o/n s

M.D.

.A„cikx4j Jl 5^^kt

^ — . ..,- , ._ . ,

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

r,

I [ .l/,>;////.t i% /hivs

I'm'. MsnVK HTATl'D I'FR^ONAI, I' X K IliT 1,A RS A R Iv TKfK T» > THK

Hi'HT oi- My KN«>\\ij.n( ■iv.ANi) i'.i:i,n:F

(Inf. .'iii.-mt

m

R^ CiA.U..rJi

Former or
Usual Residence

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

How lonfl at
Place of Death?

Oavs

PI \ri- OK M RIAI. OR RHMOVAI, 1 nA'rK of Hi HiAf or RKMoX AI,
fk(0' A A I (0 4. .,.

\ IA% of II

X IQOH

% R t- .. w I c ♦!-.„ -i,«..i,i h* ^..—ffullv nuDDlletl. AGB •hould be stated EXACTLY. PHYSICIANS should

i>. B.—— livery Item ni InTopmntion •nould be cnrofuiiy suppucu. «« ,« . ™.i. .<e ,i_i ._« .. .» • _

state CAUSE Of DfATH In plain tepm.. that It m«y be properly cla.«lfl«d. The Spe.l.l Informstlon for per-

8on» dylnft away from home should be ftlvea In svsry Instance.

!

- 1 1

».

f

I

m

];■.. ■ ' . t^ H. ;i!lli (

WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

II

/.V«9H

Registered J\^o.

224:0

i \
DEPARTMENT (IF PUBLIC HEALTH^City and County of San Francisco

Ccvtiftcate of IDeatb

PLACE OF DEATH: — County of Oo^-wj J,Va > vcv. City of O a/>^; J/vo . v ccAx^
No. ^^M?> - i"[.i.i- St.; S Dist.;bet. LoA-bvO and^lt-v

(ir otATH occuns aw«v rnoM USUAL RES I DENCE Give tacts callcd por under "special information" N
ir DEATH occurred IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. /

FULL NAME J 'i\c->vs.x]la vj oJUuxq vuai

il

SKX

PERSONAL AND STATISTICAL PARTICULARS

ft r(ti«>k \ , n

UxL<

LU.^t

I wLv.^

i> \ ri; t»i lUK 1 H

\« .1'

MEDICAL CERTIFICATE OF DEATH

DAl'H nl' I)1:a'1H

\)a

I go \

(Vf.ti)

N!..!i!h>

L ,.,,

I>a%

M..u;l,

■|iai )

\\ \ IX >\\ ill ( »K r»'\i »!■■ I }■ n

' V\l itf i II •,.« i;i ; (|<^;j.'!i.it i- III I

a

BIRTHIM. \ii:
(Stfltr <iT ('.unit I \

N'AMK ni
l-ATHi:k

RIK rnlM.XCH
<>l" I ATIIlsK
'St.i'r or I'oiinti V

MAn>i:N \'\ Mi-
ni .MoTni..R

lUR rni'i.Ai'H
<n MnrnKK

( Statf or Cnuntrv

OCCri'ATlON

i

^

\ \'-r\\\\. ^

I in:Ki;HV Ci:RTri'V, That I atlcii.lc.l tU-ccastMl fron
< ^ \t 190 < to U Ct U Kp 1

that I last saw h '• > ahvc on 1 Kp i

and (hat diath occurred, on thi- date stated aliovt-. at v)
LL M. The CAISH OF DKATII was as follows:

0

*A

rrA^X^A.--'^'>"\--'Cr*\^\. o.

k A <

.ou

d.

ruTYVxcu U/CuLc^ "

I

DC RATION }Vr?/-.? Man //is /)ays

CoNTRiniToRV LxXN^ wcx, t^: ,tj v.*.A

I/ou

IS

nr RATION : w. )'i'ars
(SIGNED )

Months

Pa vs

//ours

M.D.

•\JL

KJX,

>v

cL

iJ/A 11 TcpH (Address) SC-g '^x^.tLcK; ai

Special information only lor Hospitals, Institutions, Translfits,
or Recent Residents, and persons dyinq away from home.

o

fx^^siilfti lit Satt /•'mitii^ro lU )'rii 1

\r.<,iihs

thi

Till-; \M(>\i-' s'rMi;i> i-kksonai. i'ak iirt i. \ks aki: i"kii-: t< > Tui-:

Former or
Isual Residence

When was disease ronfrar ted,
If not at place of deatli ?

How lonq at
Place of Death?

Days

(I

iifotmniil VJ . L). O.CJUL

i I

(Addn-

SiSH-i' n h

\j

1

ri.ACl". ()1- lURFAI, <iK RI:M«»\AI. I DATi: of Hiria! or klCMiiX'AI,

^%o4a4 Cu<Mt^ • ^'^ '^ T90H

r M

o* information should b. cnrut'ully HuppUcd. AGB should he stated EXACTLY PHYSICIANS .houW
E OF DEATH In pl.,m terms, that it may be properly classified. The Special Information for psr-

N. B. Every Item

state C.41JSE

8'»n« dying away from home should he tiven In every Instance.

;|

j •
I .

#

i I

1 '
»

I M

%

ft

f

n

i

I

WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD

fH.^:!ili I N .;=»■»*.,--;; I!\ i' . . REFER TO BACK OF CERTIPICATE FOR INSTRUCTIONS

7.9(9 H

lU'gi,slei'('<l jYo.

2241

Dfffr Filed, iL'clxrWv) 1 1

\ \ ■

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco

Ccvtificate of IDcatb

J

PLACE OF DEATH: — County of--^0,->A-' '

City of ' ct >v 0 A o > v,tA^-

I

No. 550 m

c>Lsi.^^<:

St.;

Dist.; bet.

I4t

and

(ir DEATH OCCURS fl
IF DEATH OCCURF

WAV FROM USUAL RESIDENCE GIVE faC

RED IN A HOSPITAL OR INSTITUTION GIVE I

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

FULL NAME

SHX f

PERSONAL AND STATISTICAL PARTICULARS

A r( >i ,< Ik

OJvx:^ OAJiXQ) uxXX.'

^ a > V

I) w'v. or lUK 111

\(,i-.

"M

Ml, mil

MEDICAL CERTIFICATE OF DEATH

DATH Oi- DliAlH

MiiitlP

I go \

(Vi-ar)

!)..•.

)

1/

^

■-IN'.I.l MARKIKI)
Wrtti it! mieifil il.-i^.uatinu)

iiiKrm'i, \<-i

'""•tati' or i 'i .iiiit r \

XAMj; ni
I ATI IKK

niRl'll I'l.AiH
«>I" 1 Aini:K

' Mali Dt fi)nntry1

MAim:N NAM}"
OI MoTin-.K

HIRTIM'UAt'K

Of M()'i'm<:K

stall or I'dunti v)

r, 1

1 hll

iDav)

I IIHRKHV (. IkTiI-V, That I atteiKkMl .It-ceased from

that I last saw h ^ alivtnn icp

and that death occurred, on the dat<.' -tate<l above, at
M. The CAISI'! OI' Di;. \rn was .m follrms:

CL.L > X^-W-V, V.'vA X<. c > \.

DTK \TI<)N' )V.?;

t'ONTRim'ToRS'

Mouths

Pax

Hours

Is 4 ^^

Mt>Ut/lS

DIKATION ^ Vrars

( Signed ) L^\.^'>\iA'

/hivs

Hours

M.D.

i'ct \l rooS (Address) LtXoU-X^ ^ .t^

m-

OCCt'l'ATluN

fsfsi.fnf in Sint /^i inii ism

)V,,'/ . I M,>i,lh< I vJ /5<'

Special information onlv f«r Hospitals, InstltuHoBs, Translfwls,
or Recent Residents, and persons d)ing dway from home.

former or
Usual Residence

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

NoH lonq at
Piice of Death ?

Days

I m: MIOVF. STAril) I-KRS.)\ \|, I'\K iUlI.AKS AKI. I HI K l<> 1"H I *4( % ihki.ai. .i

HHST Ol' MV KN(>\VJ_,i;I)«,;H AND ISKUKI- ^Oif„ I I . I W 'C.t. \X

(IiifiiTinant

(A.l.h.-

. J. 0>UM.A<yCX./>xJ

5SD MVvA.^a^L.'C'O^ru at

« „ . . . . a ,, ..is-H AfiF iihould be utatetl liiX4CTLY. PHYSICIANS iihould

N. B._Every Item of Information .hould be c-refully f"PP'-d; p^^pe^rc •.•Ifleci. The 'Special Information- for pr-

atate CAUSE OF DEATH In plain tei«ms, that it may be proper.y ^ibmiwi^m h- •"

■on. dylnft away from home should be given In ^y/wy Instance.

\S*

■I «

i M p

WRITE PLAINLY WITH UNFADING INK— -THIS IS A PERMANENT RECORD

f "'''"' >• -" ■' 'ma^-»>HM'>-., RCPCn TO BACK OP CERTIFICATE FOR INSTRUCTIONS

A

huh' Filed , 4..^/ct<Mv-t\

190\

JReglslercd J\^o,

22^2

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco

Certificate of H)eatb

tl. S. StanDarC>

^

;i

No.

PLACE OF DEATH: — G>unty of docn^ d,>ua^rLeuL/aC(Gty of ^'/CX-/>v J Axxy>^>aUlx^o

^'^ St4 T Dist.; bet w A.a ^ Ul-l . and ' ' ' ;'

(ir DEATH occuns Aw«v rROM USUAL RESIDENCE Give facts called for undeb "special information- \ \

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

FULL NAME ^- vClmX

I I

I) ATI. or iiik I H

PERSONAL AND STATISTICAL PARTICULARS

I

I 4

111

I Month

» rat

MEDICAL CERTIFICATE OF DEATH

DATK OF DHAIH /A

(Moiilh) (Day)

1 in-;Rl-;HV CI;RTII'V, That I atU-iukMl deceased from

'9o\

(Year)

\<.H

)V,

M •<':!!

"-^INt.I.K MAkKU:!)

u ii)o\vHi> »»K nn'okCKi)

\\ ritr in ».<Hial «J« -ivnatiiMi)

C > V-

L

HIKTHIM.AOK

(Stati or I'duntiv

N \MK oi
I XTIIllR

HIRTHPI.ArK
«>l I ATIIKK

iStafi or Coiiiiti VI

MAIhKN NAMl
t»l M«)TIIHR

HIKTHI'I.ACK
«>K MOTMKK

(Htatj- or Coiiiitry

iUii

190 to

tliat I last saw li A/>>x alive on

10

X

IqoH

190 H

and that death occurred, m\ the date stated above, at
M. The CArSIC OF DJ-ATIl was as follows:

I i_» /^.

.t

CoL>uic<]Lc nJ K<xLfrtx v^

T3

r

U/<xyx' Jacv I

.a'

^ V

o

C

u

0 (] \

I ^

DIRATION Years

CONTRIIU'TOKV

Months

Da vs

Hours

Df RATION

L

I I

(Signed)

4

Years Mouths

t^ V

C /Cb ' mo H (Address) Ibl L L

Da vs

A

Hours

M.D.

«>0Cri'ATiON

Rfsidfii III San t'l ii ih ;-iii

I \

Special information only for HospJUIs, institutions, frinsients,
or Recent Residents, and persons dying away fro^ how.

.1/,,)','//. ^ /'-?

TMI-; AIUJVH ST\Tl.;i) I'KRSOVM, J' \ K 1 Ii" r I.ARS AKH TRt H l«> I HI!
HKsr OI- MV KNOW 1,1 !)( J.; WD lUil.fllK

(Infoiniant

f \d.ll.><s

Former or
Usual Residence

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

NoM lonii at
Ptare of Death ?

Days

lU ACF nl lURIM, OK RJ:M«>\ \I. I HATH o^ HiHiAr, or RliMoVAI,

im.i;ktakkk Ml v].^<X^^ '^^ ^< „

MM.- . a .. !• H AfiR Mhould b« staterl EXACTLY. PHYSICIANS should

IN. B.—hvery Item .W Information .hould be carefully -"PP'-^' ^^^'L^^H^^iLUlfled? The "Spccl.l Inform.tloa" for pr-

«tate CAUSE OF DEATH In plain terms, that It may be properly wiasameo.

•on* dying away from home iihould be given In myry Instance.

I

J.I

i < A

!i

1} i

r

WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD

It .'-< \- I N'

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

/),i/r /V7rv/.0<1^(.,

a

VA^

K

u

Deputy I

/!H/H

Jic ni si I' rri] ,Yn

2243

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco

Certificate of S^eatb

PLACE OF DEATH; — County ol '^

City of^ ^^ V. ,: s n

>N

•P4€». ^LCu At ^^\.Ui\i,

St.;

Dist.; bet.

and

4, HV ^^\.W>V^,, bt.; Uist.;bct. and

n / ir or*TM OCCUCS <(w«y rWOW USUAL RESIDtNCE give facts called roR UNDER "SPECIAt INrORMATION ■ N

W\ I »■ DfATM OCT'iWpfP IN * MCSPITA! C R i N =, ' ■ ^ ' t . r, N GIVE ITS NAMT INt^TTsn nr STBfrT ft N P NUMBER J

FULL NAME

PERSONAL AND STATISTICAL PARTICULARS

^l

CXiA

» A i i; or lUK in

\< .K

f\ ^

MEDICAL CERTIFICATE OF DEATH

Month)

kTIlA

M

*. I I» « iK in

t'l V

n lit '

at I '

-IV ■ *h It ,1. i;

I i t K mi

T<p H

up

he clHfi- ^tfli

31,

r \ I 't;

V \ Nt 1. , ,1

HIR Tit PI. \i-

' t' I' \ i n T (.-

i\

1/

lh-i\

I:

i\

n

: \- \ M \
■ r 1 1 : H

nfK'iifi'i.Ai 1'*

•'I MOIIIHR

■-tat, .,1 <-,,n!it

< HI" I ■ \< XX I* )X

A

MR-
i

DT RAT ION

(Signed )

I{)0

Rfiihii 1 1' Sim I 1 I.I

0

1 }V,7;< L Mntilht

I fours

M.D.

vu

-L

Special information only for Hlikpltals, institutions, Iranslents,
or Recent Residents, and persons dyinii away from liome.

Plar e of Ocatli ?

/)</r.v

\'\\V \H(»V|. >-l \ iIMj PFHSovM, I'M- IKTI.ARS AK1-; TRTK T< > THK

HT';ST ()i NV K v^^xK .j,;iH,l WD WVA.WA'

Fo.meror ^^^^ ' "^(ytil How Ion at

Usual Re^^^iiieKe LX^f <-

'if' V

Wlien was disease contrafled,
If not at place •! death 7

Davs

\<I.lr

^

'^^ u...

i'r\ci-: <)i' nrKiAi, <ik kkm<)\.\l | i>\

Hi Hi\i. or KKMnVAI,

•M.HRTAKKR^Tl' 1 OAAx^ Vuf (fej

.^ ^ , V .^-,.. . ^ ^\S^o.>sijJSCthMm*

(Ad.lreKs llll \TrU^.4.C0 >\. wA^

», „ ^J ir\ .HP lihould be stated EXACTLY. PHYSICIAf^S should

N. B.— ,.ver> Item of fnform-tlon .houM be carefully supplied ^^'^^-JX^^^^^^ ^he -'Special lnform„tloa- for psr-

•tatc g \U8E OF DEATH In plain term*, that It may he properly ciaasiiieu. h- •"

Hon* dyinft away from Noma ahould be given in •very instance.

*

i

i:

*

ii

I

■T

3l

I

! ' » !' ! Xi

WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD

' Ijt-- -'^PCo REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

\

l}(i/i' Filvil , ^ ,^<Hj

>-C^V!

.<ru^Ui

ro

Deputy H

h Officer

Registered JS^o.

2244

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco

Ccvtificatc of IDcath

( "U. S. Stan^arC^

A

4'
J/va

n

City of^ a >\i J'

IS v^CLv

No.

PLACE OF DEATH: — County of a>\

VcLc<XA.U:L LcLUXb^^- St.; ' Dist.?bet. and

|'\ / \r oc»TM OCCURS *w*Y rwOM USUAL RESIDENCE give pacts called for under special information' \
^, V. ir death occurred in w hospital or institution give its name instead of street and number. /

FULL NAME

\

1

p

n

I .'

I

PERSONAL AND STATISTICAL PARTICULARS

i» \ I i: t '! i;ik rii

a''-+

MEDICAL CERTIFICATE OF DEATH

MotUliI

u

/ ^l-

A«.i.;

^( luii

TrMrl

Pax

1 Ifl'iRlil'.V C1;RTII'\', That I aitciukil ileceased fmiii

lyu

IqO H

^i\< .I.I' M \kk n:u

Writ* 11! v.Kiiii i|t Hii/iiat ii 111)

lUH rui'I, \i'K

N XMI «H- 0
1 X II II' K

HIK rillM.ArH
'>! I A I'll HK

MAIH1..N NAMH
«»!• MoTllKK

I'lK IMPI.ACI.*

j'l M<>rin-:k

' stall or Coinitrv

'H'lll'A iin.V

L'^

.. ^t

tliat I last saw II .. ■ .. alive on w- -^.' ' Kp

1(1 that (k-ath nccurrcd, on the (iate stated above, at li "^0

,'it

w

Kj

(jC' CiiLt 1

/>vlccc I

M The C\ISI-" OF DHATII was as follows:

f^ ' i . ' ,

I ^^v.v I ^, (S 5i.«w-A C * CC'W.1^-

1)1 RAT I ON )\iJis

CoNTklHrTORV

MoHihs

/hn-s

Hours

DTRATION

(SIGNED)

)'cav!i

}fOflth!i

Pavs

tU\X

n J KkXojo

n

%Luj\U<j\.k

I

flours
M.D.

V.

\. 1.1 1 ess) \X\ UXOAm.

SPECIAL INFORMATION only 'or Hospitals, Insfitiitlons, [ranslenls,
or Recent Residents, and persons dying andv froni home.

f\f'shit',f iti Siui / 1 ,1 III :M'it

) V,t

]/.>/!//>

/Kn

rin: ahovk si'a nn pkrsonai, i'akthti.aks xki; rRri-; t<>
"I'^sT oi'^v KNOW i,i;i)(-.i<; and in:!.!!-!'

nil';

;ii

former or
Usual Residence

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

How lonq at
Place of Deatii?

Days

PI.ACl-; <>!

P.lk lAF, Ok kl'M<'\ \1,

f X.liltfss

I) \ 11',. if HiKiAr, or KKM<»\AI,

Ad.hfSH M u-cu^ m\xA. LI • -.

N. B.-

^^ ,, . .CP -hould be utatecl EXACTLY. PHYSICIANS should

-Every Item of !n*ormntion should be cerefully supplied, f^^^ .|.«-|#|ed The ''Speelal Informntlon" for psp-

state CAUSE OF DEATH In plain term., that It may be properly Uassifie .
«on« dylnft away from home should be given In svery Instance.

» 1

;^»-i

i

hi

^'l

I

*»«

WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD

! V.

S^'r r,^

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

nn/'i

Jh'ilisferpfl JVo.

:3245

x^\>

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco

Certificate of IDcatb

in. 5. Stan^ar^ i

PLACE OF DEATH: — County of ^Xy-u ^hMj>

City of ^ ^

No.

St.; ^ Dist.;bet. OID CrUhO^vxi and

/ ir DtATH OCCURS AVWAV rROM USUAL RESIDENCE GlVr tacts called for under "SPtCIAL INFORMATION \
\ IF DEATH OCCUWBCD IN A HOSPITAL OH INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER /

r , t

FULL NAME

f)

j^

H A^^ ' t-

4

jC\J^

PERSONAL AND STATISTICAL PARTICULARS

SI-; \ ■ * I « il.i iK N A

MEDICAL CERTIFICATE OF DEATH

M.iilli) (I)av

r HI'RI BN^ ( i:kTIF'V. 'ni.it l atft-n.h-.I ,1.

t,, ii ct^ :

I go

tVtai

H

;n-'i

\< ,K

^1'- ' . i.l- M \K K nil
\\ llMiWKlJ OR

< \\'r\%f in "(M'i-il , ,. - _

Ill:

I \ IH IK

lUR rill'I, \i F
«>l I XIIII-.H

M MIU'N NAMl-
"1 MOTIIKR

l''IKTHPI,A( 1-:
"I MOTHKN

<)i-rri'AT|(,^-

an.l tl

il Iriiiii

HI - '^ * lip 1

' t lit .I:i!r -f ;tf< '1 ;iIh ivi% nt ^

M. Tin- CAI si; <M hi ATll u

tllilt 1 lit-^l --.lu

I'll |! I\\ S

c<>NTRiin Tory

I )r RATION ^ )'t'qrs

Mouth

I hlXS

Hour

, . SU

Mouths /hns

kjhihj

(SIGNED )

iDctr 1^ lool (Address) '^^^ t<Liix

Hours
M.D.

4—

dlions,

/

;/ / ; a Hi . < it

) f'lJI S

\/i,>lf/l'

Pll 1 A

Tin: \HM\|.: si*\ti:i5 i-kk^hnai. i'AKTiorr,ARs aki': tkd; to thk
lu'.sr .,! Mv K NOW i,i,i)(,i.: AN!) in-:i,n;i'

SPECIAL INFORMATION ^'y 'or Hospitals, Insfitwlons, Transients,
or Recent Residents, and persons dying away from liome.

HoH lonq at

Plife of Oeatli ? Days

former or
Usual Residence

Wfien was disease contracted,
If not at ^ace of death ?

Ij'f'inii.ifit

^i^i

is

<Mi..s 3v I X ^ X/"^^^-^ ^^

i

1.,,UH()F^ IH kIM,J»K KHNK.VAI, j 1) \TI' nf HfMiAI. or KHMoVAl,
(Adill'-'*!* uIa

^

KXJ\J

.1 1 AfiB .hould be •t«Ud EXACTLY. PHYSICIANS .hould
N. B. Rvery item of Inffopmatton should be carefully auppiled. ^^" cl«.«lfled. The •'Special Information" for pep-
state CAUSE OF DEATH In plain term., that It miiy He |,r»periy
aon. dying away from home should be given In myry ln-t«nce.

J .»

WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD

nth ! N '-•- -afi^) p.Si ;■

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

r^JyJ II

inOH,

/^'o'/.v/f'/w/ JV'n.

2246

,tru^c4

#♦•

t

DEPARTMENT OF PUBLIC HEALTH^City and County of San Francisco

%

0 \<xv

Certificate of E)cath

X\. S. Stan^ar^

i ^

PLACE OF DEATH: — County of ' Ow^V J XCL'^\cuL<^DGty of ' ),<X/vv 0 \o.vxccaico

^ (I I

No. iSTb w J- St.; % Dist.;bet.^<XaA.U>xCU and^JjXCC>"

/ ir DtATr- occ uRs *wAY FROM USUAL RESIDENCE give facts called for unIder "special information- N

\ ir DtATM OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEA^ OF STREET AND NUMBER. /

FULL NAME ^^CL^

r>

ii

PERSONAL AND STATISTICAL PARTICULARS

11 tl.ok "S

I i N

Li>.^.t«.

i 1 I > !

11

f\ f.

M

^IN« I.K M \kls III)

wiiM»WKl» UK ;

i Wi itt- ill *;(MMa' .

A

MEDICAL CERTIFICATE OF DEATH

I) \i*i; « n' i>i: \ in /O

I in-:R \l'\' i i UTIrW

tllMl I la-t -^au li ' ■ ■"

;ui<l th;it (k-ath or«iirre.I, <.?i the dati- ^tatt-.l alMiVf. at (oO
M. The CAI SK Ol- I>K.\rn wa- a-

!at I alh-iiiUii ik'Ci-a'-cd trtnii

IcjO H

1 1 HVS

r

N \ M I I (I

I'.Ik rill-i,Ai-K
OF I ^!hi;k

">t;it- iir (."(Mint! V

MAn)l.;N NAM}-
«»}• MOTHKR

iHkTni'r.Ari-:

"> M<»Tin%K
i State or Contitrv

OUX^

LhAM

n

I

CONTRimToKV

I )r RAT I ON y^'"'^ .^

Months

Da

Iloiti^

(SIGNED

) aJvol^

Mouths
4

Davs

%>. I^lI

M.D.

ifi

Rr silt fit iti San to at'

Special information only '<"■ Hospitals, Insfirutions, TrwslfBfs,
or Recent Residents, and persons dying away from home.

), ./

M.nillv

/)(/!.

THI-: AHOVK ST\ TKI) PFRS(1XAI. iv\ k T U I I,A RS ARK TRIH To THH

HHsT <u- Mv KN'n\\ i,i: !)( ,}. AND iu;i,n:F

(Iiif..Mnrmt

X^^^

1

/^-\

fCA ^ %

rc^uoXi

Former •r
Usual Residence

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

How lonq at
Mace of Ikath ?

kys

lU ArK <)I HlRIAr, OR RKMoVM, I HAT^-: of H, HiAf, c,r RVMoVAU

„ . .pR _Hould be stated EXACTLY. PHYSICIANS should

N. B. Every !tem of Information ahould be carefully supplied, aud .„_.|f|ed. The "Special Informntlon" for per-

•tate CAUSE OF DEATH In plain terms, that It may be properly ^
son. dyinft ms^tmy from home should be given In every Instance.

I!

..»

i 1

.^ '»

i

ii

•i

WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

I>fifr Filed , \^ cWu-Uxi (I

iu(n

Jic^'i si ('red JVo,

2247

. ^Vv^^ A^K^^M^

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco

Certificate of Beatb

1 11. 'Z\ Stan^ar^

4

PLACE OF DEATH: — County of

vJ \<X <ocCity of

'^a.ix,^

Kcx ^V'CA^^e>0

Nr,. ^UuU "^ V.C:r\,Oxlu \ ^v : \ St.; — Dist.;l^t.

\ ( XT DEATH OCCU

.C:r\,Oxtu \ ^v ' St.; — Dist.;l^t. and

( XT DEATH OCCURS U A AY rROM USUAL RESIDENCE GIVE FACTS CALLCO roR UNDER ' SPCCIAL iNrORMATION \
V ir DEATH OCCURRED IN * HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. /

(^

FULL NAME Uvc

LL L-»vau^d' 4 1

rs

N.A

^

4-

PERSONAL AND STATISTICAL PARTICULARS

1 » \

RTn

U

MEDICAL CERTIFICATE OF DEATH

1) A TK I M I'i. XIH

iiob

M..iitl

M

\< .!■;

/),,

\

f)

!•! \.-K

LC >V

I \rni k

iHHrm'i.M'H

^t:i'i I iT l',)lintT\-

■^t MIiiN NAM)

•'1 .Mo'nn.R

HIk-|'ni'!,S(K

"I ^t'l■^lIFH

■ "^l:it' i.r Counli \

I lIKIs I'l'N' I l-RTII'N', Til it I attfiili-il <U-ciasf<l from

- — \ip to ~~~ I90 ~

llirit I 1m-1 -^aw ll ~ alivf nil — =— - i,^ —

aii.l that ilrafll <.. - • , ,1, < ,n t lir ^ I il »• -fa' - .1 a!,, ivi-, at
M. Tlu- C Ai "-!■; ' '1 I>l, \ I'll ' f'.M'i\\N :

A

.C

t^vU^^

K 8 A

IJIR A rioN

( ONTK ini T<»1<V

I ir RAT ION Yrars

Mnnih^

/)av

11 i^ lit

M^niths

/Ki\

^. ilU

SIGI

V)^"f ,(_ J ^ (A.Mr.-^s) v^Vt> w^^\^ v^ 4

1 1<U()

M.D.

L

<H A i i'ATiox

AV liU'il it' ^:!ll / lillli

r

'D

w, r \^A^%^~

SPECIAL Information onb for Hospitals, In^^tlfutlOlH, Tra«slfBts,
w Recent Residents, and persons dvini a^iv from liome.

)ril,

,1/

Former or
Usual Residence

Wfien was disease contrarted,
If not at >lare of death ?

How lonq at
Rare of Deatli?

Di>s

1 \l',n\ r: vTxT,. i> pKH»,.)\AI. 1' \ k T If T !. \ K ■> A K l', TKiK !< > Tllh

in.sf (,]■ Mv KNn\\ij;i)f, F, AM) iu;i,ri;K

inrfiMurttit

Ia. U). a<xn,^

]t\T}:<>'- Fl' HIAI. f»r KKMUVAI,

0^ I- 1901

.X.<.:k fe=^-^§

Juyx.^W' VilJX^^

(Ad(lt<-'«

i^H 0^' QJuUXiA, ji

' ,, , AGE should b. .tated EXACTLY. PHYSICIANS .hould ,

1. B. F.%ery Item of informRtlon .hould be carefully suppMed. ^^ cimmminm4. The "Sp^clut Inform«tlon** for p«p-

.tate CAUSE OF DKATH In plain te.m., that It may be proP^Hy .la..im

a-Jfi. dying away from home ahould be ftlven In -v.ry instance.

'<\

i
I

ri

I

i!

i I I

♦ i I

1

•I

J'<

iL:_

iff

WRITE PLAINLY WITH UNFADING INK

t^^-lar-^, H5;; I' Co

;j \

100 "i

THIS IS A PERMANENT RECORD

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

Deputy HeaUh Officer

DEPARTMENT OF PIBLIC HEALTH=City and County of San Francisco

Certificate of ®eatb

11. 5. StanOarD

PLACE OF DEATH : — County of 0~.y\J o - vc^

No. Ld-tv^^^'^^'^'

Dist.; bet.

\x V l\\ I /-.-> "l I , St.; Dist.;bet. ,,„.£. "spcciAt iNronMATioN- ■»

FULL NAME

,\

Xj

PERSONAL AND STATISTICAL PARTICULARS

^l-,\ ^'

( ( ii,t »k

i>A ri-; < 'I r.iH I'll

M. Htll

\l .1-

<J

I )-,,M

' ».l \"

M,,)i'li

%'<'.ii

MEDiCAL CERTIFICATE OF DEATH

I>\ 1 !■: til- Dl'.ATII

\

I go H

(Year)

-IM.i 1 MARKIl'.l*
SVtiteln Hocifil ck's%iKi>;»i'"" -

n

,1 \ (Dav)

(Month'

, HKKHBV CI-RTIFV. That I atUn.k-.I acr.asol fnm,
. — ■ — — lip ' t"

thai I last saw h • ' aliv.' -n — ^'P ^

,„a that .U-alhutcurre.l, on the. date state! alH.ve, at

— M. The CMSK UH HKATII was as follows:

<. >

o

lUK lliri.AtM'.

: stMic I >r I '. Ill n! I \

X \MI ( U
1- ATll l-.K

BIRTH rUAOK

oi I \rni:H

I Stati oi v'minti y

m\ii>i:n nam».

I51H rni'i.AiH

(Stati 111 fotllltl N 1

s^d^dJx

i^u.^'

Ums^'oJ-j ^'

I )r RATI ON >*'''''-^

CoNTRn'.lTORV

Months

Days

I louts

^

I

OlHMl'AI'loN ^ , » 1

Uu ^ • • ■ <^

imST OF MY KNOWI.I.IX.H AM> l-M-"'

Months

Pays

DlRATinN >''"-^

(SIGNED) U^-i^-^^'^^"^^^^

SIGNED) MT^^A^ P IQ

— I. fnr Hncnit^k Instill

Hours
M.D.

(Iiifoimant

U). ^^^

1)0 Kxt^iL^^r^v^-^^^-^

-^^— y^^-j;;^^^;;;^^ omv for Hospitals, institutions. Transients,
orleren^isfdents! and persons dying a.ay from home.

r\A , (^ u How lonq at ,

f»^'""''^ M ibrYdjl^JtLi ^'^-^^ Plare of Death? > Days

Usual Residence'i' \^y\a>>^^^

When was disease contracted,

If not at place of death ?

u' -V

1,\ 11 .,; Hi HIAI, -.1 KHMOVAI,

—" .^'\i:^?au^i

190 1

,\'l/^tA >.^/v>JUU ._ , FVACTLY PHYSICIANS should

TZTuppneZ AGB should »>- ^^-'^^^^-fspLla'! information" for p..-

of Information .hould b. cn.e.uHy «upp ^^ ^^^^^^,^ ,,a««.*.ed. The Sp

E OF DEATH In plain V-*"* ' ^J^" '' ry Instance.

^' """rtatTjAu'sE OF DEATH In P'^J^J^^^-^^i^V^Jn ;ve.; InMance.
«on, dying away from home should be gi ^^^

* 1

i <

i

;j i •■•

1 i: t.i

r

■*X -jr-^i ''.'"- I ' '

WRITE PLAINLY WITH UNFADING INK-TH.S ,S A PERMANENT ReCORD

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

J? -^ _ .^-

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

Gcvtiticatc of Bcatb

IT. 3. 5tan^a^■0

s m A '.

, ' ■ - City of^ '^ ' ' ' -- ^

PLACE OF DEATHi — County ot

'Pfo. VCl

\ ,r DEATH OCCURRED IN * HOSPITAL OR ^ H%T " ^^

FULL NAME V^ -- ' ' ^^

\

PERSONAL AND STATISTICAL PARTICULARS

r\ ■

!» \ : I ' 'I

\< .!■

U

II V.

^'

MEDICAL CERTIFICATE OF DEATH

DA IK "K ni \rn

V. Ml I

I m-RKHV CI RTII V

\i.p

|>:!V'

T c)0 i

l\\

i; ,1. -is^nntntn)

llIH fl! ri, Xi'K

1 St .it 1 1 It i

\ III IK

If %

« >! I X I'll IK
St il t t ir I ii\!tlf ! ^

MMDl-.N' N\MJ
^•]: Mo'l'lll-'K

»>|.' MnpHI'.K

State . ! t'olltltl N

,1 t hat lU'at h
M. Tlu

C \i -I' <

A ril \N i-^ a-> follnu-^

UX'LLfC-^

\

JL^

nr. I r x'l'ioN

C

rs

liKST 111' MV KN.IWI.II".!'. XN^ I.I 1.11.1-

(Inf'i-maiit

-^^xX

v)l\

CSJY\y^\j

/>c7 1

I /out^

/hi

IS

.c<

M.D.

/..i,i....s^CaxUJcmv^^v

fJ

M
i

r

%;7^;^^r?^ORMATION only for Hospitals. Institutions, transients,
^rtren^isfdents' and persons dying away fro. home.

r
1^

'. f,

Former or
Usual Residence

When was disease contracted,
Ir not at m^ of death ?

How lonq at
Place of Death ?

Days

7.,.ACK01.- m-KIAl. OK KKM-VAl

lit A C<x'..

l(<

1

N,

(A.l.lif^s <^V0 *^' V M U-V^ ■■- , -^^.>.L PHYSICIANS should

' — ~ ^^^,,„„y .oppMed. AGB f ^"/^''.^^j'j^i^'Vh; "Sped.; Information" for p.r-

B._F.very Item of •'«*^»'""«»'r.', it term, that it may be properly .l..»l«ed

state CAUSE OF DEATH In P»-J"f^'"!;;e„ la .very Instance.

son, dylnft away from home ahould be ftl . —

t^'?!

i -I

h I

WRITE PLAINLY WITH UNFADING INK

^" "■*»,

.1 . i I !

t 1!

,>. 1' Cij

I)f(/<^ niriL U,i:i.<rl>x/vi 11

100

THIS IS A PERMANENT RECORD

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

Be <^> I sieved J\'o. ^^oO

^

DEPARTWENT OF PUBLIC HEALTH=City and County of San Francisco

PLACE OF DEATH: — County of

Certificate of "Death

■ - - City of O/CXz-Yxtoj ^A^O-^i-XX;

N«. ^clvHoJ'S Ca^-^

St.;

Dist; bet.

and

)

FULL NAME

AXVt'^^-^^^^^

PERSONAL AND STATISTICAL PARTICULARS

u

J

; .

rV-

l>,.s

\» ,1

55 ,„,- 1

\l

\ 1 a!

/).M.

^I\. I.I* M \R K IKIl

\K ' ; 11 i\\ ! I > ( >R 1 » ;\ t II' r n

W ; ;!. ill -. H la' .|. -ik'U.it ii>n 1

1 1^

O

liik rnvi, \t"K

\ \M 1 < >I
I- Sill 1,K

p.iR'nif'i, \<!-:

ni' I XT HI" k

--! * I I ir I'l lu lit I %■

<>i M«»Tin;K

niR'nuM, Acv:
ni \i(>rni<,K

( state or Ciiuiitiy

«H Ct !■ AIK^N

LLC U, tVi^ "'I V

1^ a

W

4 ixjUJ- ^v^XCutU

^^s

h'r^iilfi! in S,m / i ii

) til

Mnllill

/',.'i

THU MU>VKSTVI'KI) PKRSoNAI, I'A RTH* ri.AKS A R H TK f K T< > I'll-

incsT <)i" >.tv KNtiw 1 iix .!•; AM» Hi:un.i'

(1

MEDICAL CERTIFICATE OF DEATH

DAi'H <»i ni;Aiii i I \ ,

I 11I-RI:HV CKRTIl'V, That I atteii.U-.l .W. easel fn.n

190 tn — — - i»p —

that I last saw li alivr on ^'P

an.l that .Uath ncciirrea, n,i the .late stated ahovc-. at
M. The- CArSI':,Ul" in; A Til was as follows:

L\.

1)1- R All' 'N

Yiars

Mouths

Pars

I /ours

rxi

lis CvixcL.u

CoNTKII'.rTORV

DTRATION )''-<Jrs

'wV..

Mouth.'

Pa

\s

//ours
M.D.

SIGNED) LU. VJ ^^'^*^ ^ • ^

iDot 10 rooH fA.Mn-ss) ^ OA^ta, UW<X. LaA

SPECIAL INFORMATION onl> for Hospitals. Institutions, Transients,
or Recent Residents, and persons dviny 6v,a) Irom home.

Former or
Usual Residence

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

How lonq at
Place of Death

Days

V\ MV «•! niRUU OK Rl'MoVAI.

INIil'HTAKKK M V-

XXxu ,

X.OLH ^^^ ^-'

IJAT};iit* I!i KiAi, or KKMOS'AI,

0

,a.iu.s ^51 m^^^xxj^ '^t

' ^ IfiE should be stated EXACTLY. PHYSICIANS should

Btlon should be carefully suppi.ed. ^''•^ *^ .^^jn^d. The "Special Information" for psr-
ATH in plain terms, that It mi.y be properly

N. B. F.very item of inform

state CAUSE OF DEATH in p.. • , instance.

sons dying away from home should be given .n ever> instance

' 1

I 2

I (

I

i

i i

i

Wi

i<*l

^

WRITE PLAINLY WITH UNFADING INK

-..V":^"*-, i.x.

THIS IS A PERMANENT RECORD

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

Ihifr /-'ifc'L ^ oLt^t^^" II

IfUJH

JlroisfrrCfl J\^o.

2251

DEPARTMENT OF PUBLIC HEALTH^City and County of San Francisco

Gcvtificate of 2)catb

M

PLACE OF DEATH: — County oi

City of ' Cl >^'

\

>lOl ^\cc>a. CO

^

No.

. , .,,. occurs .... r.oM USUAL RES.DENCE_c..v.^ -c-rs CAUj^o .^^^^o^ st^^ J^'no^Jm B^ h' ' )

I n SU ^ Dist.;bet.

' - iiCiiAl RFSIDENCE GIVE TACTS CAUUE

f ,. , .^.. OCCUHS •..* '"^^ ^^'ilt OR^NS^TUT.ON G.VE .TS NAME .^

V if DEATH OCCUWnrD IN * MOSP..4L OR INST W

and

FULL NAME

PtRSONAL AND STATISTICAL PARTICULARS

Ua-

MEDICAL CERTIFICATE OF DEATH

■fc

Ml nth'

1 n

;\ I IRTIFV, 'I'll '• i

i' tciii Iril > i<

ti)

a^itl tioill
Kf) H

I

tlial

W\

I l-I \i' »■

V \ M 1
1- \ I ill

:!!• !';!!M \< I

I . »

u \ MM X ^ \mj:
>\ mi»i'iii;k

<•] Mtiriii-.i.'

■^1 ati I .r < I iiuit *

I i'^ T II »:

A'/' /,/f./ jc

/ ( ,;(/( ,' 1,1

) till S

Miinfti-

I III 1

r XH..VK s, X , , n ,.h....xx,,,.vktum;uarsahK tkih to thk

HKsliU MN KNOW 1,1 l»<K ^Nl> H»-.I,n-,l-

( I 11 fii- iiuiiil

^Aj

\.l

M. *riH I

i'i\ f nil

,,,1 ihf ilati- statiil .ilinvi-, at
( )!" I )i; ATI! was as lollmss :

1 1 )()

5

l h

/ 'i/M

Iloui

c

M

\ t a

Par

(SIGNED) ^- '"^ a - - ^

I Ion I s

M.D.

"^^CIAL INFORMATION only for Hospitals, Insfitullons. Transients,

or Refent Rcldents, and persons dyinq away from home.

How lonq at
former or Place of Death? Days

Usual Residence

^R was «sease contracted,

If not at place of death ? .

UAry<»f niHiAi, 1)1 ri:m<>v\i.

C

t.

L T()0

^

d EXACTLY. PHYSICIANS .hould

N. B. Bvery Item of Infopmrttlon •hould be

;py
Htattf

Item of infopmiiiion .owi.." "• — ,^g propel

CAU«r. Ot^ DEATH l» P'-'^f'^/'^:; ***"„. v^^t l„.f«c^.

c.r.luMy .uPpi.'H. *««;;;'';;.''..V,,:i?' Th. "Spcc..; .„.„r„...lon" for p.r.

won* dying away from homo •hou

I !

. <

i L *

I I

4 i.-

V

f:
I

I
I

t

u*.

. -c

m

WRITE PLAINLY WITH UNFADING INK-THIS IS A PERMANENT RECORD

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

tS- -.. H\ I

Pa/r /-V/r'./.yc;

hj U

inoH.

Ur <> i sh'iu'fl >.V(^

00r\0

dw^VC

DEPARTMENT OF PUBLIC HEALTH-City and County of San Francisco

Gcvtificatc of Bcatb

•\~

PLACE OF DEATH: — County of

City of <^

> \

^.^

X.

' s$U.

Dist.; bet.

and

'%S^ \ § "V'\ ^\ A I V ^ ' • '^. Oti^. L'liil.f l^*» ,,K,nFR SPECIAL INFORMATION \

^ ^ ^"^^^--^-11^^^ --^^^ C,;^-!^^^^ ^^°0. STREET AN. N..eER. )

(

FULL NAME

\n

PERSONAL AND STATISTICAL PARTICULARS

1>

.1 i.iK I II

M

1' M \H H ir I

MEDICAL CERTIFICATE OF DEATH

i: Mil

DaV

I lIl:l<l;li^

kTli'N'. That I allcn.u-'l .U-.Ha^cd fnuii

i()n "

ti

that I !:■

;,n,l that .U-alh

aM oil

1 tjn

M. Tin- O

S • Ml- 1

hv <lat< -tat.-.l ali.ivt', ,a
1 \ I' II \\a-- H'- lollmv-

\\ ! 1 M iSV

W lit.

H!k rni'i \i' H

NAM I- <i1
F Mill K

ItlK , H I'l. Vi'l-:
< tl I \ I II l- !•
Stat I I It I'l ill lit! \-

MXini'S* S\M1

Ml Mci'riii:K

luu iin-i. Alls
<>t M<>riii;R

1%

\ '\ s

/sflitii! Ill >il>l I ''»'"'■ • ■

... , . ,, rxi'Tim \Ks AKK TKIK TO Tin'

lU-sr Ml- MS- KN«<\S l.l-H' .1 '^'^i' »M*''-f'

(llif-niiiaiit

It > OtA)

Dlk ATION

1 1 r R A r H > N

.1/,

nays

/Ion

rs

l/,u//^s

/hlV

//om s

M.D.

IM"

( A<Mn

•so LfrXe

^^\ t\A Kj\ % ■

4*4*-

" SPECIAL INFORMATION f) tor Hospitals InstilutlttAs, Transients,
orlren^lesidents! and persons dying away from home.

(V , ~\ , How lonq at

Former or Q '^ M U \ nX^>->'%0 ^ t piarc of Oeatli ? Days

Usual Residence I -* I ^ Ul^Mirr

When was disease conlracted,
If not it place of death ?

IiAlI', of m KtAi- or Ki;Mn\AI,

IX

X.l.lrr..s IHO^

i'^LAAnr^

gAJU'»

^^^""^ yLAyx^ ^ ' ._XLll I PHYSICIANS should

"~"^ vTTTTTIIefully «uppr.cd. AGB should »»« -t"'^^^ •♦Special Information" for pmr-

N. B. Kvery item of informatfon .hould be carefully ««PP ^^ properly cl»..IHed. The »pec

state CAUSri OP DEATH In «>'«'" **^/J"!;;e„ n Ury l««t.nce.
% nnnm dying away from home should be gi^en m

^1

J I I

H

I

I i i

I I I

M'

11. yi'

WRITE PLAINLY WITH UNFADING INK-THIS IS A PERMANENT RECORD

^^ REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

}•■ N'

0 J

Meofs/ered j\'o.

W^Wu Dep--.ty Health Officer ^

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco

No.

PLACE OF DEATH: — County of^O.
,^klM.C St.;

Certificate of Beatb

( tl. 5. StanCatC )

'%o , City ofOa/w-^^ ^.v-..^-'

and V-lau I.-

H'

"VX)

^1

K

V tr DEATH OCCURRED IN • HOSPITAL O R I n :>

■ni<:t • bet. v) 'VcOwL'WC

TS CALLED TOR UNDER •SPCCAL . N EOR ., AT.O . ■■ N
\\ NAME INSTEAD or STREET AND NUMBER. J

h

FULL NAME ^

)l,lcCl<x... V vJWlrL'>^^Lt ,

-.1 \

1 1 \\\ t •!

PERSONAL AND STATISTICAL PARTICULARS

,A

rw

II

k

^^

VcU

'f

in

\' .»■

MM ,

X

■J. I:

»! Ni , 1 r M \ H R I i;i»

w I iM »\\ I i » » iR I »i\< >Ki I'.n

W ! lt« 111 -' M ;.i: 1( -i^MlutHill '

MEDICAL CERTIFICATE OF DEATH

( MoiitlO

10

l>;iv^

(Year)

S ,,, Ki:i;V I KKTIFV. That r aUcn,U-.l .KHea..-a from

i(p

thai Iln^t^awhA. - alivL-nn ^ '^ '^ ^^

,„., that .hath .u.urre.l en the .late staua ahnv.. at

~ M. The CAl SI' Ol; I)I{ATII wa^ as follcws:

w^

a

CjCLOv 0 V<XAXCLv

1, /N /• V

rs I

I A rill-. K

HIKTllI'l.At'K
(•1 I sriiKR

M MIU-N NAMI

I'.iu rm'i.Ari',
tn- Mi»ini';K

(stall (It Country^

n

yxs

(Hcii'A'iioN Osrsf.

TnKAm>VKST\TKn.-KH<..NAi,l'ARTirt;i,XK'^AKKTK' H To Hih
HKST Ol* MY KNOW l.»;i)<-K^\Nn lU-.MI'f^

Infonnant LU mTU

rcN)- C; >

(AcMrcKs

DlkATION y^'^f^

foNTKIHrroRV ' ''

DT RATION >'"^''^

A(
(SIGNED)

Months
Months

/hiv.

'S

//ours

Pav

K.

IqO

A.hlre'.-^ ^^^^

K

//ours
M.D.

.SPECIAL INFORMATION «"!» I.r H.^pH-K In^M.ulions, I.anslrnis,
0,^" MeV', and persons d,ini a.av fro. home.

How lonq at
Former or piarc of Death? wys

Usual Residence

When was disease contracted,

If not at place of death ?

UAi'l'.i.f !l! KiAi. <it RICMoVAI,

,.LACK01^ in-RIA?. «.R HKM"VAI.

fAcMreSH

^ * 1 f^VACTLY PHYSICIANS should

E OF DEATH In plain terms, tho jt m»* ,J^^^^^

N. B.— — Kvery item

•tate CAUSE OF DEATH in p.a." ,^^' "■;';"-:„ ^^^ry instance,
son, clylnft away from home should be ftiven .« every

I I

u

»1

WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD

11. ,-.!; ! V,, :. ••*^ti,|,s:!>(%, REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

I)ff/c Filed, ll/ct<r\M.V. II

100 "{

Bogtsteved J\^o.

2254:

^

Deputy Health Officer

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco

Certificate of IDeatb

PLACE OF DEATH: — County of Ocurv 0 >^a/>\ C'-^ y . City of Cj-Oy-y^ J X<X'/VC<^.-
No. KlC ' 10 .Uu St.; ■' Dist.;bet. fc-a>^vi-i.l' and H ' ' ' '

/ ir DEATH OCCURS *W«V rROM USUAL RESIDENCE GIVE tacts called for UNDEli SPECIAL INFORMATION*! \
V IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. J /

I 11

FULL NAME r:X^^

'jA/rru>Yvt

.-i

PERSONAL AND STATISTICAL PARTICULARS

'.I \ >"> r<<I,nK '\

a\

M mil

\| , 1-:

\:

M,:til/r

\ ' .iV

Af r^

^! M.I.I* \t\Ki<n:i>
uiixiui.n nk iuv<»K(.i-;n

(Writt in -•Mia; il. -i^natiiiii)

n

.C'^v

lUkTHI'l, \i'»'
' Stati ( ! t ■, ,11 lit t \

NAMH nl
l-ATHKR

'^

LoJLci-

H I R r 1 1 1 ■ 1 . A ( • i-:
<>i' I \rm:H

I stall (II I'outitrv)

<>1 M»>TIIHR

niRTHIM, AD-;
<>l' Md'IIII'K

'"tail I .! riiiint I \

.S'.a! t

MEDICAL CERTIFICATE OF DEATH

I).\TH »»!• I)J;ATH a

(Months (Day)

I IIIRIJ'.V Ci:kTll''N', That I attemU'l (Icicasctl fruiii
W.^1j ; 190 I to <:iX<,-A-«*.-^ir4^.. TqO

that I last ^a\v h . ' alive on U^ t V * j^pH

an«l that lU-alh (UTurreil, on the ilaU- statL-d alK)ve, at ^
" >r. The CAT SI-; OI' 1)1': ATM \v:e^ as follows:

DIKAIION

)'t'ars

.youths

C C) N T R I B r T { ) R \" LLcC4w<Lt^\Xo-v c

lloiirx

.OXu

A '

T^f

J

Mouths

Pav

(^ -tl H'
(SIGNED) V. 'I ^'

L'^> \ icnH fA.hln-s.) MC'l OAAJrijUv It

7 \A4 0 I V

HoHl s

M.D.

Special information only for Hospitdls, Institutions, Frdiiblents,
or Recent Residents, and persons dving a»ay from home.

<H'«ri'A rioN

y.ai

{■

M.niUi-

fh'

rii j: amovk sTAri-'n pkrsonai, rxn if ri, \rs aki-; rnrK ro Tni'

lUCST (H- MV KNoWLJUX'.H AND HI,IJi;i'

i\

a 9

iifotninut ^ ]\. \D .

jk/WX/^^A.^

v.<t-

r\,l,lr,-,s 5.116- ^OJU-0 .'^

xi~

Former or
Usual Residence

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

How long at
Place of Death ?

Days

ri,\CK<)I' lURFAI, <»K Ri;.NH>\AI, I DATi; of Hi Kl.Al. or KHMoVAI,

^^ ^ ' i!'^ U T90M

1 i

N. B.-

. ... » ,. I5..H AfiE should be stated F.XACTLY. PHYSICIANS fihouid

-Every Item of information should be ciirefully supplied. AUD snouici "« »*"^ "«a„..^s-i l„S«„.„»ti„.," f„n t^mf-

•tnte CAUSE OF DEATH in ploln terms, that it m»> be properly classified. The Special Informat.on for per-
sons dyinft away from home should be ftiven in every Instance.

I

I

I

* <

r:

■' i' .< i ' * ■

t >l :
#1

X

:f

WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD

! I '• 'i <

-ST .-. i^>x 1'

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

lUO'i

lU'iiis/cred J\'*o,

2255

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

Ccvtificate <:X Bcatb

PLACE OF DEATH: — County of ~^a>x ' \a>xcuccGty of^ '/O/v^ Ja^X/vxc^OX^

No.

I : rs_

St.; H Dist.; bet.

5 11

V.

and

, iieiiai orCinrNrr nwr facts CALLCD rOR UNDCR "special INroRIWATION" \

( '^ r."o;:.H'^occ^%r.r.rrH "s^^.it o^".;s^^""4^."c.;.T4 name ..st.ao o. st«c.. ..o .u.bc«. j

FULL NAME wC ,

PERSONAL AND STATISTICAL PARTICULARS

(1 U « tK>

.!V

\\X^

i t ' i i 1 i K i I I

(1

\t nth •'

Ii.

-iN« .1,1" \\\\< \< ii: i»

W i i! I ill - ' :• ■ ,

1)

L %

IlIK III !'I, \i'K

'St,i!i 1 ,1 ( . iiinl I \

» ATHKR

I'.IH IHl'i. \(j.:

<>i I \rm-k

'-'lit. 1,1 riHiiit t %

MX Mil S \- \M 1

ink IHl'I, AfH
•'l- MtilllKK
"^t it( , i! i*i,nn!i \ I

L

yx^njUL M LturTTvO'Yx^

.1

MEDICAL CERTIFICATE OF DEATH

I) \ !'i-; t ii- ni; \'rii

lict

/QO H

(Yt-ar)

Month' 'I''>^'^

I Ili;KI-:nN <. l l<rn V, Thiit I alten<K-.l 'li-crase.! from
I.p'i to V up'i

llial I last saw ll

ahvt- oil

W
w

it

Icp

aii.l that diath .kh iirrcl. mi the .latr •^tati-d ahove, at
M The C \l SI- Ol' IM-ATII was as folI<.\vs

LI

in H \ rioN

} t'tlJS

\

Mouth

Par

Hour

Ci tNTIvIIUTokV ^

L>%_^>

DIR ATinN

)'r n-

Mnnths 3 PayR

()

V " t •

( SIGNED

I lour ■i

M.D.

V J A;

u^Iaux)

• •' < I 1' \ TIMN

fsf'^ldl'il III SilH /'l ll Hi I •■/'<>

)>,;;

Mnlllh^

/>,/!

IHl, AHOVK ST\TI-:i) PKKSONAI, 1' \ R lir I 1, \KS AK H TR «' K T< > THi:
in-.sr nl- MV KNnWM'.lx .J'. AND in.!, 11, 1

f

x.t.h, ss '^ H ^ J (nJUrTrx/

at

SPECIAL INFORMATION only for Hospitals, Institutions. Transients,
or Recent Residents, and persons dylni) dway from home.

former or
Usual Residence

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

How lonq at
Place of Deatli?

Days

T; u-K.M^ m-RIM. <-•< KHMoVAI. I "Vl-j.^f nrH..u. or HHMOVAI,

tJv C* > *

I

T90

H

— — — """"^ ,. , AaB«1inuldbe •t«tc.l nXACTLY. PHYSICIANS .hould

tloti .hould be c.Mfully supplied. ^"^ » cl.«.ifled. The "Special information" for p«r-

..... W..O.. ^. a...«TH In plain term,, that It m«. He properly .I—me

■on. dylnft away from home .hould be ^iven In .very In.tanc .

N. B.— Every Item of Informn

•tate CAUSE OF DEATH In p

I : *

J ,1

4 .

i

s I

:ti

n
If

i

If

M

ri

WRITE PLAINLY WITH UNFADING INK

ih/fr Filed, ^ ,ct<r\>^\^ 'I

n)n\

THIS IS A PERMANENT RECORD

REFER TO BACK OF CERTIFICATE FOR jNSTRUCTfONS

Registeird JVo, 2256

^v^»^^ Cjc/vm^

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco

PLACE OF DEATH

Certificate of Beatb

: — County of^O. >x OA„<X^ c^C^Gty of ' <Xtv 0 /^<X/>^c^<l^

m

v^\x\i^^-^ -^ " ^<. ' St.: Dist.;bct. and

i>ro. V^C^U ^ ^TCiAVwrr r.wr FftCTS -ALLEO FOP UNDER SPECIAL I N FO R M ATI O N ' \

I / ,r DtATH OC. U^.^ AAAV FROM USUAL RESIDENCE GIVE rACTS -*^^^^,^3^,„ o, s^„tET AND NUMBER. ^

V IF OC.TM OC^URBtD IN A HOSPITAL OR INSTITUTION GIVE ITS NAML NSTK.O O

j(

FULL NAME

I

SHX

PERSONAL AND STATISTICAL PARTICULARS

1

«'! HI Kin

t'.t

M.M.ih

1

11

Willi »\VKI> ok I»:\ . ik. Jl)

\<X^x.

KK^^

! t iiml I %

N \\! I ( »)•

1 x rii Ik

'>|- I \ in \M

M \ii>»:n n \m 1

'»! Morili.H

I'.IR riMM, \( K

•'I Ntiirni'K

u

1 1
(1

Xol^^XOu ^'H

-1,1

I I ii I'l iiiiit 1 \

A)

orrrivxii,)^'

JX/>f\.o ^

\k ^

A'fMiffuf in StiH /'i ,111, i^i'i) 1 I. )f(f»*

1 A .;/,'//>

/J./l

111-. \HOVKST\THn l-KKSONM, r \ KTir 1 I, A KS AK !• TRf H TO Tllh

nj';sT oi Mv KNowi.i.iK.i-; and in;i,n:i'

ni'.M 1)1' MV KNOW l.r.lK . 1-, AM» lii'.i.ii,

JXJ

MEDICAL CERTIFICATE OF DEATH

iJAii-; »»!• i»i:\Tii ,, \

1 111 KI-HV i IRTII'V. That I atlL-iKlcl -Krca-^cl fnmi

(Yi-ai 1

i()0 H

that llaM sau h ,nix. u„ ^^. ^^^- ' I«P

an.l that .Uath nrmrrrd, .>n the date stated ahove. at ^'hi

M. The CAl^I" OF I»1-ATH ^s.

\< as

follows :

xv^

^ . f% TV --l V CS-

DrUA'PloN
CONTRir.l lOKV

\1 w^^A'w'VA^^-'^*^' •
)Vdrs MnNths

Pavs

Ho It IS

1)1 RATI* >N
(SIGNED)

) \ars

Mouths

Pavs

i\.

Hours
M.D.

OiM only for Ifispitdls, Institutions, Transients,

QprCIAL INFORMATI^.-

or ReTent Residents, and persons dy.nq away from home

Q

Former or ^ IN
Usual Residence <?^'^ v

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

^it'CUv^.

How lonq at
Pjare of Death ?

Days

riACK Ol^ m KIAI, ^^R KKMOVAI

DAri". <^f lU HiAi, or KKMOVAI.

—i^—^— ^^■^■■^^■'^^■""'"''""** . EXACTLY PHYSICIANS should

.,„„ .hould b. c.r.fully .uppll.<l. Jf^^-XilL^'ci' 'xh. ■•Sp.c.ai l„for„,..lo„" for p.r-
TH In plain t.rn... that It may ."'f"''"^'*

N. B.<— Bvery Item of Infofma

state CAUSE OF DEATH In plain ierm«, *"»» - . ^..-^e

nfin. dying away from home should be ftWen In .very Inst.

» I

« t

J . I

f-

I I

'T r

hi

J i

w

RITE PLAINLY WITH UNFADING INK

■ \- I V

H/tl' <■

/////^ Fih'fl ,

'^.c'sXAj

//>'<^>H

THIS IS A PERMANENT RECORD

RCFER TO BACK OF CEBTIFICATE FOR INSTRUCTIONS

c^i s! ('I'Ofl *A^^

^^^ju<^ 3^X/\>U

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco

Certificate of IDeatb

PLACE OF DEATH: — County of

City of

"V.

XX/>"^ CA.'QC'C

and V

No.

St.: -^ iJiSt., Dei. ,, .. ,NroRM*TidN \

(, ,, DI.TH OCCO««t[) IN « HOSPlt.l 0» l-STnuTION S VI

FULL NAME ^^

A

PERSONAL AND STATISTICAL PARTICULARS

i'« 11.' 'K '

^^A,

r. <>! iiiK III

M.tif

A«.K

•-!N 1 I M\KKn'!»

lUK IHl'I. \CV'

MEDICAL CERTIFICATE OF DEATH

11

iDcb

M

Dav)

rgox

(V«ar>

I Hi:!

n-nV C1;RTI1N, That I allcn.k-l .Icvasd from

!<y'

alive- ni

NAMK UF
FATIIKR

niK iiiiM.ArH

«H I AIIIKK
*^t iti or I'outitrv

\T \n»J,N NAM J-
<tl MnTIIKK

i'.iRrm'r,A(!',

MF MoTHHK
(StHtt I ir I'liuut I \

' >Ci ri'ATION

AV */>//•,/ in Situ /

TMl'. AHOVK sr \ri-l) 1'HR-.'»N \I.

iu«:s'r <>i- MY K NOW 1, 1.1 >».»•: \

,-NKrirt!,AKSARKTRrK
N!> I!i:i,lHH

(Illfn

L^a-X^r-r

that I last ^au h

.,ih1 that .li-ath ..crurred, on tin ..au

M. The C.\rSH OF DHATH wa^ as follows

1<)0

I )r RAT ION J''"'

C( .N ri<ii!i r<»KV

.1/.

fhiv

J/otif s

nrRATinN ^

fhiv

I lout s

M.D.

4^

(SIGNED)

-^ii^I^TTi^^^^^-^'ON only for Hospitals, Insni.tio.. rra.,e„K

orfeTeSlesfde'-nls; and persons dying a.ay from home.

How long at
Place of Death ?

I).\JK<.t H< HSAi. ..r RI-MnVAI,
0

N. B.-

r'

r j
I t

I .

k.y

I '

m

WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD

Jl<iiitc! of I?

! \

1:>V1' (*..

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

/>afr /•VA'^/.UcirU-Uv 1

"^

ft

ifnj^

Be^i'S/crcfl JS^o.

S258

DEPARTMENT OF PUBLIC HEALTH=Cit) and County of San Francisco

Cevtiticate of IDcatb

PLACE OF DEATH: — County of <X^

V

City of 'J CUw ^hJXn^^^ -^

No.

^- a.L' . St.; 10 Dist.;b€t. JCL'>X<v4U-Vs and 1 '

(ir OtATH OCCURS «W»Y FROM USUAL R E S I DE NCE Gl VE facts called fOR UNDER ' SPtCI*i INFORMATION \
IF DEATH OCCURRED IN A MOSRtTAt OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. /

FULL NAME

\w >*_ F

1 ^

PERSONAL AND STATISTICAL PARTICULARS

MEDICAL CERTIFICATE OF DEATH

DATK <»F DKAl H

V

- •>- ' N . "^

v.L

DATl-; t

1 1:IK11I

I

f

Nf.

\0^,

\«,1-

^I^«,I,K MAKKIKIi

niHTm>f, \.'K

(Stn1»- ,,. I ,,ntitrv

r>

ko.

1 HHRHHV C1;RTIFV. That f .'"•-.-!..! -k. . .»,,,! fr-.m

tliat I la'-t '>aw h •■• liisf 'Ui - Kfj

aiiil that dcaUl 1 1«( u rrfl, 'iii \hv •. ■ Lafiil ahfiV«*, at b

..Mi

M. Tlic CAT^i; (»| Ii)-..\Tlf ua^ a- follnv

s ^

v^l

K O

NA\fI 1)1

I- AT in; K

lUH llll'I. \< K

in • • -ill''

»•! MdTHI-.R

JHk rHIM.ACK
'»> MoTlIKH

ll

f

iC /V^x _ _'

■u

r-s

s ■ 1

X

i\

CnNTRIIirTDKV

I)IR.\TI(»N

Signed >

fUJUxx L-

"V

wo

AJ 1 I KjO

Day

/fours

/>

\J w \Ji W W,

//nui ^

M.D.

A.Mn^~

Special information m') '^r Hos^IUIs, Insntulions, Trais»»fs,
or Recent Residenh, and persons dvini •i*^) 'fo^ home.

II'ATION />p

) I n I

I'HK ah«jvk sr xTKii PH K -ox V j, I- \ H rr f- 1, \ R - s R I iH I J. J ' » Jin;

IJKST OF MS' KNOW I.I, Ii<,K AMi i!i,i,n;i-

Former or
Isual Residewf

When ¥>i% disease (mUmM,
If not at ^i(t of death ?

Il«« lonq at
Hire of Death ?

0a*s

'I Af i; oF^ ju' R r ^f, ow

fill f. -mam

M Sin, u<x.

Ii\TK .f H'hiAi, or kKMo\ \|,
^^^-"^ '^ I90H

^^

e .. fl . , . .. , , I. s ii„ ...„»is^rl \nB «hr>uld be fftated EXACTLY. PHYSICIANS «ftoiild

Bvery item of informntion shouliJ ht- cfirefully nupplieU. ^'«o mn ,u,u -...,„ . , , a .. ,♦ #

•teU CAUSE OF DEATH In plHJn term., that it m«> be properly cl—.».ed. The Spec.l Information for pmr-

state U/%U»t: Uh IJt A I n In pi

«*>fi« dyln^ away from home nhould be ^iven in mvmry Instance.

I

S

^J?l^]

m

i!

WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD

• ^ ' ■ HertR TO BACK OF CERTIPICATC FOR INSTRUCTIONS

fhffr Fi/rf/, L'ct^l^ ■ ^

7^(9-

Deputy Heallh Officer

//■

/ Xo,

mm

DEPARTMENT OF PUBLIC HEALTH-City and County of San Francisco

f

Certificate of Death

II

X\. S. 5t^n^nrO

/>

PLACE OF DEATH: — County of

City f){

ft

No. ^ H ^ ^

St.:

Dist.i het

u

f f

and

^ t /

(

ir DitTH occups •w¥*v rnom USUAL R E S I DE NCE &i vr racTS CALtro roR UNotn

tr Dt»TM OCCURnCO in * MOSPITHL or institution GlVt ITS NAME INSTrAO or «;

FULL NAME

IC Mu L

PERSONAL AND STATISTICAL PARTICULARS

i i If I iM \

<

MEDICAL CERTIFICATE OF DEATH

I r

I III R I !'

I in II s. I

K . f

A

^D\

n

II >\'i '_ 1 1

fQoH

.\ , IT I

-vi] from

I(;'i

\^\^ ^T flu I A' -I < >r hi \TII

* ■'l .^

N

I- \ III I-.K

I'lK iin'i,\t-K

>nR riii'F, \* |.'
'•t M«>'i'ni-k

nr RATION

/)

^^^

n V

/A'ur<

Xaj\

S I

A

/l7\

(V:

(Signed ^ V'u^xl.<^^^

M.D.

Special information ©"'y '"^ Hospitals, institutions, rranslfnts,
or Rfcent Residents, and persons dylnq mi) from tiome.

H'C !

! « > N

'> 6w. ' 'I"

M.nit],^

IhlVf

rni \m>VJ* ST\ i in I'KKSnSAI, PARTIOri.ARS ARi; TRIK To TIlK

'n:sT oi Mv K \< t\\i.i;i)c;K AND nHi,n:K

Pormer or
Isual Residence

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

HoK lonq at
Plate of Death ?

Dan

Unr,

>nnrni1

III KiAf If K KMi »\' Al,
TQOH

Uob IX

PLACl-: OI- niRIAI. OR RICMOVAI.

(to OLxs^

rNDKRTAKKR AD . 0^ O AjJfXf^ W. kL .

(Address

•^^ B.— Rvepy Item of Information should be car
dtnte CAUSE OF DEATH In plnln term*
nonm dying away Immii home should be given In every Instance.

,. , %nR -hould bo stated EXACTLY. PHYSICIANS ehMilrf

efully supplied. ACih •nouin "« "*" i«#«„«.»|«„»' •„,. «■>.

thflt It mi.v be ppopeHy classHied. The Special Information for prnw

h^ '

f^

^

r"
^

' I I

I

WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

\b\j^^ ksu^>u Deputy H ^h Officer

Bc^istered J\'*o,

i3260

DEPARTMENT OF PUBLIC HEALTH=Clty and County of San Francisco

Certificate of E)eath

PLACE OF DEATH: — County of

^

No. 1 i 1 1 A^LCLVixc

1)

City ofUO^/^X- v),^CU->\.a^.4.c i

s ",^

St.; 1 Dlst.; bet.vJU\.^a.(luj<X.lL and U XX" ^

(ir DEATH occun9'«w*y rnoM USUAL RES I DENCE give facts called for under "special u nformation" \ ii

IF DEATH OCCUr^RCO IN A HOSPITAL OH INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / U

FULL NAME

\ I

I

n

PERSONAL AND STATISTICAL PARTICULARS

.i;\ (TN

ri »!,< iR

' ■'' I 1 111 IIIHIJI

\«.H

^l-.titli

MEDICAL CERTIFICATE OF DEATH

DA 11-; (tl I)1:A ill : "^

'Month) I)av)

igo .

(Year)

■^IN<.I,l-: M\RkIl.;i»
WllKiw HI, uH I»IV«)Ri Hf)

W 1 Uf ill V,,,.,;

HIRTMI'I.At'i:

' Htiitf fir I'lMi lit r \

H^li'lian. lU )

^

A

J L>\u'

I HI',ki:i:\' CIRTri'-N', That I atteii»lc<l ilercasvd from

up i fn "^ * l(p

ali\c nil V- V- \.'

tliat I last saw li ^ alive fui V. v- k; Iw I90 I

ami that <Uath .'((nrrcii, nti tlu' daii- stattd aliovc, at 1 0
M The- C \I si: Ol' I)1;ATH was as follows

J M. Tlu- C^\I SK oi- I>»--)J

N \N!r III
I NTH IK

lilKTlll'i. \(F

'•I I X ihi:k

LLrd,

'S|:l!,

<'. (.iiuntiv

<il MoTllllK

'•■IkTHiM.Al'K
oi' MoTllKR
'St.ttr ,)r Cuiiiiiry)

OClfl' \| I()\-

dto

DI'kA'i'ION }'tiirs

CONTKlin'TOKV

Miniths H Pay!s Hours

[)lou

h

.^f\XiA/>

VC

cars

7s

^^onths

Pays

(SIGNED ) A. dJ, hD

I <XC\^a a-t-^-^-k-Aj

Hours
IVI.D.

SPECIAL Information on'y for Hospitals, Instltutlotis, Transients,
or Recent Residents, and persons dying away from home.

Kr^iitfil ni Sifii /'nniiiuit | )',i!is O ^f'Hiffis I [ ^

hiv.

Former or
Usual Residence

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

How lonq at
Place of Death ?

Days

Till.; AH0VH.STATi:i> PKKSOXAI, PXHTfOr r.AKS AKi: TKIK TO TIIH
HHST OI' MV KN(>\VIj;i)C,K AND HHI.IltK

1»I ACK DI- inKIAF. OK RKMoVAI

Si ■

,cuLco^ >v

DATi; of Ht wiAL or RKMoVAI,

(Arid

re«s

y TT ArF -hould be stated EXACTLY. PHYSICIANS should

? Inffoi*matlon .hould be cnrefully supplied. ^^^* ^l-.-ifled. The "Special Information" for pmr-
OF DEATH In plain term., that It may be properly Uassitiea. P^

N. B.— — Rvery Item of

•tate CAUSE „. _„ ^

«on» dylnft away from home should be given in every instance

I '

I *

I !

♦ « .

t»

II
si

WRITE PLAINLY WITH UNFADING INK-— THIS IS A PERMANENT RECORD

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

Hnat ' f II. ;ilth I- Vo. i ■: '^'^.^J^b H& P (

Ihf/r Filed , \,xXjA>^i>^ \'X

lOO'i

Bi'iiisli'rcil JS/*<),

2261

^ I

DEPARTMENT OF PUBLIC nEALTH=Citv and County of San Francisco

Certificate of IDeatb

I "a. 5. StanDarC^ i

\ v.

PLACE OF DEATH: — County of' 'Ct->v 0 . -u
fNe. VAiA^ ^L-<3\AmXu O^^AKa.' ' St.; ^ Dist.; bet

/ ir DEATH occuBd^*w*v FROM USUAL R E S I D E N C E G I V E facts CALLE

IRRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME

%

City of i<X'^^'^*VO

and

* / IF DEATH OCCURgJAWAV FROM USUAL R E S I D E N C E G I V E FACTS CALLED FOR UNDER -SPECIAL INFORMATION \
' V IF DEATH OCCUR"*-" '" » MneoiT.i no INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. /

FULL NAME M LCLl

PERSONAL AND STATISTICAL PARTICULARS

--l.\

I'Aii; oi- HiRTn

CoKoK \

1

\x

MEDICAL CERTIFICATE OF DEATH

DATi; <)i i)i;\rii

M.Mltll

I ri\

TOO I

iNTotilh)

\«,K

5 b y,a,

(Day)

'^l.inth^

\ far,

/'.n.

'^IM.I.l- M.\RI<U:i)
WIDoUl.l) OR I>IV()Kij;i)
'Writtiii siKJaJ (UNi).^nalii)ii)

luK rin'i,.ACK

st.'itt or Cnuiitry

NAMK n|-
I All IK R

lUKTIirM.xrK

'^t.iti lit t'oufiti y)

maii)i:n namh

<»l .MOTIIHR

I'.IRTHIM.ACK

<'«■■ MiirilHR
'Stati' or i'i)untr\

i Hi{i<i;nN' cm;i<tii'v. That i atti-ii-Uii <ii<

190 \

. alivf on

I i i ,-^\

that I last saw h . .

and tli.at <katli orcurrcMl, mi tlie .lat.- stati <I

,1111 i\i', a

I(j<>

t b .

t f 'III

.M. Tlu- CAl'SI-; < M" IM ATII wa- as fnllou

*. ' I -\ •<

hwX ^t

.1/1 ';//// s

1)1 K.\i"i<)N y^v^ -^k:

C ( ) N T K 1 1 5 1 "f ( ) R V \J(^i^^'^^ ' <^A.k.

O-K^^W^

l)a\

11 out V

(}Ul

Dl-RATroN

rD

^4A^

(SIGNED)

>;wjy Months

/>,nv

ffoiil V

M.D.

,\.l(lrfss) CcIm gwO-^|V^^^^^

< K"

V$^X>(X^cJ'=UC. >->-A.* '

h'f.^nifil in Smi l-'i mu i-rn .*S0 5''"'

M.,„t/r

I hi

SPECIAL INFORMATION onlv lor HiftpildK InsfituHons. Translfiits,
or Recent Residents, and persons dying dv*d) trom home.

Tin-; ABOVK STA'n:i) I'KKSONAI. I'AKTHri.AK

HKsT ()i- ?,iv KN<»\vi,i:i)c. K AM) nin.ii'.i'

(Infnnnant \J . VJ. UU . ULCC^ t.

Rs Aki-; TKI !•: TO Tin-

fA.ldrtvss

A^xXu

\

^iA)r\^JjxX

or KClcni noiucnn, ohm ,»i.j"" • -/-i -• -,

Wlien was disease ronfrarted,

If not at place of death? _^

rj^ACI-; n|- lUKlAI^ nk k !■:%!< >\M

D

la^N

nAXH'if mwiM (IT RKM«nAi.

1 0<> i

S'tt 1^

/UU'i'^^

'■■^■■'^^■■■■■'^^■^■^■^^"■■■■■'■■^^■■'^"■^■'■^■^"■^^^^^*^'"^"^^^^ ... . . I r-vArTI V PHYSICIANS nhould

y !• ^ ATF should be stiiteu I.,xav*il.»' »-n 1 «^iwi

IM. B. Every Item of Information •houlcl be carefully supplied. /* * classified. The 'Speclai Informalion' for pmr-

state CAUSE OF DEATH In plain terms, that It miiy be pi-op
son. dying away from home should be i^iven in •s^ry instance.

in

I'

I.

;l

^

n,

WRITE PLAINLY WITH UNFADING INK

H.

V

^

1 I

i I I

THIS IS A PERMANENT RECORD

REFER TO BACK OF CERTIFICATC FOR INSTRUCTI0N3

-V -^

DEPARTMENT OF PUBLIC HEALTH-Citv and Countv of San Francisco

Certificate of E>catl:

13. B. 5t.1nDar^

-*-N

PLACE OF DEATH: — County of

C

No.

(

"- ' --' St.: " Di£t.;bet.

'r DE»Tw occurs «yv»v FROM USUAL RESIDENCE i .r t*-Ts c«.^

IF DCATH OCCURRED IN A MOSPitAI. 0« INS' "-' ;

FULL NAME

-s NAME

S 5 ' r i

PERSONAL AND STATISTICAL PARTICULARS

MEDiCAL CERTlFiCATE OF DEATH

i Tt

n

4 I

a

// .

i Kk

^ \

M<»T!n:k

0-\xX -

Signed

M.D.

'■!'!. \ I K

ir\

SPECIAL INFORMATION ^' • i^r H«^f*

' ^ . .1 »;

'UK AWiVK sT\ THr. i'KR-,<,v i
HK'«T OF MA KN.iU i.j.i,, ,j..

\H 1 1 1 ! r » k -•
■> lu i,;i f

'4^ K N.iW

'.■■- 5.11 J xA

Htmn m

If i«t if ^f #1 <f#ll :

«• «^f$.

M%

\XX>VuCX

N. H..

-Rvery Item of Information •hould be .«»-efully supplied. A»JR «H .jI.I b« .t.ted EXACTLY. PM^.SIwl4SS •^•Id
•tate CAUSE OP DEATH In pinin term., th.t It may be prr,pcrl> .l»««ified. Tfie "Spe.i.l Inform.i.on ' for p«r.
wn^nt dying away from home nhould be gUen In •v«ry Instance.

It

♦ .

I
f

It II

II

I

nt\

WRITE PLAINLY WITH UNFADING INK— -THIS IS A PERMANENT RECORD

ll.,illh )■ V.

■=r^ 1$& P Co

REPER TO BACK OP CERTIFICATE POR INSTRUCTIONS

i

Deputy Health Officer

RegisfrrP(( ,X(}.

J^263

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco

PLACE OF DEATH: — County of

Certificate of Death

' ' ^ ^ City of C3tcrCivtt ..

o^a^\!

fNo.

St.; -

(ir DC«TH OCCURS *w«v rnoM USUAL RESIDENCE gi
IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION

r

FULL NAME lc<

Dist.; l^t.

and

IVE FACTS CALLED rOR UNDER -. . t /. ^ .NroRMATION J
GIVE ITS NAME INSTEAD Or STREFT AND NUMBER. /

PERSONAL AND STATISTICAL PARTICULARS

'

ft

>1,<>R \

KAII.; (>|- HIKTU

^

I Month)

\<-i:

la

LI

i>.i\

V,.>///f.

MEDICAL CERTIFICATE OF DEATH

/^

iliayl

44/4)

I nKkKHV I

\\\. Tin-

!c(i ili-ii a'-.i M III ii;

I.

Ih

''IN'U.K MAKKIHI)

wirHnM-.i) OR inxuRCKr)

lUKTiU'r.Aci-;

sfati or !•, Militia

X

that I last saw h : alur dii

and that (U-alh nca iirrcil, 'MI the il,i' ' •. ' •' . it

M. Thf CAISI-: or |ii:\lll na-. a- f'.;! u^

It/t)

N \Ml. ni-
! AllllCR

fUkTIIPi.ACK
'»• I AlIIKk
"^tatt or Coiiiiti V

ma!i>i:n; nami.-
<>i- Morin-.K

»nk rirPLAi-K

"I MnTll|.;R'
'Mat.- or i'outiti\

L >\ ^

H

r ^

Dik A ri< >N

c(t.\ iRiinTokV

/>r/M

//,'

%

IJIR ATION
(SIGNED )

ll'ct It

Mrnths

UO LI. Jxl

n

M.D.

I()n

\(i(l i< -.- 1

iMiVXt ,.

SPECIAL Information •">'* •"'^ HiKpiyK. insiitufions, TNnsifnh,

or Rftenf Residents, dnd persons dvini) hhhv Irorn home.

) Vi7 ;

M.uitlt-

former or
llsudi Residenre

When was dKea'se ronfrafted,
II not at plaf e ol death ?

How lonq at
Plat e ol Of Jth ?

OdV'

I'm; AHuvK sTATi; I) fKRsuN \i i-\kiii I I \Ks AH i: TKi i: r<> iii»-.
'shsr oi- Mv KN<>ui,|.;iK.j., AND HI i,n;t-

I

''"•"'-nnaut CTYULu KJUY^XATV^OJj A\-tH

1

i I

I'l.AiK <>

I lit K I \!, ok kKM«»\AI. I l>V*U:"' HiKiu of KKMnVAl

f \<Mr.ss

^11

t NIiKKTAKKk W. U , U

(A.j.li. ss I I 6 I '

V^..

IQO

)A,\_

S.^*i,\-<J 'ik

1. I %rF should be «m»eJ »-^^^TLY. PHYSICIANS should
f Informntlon .houlcl H. cret'uily supplied. '^ '*':";""'. ^,,^j. The "Hp^.W IntormMiion- »'or pT-
OF DEATH In pliiln tefm., that It miiy he properly Uassmeu.

^' B.— Every Item of

•tate CAUSE or- ur,A in in p

«Ofi« dying away from home «hmild be ftlven In every Inntance.

'I

¥.

' N1

« 11

s

II. .Mtl! 1- X<

•.-- -S- ^; i;Sc\' C

WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

/hffr Iu/ef/,Vxtc{>-<^ 11 lf)0\ Jn'^jis/rrr,/ ^^n, 22Q4:

dvtrvcv^ 6<Xa/^ Deputy HeaJth Officer

DEPARTflENT # PUBLIC HEALTH-City and County of San Francisco

Certificate of Scatb

PLACE OF DEATH: — County of Oa^^, j\

■^

City of CV^Vi \0.

r%

No.

wCicLu St.; Dist.: bet. J a u and )

(ir ecATM OCCURS away from USUAL RESIDENCE give facts called fob u|Ioe« special iNFORMATiit
IF DC«|TM OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEmI) OF STREET AND N U V B E l|

f >

" )

FULL NAME Vtldc'r

c

I \

'-KX

i»A ri; I u luRTii

xi -i:

PERSONAL AND STATISTICAL PARTICULARS

I

i

■^

MEDICAL CERTIFICATE OF DEATH

I) \

n

M'.!!th

>v,.

M.'Ulhs I dl

wu

' X\ I itc in ^-icia! <It--ivniit'.)ii)

■^tati or < .nlIltl^•

^ \ M 1 1 1 1
I VI Hi; K

li'I'THI'l.ArF

'" ! \riii.:k

>t.iii ,1 C.nintiv

^' \nn.;N' N \\\Y
<»i ^f<»TIl^;K

"iRrmM, \( |-
<>> Mt)rii,..u

' "-triti or L'liiinti v»

K.y\.

; iii'R I i;\ v'i;r rii'W Tii

tlia; [ i,

an<l tli:i1 .U If h . , . - I. on tin- ■:
M. IIk- CAI SI-; c »i hi A

r I, ,,. I

t I ( ,1NI',| f I I 1|I|

I..',

y^

Dl RATHiX )

L < >NTkimT<>kV

/',/!

n,'h

U

0 OXAXX/^^nJL''^'\Xo

1 1 r R A r I < ) N
I SIGNED )

.l^'vM

Pax

%

KjO

1 ,^

- I O 1 u

M.D.

A.lili

Special INTORMATION onl^ tor Hiispitdls, Intfitutions, ffdnsienls,
or Rcffnt Resident, and prrsons dMni J^'i^ 'f'" ^'™'"'

),,//

/),n

in; Auov!.: ST All- D I'KKsoNAi, I'XK riici \Ks AK1-: rKii* Ti> riii-;
lU'.srui' Mv KN<)\vi.i;i)(; H ANj) ini.n.t'

fliifoiniMut

iD.%

Jt/C>t<r\)

Former or
Isual Residence

When v*js disease rontrarfed.
If not i\ plare of death '

HoH lonq at
Plrire of Dfdfh ?

Da\s

f N'Micss

X\\ t

cL/cLu Q

^t,

PI \(.'F or HI KIAI, iiH KKMttVXI. I i)\T

1 M(»\ \l,

roo t

N M c . ^ .. . 4rp -hr>,il.l he stated RXACTLY. PHYSICIANS iihould

N. H._hvepy Item of Informntlon .hould be cerafully supplied. ^^^^ •;"! 'j'^.^^^s";?*^,,.. "Specl.l Inform.., i.n" ,or pT-
■tBte CAUSE OF DliATH In pinin terms, thnt It mi.> He pi-opeHy vlaiisitieu. k*

won* dying away from home nhould he given In «v«p> Instance.

« ♦

♦ «

,«

H»

i

WRITE PLAINLY WITH UNFADING INK — THIS IS A PERIVIANENT RECORD

.rii.i'ih I- No. I', ■?*5:SK'3feH^i' c

Ih

(/(' F/7('ff,\J /zt<Aj^Jihj 11

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

—————— —^ — —

lOOH,

Bc^i.stcrrfl JVo,

h^^^

VXA^

\>U

DEPARTMENT OF PUBLIC HEALTH-City and County of San Francisco

Certificate of Beatb

XX. S. StanOarD )

N

^

PLACE OF DEATH; — County of

Op ;i

■^

A %

oav v'A a

City of ^ J CL

ft

St.; S Dist.;bet. IH th

and

l:i U'l:

(IF OCATH OCCURS AWAY rHOM USUAL RESIDENCE give facts CAUUCD roR UNDER SPECIAL INFORMATION \
IF DCATH OCCURRED IN A HOSPITAL OH INSTITUTION GIVt ITS NAME INSTtAO CF STREfT AND NUMBER. /

FULL NAME

.tfVj

JL- )

xy\.Q.)\

PERSONAL AND STATISTICAL PARTICULARS

-IS

^

i»\ 1 1: I II- lUkTii

A'.l-

ciii.i Ik

llJrvct..

MEDICAL CERTIFICATE OF DEATH

Ii.\'l'K Ml- UK ATI!

■ +

^INi'.I.l-: MARUIKU

\V!i!,. ;,, ^,„ ,,,] ,1, >,ij.r.)ati<(n)

Iiav

^/.,ll'/,

ISIRTHPI.ACK

N\Mi-; «)i.

I'lH IHI'I.ACK
'•I I- A II IKK
'^tal. or l*.)Ulitiy

M\ll»i;\ VAMF
<M' Ml III UK

iHKrHi'r.ACH

' '^tnti 1,1 Cnunti \ !
•'*''>I'ATI()N-

I

'^'YV^

y

i

that

I II I* k Hl;\ ilk 111 \\ rii

II

'V. :lf 1

^1 ll I [I ifll

IijT) H

a^i ^:i\V ii ^

1 \ I- I III

ailil that ihatli < icciirri-il, "ii tlii
V) M. Tllr C>^ SI- <M IM \ III u

I.,.

X

O %VU

Os^i)

Wy\j

I 'i \ I

Di i< \ri'>N

tow J^ ^

.JA

/hi

l!nu,s

Ci

'oN'l'Kliii !( iKS

L

■^f^^

^ 1 V ^

;>.^ .*w

(!ijL>..k

?

"... ll^ )n

(SIGNED)

IhjV

I on

M.D.

SPECIAL Information o"'* •••'^ Hospitals, institutions, TransifBfs,
or Recent Residents, and persons dving a^»dy trom home.

Hfsiilf,f i„ Sitn /'itiHiisfn \^ )'iin <

.V.

!h.

rin-; aijovk stai'iu) phrsovai. rxK'ncr!. \rs ak j: pki i: t«> thh

Hl-.ST OI- Mv KNOWIJIDC.K AND HKi.Ii;!-

Former or
Usual Residence

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

HoM lonq at
n«re if Jeath ?

Oav^

nnfoituant

on^ d

o-^-oi-i

£.->

A-i.ln-ss

I'^^S. Ic^l^.^^^v'^t

I-, ACK OF in KIAI. ViK KKMiiVAI. 1 Ii\TH.»f B- nial ,.i KhMnVM,

NDHKTAKKR UW- ' --^^ '

TOO I

(All.

ii 0 ^

A.A.,<iA^<i^ »u jt;

^ « ^ ,. J ArF -hnuld he -tated EXACTLY. PHY8ICIAINS •hould

N. B. Every Item of Information .hould be carefully .upplied. AUD mn i ^ ••8o«cl«l lnfopm»tlan'' for p«p-

•tate CAUSE OF DEATH In plain term., that It may be properly .laM.fled. i»e pe
•on« dying away from home should be ftlven In every Instance.

i I

.ij

I

I '

I

II

It

^

WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

IfJO'i

Ki'ois/cf'cd J\*i),

206

2"^-

DEPARTItlENT ^ PUBLIC HEALTH-City and County of San Francisco

-\^^kJs

V\yM

Certificate of Bcatb

PLACE OF DEATH: — County oi\J<X^\j -1 ^ux >vcuiX^o City of ' JOu^v J

1 ^

uCh<i4X^

•La A.

(ir DEATH OCCubtS
IP DEATH OCCU

St.; -^

Dist.; bet.

and

S AWAy FROM USUAL RESIDENCE GIVE pacts called for under special INrnRM« .
RRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND N'IMm(u

)

FULL NAME

0

KOAXlM ul u

PERSONAL AND STATISTICAL PARTICULARS

Aft roi.ok ^

^\

MEDICAL CERTIFICATE OF DEATH

I)\

i 1 i ol lilK IH

Moiith I

I> .'

.11

I in-.Rf-;iJ\'

^•t

M

^ ( r,„,

T ,

^!"^<^I,K. MAKKIKIJ

u iDoWKij OR nrv(»Kri-.i)

Writ

t ■ 1 !

1 »;'M-i:«l >It "•ik'natiDu)

lURTHPI.ACH
State or Coinitrv

f'lKTtll'I.ArK
'•' ''ATHKR

MAIDllN NAM}
<>I- Mf)TnKR

U^>xmjL;

I'/

that I

iW II

li (

X'Yv>^4.ul^\KTb">'v

^■u:

\

-^'y-^

"''I'ATKiN '^ a

QD

all"! tli.i' ih- ii:;

i»rK.\Tr<»\
^SIGNED

4.^ U r»oH 'A.M

//

xjX/'vx^

M.D.

SPECIAL INTORMATION »"'> for Hnspitdls, InstityliMs.
or Recent ReMdenfs. and person^ d)inq dv»dv froii home.

Ho* lonq at
. ' Plaf e ol Of jfli ?

"S

J Vij I

1/

I "'^ ^Ho^'K sT KTI-I) I•KK>^ONAI. I'A K f li" r f,A R -^ ARK rkri;

Jsi.^r oi- MY KN-owi,i:r)r,H AND m.i.n::-

n

Former or

tsual Rfsidenre - - "^ '

Hhen *a<i disease ronfracfed,
II not If N«"f •'***•

Fransieifs.

Dj*'

nmt

H)

Addre "

'XlH LdLdU^

A

•I. A'"i; ' M

HT KIAr, < K

A^,

rNlJKKT\KHK

11^ -CX) iX

TQoH

IP

Ac.

. • I I twi t t d EXACTLY. PHYSICIA^H nhoulii

' • ^' Rvery item of information should be ciirefully supplied. ^^'f' ^ '-^ ' " ^^ •'.SjK-.ial InionnHl. .n ' i«.r p«r-

state CAUSE OF DEATH in plfiin term., that it may be properly dasume .
«on» dyinft away from home should be ^iven In «*er> Instance.

I )

f

i >
1 I

. I

I '

II

n •

I

H

i

¥

II

WRITE PLAINLY WITH UNFADING INK

H. i!lh i Vo, 1^ t'T-'aP'^ USil' 0

/>///.' /v/r./, ilJ cXxrlv^X' la

THIS IS A PERMANENT RECORD

REFER TO BACK OF CERTIFICATE: FOR INSTRUCTIONS

Ifnj'i

Jf('oi.sff'f'pf7 ^\v>.

-32G7

Cruc^^i Jo^v^^i Deputy f iealth QfTicer

DEPARTMENT OF PUBLIC HEALTIl=City and County of San Francisco

Gcitificate of Scatb

rA

'I

!>

\

PLACE OF DEATH: — County oi'-'CL'W- ' VCo vcucCity of 'a \\ J\a i

1 Qi^;

\ '" » ,

No. Sj cLcckXo

\

St.

- Dist.; bet.

and

(ir DEATH OCCURS *WAV TROM USUAL RESIDENCE GIVF FACTS CAi i R UNDER SPECIAL INFORMATION \

IF DCATM OCCURRCD IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD Of STRCTT AND NUMBER. /

FULL NAME

.,., -w\

PERSONAL AND STATISTICAL PARTICULARS

l\ C<>I,i>K ^

LI : ''

'! ink in

M.itith:

I Dav

MEDICAL CERTIFICATE OF DEATH

I) \ rj' I ij- IU-: Mil "^

1 jij{ui:nv ^ I i< riis'. i ii . ' • ' ' '•

\'.i-

1

I

" ' ' '• '\vi;i» (»K i)t\< iRi'i-;!)

■I -'ici:il iI. >.is_'!lati.iu)

0

"'it' "! i'.illllt! V

^ 1 in-.K

lUR llll'i, xi'K
-!;il< or ruuntiv

NfMI.i;\ NAM,.- r\

"' M'>Tni.:k I

\if)

that r la^t -.iw Ii
and that ikatli .■

re' • •" ♦ lit- 'latr -tati

at

'^

M. TIu- CM Sl^»l l»i;.\TI( -V

-^

I K

I. V \. <. k._^

VCM_^X^

n

'•'K r HIM. AC J-

«i| motiikk'

^tati ,,r CouiitTV

nrk.iTioN

CONTKIIUTORV

/»

//.

) V(//

,0 ^/D\

(Signed )\jf\(nnjXj

M ■nt>

iiE.IoIlU

/ ) r,

>viL

M.D.

"UUYU

.. t-

iqo

i \.\Axv^^\ LC vCnVlVfi V .

nnl^ lor Hospifrfls Institurtohs, FranMenls,

r

-hXX.O.

) 'rtJ I

M,.„ih'

I hi

SPECIAL INFORMATION

or Recent Residents, dnd persons d)ing dHdv from fiome.

.1 I Ho* \m% at

Former or
Usual Residence

Oivs

When H3S disease contracted,
If not at place of deatti ?

I Hi; .\H()VF. sTAri:n i-kksonai, p\K'rrrrr,AKs arj: iKti-: to thh
I'l'.hr oi. MY KNir^x i.i;ih;k and B};i,n:F

fliif.irniant

I'l.ACK OI- HrKfAi. OK Hl■^!<<\ \:

il'at

ai I'. \i.

A^4,W& >v

N. B.— Every Item o?

•tate CAUSE OF
sons dying^ away

tnte.l f.X4CTI.V, PHYSIwlANH should

,.»■ i«i^... :,.l Int'.ir-rnMt ion" tfctr D*!*-

r , u;f.sh-H,lclheM«t..lf.X4CTI.V. PHY.S.w. a >- sno„

Information should bo carclfuily Rupplieil. ^«"' ,„..u'|-d The "Spcwiiil Inl'ormatim »or p.

OF DEATH in plain term., that It m.-y He properly .l—.Hcd.
ay ?rom home should he ftlven In es^ry instance.

I i

#

If

WRITE PLAINLY WITH UNFADING INK

iK :.lth r Nn^ \-. ■{•

.**.r>

;^#j ]ISl\' Co

/>.//.' /vAv/, tlctJ^L'

THIS IS A PERMANENT RECORD

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

hj la

IfJOH^

Begistf/f'r/ Xn,

oo

08

'^^US

. Deputy He

DEPARTMENT OF PUBLIC HEALTtKitj and County of San Francisco

Certificate of Scatb

,)

PLACE OF DEATH: — County oiOcLrv

No. T QlH Uxxc-^^CX. , .

City of -'XX>v Ac

(

Dist.j bet.

ir DEATH OCCURS AWAV FROM USUAL R E S I D E N C E G I V C FACTS CALLED TOR UnJeB "SPECIAL INFORMAT
ir OC*TH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBE

Xc^v<rv\A'

and

ION
R

0

FULL NAME

V. i

PERSONAL AND STATISTICAL PARTICULARS

~ I \

Ji

Col.nk A

0..t

M..iith>

I)av

\<.H

MEDICAL CERTIFICATE OF DEATH

DA 1 ) . ill- 1)1 . %i II

II

u

?

5 .a

^IVt^l.K MARHIKI)

^^!it«in siK'iiti (ic^iiMiat i< 111)

J'.IHTm-i. \cv,

stall ,,r c, ,,,,,(,

» \ I li i;k

r.IHTIU'I.Ai'K
**'■ ! ArUHR
' "^t It' r,r ruuiitT V

^IMI»1:n NAM}-
•'1 MOTFIKK

'•-IHTHI'I.ACH
""■ MoTHKR
state .,r Countrv

L. '

A.>xci, CjyKjLt

thnt I

. I\V 11

Hill I hat ilralli < Hfii ricil, nii tin '

C

n

M. Tlii- CAISI-: nl' Id \ ill s

U/(x- ■ J y fr\

1)1 k ATM >N
CONTRII'I'IOKN'

M^'ii/i

//>un

0

3

y
P

i)rk.\Ti<»N
SIGNED)

^

),w/

M.'Ntll

/Kns

M.D.

r I jo

fA.l.In-

i t I ■

Special information ""I) '"f Hospitals. Institufions, TrdflslfBh.
or Recent Residents, and persons dUng dWd) Iron tiome.

Nam lonq at

PIdif ol Ofjtii? OiH

)>,7i

M..>,tl,

I '"■ >'';.>VK STATl-.r) PKKSONAl. !■ \ |< rrc I I, A H - ARi; TRfJ- To TIH-
»i'.-I Ol- MV KNUWMCDCH aM> I'.}.;i.I l.h

Former or
Usual Rpsidencf

WfiPfl »as disease rnnfraf ted,
If not at plare of death ?

flnfornifint

l^f.ACi; III H'

K ' \r, (iH K I;^tl '\ 'ii.

m ri;

M ; Kl Nfti\ \i.

Ton

A.M.. s. t) I ^ ' a <5.cH,o. -> > ^%xU I

^' **• Rvery Item of Inform

•tate CAUSE OF DEATH in p

,. , niT sMo il.l be «t»te«l f.XACTLV. PHYSICIANS piHouIcI
Btlon should He cnrefully supplie*!- ^ ' ' i„«.ifud The "Si»tfcl«l Informal im" I'ur p»r-

4TH In plain term., that it may he properly cl»«..».cU.

•on« dylnft away from home Hhoiiltl be ftiven in every instance.

. I

'993^'v!K^i9if

I

J

' » ♦

II,. Ml

'■^te nScV c

I)ff/r Filed ,

1

WRITE PLAINLY WITH UNFADING INK -THIS IS A PERMANENT RECORD

REFER TO BACK OF CERTIFICATE: FOR INSTRUCTIONS

Registered JS^),

n

13l

If) OH,

<^\A^

loi/

0059

^w*^'

DEPARTMENT OF PUBLIC HEALTH=Citj and County of San Francisco

Certificate of H)eatb

( tl. S. Standard

%.

PLACE OF DEATH: — County of C a

n

"No,

U ^\tuu) G

^ City of 0 Ct IV J \ o

and

( " "DtATH^Orr,ll»'^n'/''l'* ^^^*'- RESIDENCE G.VE FACTS CAtLCD rOR UNDER SPECIAL INFORMATION \
\ IF DEATH OCCUI^RCD IN ^ HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER )

FULL NAME

-LLLlOliyv

PERSONAL AND STATISTICAL PARTICULARS

l.IKTII I

iMotit !i

MEDICAL CERTIFICATE OF DEATH

I A

(II ill

' ' ''' '" -'-* ial .1. •-iiMialMii)

I iiI':r i;i:\' cikTirN . rii
\ip — — fi.

It I

"' ' ■iiMltiV

■^ \M)-: ni
I A III).; K

H I k I

'»i^ I
■^t it,

M > 11
I >\

III'I.ACH

N r H I-; k ■

' ' *^'i>iintrv

N N\M1,

lliat I l.f-t saw h

ali\ i- i>ti
and that dratll < (rciirrt'd, nii tfn

--111 frotn

•vv, at

d; OF i>i; \T

1- as (,

\\ '-

\ o

'-* -,

/^i/l s

J li'Uf \

?

^i')Tm.;K

•■ii'i'Hi-i.Ari'

"I \!i.T||,-k'
' '' ' "5 * ' mtiti v)

''■I'A'lluN

I lotlt s

M.D.

'•'.^1 (U MV lvNnW!j;i,.;H AM) nHI.IJ-F

I>1 RATION )r./;s M.'uths

C< >NTR Il:rT( tRV

DERATION ^ );./;v ^ ,1/ - '
(SIGNED) KjsVirs-sXK ' D V',

; —

Special information mI^ for HftspitdK, Instiluflinh, Frjnslfnh,
or Recent Residents, and wrsons dvinq mAs fro-n home.

former or ^ ^ r ♦ **"** '""'' *'

Isual Resldenre I UW g 5 , - PLne of Dedth? Din

When WIS disease fontrrirted,
If not at plare of deatli ?

IhiVK

A Wa

i'i,\( 1' 1)1 i;i kiAf, <»K ki:m<»v\i, | i»\n

J

,>l..^AA/

. . . lit KIAL t H I- M( i\ \I,

:xJkiAA^ A ' L t c <

\.i.i.r.. blH ^Bv<h:?^

Lo-

H

<\.icireH«. lUO UWV\A/Cr>% *JAJ -a.i.ii.s^ w ^ v -. . w-^w. ^.^

^_^___^__ ,. Li

-Kvery Item of Informntlon should he cwrefully nuppHed. UJB «hr.„ld Ho «tnte,l r.X4GTLY. PIIY.HICIANS should
•tate CAUSE OF DEATH ?n pliiin X^rm%, that It m«> be properly wl.Mlfled. The '•8,,L.i„l InmrmHllun" for p.r-
«on« dying away from home nhoutd he given In %\^ry Instance.

I

» .1

t

u\

1

■I

II

^111

' J III i

i

WRITE PLAINLY WITH UNFADING INK-THIS IS A PERMANENT RECORD

• "'' '^'^' WErSR TO BACK OF CgRTIFICATE FOR INSTRUCTIONS

If^OH

OQ^

^^70

\,M^

DEPARTMENT OF PUBLIC HEALTH-City and Connfy of San Francisco

Certificate of H)catb

^

T'

PLACE OF DEATH: — County of

City of

\, v-w

j^iXx^r St.; Dist.;bct.

r F DEATH OCCUBS AWAV FROM USUAL R E S I D E N C E G i V r FACTS CALLFD
\ ir DEATH OCCURRED IN A HOSPITAL OP INSTITUTION CltfC ITS NAME

ro A

and

)

V

FULL NAME

,d.

H

i-

PERSONAL AND STATISTICAL PARTICULARS

MEDICAL CERTIFICATE OF DEATH

\l I

L^

Ml, I ' '.

u

M

\] <V I

' II F V J n c t I k ^<4 v_

~N

I lout s

1)1

\ 1 . \ )V<7;

Signed) ■

-\T

KX:

M.D.

r\ K

TuJUtuyvcI

% ,li Tc^H (A(l(1rtS'4)(nSl UgJ

L^ ,li

tCUt At

Special information only ''•■ Hospitals, ln<>tftutions Irdnsifnfs,
or Recent Residents jnd persons dyinq away from home.

na\.

'.I. SI ui MS KNuW 1,1 iH-.).; x\i;

Former or
Usual Residence

When wisdisfasp contrarfed,
If not at ^are of death ?

Now lonq at
Wife of Oralh ?

Oavs

) lU'l I I «

Fnf,

iii'int

^XXX.'^Mj ' H fVuUXA;

i»LACR oj- niRiAi, OK ki;m«>v \

DML. .' H! iM \

cru. L

i

^..fiHOA.

l&

TOOH

fAa.lrcs, 111 M1\4.44x^ 3i

., . Ar»B -kr».,l«l b« atated nx^CTLY. PHYSICIANS «liould
,...„., .h„„.,. .... .arc UM, .uppM.d *^«;J-^''„T^7'VHe S,.cl.l .„,-..,n„.,„„" r„. p.,-

1 iH in pliiin term«, that It n%9^ "« prwR^^ij'

N. II. Rvepy Item of In »,,,.„,

■tate CAU8R OF Dl:

"'»n« dying away fi-om homu Hhould be ftlven In •vary Instance

i

I;

11^

III

III

* i

1

M

*

WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD

REFER TO BACK OF CERTiriCATE FOR INSTRUCTIONS

l>,,.,,,i ' II, lit h I No I" *'^.'^\;''*^ n^i i

/)(//(' I'^ilcd ,

K.'

Deputy Health Officer

Registei rd JVo,

DEPARTMENT OF PUBLIC HEALTIi=City and County of San Francisco

Certificate of Beatb

I XX. S. StanDar^

r^

^u

PLACE OF DEATH: — County of a >\ \a^^

f 1

City ofU/tX'>v J ^ A '>vc^.c ^i

%

0

A' 1

N«. V^Clu '^ LtrVC^^vtu ^L . St.; Dist.:bet. 'and

( / ir DEATH OCCUR^»VW*¥ FROM USUAL R E S I D E N C E G I VE FACTS CALLED FOR UNDER SPECIAL INFORMATION '\
J \ ir DEATH OCCU|<RED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. J

y\

■\

FULL NAME

\ > ■

PERSONAL AND STATISTICAL PARTICULARS

^-\

I Ml .»K

»r liiKiii

^

k

Month)

MEDICAL CERTIFICATE OF DEATH

DA IK

!• !• i:i;\ I

nrx

ix

) ,„•

IC;

1/.

1 M \RI< Ii:!)
M I> « >R H!\-nRrKI>
' i'liatidii)

< 1

M;il» or I'oimt! V

A

H^l-^

A

lukTni'i.ACK
'•' i XrHKR
^^M' oT I'ountrv

<»i- M<>Tin-;k

'■'•< I'HI'r.AOK
"t MoTUHr'
^tit. ,„ ronntrv

Lcj\.'

i<

that I ia>,l saw ll ■ ' ntivi- on
and that .K.ilh orrurnMl, on the

; . \ •

I itts'itik'fl (ll I ' 1- I <1 fi'illl

ir.l al

M. The CM >!■; <>!' I>i;.\'ril u I- a-^ 0)11. iws

nrixATK >N

}'tdr

TU^LccUi

c

til

uJx,

i u

.Ow^r\ '^

~> \

CoNTRIin r(»KN
DrRATION _ ^''^''^

a,A.. , ...<^\

I lout s

Month'

/hiv

CL/Vy^^vOJ

^KlXjOuyx/L

(XjL<

<>Ccri'ATl()X/'0

(SIG

/CX

lu 'U o

TOO ( AiMrrss) ^^^H. ^^ "-

.L INFORMATION ••nl^ t"r IWspildK

iL'OA

/fi'Ut s

M.D.

Special —

or Rctfnt Residents, and persons d)inq dHa> from home.

Insfitutlons, Transienls.

\f,,i,tii'

Former or u a Q { f
Usual Residence ^^ ^ ^

When Has disease rontrarted.
If not at plare of deatfi ?

HoH loBfl at —

Plare of Deafli? I Days

'"I; M'.OVl-; srxii.i, I'KKSONAI, I'\KTI(t I.AKS AKI-; IRI K T< ) Till-:
i.l-.sl ul Mv KNuWil-DC K AM) III;M);i*

'l..fon„a„t U . \J . Kd. Clo^W

%crUL C^^^ ^ .

DXU-o! l!!Ni\i or KI:M<»\'XI,

©ct a looH

Y\,<5\J

^

• **• Rvery Item of information should be

state CAUSE OF DEATH in plain terms, that it may be properly
«on« dying away from home should be given in every Instance.

" ^ a7f should be stated EXACTLY. PHYSICIANS should

carefully supplied. Adb '*"'*,'" ,„^. ^he "Special Int'ormHli .n" tor p«r-
.. , .^ .. K- ncnnerly classitieu. ■ "^ »

I I

t i

» LI

11

f

i

WRITE PLAINLY WITH UNFADING INK

ISi.

:.,. 1^ -t-f;"^^^.-: l!«v

s^v c

I

)<ih' nii'd, L'^WInov

THIS IS A PERMANENT RECORD

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

la

1 !)()"{

BPois/ci'pfl J\"r,,

2272

,<r^u<A

Deputy Health

DEPARTMENT OF PUBLIC HEALTH-City and Connty of San Francisco

Ccitificatc of Scatb

PLACE OF DEATH: — County of JOurv JAyCuwc^^ec City of Oorr^ J A^ ,

Wo. lIu "^ ^v

St.:

Dist.j bet.

/ ir DCATM OCCURS AWftV FR<>M USUAL R E S I D E N C E G I VE FACTS c,
\ ir DtATH OCCURHCD IN A HOSPITAL OR INSTITUTION GIVE ITS N

I

and

ALLFO FOR UNDER _ , . JRMATICN \

AME rNSTEAO OF STREET AND NUMBCB /

FULL NAME

I!.

PERSONAL AND STATISTICAL PARTICULARS

rni I »k

I

<XAA

MEDICAL CERTIFICATE OF DEATH

t

^«. o

^!

)i

/(jn I

1 n im

lf,n

uf) i

that I la

J

M \R l< III!

1 I > < IR I I • \ , 1 I,. , )■ I,

^^

\j-<x.<L<xj

I II Ik

' liiiliHiv

'1 ^ N\M1

'•• ^'"Tiii.r'

'*" ' I'\TI()X ^

aihl that

>r. Th. CM SH <)l' IM- ATI

A

4v<v:^K

Aj-V^xX^

DIR ATION

I (»NTR Ii;rT<)kN' ^'^■

/hir

Ih

HI s

IM k AIM >V

i Signed

) •iir'i

M<

Hills

Ihu

%

//on I s

M.D.

Mf)

SPECIAL INFORMATI

or Recent Residenls, nnd persons dvini) a^a) Urn nome

ON fl"!'^ 'or iospifdis, Ifistifuflons, FrinsifBh,

former or
lisual Residence

I

N W- U ' • -'■■'

NoM \m% at
PIdff of Death .'

Oavs

) lUl I

M.uiili

I H'fien was disfasp ronf rafted,
If not at place of deatfi ?

n II, xk-- A Ki; TH! !■: !•» i ni-:

I 1 1.; K

;mi »\ \i.

I) \ ri

I M.i k r M 11^

I'l.xcj-: <•! nrKiAi

iqc)

N. B

v.

„ A.;r. «h..uld be Mi.te.1 lAACTI.Y. PHYSICIANS .ho„ld
•t.te CAUSE OF DEATH l„ pl„i„ ,er,„.; »h«^ I. m„^ H; pr.pcH. c.«.iflccl. Th. 'S.^.i... .n^or.„...i..n" .or p..-

very Item olf informntlon should be cnrefully mippMed

"""• **>ln4 away from home Hhould be ftiven in every instance.

r'

P

^
^
X

r

*

r I

J ♦

ii

I

m

III '

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

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

I ' I \

■»"^ HSc I' C.)

.<.KJS

Deo

JfUJ^

Registeipd Xo,

DEPARTMENT Ot PUBLIC HEALTH-Cily and County of San Francisco

Certificate of 3catb

PL^CE OF DEATH:-County ofCc^ >x. u v , . ^ of CJct>v ^ '■ - ^. .

..II ^^ k *

XUvc^^i; (k)5-^^d

a J. St.:-

Dist.; bet

/ ir DC*TM OCCURS .WAV rRo* USUAL RESIDENCE GIVE facts'^/

\ ir DEATH OCCURRED IN A HOSPITAL OH INSTITUTION GIVE ITS N

AILED f ^

AME 1%

^ and

'ECIAL INFORMATION" N
lEET AND NUMBER. /

U

FULL NAME ^V^K U

I I

PERSONAL AND STATISTICAL PARTICULARS

MEDICAL CERTIFICATE OF DEATH

II

H;iv

liai

at •(Miill'

fn.t,

M nth

I),tv

M..„<lr

• ' ' i '1' -ly tia! iiiii )

I

III \

.oJ

that I last siiu
and t hat (h ,1'

Ul

tr. UCb

0 rl

il. on the dati- slatcil

M. Thi- CM Sl{ ni' Dl ATIf was

iii\t-. at U

i\\ s

1

so

h

J .cU>4AX^v.*.C^^k,d C",

ciMrvi

i

K/\\

M ■ Is A 1 K 'A

C < tNTRIIirToRV

//

>'n< riii'i.siF
"^ ^ \riiKu'

sill, , .

^'\'"i N WMF

'" ^t••^IlI,R

'''l<TII|.|.\(i

'^t,

"i lll-.K

DIRATION

(Signed^ IX

) (Ull

Mouths

n

^cL

I ( jO

Ili'HI S

M.D.

^Jl

' t'oiiiitiyl

Special information ""'^ '"'' HospUdls, InsHfufions, rrdn>ienfs,
or Recent Residents, and persons dving andv from home.

/I,

Former or
Usual Residence

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

How lonq at
Place of Death .'

Dav*

}'■ To Till'

I-I.ACK OF m-KIAI, UK K1:M.iVAI, I I»ATl^,.f JS.Ki.Ar -r ki:M<

>\ M,

(Ad.h,.ss ^oavtcrw^AA. A

IQO

»"• dyinft away from home should be 4lven In every iiiHtance.

r

♦ '

m\

?t

i

WRITE PLAINLY WITH UNFADING INK-THIS IS A PERMANENT RECORD

/y.//r /•:

/A-/. O^t^W,,

la

/^^>H

REFER TO BACK OF CERTinCATC rOR (NSTPUCTI0N3

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco

Certificate of IDeatb

tl. 5. Stan^ar^ ;

•<^

>"

City oi

PLACE OF DEATH: — County of "^^ a

U ^\lv<xl L V>vc^m >vCM : / ^ ^ . ,st' Dist.; bet. ~

f >f DE^TH OCCURS A%AV rROwlUSUAL R t S I D E N C E G i V r FACTS CALLro rnp UN r
\ IF DtATM OCCURfUo IN • HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAO O

J

a

and

I N FORMATIO N
N D NUMBER.

)

FULL NAME

■ I

PERSONAL AND STATISTICAL PARTICULAR!

MM

)

i< I I.I Ik'

WV- W<w

MEDICAL CERTIFICATE OF DEATH

M.iiitli

/of) "i

I III

- \Kk n:j>

i' "';■ n;ii j,,!| )

1',

Mmth

MIR

it! S

N AMI-

■I IK

'•< >ni'F. A( ].

<xxv^^d^

an, I that d.at

li.KJ

ite stated

^r. The CAfSH OI

.'U^r^a.

i^ \a.

<x^

DIKATlnN y,d}s

i ' 'N TK IIUToRV

.1/,

//

A. > V \^ O

Vl/>%ajL

0
(

'»! N!ii

Itl-K

■' * "Ulltry

on

(Signed ) Lc\^>^^'v ^ •

M.D.

^viX4 "^ks

''^ \'\'K'M^

OP D

'■'11, \MuvK ST\

Special Information "niv inr HospitdK. instiiufidn^, fransifnts,

or Recent Residents, and persons dvinq A't^is from hnme.

1/.

(iiif,

'nnruit

<'l MS K.\.)\vi,l.:i„-.H AND Mi;j.n;f.

N. B — r ^

Former or ^ , , \ ,
Usual ResidfRip

When Has disease contrafted.
If no( at plat e of death .'

HoH lonti at
Plate of Death ?

Oavs

I'l.ACK "1 lU KIAI. <»K RKMOVAI.

t'et

hi:mi»\' \i.

IQO

rNl>ia<TAKKKLCLLi^>V^% Ll^^aX^^k^.^ \

Ad.h..^ H 0 € V* ^vv^

;ery iten, o? I„fon.„„tlo„ should be ca.afuM. supplied. AGB «H.u.d '^^'^V'^^.f'^^^'^; .rT^iJ^ul^-lc^p;!^
•tate CAUSE OF DEATH In plain ter.ns. that it ma, be properly .lo.«itled. The Spc.al Intor.„Hlu,n p.r

sons dyinft away from home Hhould he 6i%en in every Instance.

I !

'I

• .1 I

r

inif?;ir''."'V4?ff|i,

I

I

I

".■,. . - •*

WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD

^'''^''' ' REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

U(' ill sh' I fil .S^o.

r\

\^^Aj^ IjL^Ki Deputy Health Officer

)F

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco

Certificate of E)catb

1:1. tT'. '?tnllDar^

X

K1

PLACE OF DEATH: — County of

City of

W .,-v. \

St.; 3 Dist; bet.

(ir otATM occuns *.v*f FPOM USUAL RESIDENCE Givr rscT«i r%
IF DC*TM OCCUBPtD IN • HOSPITAL Ol

R INSTITUTION GIVE 1 T a NAV

FULL NAME

PERSONAL AND STATISTICAL PARTICULARS

">-%

MEDICAL CERTIFICATt '^ lA , h

tijo

v^'j r

^ rs

-\

•^<.

%-,

^
- ^^^-

Signed

M.D.

SPECIAL INFORMATION

»*>

sJJ^n^jj X

J I

8.

-E*epy Item of Infopmation should He .a-sfuU* «jof>fUd. '
•l«t€ C^tSE OF DEATH \n plain term*, that M ma> ^^
•-«» d>iiig away from heme should be gl^en m e^ci-> listen. ^

* •tafe' fA%*TLV

J8«»

ifjf -/•

li

a .
I-

I

•^PS^fK*

I

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

H..:n.1.,f H. .'rh r V - 'r^_^;^i.i)f^v r. , REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

(l1

Deputy Health Offi

cL^rUA^

Ihiil si i'i ril X').

ja276

/^ Ck ••

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco

Ccvtiticntc of IDcatb

n

T^

H.ACE OF DEATH: — County of

^^C ! 'w'w\,S

City ot

NcVLlu. <\^^:XXj^\Xx\ .'v, St.; Dist.;bet. and

I f \f DEATH OCCUHfe AWAV r R 0 M USUAL RESIDENCE GIVE facts CALUtO FOR UNDER SPECIAL INFOqMAT;ON \
% V ir DEATH OCCyRRtD IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET asp ^. m m r, r a ^ /

FULL NAME

vlLCitt

y\j

\^

Vix

cxvd.

PERSONAL AND STATISTICAL PARTICULARS

"*^

y.\v. I 1

vOl.itR *

MEDICAL CERTIFICATE OF DEATH

DA

il

•xccu

L'

u

\

|)

I inHi;n\

t t.iiii

■ 1 < iK l>l\ I Ik ii»
' -ikrnntioii)

III'I, \i-K

'0

1

1 *;'

;in.l that .1.

Jl'

^l.HO

\\v c'A,' "^1^ < *'■ i'i':.\rii

U,ls ,l«-

W '-

KC

ill

\i III.K

' ■ vriii-:K'

^wL^

IMKATION

]/ •••

Ihn

//,

' i'liiuitrv)

■^lAIHKX NAMj-
•" MoTHKR

iHRrniM.ACK

<>! MuTHHr'

'^t:it< ,,]• rdiintty)

iHXri'ATlON

4

I

V

^ oSXjjl

h o

CVUw\.v

DlRATroN

W r-

SIGNED) J-^n^ dbaXl-

/»,/rv

Oct

iijn

Hi'HI s

M.D.

1

\£U>VCX

SPECIAL INFORMATION onU for H«kpitdls. Insmutions, TNnsienls.
or Recent Residents, M persons dying dwdv from liome.

' "p,!^'!!.*^''- ^^ixri' I) I'KKsoNAi, I'XKTuri \Ks AKi', rKiJ* ii • ini;

'■'■^I «»1 MS,^KNn\vl,l^M-,H AM) i;i:iji:i

\iMrcHH Lclu xUo Ad d-^i|vaA,ccI

When was disease contrarfed,

If not at plare of deatfi ?

HoH lonq at
Plare ol DfHlli 7

Da^s

IM.ACH nl lU RIAL «iK KHMoVAI.

10

l» \

iL'c;

1^ I M< i\" \I.

ion .

I NIil'KT

N. B. Bv

^^'^^'^"■^^^■^^^■^■■■^^^^^^^■^^^'^'■^"^^■^"^"'^"'^^*^"^^^ 1 rv*r"ri V PHYSICIAN!^ should

ery Item o¥ Information should hi cfirefully supplied. Aun sn . ^,^,. ..Spe»;lai Int'ormntion" foi* pol-

ite CAUSE OF DEATH In plain terms, that It m»y he properly wla«»me .
*y1ng away from home should be given In «vory Instance.

[ ll

i1

fl
ill

!•!

II

J

I

I

WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD

tUmrt] Mil,

V„ I ; t"V-Br;-.Ti-, H5;; I' Co

REFER TO BACK OP CERTIFICATE FOR INSTRUCTIONS

100 \

Meiistercd JS^o,

2^7

Cr^AA^ dsA.\}\

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco

Certificate of IDcatb

. "U. 5. Stan^ar^ j

PLACE OF DEATH: — County of

^

(1^

,n

City of Ct^-x; ^i\XX. > v.Cv^.
No. 11 H L » ^oClL > vcv. I St.; 1 Dist.: bet. cLu n Vl; and o UX\

/ ir Ot.TH OCCURS *W«y from USUAL RESIDENCE GlWt facts CALLtD roB UI^OER • SPtCIAL INFORMATION' \
\ IF DtATH OCCURRtD IN A HOSPITAL OR INSTITUTION GIVE ITS NAME .NSTEAD OF STREET AND NUWBER. J

FULL NAME ^

Y>V

^TAVet

PERSONAL AND STATISTICAL PARTICULARS

^

jU

i'O! .( »K

•¥r

MEDICAL CERTIFICATE OF DEATH

1) A'li-; 1(1 i)j-,.\ rn

^

< ' I I ; ! K 1' n

iftfoiith '

) >„■

n,
1)

( Day)

M-i,'li

■' M \R \< n:i)

! I > < >K IMXl iKi'KI)

Kill ili^i',' jiat ii fii)

I'l, \r\:

, I

Ui.-

I hi;r I':hv t
Lei " . .

that I 1.. !

ami that ilcatli nci ur la-

t piiil

(»0 *1

1)11

aiiiivi, ai

I()0
I(/0

b

^ M. Till' CXIM^ Ol' 1>1 ATI! u;

as

lUs

/?

wdL

I \ I HI R

:•'-' III I'l, \CF

' '^ r 1 11% K

t I'liimti V

MAIDKX XAMJ-
•»l MOTIIHR

•iii< ^ln'|,\(•K
«'^ motiikk'

'^t;iic ,,1 Countrv)

'>* *'ri'Ari()N

AVwff^j/ in Siin /'litiuisrn

CONTKinnnRV

M,>i,th<i

PilV

IloHt

1

nr RATION
(SIGNED)

y, ir

Mnulhs

Ihiv

in rA.l.ln-)t05^XLo

M.D.

M„„Hn A. i />'?!

HK A»(»VK STA Tl'I) I'KKSONAI, I' \ K I* ir I' I. \ KS AKI! TKrK If » I'HH

in,M- (,|. \ix KNuwi.i.ix.H AM> iu;>ji:i'

'I II I'm;

maiit

N. B.

fA'l.lr.ss 'DsTi LAIaiIaXaU! UA ^^^^__

i— — -^— --■^^«-i^--^-— -— — •— ■"'■■'■'■'■^— "'""""'^ EXACTLY PHYSICIANS iihould

o.- Information .hould b. c-refull^. supplied. ^^^^^^l^.'jU^fi.'i^'^h: -Spccla; Information" fo. pr-
E OF DEATH In plain term., that It mny he properiy

CIPECIAL INFORMATION o"!^ tf Mo'>P»«"^ "'^""••'»"^' '""^•'"'^'
or Refent R esiJenls, and persons dying hhhv froni home.

HoH lonq at
formfror pi^^^ ^f pfath? Da^s

Usual Residence

When was disease fonfrarled,
' not at place of death '

|»\ TU '■' !•' Hi\i

n.ACH <»r HIKIAI. (iH HKM'»V\

1 90

■Rvery item

•tate CAUSE _. _„ ^

•on. dying away from home should be t'^^cn in -very Inatance.

w r

r

WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD

R..:i-

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

I i

* *.

J .«'

I!

I

I

Ihilc Fili'(l . \j(^XjAj^O\j IX

U)OH.

]}i'l>isfci-t'(l ^n.

278

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco

Certificate of IDeatb

A

-iTN

(^

^u^

City of O^cm; o,\.a^ , '^^4
--— and ^

PLACE OF DEATH: — County ofCJ<X>v : \<X .

CrVv\jl ItfV X.lxi. L^Q ' V St.; ^ Dist.;b€t.

X K i. iic.iAi DTQinrNCF r iwc tact^ cALteo for under special information- \

( ir DtUkTM OCCURS »W*V rRO« USUAL R E S I D E N C fe. give facts. ^'^^^ .„=Tr»n ^r crTRrrT AND NUMBER. J

\ IF BeATH occurred in AiMoSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET

r^ I

FULL NAME

PERSONAL AND STATISTICAL PARTICULARS

COl.nK \

<•!■ I.IRIH

I Month n

II

^0

J

1/.

WllH 'xV HP UK ni\t (KTl'l)

Wnt' ill >,-Ki;il lU -.is.'n;iti<iii)

nil; ■ i!l'! \,-|-

.1

v_

(1

n

I vni Ik

'• I K I I M • 1 , \ r F

ot I \i*in-:K

' "^lati , >! Count ! V

M Mlil'N XAMl-
<>I MoTHKR

'•II<Tin'I.A(i.-

'" MiiTin-;K

' ''t;it<- or Cuunirvi

nscri'A'iioK

KX.'

Xka,^ L^'

MEDICAL CERTIFICATE OF DEATH

I 1 ■!

11!

^1

If

/o

CJX'v'

I 111 |^M;V i 1 l< ■ ir\. That Iatlc.l.k.i.kHvaM-,1 Ipuii

that I la*^! ^aw h -S-^ alive oti

a'ld that .li-ath ..rnirtvd,

(111 Uu- <l;it.

,1 ^1)0

y M The CATSI-; OF Dl- ATI! ua^ a- folL-u^:

I

■*1

1

niKA rioN i '

CONTklHt'ToKN

; . ,/;■

1/

/'./

1 ^

Ilniit s

jlin^JL

DTRATloN

(Signed)

jrs

Months

/Itr^

Hours
M.D.

IqO

(A(hlrts.)

Uct. u ^

"c^PECIAL INFORMATION onlv tor Hospitals. Institutions, Transients.
„r1eren^1esidrnts! dnd persons d)ing a.a. Iron, home.

/Oc^vd^

oo

f\i''i,f/-,> III Sitfi /'i iiiii iWit ^,' • ' )»i//

M.oitli

Ihn

'HI.; AHOVHSTATl-I) I'HKSONAI, PA KT UT l.A RS A K l'. TKri-. Tt » TIIK

HHST OF MY K N( )\vi,f;i)(; f; AM) in:i,n;i'

XoJkc

XjoJm-

Former or
L'sual Residence

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

n.ACKOI^ HriUAI, OK RHMi'VAl,

Death ?

Oavs

I'ct

VI or Ri;Mn\- \l,

a TooH

rNI)UKTAKHKH..U, W V^,

(A.V.ln- 111 ^

'^^ B.— Kvepy item of in?ormnt!on iihoulil

mote CAUSE OF DEATH in plnin terms, that it m»>

I I nr PHYSICIANS should

"on. dying away from home should be given In every msi

I

J I

h

^

?

lii

I f »

I

WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD

II, -M 1 V<

lUS:!' Ci,

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

/h,fr /•V/r//,lL/c:tcrLilhj 11

liHf'i

UcLii^lci-i'il -jVfK

.^r\AJ<A

X>\A

Deputy Health Officer

DEPARTMENT OF PUBLIC HEALTH=C{ty and County of San Francisco

Certificate of "Dcatb

A

HTs

PLACE OF DEATH: — County of

City of ~ ^" ^^^ ^ ^^ ^

^

A

No H'it^ LU-<X,l-^.Liv St.; K Dist,;bctXlaAXC/Uc.i. and ^H^

.Xh occu.S .w.v ..OM USUAL RESIDENCE o.v^,,^CXS C^^o _^^.« ,^;S^i^?'^;-- ^^ )

/ IF DtXn occurs *W«y TROM USUAL RESIDENCE G.Vt FACTS CftLLEO
\ IF ^CATH OCCURRED IN • HOSPITAL OR INSTITUTION GIVE (TS NAME

FULL NAME

\A

Kj

( s ' >

PERSONAL AND STATISTICAL PARTICULARS

C •! .1 iR

\

II

I ♦

«>l lilKlll

M.iiUhi

\(

?,

) y.i

(l>;iv
1/ ..//'/

-•I^'.l.I- MXRRIHI)
U ilH »\\ I |i OR I»IV«»Kr KD
>'' 1 lal (1( >-ii'natiiin)

• < . illllt I \ !

\M1 i>i-

\ riij.R

'" I N iin-:R

■^t It, ,,i r.iimtrv

MXlIiKN NAMK

<" mothi-:r

''•Iin'IflM.Ai'H

'" Mn'rin-:R

C^^nu J ."vet vx^cv,^

:tnf\'V^ 0

V

i>\

that I

MEDICAL CERTIFICATE OF DEATH

111 |.;i i;V ( lJ<'rirN'. That ! nt!eil.U-.l .U- :i-^<l li""'

, ,, lirf) ~

,■ . - ;lu' il ill- '-ta!(<l aliovi-, at

,1 that (Kath

M. The CArsl{ or 1M.\ ni u

\\ >^

1)1 R ATK^N ^"''

CoNTRIi^rToKV

Mouths

Par

//

DlRATIoN ^ J'''^'^

/hiv

IN ED ) Ur'

-"1

'""■t It' or I'uuiUiy
nitil'ATlON

THI- AMOVF. STATl-l) PKR^ONAl, 1' \ R I' HT I, \ K^ A R I', IRlK T< » 1 " » •
HhM' oi- MY KN()\vl.i;i)C.H AND in-.I.Ii;!'

M.D.

(SIGNED ) UrV<r>-aA^

""special information »..lv f«' Hospitals. Insti.utfons. Irans.en.s

orlefen^ Ments! and persons dying away Iron, home.

NoH lonq at
plaf e ol Death ?

former or
Usual Residence

When v»as disease contracted,

If not at place of death ?

Oavs

lATi^'.f H' KiAi '•' ki:M'»vai,

i( ... ILL. PHYSICIANS Hhould

TH In plain terms, that it ma> ."« f J

'^^ ^- Every item of Informa

state CAUSE OF DEATH In p.«... - Instance.

•ons dying away from home should be given In ever*

PI

n

N ^

■i I ^

i!

H

t ir j.i- F V

WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD,

'"^''^ ' ' REFER TO BACK OF CERTIFtCATE FOR INSTRUCTIONS

oK^ Deputy Health Officer

lle^is/ i'i-('f/ ^\V>.

oo

Dnlr Filed, liiclMM^. \X

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco

80

Certificate of Beatb

PLACE OF DEATH: — County of

City of^'a>

t. Li

St.: Dist.;bet. JtAH, -.,.- ^nd ^^-

(\f DtATH OCCURS AWAY FROM USUAL R E S I D E N C E C I V t FACTS CALLED FOR UNDtJR SPECIAL INFORWATION \
\r DtATH OCCURRED IN A HOSPITAI. OH INSTITUTION GIVE ITS NAME INSTEAD ^V S7RECT AND NUMBER )

FULL NAME

\ ii

Lk.

PERSONAL AND STATISTICAL PARTICULARS

ft <.'<>I.«iK

clU

L

MEDICAL CERTIFICATE OF DEATH

WCAj

I I

I)

iUH 111

V,

J V,/

X?s

i II

I I I N

^%

I i
I I

1 i '1' -is.»ii:itiiiiii

I'l, \K\

' I 'iiniti\

^ 0

^\MI ci!'
' VI' If IK

- niKk

' 'i t''iiintT\'

"I MOTH Ik

'•"': I lIl'i.NCF
<»l MMTm.:K'

'♦^'■'I'A'riON'

V
^

tlnit I In^f '^iw li , :;.

,111(1 tha! (Ualh iH-riurt'd, dii tin- ' '*.

M. Thr CAISH OF |)|;A 1 il u,

I','

xcucb

>^_

CUUL k.

vru

JUL<1

1

CONI k IIU TOR V w.\^v- '

/hiK

//,

nrRATiox

)V<7r.s- J/i>f////

/hn

(SIG

If)

NED) Jfth/ysj w'

//,'!,rs
M.D.

w I

ff^siiifif III Sun f'laiuif^ro

<x.

\ V

• \

)'iin

1/ :>f/l>

iu.sroi. Mv K\()\vi,i;i)(,H and in-i.n-K

n-; Ti »

r 1 1 J-:

SPECIAL Information ""ly J»r Hospltdls, institutions, Transients,
or Recent Residents, and persons dying anav from home.

HoH lonq at

Place of Death? ■ Diys

Former or
Usual Residence

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

\'l<lrc!

kix

^ u crvcLt^i^ U/cxti '' '

UATI' "' H' 1 lA'. <if KKMnV\l,

1 - t

PI \CK <)1- JU-RIAI. «>K KI:M<>\\I

ion

N. B

""^""^^"™"^'^"'^""'^"'^^^^^^^^"''"^^""*^^"""~"""'*"''"'"™"" ^ lu. f t I F.XACTLY. PHYSICIANS nhould

•Kvery Item o? Informntlon •hould be carefully supplied. AGB should • • %he 'Special liUformation" lor p«r-
•tate CAUSE OF DEATH in pl»ln terms, that it may be properly classmea.
« dying away from home should be given in every Instance.

I

I
I

i\ I

'M

H

m

i

WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

[I. i'-li r N.) I ; 'S-F'iacvJl^ HM' Co

\. 1:1

lf)()^

]ii'oish>r> <i X(h

00 Q

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco

PLACE OF DEATH: — County of .a

Certificate of Bcatb

I XX. S. Stan^arO 1

City of O

i

V

Nc).

f\

s.. ^

U^^ ' St.;

(tr DEATH OCCUf^S »WAY FROM USUAL RESIDENCE Gl
ir DEATH OCCiURRCO IN A HOSPITAL OR INSTITUTION

FULL NAME

A ) 1 '

DisUbct. U<X^v':. . and

IWE FACTS CALLED FOB UNDER SPECIAL INFORMATION
GIVE ITS NAME INSTEAD OF STREET AND NUMBER,

)

■i

PERSONAL AND STATISTICAL PARTICULARS

^^

i< >!.< >R

-<XU

'! I.IK in

MEDICAL CERTIFICATE OF DEATH

H IHN

I Idlll

Month

a

I

^ lit I tR iMViiK <■»•;?>

' ' I'liiti \

^'1 1. 1

''IK iiiri.srH
•" I XIIIKU

i

A

that I 1h
aild thai 'Ii I!

'Ml

' vn aliii\i\ a1

M. rhv CM ^1' <'!■ 1)1 ATI! u

•^

nit T \'

M\Ilii:\ WMj.
01 Mmiiii-k

''nrririM.Ai'H
'•' "^'o'i'iihr'

'^'^■^I'Xi'lOX ^p

?

>vo^

Sit ft I'l ti)u isro ."Su 5V(f/A

»'»,si or MY KNowijvix'.K AM) iu;i.na-

1)1 U A 1 i' 'N
DlRATtON

(Signed)

I' ^ .

( 1/

/yav

I lout s

)V/r

K.

Months

A

Ihn

M.D.

fA.Mri-^) l^u'A ' ' ^^ '- '

■ SPECIAL INFORMATION onlv for HospiWs Innfitulions. Iransienfs.
or Recent Residents, and persons dvinq dw^v fron home.

M.iiifin

I his

ARi; TKiH T<> rill-;

''"f'Mni.iiit

X

U^A

\<l<lrcsM

5Su^

Former or
Isual Residence

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

Ho>* lonq at
Place ol Death ?

Davs

PS \CF nV lUKJAI, OK KHMnVM.

1) \ rj

K i;Mti\ Al,
\C)0

m.,.:ktuL^^Ui^ \oXx iLvuUv-U^.

Ad.Ilrss OS ibo .1 ' - -^^

1 1 — — ' I fXACTLY PHYSICIAINS should

nfar,n«tlon .houlcl b. cnrefully supplied. A<;»^;;;-;;^^.^»;"%h: •Sp.cl-i InformHtion" for ^r-
►F DEATH In pl«in termR, that It m»> be properly .!»«»'»

^- **• — -Rvepy Item of I

•tate CAUSE OF ^^^ . .. ... m-"".

•on. dylnft away from home should be aivcn In every instance

,»

!

1

If

WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD

n i!i I ^'^ •- tS-r:3^^^fi^i'C,, REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

/)u/r F/7('(/ , C

OwC^\.^«w^

hj 13

IfJ(J

Mesjisfc/cil A\).

OQQO

\.

Deputy Health Officer

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco

Cevtificatc of IDeatb

PLACE OF DEATH: — County of

i

XX, 5. StanDal•^

^

No.lH5lU..cA-v,

St.: % DhuhttSJ J/OAXXLi'

X

a

and

(ir ocATH occuns aw«v from USUAL
ir OCATH occunncD in a hospitai.

RESIDENCE give

OR INSTITUTION GIV

fACTs cailED FOB UNOtR "SPECIAL INFORMATION- \
'E ITS NAME iNSTCAD OF STHCtT AND NUMBfR /

FULL NAME

n

.L'^

PERSONAL AND STATISTICAL PARTICULARS

MEDICAL CERTIFICATE OF DEATH

\i \ ,

/ , /. )

1 Q

J'('.l» *

II):

l/..//'/-

MARK n; i>

i> < »K I » ^'i iRr i:i) n

- >i ;,i' ill »ii'iia(!'iii) -^

1 \

IMKTHI'I.Ai-H

"' 1 X fii i:r

MA
( )

'\lli|.\ NAMH

I II i;K i- I^V i I RTfi'V, Thai 1 attcibU-.! -1.

til at I I 1 alive !,n

aii.l thai .! '""■

M.- The CM ^K "r l)l':A'ri! u - ., ,

tillll

U)>l

R

t * i)UlltT\

'-IH |■HI'I,A(■F
1 I'niuitryi

iftLmJj UJcJLc I

DiRATinN )

C nNTRiniToRV

M.'uihs

/hn >

M'//;

DIKATKiN

)'tai

irs ~s

Mmiths

/hiVs

'^' ^'^vvvuiy,

f^'^^iti/->f in S,ni /f^,j,„ tjfo /, ) Vu i s M,.>iffi^ ^^'^' '

"",M^'!V^'*'^^'rATI.:i» I'KRSONAI, I'XRTriTI.XKN AKHTRIH T< » TIIK
'•J-.SI Ol- MY KN<J\VJ.!.:i)c-.H AND Hi:ijl,l

^Informant NlVvO t) UO \

(SIG

HZO'SjtK-^y^^ -

M.D.

iL'ct 11 TooH M.Mre^^O Ule-r.Cv^

V »

QprciAL INFORMATION ""b tor Hosp.tals, InUituffdns. Iransle.ts.

or Rerent RAfdents. dnd persons dving d.dv from home.

cua;

Ud.lr.ss iHC^Qv

l)0jU>4-t«A.'

former or
L'sual Residence

When was disease fonfrarte^,
If not at plare of death ?

HoM lonq at
plaf e of Death ?

Od*s

",.,.\,Knr m KIAI, MR KKMOVAI.

tNI)i:R'l'AKHR

I»A-ti;.>r HiHiAi, ..r KKMnVM,

'H

A,,h.s. (oiX* ^^ I U- 1

N. B

t.^^^lLL PHYSICIANS .hould

•Every ,te„, of l„for«,a,lo„ .hould be c«r«fuM. supplied. ^f^^-J^'^Umci! 'tM •Sp.cl-I Infor^-tlo"'; fo. P-r-
•tate CAUSE OF DEATH In plain term., that It may He pf-oP^

nnm Am.,\.^jL 0 — I _i I

•tate CAUSE OF DEATH In plain term., that It may be prop
«on« dying away from home should be fciven In every instan

I r

it

I

f

I,

WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD

noardofiu.-nth FXo..,il^^H.^PCn ^^^^^ j^ ^^^^ ^p CERTIFICATE FOR INSTRUCTIONS

Dfffe Filed,

X^' \l

lOO'i

Begistei'cd J^'^o,

ja283

Deputy H

'^cr

rNo.

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco

Certificate of 2)eatb

( tl. S. Stan^ar^ )
PLACE OF DEATH; — County ofOxX/^ru ^hJX\\.ZK.^. . City of Qxn/w JXcu\xc< ^ ^ <

St.; ^ Dist.;bet. VJ and \l<XA.k

- 5-[\

^> . w.

(IF DEATH OCCURS AWAY FROM USUAL R C S I D E NC E C I VE FACTS CALLED FOR UNDER "SPECIAL INFORMATION"
IF DEATH OCCURRED IN A HOSPITAL

OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER.

FULL NAME

^

\.

fO

)

L(lAAeo.<lcL.,

PERSONAL AND STATISTICAL PARTICULARS

I c<)i,oR\ a

DATK <)l lUKTII

.1

kiX.

AX,'

(tvtonth) t

A(.K

) rtt I

U

\

iDav

Mnnlh.-^

MEDICAL CERTIFICATE OF DEATH

DA IK <)1- DKATH >

I' ' -^ I •;

TQO H
(Year)

( Vear)

Da 1 .

SIN«-,|,K. MAKKIi:n
WIDOWKI) OK DIVOKCKI)

iWrittin s<KMal ihsij.'ii:iti.in)

t

lUK I'm»I,AOK
(Statf «)r Coniitryl

. \ -,

XA>fK c»r(]a ft \ ly

iMoiitli) il):iv*

^I HICRHHV CI'RTIFV. That I Mttemled ilecvascd from

d.^cl U ic^'; to 0<tLt !X

that I last saw h a.. - aUvc on ^^ I \

an«l that death occurred, on the date stated above, at L 6
M. The CArSl-: Ol- DI-ATIf wa^ as follows:

190H
190 H

r^

BIRTHJM.Ai H
OF I'ATHHK

(State or Countrv

MAIDHN NAMi; ^
OF MOTllKR

0

U.t

UXavoucLd
1 %

DTK AT ION

CONTRim

a

K,

c

Yt'fi^-R Mouths /)ays //ours

TORN' ^J . ViL, -> ^ ^ a,'tc^-^wJl ^ sS J^hTt-K;

I ^

d

1)1 RATION

)

Its ^

Mont)is

/)avs

/lours

Ic!

HIKTHPI.ACK
OF MUTHKK

(Statf or Countrv)

OCCFFATION

wcLo

IVO^CVO

(Signed) vJ . U. \\\Vk m.d.

^'clj I's. rcpl (Address) blH- 1 >x,<i. Uv^s.

SPECIAL INFORMATION only for Hospitals. iBsllItttloiis, Transleiih,
or Recent Residents, and arsons dying dMd> from home.

Rfsidfii III SiiH /'null nr'ii

)'fUll .

,1/,*/////v

/i.n

run ABOVK STATi:i) PKKSOXAI, I'ARTfCfl.ARS AR1-: TRCK T< » T!I»;
HKST OF/ALV KNOWI.FDCK AND Ii!.I,N:i'

(Tiiformatit 0 , \JJ ■ V<XAy^^lXX..cLOwJL >x^

Former or
Usual Residence

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

How lonq at
Place of Death ?

liys

(Afldrt'ss

IXS^x - 5tk

I'I.ACF: 01 IITRIAI, OR RF:Mm\ \r, I HATKof Hi hiai, or KKMOVAI.

AW

mJ]

v^x

r N I ) 1; K r A K t: K \| I L 0 .O-v^aj M^ ^^^

A.l.U... ^11 ^\^ (11L4'U\. Oil

190 1

N. B. Every Item o* Information ahouid be cnrefully suppHed. AGE should be stated EXACTLY. PHYSICIANS should

•tate CAUSE OF DEATH In plain terms, that it may be properly vlassifled. The "Special Initormatlon" for p«p-
sons dying away from home should be given in mvcry instance.

1

» I

. H

i

'* ^1

"f I

m

WRITE PLAfNLY WITH UNFADING INK — THIS IS A PERMANENT RECORD

H..:,i-1 of H( altli — !■■ No. u "^^^^^ lUtP Co

re:fer to back of certificate for instructions

Dafe Filoil, L cl<rVvt\i i3

D

190\

.<riAA^

Rcgi,stered J\'*o,

DEPARTMENT OF PUBLIC tIEALTH-City and County of San Francisco

Certificate of ©catb

( "CI. S. Stan^arC> )

\ ^ J op

PLACE OF DEATH: — County of 0<X/ru OAxXn^c^^ci City ofO/(X>x- J;v(X^rcc<^xi.co

(No. bM i

(IF DEATH OCCURS AWAY FROM USUAL RESIDENCE GIV
IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION <

St.; X Dist.;bet.M I UnX^at^^UYu. and JLI^Ulavm

"OR UNOERfT'SPECIAL IIM FOR M ATIO N '■ \
NSTEAD OF "STREET AN<) NUMBER. /

E FACTS CALLED FOI
GIVE ITS NAME II

FULL NAME

^UyyxL^

PERSONAL AND STATISTICAL PARTICULARS

si:x

DA ri: {)}•• luKTii

A<'. K

CDI.OR

^\\XX^K>

/Uo

Mniith)

HH

3 V,/

I)a\ )

A/.,tt//i^

\ ca r )

Pti rs

SINC.I.K. MAKKIHlJ
WIDOWKI) UK l)I\(»Ki!:i)
(Wiitfin sfK-ial <1< si^Miation)

HIRTIIl'I.ACK

(State <ir Cuiuitt \'

MEDICAL CERTIFICATE OF DEATH

DA IK ()!■ D};Arn ^

U 1 ^

(Day)

I HI'Rl-HV CI'RTff'V, That F attemk-.l ilen asi-.l from

— — — lip to

yet

(Month)

(V«-ar)

that I last saw h

alive on

I90
1 90

and that death occurred, 011 the datr stati-d above, at

w-o\/^x.cL

ft)

/Cto^<xd-0

NAMl'- oi
K ATI IKK

lUKTUFM.AOK
<)I- I'ATIIKK

(State or Country

MAIDKN NAMK
OI" MOTHKR

lUR THI'LACK
OK MoTMKK

(State or Country)

(?i

M. The CAI'SK ()!• Dl ATII wi- a^ follows

Dlk.XTloN )'t'ars

CONTRII'dTOkV

J /on //is

/hir

lion

/ s

I )r RAT I ON . }'iars ^. .l/,>n///s Days

NED) .Ur^XTYOAj J '£>. LL i.. ^

N>>^

(SIG

) I o

\xrY\XN ^ m. ^

X.ldre'^s) \w(r\,ftOViA4 W.4 ^

Hours

M.D.

iqo \ r

SPECIAL Information only for Hospitals, Instltutlo^rs; rMiislfiits.
or Recent Residents, and persons d)ing dwa> from home.

OCCt'TATION 5 A

Resided in Sati I'nnni,

■ yjn,,!),:^

fhn

Former or
Usual Residence

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

How lonq at
Place of Death ?

liys

THK AROVK STATI:T) I'KKSONAI, I'A KTICr I.AKS A K K TK C K Tn THK
HEST <)1' MY KN(>\Vl,i;nc.K AND WVA.UW

(Diforniant V fl- LAj . V-<XAJk,VA A. ' ^ ' -

I'l.ACK OI" mKIAI. c»K Kl.MDVAl, I DAfK of Hi rial or RKMnVAI.

I'NDKKTAKKR U&'lxiXAXj J al ■ UAO/djAXoJvWk
(Ad.lr.Hs 3''^^ I \J rW^^t-O > t

190

N. B. Every Item of Information should be carefully supplied. AGE should He stated EXACTLY. PHYSICIANS sheulj

state CAUSE OF DEATH In plain terms, that It may he properly classified. The "Special Information" for
sons dying away from home should be given in 9\Ty instance.

■-n

P

iTKs

w

I

It I

I!

WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD

!*oM!(l of If.nlth I-

A-^ «•

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

!'^

XJo^^

K^ \Z

ino'i

Jfeg/sfc/'rd A'*o.

J^285

\J^\^^

DEPARTMENT Of PUBLIC HEALTH=City and County of San Francisco

Certificate of Beatb

( XI. S. 5tan^ar^ i

/T)

PLACE OF DEATH; — County of ^

>. V

uxa

^

I

City Or

tnv

m

No.

St.;-

Dist.; bet.

and

IF DEATH OCCURS AWAY FROM USUAL R E S I D E N C E G I V E FACT

OR INSTITUTION GIVE I

(IF DEATH OCCURS AWAY FROM USUAL
IF DEATH OCCURRED IN A HOSPITAL

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

FULL NAME

X

PERSONAL AND STATISTICAL PARTICULARS

/rt"kVtYva/vvct t \\.

4-

\

\ n

!» \ ll. t »I I'.IK III

Miiullil

\' .1'.

-i\<.i,i-: NtAKRii'.n

\\ I IX »\\ i:i» «>K IMVt r.'
' \\ I it! ill ^iKi.-ii tji-^i^' r,.,:

lUKTIII'I.AOH
' st.itt (ir »"'niiitiy

NAMl- Of*
1- ATin:R

niK'rin'i.Ai'K
oi' I Ai'm'.K

i Sta! ' (i! v"(iuiitr\'

I>:

l/.'»,''//

(\\-.n

ID

~<y:

'/

MEDICAL CERTIFICATE OF DEATH
DATE <'l I>1". XIH

1^ 1'^°,'

(Year)

(%foiith) 'Diiy)

I H[';Ki;i'.N' f i; RTI I-N', 'rimt I atU'ii.kii »k-(ease«l from

— I.'

that I last saw h

• alive nil

■JgO— — -
190

and that <Ual1i ()rrurrc<l, 011 tin- <lafi' stntid alxn't-. at "
M. The CArSI<: Oi" I»l-;.\ril was as ff.U.iws:

. r ( '^

I )r RAT ION )'<ars

C< >NTkHU'T()RV

DI'RATION , )'r,irs

Montfn

Pax

Hours

Month}

Dav

maii)i:n NAM1-;

OI" MOTHHK

lUR'ruri.Ac'K
()i M<»rnKK

(state Df Cinintrv

ucc

CrLcLoUv;

f\r>ii{iif in Sun /'iiini/

);,i

M.oilli^

I hi

VnV MIOVK ST\'n* I) I'KKsON \1. TAR ri'TF.XKs, \KI, IKIi: r<» THH
liKST or MV KNo\VI,i;iioK AN1> HHIJKI-

(Inf-.nnant VjOCU^ \J . Ll - dJ-VVtl

AMI. LA.. Ov. <L'

f Address

<X\JA-/^

( Signed )

•4-

//ours

M.D.

fA.l.lress)Mria.-V\AX<L ') J

Special information »"!> '^f Hospitals, Institutions, Translfnts,
or Recent Residents, and persons d^inq Hv»dy from home.

Former or
Usual Residence

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

How long at
Place of Death ?

Oavs

pi.Ac;}-: 01 luKiAi, oK hi:m<>\ai,

MUX^-^w^

r N I ) 1 . K 1 A K i: K

l»\ri;<>t 111 KiAi. or RKMoN'AI,

L'CA li T90H

'\ ^1

"^ Ti ATF -hnuld he stated KX4CTLY. PHYSICIANS should

N. B. Every item of information should he cnrefully supplied. J*''^ «^ ^assified. The "Special information" for p-r-

state CAUSE OF DEATH in plain terms, that it may he properly Uassmeo. ^

«on« dyinft away from home should be ItWen in every instance.

i

I

lA •

y

ij (

i' ^

l»ii

WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

i; ,'.1 ..f !T«T»1tl! }■ v.. '^ t^^S^^. lU^P Cc)

" ■- *- ■-'•- <»

nnfr FiJnl , C'/tlXxrls-Uv IS

tj5^^

V)0'i

Bo mistered JS^o,

*^^86

Vw

Deputy Health Officer

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco

Certificate of IDeatb

A^

PLACE OF DEATH: — County of

A.

n -
^ w I ^

No.

^

' X City of CL^x V

St.: Dist.;bet.^t^ck,te--'\' and v. va

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

FULL NAME

ll. ..•■

UX

cs^'.,^

PERSONAL AND STATISTICAL PARTICULARS

/\ I'OI.ilk

^! A

1) \ ri; t»i lUK I'll

A<'.H

\.

I

MEDICAL CERTIFICATE OF DEATH

DA ri-; ul DKATU I "N^

u

(M

>lUll I

• fiHi-

aa

ih

sl\» , I !■: M \KK IJ 1)

U IlMiWHI) OK I)I\»»Kt HI)

iW'ritiin siK'ial <U«-ij.'!!iitHMO

f)

/ ,

Ox>^aU

niRTIfPf.Ai'H

Stiitt I iT < iniiit 1 \

FATii i;k

niKriii'i.A*!.:
oi- I \ini:R

(St;it< D! (.'(Mint I v^

maii>i:n n\mi-:

HIK rilPLAi'K
(U MOTIIKK
(Hiatf or Countiy

0

^ \

1 N

iM.milO

liav^

(Year)

I IIi*;R lil'.N' CI-RTII'V, That I altcii«l(.il lUtxaseil from

I ijd

t., U cl.

1 I U)0 H

*

tliat I last --aw h - ,iii\i'>il ^ C^ i I90 '

aii.l that (Kath ocrurreil, nti thr dati- --tati'd above, at U
^^w M. Thf CArSI'! 01- DKATII was as follows:

niRXIloN )V</^v Mi))i(hs Qays

'I • '

//out s

DC RATION , )V<7r.v
(SIGNED ) cLo^v

Months

/hiv

L^cL

IqnH

//out s

M.D.

Special information «nl> 'n*^ Hospitals, InsfitMtlons, Tra«slenl$,
or Recent Residents, and (icrsons dying away from liome.

<)L'cri'\ 1 ION I

Ri-sitlf't! ill Sail I'l iuii isi'ii O )'>ii>^

Mniitfr

rhi\

THK AHOVK sTXTlJ) ','KK>^ON \I, I' \ K P HT I. \ KS AKl-. TKll- T< » TIIH
IlKHT IH' MV KNOW IJ-.lx.H A Nl) BMI.n'.l'

(I

Former or
Usual Residence

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

How lonq at
Place oi Death ?

Oiys

I'l.ACK <tl lU KIAl, <»K Kl',Mo\AI.

UAIL;!': Ill hiai, iir Kl-:M(n'Al,

ii^-t

TQO

N. B. livery Item of lnformHtlo« .hould b^ carefully suppllecl. ^^^ "^"!l''',^,*,;^^ Information" for p.r-

•tatc CAUSE OF DKAT?? In plnln term., thnt It may be properly wi«««itieo.
fions dying away from home nhould be given in m^fmry Inetanee.

m

i

N I

h

I i

WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD

»»,,:il.! t III :t"tli i V'

life!' C<

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

I
I

dUrvu^ Xt'\HJ Deputy Health OP

DEPARTMENT OF PUBLIC HEALTH

Jlo^jsfej'cd JS^o.

22H7

City and County of San Francisco

Certificate of S)eatb

( ia. S. StanOarD )

PLACE OF DEATH; — County ofUCLA-v ^^

City of vJ-^^^-^^^ JX<X>\ C'.c

1 V

N(

o.UJaXdjL

t

.VULAiyn {l\^ ^<l'(\jJ^ClA: St.: ^ Dlst.;bet. and

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

FULL NAME Uu^xnr^xJL

PERSONAL AND STATISTICAL PARTICULARS

■^'•■^ (^

( ' ( 1 1 ' ' K

JX/YY\XkXi

DATK nl lUH 111 PN

a

.f

M-.m)

a!

A'.i:

/hi

si\. .i.i' M \KK n:i)
un)n\vi:it OR i);\i iri*i:i>

^

OJ'J

!UK rillM. \0K

stati III ('iiuiitr%

NANfl-' nl
HATH IK

lUR'nH'!, \i'K

«>i' I \iiii;r

' state i>r i'oniitt \ '

MAIDHN NAMK
ol- .NU)riIHR

HIK THrF.M'l,
()!■ MoTHHK
< Statf <jr Coiinti y

OOCITATION

cn

d,)

I w

Vv '

il

MEDICAL CERTIFICATE OF DEATH

1) \l\: I tl m-ATII

(M.imii

(Dav)

N. ai

I II I'K i;i'.\' i' !•' RTII'N', '^'tiat I ;itUMiili-(l ik-rcHsetl from

that I last saw h -.-' alivr ow W CAj 11 190 :

and that lUatli nctnirred, <,n tin- tiat.- ^tatiMl abnvt-. at ^10
M. The CAl'Slv (»!■ hllATIl was as follows:

2 /^ jktC.LfrVAA-C'-tC

,a.aX Jx^xjUwoJL \^^

DIR ATION

Years

A

Moutfv

/hl\ s

/four's

CONT!

DIR ATION

(SIGNED

RIHITORV uxKa,^-^ <X/w<^^ U w^\-<X4.<. V

)><//'

n

Mnnths

fhlVs

.^X-

Hours
M.D.

\>^

KrsitUui III S.iii li,ii', nrn <*. ^. ) '"

M.'iith'

Thj\.

THF \m)Vr STXII-.I) RKRSOWI, PARTICfl.ARS ARi: TKIK To THH
HKST Ol- MV KN()\VI,1<;Ui;K and lU'.MhH

(Infcnnanl L) . > ■ X^ CKVQ^^IaJ

(A.Mrcss

bl^ \-«AXUX Ol

0

w

'<ct ili Tl

K»

fA.hlriss) I?

c^.l

Special information "nl> lur Hospitals, Institutions, Transimts,
or Recent Residents, aU persons dyinq awdv trom tiome.

Former or r ^ a H p ^ ^ , -

Usual Residence to^6)<C^'4.A^

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

HoM lonq at
Plaf e ol Death ?

Days

PI.ACK Ol' HrKIAI, OR RI'.MmVAI

l>\ri", .»! liiKiAL or ki;mci\\i.

TC)0

.^AX-W,

N. B.-

-Every Item of Information .hould be cnrefully supplied. ^^^ classified. The -Special Information" for p«r-
state CAUSE OF DEATH In plain terms, that It mny be properly wiass.tie
son. dying away from home should be ftlven in ^^^ry Instance.

s

^

<= t

^

I!

lift

'I i!

h ;i

WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD

j;. -.' ■ f n<:tlth 1

V.) .- t--"™^ H.v^l' Co

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

I)f(fr Fi/rf/,\Jzt(Ay<Kj 1^

If/OH

Re<9i\sfcrcd JS^o,

2288

^

^■J

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco

Certificate of S)eatb

"U. 5. StanDarD )

No.

PLACE OF DEATH; — County of

City of U ^' '

,'V\

Vj -

• Stif

Disti? bcti

and

(

ir Ot«TH OCCUBS *WAV FROM USUAL RESIDENCE GIVE FACTS CAttED FOR UNDER SPECIAL IN
IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD Or STREET AND

FORMATION" "\
NUMBER. /

I

FULL NAME

La

!-\ A

PERSONAL AND STATISTICAL PARTICULARS

A tVcuU

wk: .

DA ri: I iF lilK 1 II

A< .H

^fonthi

n-,n

M..,!fl,

\i ,t! 1

Ihn.

MEDICAL CERTIFICATE OF DEATH

SINT.I.R. MAKHIi:!)

wrnowKn or divuki*)- d

Write ill social <U-^i>f!iat'i n '

I'.IR rifPI^ACK

L\

^^

NAMI-; ni

FATn i;r

BIRTH IM.ArK
«)! lAIHHK

(Statt or Cduntrv

maii)i;n NAM1-;

iW MDTHKK

p.iKTHpr.Aci-;
III Mo'rm':K

' stall' ur Country

DAT}-: Ml- DKATH ( \r\

(Month) f 'Davl (Veart

r m';kI';nV CliRTll'V, Thai I atun-k-.l .Unascl from

tliat I Inst saw h ■ alivt- <ii) - — up

aii<l that (U-atli o(>nirre(l, oti the <lati' -talcd almve, at
^ M. Thf CAi'^i; ni' hl^ATIl was a-; follmv^:

J^U

AM^-4^w ^^^<\.

t

1)1' RAT ION )'iars M<>>if/is fhivs I/onr<;

CONTRIlirTDRV

Dr RAT I ON )V<//

,NEDlLL

^r,'ulhs

Pav

(SIGI

"Vl'A.

0 TnnH f

//ours
M.D.

Oi'Cll'A i'l'iN

^

Rfsitlril ill Sail I'laihi^m

tit i s

1 A .;////.

/),n

rill- Xnovr STATI'D PKRSONAI, I'XRTIOII, \K^ ark TRtK t<> thh
lii:sT OF MV KNo\VI,i;i)(".H AND IQ^I.H.I' ,_

(Itiforni.'int

fAddrcss

Jo^ \X- ck-

Cuvv^

H__Li__il!2
C&AL INF

A.Mri'^s)ll.U. Li. J

SPECi^AL INFORMATION onl> '"f Hospitals Instifutlons, Transicnls,
or Recent Residents, dod persons d>lnij awdv from fiome.

Former or
Usual Residence

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

Now tOR4 it

Place of Death?

Days

I'l.ACK OI- BIRIAI, OR R1;Mo\ AI. IiAT^-; of Hihiai, or RHMoVAI,

t NDICRTAKKR

(AiMm'ss

l.^ ^^kt

Ll.

'H In plain terms, that It may be properly clBMitiea. h-

N. B. Bvery item of in?ormat

•tate CAUSE OF DEATH In p

monm dying away from home should be given m every Instance

ml

i

WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD

REPER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

'I)(f

fr n/rr/, ILlctMMA;

\^

IlJO'i

lioo'/sfrred JV^o.

'^^o9

A^ osjt^nj

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco

Gcrtificatc of H)cath

( "U. S. StanDarO )

PLACE OF DEATH: — County of

City ofv-t^'WTUL WVv<,

Nc-

St.;

-Dist.; bet.

and

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

^

[1

>

I

I

FULL NAME '^^

s^

.U^ <^

-'Si^ v_-

PERSONAL AND STATISTICAL PARTICULARS

^ 1 . \

n

I > >!.' ik

I t

MEDICAL CERTIFICATE OF DEATH

DATl-; ni I»i;.\ Til

\

DATi; t ij 1;1K iH

Xf.K

K

M.,iit'

^„

[>a\

.V.-»^,'^>

Wl I>( »\\ I It » »R l»l\t if.'tl r>

lUKTHlM. Ai'J-:

--! • . . i! 1 ■ 111 nt i \

\ \ \t 1 1 »1
I A I II IK

FUKriii'i. \cv:
ni- 1 Aiin;K

I state lit i'mititrs 1

^T\II)^:N N\M}-:

nl- MOTIIKR

HIk lIll'I^ACl-;

<»!•■ M(»Tin;R /

l^^tatf or 0<»unti n i.

otCll'A 1 loN

^rS!. ml

'i

UmvI iVtari

I IIi;ki:HV CI^RTII'^V. That I a1trii.U'<l ilci lasf.l ftnm

— — , . — ,,^, , — (, , — — — ,,p

that I la"-! <a\v li alivt'Ui —- — — — Kp -

anil that <U'alli oriurred, on tlu- «latf ■-takil almvc, at
M. T1j<-' CArSI', Ol' l)l',.\ Til \\.is a-^ fn!I<.ws:

I >r RAT [ON )Vc?rs-

CONTRIIHTORV

Mo)Uln

fhn.

I Ion I s

Dr RAT ION

)\ays

MiOiths

Ihn

C

u

A'f-siif/tf in Situ /'luihi:'

Months

Ih

(SIG

i,

NED) OkO.d.

a

Hours
M.D.

I

T()0

r A.Mriss) ^XjKkj

vgp^QI^L Information nnl'^ '-'f Hospitals, instifuffows, Transients,
or Recent Residents, and persons d)inq anav from home.

THH AHovr: sr \ ri:!) phrsowi. i-xr ihmi-aks ari- tkik m riU'

lilCST ni- MV KN'oWI.l'.lx'.Ji AM) iii:i.ii-.i-

(Iti fiHina

111- ,-.11 IN ,-«« f >»»,•. •'■ ■ "i ---"v A

( \<l<llfSS

<X/X?^0

former or
Usual Residence

When Has disease rontrarfed,
If not at place of death ?

HoH lonq at
Place of Death ?

Diiys

J'l.ACK iif lURIAI. OK RKMt'VAI

I)\I.j:ii! I'.i KiAi, or KKMuVAI.

190

rxniR TAKHR

I'Aiidrcss

y TT ,. . AHF Hhould be 8tote«l nXAGTLY. PHYSICIANS should

N. B. Bvery Item of Information .hould be carefully suppi.ecl. J''/' .^ clawlfled. The "Special Information- for p«r-

-— . CAUSE OF DEATH In plain terms, that it may be properly clawmea.

state CAUSE OF DEATH In pi

Hon* dying away from home should be given in every inntance.

i I :l

!i

t4l

I

f

WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD

noarfl of Hcnitli 1 N

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

il

\

Br mistered JS'^o.

Ddh' riled, t'xXAAyJLK \'h H^O'i

xtruu^ LtA^u Deputy Health Officer

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco

Ccvtiflcate of S)eatb

*a. S. Standard )

^

^

^V

City of U<Xyw 0 '^ '

PLACE OF DEATH:-— County ofua

r^o. VLXC^. r ' '-^ }■ dJ.LL,..^. ... 'V St.; — — Dist;bct.

ir DEATH OCCURS «W«V fROM USUAL R E B I D E NC E G I VE FACTS CALLED FOR UNDER SPECIAL INFORMAT
IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBE

and

(

" )

■\

FULL NAME

14-

Nl \

PERSONAL AND STATISTICAL PARTICULARS

t ■ ( ) I . < • K

A

rVc

1» A 11 I il- lUKTII

\* .}■:

\

MEDICAL CERTIFICATE OF DEATH

DATH <>! 1>i:a 111 , \

l);i\i

iVtar)

r III'iRI'll'V CIlRTIl'V, That I aliL'ii<li'.l -liixa^t'd frniu

M.iitli)

< I):iN

■> ' .11

) r l! I

1/

siNi m: MAKun:i>

WIUOWKI) OK IHVOKi i;i>
iWiitfiii siHJal »U— i^fuatiim)

lUK TlfPLACK

(State (Il l". Ill lit I \

NAMl, «>!•■

I- AT hi; R

RIKTIII'I.MH
Ol- I APHKK

(Stall ur Cntnitrv

MAim.N NAMK
<»I MoTin-'.K

lUR THIM.ACH
<)»■ MorHKR
(Statf or L'ouiitryi

occri'A'rioN

%

(^ wQ

V.

t

I {pi t<» W i_L.' I(p

i
that I last saw h ■ alive on ' l«^

and that (hath occur red, on the date stati'd above, at J

M. The CAI SI-: Ol-" DI'lATII \va< av OjH.nvs:

J

ro

DIRATloN )'i'(Jts

CONTKIIU'l'oRV U^j

C^

Rfsidfif iif Sat I /-niin />,•>>

)

Moiilfr

Din

THK -XHOVKSTxri:!) PKRSONAI. 1' \ KTf*T F, A K s A K l- TK T K To THH
JIKST Ol- MV KNo\VI,i;i)«.H AND lU'.M' I

(Inforinaiit

CL

f'V'

K

> \. c

(Arldrcs^

lOOM.

i

kji^J^^

X^AfiU^Js'r^

DIRATION
(SIGNED)

)V<7; s

Mnnlh^

w^w

Mnnths

Ihiv

Ih

IHt s

/hns

I lour s

M.D.

KjO

f

A.idre.s) Hn^La\.M

SPECIAL INFORMATION only lor Hospitals, Institutions, Transleits,
or Recent Residents, dod persons dying i>t,A\ Irom home.

"'™"" ^]kaAj^

\

Usual Residence

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

<x

How lonq a\
Place of Death ?

Days

^ULCcLwa.

I'LACK t)I lUKIAI. OK RKMOVAI

'I

0<Xyvu

UAl'Kof ni Hi.u lit RKMOVAI,

V. ^ I H 1 90 1

INDl'.KlAKl'.K \l I W

T>

A N

A<1<lllSS

■"""■^ 73 AGE should be stRted EXACTLY. PHYSICIANS •hould

of inform«tion .hould be cnrefully supplied. ^^^^^j^^" "if led. The •'Spccinl lnform»tloi." for p«r-
E OF DEATH in plain terms, that It may be properly wl.ssitiea.

N. B. Every Item

•tate CAUSE vri w»-- ^ . 1 . „ .,

nous dying »w«y from home should be given In .v^ry Instance

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

REFER TO BACK OF CERTiriCATE FOR INSTRUCTIONa

2291

. ■*.irrv^,3x. i,M t"

.tcA>

Dale AV/f'^/, L^cTcrlhXKj 1^

Deputy

'%J^^'' ^ '

h Of

Ee^ish'rcd J\'o,

I i

« k

\i I

DEPARTWENT oi= PUBLIC HEALTH-City and County of San Francisco

Ccvtiticatc of IDcatb

( •a. S. StaiiCatD ) ^^

J? © i ^

PLACE OF DEATH:-County of OC^O^ JyVa.xC. .Gty of ^^

' \

\

U ^^ ^^M ^ l^lST., DCU .-spj-cAL INFORMATION' \

FULL NAME ^

)

%

J,\,U^dw^v^''^ .

i I I

p!

p^pSONAL AND STATISTICAL PARTICULARS

DATK OF I'.iKTH

u:

\t.i-;

M..iiSh
5 , ,;»

/ ^

I i.iv

^1/ ,,,///

Af 1 A

MEDICAL CERTIFICATE OF DEATH

(Day)

( MoutlO

1'!

(Ytari

WIlH.W 1- 1) OR MIN"^' ' '»
I \Vi it<- 111 -'H-tal di-n-n .t!..ni

lUH rm'i.A^'H

stall- or CouiUiy '

llWvA^^

M^

lx\

S \Ml- «»l-

, nKKi;HV CHHTIFV. Thai 1 alU-iuU-.l .lerca^cd from

that lla^t <MW h ■ '«l>ven„ ^ ^- - ^

,,,Hhat death .>..urr..l.. -nth. aatc.tat..lahnv.. at

^ M. Ths{CA^SI^ <.l; 1 .i: ATI I was a. I0II..W.:

yuDLVx

P I'M

HlRTHI'l,Ai"K

()!• J \rm-:K

I Stat<' in rituntrv

\1 \I1)HN NAMJ"
nl MOTIIKR

HlKrHlM.Ari".
(Slati- or Countryi

Ur RATION >''(?/<

CONTRIIUTOKV

DTK ATI ON >\'<^'*-^

(SIGNED) L^ ^ ^

Months

/hns

i/iun s

M^^nlh

n<n

M.D.

Qm ^ I ^t ! -

w --*•' _! -^ • , H^.:. .1, i„.:»i»iififtn«L Tr

,3««Ue*«t ' aad pe.sons dvin, ...» f.»^ *'™'-

nrori'ArioNQp^ y ^

\r,,„tii-

/>.r;

,„,sr..,.MVKN,.^-...-.-' n .,

former or Q 1 .

Usual Residence 0 i u

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

. Hov* long at
I Place of Death ?

Days

I.Vri'"! H' KiAl. or RI%M«»VAI.

IL C. t. "-' ^ T 90 i

( \(l<lrrss

X

0 10 UJXAMA.*-.' ' ^ "" PHYSICIANS should

' 7„ ^uoDlied. A«B should »>n.'*'»'^:;.^. ..g ' Jli.*! Information" for p.r-

„, ,„fo.n,«t1o« should «;; --^^J^-^ --^;t P.OP.H. ciassir.ed. Th. 8p..
E OF DEATH In P «' "--:.' l*^"* ,,ery InBt.nce.

^- «-r:r Ja;^. op death . ;-—-:.... ....ce.

sons dying away from home »

I

WRITE PLAINLY WITH UNFADING INK

of II. :i!tll 1' N'

Dah' Fllcil , \jf^kJ\>X^ 13

/ U 0

THIS IS A PERMANENT RECORD

REFER TO BACK OF CERTIP.r.ATE FOR INSTRUCTIONS

DEPARTMENT OF PUBLIC HEALTli=City and County of San Francisco

Ccvtificate of 2)catb

I XX. S. 5tanC»a\:D )

f H (\tAjlXAxr 1 >

PLACE OF DEATH:-Co.ntv ofM -^-A.^-. ^ ^Uy ofM ^tic^.d^ ^

No.

wi

' Vila*-* . ' SU D'^'-'^*- .„„u.n„s»c,..,~r;\"t

I ir DEATH OCCURRCO IN A HOSFHHU un

\ 11 U]|l

)

RMATIO
MBER.

..)

FULL NAME

PERSONAL AND STATISTICAL PARTICULARS

MEDICAL CERTIFICATE OF DEATH

.1'!

I) \ I K I t| lUK I'll

1 I

il

a.

/^t

\< .!■:

6 I

(Day)

M.oilli^

Vi ari

/)..•

I>\TH <>1 1>KATH [( \

L

(Day>

IQO i

(Yt-ar)

\Viit(

A

-...lal il.

I, -•

"\

i ilKkKHV CI'KTIFV. That I atU-u-k-.l <lcccasea from

-. - 190- tn __,,p —

that I last saNV li '" alive on — ''^

,„.l ,uat .U-atl, nccurre.l. .u, t1,c .lat. stated ah-.ve. at "

— M The C\rSi: Ol" 1)I)^TII wa^. as foll.ms:
-15 ' ■

^1

'^

L

(0

lUK nii'i, xr}.;

1 A I'll J K

niRTHIM.AiH
Ol- 1 AinKK

1, statt lit rodiit! y

MAini.N' N\M»

lUKTHlM^AiK

()i. M(>'i'm':K

(stall "t I'oniiiry

occrrx rioN'

1

U^/.

DU RAT I ON ^'*''^

CoNTHllU TDRV

}/,>>///ts

Pav

IIoHt S

.)r,>>itlr

Pars

Hours
M,D.

Rfidn! in S,n' /''

Il III ! I'll '

) , ,/.

fhn

n....juiiv 'y.v

(SIGNED) V(j/J^^JCwUv.,-.:

SPECIAL INFORMATION »»M"««l'i'*.l"^'''*"^' •""^'"'^'
«, Refe^ Wdenis, and persons im «■» >'«'' "»'«■

Former or
Usual Residence

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

Hovv lonq at
Place of Death ?

Days

rXACKOl- ni-RlALOR RKMnVAI,

0

AiMtf^*^

UHvjUaaa ^^

1)\TJ •' U' KiA!. or RKM«)VAI,

T90H

*" ^ , FVACTLY PHYSICIANS should

,.„ «Hou.a H. c«.e.u,.. :^PP;^t .^hX^I:- "- --^ «"^--^'^^"" "^ "^"
m in plnin terms, that .t m»y hfj; ^

N. B. F.very Item of Informsit

state CAUSE OF DEATn m P'""" [---j^^^ ,„ ^vory instance,
son. dyinft aw»y from home should be fe.ve

« t I

h
I

wi

WRITE PLAINLY WITH UNFADING INK

THIS IS A PERMANENT RECORD

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

2293

Registered JSi^o.

I)(,fi' /'V//>^/,(DiitA^. li lOO'i

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco

Certificate of Death

( "a. S. Stan^ar^ )
PLACE OF DEATH: — County of O^Lox; Jxa.^CA^4c City of Oo^^ J Axx/y\/c.4.^^c
No 15^'i^ "^O ' . St.; 3s Dist.;bet.ciiXlAH.')VCU1f\ii)and WW-U

/ ir Dt*TH OCCUnS *W*Y prom USUAL RESIDENCE Give facts called rOR UNDER "special INFORMATldVl" \
V , ir DEATH OCCURRED IN A HOSPITHL OR ^STITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBEF^j J

FULL NAME

>-i.\

PERSONAL AND STATISTICAL PARTICULARS

jIMotith^

W

I,;

I) \ li; It!- lUKTIl

\<*. F.

<Dav)

M.mth'

\ tar)

Ihi

SIN<,|,J-, MARKII'D

\vinn\\i;i» ok i)i\( iRk i-r)

•\\'iit«in 'sofial d' -if iiat i. m >

KhjUiA^

HIK rHIM.AOH

1 Statr or Country

I A 111 IK

HIKTIIFM.ACH
oi- lArilKK
^latc or Country

MAIDKN NAMl
(»!• MOTIIHR

niK rni'KAci-:

oj' MO'lJllvU
(State or Country)

OCCri'A TION

Tn

i

0 X ex ^ V- 1

^

V

\ I 1

n

DC^ic^ u 1 1 \.

fCf'iif/'if ill San I I ttih

)'t',n s

A/,iiif/is

/>,i

THl* AHOVK STA IKl) J'KKSoNAl, I'AR riCC l,AKS AR)' TRt K K > THK

BKsr OI" Mi' Ky<)\vi^;i)c.H and ni:un:F

(Infotniatit J . vJ

MEDICAL CERTIFICATE OF DEATH

DATK OF DKATH A

(Year)

(Month) (Itey)

I m:Rl':BV CI':RTIFV, That I attemU-.l deceased from
...... igo'i to A^ wL \X 190 H

>^:- - ... -. /

0
that I last saw h

alive on

w -ct-

1 I

190

^i

and that death occurred, on the date stated above, at i oO
'. M The CArSK OF DKATIl \va^ as foll«)ws :

Q^

c 3<X.<->L<^> ' '

d.^

DTK AT ION y'l^ars

CONTUIIUTORV

DTRATION y'mrs

Months Days

Hours

Mouths

Pass

( SIGNED ) wv^-MAX WK/O. ^ -v.. . , ,

Address) utcUxKi X

Hours
M.D.

H)o

(

4/>A^\^

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

Former or
Usual Residence

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

How long at
Place of Death?

Days

i)ATi:<if HcHiAi, or kf:movai,

OcX I'l 190H

l'I,ACH OF lURIAI. OK K1:M<>VAI,

INDKRTAKHK M^- 0 AXXU ' ^

5S1 ^dA^aijuv. 'n.t

(AtUlrcHs

State CAUSE OF DEATH In plain terms, that it may be properly ciassiTsca. 1 • «j p
«on« dying away from home should be given \t% ms^ry Instance.

I in ; I

i

t

ST

I

WRITE PLAINLY WITH UNFADING INK

2^>'6>H

THIS IS A PERMANENT RECORD

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco

Certificate of ©eatb

( XX, S. StanDarD )

PLACE OF BE ATH ; — County of

City of

\<X

(1)

/yXAAJOu

^No.

St

Dist.; bet.

"and

/ IF DEATH OCCURS AWAV FROM USUAL R E S I D E N C E G I V E FACTS CALLED FOR UNDER "SPECIAl I N FO R M ATIO N " \
( ,F DEATH OCCURRED .N A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. J

FULL NAME Ox

•^ix

I \ 1 i: < »! lURl'Il

PERSONAL AND STATISTICAL PARTICULARS

Ji

f)

OAhjJi.'.

(.'ui.t )k

M.iitht

\<.i.;

}:•,!,

(Writ) in - •■ i il lU-^iy iiati. m >

RIRTHl'I. \tM-,

(St;it< iir I'.iniitrx'

I- AT 1 1 l.R

><

lUK 111 I'l, \< H

OF lAini-.K
(State nr Cmintiyi

M\II>i:N NAMl",
(H- MOl'lU'.U

/

p.ik rnri.At'K

ol MoTlIKK /
(Statf or iNnuitry)/

^

orci rATioN S A

rl A 8 K 1 I '

K'fsiifrif ill

Sti II I'l ti Hi 1 ■' '1

(Year)

MEDICAL CERTIFICATE OF DEATH

DATK <>J' 1)1. \ 11 1 (V\A

(Month) K (Day)

1 illiUlUJV Cl.RTII'V, riiat I att«.ii.K-.l .kHxasctl from

• — 190 to 190

that I last saw h - — alive on — — — i^ -

and that death occurred, on the date stated ahovc, at
"-™ M T!ie CArSI<: OF DI^ATH was as follows

4 ,

),<n

MntlHl^

/),/K

Tui- \n()VKSTA'n:n pkrsowi, rARTim, \rs akk TRri- t*> thk

l!l-;S'r OF MV KNOW 1,1. Du^K AJ\I) lU.UIll-

( \<l(lr('^«;

DTK AT ION Ycais

CONTRIIU roKV

Months

Days

I lout s.

)'i'ars

Mouths

fhivs

nrK.xTioN ^

,NED ) /.. V9. a.\jL£urivc. . .

b i„oH (Ad.lress)M llo^'YV^Xa V

(SIGI

Hours
M.D.

SPECrAL INFORMATION only 'o^ Hospitals, institutions, Transients,
or Recent Residents, and persons dying away from home.

Former or
Usual Residence

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

How lonq at
nart of Death ?

Days

I'l.ACK Ol" HIRIAI. OK RJ;M«i\AI

l»\ll o! Ml Ki.^i. or R1":MoVA1,

190

be stated EXACTLY. PHYSICIANS .hould

N. B._Bvery Item of l„tr.„„tion should be c«..fully -ppl.ed )^^J^;f^^^J,.^^^^^^^^ ,„for„,atlo„- for p.r-

«tate CAUSE OF DEATH in plain terms, that it may be properly classiiiea. i

state CAUSE _- . • » .^

fion« dyinft away ?rom home should be given in every instance.

J s

WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD

Bonn! nf Ihalth !■ Vo. ;- -f-^-^ar;^ H&P Co

REFER TO BACK OP CERTIFICATE FOR INSTRUCTIONS

R

r\

Dale Filed ,

a.

190'i

Be^istered JVo.

2295

du^vco^ Ilxki Deputy Health Officer

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco

Certificate of H)eatb

J!

( TH. S. StanDar^ )

Q^

PLACE OF DEATH : — County

(IF Dt*TH OCCURS Aw*V
IF DEATH OCCUrI^ED

ofU/OLA^ OA,<X.-v%CUi-'Gty ofO/CLA\; 0AXX^^v.cu4./ec

Mli

ksfea

Dist.; bet.

and

USUAL RfeSIDENCE GIVE FACTS CALLED FOR UNDER "SPECIAL INFORMATION" \
aSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. /

FULL NAME

i I

♦

i

PERSONAL AND STATISTICAL PARTICULARS

DATH <>I lUKTH

.l).kc*

M.iiitir

AC.K

SC

r,\i>

Dav

M.nilfis

(Vear)

Dii I .

SI NT, 1,1' M \Rkn-:i>
WFI>()\Vi:i> UK !)IVnKv*i:n

lUK rniM.At*!-:

f Stiitt or (.Dimtr y

Oxj>r\jc:v\X

dxu.

-*^ V > \ \

N'AMl' ol-
I- AT III-; R

RIKTni'l,A(.K
Ol- lAIIIKK

(State <ir CiMint! V

MAI 1)1 "N N A Mi-
di" MOTIII-IK

lUHrniM^ArH
Ol' MorHKK

(stair or t'otuitiyl

MEDICAL CERTIFICATE OF DEATH

DATE OF DKATII | A

li'ct II

(Month) (Day)

I HI'iRIUJV CI:RT1I'V, That I attended ileccased from

-, to

rgo 1

(Year)

that I last saw h

I90

- alive on

190
igo

and that death oceurred, on the <late stated ahove, at

M. The CAUSH Ol" 1)!;ATH was as follows:

1)1' RAT ION Years

CONTKIIU'TORV

Months

IMvs

fS

1^

(KcrrATioN J^ 0

h'f'yi,frtf ill Sai! /'i tiiii />,•!>

) III

M,„it/i^

Din

THH AHOVKSTATKD PHKSONAK I'ARTnr I,AKS A K I
iIksT Ol'" MY KNOWIJ'JX'.K AND r.HMI-.l'

IRIK TO THH

(Informant

(A(1<lri-ss

TO- SA^d. Jt

DT RATION VciJys MwfAs ^ Days

(SIGNED) urXr^jLhj 0 .yj.U). ouX'.'. . .A

Hours

Hours
M.D.

lli^. U

I()0

(Address) WUTnO/U)

m

. .St*-; xi**-- * . ,

SPECIAL INFORMATION on'y 'or Hospitdls, Institullm, Transients,
or Recent Residents, and persons dying away from home.

51

HMa^--"^

Former or
Usual Residence

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

1

How long at
Place of Death ?

3) Days

ri.ACK OF niRIAI. OK KKMo\ AI
tNDi:RTAKF.R *■• VJ . W

DAi'l'.o! Hi KiAl, or RKMoVAI.

190' i

,. . The Hhoulcl be stated EXACTLY. PHYSICIANS should
N. B.— Every Item of mformetion .hould be caretully suppl.ed ^^^ «houhl be ^^ Information^ for p.r-

state CAUSE OF DEATH in plain terms, that it may be properly Uawitiea. h-

fton. dylnft away from home should be given in ^y^ry Instance.

~f

n-

I

\il

•A

i

if

,,f lli:<ith I- V

WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

•w-^^ H\.!'

Dfffc Fi/('r/\^ctA>^i>v I

rjoH

Ilc^islci'etl jYo.

,^r\xM

Vi f

! i

I) f

M

\ '

Deputy Health OfTicer

DEPARTMENt OF PUBLIC HEALTH=City and County of San Francisco

Ccttificate of H)catb

( "d. S. StanDarD )
PLACE OF DEATH: — County ofOa^x ^ \0. ^v-' < :<■ City oi^Ou^ OAxx^vvccO ' (

No. ll

Q

I V. V

^f<y

fOi

( " "^roz^^nlTcln^to ^'nl^HosPn^Z or 7nst",tut:on give its NAME instead or struct and number.

IS AWAY FROM USUAL R E S I D E N C E G I V E

tut,

FULL NAME ^VjO,

Of 4 M

St.; ■ Dist;bet.LL'<XA'tXCY\.a- . and

IIDENCEGIVE facts called for under "SPrCIAL INFORMATION"

i}

)

)

A\

OXaJ.

OJiM

-^\ \ {

.,* m

PERSONAL AND STATISTICAL PARTICULARS

A r<tl.i)K

OX
I) \ 11; til i'.i R rn

Ai ,1-

A

i^

Mnith-

r\\^

\ rar

Ihi

«^i\i ,i,i" ^T \K 1-; n'i>

1 Wri!.^ in -■ .111' !.-t"n.;ti. n)

I Stnt. 1 M I ' •nnti \

I A rn IK

Hik riii'UAt H

<)!■ I A 11 IKK

(Hlat< "ir i"(miit;\

MAIKIN \\MI,
<)1- Murm-'.K

HIRTlll'l. \K v.
»»I- Mnilll-.K
(Slate or i'lMiiitty

/^ 0 n (1

MEDICAL CERTIFICATE OF DEATH

DA 11-; i)i- ni'.A rn

M<iiith>

I I
(Day)

IQO \
(Year)

I Hl';kl';i5V C1:RTII'V, That I aUciuk-.l (ItHxascil from

— — — — — up to IQO — —

that I hist saw h :: alive mi - --- ~~ 190 ~

ami that lU-ath occiirrcil, nn the date stated al)i»ve, at

M. The CAlSh: OI" DIvATil was as foil

a

(»\VS

O^V^t » V-V NV

"^

OvTlTA TION

t V

R>-^itfr,{ ill S,;)i I'jtui. i-'-n i Ij

nojO^ Ox^C^

;i

) ,,ii

M,,Uth:

lhl\

THr An<)VKSTATH!)I>KKSnNAI,r\RTnTI.AKSAKK TKIH K • Till-
lil'STDl- MV KNO\VI.i:i)C.K AND iU-.I.n.l'

(Iiifoimant

QPrw

I

X.Ulifss 1 V J -V

Drk.XTION )'t'ars

CONTRIIUTORV

I )r RATI ON )'cars

Months

/)av

//ours

Mouths

( SIGNED ) L^r^un-vih. J m UJ-

J

Ihivs

I lours

iDct

W IqoH f

Addri'^^) W

^\j^y\XhJs

\\,^ M.D.

Special information only 'or Hospitals, InstitufioflV, Transients,
or Recent Residents, and persons dyinq away from liome.

Former or
Usual Residence

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

How lonq at
Place of Oeatli?

Days

PI \CH <»I' IirKIAI. «'K Kl.Mt'XM

i>\ri", o! lu KiAi. i>r ki-:m<)\'ai,
'^ \\ T90H

fNI)i:KTAKi;K

ir, .^^B should be Rtntecl EXACTLY. PHYSICIAINS should

^. B.— Every Item of 1nform«tlon should b. curetully «"PP'- • ^^^T;,^^";,^^ The -Special informntion" for p.r.

state CAUSE OF DEATH !n plain terms, that it may he properly Uassme
sons dylnft away from home should be gtWen In every instance.

I

* I
a:

h \

I I"

:ll

I;

1

1

'

H

4 il

1

H

]5,.:i1,l '.!' I

i I .; : ! ;i

WRITE PLAINLY WITH UNFADING INK

li)0\

THIS IS A PERMANENT RECORD

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

lieo^isfrrcd A'o, ^^ J7

CU_

\ n. (

ue

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco

PLACE OF DEATH: — County

Certificate of S)eatb

( 'd. S. StanDarD )

U)

and

No %HC OcLl^vA.' St.; ^ Dist.; bet. J a.My V C

I rx c^ c

w L\„S^

FULL NAME

^ic.,

V

A

L

.a

PERSONAL AND STATISTICAL PARTICULARS

•>1.\

C< >1,< »R

J.

I) \ 11-: >»r ink 111

V\

Mutll I

/ tj it.

A». 1%

).i \

.V-.i/A//

* carl

/hn-

-I\i .!,1" M \K 1< 11 1>

W I !»t i\\ 1 I > ' -'■ ' '"- ' >*• ' 1'. I>

Writt :n

HIKTIll'I. \i")-

»• A 111 i;r

I'.iR'niri AcK

<)! lAI'Hl'H

' stii! ( iir I'tiiiiiti %

III M(»'rni K

11 »

y.

MEDICAL CERTIFICATE OF DEATH

DAll-: <»l- Iil'.ATll

u

I);iv)

(Year)

f Month >
I Ifl*;Rl!l5V el.RTII'V, That I attciulcMl (ieccasctl fiDUi

: — — — -r— — - iqo ~

: -. ;.. Up ■

li)0

~ alive oil

in

^

:l

AXLh)

(\

£L

'1)

)JLn

A

lUK'rmM.Ari-:

Ol' NtoTIIKK

( Slat' ' >'i Ctnint i \

^ I

(nCri'ATltiN

'K

) r.ii

\/. ■>■//!'

/>,M

TUKMK.VKSTXTrni.KKSnNXl.rXKTU-t-KXH- XRKTRrH To THK

HKsr Ol- .\n knmu i.i.ix,}-: and lu.i.ii.t

ill fiiniiaiit

cM-/^v^Ou

\,l,lrc>-^ u I w

OS?

M.V

1 u.

that I last saw h "^^"^

atid that (Uath occurred, on the date stated above, at
'^ M. The CAISI^OI- DIIATH was as follows :

w<.U

La

I )r RATION )'rars

CONTRIIU'TORV

Month}

Pavs

Hours

I )r RATION
f SIG

)',■,! IS -. Months

Pars

NED) UfurrWv J,mlU.llJbxA\'^

flouts
M.D.

\».

TQO

f

! SJ

SPECIAL INFORMATION on'v '"^ Hospitals, Institutions, Iransients,
or Recent Residents, and persons dving away fro:ii tiomc.

Former or
Isual Residence

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

How lonq at
Place of Oeatit?

Days

I'l.ACK <»1 lU RIAl, OR K1;M<>\M.
oX<VU^OL. rw

■Nl.l.RIAKHK b /<xLt'-r\^ J n\<YV^>'^^

nxi'i'.o: HiKiAi, or ri;moxai,
liJ/tlX .4 190 1

■"^ TT ,7 , AHF should be stated EXACTLY. PHYSICIANS should

tem of !„?orm«tion should b. cnr«»«IIy suppi.ed. '^^'* ^^^^^^^^^^ The "Special informalion" for pT-

AUSE OF DEATH In plain terms, that it may be properly classified. \

!„>. „..,-„ «««.« hnma should be ^ivcn in every instance.

N. B. Bvery I

state C

none dyinjk away from home should be A

li

r

I,

IN

I '

H

WRITE PLAINLY WITH UNFADING INK

H. at.l '.f f!< :i;'!> i V.

l;:^!' c

VJO'i

THIS IS A PERMANENT RECORD

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

lie^istered J^o, ^^2 J8

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco

Certificate of Beatb

( Xk. S. StanDar^ )

PLACE OF DEATH: — County oi^^O^-f\j ^^ ex.

i

m

No. I eijacv,-v.

i

St.;

Dist.; bet.

City of ^ OwA^ 0 Axx

and

CCURS AWAY FROM USUAL R E S I D E N C E G 1 V E TACTS CALLE^D "^OR^UNOER ^ ^ PCC^At J N ro R M ATK> N ^

( ir DEATH OCCURS AWAY FROM USUAL H t i. I U t Pi ^ t u. v t .-v,,o --•-"- ,„«TrAn nr «;Tl.rrT AND NUMBtR
t IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER.

y

FULL NAME

\JXrs\xx.

\

^iixi.

h

^

I» A TJ' < >! iUK 1 H

PERSONAL AND STATISTICAL PARTICULARS

(■(tloR

iDav)

A I . J-

)•.■..'

Vtar!

/',/

SINT, l.I-: \IARHIl-:i»

\\'FIH >\Vi:i> <tK niXMRiKT)

: Wt w 111 ■..M-ia: ,1. -u-!Kit;i.;i '

lUK'nii'i. \i'i:

<t.i!i I .r • 'i Hint! \

N \M 1 «»l

I- Alii IK

lUKTHJ'l, Avi:

oi isriiKK

I stall III i'liuntiyl

MAini'.N NAMK 0

OI' M»)i"ni;k S-

lUK rui'i.AOK

I Siati I iv v'l miiti X

/^^^'^^oAA

0/Ouy\j 0 '^

r'>

A

-^

•v

Aj

1 (■>

LoJ

.CifrV

oCCri'ATlON

Kt-si,!f,! in Still I'l !,•

'^

) ,■,;

M ,iith

MEDICAL CERTIFICATE OF DEATH

DA 1 1-, (H Dl.A I'll

^

vi'd'

I (JO

(Yea I I

(Mi)iitlii <I)av>

I Ul':Ui;i'A CliRTII'V, That I alteiidcil dercascd from

— to — __

igO

— — — — ^^

that I la-^t <a\v h " alive on - ■ ~~— 190
and that «kath orturred, on the date stated above, at
M. The eUVrSI-: Oh* DI'lATH was as follows:

I) r RAT I ON Years

CoNTRlin'TokV

DTRATION YtQrs

(SIGNED ) %

yd; •'

Month's

Pav!

Hours

Months

Pars

Hon

rs

T<)n

\.ldress)lClk)UJaAi

'\.CTU^

M.D.

opFciAL Information on'y '^ HospiUls, lnstilutio»/s, Transients,
or Recent Residents, and persons dying dwav from tiome.

TflF M5<)VHSTATKI>l'KKS<.XM.rNKTKTI.AKSAKI- THl K To THK
lil'-ST Ol- MY KNoWI.l.lK.i: \M> Hl-.I.Uf-

(Informant \J I LOv'T^.-U-A' \! I U^

A

Former or
Usual Residence

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

HoM lonq at
Plare of Death ?

Davs

ri.ACH 01 HiKiAi, OK ri:m<»vai.

mt OLv^

rSDlCKTAKKK

DATlliif BiKiAr, or KKMOVAI.

1

,. . Thf Khould be stated EXACTLY. PHYSICIANS should

N. B. Every Item of InWniHtion should be carefully fuppl'^rf. „;''^ * °,,3««;jied. The "Special information'- for p.r.

•tate CAUSE OF DEATH In plain terms, that it may be properly ciassme

•nns dying aw«y from home should be given In every instance. ^

f I

I

i

SHMi

WRITE PLAINLY WITH UNFADING INK

li, an' ..t 1I( .iith ■ !• No i^ '^-'tc^'^ "^'' ^"'^

/J.///^ /'7/fv/,U^^UWv) 13

ie9(9H

THIS IS A PERMANENT RECORD

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

Registered *A^. ^^^3

^Hj Deputy Health Officer

DEPARTMENTOF PUBLIC HEALTH=City and County of San Francisco

Cevtificate of 2)catb

( Xl. S. StanDarD )

e

PLACE OF DEATH:— €t:)unty ef Ocunrv Wjl m\ b City of d^^^ ^

w ^ ■

y

No.

St.;

Dist.; bet.

and

w ,„^». IICIIAI Rr«;iDENCE GIVE FACTS CALLED FOR UNDER "SPECIAL INFORMATION" \

Wi'

FULL NAME

U

xj:xhXu

si;\

PERSONAL AND STATISTICAL PARTICULARS

i \ . .

'I »

DAii". oi- lukin

Muiithi

\«.i:

]',,,-;

Da VI

M.mihs

( Vearl

/).;i.'

H1N< ■,!.!: MAKKI!'.!)
'Write in -iM'ial ii« "-ii'tuitn'iil

lilKTHl'l. \i'l-:
(Statf I'T I'liunt I V

l\ IIU-.R

BIKTHI'l, AiK

ni* 1 A rm.K

(Stall of riiunti s

MAtUF.N NAMH
n! MoTllKK

MEDICAL CERTIFICATE OF DEATH
DATE Ol- Dl-.ATH , ^ ft

LlkxJL

(MdntlO

a)ay)

(Year>

1 in-:KHBV CICRTll'^V, That I attended deoeaseil from

, , 190 to 190 """

that 1 last saw h •^^- — alive on — '9° ~

and that death oeeiirred, <>n the date stated ahnvc, at -—

M. The CArSIC Ol' DIvATlI was as followR :

^/

V

/

lURTmM.At'l". /

()!• MoTUl-'.K /

(Stall- iir CouiitiNy'

AVsiiffif ill ">'"' /•'nii'i'^'"

) III I

1/,M/,'//.

/•

TMF AHOVF STXTF.I) «>KkS()NAI. PAKTUTI.AKs AKK TKn- Tn THH
liKST OF MY KN.»\VUKU«.H ANJ> HICUIF

c.a

(Itifo.mant N I La.yt^'

I )r RAT ION i'tars

CONTRinr TORY

Mofit/is

Days

I >r RAT I ON

Vtars

Months

!\jvs,

( SIGNED ) VA- ^ . 0 M \iO^<: \

Hours

Hours
M.D.

kx.O^ W iQoH (

Address) \)l UX/yuJUt

SPECIAL Information ©nly 'or Hospitals, institutions, Transients,
or Recent Residents, and persons dying away Irom tiomc.

Former or
Usual Residence

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

How lonq at
Plareof Death?

Days

ri.ACK nl' niHIAI, nk Rl-MoVAl,

DAlJi >f HiKiAl, or RKXfOVAI.

190

U-tt 15

I \ \

dv

IN!)1:RTAKKK

(AcMus'i

— ^ , .. ,. , InF should be stated EXACTLY. PHYSICIANS should

N. B.— Every Item of information .hould be caretully f"PP •-^- ^^^^ classified. The "Special Information" for p,r-

Btate CAUSE OF DEATH in plain terms, that it maj be properiy »

iton. dyinft away from home should be feiven in svery instance. A

i

P

IM

M!

•t;

•l^'l

WRITE PLAINLY WITH UNFADING INK

11.,;, 1,! .,f IKallh r Vn :^ H.H:^*' '•^'' *""

I)

((/r Filed . ycLrL^

.MA* 13

i,96>H

THIS IS A PERMANENT RECORD

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

.^cu5 Lc 'I. Deputy Health Officer

DEPARTiyiENT OF PUBLIC HEALTH=City and County of San Francisco

Ccvtiftcate of Bcatb

( Ta. S. StanOarD )

PLACE OF DEATH: — County ofOctA^

1 V. ^

J (^

City of Uxxn^ J/i

No. .

Ml^dluJ

NJK V.VV....^.v St.; % Dist.; bet. cLao ' ■., . , . •. and-

/ ,r DE.TH OCCURS .w*Y TROM USUAL RESIDENCE a.vt r*CTS called ^onj^oz^ j;"'*^ '^^^J^^J'^"'* )

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

)

FULL NAME

a

I <

><tHCUL^

^'■^ (hn

PERSONAL AND STATISTICAL PARTICULARS

v|

c

n

1» All: ( >I UIK III

\« .1-

Ml. nth

b

ll):»vi

5,./

M ,>illn

V< at

Ihi

siN(,M- \!Akun:i>

\\ I i)t >\\ i: It < »K i>i\< ii'i !•■ I)

iWiit' in ^iiiial di -ii'iiat I'lii)

HIKTin'l,\»»

'St.lti or ('H! lit 1 \

N\MJ', nl

lA riniK

HiKiiii'i. \ri-:
«»i 1 \ rm.K

(^)t,iti <i! i"iiimtf\

\1\im.N' N\MI-
.11 MoI'Ili: K

lUK rupi, A»i",

()l- Mu'l'in K

(stall -1 *'-iinti \

occri'A rioN

K\M,If,l in San I'uix, ;

IX

\

1

\ K ^ .^

,L-'

U

r../

M.nill, V. //,/

Till- MtoVJ.ST\T1l)PKK«;«)N\l.l'AKTUri,\KSAKr. TKfH To

ni;sT«>i Mv kn(»\vi.j:i)<'.h and lu.i.n-.h

in-;

NjlLvok/CuX

r\.i.iii

"W^

v^-w \

Medical certificate of death

DATH OF I)1:aTH

,.A

(Mi.ntli>

(Dav)

I go
(Year)

I llI'lklll'A' CIRTII'V, That I atteiukMl (U-ccased fn^n

t

L 190 H to Uc^ '5.. 190 i

that I last saw h .- alive on W CX '5. 190 S

anil that death ncciirrcd, on the date stated ahove, at ! •
M. The CAl si: Ol' DI-.ATII was as follows:

M rLiryxAy-yxXlAxxX ''lbjw>^xc\

DT RATION

c oNTkim r<»KV
nr RATION

( SIGNED )

Yea

Mouths

Pax

Hours

Years

Month

Pin

'S

A 1

^\_

Hours
M.D.

(Address) 5Hb O^UXLiH.'

Special information only Jof Hospitals, Inslitutions, TraJisieiits,
or Recent Residents, and persons dying away from liome.

Former or
Usual Residence

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

Now lonq at
Hare of Oeatli?

Days

ri.ACK oi- niKiAi. OR rj;mo\ai.

1> \I'J: .it" Hi KIM. lit RHMo\AI,

l9/ct S% 190H

^A^Xi^tV

/a. .w

. TT A,.p «hoiilil be stateil RXACTLY. PHY8ICIAISS should

„. B._Kvery Item of information should b. c„r«fulfy «UPP'- • „^^ f^,!^ ",„Uwird. The -Special lnf«r„u.ti«n" for p-r-
state CAUSE OF DKATH In pliiin terms, thot it mtiy be properly uaiiemeu.
Aon« dying away from home Hhoultl be given in .very inntnnce.

t

"'■•I>.

. • ' »

•^.Ai

.''I

t

4U

i*

i^' '

<*.♦■

'a

^v ■

; '

LOCALITY OF

RECORD S

SAN FRANCISCO
COUNTY

S AN FRANCISCO
CALIFORNIA

HEALTH DEPT

M ICROFI LMED

FOR

( ■>

T H E G EN EA LOG I CAL SOCIETY

OF SALT LAKE

C I TY

UTAH

C A L I FORN I A

DATE

APRIL

1

1975

PH OTOGRAPHER

MAX JOHNSON

CAMERA ■no2683" RED 1

I

VOLUME

RECORD

"■

300

t ^.

* ',

■- /

' ," 1

«»

k

lw>.

.,>

>•-

I '

• * I

•

mwm

LOCALITY OF

RECORD S

SAN FRANCISCO

COUNTY

S AN FRANCISCO
CALIFORNIA

DEPT

M I CRO F I LMED

FOR

T H E G EN E A LOG I CAL SOCIETY

OF SALT LAKE

C I TY

UTAH

CALIFORNIA

DATE

APRIL

1

1975

PHQTOGRAPHER

MAX J OHNSON

C AMER A MnO 2683M R ED ]

VOLUME

YEAR

RECORD

CERTIFICATES

J

301

:6

4

I

EGIN

i I

•<..»

i

^

of ^'

"

, )!)(-. \M^^'

ea

V V

Bjy

OE'"''^^'

•l

WRITE PLAINLY WITH UNFADING INK

Hnnr.l ,,( H.Mltli 1- No. i '^ ■?-'?;Scp;'A;) USc IT.,

/)((/(' Filed ,

lOO'i

THIS IS A PERMANENT RECORD

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

2301

Ec^istered J\^o,

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco

(No.

PLACE OF DEATH:— County

.a.

Certificate of 2)eatb

-i\j J ,A.a'>vCi^. C.i. City of ^ /O^'^vx;

St.;

Dist.; bet.

.{rTd.ai5.>.^xCli(. and

UNDER "nSPECIAL INJfORMAT

K.<X\.r^'\. )

( - ;;^i;i^^c:^R^v,?'- ^^t --|^?ij^^;^^;ij^m^ .^^" x:ivr\^^:z^- )

/^

f\

FULL NAME J^t

n

^l.X

PERSONAL AND STATISTICAL PARTICULARS

ftldl

r

1» AIi: » »f I'.IK Til

\ « . 1-:

(\

ipil..uth

D.iv

,'n

M,n,{ln

Iht

SI\r,l,K. MAKKIl'.n
WllXtWl'lI) <»K l)I\< X-S 1 I)
Uiit'-in ^iK'ial di -i-.Miat i< ni >

i!iR rm'i, \»'i^ \

' Statt 111 I'oiintrv s I

A

ci^C.

V

NAMK nl
FATm;R

TUKTniM,.\t.'K
«H lATIIKK
(St.ttf i>r Counti V

MAIDKN NAMl
<)!■ MOTHKK

HlKinri.ACK

«)J- M»>THKK

i Stall or Country 1

4 I I -• ■

i

I go

(Year)

MEDICAL CERTIFICATE OF DEATH

DATH OF DlvATH j ^

(Month) (Day*

I II1':RI':BV CIvRTII-V, That r attended (U-rcased from
^'.^■t: ', 190* to v.d' 11. 190 H

that Mast saw h .'■- alive on W - >^ '^ 1<P

and that death occurred, on the date stated above, at
M. The CATSlv OF DliATH was as follows:

o

^cu

4 .

l^i

ClI. ^ -^ -^ Ml

iCC^^'.^

(^.

d.xxA^o-'vC^ •

Oivtl'A rioN

KfM'di'ii i>l SiUt /'l il II, /•

rvl )v,/

M.'iitli-

I hi v.

T.lHAHOVKSTATKI>I'KHS.»NA1.rXKTirri,AK«^AHU i-Kl K To THK
HKST OF MY KNO\Vl.F:nc.H \Nn HIJ,I1.»-

(I iifoimant

Addrt-ss 1 6 I

a

Mk(X

tXA-Aj-CUx.

i

DC RATION
CONTRIIiU'

)Var5

Qflojt^

Months Days

Dl' RATION )'fV?r5 Months Pays

(SIGNED )... La • Ob. vwo. .A.A«a^V'

.ned)..LI- ob. vi

%)s:iu..X^ iqoM (Address) 5 0 a. 6^^

Hours

.), .. -....i

Hours
M.D.

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

Former or
Usual Residence

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

How lonq at
Place of Deatli?

Days

I'l.ACH «)1- nrKlAI. OR KHMOYAI.

rNI)F:RTAKKK

(Add I CSS

— ""— "■"■"■"""■"^ 77i \ II «..„«r.^d AGE should be stated EXACTLY. PHYSICIANS should

N. B. Every Item oi information should be ^"'•«^""y «"P^ ' ,y classified. The •'Special Information- for psr-

state CAUSE OF DEATH In plain terms, that it ma> he proper y

Jo^s dyini awy from home should be H^iven In every instance.

WRITE PLAINLY WITH UNFADING INK —

I'.oanl of Health -I- No. is "^"I'-^J-i^ H-'^l' t'o

I)(f

te FUe((MA-jX>^^ 13>

VJO\

THIS IS A PERMANENT RECORD

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

Registered ^'o, ^-o02

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco

Certificate of H)eatb

( Vl. S. StanSacS )

PLACE OF DEATH: — County ofO-OAV 'J,\XX>\ct-<i,C' City oiOo/y^j^KXK

(No.

(

an

d

and

V..acl\' St; ^^ Dist.;bct.

IF DEATH OCCURS AWAY FROM USUAL R E S I D E N C E G I V E FACTS CALLED FOR UNDER 'SPECIAL INFORMATI
IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBE

ON" '\

FULL NAME

:tr-CLLu^-U)

-tH-

PERSONAL AND STATISTICAL PARTICULARS

si;x r\ -» I col, OR > A

\<xXx

DA'l'l". OI' iilRfJi

A<-.i-:

(Moiuii)

) V',/

Day

M.'tith^

(Vt-ar)

Da V

\\i IX )\\ i: 1) » iK ni\'oKri:i>

(W'lit! in --iHial (U'si<.f nali m )

BIK THl'LAOl".

'Stat< or i'nmiUy

,1

>uo

Ojy\} OXx^-vx^^<La

N \Ml' Oi'
1- A Tlll-.R

niKTHPl.Ai'K

OI-- i-Arni:R

(Stall oT Couiitryi

MAIDI.N NAMK
OI- MOTIIHR

!UR rm'LAt'H
(>!• MoTHKR

( '^lat' I .t Cuttiitry

oiori'A rioN

^ r I

CMrl.^-

O^La.1^

i I

' La.\' '^ (i,<x.cc'

A'f^iil/if III Siiii /■! ,111, /',-,> I )'r(irs u .^fiintli> ^' I >,

THi' M'.ovi-: sr A ri:i> pkksonai, i'aktum'i.ars ari-: trii-; to Tin-:

lil-:sr O]- MV KNoWIJ-.lx.H AM) lU-. I,!)-",!-"

nnfoiinant

1 4^. -: \ t

MEDICAL CERTIFICATE OF DEATH

DA'n-; oi-' i)i;atii o ^

\]

Ktr
(Dav)

TQO'K

'Yearl

< Month)

I llHRKliV ClvRTlFV, That I atteii.kMl tlcixasod from
li/<db. "^ iqo'l to ©/ct U

that I last saw h !' alive on U^ i^ I90

and that death occtirred, on the (hite stated above, at ^
LL >L The CArSK (>1« DlvATH was as follows:

^X^A-XoaX^Jxa^,

I )r RAT ION

)'i'ars

Mo>it/is 1 Ihivs

r.

Hours

CONTRIBl'TORV O^wCrvxJL -O^^i A'^'^ <^

DIRATION

^'xat's

(SIG

.E.) kl%

Mouths

/htys

//on

rs

A

190

(Address) Tb^

boL/^

M.D.

V^A^<X

\t

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

Former or
Usual Residence

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

How long at
Place of Deatli?

. Days

I'UACK OF HI KIAI, OR RFMoVAI,

I)ATl-;of HiRiAL or RKMoVAr,

T90

N. B. Every item of information should be carefully Kupplied. AGE should he stated EXACTLY. PHYSICIANS should

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

f

r

WRITE PLAINLY WITH UNFADING INK

Hoar.! of H.-mUIi-J' No. i^ **^3£:?* »*'^1' *-'"

Dufr Filed ,

IS

lOO'i

THIS IS A PERMANENT RECORD

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

Registered J\''o, 2303

,^UwA.d ckjl/U-Vi

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco

Ccvtiftcatc of 2)catb

( "CI. S. StanC»ar^ )
PLACE OF DEATH: — County of Oc^^' O.VavvC.^r< City ofO-CV^^ O.rvov.^^4 •

(no. M "0 1

(JO

St.

(

^sL, r., -

\r dtnTM OCCURS »w«y fROM USUAL RESIDENCE oivt FACTS
rr Dt«TM OCCURRtO IN A HOSPItAL OR INSTITUTION GIVE 1

Dist.; bet. 1'3^ Ci\^ and 5.?.' V <■* )

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

FULL NAME

^\^1A l.^\a\J

Q/Z.tJLx.':

r-

PERSONAL AND STATISTICAL PARTICULARS

si;.\

iTiowU

COI.oK

DATl': oi" lUKTH

Ar.K

l(^

4

(Day)

M. nit It'

A"-'

( Vt-ar)

Da 1 5

SIN«.l,K. MARKIl'.I)

\vinn\vi:n <»k divokckd

iWtitfin xiM-ia! <U*iLf nation)

WA.A'VC

r>i

lUKTlllM.ACK
(Stati- <ir Oountt V

NAMl-: »>l-
FATHKR

lURTHPLAOK
<)|- F ATI IKK

(Statf or Conntiv

M A 1 1 > !•: N N A M 1 1
«)1' MctTllKR

0^

i/(X/>ru 0 KXX

w _ » V-^

ii

"s

IUKTIiri,Ai.H

(M M(>rni:R

(State or Cotmti v

OCCri'A'IION

MEDICAL CERTIFICATE OF DEATH

DAl'l-; (U- DlvKTII

(Month)

( Day)

IQO 1

(Year)

I III'RI'HV CliKTIFV, That I atteiuled deceased from

iL}.ct IC) i9oH to Ut:±... I'S . 190H

that I last saw h ^. » alive on ^ ' CV i ' 190 i

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

M. The CAUSIC OF I)I-:ATI1 was as follows

DT RAT ION Years

CONTRIIU'TORV

Mouths

navs

Hours

DIRATION
(SIGNED)

/)<7|,s

Krsidfd in Siiii /'i ti it, /•■t\

) 'ta » T

yfontks b DiJ I >

rin- \HOVF. ST\ III) I'KRSONAI, PARTIOri.ARS ARK TRUE TO THE
HHST Oli-^IV KN<»WIJ:I)0K AND BKUKF

(Infotmant VJ yrVC/VS^iv

f \.1.1ri-ss .1 61

Q^

Years .^ font /is

3i iQO H (Address) XVWs \|JX^■a/>vt -It

/flours

M.D.

nsfftt

SPECIAL INFORMATION only for Hospitals, Insmutlons, Transleiils,
•r Recent ResMents, and persons dying away from home.

Former Mr
Usual Residence

WkeH was disease cMtracted,
If lotatplaceof deatk?

Now loRf at
Plareof Death?

Days

LACE OF BT RIAt. OR REMOVAI,

PI, ACE C

^%)

DATKof HCRIAI. or REMOVAI^

0,^ IS looH

(.Address

110, I

IS. B. Bvery Item of lnform«tlo« •hould be carefully «ii f? '• * OWmhouW b« sta^jiXACTLY. PHYSICIANS ahwiM

state CAUSE OF DEATH In plain term*, that It r in c .p«#|y claMlfted. iHba "Special Infformatlon** foi>
•on* dying away from home should b« glvsn t« ^ui^ lastanca*

:i

4i

WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD

,,,.„ „r n. .UU K No . ^-S^^ .u".!' CO REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

304

i)<t

to Fihul}jAA}^^0\j 13

190\

Registered J\^o.

cLcrvvw^-^

Deputy Health Officer

DEPARTMENT 0? PUBLIC HEALTH=City and County of San Francisco

Certificate of 2)eatb

( xa. S. StanOarD )

PLACE OF DEATH : — County of O^X^-v

JA.

o

d

f3i^

■ CA.A-r.'. City of U/CL/^-X' 0,a.<X-\a-C'.

rw©. 0 JlAA>A.a/^\J (]bChMxv.l<XL St.; — ■Dist;bct.— 7- and - -

/ ,F DEATH OCCURS AW^ FROM USUAL R E S I D E NC E G. VE TACTS CALUED ^OR "NDER Jf^'^i ' J" ^°;;*;'„° '^ ' )
V IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. J

FULL NAME

\'yki..A

!

4

si: K

PERSONAL AND STATISTICAL PARTICULARS

COl.OR \ (j

f

M.vvy. t)r' iiiKTii

5""""M

A(',i-;

H -,

)'/■<// .

M.nilh^

(Year)

/).7 r.

siNf.l.K, MAKKIKI)
WtnnWKn OR DIVoRiKI)
(Uiitcin social (Usi^'iiatioii)

BIRTHPKACK

(State or Country

NAM}-: oi-
1- A riii;R

BIRTH ri.AcK
()|- 1 ATIIKR
(Stati- or Country)

MAnn:N NAM1-;

nl- MorilKR

niRTnri.ACK

iW MoTHHK

(Statf or I'onntry '

ID

r

U.u

Xjr\j M I. V

oi'CfrA'flON f'^

fCr-^iiffif lit Siiu /'i mil i.uti

) tUl I .

* .^f<ni//i'

Pa V.

rni- \H()VK STATJ-.I) I'KRSONAI, rAKTIClf.ARS ARK TRIH To THK
iIksT of my KNoWI.l'.IX'.K AND »HI.I1:K

IiifotTuant

MEDICAL CERTIFICATE OF DEATH

DATK OF DHATH 1 1 \

(Month)

(Yfar>

(Day)
I !I1';K1';HV CI^RTII-V, That I attended deceased fron

V, cl. H up M to L' c;t li 190',

that 1 last saw h a. . , . alive on W CA^ tl 190 ^

and that «leath occurred, on the date stated above, at 10
M. The CAlSlv OF Dl-ATII was as follows:

Dr RAT ION

}'cars

Mouthsi Pays

CONTRIIU'TORV J Axl>XN-^S<^wJL<Xhj. oi

Hours

DURATION
(SIG

Years

Mouths

NED) A.yS Ccririi/>xL.

(Ad.lress) JxK.^>

I"
Pavs

i.. \\_A

90

n

Hours
M.D.

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

Former or n ( /r

Usual Residence \k\D^

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

How lonq at

Place of Death? -^ ... Days

OF ni'RIAU OR RHIMOVAI. 1 DATR4>f Bt RIAI, or RF:MoYA1.

(Address

ri,ACK

fNDKRTAKKR flU-^xWUJ i OO. .^

(Adclress...!lD 1' . S Xiv Bit

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

state CAUSE OF DEATH in plain terms, that it may be properly classified. The "Special information" for per-
sons dylnft away from home should be given in uv«ry instance.

JB^

WRITE PLAINLY WITH UNFADING INK —

1)

nlo Filp(lM<^.A>^Cr\j 15

li)0\

THIS IS A PERMANENT RECORD

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

isos

Re^istci'-d Xo.

ll/vvu Deputy Health Omcer

DEPARTMENT ()F PUBLIC HEALTH=City and County of San Francisco

Certificate of ©catb

{ "CI. S. StanDarD i
PLACE OF DEATH: — County of OCX^ Oxa/^VZAACt City of ^0^-^-\' ^ AXJ- -^ " v -•

Wn.

%^

aU

-Yvfcu (jb^-iwl^' St.;—- Dist.;bet.

and

- )

A / ,r DtATH occursVaway from IuSUAL residence G.vt facts "^^/-^ ';f " "^°" ^'^^"^^^^^^

11 ( ,f death OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBtR. /

Aj vJ- O Crujj<xL ixau

FULL NAME

PERSONAL AND STATISTICAL PARTICULARS

I coi.oK ^ , 1

i)A ri; «ii- iHKTii

A< .1-;

tl

f\hXj

Mottthl

5V-,

'T

i i'

I Day)

V .u'>n

Vi

/

» tar

A J 1 .V

-IN'.I.i:. MARKIKl)

\\ IlxiU HI) OK I)IVt>Kii:n N

(Write in <^ucial dt-si^'nat iim)

lU.ccl^

HIRTUri, AOK

' Statr iir t''ntntry

N \\ti-; <)i'
I A rni'.k

niK liiri.Ai'i-:

n! ! \I"HKK
^lal' I ir (.'onnt r\

MAilU'.N N'AMi:

BiR'rmn.Aci>:

»)l MorilHR
^tatf or Country)

fS

I * -^

J

cjc4^xa^<xLk

1

LU^<X,

Ilia-

KKAJrO^K

« uHl TA rioN

K^fiifeif III San f^iaiui.-m Au 5V<7;a

rb

.\r,„itii^

Par.

(InfoTnifint

VWV \noVK STXTKH I'KRSONAI. rARTIClLARS ARK TRri-: T« > TIIK
linST t>l";4V KN(>\Vl,i:n(,KANI) BHUIHF

DATH OF I

MEDICAL CERTIFICATE OF DEATH

.KATH jQ

(Year I

11^ ct IX

iMonth' <I)ay<

1 lIl'MxiniV Cl'.RTII'V, That I attcii.lcd dtH-case.l frnm
Ct ii 190M to L) ^ 11 190 H

that I hist saw h .. ahve on w Sl\j 190 1

aiul that death orcurrcil, mi the date stated above, at I 10
M. The CAT SIC Ol' I)l':ATn was as follows:

DTK AT ION )'t'i7rs

CONTRIIUTORV

J/o?t//is

/><ns-

//oios

I )r RATION }\-ars Mout/i.s

5 \A. Ob/Q->N±.

f^avs

(Signed)

Ltti \X

Tqo

1,1

(Address)

v&

Hours
M.D.

0 0b(Kk^U.l

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

Former or
Usual Residence

b I H JvLOAAAA.4 J I Place of Death? 1

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

t

Days

DA'n; of IUriai. or RKMoXAI.

PI.ACK OF niRIAI, OR RJ'.MoVAI.

l-NDHRTAKKR UtOXA \. Uj \J (Xil\U^.

(Address ^ Jp^b UJ/O.A>KA^^'>-Oyt>

190 \

N. B. F.very Item of information should be carefully supplied. AGE should bo stated EXACTLY. PHYSICIANS should

state CAUSE OF DEATH in plain terms, that It may be properly classified. The "Special Information'* for per-
sons dyinft away from home should be 4iven In svery instance.

WRITE PLAINLY WITH UNFADING INK

}?,,nnl of Healt}v- V Sn. .-^ t-'.-^W) H&I> Co

Dff

to Filed !\U.Aj^^ \'h

190\

THIS IS A PERMANENT RECORD

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

Begistered JVo, J^oOo

* I _ ^^ I 'k.

i r

DEPARTMENT Of PUBLIC HEALTH=City and County of San Francisco

Certificate of ©eatb

( XX, S. StanDarD )

oi Q Cuyv 3 )^<^Jy^J<:^J^y<^o City of UjCKatv J A.cx.>a.^^ulcx)

PLACE OF DEATH: — County

N

o. ao^

n (N

St

Dist.: bet.

ib.1

t\i

and

t

,' " ' " " .„ r„«„ iie:il»l PCCIDFNCE GIVE FACTS CALLED FOR UNDER "SPtCIAt INroRMATION" \

( '^ ^F"D;ATH^OCC^%;rD^"^Ho"s^VT*AL ?« fN^'^J'^^'o.VE .TS name .NSTEAO of street and number. )

FULL NAME

.0

1

i-YV.

„L.ru^tA

s 1-: \

D.VIV. ()!• P.IKTH

A*.}-:

PERSONAL AND STATISTICAL PARTICULARS

, I C(H,(>R \

,j<w

LI.

I

.7X

jy\Jb

/i (Month)

)V,/

1^

(Dav

.1/,. >////'

(Vt-ar)

>

Prz I .

SINt'.I.I". MAKKIKI)

\\Il)t )\Vl-:i) OK I)IVnRcl-;i)

(Write- in Muial dt-sit'-iiat ioij)

I!IHTni'I,Ai*K
I State or «/ouiitrv

\ (^ (1

MEDICAL CERTIFICATE OF DEATH

DATE 1)1' DKATII

(Year)

(Month) (Day)

1 HEREBY CI:RTI1'V, That I attended deceased from
ct U icpi to U^fc IX TOOH

190 i to

that I last saw h '.. > • alive on

T90

and that death occurred, on the date stated above, at Ij.^ -3
- M. The CAl'SE t)E DICATII was as follows:

OXiUwA.

-CU.

OOu-r\j 0 A^XX^YVC C4. wO UO.'

NAMi: nl-
f- AlUlvR

. \ I

)>^ •

01* I'AI'UKK

(Statf or Country

MMIU'.N NAMK
()J- MoTIlKR {

niK'ntl'UACH
<>l' MOTIIKR
(Statr or Country

f

o

I

IK

OAXX kG rV

[^

11

OCCtTAlION

f\/'>i(iri1 III Sim 1) iiiii ni'o

Axac'

DC RAT ION Years

CONTRIIU'TORV

Months

Days ■ Hours

DTK AT ION ^V'li:-^ Mouths

(SIGNED)

0-t .

Days

TC)0 I

(Address) ^H'l" IbA-k vVt

/fours

M.D.

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

)>(/ / A

Vm;////.'

/),r

Tin* MtovK ST\ ri'.n pkh'sonai, par net i.aks ahh trck to Tin-;

Hi;sT ol- MV KNoWI,i;i)C. K AND lUlUIl'.K

(Itiformant

UjvlivuA; \9. \^J^\^Xx

A<l«lri'ss rfvO O ^ /

I -Jl

Former or
Usual Residence

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

How lonq at
Place of Death?

Days

I'l.ACK OI" nrRIAI. OK RKMoVAI.

DA.ll-.o! Hi HiAi. or RKMOVAI,

(Ad<irfss Xb b.b M rtv:^'«^^Max,..uli

IS. R Every item of information •houfd be carefully Hupplied. AGB Bhould bo stated EXACTLY. PHYSICIANS should

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

WRITE PLAINLY WITH UNFADING INK

I'.oaul lit lit .'1th -I" N-

^•?^i«r^ ikSii* Co

Date Filed ,

ho 15

190\

THIS IS A PERMANENT RECORD

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

Beo'ustej'ed jVo. 2307

AjyVhM

m^

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco

Certificate of Beatb

PLACE OF DEATH: — County ofOo/^v J'vo.^vcv^ccCity of vJ<X,^v J,Xa .-:•
UAxtuxl I— • - - • > ^ - ':•-> ' T^-*-' ^*- — — — — »"'*

.^A-Vl*VQ/.>XC

t >v

su

Dist.; bet. — ~

7(;:.7,;;;^ us'u.t B"ToiNCE_.,v_t,..cTs;«LL_cn ;o_-^-»cj ^^'.'^I'ijrrre"',""" )

( •' r"„r.,^^^^c■;r»^"T-o,^r.t r„^?^^%"Jv^or<f,;r,;i nam. ,;s,„o -; =,-... .«= -..-=.-.

<^

FULL NAME /^-ay>^

^

llxl

-S-.

^i:\

PERSONAL AND STATISTICAL PARTICULARS

COI.oR \

V]U

V

DAl'i: nl lUK III

A< .1-

M.-iith

I

l):.v

M.„ilh.

IS

iVtar)

/'<n

MEDICAL CERTIFICATE OF DEATH

I>ATH Ol- DKATH

»-^ ywA^

(Month'

/(JO

(Year

(Day)

I lllvklU'.V Cl'KTIl'V, That I attciukMl tlcct istd from

to __ -— i(jo

1^

•^ IN". 1,1' M\Kun;i»

WIIn )U KI» «»l< 1»!\< tki I'D p
iWritf in ••iK-ia! ih "-u'tiat i"ii ' ^l

BIRTmi. \')

^t.itf <>r t'liunt; %

lliut I last saw h ••— alive on ^™ ^^P

aiul that .k-ath nccurre«l, on the .late stated above, at
M. The CAT SIC Ol' l>i: A Til nv;>:^ a^ follows:

LAMrVC^'

V

NXMl Ml

J- A riii-.K

lUKTm'I.AiH

oi- I Aiin-.K

iStriti or t.'o>i!lt! V

MAIDKN NAMi;
OF MOTHKR

HIK'nil'LAt'l-.

(U Morm-.K

stall .11 (.'ounlry

\

K.<X/rU

u

/t)

J. lL.l

^

«Ki n

AlioNC

I

CL'N^A.'dj^

A

-^ \:

'V

h^fsiiiril III ^iti' I

JV.;,

}h<l!tlt'

/>,l^

Tni' \mn'v stxti'd i-kksonai. i-akti^ti. \ks aki: iKn-: t.» Tin-

BI-;sT nl" MV KN'nWI.l.lx'.K AND lU'.I.II.l

(Itifonuaut

,f ^^ if

■ N I • . ?.

(irrw

't

0

1)1 RAT ION Years

CONTKIIUTORV

Months

PiU

•s

No HP

Dl'RATION ^

}'tars

(SIGNED) UfUmJLh^ oAl^ UJ dJ

1f(>fif/is /hns

LKjx ,

flours

M.D.

^.^

\X TooH r

Ad.lress) LfrXO^vtA^ l^ Jr^-- C^c

SPECIAL INFORMATION only lor Hospitdls, Inslituthms, Tr«insienls,
or Retenl Residents, and persons dying a\*ay from home.

Former or
Isiidl Residence

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

I, -A k I i, \^Ho»» lomi at
i3)00lXUUCKI«>v Hpiaff of Death?

Days

0 fl

'OJ

I'l.ACi: «>l lUKIAl, nK K1;Mk\AI,

INIH;K lAKl-.K >'

DAIJ: o! lUKlAI. or RKMOVAU

iD/ctr I'i 190H

/^'y'wXA

i

^

V

A<i.itt^s \L'<X,kJLo^A,.^cL \^oJ^'

— ^ TT 1^ I AP.F fihoultl be stnted BXACTLY. PHYSICIANS should

N. B. Bvery lt*m of Information •hould be c.retully f"PP"«^J^- "^ ' ' , classified. The "Special Information" for pmr^

•tate CAUSE OP DEATH In plHJn term., that it miiy be properly ciassine
«on« dying away from home should be given In m^^mry Instance.

Ill,

H ;

^

uU^

WRITE PLAINLY WITH UNFADING INK —

1<, ,:,!.! ..r ll.-.dth I N''i

V c

I)((h> Filed ,

M^OO^

W

vj(n

THIS IS A PERMANENT RECORD

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

Eeiistcr('(l' J^'o,

^•^08

Deputy Health Officer

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco

Ccvtificate of ©catb

r\

PLACE OF DEATH: — County of

City of ^

u

^ 1

^No.-

St.;

Dist.; bet.

and

)

( - ---^^-.-vrn^^t ii^±^^^i-:hi^i:^^^^^ -:^^ri^or::ir" )

FULL NAME

<tL

,0-'"\^-^iA^

■, h

■~ ^^

PERSONAL AND STATISTICAL PARTICULARS

(■nl,t»k

I) \ 1 1: < >i- r.iK 111

\' .1-

M

M.Hl

' I)nv

MEDICAL CERTIFICATE OF DEATH

DATK i)F DHATll (( \

(Month)

(Day

IQO

(Year)

'U

!/ ,i.

/J.M

-^1^| .1.1' M \K K I! I>

svii" i\\ i:i» »>H k: \t >Kri:n

( U'l itt 111 •"'trial lit -li-' ii.it I'lil)

lUH TIIIM. \>M'
(Ht ' 'unit I \

\

Ul) cd.^^<>-t^u

I m«;ki:BV CI-.RTII'V, That I alUu.kMl .Unascd from

up t.. — — "I<P

llial I last saxv h alive on "' ^^P

and that <Uath uiTurred, nn the .late stated alwve. at
M. Thf CAl'Si: ol- DI'ATIl was •» follows :

X

\ \M 1 < il
1 A I 11 IK

niK THI'I.Ai J%
(H 1 AlinR

~,' l1 . . • t 1 111 lit 1 %

M A ! 1 » I : N N A M J-
()l- Mt>TlIi:R

liiK rm'i.Ari:
t)i M(»riii:u

1 Slate m r>i(ititi >

ru'iri'A rioN

AVv/,//!/ in S.iH /'mm rr.i

Ol V

DTK AT ION y'rttrs

CONTRIIU'TORV

.l/o>i//is

Pays

I lout

DrUATION
(SIGNED)

YiCir^

AFi'utlis

PilV

//ours
M.D.

) r,l

M,>ii!li

Ihn

THK SHUVK ST X ,,..>. .KKSt.NAl.XKTU-i.VH.AKHTKrK T- - TM..

iu;sroi Mv KNOW 1,1, i)«.h \^" 1.1 1.1'^

D 0

(Infoimaiil

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

Former or
Isiial Residence

Wlien was disease contracted.
If not at place ol deatit ?

How long at
Plareol Death?

. Days

PI \ci* or lUKjAi, t>k ki:m<»v w

lU

,., ^0.0.^ te

^ V > \.xX^

i)\Ti-<i; I'.'iuAi lit ki-;m<>vai,

190

r~

Addt fss

,,, . AGB .houlcl be stated EXACTLY. PHYSICIANS should
N. B._Bvery Item otf 1n?orm«tlon .hould b. -"-"^f^ f"^„l e properly cfslflcd. The "8pecl-l Information" for per-
statc CAUSE OF DEATH In pl«1n {'''-•j^^Jlf J*,,"^^^ rns^-nce.
sons dylnft away from home should be fttven In svery

Jiicnek

it.

WRITE PLAINLY WITH UNFADING INK

I!,,:,r.l .>f llmlth I- N". ir, ^•^.^•;

/i^//r /-V/f'^/, UctcrlMA^ IH

i^y6>4

THIS IS A PERMANENT RECORD

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

llei^istercd ^'o. 2309

.<H^u^

Deputy Health Officer

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco

PLACE OF DEATH:— County of

N«.Ot LaUvcV'.. . - . ^ ■■ St.

Ccvtificatc ot Beatb

( "U. S. StanDarD )

-^ ^ City of O/O/^^ 0 AXX >xc ^.

-^

V(X/"NvC

Dist.;bct.

and

)

(^'^^ioc^s.-- "n^r^t r-?^^j;:";^^;i'^«^ ^^°" s^^^n-^r^eir- )

FULL NAME Oa\x>.rv

0 xo, 1

\

PERSONAL AND STATISTICAL PARTICULARS

L

L

WW

Ni.iiithi

\" .i:

NiNi I.I" M NH K n
\\ 1 1 H l\\ J- 1 1 » »K 1 I

\\ • St- 111 -H-iai ■;• -

isiK rni'i. Ni'i-:

«-,t,it • ' '• < '■ .11 n 1 1 %■

1/

» .-III

/',

(Vi-:»t >

MEDICAL CERTIFICATE OF DEATH

DATH OF DHATII ; \

I Month) 'J'^'V^

I lli;UI<;iiV C1;RT11-V. That l atlcn.lca .kceasca frnni

_____ Kp t(. — ~~"190

tliat I last sa\v h ^ ' alivf on ' '^o

a„.l that dr till net ttrrc.l, .-n the .late statcl above, at
M. The CAtSI'; Ol" Dl'ATH was as follows:

n

N \M 1- ( >l
1 AI'll 1 R

15IKIIII'I,\i"K

«M I \iin:K

'-^^i'. . ,1 lllUlltl \

M \!I»i:N NAMl.

i»i M(»rm:K

niK rniM. \ti-:

(H NKillIIU

( Stiti n! eiilttltl N

uo

JJccLcrvAT

juLL*^OwT>^

.V.U.

DT RAT I ON J''"'^''''

CONTKlIUrOKV

>la--o Oc.JLc^v.c

Mouths

/hns

Hours

n

,'V.

n /cuwouTX* 0

I )r RAT ION

) V(/r

^

Mofjf/ts

r SIGNED )Lc\C ^ ^

ly^iLt I'l tnn'i (A.l.lress) llft'XC

..a

Hours

M.D.

1()0 \

I I I I

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

(HATI

"'■""■UcU

fr\.C\.r.

Ri-^idrd III '^>!ii I 1 1'

M.,iifli-

Ihi

TinrXH<>VKKTA.r.MM^K.nNX,.PXKn.rKNK^AKKTKrK rnTl.H
Ml-sTol' MV KN..\VI.ri).<.l': \M' I.I.I. I' I

AJ^ U ^,

Former or
Usual Residence

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

How lonq at
Place of Deatfj ?

Days

I) A i',!'. ')! lit UIAI. or Hl'.MoVAI,

11* I.

1 ^ I 90 '

, xoi- <>1 lU HIAI. .•!< «1-:Mm\ AI,

(Tit tlt..vM± ^^

INI

f A.Mi. s^

.. . AHB should be stated EXACTLY. PHYSICIANS should
of informntlon should be cnrefujiy f"PP''^«; ^^„„^Hy classified. The "Special information- for pT-
E OF DEATH In plain terms, that .t may ^^^^

N. B. Rvery Item

•tote CAUSE OH UtA . n m p.«... —■"-_, ^ Instance,

•on. dylnft away from home should be ftUen In • o >

w

RITE PLAINLY WITH UNFADING INK

,! ,,f Hi iMli I" Nn

:.?^'^; M5.PCO

/)^7/r /7//'^/, Lkt<rLt>v IH

190 "{

THIS IS A PERMANENT RECORD

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

Ee^i\sf('/'pd JSl^o.

t I

^-CM^j

Dcpt .

DEPARTMENT OF PUBLIC HEALTH-City and County of San Francisco

Certificate of IDeatb

( 'XX. S. GtnnDarC^ i

fX)

PLACE OF DEATH: — County of

:\

Y\j ■' /V,C .

c\

VI

City of "^ 'ay>^ J ^^xx y vc u^

ffe LCUl "^ Wu.-rjj.J '-'^ ^V ' ■ „,^*•^^,CEa,VtHc^^C^J^D^OR UNDER 'SPEC.AL.Nr^AT.ON)

FULL NAME

4-

PERSONAL AND STATISTICAL PARTICULARS

-KX A

it il,« >R \

M iXolU

11

1» \ I i: < •! iliK IH

\i.K

^INi ,1,K M \H K i 1 1 '
\\ I |H i\\ 1 ! 1 I >!•; p ' ■
\\ ! lit ill :

lUk rH»'l.\*"K

I* A III 1 R

Hiu run. \i !•:

Ol* FATlll.K

'Htntf- nr I'iiuiit ! V

MAIIM.V N\Ml

OF Morm-.R

n:iv

1/,

V. ai)

I K_; 1

MEDICAL CERTIFICATE OF DEATH

DA I'l'; »»!■ DK A TH

iVt-at )

A 0 i
nrx^<nr^ V' '=

I UI-RKHV ClUniFV, That ^I aticn.UMl (kcA-a^cMl from

. ' . loo'l to I ' ■" i')o'^

' 1.1

that I last ^aw h '■ ahvc on ''^ '

and that .U-ath orcurre.l. nn tht- .late stated atove. at I
M. The CAlSh: ()}• ni'.ATll wa- a< follows:

nJVCTN^N-

"^ Qi\v,

-^

lUKTinM. ACl.
Ol- Molin-.K
(Slatf 1)1 ituilUi \

ocerrA'ri<>N( u 1

I )r RATI ON ^'^<^'-'

CONTRIIUTORV

.1/, '/////

'"■'^'■''""•' QK\'''n

KrsitfrJ ni Sn>i ri.iiii i^rn o > ""

Moiith-

Ihiv.

Hl.sTol MV KN()\Vl.i:i)<'.l'- AM) Hl-.l.n.l

(Inl

(SIGNED)

!____ ,

"special information only lor Hbspitals, Institutions, Transients,
or Recent Residents, andjicrsons dying away from^home.

Former or H ^ '3, n ^^« .,,
Usual Residence I'JO vJXoa r .

When was disease contracted,

If not at place of death ?

, How lonq at
" Place of Death?

\<

Days

ly \CK <>!• HIRIAI, OK Kl-.MoVAI,

"L CLlU to.

CXX

DAliiof Hi KiAi. or KKMOVAl,

MOBI

n — — — ^^—^—i ^■^— ^^— *^^^^^ * * ^ FVACTLY PHYSICIANS should

E OF DEATH In plain term., th« .t may »\* ^JJ

N. B. l.very Ite

.tate CAUSE OF DEATH In P""",."' ■":';„,„ .^ery Instance
«nnm dylnft aw«y ?rom home .hould he ftlven In every

'1

i. i

i

WRITE PLAINLY WITH UNFADING INK

]5(.;..r.1 .if lUnUli- I

.- xo I ^ -J-SS^ H&P Co

Jht

fe Wrv^.Q^cbrlo^; IH

lOO'i

THIS IS A PERMANENT RECORD

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

2311

Registered JVo.

DEPARTMENt OF PUBLIC HEALTH=City and County of San Francisco

No.

Cevtificate of 2)catb

( -a. S. StanDarD )
PLACE OF DEATH: -County ofCJOA^ J,\cx>vcv^-' City of

i/(X/>-v

0 ^^^^L'-^VC <..4

St.

and

'special informatio

( - .VorA.°"oc:u%r;.-rHo^s^r.'it o%^?^?f.?u^4ro^;r.rs ?.AM^e .;\^.7o°o? s.^... ..o .u.b..

FULL NAME

PERSONAL AND STATISTICAL PARTICULARS

/XkX

I) All-: OF r.iKTii

A<.H

ri.k.u

Uct

) ■«'(7 i

(Day)

( Vi;ir)

Pil vs

MEDICAL CERTIFICATE OF DEATH

DATK *)1- I)1':ATH

'.cfc

(Yf.-ir)

-.INT.l.K. MARRIl-'.n
\VIlM)\Vi:i) OK DIVORvl'I)
(Write in -(n-ial .l.'^iiMiation)

niKTHlM. \i'l-.

(Slate 111 i'duiUi v'

NAMl" <H
FATHl'.R

HIK TllI'l.AOK
Ol' I Ar!li:K
iStati or Country

M \II>KN NAMi: /^ /^

CJ/CLAV OiUXA vCUl^Ct

(Month) 'J>='V*

I lIIUiHHV C1:RTIFV, That I atUn.lcl .U( cased from

ifl dfc II 190 H to ii)^ '3^ 190 H

that I last saw h^^^^ alive on Iki/ct )X 190 '^

and that death occurred, on the date stated alxn-e. at
LI M. The CAI'SK OF DKA'PH was as follows:

uWv

-N

KCy\xt<^

()l- MOTHER

HIKTHPI-ACK
OF MoTHHK
(State or CotUJtry)

1

m

DV RAT ION

} 'ears

1 J I K A 111 ^ .> / c .. /^ .youths H Days

CON T R I lU'TOR V \^. <X^<^ '^VVA,-^^

Hours

4,rwW^A,0*■; '^

nu^^c c

nr RATION
(Signed)

190

Years Months Pays Hours

dA^cc^cua Llv .' M.D.

'i (Address) il5 5 U^cbxA^V<X

SPECIAL INFORMATION on'v for Hospitals, Institutions, Transients,
or Recent Residents, and persons dyinq away from tiome.

)'*•(?)

I Af,,nf/n tS.J /iti\

THF- .xnoVF>.TATKni'KK-oN-Al.l'ARTUM-l.AKSAKF. TKIK TO THH
liF:ST OF iv KNoWI,i:n..F: AND HF.IJF.F

(Infoiniant

WaaXX/'^a^ VtrV'lXXX. 1

A'Mress

XX'\

Former or
Usual Residence

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

Itow lonq at
I»lare of Deatli ?

Days

VI \CK «>1- lURlAI, OK RF:Mo\ AI.

D^riCof Htkiai, or K1%M<)VAI,

V^

■oX'^rwCV. 1) t

T90

^\drtrc<*s „-

IN. B.

""""""""""""""""""""^ T7. I- ,1 nr.F sSnuld be stated EXACTLY. PHYSICIANS should

-Bvery item o? in?orm»f.on should b. c«reVulIy suppi.ed J'^^J^''^^^^^^^^^ ..g^,,|«, information" for p.r-

state CAUSE OF DEATH in pinin terms, that it muy be properly classitiea. 1 nc p

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

i ri

I

WRITE PLAINLY WITH UNFADING INK —

Jioitnl ..f Hialth- 1 N

Dale Filefl^U^td}-^ \^

190 H

THIS IS A PERMANENT RECORD

REFER TO BACK OF CERTIFICATE FOR INSTRUCTION3

Be^isterecl J^^o.

2313

S

DEPARTMENTOF PUBLIC HEALTH

City and County of San Francisco

Cevtificate of IDeatb

( XX. S. StanDar? )

PLACE OF DEATH: — County ofU<l.C\.<X>>

V L c

J , i^j

City of Q<XyQAJD^'>r\yJL'^^^

/D

No.

CHlK^t'X^

St.

-Dist.;bet.—

and

— )

A^ UUU-NLIVVV.. A.A prS^ENCEG.Vt ^CTrc^rteO roR under "SPCC.au INrORMAT|ON ■ \

( '^ fc°H"occ^%ro\"rHo"s^PrT"^^ o^"^;sf.?u"o^'^c.v. .ts name ..st.ao or STR.ex a.o numb.r. ^

FULL NAME

PERSONAL AND STATISTICAL PARTICULARS

^{\J^\jJ:JO^^

S^>\-

^

SKX

il

\<xX

COl.OK

n

uc

.OJxJU

i» \ 11-:

()!

lUKTll

'Mmitlj

\«-.K

'1 (>

5 'ra ) >

(Day)

M.niHn

{

( Voar*

A/1

MEDICAL CERTIFICATE OF DEATH

DATK OK DKATH

Id:

(Month)

(l)av)

jgo »

(Year)

I 1II":KI':BV C1:rTIFV, That I attcn.UMl .Icceased from

____ —— - igo to i^P "~~

that I last saw h r— alive on I*)0

si\<-.I.i:. MAKUIHI)
WIDOWKI) «)R n!VnK<Hn

iWiiftiii -iR'ial (l.-is-Miation)

HIKTHl'LACK

(State or t.'imiitryi

1- A iin;R

TMKruri.ACH

'Stati 1)1 I'oniitry)

MAiniN NAMl.
«)). MDl'm-.K

inKTiirLACK

ol- Mo'nil'.K
(Slalt "I C(i\intry

lUiXAAAX

u

an.l that death oceurred, on the date stated above, at
""" M The CAl'Sh: OI*' DlCA'l'll wa^ as follows:

^y~v\An,^.^

DT RAT ION Years

CONTRinrTORV

Months

Pays

Hour

DT RATION

Years

Moyiths

(SIGNED) \ l\ ^- ^ 1^ ■ ^
\K\Jt. \ I ..-„'. ^\ddress) C)

Days

11

IQO'I (

XXXIAXU^W^^

Hours
M.D.

(utMi'ArioN rx J

,\j

Resided III San /'inn, i^fo

)'i(ii

MniiUn

l),i\s

IHJ- MU.Vl- sl\Ti:nPKRS()NAI,rAKIUTI.AKS ARK TRIH To TH1<
iu;sr Ol. MY KNOWUV.IX'.K AM) lU-'.lJI'.K

(Infiirnuiiit

LIvcLhJLcrtlji

Address . J . ; 0 V

WVCL

SPECIAL INFORMATION only for Hospitals, Institutions, Transients,
or Recent Residents, and persons dying a»*ay froni liome.

Former or
Usual Residence

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

How long at
Place of Deatlj?

Days

PI,ACH Ol" lUHIAI, OR KJ:MoVAI.
INDHRTAKKR ^ <X L

Dyi'i; of Ht RIAL or HKMOVAI,

T90H

dress 1. 5 rXH oX^i-tJi-yLtrk'^ lit

N B —Bvery Item of i„form«t1«n should be carefully Huppllecl. AGB .hould >»• •i-t«i^^'^.^CTLY PHV^'f*^":!® •h°">;'
Ttate CAUSE OF DEATH In plain term,, that it may be properly classified. The Special information for p..--
•on* dying away from home should be given in every instance.

I

WRITE PLAINLY WITH UNFADING INK

,V,ar.l of lUaUlr l' Xo. is ^Cl^^^^i^Sl

T)((fe Filed,

IH

IDO'i

THIS IS A PERMANENT RECORD

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

Registered J^'^o. -^olo

_^\hu Deputy HecSth Officer

DEPARTMNT W PUBLIC HEAlTH=City and County of San Francisco

Cevtificate of Beatb

( XX, S. StanDar? )

\.<XAXCCVC^ City of O/Om; JX.O.^'VCC<LCC

PLACE OF DEATH: — County of

rNo

M

k^.

(IF DEATH OCCUB^ AWAY
IF DEATH OCCURRED I

St.;

Dist.;bet. - - .and^

-)

FULL NAME

si:x

PERSONAL AND STATISTICAL PARTICULARS

DATH or UlRTH

m

AC. K

b

(Day)

Motif h^

\

\%

I Vcnr)

Par

MEDICAL CERTIFICATE OF DEATH
DATE OF DKATIl '^

(Month)

15

(Day)

igo >

(Year)

-C

mNC.LK. MARKIl'I).

\vn)<>\viu> OR nivoKtKi)

i\\iit<-in MK-ial lU-^iiirnation)

I III:RKBY CKRTIFV, That I attended deceased from

^-^ofc 15 igoH to .. tD/cl . .i.2x 190H

that I last saw h -* alive on V^ cX L.> 190'.

and that doath occnrred, on the «late stated above, at loO
* M. The CAi;SI<: OF DllATlI was as follows:

dJ JlJL</VXA.^-/>^kXJ . J

VI

^

J\JL>'^v^ vX^^'w J^

lURTm-KAOK

(Statf or "'oiuitryl

I A rill'.R

niR'nn'i.ACK

oi- lATHKR

(Statf or Cniintry)

MAIDI'.N' NAM!'.
()|- .Mo'I'in: K

niRi'in'LACH

OI' MnTin-'.R
(Stati or vNiuntry

1 1 K.

DIRATION YtiUS Months iO Days Hours

" (3 N T R IIU ' T () R V - ^ /OUfty^^A/vK^ L-O'^vx^X.fiu.^-^- &"^ ^ - ^

i'

DURATION

Years i\fontfis o Pays

Hours

yCXA^U

W

OCCl'l'ATION

Rf

siiifd in San I'l itn, is,-n Ki<i )'r,iis

(SIGNED) JjU. Id. UJ -U^V\A.e^-^ lyi-D.

Q/Ct I'l iqo (Address) ^C^5 Ua.Lt\ve\.a. A

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

Miiiitli

/>(i\

Tin- M5(n-l.-STATKn»>KRS«>XAI. I'AKTHM-I.ARSARl-TKrK To TIIH
BK^T 01 MV KN«)\VIJ:I)<-.K AND 15KIJ1J-

(Infoiinatit

Former or
Usual Residence

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

How lonq at
Place of Death?

Days

I'l.ACK OV niRIAI. OK KHMOVAI.

DA Ti: o! HrKlAi- or K1-:MoVAI,

i-ndkrtakkr'^^SA.^cLiav s3<xtx LL^vd^NLo^VU/

(Address . AH%3i M iXuLA-A-^Cnx. . J.t

-vxa W

. ~, V^. ., . AHF Bhmild be stated EXACTLY. PHYSICIANS should

N. B.— Every Item of ln?orm«tlon should be coretuHy suppl.ed ^^^^^^^/^^J^^.^i^ ^^e "Special InformBtlon" for psr-
state CAUSE OF DEATH in plain terms, that It mn> be properly classitiea. me ^p^

sons dying away from home should be ftlven in every Instance.

v.A=^

i

n

Ponrd of Ht.iUli I- N". is

WRITE PLAINLY WITH UNFADING INK-THIS IS A PERMANENT RECORD

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

31 4

T-^^-K^J- I'.SlP Co

Registered J\'o.

Date VneiiMAjXA>j 14 VJO'i

L^iioK. Deputy Hec^thOfn-^^r ^

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco

Certificate of Beatb

( "d. S. StanDarD )

(^

PLACE OF DEATH:

"V

County ofOCL^ 0,.V<X vvO^r- City of ^^X/>^ JX^^V'- -J -

I?

^No.

(IF DEATH 0(
IF DEATH

.fUcLcul:

and

-^!^^^t -^J?^j;;-?^S^^^" -^riN^ -j^r ■• )

~ )

FULL NAME

\Xcc-^..

PERSONAL AND STATISTICAL PARTICULARS

SI

JX/Y\

CO I, OK

OLr,

OTntlthl

AC I-

O I T/'in

(I)av)

Mnuths

(Year)

/i.;

MEDICAL CERTIFICATE OF DEATH

DATK oi- i>i:ath

/C.

:t

(Month)

(Day)

IQO \

(Yfar>

I III':RI';BV CI':RTIFV, That I attcnde.l «leccascd from

that I last saw h

190

to

alive on

lO.ct

190 I
up '

SINOl.K. MARRIKI)

SlXt.l.r. MAKKir, 1'. «

\VIIM»\\ I-:i) OK DIVoRCKI) U fj

iWiitfiti -ooia'i (Ic-i:/ nation) -^ U

HIKTinM.AClC

(State or Country

NAMi: <>?•

FA'rm:K

1UK IHIM.ACK

oi- 1 xriiKR

(Stall of roiintry)

M\n>i:N NAM)
«(1 MorilHK

HIKlIll'LACH

i Stat I or *."onntry)

OCCVPATIOX

Rr^idrd in S,ni /'kiii,

,tJUH

*7 I -
and that death occurred, (»n the ilate stated above, at ^ ^

M. The CAl'SI-: Ol- DI'.A TH was as follows:

I )r RATI ON \ y'l-ars ■l/on//is Days I Ion

ys

?

)'i tj I

A/,,uf/t^

/),n.

iX V > V. cv.xU.0.
1)1' RAT ION Vt^irs

Mouths

Days

/fours

( SIGNED ) «sy. vi . wvcxAryva.'. M.D.

lU^. .11 too'. (Addres.)U\AJUxil/VV^ h

iNED) fo. I. OvcJlrtAX'.

a.

Special information only lor Hospitals, Institutions, Transients,
or Recent Residents, andjersons dying a^ay from home.

Fftrmpr or Ml I Now long al ^ ,

Isiral Residence 1 1) \ I dUXA>UMX <1.\^ Place of Death? ^ Days

When was disease contracted,

If not at place of death ? ■

Till- M5OVFSTATl-0l>KKSONAI<IV\KriCri.ARSAKKTKrH TO THK
liKST Ol' MV KN'OWIJ-.IX'.K AND Hl.UU-.l'

(Infotniant

)Lc^JLm lo Qn\^v^l

\^co„

r\ ^

( AiMrcss

IM.ACK Ol-;, lUKIAL OK K1-:M<)VAI

)ATl'nf HrKlAI, or RICMoVAI.

(Address Ji I ^ G' i .OL^V^VXII .A).i

N B — Bver. Uen, o* in.o.„,ntlon should b. cn.eful.y supplied. AGE should »>« ^^^^'J^^^'^.^i^^^^,^- ,rnl^jfiL^„^, Vr^'^rll
state CAUSE OF DEATH in plain terms, that it may be properly classified. The Special Information for per-
sons dying away from home should be i^iven in every Instance.

h' ^' y

mf

1

i

H.);ir.l ..f Hi-aUl! l" N<

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

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

^^9 J ■ %J

t-'^'^'^^j ]i8cl' Co

190^

Bc^i'Stcrcd J^'^o.

I)((fi> Fi1r(L\Ji^:kJ^ IH

DEPARimENT OF PUBLIC HEALTH=City and County of San Francisco

Cevtificate of IDeatb

( tl. S. StanDar? )
PLACE OF DEATH:-County of 6o^ J ;va^.c<. c . Gty of 0 A/>.. 0 AX^ v. c ^ '^ c

(No

,.ntJ

su

Dist.; bet.

— and

)

FULL NAME

aXIa.o..

f\.^-^

PERSONAL AND STATISTICAL PARTICULARS

;i:\

i I

COI.OR

I) All' <>I- in K I'll

\».i-:

M.lmhi

J

U

5Vu-/

M.nilli^

■> I ai

/),/ 1 ^

1).

MEDICAL CERTIFICATE OF DEATH

ATK OK DKATH jP^

(Month)

1 '■^
(Day)
I lllvRlCBV Cl-RTIl-V. That I aUcn(U<l tkrcasc<l from

— — - — — — ~~~ I90 ~~~' to

that I last saw h -n— alive nii

and that (Uath nccurretl, <>n the date staled ahnve. at

IQO

(Yoar)

IC)0 ~"
190

SINT.l.l- MARKn:i»

wiotiwin OK n:\»»Kri-n

AJacLoa

I »-

HiK Tini. Aoi-:

fStatt iir «.'imnti v

NAM)- 01
FATlllR

BIRTHIM.AOK
iW lATin-tR

(Statt or t'ouiitiy^

MMlil-.N NAMl-
(tl Mi)r!ll-:K

lUKTinM.Ari-,

iW Mnrm-.K

I Statt or t'lmiili N*i

)a

,<Xt\^IA> \

M. The C.W SI-: Ol" DI'ATH was as follows:

1)1 RATION )Va/.s

CONTRll'.rToRV

Mouths

Days

//ours

XC<

LV^Clt

Ol

cLc *» "^

DTR xrioN .^^ )V(?;.v ^/out/is /hivs

(Signed)

T(jO

(Addres-;) W^

//ours

M.D.

w\4

SPECIAL INFORMATION on'v for Hospitals, Institutions, Transients,
or Recent Residents, and persons dyinq av^ay from home.

( urri' \ I'm:

THl- \HOVl.-ST\Ti:t>)'HKSON\I. 1' \ R I h' r 1 \ RS A R l- TK T K To

" ,u>T (.V Mv KN..\vijn..i: AND iu:i,n-.i-

rni'.

(I

I i I ■, .-< I » ■ 1 • ■ ' ■ ' " ■

Former or
Usual Residence

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

run, onu pcisuns vjt"^ un«» ■•"

lays

Pi.ACl': ()I- lURIAI, OR KlMMVAl.

W\

UkX^^ cL<Xx

KxLcttX/tL

DATKof 151 RIAL 01 K1':MoVAI,

(Address

N Ttc^-A.A.-'<nrX "^1-

N. B.

""""^ ,. .. It 1 \rp ahniilil he stated EXACTLY. PHYSICIANS should

Hvery item of in*.,.m«t1on should b. cnrefully Hupplied /^^;f;^^;7/^'^^^^^^^^ ^*Sp..\Bl Information" for pT-

state CAUSE OF DEATH in plain terms, that it may be properly clossmcu. nc i
sons dying away from home should be ^iven in every instance.

WRITE PLAINLY WITH UNFADING INK

THIS IS A PERMANENT RECORD

REFER TO BACK OF CEBTIFICATE FOR INSTRUCTIONS

Th

100^

Up mistered ^Yo,

2?A%

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

Certificate of IDeatb

( tl. S. Stan^arD )
PLACE OF DEATH:— County ofO^X^v OAXu^vcc^

a'

City of Oo^y^ ^^^^

fTs

^0

No. T)^H \-' ' .^Vi^'^-vlVTVO

1

I tl

o r I

(IF DEATH
IF DE*

OCCURS AWAY F
ATH OCCURRED I

n St ♦ ^ Dist • bet ^ ^ '^ ^"" ' "

e

FULL NAME

Ld

%

Lu«^^-^-

PERSONAL AND STATISTICAL PARTICULARS

(.•()1,<)K N

si:\

1<XU

DAll". «>l- iilKTU

iMiiiith)fr

\< . !■;

)V<n

(Day)

M.nilli

\ (.'ar

/>./

MEDICAL CERTIFICATE OF DEATH

DAl'H ol Di: ATI!

(MoutlO

1 ron

iDav) (Ycari

mxi'.l 1". MAKRllvD.
\Vll)(»\Vi:i) <>H DIVORrKI)

(Writtiii •-iK-ial lU-sii^Mialioii)

IHRTin'I.XOK
(Stall or t'ouiitry

1 A 111 I'.K

HlRTHIM.AfK
OI- I AT 111- K

( stati I it I'l iimt 1 V

^^ mi)i:n namK
1)1 Morm-:K

111 Mnrni'R

. ^t ,) , , ,1 k' , uinlt y )

I in':RI':BV CIIRTIFV, That I attoiuU-.l .Urca-^cal fruni

Jcl- ,. I90*^ to iQvCt- "^ '^>o^

that I last saw h^ -. alive on - ^90^

an.] that death nccurre.l, <hi the date -tate.l above, at ^ 3Q

(B

M The CM'SROh' Dl-ATH \va< as follows:

rvO-'rv.'C^'^'wO

rs-\XA^K. A .

)rRArH)N )'rars .Months o Ihivs

I lour ^

\ju\<x^

Ytatis I Months

NED).LLma; 0.

DIRATHIN
(SIG

Days

OJx

Hour a
M.D.

^'^

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

5 V'((/

Mnllth>

Ihn

THI- \H()V1- STA-n:i) I'KR^ONAI. I'A H I' U' I " I A R s ARl- TRIK
HHsr ()1^ MV KNOWI.KIXU-; AND lU-I.iHK

ro rni-:

(DifoTinaut

Ol(...c.-.. ^^v

V I .

(' \iMi(,-s

TXH UU/Y>XJtA^lAy\va. '^U

Former or
Usual Residence

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

How lonq at
Place of Death ?

Days

I'l AC1-: <>I lURIAI. OR RHMoVAI.

indicktakkrM IV 0 CUTvCaX

D\Ti:.>f Hri<iAi> or R1-:M()VA1,

T90

(AcldllSH

tu

,\J5^^,A^~'* w

, ., ,. . APF shnulil he stated EXACTLY. PHYSICIANS should

N. B.— Bvery Item of Information shoucl be crctully fuppi.ed J^^J;^^^^/^'^^^^^^^^ ..gpeclal Information- for pT-

state CAUSE OF DEATH in plain terms, that it may be properly ciassniea. i nc ^i
sons dyinft away from home should be jii%en In every instance.

t

WRITE PLAINLY WITH UNFADING INK

n.,Mt<l..f !I,:,M]> rN.> ..'^•g^^L-Hfcl'C.,

I

/>r//^' Vih'd ,

IH

2.9 6>H

THIS IS A PERMANENT RECORD

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

<)jLa^

DEPARTMENfOF PUBLIC HEALTH=City and County of San Francisco

Ccttificatc of Beatb

( n. S. StanDatO )

PLACE OF DE ATH : — County of

8 3

I > v.'^

/"^ '-^

City oiKjaJLLo.

rN

o. S H S \Js\JJ^J^

St.

Dist.; bet*

— and

FULL NAMEQct'^-^^ ^ ^ ^'

~ )

kV- ^-l

> It"

-^i:\

U

PERSONAL AND STATISTICAL PARTICULARS

i)\ 1 r: f! iUK III 0

!• I.

8xkt

M.,inh '

A' . 1%

L^

Dav

1/., >,','//>

1

IQO

(Year

MEDICAL CERTIFICATE OF DEATH

DATK OH I)i; ATH 9 ,

(M.Jith) <I>='V'

I in-:Ri:r.V CI-RTII-V, Tliat I atlciuU-l .U-t cased from

to ..———-" — TQO

■ itp

190

na\.

HINf'.l.K. MARKIKD

wiiioxvi'.D <>K DivoKi i:n

(Writi^ in -ih i.il (h-vi^'n;iti"n '

BIRT^1•!.^^'1^ (A

'Sta'' 1 >! < "' umli y '

NAM!- <'I
F A Tli IR

BIRTH ri.ACK
(»!• } AlllKK

(St lit iir i'.iutUrv

A

Hl>

tliat I la^t saw li alive oti

aiul that .Uatli ..rcurre.l. ..11 the .late stated above, at
M The CM Si" 01- IH'.ATH was a^ follows

/13

,-^

MAIUJ-N NAMK
tH- MOTHI.R

HiurniM.AOK
oi- M»)rin-:R

I >^latl III i'liuut! '•

ovHrrA I'loN

~\>:^

DTK ATI ON )\ars

CoNTKIl'.rToRV

Monlhs

Davs

Hours

nr RAT ION Years jr<".-f/is

/?<n.s-

(SIGNED)

/fours

)V„'

Month-

/h!

ruV XBOVF STATKU .■KKS..NA1. 1' A K T IC r I. A K S ARK TRl K To TlIK
HFSTUl' MV KNM\VI,j;iH-.F. \NI> Hl-I.lhF

\ildrcss

SPECIAL INFORMATION only for Hospitals, Institutions, Transients,
or Recent Residents, and persons dyinq av»,i> Um liome.

Former or
Usual Residence

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

How lonq at
Place of Death ?

Days

•l.AOK Ol- lURIAl. OR R^I-'.MOVAI

n

l-NI)KRTAKKR U^Uj-0|^ \£)/U<T^

I)\T1'. of Mr RIAL or RKMt>VAl,

t \H

190H

V 'A

A_

, ,. ,. , KCF sHnuld he stated FiXACTLY. PHYSICIANS should

son. dyinft awoy ?i-om home should be feiven in every instance.

WRITE PLAINLY WITH UNFADING INK-THIS IS A PERMANENT RECORD

REFER TO BACK OF CERTIFICATt FOR INSTRUCTIONS

HiCll

(1 of II. :ilth 1' N"

I

J)((h' FiJc'l ,

IH

VJO'i

llec^lslcrcd J\^o,

3318

Lt^LvKj, Deputy Health Officer

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco

PLACE OF DEATH: — County of

Certificate of S)eatb

1 Vi, S. StanDarO )
O/rv oVxX^cvi--' City of a,<XA^ Jxxx^CLC. •

%^

No. ^^^

e

A

FULL NAME

a.'d

<^ \.\.w^

PE

RSONAL AND STATISTICAL PARTICULARS

^l.X

^

COI.UK. \

4 I V
1) \'!'l' <»I I'.IK 111

\« .!■

n \

M..!\I'

ISA

EDICAL CERTIFICATE OF DEATH

It
(Day)

I go .

(Year I

DATE oi- i>i:ath ( ^

(Mntltll)

I ni-:Rl':r.V C1.RTII-V, That I atU-n.U-.l (Urcascl from

■" -~ 1 1)0

M,n,tln

/hn.

WIDiiWl 1> < »l< l):\(»Ki' J- 1>

l(.p to

- alive- on ~

that I hi'^t saw h ^—
and that dc-ath occurred, <.n the- <lalc .tatc-.l above, at
M. The CAlSIv OV Dl'. AT 1 1 was as follows:

up

^

C

A^^Jv/tv^«H^^A^^ ^t

"^v^Aa a,

.. .L

lUK rni'i. \^"K

N \\1 I- <»1

!\iin;K

HIKTHIM, ACK
()1- !• A TUKK

(Siatt III i"(iu!itr\'

MAinr.N NAMl-
nl- M*)THHK

ntR'rni'i.Ai 1*,
<»i MO I'm: H

I <!ati ot i oUlltt N'

« n (Tl'A rioN W

>l,v

%V

I )r RAT ION >'«<7r5

CONTRir.rTORV

DTRATION

Months

Days

Hours

(SIG

ct

,TI()N )V.;-5 ^ AI[o,tl>s Pars

NED) Lcr\^rr>JLH^ ^-^/^^ duXamL

Hour

M.D.

,n

T<)0

SPECIAL INFORMATION only Jor Hospitals, InstituTKTTFanslcnls,
or Recent Residents, and persons dying away Iron home.

I ,.

AV ;,//•/ /" S.tti / i,!H-

t )V.f<

\f,.,ttli^

n,i\

UKST «>!• MY KNoWl.J.lM.h AM) Hhl.H.l

Former or
Usual Residence

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

How long at
Place of Death ?

. Days

l'I,ACK Ol- nrRIAU OK KKMOVAU

1) ATI'. <)! HiKlAl, or KKMOVAI.,

CtJb iH 190H

N. B.-

^ ' T' ,. H AGB should be «tated EX4CTLY. PHYSICIANS should

-Every Item of information should b. carefully supphed AG „«,,H-.cd. The ^Special information- for psr-

state CAUSE OF DEATH In P'«'" J^r-"'' ^j^" „'*,,"^;^ rnstance.
sons dylnft away from home should be ft.ven .n every m

I. t

i

Wl

R,TE PLAINLY WITH UNFADING INK-THIS IS A PERMANENT RECORD

^^. „„, HEFER TO BACK OF C-^'^-^^r FOR INSTRUCTIONS

(>Ur^^^

Deputy hiealth Offi

lie <^ isle rod •A^'o.

DEPARTMENTOF PUBLIC HEALTH-City and County of San Francisco

Certificate ot Seatb

( la. S. StanC<arO )
PLACE OF DEATH : - County of 0<^' ^ ^<^ ' ' ^ ^.ty ot ^

r I a< ' . ^ ■ St., a Dist.; bet. '^^i^e^.ilff^u-X '

)

FULL NAME

(^

-^\. > V.\.

si:x

PERSONAL AND STATISTICAL PARTICULARS

V

I

!) \ ri: t>i- lUK I'M

L

4

axH

MEDICAL CERTIFICATE OF DEATH

i' Month)

IH

(nay)

I go \

(Yt-ar)

, M.i^ltll)

Ac^H

M

\ I )V,M

! 1 . \

M.niiln

Vi at

/^./)

--IN. ,1 I- M \HH n"i>

I \\ I it'- 1 11 ^1 11 i.i; iii''i' ii't ;• '- ■

^^[Koov

xo-'cL

"' 1 in-Kl-l!Y C1:rTI1-V, That I atUn,U..\ ,lccc.nsc-.l fron,

Cllvvd a upi to a^t 1^ upH

,„„^ nas. saw h -^ aliv...,, ^ ^^ i^ .^ ' >

„„HI,at,Uatl...ccurr..l, M„tlK..laU.stal.-.lal.,.vo, at .i

j.. M. Tlic CAISI' til'^ilvATII was as follows :

(0

0

^ru

L

11 1

V

lUKl'Hi'l.Ai'l"

I st.iti or ^'^ .iiiil! \

\ \M1 ni-
1 X'l II 1-R

(n 1 \rin-:K

«,! I- . I ir <.'iiiiiitt V

M Xini'.N NAMK
(»1 Morill'.K

HIRTHri,AiK

oi M(>rHi:K

( Stat.- Ill t'oiuitry!

ofcri'A rn>N

,yy,^jLA IvXakjyxJL

I )r RATION 1 y'-^Jf'-^
CONTRliirrnKV

MonI/is

Pax

Jlours

n

1

e

f)

DrKATlllN
(SIGNED )

jr,y>tt/is

)'ttirs

, 0 J OJvVOJx.

/)</l'5

//ours

M.D.

\H iqoHJjLlU

Is, Insltt

SPECIAL INFORMATION only for Hospital
or RefeM Residents, and persons dying away from home.

utions, Transients,

D

a . ^0

)V,n '

\r,>,iiii-

Ihn

lU-ST <)l- MV KNn\VI,l,I><.K AND lU.I.H.i

SuJ^idenccVJA/^^.^ ^^

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

How lonq at
Place of Death?

Days

(I

,„ ^'?.«c^_ -i--^

t.c^X

DATl'.o! Hi KiAi- or KKMOVAI,

IM.ACH 01-- lU KIAI, UK KKMnVAK

r.M'HR I •'^'^*''* TTs fl I) (*' 1

(9

I
I

I

I

I

WRITE PLAINLY WITH UNFADING INK

THIS IS A PERMANENT RECORD

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

Pff

fr /u/rf/M^<:tJoJihj IH

I^O'i

i^^M//,s7r/'^^/' *^yo.

'^fji^^U

DEPARTMENTOF PUBLIC HEALTH=City and County of San Francisco

Ccvtificate of 2)catb

n 'V-, J lop

'V

O.. .^^■

City ofC)xX^-'^-'C^>^-^

I

PLACE OF DEATH : — County of a. >x

n U% S 1 A St.; -^ UISTm OeU .,^„p„ ■special INFORMATION" \

FULL NAME^^ ^

PERSONAL AND STATISTICAL PARTICULARS

-^I'A

J

II il,' iR

(»i I'.iKin

4

M. nl U

^ D.iV
1

MEDICAL CERTIFICATE OF DEATH

^ .wW

(Month)

1 ' \

(Day)

tVcai >

5

I >iir

U;i1

I ^latr i.t *■' 'tin! t \

, niKi:HVCI,RTI.-V, T!,al I a.Un.U-.l .U..va.c,l fnuu
,. ,• ,„„■ to 0^ '^ "^^

thai I l;.-t >aw h alurnn ^ ^

a,„Ul,at ,U.atb -VUTCI, .„, tlu- .la,>. ..a.c.l al,..vc-. at

NAMK «H
FATIIKR

lUK rin-i, \< K
oi? J Arm-.K

iStiitr m riiuiit!

b'lx b 1

. '..w.

^1 Tlu- CMSIiOl' l)l^ATIl was a. follows
CONTKIIUTOKV

Ilotii ^

/></t'

M \n»l- N NAMl

I'.iK rinM.Ai J-:
(II Miiriii'.K

{ St ;it 1 .it il illtit 1 ^

(SIGNED) ^-TiTV^V

//ours
M.D.

Fecial information ohH lor Hospitals, Institutions. Transients,
or Re«^ Residents, and persons d)in^ a.ay Iron tiome.

Former or
Usual Residence

When Has disease contrar ted,
II not at pla« e ol death ?

How lonq at
Place ol Death ?

Days

HHsroi MV KSnWI.l.D'.l-. ^M> "r:'-" '

^M.ACKO^ lUKIM. <M< KI-^NK.VAI,

I1I%-1 » '»■ •■• ' J^ . /^N

(I„f..nnant ^ <XyyK.^^.jJ^ '

ex.. n X^

,,,a,.... IHl h<X>V^^^^'^

\\

rNitJ.HrAKi-.K-

i)\rj/'>! Hi imm i>i ki:m<»vai.

\b

TQO

(XMr.-^M ^ '^ " ■" L ,i_|L L PHYSICIANS should

■ ' ' ' , , , H^ ..rufully Huppne.l. ACf. h^ouIcI »\^..^;"'^^J; ..^..^.i^, Information" for pT-

y, B.— F.very Item n* •.nform«t1«n «houhi »^^:;"-;;7^ ,, ^;,, ,.e properly cl««s.».eU. The t»P.w
state CAUSE OF Dr.ATH In »» "'" ^^7^:;J;"|„ .very Inntance.
«an, dylnft owoy ?rom home Mhoulcl be fe.ve

WRITE PLAINLY WITH UNFADING INK

Dale /-V/r'/, ID-ctXuu IH T'^0\

S

DEPARTMENT OF PUBLIC HEALTH

THIS IS A PERMANENT RECORD

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

Ec^isterecl ^^o.

City and County of San Francisco

No.

Ccvtificate of "©eatb

( in. S. StanDarD j
PLACE OF DEATH: — County ofOo^x; OTva = City of ^/CX.>v 0

d/CLAV JXa , . ^ St.; -rDist.;bct. — -" " ' and

:v

n

i r- (

fy '

AY FROM USUAL REsTdENCE GIVE FAcVsWt^D 'OI^UNDER l^fffj^i Jq "^u M BE R^ " ' )

/ If death occurs away from usual H ta I UC i^v..^ u.»i. ",'l I,amF i^-QTFAn of stree
C 0 "^ DEATH occurred IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREE

FULL NAME U<x Oo

PERSONAL AND STATISTICAL PARTICULARS

ri II, I tK \ f\

n

n

1 o y

I» \li: «)l l;IK I'll

\< .I".

iNt.nth

);■.!,

.1

!);iv

M.,>,lln

/',(

/

w iiMjivHi* <)K DtyttHrKD

Wiitcitl liticiiti ilr^it'Ilatioll)

IHK rii»'i, \'' 1

/

rgo

(Yi-ai t

MEDICAL CERTIFICATE OF DEATH

(Month) (Day)

I III-:kl':HV CI.RTII'V, That I attcJuUMl .loceascd from

— — — — — - up to 1<P "

that I last saw h .:r— alive (mi _— — ~ igo ■

ami that (Uath occurred, on the date -stated above, at —

M. The CAI'SP: Ol- Dl-ATIl was as follows:

I- A riii'.k

of 1 \ III i: k

^tati nr I iiiiiitrv)

Ul" Moini K

isiK'rm'i.Aij-:
111 Morm-.K

I >t ill . ir fiiutiti \

M

/

( »i'k r !■ \ rioN

^

RciiirJ III Si! I' I'l lUli I-, ,1

^r<niths

Ihiv

Tin \HovF si\rin i'kk-.on \i, r\R iii-ii.aks aki-: tkih To Tin-
iu;sT «>i' >.n KNOW i,i:u(.i, wd nv.x.w.v

(Itil Mtjumt

L<A'CrY%X^^ UXwUL

\A>^^A>J(xAj|^'<f^^

\ ^ A

Dl'kATloN Vi-ar

CONTkir.lTokV

M out In

Pays

//oil PS

DlkATluN

(^

) Liirs

Afoiiths

( SIGNED ) WUTAJUV J .mUJ <ixl

/hiy

C\

//ours
M.D.

^

t<)0 V (/

Xfldrcs^) WuHAJl^^ CU V

Special information onU for Hospitals, Instituttohs, Transients,
or Recent Residents, and persons dying awav from home.

Former or
Isual Residence

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

HoH lonq at
Place of Deatli ?

Days

I'l.ACl". nv niRIAI, OK KKMnVAI

l)ATj;..f UiRiA!, or Kl':MnVAI,

0^ IH

I \'Mrc

d^.y. y. J vulavvolUxu

INI) !•: K T A K i: K V3 CAXJ-Aj \l. LL Jr k-KAJL ^

T90

IM B. F.very Item of in format Ion ahould hi carefully supplied. AGB should be stated EXACTLY. PHY8IGIAN8 should

state CAUSE OF DEATH In plain terms, that It may be properly classified. The ''Special Information'* for per-
sons dyin4 away from home should be &iven In every instance.

WRITE PLAINLY WITH UNFADING INK —

2^(9H

THIS IS A PERMANENT RECORD

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco

%

Certificate of Beatb

( "a. S. StanC>arD )

PLACE OF DEATH: — County ofOaov OX^ix^a. City of ^X^^v J;u<X>vav.^

ft I

,. Ci

f4e X^'^lVvAcVLi, V St.; Dist.;bet. and

/ ,r dk.TH OCCURS AWAY FHOM USUAL RESIDENCE give facts called for under special information • \

( !V'dE*T» OccJrRED .N A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. J

(^ ^^ 5 ^ ^
V ' :^

FULL NAME vC v

)

I t

• ■)

SIX

PERSONAL AND STATISTICAL PARTICULARS ^

m

I) \ ri- <)! niR I'll (f\

Mwiilh

A«.l-

t:-

5

L

I 1 )a \- 1

_\; ■>,///:

/ u V.

(VciU)

/?,n

iW'iiti ill ^noial (U>«is.'n.ui<>n)

HiK rm'i, AOI-:

I Stiitc <•! '.■'Hint I \ I -

W

m-

1- A iin.R

niKini'i.ACH
ni" ! \ rm:R

i --it:!! I 11' i'l lUnt t V

M \ 11 ) 1 N \ \ M K

1)1 Mdini R

lUR rniM.Ari-:
»»i M<)riii:R

w / >

y

^^v^-o ,

KCL/TVJt

(

X.C

k'l- i,{i',l in San /'i iii'i isr,> ^Q )''ii's

A/, '11/ /is

/'<M

rill' M'.nvi* sT\ri:n j'Krsonai, iv\Riii'ri,AHS ari; trtk to tiih

in>r <>I MV KNn\Vl,l-:i)<'.H AM) Hl'.l.lKK

MEDICAL CERTIFICATE OF DEATH

DATK Ol' I)1;aTH

\/c1j

IS..

(Day)

(Year)

(Month)
1 in':Ri;P.V CI:RT1I'V, That I attended »lcccastMl from

B.x^xX ■ J : 190- to . w;cfc. - u. T90 •.

that I last saw h ■:— alive on - —"■ ^~" T90

and that death oconrred, on the date stated ahove, at
M. The CAl SI*; OF l)i:A'rn \va^ as follows:

1

-U|\<^cLo„U,^ AJ<

DIRA riON

}'i'iJ)S

Mo ft //is ^ /hivs Hours

DT RATION

^^ouths

(SIGNED) \J. J \J r-^ ^

I3i tqoH (Addrev,s) \X%i

/hiVS

//om s

M.D.

-^

Xa

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

Former or
Usual Residence

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

-\-4-q,^ U h j ' Mow lonq at
0 h ^<L^KM k{ Place of Oeatli?

Days

ri.ACK yi" lugiAi, or rhmovai.

DAT!-; i>!' HcKiAi. or R1-;M0VA1.

Qt* IH T90H

(AdcWeas Iti"^ \mA..^^V^rA.Jjli

N. B. Every Item of Information should be cnrefully supplied. AGE should be stated EXACTLY. PHYSICIANS should

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

I

1 '

I i

•III' it

WRITE PLAINLY WITH UNFADING INK —

I!. ,;,!,! 1,1' II. ,i!'h 1^ No

1' Co

Date FiJo(l /k)^<:XAyJC\) I

r

2^(9H

THIS IS A PERMANENT RECORD

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

^

Jr^^j^"^

Deputy Health Officer

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco

Certificate of Beatb

( "a. S. StanDarC* )

ofO/CX/>A; wA.a.^xCU.CA. City of ^ <X/^yv o/uxa'^c^.>

PLACE OF DEATH: — County

"^ ubM..kLta.».. St.;

.. 'kI. i

(No. WCu. V Wuy'

^

Dist.; bet.

and

T / .F DEATH OCCURs4«AY FROM USUAL RESIDENCE GIVE FACTS CALLED FOR UNDER "SPECIAL INFORMATION" \
\ ( IF DEATH OCCURfl^D IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. J

FULL NAME

AAN-.^.

PERSONAL AND STATISTICAL PARTICULARS

Sl-X

ni<

COl.OR \

DA 11, ( >1 lUK lil

ID

A\J^^^

t .

M. Mil 111 K

iDiiv

\« .1-;

I \ Y,a>

lar)

/>.M.v

^1N<.I,I' MARUIKIV

\\ IIi< (Will (>K ItlVoKi »-l)

' W \ itf ill -"rial >\< -i;.'!!a! loul

lURrniM. \c J-:

1 SUltl lit I'l MUltl \

NAMl nl
FAT 1 1 J K

/^n

on 1

VJ

/YVcLcK) 4ja.

IcxU

W wJw,

HIK IIUM, \OK
III I \IIIKK

i^ititt )! roiiiittv

MA!I>I:n" NAM!

<»i M()i'm;R

I'lIK IIU'UACI-;

«n- mi»iiii.:k

J/ux .

\\jxAj

n

^AA^Jb ^Ux

'\

I K\'frA'rinx

0 ;ux>v<:ix

M.rilUn

/*,;i

xwv. \ni>\i: six i'»:i> rKK^oNAi rxk tiiti.aks aki; TKri-: Tn rin-;

lU'.sTol MV KNOW 1,1, D^K AM) Hi:i,I);j'
(Illf..:iuillt vJ-M5

MEDICAL CERTIFICATE OF DEATH

DATl-; Ol- Dl'.ATH

Uct

iDav)

TQO H
(Year)

..5,t.fc

(Month)
I 1I1':KI:15V CIIRTII'^V, That I attt'iiikMl (IciiascMl from

10 190 H to ^/otr \X T()oH

that 1 last saw h u. . . x alive on ^ ' * >- i<>o •

an«l that (Icath occurred, on the <late stated above, at 1 a aO
tl. M. The CAISH OF I) HAT 1 1 was as follows:

Dl' RAT ION Years

CONTRIIUTORV

Mouths

Da ys

Hours

DIRATION
(SIGNED)

Ycixrs

IqO H ( A<h

^fouths

Pays

Hours
M.D.

nlv for Mb

1

SPECIAL iNFORMATIOr

or Retent Residents, and persons dying andv from home

Former or i 1 1 q \ 4 j ♦

Usual Residence \\^\ UA^Cm^)

HoH lonq at
Pla( e of Deatli ?

Days

Wlien was disease contrarfed,
If not at plare of deatli ?

f \.l«ll.ss

,^ I I", <>I

0,€t

IM.ACH <»l HIKIAI, OR RKMOVAI,

r N I > V. R r A K K, R 0 xXaJULm . V -w w^^vy ^

DATKo! Hi Ki,^i. <.i KKMuVAI.

^iD

wO-

jM. B. Hvery Item of informiition should bj ciirafully supplied. AGE should be stated EXACTLY. PHYSICIANS should

stHtc CAUSE OF DEATH in plain term*, that It may be properly classified. The "Special Information" for psr-
sons dyin^ away from home should be given in every Instance.

jg^fcatfegJMifgfii:

Mte^^^i

}!.,;, nl .'f 111 rillh 1' X

WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

t«* x:- ?.i-. HJt r ('

Dafr /'V/rv/, U/CX<rlM>J

;,9^H

Be<!isteved JS'^o.

Deputy Health OflTicer

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

Cevtificatc of 5)eatb

( tl. S. StanDar? )
PLACE OF DEATH:— County ofOxXAXi JtvCXAvCl..' City of O-Cc-w o ^XX/v^x^<^v

fsJo. v.i-^U

cru ,X'-

%^

St.;

/ ,r DEATH OCCURi AWAY TROM USUAL RESIDENCE G.VE FACTS CALtED ^OR ^V^" STR E eI^AN D 'n U M B t R^ " " )
K IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. J

FULL NAME LL ^'

Dist.; bet.

LE
Ml

and

)

ft

,<X >> V

^j„'

. VL C ! \.

-^i-.x

PERSONAL AND STATISTICAL PARTICULARS

C()i,<»R ^ ^

i»\ri-; <)t- lUK in

LL^Vwi ' f

^

i Dav

\< .!•;

I (J^ 5V,/<

M'titli

■ar)

/>.; 1

sixr. ij.-,. MAKi<i}:n
\vn)(»\vi:i) «)K i>:vnKi'i-;n

iWiit< in s(K'ial (U-«-i>.nialii)n)

lUK IIM'I, Ai'J".

'Statt iir ('■HUiti %

%

r\

NX Ml", ni
lAllll-.k

I'.!KIHl'l,\t*K
i\V I AT ill-; K

' Slati 'i! i"ii\nitrv

M \I!»1:N NAMl '
Ol MoTlll-'K

uiK rHri.,\i*i':
»>F Morm: K

fHtatf or r.iuntrv

-Y^X. ^^VjCC'

a..

Ml

LX. M

MEDICAL CERTIFICATE OF DEATH

I)

..... .. ,....., ^^

(Nfontli)

(Day)

(Year)

I I!1':R1;15V CIIRTIFV, That I attended .k'ccasetl from
\L)ct: T.^': . .to L.<ct..

I90

£)^

190*1
that I last saw h .4-<W\ alive on VLf ev ! i igo i

and that death occurred, on the date stated ahove. at
L-l M. The CArSI-: OF DI-ATll was as follows:

DT RATION

Years

Months

Days

1

Hours

>A.A^c^ ^

^^ )'i'ars Months l">avs

1)1' RATION _ Years

(SIGNED)

S.(i. It

Hours

M.D.

ID/Ctj IH TQoH (Ad.lresgUtu "'^Co.. dbo^\<>W

SPECIAL Information only for fiospltdls, institutions, Transients,

ot'Cri' \ I inN '^

h'f iihil in ^(lll flillliii'i

) V(7 » 5

M nil His

f hi 1

Till" \I!« >\l' -^'l' \ 11' I> !•». RSON \1, I'AKTICn.ARS ARK TRIE To THH

IIl>-,Tt»l MV KNOWI.I.IX.H AND HHUIKF

(

(D)fi)iiiiant N— ' .

f\d.lt•t■'^S \^'

i^

^..Lo. 0loMti\AAXxX

•r Recent Residents, and persons dying away from liome

flow lonq at

Former or ( !a

Usual Residence VD UXuTO^i^^^^

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

Place of Death

Days

rj.ACK 01

M

DAlHof niKiAl. or RKMOVAl.

s'DKRTAKKR ^A , WW • M M^/OjAXv-yVr

(AddrcBs „5l^..L) J <XA.AXMj

190

IS. B. Kvery Item otf InformntJon should be carefully nuppl cil. AGB should be stated EXACTLY. PHYSICIANS should

state CAUSE OF DEATH In plain term., that It may be properly classified. The "Special Information" for psi*-
ftnns dying away from home should be given in every instance.

I

n

» I

»#

WRITE PLAINLY WITH UNFADING INK

\u

,a!.lof lli:.MIi 1- No .^ ■*-?; flK^ n^ 1' Co

/>///r' /v7f></, L^cto-l^N^ IS

i^6^H

THIS IS A PERMANENT RECORD

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

Resiisfered ^'o, ^Of45

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco

Certificate of 2)eatb

{ tl. S. StanDarC* )
PLACE OF DEATH:— County of ^ 'Oaaj . Vo, ,

A

(^

City of O/CXy^v 0 /uo^^-v-c lk

No. XCC^AJI/

A

(^<S.,iA

.d

^

St.;

Dist.; bet.

and

)

/ ,r nr*TH OCcJbS »WAY from USUAL R E S I D E NC E Gl VE FACTS CALLED FOR UNDER "SPECIAL INFORMATION" \
( Tf DEATH OCCURrTd.N A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. . J

FULL NAME ^^

. V.

4.

PERSONAL AND STATISTICAL PARTICULARS

-l.N rjPl A ! COM)R

vJX/YWO^Ll

i;i. ^ ^

i> A ii: » »!• I'.iK rn

\« .!•:

JMonlli I

!,-,.■/

(Day)

M.,»,lh:

I Vcai )

])n\.

\\ii)«»w!-:n ok ni\»iKri-:i»

l\\iit< ill ^111 i. 11 ili-.is.' iiat ii ill)

IHRI'IU'I, \i*i-:

(State I.! Cmmt r y

.dLcruj-

J A Til I'.K

lUKTIIIM.Ail-:

til I \iiii-:k

-^t it' III t'ouiitrv

M \11»1'N NAMl-
(»1 Mol'Ill-.R

lUR'IHl'I, Mi:
kW Mo'l'lll-.K
(Statr iir I ouiiti V

) I

(ll

9

XA

.0

4 I I 1

\ \

\

MEDICAL CERTIFICATE OF DEATH

DAri", <)!■' HKATM jf\

\

I go \

(Year)

(Month) (Day)

I ni:Ri;HV CIvRTII'V, That I altoiKkMl ik'icased from

LLc^.c^ \- 190'. to .^'Ct IH 190'i

that I last saw h .i..' . alive (in w cL i'\ 190 \

and that (Uath ociurred, mi the date statetl above, at Olb

J.. ^F. The CAl'SH OF I)J<A TH was as follows

'\

^rv\.<XwUi

nr RATION ^ Years
CONTRIIU'TORV

Mouths

Pax

Hon PS

niRATION

(Signed)

Years J\fonihs

Days

flours

I r

lc)0

(Address) ^^^ V/^VwAw^.'C.^u J a.

M.D.

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

oiCl I'A rioN

h'f'-ui^if i>i Sun I I a Hi

) ,,;/

1/. -/////.-

/»«/>

rm- MiovK sT\'n;n t'KRsoxAi. partum i.ars aki; pri i-: m Tm-:
lii'sT »)i" Mv K NOW i,i;i)(', !•; and iu;i,n;i-~

(Inftiimant

A- ,:_-<-

0 vv

uUlIaaXx^

Former or T ^ 1
Usual Residence t -J I

^^ai

1- "t . How lonq at
XkXS' Pldreof Death?

Days

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

^I.ACH Ol- HIKIAI, OR K1:Mo\ \1,
INDKRTAKKR VX>JnXUJ" ^

I»\ri<: .)! 151 uiAi. or KHMOVAI.

T9O I

(AdilreHH ..

<X/>\i

N. B.

-Every Item o? Information .hould bs carofully nuppflecl. AGB should b« stated EXACTLY. i»HY8ICIAN8 should
state CAUSE OF DEATH In plain terms, that It may be propsHjr classlflsd. Ths ''•HiiilMHMM<lon*' for psr-
sons dying away from home should be given In svsry tfi|$§j

mff.i.jA

> I

,*

WRITE PLAINLY WITH UNFADING INK

Hoanl ..f II, :iM)i 1

\-,, .- ■t-^'s^-^liScVCo

I)

lilv /'7/r>r/, LlctcrWv IS ^^O'^K

THIS IS A PERMANENT RECORD

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

2325

Re^i^tered JS^o,

fff cef

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco

Certificate of Death

( tl. S. StanDarD )

of OOmj JAxx^-vcc;.. City of O/Cl^tV 0/UX^^x<:a.-^ c.l

No.

PLACE OF DE ATH : — County

^CKKdxx-<.

St.;

Dist.; bet.

and

\^W Y VX/ ' -^ \1 >C<|I \-v^ws^v_^ . orti^nFNCK riwr facts CALLED for under "special INFORMATION" \

( '^ rF"orATH^S^:u%ro\"rH "s^rAl: o"r"n^'.?u" "^a.vr.;i name .nsteao of stre.t ano number. . )

FULL NAME

la.'. .. Lcrl In

-0.

si;x

PERSONAL AND STATISTICAL PARTICULARS

I COI.OR

./■

rc<

DAii". <»|- luurn

\C. 1'

/YV

M..iith>

5 ></ '

(l)a\ I

\/.,ii//r

r u -^' i

(Year)

/>

(7 I .\

SIN«;i,l... MAKKll'.n.
\Vn><)WKI) OK niVoKCKH

(Wtitfin •«iHial di '■it'tiatioii)

lUK'nii'i, \oi-:

iStnti- III (,'iiillit ! >

K^

dLcruj-

1 A riii'.R

lUKTniM.ACK
oi- I A I'll HK
-^Ittc III (."ouiitryi

M\!IH:V NAMl

oi m()Tiii;k

lUKTm'I.ACl'.
^^V NH»TlfKK
(Statr i>r Countrv

'i I

4^ tX^C^^AA.^.

/CXAAXJuC^ A,^^ .

\ \

OXJ^

A .

s\

XXAACCClvN^v

MEDICAL CERTIFICATE OF DEATH

DATE OI' DKATH

(Mouth)

(Day)

/po .

(Year)

I HI':R1:HV CI^RTII-V, That I attoiidcl deceased from

U. 190' J to iil^ .11 190 H

1

^ IH

that I last saw h t^ alive on S^ ^:>^.- i ^ 190

Q U C

and that death occurred, on the date stated above, at - l •>
J^- M. The CArSK OF IMvATII was as follows:

I) r RATION ^ )'t'ars
CONTRIIU'TORY

Moulin

Days

Hours

DIRATION

(Signed)

Years Jl[<^'f^^^

/Mrs

y \ s^.

X^^ '^ IQOH (Address) 3>X3»LI\AA/vdki -Jt

Hours
M.D.

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

oiHTl'A I'lON

) lUl I '

.St.uith>

/hn-

THi' \H«»vi.: sr \'ri' I) pkr^onai. tak rut i.aks aki-; trik to thh

Hl'.ST Ol- MV K NOW |,):i)(.l-; AND lU.MI'.l-"

(111

f..n„ant OOVv^ ill. ^--^ '. "^ ^ '

fAd.lrtss i b I M lA

N , ,*

;v c\.L

Former or -T^iUh'^ni
Usual Residence I 0 I N U WL*

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

^iHow lonq at
SA'OAflareof Death?

Days

iji.ACH OI- m'KiAi, OR ri:movai.

I)ATl-;ot HiKiAi. or Rl'.MOVAI,

{AihUvss..'^°iM<X'y\j \rUA^ Lk

N. B. Bvery Item of informHtion •hould b.- carefully «iippliecl. AGE should bo stated EXACTLY. PHYSICIANS should

state CAUSi: OF DEATH in pinin terms, that it may be properly classified. The "Special. Information" for per-
sons dyin^ away from home should be given in svery instance.

te^

r^F!

•. 4

-•l!lf| i

WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

Honrd^.f lh:,!!h- !■■ Vo ..t-X^y-i^lU^VC'-

I )((!(' Filed ,

V 15"

100 'i

Brgistered J^o,

2326

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco

Certificate of Beatb

( "a. 5. StanOarD )

Q^

PLACE OF DEATH: — County of

1

"V and OwAlCL,*-

FULL NAME

^AKX.

PERSONAL AND STATISTICAL PARTICULARS

k..!

5

DAli: «»F- lUKl'll

KV.V.

CUj,

Day)

(Veur)

5-

M,.nf/l'

Pur-

\viiH»\vi:i) OR i)!v«tKri:i)

(Writt- in -iHMal lU-iL'iiat i' m >

lUR inri, A01-:

st,il< " i! I'nuiitry

»• Aiin:R

lUkTHri.Ai'K

oi- lArin.K

'Stati or v'Diinti V

MEDICAL CERTIFICATE OF DEATH

DATK «)I- DlvVTli ,r\

Day)

(Year)

fMniith)
I lii:i<!;i5V CI'KTII'V, That I atteiukMl .ItH-tasc'.l fmm

to ik/.^ I.H. Kp .

I9O

-^

ItjO

'^^ v »^

SI (fe

MMDKN NAMH /TS

nl- MOTIIHK

UKxxAJLrtLi' dOAlrc

lUK rnri.ArH

01 MnrnHK
Mat' or Country

-J (^

that I last saw h -i^^^ aHve on w '-t.1 ■ "

and that death occurred, on the <hite stated above, at 1
... M. The CAISH C)J- I) i: AT II was as follows:

1)1' RAT ION }'(ars

CONTRIIUTORY

.0

MoHi/is IH Days

Hours

0

or RATION

Years H Months
( SIGNED ) AX<LlLcu.xLi Vij.hj
iD/ct IH looH (Address) niffCUj

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

f\i'-nh\i in Siin /'i ,in, (M'li

)%,ji< O .\r>ntli> \ rhtv.<

\\\V \!!OVI-- sr\ ll'O I'KKSONAI, 1' \ K l' IC t ' I, A R S A K I- TRri-: P" » IHK

Hi;sr <)i- Mv KNOW i,i;d<.h .vnd bj:i,ii:f

,I„f,Hn,ant H>VuO wA UJ.OUUa^

\.\.^^w. L

y

^\(l<lress

1 1 lb VJCKAK.LI dl

Former or
Usual Residence

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

How lonq at
Place of Deatli?

Days

I'l.ACK ni' m RI.M. OR RKMOVAI.

DAri'.iit r>i KiAi, oi ki:m«)vai.

IQO I

INDICRTAKKR

0-<ij,X»-

AdJress 3(^5" ^VUrnXtytn^v^LxKA^^

tyts^^

j>, B Rvery item of Information should b^ cnrefully supplied. AGE should be stated EXACTLY. PHYSICIANS should

state CAUSE OF DEATH in plain terms, that it may he properly classified. The "Special Information" for per-
son* dying away from home should be feiven in every instance.

f '

I I

!il

^g^_

WRITE PLAINLY WITH UNFADING INK

I.,,.i!.l . t I!> -Ith !■■ N.). !

. t"*^"^;- r.fv 1' f

n^o'i

THIS IS A PERMANENT RECORD

REFER TO BACK QF CERTIFICATE FOR INSTRUCTIONS

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco

Ccvtificatc of Bcatb

( 'U. 5. 5tanC>ar<> )

L. ■,'-'-'■'. - City of ^'^^-'^^ 3/VCV,. vVCA,4C t

c^

-Ul

No.

PLACE OF DEATH: — County ofOo.->x. Jxa ^ -

M P ^^^< --,- , , ,■ ' • St.; Dist.; bet. cUaa.

■ ' ^ ^ ,,«;i,Al RESIDENCE GiVE FACTS CALLED FOR UNbcR "SPECAL 1 N FOR M ATIO N " N

( '^ .7orAtt"oCCU%rEV,rrHOS^"*^ :r'?^?t'.T "4^/o.VE .TS NAME ..STEAO OF STREET A.O .UMBER. J

andUa„LU-\

FULL NAME

,rOC

UJvC)

f.

PERSONAL AND STATISTICAL PARTICULARS

^

^

i I \ I 1 ( if ill Kill

M .nt'

\| .1

Wl

1/ .»/,'A

I » (';ir '

/),M

! I- M \KH IJ'K

.1, ^i ..

!)

n ■■' H i,i 1

L^^C

MEDICAL CERTIFICATE OF DEATH

DATl", Ol' 1)1. ATI!

ki

13

'I);iv)

(Year)

I Month)

I HI'Rl'l'.V CI'.RTIl'V, That I atlL-iukd (kHxased fruiu

190 ~

I90

to

HiK rnri. \iM'

( Statf I iT ' "'in III 1 ''

N \M1 OI

, \ rm:K

inHTni'i,A<K
of I \ rm:R

M \11»1:n NAMl.

(>] .M»)riii%K

iuHrnri,Ari".
(>i Mtrini'. k

( Matr 1)1 i'nuntl \

?

T3n

s.

OiTll'

h'r^hh-if III SiHi il iiii- '''

)

\/ .,:'/>

/'■;i

in>r <>1' MV KNOW 1,1 IX. 1-. AM) lU-.Ull.l

K>- AK1-; TKIK TO II 11%

(Infininanl

fAd.llH■ssU^^XAJba^^^ v)

that I last saw h alivr <.ii

an.l lliat (Ualli occurred, oti tin- <latc slated above, at
LL M. Tlu' CAISH ()!• DKATII wasas follows:

190

10

DC RAT ION Vc^irs

CoNTklPdToRV

Monfhs

Days

Hours

DIRATIDN ^

( SIGNED ) C<A^C^AJl>V

Days

flours

M.D.

Years ^ Mo}iths
T.,nH r Address) L^VOAvyv^ H^ ^

ON only '"r Hospitals, InstitutiM, Transients,

SPECIAL INFORMATI

or Recent Residents, and persons dying aH.i\ from home

Former or ; ,
Usual Residence^ '

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

How lonq at
PIdf e of Death ?

Days

/VOUCVU\-AV

X

I'UACK 01 I'.IRIAI, nK K1:M<»VA1<

rN„HKTAKKK tk<X^ \m^. \S'^Aj^

n\l'l"i)i I'.i HiAi. or KKMOVAI,

^ ,, t ;

TC)0

V

f>^„<r>\j

State CAUSE OF DEATH In plain terms, that it may be properly Uossmea.
«on» clyinft away from home should be feiven in every mstance.

pr"

f t

WRITE PLAINLY WITH UNFADING INK —

,r,l ,.f II. I'th t- N<

1- »•<)

2,9^'i

THIS IS A PERMANENT RECORD

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

QOQQ

Re^ititcrcd ^'o, ^o^^ci

l^^lxo^^ Deputy Health Officer

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco

Certificate of Beatb

\

PLACE OF DEATH: — County ofOaA^ J A^

City of O/OL/YV OKXX'^x.^CAM

ILL. litAiVLcKXi'dL. U luA^i.- St; - Dist;b€t.

^fo. V^UJuL ^'^^^'^^^™^^ ;; ! ' „ USUAL RESIDENCE GIVE r*CTS called roR under

1 ( '^ r/o;rH"oct%ro\;"rHo"s^"'iL :« ?.?t..ut.o. o.ve .ts name .nstc.o or

and

ORMA-

street and number.

"special INFORMATION" '\

FULL NAME

\jOJ\1) ^. C\

-.i.\

PERSONAL AND STATISTICAL PARTICULARS

riti.iiK '

iiA n < 'I iUK i il

Pas

M,.iitli

•an

/ )./

MEDICAL CERTIFICATE OF DEATH

DATK OF DKATH , ^

(Month) ■''■'^■'

I III'Rl-BV Cl'RTII-V, Tliat I atten.le.l .lecvascl fmui

iVt-ar)

n
y

I 'A

-I\< .1,K. MAkK 11 1»
a !i>< i\VHl> <1H II '^ I I'sKH
U-M. Ml -..• i:.' ■! ^;-n.,ti.,ni

niK rm'i. \»"i"

A

\ \ M 1 < >l
\ All! 1-K

HIKTHI'l.ArK

«»i- I \ rm-.K

IStati . T I'.iimt

M \ I DIN' N \M1-

t»i Mtti'in-.K

I'.TK'niri.Aii*.

(U Mit'nil'.K
st.iti .11 I'muit t y^

T5

LoJul vJ^O.

T90 , t.. '-^ ^*^ ^

that I last saw h • ■ alivc' <m "^ -^ ' ^^^ '

and that .leath nccurrcl, on the .iatv ^tatL-.l al.ove. at »2^ ^S
M. TIk- CATSI'IOI* 1)1' ATM Nva< a< follows:

S, I %- ^rS.-*..

DTK AT ION y^-ars

COST KHUTOR V

Monlhs "^^ /^MA- /fours

n

0 -IAT) 1 xcx-'^-vu

oocrrA'i'ioN A-Y^

)V,;,'

M.u,f>'r

Ihn

THH ^m>VKSTATKl>l.KR.<>NAl rAKTl.ri AK^AKKTKrK T- > TUK

in:sr oi- nu' knowij-.ix.I". and lu.un.i

Years Arouihs I^ay.

it>o

H (

Address) \XXj

IIou) s

M.D.

1)1 RAT ION
(SIGNED)

Oct n

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

rywJ^vsJi:

Former or
Isual Residence

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

How lonq at
Place of Deatfj?

Days

(InfoMn mt

fXArX^^^

V\ \CK 01- lUKIAI. «»U U]:M»)VA1.

<0 xs.rs^'^'x.^x ^ ^yJ^J^
ini>i:rtaki',k

i)A'ri%ut HiHiAi. tit ri;m<»vai.

V^,.

A.M,-.ss SbiS-.-njJ,

,0^

'^

Si

,. . Igb should be stated EXACTLY. PHYSICIANS should
of informnf.on should b. careVully suppi.ed. ^^^^^ ^^^j^^^.y.^d. The ^Special information" for p.r-
E OF DEATH In plain terms, thot it mny be properly class.t.e

N. B. Bvery item

state CAUSE \tr L»»^rt • ■■ ■■■ f" -- — ■ , \^^^»nc-^

sons dyinft away from home should be ft.ven m every .nstance.

!. ^

a 1

WRITE PLAINLY WITH UNFADING INK-THIS IS A PERMANENT RECORD

^-^ ,„. RgFgR TO BACK OF CERTIFICATE FOR INSTRUCTIONS

2329

t V.

/),(/(> rUetL Lc

t{KMA;

i

Deouty H

Re^i.^lcrcd ^o-

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco

Ccvtiticatc of IDcatb

( "U. 5. StnnDar^ )

No. ^;^^C

PLACE OF DEATH: — County of J^^^ o 'va/YVCULc^v.ity oi

J ' St* — — Dist'bet ^^^

FULL NAME

V

!u^cUvL' LuA.'lV^.Y^ '^!

PERSONAL AND STATISTICAL PARTICULARS

C< ll,( iR "^

LO. kctt

> ( a!

MEDICAL CERTIFICATE OF DEATH

DATl-; OI- I'l'.ATll

■^.a

1 \! \ K K nil

III

IM!' :'ii iM, \t' I

u

Ml ill

\ . 11 1 . 1<

ink 111 ri. \i l^

til Miirill.R

HIH IHIM.Ar}:

1 IIKKKHV CI{RTIFV. That I aUciuUMl .kHva^ol from

that Hast .au h .- alive- o„ "^ ^ "^ ^V"

^„„, that a.ath .K-currol. nu the .late .tate.l ab.ive, at I 30
.1 M. The CM SK tH- DKATll was as foll..svs:

1)1 RATION

C ON T R 1 1 U T O l< V W<XX a

Years J/on//,i ^ A?,.?

Hour

\xx.c

i .-^

DTRATION )V^/r,v

( SIGNED ) L<LuJ-v>v

A (J

Months
KLk

Pav

Hours
M.D.

^o

K,-!.t,,

■., • (/ I I ll >

) , ,,'

1/ -Z//'^'

/),/)

■nn: .MovKvrsTrurKu.osu r;Kn;r.,vK-AU,,T,<rK TO Ti.K
iii-sT t»i- Mv uNiiw i,i;i)<.i-: AM) i;i,i,n,i

» n 1 ^ »

(Iiifoiinaut

c

\'Mi

•^yo^'y^^^'

"special information only tor Hospitals, Institutions, Transients,
or Reienl Residents, and persons dying away from home.

i , I \ I How lonq at

Kwdencdf^^O/yvX ll.av I Pl,„e o. Deal!,? > Days

When was disease contracted.

If not at place of death ?

l-I \CK ni- Hf KlAI, UK RI:M<»\ Al

r^ KfrV

LJaQr

saXa. K„<

rNl.l.KTAKKU Mfl.^rVCW^^

(All. his'; OO o" OO L

l)\li: ll!' 1!i lUAi. or KlvMoVAI,

wU 190

'<

JAa^

^i

/I ^— — ^M^wi— ■^'^"^— '"*"™*"*^^ r-vArxiY PHYSICIANS should

^. B._Bvcry Item of ln?.>n.««t1on Hhou.d he c.,rc.'..t.y sup,, he. ^^ ;J;.^,^;:,„^,.,.,,d. The ^Special Information" for p..-
state CAUSE OF DEATH hi ph.in terms that .t m»> ^f J ^
«on, dyinft away from home should be ^Kcn .n every instance.

'■ *^

^ml

*• i

R,TE PLAINLY WITH UNFADING INK-THIS IS A PERMANENT RECORD

REFER TQ BACK OF CERTIFICATE FOR INSTRUCTIONS

^ 15 1""'^

Uro isle red J\^o^

Deputy

th Officer

DEPARTMENT I^F PUBLIC HEALTH=City and County of San Francisco

Ccvtificatc of IDcatb

PLACE OF DEATH: — County of

City of U ^iXXi 1

— and

No.—

"HirS^^j'^D rOR UNDER -SPEjAt. >NrORMAT.ON ^
"*^I? ^.««r .„=TrAn OF STREET AND NUMBER. J

")

J^'

FULL NAME

PERSONAL AND STATISTICAL PARTICULARS

h-

MEDICAL CERTIFICATE OF DEATH

DA I'!-. < »1 I'l' ^'''"

I iii:i

.I:HV n I'lII^V. riiat I attcn.UMl dcrcasd from

-— - IgO

t»»

that I la-t saw li
aUt

iiis<- oil

1 I)

M. T!u CAI-i: nl- I.i:\TH %va. a. follows

ii'i \i" r

w*^

Ml ill

HIK ! II I'l. \fK
• M I \ ill J- K

>-,f : • . , ! I 1 11! nt 1 %■

III MDTm: R

luR rm-i. \cv.
(ii MMriii'u

I SI. lit 1 i! t'uunt 1 ^

in RATION )'riirs

C<>N TKlia TORY

DT RATION ^ >■'■<?/■-<

Mouths

f)av

//i)iirs

Mouths

Ihu

'S

(SIGNED ) -i^O.^ . ^'- ^_

Kp

'1 ^*N

UvClTA TioN A ^ I l*"

-Special information only f«r Hospitals,%stituUons, Transients,

or Refent Residents, and persons dvin-j av^ay from home.

How lonq at
Former or mt ii\ Death? va)s

Usual Residence

When was disease contracted,

If not at place of death ? —

R,,,ir,f ni Vc' /■■'.'".

Ki )■ I'O l'"l'

IU->.T r,l MV KN()\Vlj;i)>-.H AND lULHJ-

(InfiHtnaut

yi xci- (>!• m-KIAl. OR RKMOVAI,

rNI)i;RTAKHR

(Aiidn'ss

■"■■^ !• I \CF should he state

;very item of information should he — ^^''^ ^^f, rhe P-opeHy classified,
tate CAUSE OF DEATH in p ».n ^/•"-''J;" „'*^;;,^ instance,
ons dyinft away from home should he ^.ven m every

DATi: of r.tHi.Al. or Kl%M<)V.\I,

y^ js- 190H

v\X)^

HfeS O Cr^-^-^-Uj

N. B. 1

8

sons dyinJl

d EXACTLY. PHYSICIANS should
The "Special Informiition" for p«r-

ams

m

WRITE PLAINLY WITH UNFADING INK

I f IT... I it, • Vii I- ■?•?" SBf«"—») I'lt 1' t n
H<i.'iiii 111 II' all n . ^'> > "...^-j*

/

njot

DEPARTMENT tfF PUBLIC HEALTH

THIS IS A PERMANENT RECORD

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

Registered ^''o. ^^331

r-iw^cA^

=City and County of San Francisco

PLACE OF DEATH: — County of

Cettificatc of 2)eatb

- , JAXX/>V^1^^'- City ofO/CX/>v ^h.<X ,v :c

No. ^^H Vl3(X».

0

Li I I

St.; b Dist.;bet. 3^ 1 ^^^

and '^^

^

( ,. ^.,^^cr.-; .w.v .no- osu.. -sifL",=^-".f,;.",;rN*»«7 r,c"ri? sT%%%Ti«o"r::r-°''' )

D

FULL NAME

\*

■H-

1*

>i; \

+

PERSONAL AND STATISTICAL PARTICULARS

Wet 15?

(Month)

AT.K

) V'ln

Das'

}/,„if/l:

(Vc;ir>

An

(Year>

slN.-.l.i:, MAKKIl-.n
WIDOW l'I> «»K lHVoKlKn

(Wri't ill ■^tH'ial (U xi^fualiDii)

TUKTlU'LAi'l-

I Stati or «."i)untry

SAMl- n|- ^,.
FATIIKR U\

^\xAj

^

aJja)

e

niKTin-i. AiK

r>I- lATlll-.K

( Stall- ( >r i'liiinl i v

MA'Id.N" N\M1-:
((I Mnl'in.K

lUK rill'I.Ail',
nl- M<»iin:K

(Stall Hi CiiutitiN

0

fliJUr" I\d cl-v^x^v^^ '. ^ ^-

MEDICAL CERTIFICATE OF DEATH

(Month) (Day) _

1 III-RI'HV Cl'RTIFV, That I attemlea aeceased from

lD..db -' i9o'i to.- - -....190 -

that I last saw h .— alive on — "~ "^^ ^'P "

and that death occurred, <^ii the date stated above, at 11^0
I' M The CAl'Sl': OF Dl^ATH was as follows:

^tai"(Ecyvvv Jvd^ 4^-t. I .... JyO^

DT RAT ION )'rc7rs J7ofi//is Days

CONTRIIU'TORV

I Jo UPS

n
-10

iX^UJA;

4^vu i 1 s.

DTRATION

k).l5

0 ^^

/lavs

(SIGNED) LU. U. V-.^i'VUUj.rv
^Avt II u,o'i (Address) ot^

Hours
M.D.

?

bo^dl.

SPECIAL INFORMATION only f«r Hospitdls, Instilulions, Transients,
or Recent Residents, and persons dying away from home.

(HLMjVu

a.

oCCri'ATKJN

AV.w.fA/ ill San ria>i,i^r,>

)'rU1l

M.oitln

Ihl

Tin- MU)VK ST\TKI)PKKS<)NAl.l'\RTI^TI.XRSAKi:TKrK To THH

(informant J AXxI- L. L%>xXK'-^

/I) li

( Addro'^'! O <^ I

Former or
Usual Residence

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

How lonq at

Place of Death? Days

IM,ACK <)1- UrRIAI, OK KKMOVAI,

i

Aj<j^>-^

):

DATlCof H' KiAi- or KKMoVAl.

0^ n T9oH

U-

State CAUSE OF DEATH in plain terms, that it may be properly classmea. i nc p
sons dyinft a%vay from home should be ftlven in every instance.

)l

WRITE PLAINLY WITH UNFADING INK

Hii.lKI I'l lli.lUll I ^"- '^ ",».,-■•

I)(ffc Filed,

• IS

190\

THIS IS A PERMANENT RECORD

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

Registered ^'^o, 23o^

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

Certificate of Beatb

"d. S. StanDarD )

PLACE OF DEATH: — County

ffe

.A^v^

'D

,i UUrUy

AX4.^1-^^-^^'-St

♦ —

Dist.; bet.

and

- )

'Da (\ Ion

FULL NAME

II

XLC-

PERSONAL AND STATISTICAL PARTICULARS

Sl-.X

DAli: <)!• UlKTll

A<.K

coi,(»R\ n

MEDICAL CERTIFICATE OF DEATH

DATK OF 1)1;AT11

a

Ou

Momhi

I I):iv»

> M,.ulli'

T L

f Year)

D,! !

(Motith)

(Day)

I go \

(Yt-ar)

~ I HI" kl-BV Cl'RTlFV, Thai I aUcn<lc.l deceased from
QXaV It 190 H tn O^t % 190 H

wot t

•^IVC.IJ". MAKkiKI>.
\vii>o\vi:i) OK i»!V«»Kri;n

(Wiiti in -iK-iai dt >^is.'iiati' m

HIKTHPl.Ai'H

(Stall iir <'<iU!it I V

N \Mi" or
I A I in: R

lUKiin-i.ArK
01 I \riii':K

(Stat<- 1)1 riiuiHi v)

MAIPJ-.N NAMl
<H- MuTHKR

lUK rm'I,Ai'l',
statt iir Cotintt y

[90 "\ t<

tliat I last saw h • alive on wot t 190 ^

au.l that rteatti occurred, on the date staled above, at H -^
* ^ M. The CAl'SH OF DHATIl was as follows:

r^AJL\XM.

DFRATION Years 1 Miyuths ^X Days Hours

CONTRIIUTORV

\Xjy\/y\KAj

Ur RAT ION

Years

4lfl)f/f/lS

/h7VS

(Signed) UJ. ^. U^noLo/w^

k)^ ^ TQoH (Addres.) UJU^a^

//ours

M.D.

/y

"^■^■^■•"■'■'•^^%.a>x^x^

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

h'r.ii/fif III Sdii I I C.I!

M.nilh^

/),7 1

THl.-MU)VKSTXTini'KKs.>NA1.rAKTUri,\K^ AHKTKrK To THK

\A

ljT<\h}i\

Former or
Usual Residence

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

How lonq at
Place of Death?

. Days

1

(Infonnant J A./Q-/'>

i;i)<". K AM) r.i.ijj-.f

(A.Mrc

n.^A-^-'^i.

j'i,ACK oi- nriu^^u. OR ri-:m<>vai

DAI'I", i)t 111 KiAi. or Rl-MoN'AI,

U/cti ^ S 190' \

rNI)i:RTAKl'.R

f Address 'ib^^" ^^ W ^^

■ „ . .. . .^R «H«,.i,l ha Rtatetl EXACTLY. PHYSICIANS should

«on« dying away from home Hhould be felven In every Instance.

t I

m

WRITE PLAINLY WITH UNFADING INK

,,,:,T.l of H.altli !■ N" ' '- '^^.^^-'^^ ^'^^' *■'"

/)((/(' /'V/^v/,yct><MA; IS"

7.9(9 H

THIS IS A PERMANENT RECORD

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

2333

Fie^istered JS^o.

j^^ Deputy Health Officer

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco

Certificate of ©eatb

( "a. S. Stan^arD )
PLACE OF DEATH: — County ofOxiyYV JAa/>veuC(. Gtv of Oajy\j ^KOjyxj^^

0 /o n A

^No

,AUJ.J ' Wu.TUl(

^vwA.'xm-L, .St.;

Dist.; bet.

and

: ( - --^^ic3«^v.:r:: ™ r^^^^^c^i;^;^-! ^m^ .x^s; ;?;^^njo ^:;;ir )

FULL NAME ^ ^^-^^^

PERSONAL AND STATISTICAL PARTICULARS

COI.oR \ )

^

si:\

i)\ri: (>!■ lukfn C^

I

(Dav

A<.1'

M.oilh

S I

/'./>.

SIN* '.1,1:. MAKKll-:!)
\VIl><>\Vi:i) OK !>I\< »Kk'Kf)
(Wiittin Hinial dt "ii-'nnt ii nO

HIK TIU'I, \CK

' Stntr oi »'. lunti \

c^

N \M1. <U
FATHl.K y

HIKl'Hl'I.ACH

ol ! Ariii:R
(Stat»- or foniitry)

MAim'.N NAMH
OF MOTHHK

niKTHPUACl-:
«H- MOIUKK
(Stall- i)r Ooiintry)

nrcri'ATloN -P J

^1 \\L \

XxJ\

'\!

M^

Rr>ided m S,iir /'i mi, n

)',ii>

^f,„ifh'

fhivs

TIM- \noVl.'ST\l!-l) PKK^ONAl. P \ K I" IV T I, \ K S A K l- T K T H To Tl!H
iIksT 01>J4V KNo\VI,i;i)<-.K AN!) Hl-I.n.l-

(Informant JAXX/vJk LI- O/cix/Yvv',' .

UJyw^

MEDICAL CERTIFICATE OF DEATH

DATK Ol" DKATll

(Month)

(Day)

TQO

(Vt-ar^

T I IIlUxlU'.V CIIRTII'V. Thai I attc!i<k'«l (k-reased from

ox-kfc n KpH to ... A9/ct u tc^H

. alivf on ^i/ /CA^

up
that I last saw h ^ alivt- on '^ ^ZJ^ I i jyo

and that ck-ath occiirre«l, on the date stated above, at H t
M. The CAl'SIC Ol' DlvATIl was as follows:

0

f\A,<n^>^<:. C

La^va.xx^A,

u

I )r RAT ION )'iars

CONTRIBrTORV

Moni/is <>>0 /}a\s Hours

DURATION

)'i'ars

iXi

,U()/t//is

(Signed) Uj. ti). L^irrJUx^x,

liz/cij \'k xqo'\ (Ad.lress) UX'^'^v4J'

/)ays //oias

M.D.

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

Former or
Usual Residence

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

How lonq at
Place of Death ?

Days

rr,ACK oi- niKiAi. ok ki:mo\ ai,
/'D

UtO^JAjM !UA^

,y^ ' V.C

.NJ

I)Ali;'i; HiHiAl, or kkmovai.

190

rNl)i:RTAKKK

V%

<xxY^.

.\d.ii.-.s SbhX' l^\ Ox.

■■■■■"""'*"^ .-. .. i. I %rF fiHmilii he Rtnted BX4CTLY. PHYSICIANS should

N. B.— Every Item o? Information should b. cnrefuHy fuPP'-'- Jt^fj,lZ^'^t\^^^^^^^^^ Information" for p.r-

state CAUSE OF DEATH In plain terms, that it may be properly classitiea. me 1
sons dyinft away from home should be given in every Instance.

ii :i T I ; 1

WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD

H, .1,1, , N. . t..?^.n5tPCo REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

])((

fc /v7^>^/, \!^£brW^ IS

lOO'i

Registered J\'*o.

2334

\J^\^

j^

Deputy Henlth OfFicer

ii

DEPARTMENT OF PUBLIC HEALTIi=City and County of San Francisco

Certificate of 2)eatb

( Vl. S. StanDatD )

J? m A ^

PLACE OF DEATH:— County of OxXm; J AXX-^wC^ v - < City of O/O/^v J.>u<XAax^c4. -

J? n VI (^ 4

■No^jJkxWvli. L4rYXMrM^dKXyY\Ajto.^^i.Sln v^. Dist.;bet.

* \\\, ._ ' ^ ../.», r = «u IIQIIAI RTSIDENCE GIVE FACTS CALLE

and

W

.ro'EATH^occuRS a/.v FROM USUAL R E S I D E N C E G . V E FACTS S^^^^°.':°A_".'l°5rl'r.'f:*!:Jr°?^*JL°''

OFATH OCCURS A\iAV FROM USUAL R E S I U t IN i- t Giwt ^«^-l^ v-«i.i.tu, r w r. w „ ^ ^ ., -. ■ ■ " ;^-. )

°, OC.TH Ic"!hrTd IN ° "oSPn.l. OR ,NS.,TUT,ON GIVE ,TS NAME .NSTt.O Or STREET .ND NUMBER. J

FULL NAME I'^

i.

.<X4.

>i..\

PERSONAL AND STATISTICAL PARTICULARS

0^ ' ' ^"'-"^

JX^Y^XXxXl

DAI*}-: nl' I'.IKIH

A (.I-:

N!i.iith>

X

Q

)V.,-*

lU'ritciii -liiial ill -ii/iiatitiH I

L

iDav)

1 /,,?/.'//.'

.^AX^

f w<_-.-^

.^7>T

k lar

/'</ 1

iUKi"iiri,A''i:

I Statt < i: 1 ' iimt I \

NAMl.; OK
I- A Til IK

HiK mri.Aci':
ni- 1 \iin';K

(Stat< >.i i'ount! \

MMDl.N N\M1-
nl- Mt»lll}:K

r,iRTinM,Ai*i-:

nl- Mnflll-.K

I Slate 1)1 I'ollUt! X

i)(.Cri'ATION %P

0 l^

y<i

(J

MEDICAL CERTIFICATE OF DEATH

DATK Ol' DKATH

IH.

iDavl

(Month)

/go

(Vt-ai i

I IIKRI'BV Ci'.RTII'V, That I attciidtMl deceased from

■ up to - itp

that I last saw h -: — aHve on ~~"^ i<P

q uir-

aiid that <Kath orcurred, on the date stated above, at 1 ^
Ou M. The CAISF': Ol' DI-'.ATII was as follows

Dr RAT ION )'{'<trs

CONTkllUTORV

MohUis

Days

Hours.

V

Hr^uird III Sun I'lttn, i^rn

);-,u

.1/,. ;////'

n,n

•nV XHnVKSTATKI.rKKSnNAl.rAHTU-rKAKSAKKTRrK T. . TlIK
m:sT nl- MVKNOWIJ-.IHU-: AND in-.MJJ"

(Infuiinant

(A.Mn.s. ilOO LxxX4<:^Vv^.^^ ^ It

niRATION
(SIGNED )

)'iars

(^d)

Moullisi

Day

Address) Co-XXr^UX^S yil C

T<)0

{>

ST

Hours

M.D.

gp^QI^I_ Information only '»r Hospitals, InslitutioflV, Transients,
or Recent Residents, and persons dvinj away from home.

Former or If H • I ""* '*'"*' **

Usual Residence \XXAA,h-X5\)XAAJl ^^O^v place of Deatli? .. Days

Wfien was disease contracted.

If not at place of deatli ?

I>ATJ%f>f I'll HI \i. or KKMuVAl,

PI.ACK <)1" lU KIAK OR Ki:MnVAI,

State CAUSE OF DEATH In plain terms, that it may be properly ^lassmea.
sons dylnft away from home should be given In every Instance.

I

I

I

WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

2335

H.,a,.l of IKMltl. 1- Xn. i. t>.g^» 1)5: P C

Dad' Filed ,

IS ^^ftl

Deputy Health Officer

Ee^iiitcvcd JS'^o,

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco

Ccvtificate oi Death

( •a. S. StanDarD )

m

[^

PLACE OF DEATH: — County of UO/n^ -InXLA^CA.^.^ City ofOxxorAj - r^^

o ' ^

V"

and

«JL_ \ 0 'v\i"h nk \) I A'-va1\X^ ■ M db^JslJ^J. Dist.;bct. -

]Sfo. VJt^r\A.^O^V) WO^UUU^. 1_,,^; oriToENCEGtvE facts called roR under "special information- \

( '^ rrDrAT°H"0CCU%r4V/N''rH0"s^rAL o"r' ^^ S T^^^U^^^'c . V E ITS NAME INSTEAD OF STREET AND NUMBER. )

FULL NAME

.i\rr.

^1
it

si;\

l)\ri-. <>f lUKTU

\<.i-

PERSONAL AND STATISTICAL PARTICULARS

Col.oR \ n

i - '

a.

/ -

2)5

),,..;

|):iv

!/.,»/.'//

■> tar

SINi'.l.l". M\Kkli:H

\\II)« (Will < >K DIVMki 1 |»

■Wiit* ill -oi'ial I'n-i'jiiati'iii)

(Stair iir I 'o'llltl N

NAMl <»l
F A IH I'.K

fUK rm'i.AOH

<)»■ lAI'lII-.K

' Stat I ■ ii I'l iimt t \

MAIDKN NAME
OI-- MoTIIKR

lUKIinM.AfK
OF MoTllKK
(Sl.'itr or Country

occri'A'rioN

h!,-iiir.l til ^oii I mil' ''"'"

IQO '

(Year)

MEDICAL CERTIFICATE OF DEATH

DATK OF DHATH d \

(Month) '•>:'>■>

I H1':R1;BV CI-RTII-V, That I atlcii«U<l «k-rt.ased from
^x:% .'X 190 'i to ii/^ ^^ ^QO"^

that I last saw h-c alive on V^ !0 190 ^

and lliat .U-atli orcurre<l, oti the date stated above, at V
M. The CAlSIv Ol' I)I':ATII was as follows:

cr>-

^^

^

QJb > > vC^lc^.

DrRATION

CONTRIIUTORV

P %

DIRATION

Years

Mont lis Days

/hJV

Hours

'hZ

)

W M.Hllh'

n,i\ .

T„K^,U>VHS■.•^TK..PKK.<>X^. rjHTrCtMAHSAHHTKrK TO THH

SIG

NED) U-OrVOL^ A- ubx\/i,^:a-

0 ... :0JI,

//(»//

; .V

1)

M.D.

I«>o

(Address) Ub CrU-C^

t

Special information «nly for Hospitals, Institytions, Transicnls,
or Recent Residents, and persons dyina av^ay from liome.

Fnrmpr nr ^ ' Mow lonq at

S Re'wrncf isO^b k^^^- • P:a« of 0«.l,?

When was disease rontrarted,

If not at place of death ?

J

^

Days

I'l \CK Oi- lUKIAU OR KHMt'VAl.

rVDHRTAKHR OVD -tO^VAAJ,

I)Al'i:of Ht KiAi. or KHM(JVAI,

Unt. lb T90H

>^-LKi

Cx.

m.

N. B.-

B.«ii»iii^— — ii— ■^^■^■'■"■■'■■■'■■^■'^^"'^■"""""^ . , . 1^ gtated EXACTLY. PHYSICIANS should

-Every Iten, of Information should b. carefully --^^'^^^^ p^opeHy'aBsifled. The "Special information" for p.r-

-♦«te CAUSE OF DEATH In plain terms, that it may |>e propc

;in. dyfni away from home should he feWen in every Instance.

Bmnl ..f IliaUli H No. n ^-^^

WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

2336

*'5^!:

lUS:!' ('.»

Da/c Iu/efI,VctAMJv 15"

■^ cL.C'VK.|

VJO\

OWicer

Registered J\'^o.

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

Ccvtificate of Beatb

( H. S. StanDarC> )

J? ' om ^ ^

PLACE OF DEATH: — County ofC3.o_>> J^^vve^c. ^i Qty of ^J-O/vv -3 AXX/YVCv.^ c e

(^
'No. Tn JX'->x>vLv ■ St.; Dist.;bet.

"^

\\

and

^ IIn

/■ „ oc.t'h occurs .w.y rRO» USUAL RESIDENCE CVE F.CTS C.ULIO 'O" "N"" ^icr'iND 'nJmbJ'h""" )

( IF Dt.TH OCCURRCD IN « HOSPIT.L OR INSTITUTION GIVE ITS NAME INSTC.O OF STREET «ND NUMBER. J

FULL NAME

h

\

n '

<XhXx.L

L.'

PERSONAL AND STATISTICAL PARTICULARS

i»\i i: «»i r.iKi'ii

rol.n

>< ]

[Dkd.

iMoiflh)

Day!

\».)-;

{

)■,•,?»

M.nilh-

n

(Yt-ar*

Par.

sl\(.l,lV MARKll'I)

wiix iwi: i> (»K i>!Vt»Kii-:n

iWiiti in >-ocial <li»i',M\at i< in '

lUK THl'I. \oi-:

(Stalt (I! <■' illlltl y

FATHKR

lURTHPI^^CK
«)»■ » ATIIKK
iStaU or iinmtry

MAIIU'.N N\Mi;

()i M()rm':K

lUKTHlM.An-:
Ol' MnTHKK

(Stati or Count! >

n 1

n^cL

Tlil- \!$()VK ST\ ri'I) PKKsONAl, I'AK'rUTKAKS \Rl-;TKri-: ID TUK

(Infoiniant

MEDICAL CERTIFICATE OF DEATH

DATK in DlvATH

igo\

(Year)

(Month) (Day)

I III':KIUiV CI':RTIFV, That I attended deceased from

/>%/ .ic 190H to UcXJ I.2i 190 H

that I last saw h C aHve on v,- C.^ I ' 190

and that death occurred, on the dale stated above, at I

M. The CArSI<: Ol- Dll.XTII was as follows:

nr RAT ION Years

CONTRIIUTORV

Mouths

Days

Hours

nr RATION
(SIGNED)

Years

Mouths

Days

lnrv^A-^^A.

U-

Ucfc l?> U)o'\ (Address) llHb

^}\JLry<JjuuUe^

Hours
M.D.

-^

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

I, Triitsients,

Former or
Usual Residence

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

How long at
Place of Deatli ?

Days

ri.ACH Ol' lUKlAI. «»K KHMoXAI,

I>An;o!" in RIAL or KHMOVAI,

0^ lb

(Address 11^ M rU.A^^-A.-<r^% uXa

T90I

„ B —Bvery Item o* in?ormHt1on •houlcl be carefully supplied. AGB .hould ba«tatcd EXACTLY PHYSICIANS .hould
.tate CAUSE OF DEATH In ph.ln term«, that It may be properly classhlcd. The -'Specal informat.on" for per-
son* dylnft away from home should be given in every instance.

i

1

.

.

"\

WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

iKihj

lOOH

Registered J\^o,

2337

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco

Certificate of Beatb

( U. S. Stan&arO )
PLACE OF DEATH: — County of O OAA; 0-^UX/^n.<X4.oo City ofO/CL/vu JhXXy^ ^^ .

No. tx i wLL^'>\

St.;

. 'S

Dist.; bet.

l^:

i

and ^ >

/ IF DEATH OCCURS AW.V 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 " ^
\ IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. J

FULL NAME

1 rUxa/tLo-^:

0

v^

Xlaa.cc

PERSONAL AND STATISTICAL PARTICULARS

i>A'j 1-; ni liiRin

\ ' . }•

axi^Jt

• Nt.iiitn)

10

(I)av)

,11H

MEDICAL CERTIFICATE OF DEATH

iii-ct

(Month)

15

(l)avl

(Year)

loO

J

Mmitll •

^

Star)

Ihix

1 inCRinJV CHRTrFV, That I attfii.k-.l .leceascil fro

^t\

111

1 90 ' i

to

kLlct

r:

'-'IV'. 1,1" MAKklKI).

\\ ll)»»\Vl-:i) <»K 1)!\( (KfKIl

i\Viit< ill vocial ili-«ii'natii)!i)

a

'■"^

HiurniM, \fi-:

' Stati (i! t ■.iiiiiti \

I

/ 1 ,

that I last saw Ii ... ' alivi- 011 C- 7. L

I()0

up

ami that death «KHiirro(l, on tlic date staled al)ovt', at ^ "^^
U. ^^I. The^CAISIv Ol' DKATII was as follows:

NAMi.; m
f-.\riii.K

0

V

HIK III I'l.AiH
«>l- IXini.R

'Stall Ml (■..luiti V

MAII)1:n NAM}.
Ol- .MOTHHK

I'.IRI'iri'F.ACl-:

01 MoTIII-.K

I Slate 01 i'ouiltt v)

IX RAT ION

) 'ears

Months \X nays

Hours

?

nrRATlON Years .Months X /lavs //our,

(Signed) at jl' > . . - • |y, q

^ IS' IQOH (.Address) t I'h OAAjttln.. V^

,Ph

u

?''^9'<i'- iNfORMATION only for Hospitals, Institutions, Transients
or Recent Residents, and persons d>ing away from home.

h'fsiitfff ill San /'uim tsni

) t ii .

'/--»///•

l)ii\

Tin-; M!o\i: sr \ ri:F) ckksonai. I'artuti.aks xui; trik to vwv

HICM" Ol- MV KNn\\4J.;i)r;K AND ni;Mi';F

crrsj J-

Former or
Usual Residence

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

Now lonq a!
Place of Death?

Days

f Iiifiir niaiit

/^ n

XA-O^A/OiW

Acldrt-s.^ «^ I

.nr\Xj^yy\XK.

A

I^ACH t)l- IHKIAL OR Hi;MoV.\I,

1

r\K.UL4 d^jC^KAj-^

INDl-RTAKHR i'VD , -J. 'JXA^AA; ^

l>HTi;«>f III hiAi, ..r KHMoVAI,

190

<.u

N. B.-

-Bvery Item of informRtion should he ctirefully supplied. AGB should be stoted KXACTLY, PHYSICIANS should
state CAUSE OF DEATH In plnln terms, that it may he properly classh'led. The "Special Information** for par-
sons dyin^ away from home should be given in svery instance.

f I!, ^^'t'l

WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

3?- .3oi I!^v!' !•.,

l)(h'(' nird ,^f<ij

i '

Deputy H

inrn

hC

Registered J\^o.

2338

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco

Cevtificate of 2)catb

"U. 5. StanDarD )

PLACE OF DEATH: — County ofUCL-v\; J.Va

((T?i

No. i H

x_<^

CU..'

(I r OC*TM OCC U RS
ir DEATH OCCU

St.; ^ Dist; bet.

J? (^

City of '^ <^^-^'Vu J \x^>vc<,^

ft) J

X<xdx>v' and Lt'..-

s AWAY FROM USUAL RESIDENCE Give facts called for under "special information-

RHED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER.

FULL NAME

PERSONAL AND STATISTICAL PARTICULARS

)

•A

^>^JU

jXjxXx

V

, v. o

i» K i H «»r- iUK rn

\' i-

M..iith'

13,

/ -

\o%

M

> car'

/),/

sIN't. i.i- M \K K nil
I U'l itc ill s.M-ia'

IUK riU'l, \ri;

' Statt iif <'i luiiti \

^,ti..i!)

\xk/y

MEDICAL CERTIFICATE OF DEATH

DATK OF DKATH /P\

iMDiith) (Day>

J I in:Ri;i5V CI:RTII'V, That I atteti.lo.l ikHXascd from
Q-i.lxt XL u^o'. to li/^: i.3L

/QO I

(Year)

190 H

\\

jX'W J.\. T9O

that I last saw h ' alive on ^_ .„ u • » jgo

and that (U-ath .HH-iirrcd, on the date- stated above, at is-'h^
O^^M. The CArSl<: l)}« I)I;aTII was as follows-

r\xxA

-i^"vvwcrV\Jxa.,q

■XC .

i

N\MI «)!
FATII I.R

TUUrn I'l, AiH
<>l' 1 AIIIKK
' stall ot Couiltl \

M \ M >! \ N \M J.,
<»l .Mnilll.;K

IUK llllM.Ari-:

<>i- M()ini-R

'Stall 111 *\ 111 nt I \

Wv

-il

A

(J

'VX/

IM RATION }'t'(irs Mont /is H Days

C'oNTRimTORV W>J[v<X^\^ '*' cvx

Hours

\^

•\

sM_xa

OJxXMxx^ cUXaoaxaac -

<x-v

• Kori'A riiiN f'

u

or RAT ION Vc'ars

(Signed) LcLcu-cx.'x,<:L <^<x,o

.'IfoNt/lS

r>avs

CAj

i 1 ic)0

(Address) I^CX

Hours
M.D.

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

yfitiitiu

/>a'

IHT', AHOVl*. SI" \ li:i) PKKSONAI. I'A RTICr I,A KS ARK TRI'K To

iu-:sr oi- Mv kno\vij-:d(;k and iU':mi:h

Tfn-

Former or
Usual Residence

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

flow long at
Place of Death?

Days

PLACE OV nURIAl, OR rj.:mo\ai,

1.

rXDKKTAKKR KX>J\JLA..Xr ^*^

I)ATl;of I!t KMAt. or RKMo\AI,

s.^ Ww' 1 \ 190 t

(A(l<lrt-<s 7S\ U

<X'YW

IN. B.— Every item off information sliould hi careffully 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 dyin^ away from home should be given in every instance.

k^£#

^W

i 1

i It

\

I I t

I

I

WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

liiiaid of Hiiilth !•■ No ;< ■&'%:»&.^HS:P Co

l)((fi' Filc(l ,\^ <:X,^A>~V\) \S

roo'i

Megisicred Js^o,

2339

.(r^M^4

/\M4

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco

Certificate of IDeatb

( "U. S. StanDarD )

PLACE OF DEATH: — County of* ' a^x ^ •

City ofQ-<X/>^ JA-<X/yX/CU4

No.

± ^^.

Ctu. ^WvLvJ.„. ^ St.; Dist.;bet. and

1 /■ rr DEATH OCCURS kw*V FROM USUAL RESIDENCE GIVE FACTS CALLED FOR UNDER "SPECIAL INFORMATION" \
J \ IF DEATH OCCUrIrED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. /

FULL NAME

L")XU

J\a.aJ\..0.. >

^

sl'X

I>A 11, ( •! i;iK III

PERSONAL AND STATISTICAL PARTICULARS

ft Cni.oK

M i I c

II

M.nstl

V

Ii;r

(Vt-nr)

MEDICAL CERTIFICATE OF DEATH

DATK ol" DltATII

I* 1 -+

(Year)

\'.H

/h,

'\\iitt in xiui;il ill vi;,. ii.it 'nil)

HiK riiri. \(-i-:

(Sfati I It 1 I Miilt I s

JXAV.0.

^'\

NAM I- «U-
I ATHl'.K

niKTniM.A*, K
(H- I AIHI^K
(Stat« or t'outitrv)

MMKI'.N N\M)-;
nl- .M()THl.:k

lUK'ruI'I.ACH
«»l' MnTHI'.K
(Statt .ir riiiiiili %

<H\'ri'ATlON

^

\.^_'

0.

I Muni hi (I);iy)

I HI'RIUJV CI;rTII'V, That I attcn«k-<l deceased from

lip . t,. ^'cX 1'^ itpn

tliat I last saw li - alive on -^ ^.^ 190 '(

ami that (kath occurred, on the date stated al)Ovc, at 5^H5

G

M. The CAISI-: ()!■ DICATII was as follows

DTK AT ION
CONTRIIU'TORV

y'l'ars Months

Da ys

Hours

.ijorXju..

0.

Dl'RATlON ,-v-. J'aC'y

^ ft

(Signed)

Months Pavs

1

lU.t

^ w. I l KjO

(Address)LcU^

\

I touts
M.D.

SPECIAL Information only for iospltals, Inslltutlons, Transients,
or Recent Residents, and persons dying away from iiome.

Sj>/ /'tiiuiiarn it )'iiii^

Months

fhi\

rm: ahovi.: staii;h i'Hk^onai. I'AKTuri.AKs aki* tki'K to tiih

Ili;Si- Ol- MV KNOWl.lCIX'.H AND IJKI.lHK

f Infinniaiit

(Address

Former or iruw
Usual Residence -^ v "

When was disease contrac
If not at place of death ?

How long at
Place of Death?

Days

PI.ACH OF IHRIAI. OK RKMoVAI. I DATH of Hi kiaf. or KKMOVAI

•'YX;

(Ad<!i( ss ^ i H U J <X.hJ\jJiJ.

N. B.—— Every Item of Information •hould be cnrefully supplied. AGB should b« stated EXACTLY. PHYSICIANS should
state CAUSE OF DEATH In plain terms, that It may be properly classified. The "Special Information" for per-
sons dyln^ away from home should be given In evsry Instance.

(S

i

i

^^b:^'

WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

V ■- ^■; sz:^, v,$^v Co

IS

li)OS

llci^isl ci'ed J\^<),

2340

A

M

\. "^

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco

Ccvtificatc ot IDcatb

I tl. S. 5tan^nr^ )

QRs

PLACE OF DEATHS — County of U<X>x xn

City of Oxx/w J /VOL

•\

T\

No.

St.; .^ Dist.;bet. . AC\<X \^\.. >\'.( and^ ' ■ " 'v ^

(ir de«t4 occurs avwav from USUAL R E S I DENCE Give f*cts CALLto for undtr "special information \
ir DEliTH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / L

FULL NAME

15

LO-NiA.k.^ '^

PERSONAL AND STATISTICAL PARTICULARS

VIIICLU

\yi tir i;iKi

/JM.-iuh

DaV

\< . !:

W.

--!\' ,1 l- M \R K 11" !»

\\ I 1 H »\\ r 1 > I tk 1 1 ;\ i )- , 1 i )

->t.,i . . .; I . .11 111 1 V

i f

I X I'll IR

liiKTin-i.xtj.
oi I \rm-R

(St:iti .1(1 lUli;

ni .Mi>ini;K

luk ini'i, \\ ]■:

1 Slate iir I'uuiili \

MEDICAL CERTIFICATE OF DEATH

1) \ n; «»i- ni: A Til ;,^

I Ili;i<i;r,V ri:Rril'V, Th.H l aii.n.l. ,| ,l|.,r;isc«l fmni

(li;il I Inst saw li ali\«' mi . u^n

and that diatli <h riirroii, on tlir datt- '-tatiil ahnvc. at
J. M. Thi- CAt'SI- (M' hi; A 11 1 vnis as kill.nvs-

«H I 11' XIIMN'

DIR A'IMJN

CON ruiiu'roRV

nr RATION
^SIGNED )

)'iii/

Mo'ilh^

/hiv

IIoi,

; V

)'i(irs

JA »;//// s

/f.irs

U^.

f Adiltis^) 10 1)

//ofn s

M.D.

) {

Special information only for llos^ldls. InsHtutlons, Translenh.
or Rccrnf Residents, dnd persons dying ciHd) Irom home.

I 1

A' : i.

' >• I I :'ii

) .,11

M..1HI,

fh,x

rm: \i«>vi*. ht\ti' n pkrson m, r\Ri!i t i. \ks aki; iKri-: i' > 1*11 1-;

IU*>r «)l MS" K N< lU 1,IU»' ■••■. AM) IU:i,!l I'

1 1) ti 1; iilrint

f\l<li.-.v 1 1 Xb U\D ^Ci'C*

former or
Usual Residence

When ynis disease ronfrdded,
If not dl plare of death ?

How lonq at
Place of Death ?

Days

I'l.At'K «>l- lUKIAI, MR RIMiiXAl,

C

.nI)i;kiak}:k \4j

IJATI .)• Hi iiAi. f.t KliMuXAI,

U-rt, It, ,9„ ,

N. B. F.very Item o? inff>rmHtion should b^ cfirBiully Hupplied. AGR should be stated KXACTLY. PHYSICIANS should

state CAUSE OF DEATH in pinin terms, that it may be properly i,los»il?led. The "Spetlal Information" for per-
sons dying away from home should be i^iven in ^\9ry instance.

it

f

1

» t

WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD

! * 11, HI. IN.) :, t.^a?>>:. (s.ScJ'Cn REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

Registered JS^o,

2341

X(rU^U loL^. Deputy He&ilh Cfficer

DEPARTMENT OT PUBLIC HEALTH=City and County of San Francisco

Certificate of IDeatb

( XX. S. ir'tanc»arC> )

PLACE OF DEATH: — County of OCla^ J AXXy>vcui.coCity of 0/CU>v

L^a

No.

il

,Ouuc

u U/Ct^'x^.ta

tnv

St.;

Dist.;l)ct. *

and

f IF DtATH o|cU«S *WAV FROM USUAL RESIDENCE GIVE FACTS CALLED FOR UNDER SPECIAL INFORMATION" \
V IF DEATmIoCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. J

lEATH OCCURRED I

i 1

FULL NAME cU^tuj

^Aj-crt. ^

■-i;\

PERSONAL AND STATISTICAL PARTICULARS

I» \ 1 1, 1 il i;i K I II

^

\X)r\^sjJo

• M.inlh

\| .!•

M

I

i I):iv

,v

> ■ :il

I hi

SIN. .i.i;^ M \K k ill)
\\iiM»\\ !•; i> ""K i>i\< »Kri-;i)

'W'littiii >.(Hi;i! ih^if iKit ii)n)

I'.iK III j'l. \('i-:

Slati I il I '>iimtl V

NfH

r\

A^<s\Jj\J^

N \\n 1 >i

! X I 11 IK

MIK rHI'I.XCF,
ni I Allll-K

' St:it( . i! t'diillt I y

M XIKHN NAMl-
»»l M«»Tm;K

HIKTHIM, \( i:
«»l MnrilJ'K

i '^tjllt i)T ((illllt I N

• •' rri- A riuN

/'

()

rgo

(Vfijr)

MEDICAL CERTIFICATE OF DEATH

DATK <il Di; \ III iCS

fMotilh) (Day)

I 11I';RI':IJV CIIRTII-V, That I aUcnded (IcHvascd from

— — — ■ — JyO " to ■ It)0

that I last saw h --r. alive on — 190

ainl that <Uatli octurred, on the date stated above, at — — —
^^ M. The CArSl- Oh" DliATlI was as follows:

\

h'^sidfii in S(in I 'hi II I I Silt ^ O ) rn 1 s

Miiiillis

th,

rill' \HoVK ST\T1'',I) I'KKSONAI, I'A l< IIi' r 1, \H "^ A l< I , IKIH To llll-:
HHST n|. MV KNnW'I,j;i)<".K AND nKl.llll-

: !iiriitin:iiit

%.%

e

(AcM

t('»iS

iiH LdU

I

DlkAl'loN )\ius Months Days I Jours

CoNTIUPd'TokV

I )r RATION Vtius .'Sronths Days I/our^

(Signed ) LcrX^-xM^ J. vfi.UJ.dJi^ M.D,

k)^ V\ Djo' (Ad.lriss) L(HWvUL^^ \y4iu.C..w

Special information only for Hospitals, Institutfons, Transients,
or Recent Residents, and persons dyinq away from liome.

M rUx4.<rv

Days

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

DATK ()! Mi KIAI, or Ki:MnVAI,

I'l.ACKoi* in KIM. OR ri;m<»\ai.
\JuJr\KJLAAj cLcLa-U ^ x.

N. B. Bvery Item of lnf«rm«t1on .houUI be carefully nupplled. AGE .hould he •tatecl EXACTLY. PHYSICIANS should

•tate CAUSE OF DEATH In plnln tei-ms, that It mny be properly claaslfled. The * Special Information • for p«r-
•on« dying away from home Mhould be given !n •y/mry Inetance.

^

^^'

*A

» I

WRITE PLAINLY WITH UNFADING INK

I)((h> FfJo(L iL^cLcrW^' IS^

Deputy y 1th "

THIS IS A PERMANENT RECORD

REFER TO BACK OF CERTinCATE FOR INSTRUCTIONS

Ecilsivred Xo, ^34l^

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco

Certificate of Beatb

( "d. 5. StanC»ar^ j

PLACE OF DEATH: — County of J^^f a^^ > > x

City of

V

Uru/n.

XCA. Y

No.

St.;

Dist.; bet.

and

/ ,r DC*TH occurs *VWY FROM USUAL RESIDENCE CVE r*CTS calutd '•O" 7"« ^rT^iNTNUMiEif*" )

( ,r Ot*TM OCCURRED IN * HOSPrTAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET *ND NUMBER. /

FULL NAME

\<r>xL<^

^^ruj-v

PERSONAL AND STATISTICAL PARTICULARS

I x

( < »i ,' >k

PA

I LOw'^

i»A I i t »!■ HIK ill

no

M.iilli

LI

I».IV

\*.\:

I 1/

siN( .I,!' \t \H H n:i»

u !f»owKi» < »k iHVi »pi i:i>

Writt-iii -iMial i|ri.isf tiiil !• ill i

luirrm'i, \»*k

-'t..*- ..' ''.,11111'

<X^^.VU.dL

l\ I

\ il

\ \ M 1 1 »I
I A'l U l.R

HIHTH!' r, \t K
' »| I A I H i; K

St.lt ( iiT 1 iiU tlf t S

MAIhJ'.N' NAMi:
«»1 MuTIII.K

iUK I'HIM, \( K
lit MO'IIII'K
^t;it» or t'oiiiitr \

.^

> >i II i'A 1 ION

nf>^.

A'f/tf/'it in San /laiiiht'n

y^at i

Months

no V.

IHKABOVKsTXI HI»PHHHONAM'ARTICrLARHAKl- TKtK TO THK
UKHT OI MV KNOWI.KIX'.K AND HKIJRP

f Iiifiit iiiaiit

'\»1<Jre»ipi

MEDICAL CERTIFICATE OF DEATH

DATH i>l- KI'.A TH

4

(M.Mith)

rgo .

(Yrar)

I HI:KI;HV CIIRTII'N', Thai I attended .Icctasftl from

— • — — i^ to " 190

that 1 last saw h alive on ~ -— I90 "^^

and that death nceurred, <mi the date statetl above, at

M. The CMSI-: OI' DI'lATII was as follows

c

A^'

V'

DIRATION }'ears

CONTklHlTOHV

/IAm////?

Days

Hours

duration
(Signed)

Ycat %

C 6

Mi>fiths

/hlVS

Hours
M.D.

y^ IH i()oH (Address) ytXA"yUA.t^-L^>->^ Lxi

^. _JIAL Information oniy for Hospitals, institutions, TraBsleBls,
orlKeiit Residents, and jiersons dylnj away from home.

Former or
Usual ResMeRce

When was disease centrarted.
If notatplKeafdeatli?

Now lonq at
Plareof Death?

. Days

PI,ACE OH BURIAI, OR RKMOVAl.

iiJLA>-^

I)A'ti':of BUHIAI. or RKMOVAl.
liJ/C^ ..lb TQo't

INnHRTAKKRUAXJLtXxL \krV\AjJ\X/oJfiJ^

N. B.-

E OP DEATH In plain terms, th.t It m.y b* ifop^Hy cl«.«lfl«d. The Special Inforwatloii for par-

-Bvery Hem

•tate CAUSE _ ^ , . ^

mnnn dying away from home ahould be given In avary Inatanea

WRITE PLAINLY WITH UNFADING INK —

f ill .!ll)l

|- No 1^ t-^-T^: ]>,Si\' C

I

f t

/)ft/(' t^iJcd ,

y<K) \%

lOO'i

THIS IS A PERMANENT RECORD

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

2343

RccJisforrd J\^o.

Deputy Health Officer

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco

Cevtificate of IDeath

I tl. S. StanDarJ> )

PLACE OF DEATH: — County

o{0<XrY\j J.?vo^-wc v.^.-..City of O/CXyvu 0 .;^^o. Yvi^\^ o

No.

\n^

.1

%

chUv*w

tccl

St.;

Dist.; bet.

and

\ »

I ,

..:n

/ IF oc»TH OCCURS AWAY r^ o M USUAL RESIDENCE GIVE facts called for under special information \
( IF death occJrrTd in a hospital or institution give its name instead of street and number. J

FULL NAME

,0^h\.0^

u

PERSONAL AND STATISTICAL PARTICULARS

si;\

ecu. OR

\A

I> \ IT « 'F I UK III

r%

M..ttth>

\ < ; I-

t s

I);iv

M.iitli-

/ht

si NCI, I- M\RUl)!i

\\1I>« »U l.Ii « »K 1) \'« »'• in

I \Vi iti i !i -■ .< la: 'li-^ii- !i,it mn)

lUK nii'i, SOI-:

NAMI' <»f
I- A 111 IK

lUKTIiri, \CK
«>I I XIIII'.K

I >t,ll I 1(1 I'llUtlt ! \'

MAIDMN NAMI-;
«H- Mori IKK

lUK I'lIIM.At'K
<'l Mo'rilHK

< Mati nl t'lMltltl >

H-ori'A rioN f D

1
(

Y^<X

ex.

il

h'r.i\f<',f til S.nr / j,ii>. '■'■'

)V

1/-. ;;///-

/hn.

THl- AHOVK ST\Ti:n I'KRsnNAl, PAKTUT I, \ KS ARl'. TKlH TO TUF,

in<sr oi- M\' K NOW 1,1 .1 H',!-; and luii.ni-

MEDICAL CERTIFICATE OF DEATH

DATH OI' 1)1;aT11

/go

(Year

(Month) 'Day)

{ 1! lUv i;i'>V Cl'lKTIFV, That I aUciuk'd ckHcased from

— to

I90

that 1 last <a\v h -. — alive on -__ —

ami that death occurred, on the date stated a!)o\e, at
M. The CAT SIC OF DICATII was as follows:

■190

Dl' RAT ION }'fars

CONTRII'.rTORV

Mouths

Days

Hours

DIRATION

Years

^fovths

Days

SPECIAL INFORMATION only for Hospitals, Institutim, Transients,
or Recent Residents, and persons dyinij anay from jjome.

Former or
Usual Residence

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

1(DSm<l^- '-^

How lonq at
Place of Death?

Days

ri.Aci-: oi- m'KiAL ok ki-:movai,

rSDMRTAKHK IJw LU ^ ^^^

DAIHo! Ki KiAi, or K1-:Mo\AI,

S:J i<iXj 15 T90S

^rp"

Q

,0

P

Ron« dyinft away from home should be a«ven in every instance.

•! ^^

f

%

WRITE PLAINLY WITH UNFADING INK

!! .:il

,1 ,.f Health 1 N'

t.£T^t^: HSiV C,

I)

nte Filed. iL).ct<rl^^v IS"

VJO\

THIS IS A PERMANENT RECORD

REFER TO BACK OF CERTIFICATE: FOR INSTRUCTIONS

2344

llvihtered J\'*o.

\

i

^. ^v L

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco

^

I »

■f!

Certificate of 2)eatb

{ 'CI. S. StanDatD )
PLACE OF DEATH: — County of 0 Orvx. J XxXAo^t o - ^ City of Ooyw J /ua/v\xxA,x^^

^^X ^ %^ , ,

Nftdt ^\^ ^Iv ...' ? St.;— Dist.;bet. and ^~~~~~

/ ,r Dt.TH OCCUBS aU*V FROM USUAL RESIDENCE GIVE FACTS CALLED FOR UNDER "SPECIAL INFORMATION • \
( Tf DEATH Ocr^RTcD IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. J

FULL NAME

>- 1 ■ \

PERSONAL AND STATISTICAL PARTICULARS

Col.oK \ A

UO' '

n^KXh

I>\ 11-: of lUKTII

\t .1",

Nf.iiith

t).A-

11

I).iVi

M.;,th^

x

\ trir)

/'.n.

^IN<.I.l' MAKKll-n

\\\ !»< i\\ I'll Mk I)'\'< >K I W I)

\\ ; ■!' Ml -> .. M ; il' -i^.-nat i'lll)

Ox^

luKi'inM, \ri-: 0

Mati Mf I'liuiill \ — ^f

^-vc^^ cc

N XMi: ni

1 All! i;k

!UK rHIM.AiK
()l- iAIHl'.K

(Statr 1)1 I'liiinti %

A

Kxxx: c

^s

1-^

^

(>i. M.niiHK Hill \m

lukriiiM.Aci-:

<ij- MOTHK.K

' Mate or Country)

t)rcri'ATl()N

Rf.^iifrif in Suit I'l iin, i^rn

,<x ,

5 'f'a I

}r, tilths

I hi 1

THF MU)VK STXTI'.l) I'KKSnNAI, I'AKTHM- lA KS AKl'. TRVK To THK
iJksT OF MV KNOWI.KIX'.K AND nHMlJ;

(Infonnant lo -eXAMxt NJVLUAA.^ C K
(A.l.lr.ss %C^1 ^J-LmX JX

MEDICAL CERTIFICATE OF DEATH

DATH OF I)1;ATH iCX

iL'A^.t I':

ipo S

(Year)

(Mouth) 'Day)

I IH<KI'I5V CliRTir^V, Tlial I attcMideil (kccasLMl from

iDtt 1.H

190

H

to

i()oH

t
f

tliat I last saw li ■ alive on Ifp

ami tliat cloatli ocriirred, nii the date stated al)Ove, at D
VJ ^r. The CATS I-; OF I) i: A Til was as follows:

L<r~vA^Ou^^A.'U_/0tJu LUjuul*. . ' .

Ur RAT I ON }'i'ars

CoNTRllU'TOkV

Months «*.. I^ava I A I Jours

DTRATION

)'i'ars

Mouths

l^avs

Hours

(Signed) Jyrur>^ruxA u- '.Jax > , ._x„ ,., M.D.

liJcfc 15 Tool (Address) ^ii. L aJJyvyCX^ JJl

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

Former or H®^ lo"*) «*

Usual Residence P'a'^f of Death? Days

When was disease contracted,

If not at place of death?

I).\XKof IMKIAI, or REMOVAI,

M^ It.

Ui,ACK OF- lURFU. OK KI-MoVAI

T90H

(Ad.

N. B.-

""^^^ a ,. ,. . AHF ahniilri he Stated EXACTLY. PHYSICIANS should

•ons dying away from homo should be 4'«vcn In every Instance.

I'

;s^A

WRITE PLAINLY WITH UNFADING INK

I

I)((

l(> lu'/rti, t'ctfr^jOA' \^

n)(n

THIS IS A PERMANENT RECORD

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

^.dvc^.'^ ^'

DEPARTMENT Ot^ PUBLIC HEALTH=City and County of San Francisco

Cevtificate of 2)eatb

I XI. S. Stan&arP )

o;:

(1^

», ^

No.

t I

PLACE OF DEATH: — County of 0/a.i\
H ^ % I a JjsjJ^^xL.^ . > . '- \ St.; ^ Dist.; bet. cU -UX^^ >>^c

/ ir DE»TH OCCURS AWAY TROM USUAL RESIDENCE GIV
V \r Dt*TM OCCURRED IN A HOSPITAL OH INSTITUTION <

City of 0/CX/^r^j JAA^^^^C44^Ct

and qU C<^"vowCc.

)

.E FACTS CALLED FOR UNDER ' SPEC
GIVE ITS NAME INSTEAD OF STREE

FULL NAME ^ '^^

Id

1k\

MVnia-u..il)

:IAL INFORMATION" \
T AND NUMBER. J

0-

PERSONAL AND STATISTICAL PARTICULARS

si; \

vi »i < >K

It

;» \ li •>! 1:1 R I'll

\< .1-,

' Ml

1 Dav

!/,.>////'

Vtar)

/h! I

RfN< .1.1". M \KI< n I>

SVIlx t\\ i:i> < >K D'V' >K*'i:t>

iWtitriii xiHi.ii (li -iyiiati- iU)

c3xaax>''

niR riuM. \ri',

St.it I I '! ' '<nnit I \'

NAMi: <)I
I .XTllKK

lURTmM,.\OH
<)1 I APHKK

' St:it«- or Coniitiy)

M XlDl.N N AMI'.
Ml Mnrni'.K

IUKTHri,AOK

()i M<)'nii':K

I Stall' *ir Cimntry

oeciTA rioN

(^ J

I)

h'ritirif III SiUi /'i an, r-rn

) 'ill I *

y J, tilths

I hi 1

TIIK MU)VKS'r\Ti:i>I'KKSnNAI. rAKTIori.AKsAKl-TRrH To THH
liHST Ol MV l-LNOWl-EDCK ANI^Hl-.I.Il .!•

(Iiifinmaul

O'Ol.

A ,

(Address

4*^1 1 - 11 1^ '^J'^'

MEDICAL CERTIFICATE OF DEATH
DATE OF I)1..\TH \

I go \

(Year!

(Montir> (Day)

1 miKiniV CI'iRTIFV, That I attcii(k<l (k-ccascnl from

' Kp '. tn ~ ~~ T9O ~

that I last saw h — aUvc on " ^ '~ Itp

and that death occurred, on the date stated above, at
M. The CAUSH Ol- DICATH was as follows:

i aaJJL il.^^~ .. . , .

Dl'R.VTION Years Mouths Days

CONTRnU'TORV U! A,^^4:oihrL^ tl.

l/oit

ts

DT RAT ION
(SIGNED)

Years

Mouth:

iCLLUtVli.-

Pars

^\i f^ ^u (A(hlress) VJ/CUVvCKtAj vJjXd.

Hours

M.D.

y^.t

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

Former or
Usual Residence

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

How long at
Place of Deatli?

Days

ri.ACK Ol- jiiRiAi, OK ki;m<»v.\i.

i).\ri/:of iji Ki.^i. or ki':movai.

Uct

rNDKKTAKKR WVVAjtjxL LL^yvdjL\A>D»^ I^JJV/i

T90

M

N. B.-

""^ iT". Ar-P ahn.ild he Rtntetl EXACTLY. PHYSICIANS should

-Every Item of Information should be c«refully -PP'-^. ^^^J^^^l^^^^^^ \^^^^^ Information" for p-r-

state CAUSE OF DEATH In plain terms, that It may be properly «.la8*mea. me 1

sons dyinft away from home should be 4lven In every Instance.

£»1

1

WRITE PLAINLY WITH UNFADING INK

M. ,;.!<! . f Hi iilllv I' N'li

N-,, ■. ■!4.**^'Sa-, iSM'O.,

Dale Fih'(l,ijizLA>-Vs. \^

lOO'i

THIS IS A PERMANENT RECORD

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

Reo^isfpvrd J\^o. 2346

s

^V^<,^'

I

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco

Ccvtificate of IDcatb

A

XX. S. StanDarC>

PLACE OF DEATH: — County of - ^^>^

City of OcLA^

<;. ^. <.

No.

^

LC'

(ir DEATH OCCUB^ AWA
IF DEATH OCCWiRREC

'I

I

and

A^A^^^jhi Ol^^^^'L^^ ' St.; - Dist.;bct.

^rVX/Y\.MU, ^ ^ .Toi.A. orcJnFNCF GIVE FACTS CAtLED FOR UNDER "sPECIAt INFORMATION- \

U.i AWAV -OM^.U^SU^AL J„^f^°f,,^,^4-^,^;r,;| NAME INSTEAD OF STREET AND NUMBER. )

0 / A

Y

D II

FULL NAME

..L\,Q

PERSONAL AND STATISTICAL PARTICULARS

X

\Jux\mx1l

I

)

DA II-'. < >l ii K i II

\<.l".

a

Month

Dav

* I .11

s

WIlM lU I I > • >K 1 ) ;\ 1 iKi 1 |>

W'l i!' ill ---», ml .i< -11.-11,111. .11)

MEDICAL CERTIFICATE OF DEATH

i).\Ti-: oi- i)i:aiii ,, .

I lII";ki;i'A' ti;k'ril"V, That I alton.U'«l .Utxascd from

Lc^q i^ M>o'i to v^ct' it 190 H

tliat I last saw h ^- • • valive on

.^. v

u

Jip

and that .Uath ocrurreil, on the datr stated above, at b, 6C
O, M The CMS!*: Ol' DIvAlTI was as follows:

Stati 0I I'l iilti! 1 \

N \M 1 111
l.\ i II l.R

luRriii'i.Ar}-:

nf 1 AIIII'K

^t.i! I .1 Ci 111 lit ' \

maii»i:n N\Mi:

<»|. MoTlll.K

^TvC|/Li

t

1

HiR'i'iiri, \*"i-:

<il MnTlll'.K
' siatf in «.'<)Uiiti \

nrtri

A rii)N ( y

h'r>iifr<t III Sail /'nm, i^<-i>

I I .

),,i

Mnlltff

/hir

'IMIKXHMVKSTXIM<n.'KHS.>NAl rXKTU-rLXKSAKKTKrKT..

• III'

(IllfuMllIlIlt V>

(\.l<ll

Lttu^

uLoLAXt

-VL/trvv-XUvu

•hji^' \.

} lurs

DIRAIION }<^n

CONTRIIUTORV Ur:

Months Pays Hours

C/Vx/CL^

i\fi)nlJis

(SIGNED) J . ^A. OV.0^1

/hivs

J/Ci 13> i.,r,H (Address)

it)

Hours
M.D.

SPECIAL INFORMATION only for l4spltals, Institutions, Transients,
or Recent Residents, and pepons d)ina dv^ay froni liome.

Former or ( A «r i * 'l S^'T/.h, -

Usual Residence b A.^ i-^ > v.^ ^ Place of Death ? a

Wlien was disease contracted,

If not at place of death ?

Days

IT \CK <>l- IHRIAI. OK RI;M<>X AI

)cu[v>A^-'

INDI'.R I'AKHR

DATJCof HiKiAL or K1:moVAI,

190 \

V^ 15-

■■^ ATP «it,.,.ia ho Rtntetl BXACTLY. PHYSICIANS should
N. B.— Bver, Ue™ „« .„.n.™«..o„ .h.u.d h, c„r..un. .upp.--. ^^p^,';" '^'..^^.^''th: ••Sp.C.I lnSor.n...„„" for p.r.
•tate CAUSE OF DEATH In pinin term., that it mny be propeny
"n. dylnt aw., from ho,n. .hou..l be ft.v.n 1 y ln...ncc.

h;

if

ii

1

tl

WRITE PLAINLY WITH UNFADING INK

i.,n.! ..f lh:.U1i 1^ Vo. I. ^^}r^ H^P <'o

0

Dft/r /'V/r^/, Uct<rW.\j I 5"

lOOH

THIS IS A PERMANENT RECORD

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

2347

Be^istered JVo,

d.tru^^ ^ Deputy Health ORlcer

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco

Certificate of E)eatb

( -a. S. StanDar^ )
PLACE OF DEATH: — County ofO^Vw OKxX/vvX^^^ City of J<X^ ^Axv

\ / ,. orATH OCCu4.W*Vr«OM USUAL « ^ f ^ ^^^, ^^ C^^^<;-,^. /^.^S NAME -N^STtAO OP STHCET AND NUMBCR. )

( IF DtATM OCCUf*fe AWAY FROM USUAL R E S 1 U t PI V. t u . V ^ r -.,
( Tf DEATH OCCURRED IN A HOSPITAL OR , N STITUTIO N G I V E I

JCCURRtD I'M « MU»r-i "1- ""i ,.,^,.._..- ^

FULL NAME LcCtkLVo^ vi '~ lt|^^

4^

si:\

PERSONAL AND STATISTICAL PARTICULARS

ic)l OR

UkJt

kJJ^

I) \ ri' « -i HIK I H

\(.l'

IVX

\!. .iithi

)V,;)

(D;iv>

Miivlh

ar)

/),.' 1

Willi »Ui: 1» «»K I>I\ < iKT}- I»

A.) XxL

<nxr

MEDICAL CERTIFICATE OF DEATH

DATH OF I)1;aTK lC\

(Montli)

I go \

(Yt-ar)

f\

(l>av»
I HI':RI':HV Cl-iRTIl'V, Thai 1 atU-ndcd deceased frnm

\^tx,v ...;. 190H t.. . i)c± 11

that I last saw h '•' ahve on U tJu I.

and that death oeeiirred, on the date stated above, at
M. The CAISIC OF DKA Til was as follows

190 H
190 *

niK rniM, M'l",

(Stati iir <"i)iinli\

NAM)- m-

1- A 111 I.K

lUK'niiM.ArK
oi- 1 A rin:K

iStatt lit I'ottntry

MAIIM-.N N WW.
<)1- MOTUHK

lUK rHl'LAi'1%
1)1 MoriU'.K

tStatr or Coiiiili V

11

^

(\

OCCri'ATION ^

1

Kf<iiU'd in Sim I i an, r^ro

yf.utth

Ihn

THK AHUVK STATIC. .M^KSnNA.rAKTirrKAHSAKKTKtKn. THK
IJHST ()1- MV KNOWIJ'.DC.K AND lU-.Ml.f

OAXX>^>\A

.. O^^^'Y^*^^^-^^

VJJLa^wM^

\

DC RAT I ON Vi'iirs

CONTRIIUTORV

Moulin

.„. K

Days

Hours

DT RATION )'i'iJrs Months Days

(§IGNED) lU- C9. UnnJC^

,<,oH (Address) UJ-^^V^A.^^^

SIG

Hours
M.D.

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

Former or
Usual Residence

Gli^

W^^^<'

How lonq at

Place of Oeatli? Days

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

IM.ACH OI- HlKIAr. (IK RllMoX AI,

)QLuU'

D.yXKc'f HrnrAl, or KKMOVAI,

'^ <-!■

190

^^^^^AX.

INDKRTAKICK

/O^Ct ex. ^

(Addres

sm..S1d1.^^- la

"^

A

i

.. . -pp aHould be stated EXACTLY. PHYSICIANS should
N. B._Every Item of information should be cnre^ully «"PP'-^ AC.E s ^^^ ..^ , Information" for p.r-

stflte CAUSE OF DEATH in plain terms, that it may be properiy
•on. dying awy from home should be given in svory instance.

H. .n

WR

H. -lUh I' ^'

i t

ITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

2348

^ *-!r>n»i.^i-, v.Sii' c

lU'!^isteved ^^o.

I ' '

'• I

Ifrvu.^ Uvu Deputy Health Officer

DEPARTMENT oIf PUBLIC HEALTH=City and County of San Francisco

Ccvtiftcate of IDcatb

( tl. 5. StanDarD )
PLACE OF DEATH: -County ofCcoTv JXO v - : • Gty of O^x^ J ^^tvc^ - ,
.^XlfKL^-vti ,. I SU Dist.;bet. and

^V ^^J^'^ > VV\,. .;.:., ^, orCmFNCCGIVE FACTS CALLED FOB UNDER 'SPECIAL INFORMATION" \

\ f ,r DEATH OCCURI^ AW*Y FROM USUAL f f S > ^ E N C^E^GJ V^E J A CT S C^A^L^ ^ ,^sTEAD OF STREET AND NUMBER. J

(

r-'r»T°-"cc"J.*.ro',"°:oSp" ". "n .NST.TUtToN CWC ,T. N.ME ,NST„0 or ST.C.T .NO NUMBER.

FULL NAME

^w W_'^ ^.

1 >

t »'

1

si:\

[)\ri-. «>i inurn

A< .1%

PERSONAL AND STATISTICAL PARTICULARS

I

(Kliinth

lUav)

\l,,nl'n

■> t ;i! 1

/>a

W 11)1 >\\ I'U OK !>!\ t>H«i:i)
\\!it« in *'ii ial ill -i;^iiat i"ni

lUK rHI'I, Ai'K

I SUit t lit t"i iiuU t \'

MEDICAL CERTIFICATE OF DEATH

i)\ 1 1-; tM 1)i:ath

Uct

(Month)

l>:iv

rgo

(Yi-ar)

1 HICKICBV CI'RTIFV, That I atteinUil tlcHcascd from

n^int; \H T^H to Az-ct}

tliat I last saw h '- alive on ^ -^ •• 19° ^

and that (Uath nccurrcl. nii the date stated above, at

10

\iAhx^

VAMi: OF r^)
!•ATH1^K

HIR rill'I.At J".
(>|- I AlllKK

'Staff oT Oounti V

MAIDI'.N NAM}-
01 M()Tm:R

lURTHIM.ACK
<)»■ MoIHKR
(Stale or Country

+

^^jJaXX/vu U-Co^x^uv,

OCC

ri'ATioN J) n

h'fsidfif ni Safi /'inn, i'-t-it IC ) '-■'

^r,„itln

Ihi

HKST <)1- MY KN-«)\Vl,l<;i)<.H AND Hhl.nj^

M. The CAr^>ii Ol' I>1':ATH was as follows

DT RAT ION >Var.?

CONTRllUTORV

Mofiihs

Davs

I )r RAT ION ,
(SIGNED) '

ly^ 15 11,0

) 'caj's

J f ON //is

y^ o.\. .

Days

Hours

Hours
M.D

(Ad

Iress) LaJxi^C^. d^^

ON only for Hospitals, Institutions, Transients,

SPECIAL INFORMATI

or Recent Residents, and persons dying awdv trom home.

Former or ^ . ^ 1 ^ , l ^ * "f* '"IVSk. 1 ^

Usual Residenceim dUXhJp^ >v Place of Oeatli? -

Wlien was disease contracted,

If not at place of deatfi ?

Days

I'UACK <)l* HIRJAI. OR KHMOVAI

DATlCof m-KiAl. or RKMOVAI,

0<::t IS^ 190H

(\<i(ii

^

X

INDKRTAKKR

"v%

(Address 3 (o1 X. " ^ ^

tL>

■— — y*™ .. . -^p „w„..iH he Rtntetl EXACTLY. PHYSICIANS should

N. B.— Every Item of Information •hould b. cn.efully supp .ed ^^^B «hould^^^^^^^^ ^^^ ..^^^^^^^ Information" for p.r-
■tate CAUSE OF DEATH In plain terms, that it mn> ne proper y
•on. dying away from home should be given In every .nstance.

^

1

I i

WRITE PLAINLY WITH UNFADING INK —

Bi.a; t ..( n>:.U

ui, ! V-,

IV ()\

THIS IS A PERMANENT RECORD

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

lie i^i stored ^'o, ^o4J

l)(iti' Filed , \j <:LKj:Xs-<y>^ IS"

\ ' \

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco

Ccvtificatc Q>i IDeatb

( XI. 3. StanDarO )
PLACE OF DEATH:-Countv of do... Jxa > " ^ Gtv of 0.^ Jx^x^-cc

a'

c-„^ ^ Sf 5v Dist.;bet.Cj-<XXlVXX\^\XivUand

I n

)

FULL NAME

\

-. <

,<X.Lvk.c. i.

,t > > vc ^

PERSONAL AND STATISTICAL PARTICULARS

idl.oK ^^

(\'i-:(r)

\ < . J ".

5V,/*

M,,„th

Pa v"

MEDICAL CERTIFICATE OF DEATH

(Month) '>>'ty^

I lIlCRl'iHV CI'RTIFV, That I attciuU-.l dcivasca from

(Year)

til at I last saw h

I90

to

alive on

190
T90

SIM, 1.1' M\KKii;n

WII>«i\\i:i> <>K IMVoKCl-:!)
(Wiitf in -.(H ial di '-iv Hiitioti)

HIKTin'I.Ai'K
(State '>r I'mititi v^

XxX/C. ,

HA 111 l.R

«)ct:ri'A iioN rVVY ^ ^

HIK riM'I.AlK
Oi- lAIIIKK

(Stati 1)1 I'ountrv^

MAIUKN NAMl-

Ol- MoTm;K

lUKi'mM.ArK
i)V m<>iiii.;k

(Stati- III Cotuilrv

X<X'-YV

aii.l that .U-ath occurred, on the .late stated above, at
M. The CArSIv 01' I)I':ATII was as follows

DT RAT ION >Var.v

CONTRIIU'TORV

Months

Pav

Hours

DIRATION

Years

Months

Pays

( SIGNED ) \j!i\Jr^^\X>0 ^ Vd. U). kxXojysjL
iDcfc 15- iqoH (Ad.lress) WutW^A^

Hours
M.D.

h'rnlr.'l ,n Shn /'i,ni, !•-,■,>

\r,.nfh'

Ihn

ni-ST Ol- Mi: KNOUI.IIIX.K AM) HI. 1,11. »

r 1 1 1",

(Infi)iinant

I A, > N v<''^^

fAtMrt-ss oO ck

Uut/YYvJtnoAi

SPECIAL INFORMATION only 'or Hospitals, InstitulTotis, Transients,
or Recent Residents, and persons dying away from liomc.

Former or
Usual Residence

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

How long at /^

l»lafeof Death? )\ Days

nXJ'Hof HrRi.Ai, 01 KlvMoVAI,

>ct) lio

ri ACH OI' mKIAU OR RKMOVAI.

190H

N. B.-

i„,^„„^^^^B«M^i^«i»i— •i'^"'"'"^""^^^^"'^"""*''^"^^" I f^xACTLY PHYSICIANS should

-Every ..em o« .nformB.Ion .h„u,a be cr.ful., .uppHed *««^;/;,„.,°„:/ Th^ •SpeCa. ln«orm»..o«" Cor p.r-

» • f-AiisF OF DEATH In plain terms, that it may nc pr«M ^
:r. d^-Ji .w°, f~m hon.. Should be »,..n .„ .v.r, .n...™c..

4 #

I 1

11

» I

f Hi :i"'! I "^

WRITE PLAINLY WITH UNFADING INK-THIS IS A PERMANENT RECORD

REFER TO BACK OF CERTIFICATE FOR IN9TRUCTI0N3

2350

:'•^,^ HJ^l' v"

lOO'i

Beo^istcred JS!*o,

i \

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco

Cevtificate of IDeatb

{

"Vs

J? Q!^

PLACE OF DEATH: — County of^a-^v -. ..a

City of OO-AAj OAxx->^cUi.c(.

5'

No.

I L <xLvx<x\.cx.

1

St.;

Dist.;bet. ^^

and

'"YX^w-A.'

)

c%%R"v.rrHo^s^prTit :« Tr;sT^Tu%To';'v.;r.rs name- .NSTCAo^or str" E^iN o ^N ::BrR°'* )

" ''^ ~^cinc-tu/>C-riur TACTS CALLED FOR UNDER S

/ .r (.CATH OCCURS AWAY FROM USUAL R ^ S I DE N C E^OJ VE JACTS C^^^^ .^s^EAD OF

\ IF DEATH OC

(

FULL NAME

K

w'. \-

v4

i.^ w-

ULllc.

PERSONAL AND STATISTICAL PARTICULARS

^i:\

"\

r< uj >k

wCa—^-,^

L

I . V.

I) A 1 i: <il lUK III

A«.H

V

3 ../<

Da'

1/,. »////>

War)

/'(/ 1.

TQO '

(Year)

-^!^<.I,^■. MAKun'.n

Wiiti ill -.(.lial lit «-is.'natii>n)

IIIRTm'I.MM

FATni:R

Dj

Iclt V

A^(j

lUK'rmM.Ai'K

oi- 1 ATJIKK
(Stale or Coiinti v

M \I1>1",N NAMK
ol M»)Tin;R

lURTIiri.AiF,
Ol- Mo'I'HI-.R
IStaU- or Cotinti y '

OCCrrA'lKJN

MEDICAL CERTIFICATE OF DEATH

D^k ri-; «>F DICATII

(Month) (Vi^

I m<:Ki:BV Cl'RTIFV, That I atten.lea decoased from

bCL. ni. L-'. .190. -tnj^^^'--^ -'••; 190

tliatlla.tsawh.^^- alive on W/sii.. IH '1 " . 1 > . loo ' ,
an.l that death occurre.l. on the Mate stated ab.n-e. at olX
t, :m. The CATSIC Ol- I >l'; A I'll was as foU.nvs:

^lJLvJl4L0 oXti_K^ X>v<r>^v

.A\Aii^

DTK AT ION

CON TKIIH TORY

'■'W

Months 3s /;<ij'5 //t>//r.s

OXQ-^-'lvw^^-q.

ft

0l/a7\O.

'^0lC4Aaa.<l-^

I \

duration
(Signed)

Yeat

Months

Days

C/HVx^

Hours
M.D.

^^

iqO

(Address) SO '6 ^1 1 Inni^^Ll.-

SPECIAL INFORMATION only for Hospitals, Instltullons/Translents,
or Recent Residents, and persons dying away from home.

) ra I

Mi,u1h>

Ihn

HKST Ol- MV KNOWl.lJH.H AM> Bhl.n.b

{liifoimaii

U

f Addrt'ss 0 *

Former or
Usual Residence

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

How lonq at
Place of Death?

Days

DATliof lU HiAt. or RKMOVAI,

^ A

VI ACK Ol- ^IRI.M. t»«< R1;M0VAU
rNDKKTAKKR mXu^^ vj Crdx

(Ad.iLs 50 5'\In^AALyrv>AXA^

-CL.^^)

._ ^uouid be stated EXACTLY. PHYSICIANS should

N. B.— Every Item of Information .hou.d H^' --^"''^^ -^^, ^^ Jtofjly classified. The "Special information'' for per-
. *- r'AiiiBF OP DEATH In plain terms, tnai n mwj "»^ m *-
:r; "n"» aZ ."L ho„., ,hould b. t.v.n I , .n..."«-

<

«

f » i

i £

IV

w

f , '•'; r V

R,TE PLAINLY WITH UNFADING INK-THIS IS A PERMANENT RECORD

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

2351

■iyf^^^,V.Fc)-

Ih

f/r Fi/('f/,Vc)iJj-V^

JfJOH

Medlsfered jVo.

0

cX.CrVM^^

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco

Ccttificatc ot Bcatb

( n. S?. StanDarC* )

J ' Pn J <^

PLACE OF DEATH: — County of ^a^x ^^ty oi

- ^'^^ c* M n^«:f'V^t (u X. K: and

■ I f - < ^^'^ ^ UlST., DCU ..spj-cftL INFORMATION" \

)

No.

FULL NAME

PERSONAL AND STATISTICAL PARTICULARS

(•< >I,t »K

Vk^U

I» \ 11 ( >! r.iK S li

iM..iit!i*

\' ,1-

/ ^

b 3

)V

10

l>:tv

1/ ,ii'/t'

I w

Vi-art

l\t\

MEDICAL CERTIFICATE OF DEATH

DATK OF Dl'.ATll ,, ,

rMontlO

f Dav)

I90\

(Year)

I 111.-R1-;BV C1-:RT1FV, That I attcn.kMl <kocased fro

111

that I last saw h

alive on

Vi

I '^ , 4'

190 H

190 '<

>>IS«,l,K. MARK n- n

\viiMi\vi:i» OR i):\ <>K. 1 n

Wtiti in >iKial (It >.itf nati'iii'

A

f\<XXN.^xd.

ana that death occhrrc.l, on the dale stated above, at I • O U
(X M. The CAISH t)l' DHATH was as follows:

lUR riUM.AOl"

iStatr or *,*i>U!it I >

NAM I 01
I- AT II l.R

HIR'niri. \0K
(>!• I AIHI-.R

(Htatf .ir v'nuntrv

M \mi:N' NAMl".
1(1 MoTlll-.R

lURriMM^All-:
OI' MnTHl'.R
(State t)r Ci)\intry

OCCII'ATION

11

JL\,

I )r RATION

} 'ears

ruo^

Monlhs

PilYS

Hours

\ >

O. ^ \A

?

Uo-jU. nI^I^^-^

years

Month.

.\11J(UL^ Lc<J

DURATION
(SIGNED)

\Ji\^ V-

SPECIAL INFORMATION only lor Hospitals, institutions, Transients,
or Recent Residents, and persons d)ing away Irom home.

l{)n

r Address) 14 Aj v V LMAJLRa.

Days i t Hours
M.D.

/!,,M

n..;,>^-^,'^;™^ ■'■" '"'-^

(Address

Former or
Usual Residence

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

How long at
Place of Death?

Days

DATI. "t" HrKiAI, or REM<)\'AI,

J eL 11 190 H

_^^— — — ■^^■^■^*^^'^*^^^^^ 1 I K » t I EXACTLY PHYSICIANS should

State CAUSE ur Mt/* • • f . aiven In every instsnce.

sons dying aw.y from home should he ftUen m every ^^

1

> > i

: U\\

* ' i

W

RITE PLAINLY WITH UNFADING .NK-TH.S IS A PERMANENT RECORD

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

2352

. ^*r:^^; :I:^.l■r,,

lf)OH
Deputy Heclth Officer

Bcili^stercd JS'o,

Dufr rih'd,}U;QX.C'c ■

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco

Ccvtittcate of Beatb

PLACE OF DEATH : - County of 0 Oa^ J XO . - City

-City of 0<X/YV OAXXy>VCV.<i.Ct

:\

'H

1 \

\^f4 ' ^^ ' Dist.;bct.

—and

^•"^'"1^^^^ -^c-.^",-" ^^t r^f ;^^^-;^^P"^ ^^" ^-

lAL INFORMATION- '\
T AND NUMBER. •

FULL NAME

IvLd U

PE

^i;\

RSONAL AND STATISTICAL PARTICULARS

n \ I 1 ' >i luK in

\<,i-:

M.uitl

I):.v

\l.irh'

(\. at

/),M

M

EDICAL CERTIFICATE OF DEATH

DAT}-; uF DKATII j A

igo

(Year*

(Month) 'I'^'V^

I IIl<:Ri:r.V CI:RTII'V, That l aUcn.UMl .Uccascd from

— — — — — ~~ igO ~

- .- up to

tliat I last saw h r:— alive on

190

six. ,1 J" MAKKIl'U
WIlHiU I-U OK l»!V<»Hri,0

Wi itt ni ^luiai lii-iv'":"""'

HIKTHI'l. \CV

Stat t m! I'liinit I >

a„a that .U-ath ..courrea. on the <late stated above, at
^I 'fiie CArSI':()F I)1*:ATII was as follows:

r ^

NAM J" Ml
i AlII 1*K

lURTllIM.Ai'K
«)! ! AlIIl-.K
stall 1! I'liuilt 1 \ '

M XlI'l.N N AMI,
Ml MoTHJ-.K

J'.IH rm'I.ACl",
Ml' MMTm-.H

iSiati- <ii I'Hiiiti \ '

/
I Mil TAlloN'/

x^/

L^wlw^'"^-^-^^^-^ n ^

1)1 RATION >'''^^-^

CONTRlIUToRV

Months

/hivs

Hours

■\

N

X

/

Uf RAT ION
(SIGNED) ^

Ucl IH TCP

Ytars

Months Pays

I /ours
M.D.

ipECIAL INFORMATION only lor Hospitals, Inslitutliki^, Transients,
or Recent Residents, and persons dying anay Irom home.

Kf-idrd III S,ni I'liui. iy>'

,1 1 V

\r,,iitiis

I hi v.

■ ■ ' ' . ,.,, ..xpriiTI XRs \ K 1-. r K \ ■ I". '!■' » l" " ''"

(Infoimnnt 'v.C ^-C

Former or
Usual Residence

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

Ho\« tonq at
Plare of Death ?

Days

I'l.ACK Ol- lUKIAI, "K KI:M<>VAI.

I)\rj". o! Hi uiAl, or rkmovai.

190M

( \.lllI<•s^

N. B.-

^^^^^^^^^^^....i^^i^B^B— ■^i*-"^""'""^^"'^^^ , FV4CTLY PHYSICIANS should

Btate CAUSt ^t- UL^ • „.„,., J he Aiven in every lii«t»nce.

son. dying «w«y ffom home should be l^.ven in y ^^^^

R,TE PLAINLY WITH UNFADING ,NK-THIS IS A PERMANENT RECORD

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

2353

» }

]00'\

llcoisterefl JS'^o.

Dale FiJv'l. y.cX<r\>JlX'

DEPARTMENT h PUBLIC HEALTH=City and County of San Francisco

Dc

cer

• ! i

*

Certificate of 2)eatb

PLACE OF DEATH: — County

ofd/OA^ J/v€u^^^^^^CUy ofC)<^^^ 3;^c^>^^--

^^

No.

St.;

Dist.; bet.

, I

and

.1

RESIDENCE GlVt FACTS CA

LtED FOR U^DER SPECIAL ' ^ "^O "^*;'° ^^ " )
r. _ «- .^TorrT AND NUMBER. •

F STREET AND NUMBEI

FULL NAME

n

PERSONAL AND STATISTICAL PARTICULARS

\.

\ IK (tl lUK 1 H

\i.i-:

SIM ,i,i- Nt AKK n:i>

uiiH i\\ 1 n < >k i>iy< "i^^ t I'

W 1 .», ill ~ K Kil 'li -ii'n.ii •< iH I

^,( ill I ll ' '. lllllt I

\ \M 1 < »:

1- A III I-.H

niR'nn'i.Ai'H

-tit. I it (.■< lllllt 1 \ I

\! Ml UN NAMl'
(U Mo'nil'.K

.1.

(Yt-ar)

M,,ut

T

/',/r^

MEDICAL CERTIFICATE OF DEATH

DATK «>»• i>KArn i, 1

(Month') '^»='y^

I IIKKHHV CI'RTiFV, That I aUc-n.U-l .leccascl fr-m,

t„ : KP

I(p

lip

tliat I last <.aw li — alivr <hi
,,„a that .Uath .uHnnrc-.l. n„ the date staU-.l ahovc. at "
— M Thf C\t SI': Oh" Dl'-ATll was as foUuNvs :

TV ■ ■' -^' •■ •

DIRATinN )Vc7;.s-

Moulhs

Pays

I /ours

lUK rm'i.Ai'i-:

'Still , III IdlUlt I \

/

DrUATION

) Var.v

/hlVS

(SIGNED) UYt>vllAj V

L' r t

,,f, 'i {A<hlnss)

i<)'

} foul lis

' IBIL

//oui \
M.D.

s^) WVO^AiAA

ftfr- —
Ukii, Trai

/

ore rr \rit>N

h'r^i,lr,f III Sail I i.nn /■>"

) V(M

M.,,illi

l>.

, ,.XK1I.-I LXK-^AHl- IHl K T" TIM'
1U> r t)I- MV KN«»\\ I.lIXii. N

"^PFriAL INFORMATION only for Hospitals. InstilutUi^*,. Transients,
or Rertnt Rfsidents, and persons dying anay from home.

Ho^ lonq at
Former or p,^,^ „j ^^^,1,1 .. pay.

Usual Residence

Wlien was disease rontracted,

If not at plare of deatli ?

!I-:n I'KKSON \1

„f.,nnant ^^JS^JTYS^-^^ ^|

f \.lili'^'^

,.1,AC1^ nr lUKIM, OK Ki;M«'\ \l.
rNI)i:KTAKl.H

li\lj 1,1 111 HIM <»i l<i:Mn\AI,
K, ■ J^ TQO'I

\

u.i.i.^^^blX

■"■"■■'"'''■'^^^■■^""^^"^^ . I FVAGTLY PHYSICIANS should

.t«»e CAUSE OF DEATH .n PJ^^ J-f^ :^^„ ,„ ,,,,y |„fnce.

RITI

, dying away from home

'il

♦.
I

h

: t 4

^

tJ

^ ♦

WRITE PLAINLY WITH UNFADING INK

^. " ^iT" "'*, livV I VI)

Pair /<'/•/(''/, y.ctA)^t^V' 1^

THIS IS A PERMANENT RECORD

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

Rc^islercd ^'o.

2354

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco

Certificate of ©eatb

>^^ -^ ^

( n rvv ■ \a ^ V <^c^X'. City of 3<XA^ ixxX/WCUj. ■:.
PLACE OF DEATH: — County of -J ^'

-^ ; \ i . , ''' . ^ ,1-1 St.: Dist.:bet. ^"<J

)

11 U i \ . ' - i St.; ''^'' .,„ p„» UNDER ■SPECl.L INFOBM.TION" ^

(. ,r DE.TH OCCUn-lD .N • HOSP.Tl. OR INS

FULL NAME'-O^JLuxv^^' 'J^- '^-^ ■'■

-l.\

DA 11 •

PERSONAL AND STATISTICAL PARTICULARS

riil.oK ^

n

,^"^

\j

M .mil

I:

\< . 1-:

!/.)■'//

S( .11

/',;

MEDICAL CERTIFICATE OF DEATH

DATl". Ol- Dl-.AllI

Month)

H

(Day

/ QO

I Year

t 1

190

W 1D« iWl D i>H D!\' >'•■' HH
<\Xix\> in -.. nil ,l.-i-n,iti..ii)

L

l.^c^-f^

m it 1 . 11 t I 111 lit 1 >

NAMl 01
FATHIR

lUK iiiri,\<H
• t! 1 A I'm: K

■ -,t it » ( If l' •<! "f

MMDl.N NX Mi-
ni M<»rHl-:R

!ui< rniM.ACH

(»|- MOTHKR

GyxaA-^ '

1^0-

I 111;KI;I'.V II-RTIFV, TIimI I :,1U.,i.U.1 .UT.iis.'.l fr.m,

U/J ■" — tt)

that 1 la-t V..W h " alive- oil —
a„a that .Uath nrourrcl, .-., the daU- .taU-.l al.nv., at
M. Tlu' CAISI- t)I- ni'ATli was as follows

A.A.4^J.J.

DlkATIoN
CoN'nUl'.lTOI

Vaus MonUn J^iys

Hon IS

I * (

■As.

'(

e

)Vrn.v ^ Months

nay

nrRATioN

(SIGNED) W<r^^-^ J -^A^

Hours
M.D.

4 c

1 . ,- . . 1

) ../'

^ : ..,, ,.M. ri.Ti \K- \Hi: i-Kij-. H' 11II-,

fD.r...n>ant UJ m\/ "^ '

X-l.ln-^s 11 D

IprciAL INFORMATION only for Hospitals, InstitufiW^. Transients,
o^Reielu R 'sidenfs, and persons dying away Iron home.

Former or q «
Usual Residence L »

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

How lonq at
Place of Death ?

. Days

) r^

OiAtm. UaIx U.

,., KCK OF HIRI.VL OR KHMOVAI,

DAIH;. tif I51HIAI. {)r R1-;M0VAI,

^ ""A' lb 1 90' I

rNlJKRTAKl'.R

'^^'""'^ II. PHYSICIANS should

state CAUSE OF DEATH m P'»'" J'^7 ^,„ •,„ «ver> instance.

sons dylnft away from home should be give ^^ ^^^

M

1

* i

( •

'J<

WRITE PLAINLY WITH UNFADING INK

lU'vT ^'

THIS IS A PERMANENT RECORD

REFER TO ..o^.P.rATE FOR INSTRUCTIONS

Iht/i' Fih'fJ, i-'ctcri^N.'

lOCi

Bc<^>istered .A^o.

2355

1

0

OEPAmENT 0^ PUBLIC HEALTH=City and County of San Francisco

Ccitificatc of S»catb

XX, %. StanDarD )

J? (^

No.

J? On -\ '^

PLACE OF DEATH: — County of Oay>rv ov ^^ o.

' t - • St.; ' UlST., DCU _„ ,,^_,pp ■■special INFORMATION' \

V IF DEATH OCCURRCD IN A HOSPITAU ^ ^1 ^ i]

)

FULL NAME

\ N.

\jXJuu^of\^^

c^.

.j:n.

PERSONAL AND STATISTICAL PARTICULARS

i

11 \ ri: t '! 'M K I li

M.nt

> !>;i\

Vi'.M '

MEDICAL CERTIFICATE OF DEATH

DATK OF DKATH iPj i ! /^

(Month) "•^'^■^

I IIHRKBV CHRTIFV. That I alu i-k.! .Icrcase.l fnmi

/90 »

(Year)

t

\L)^t 1^

T()0

A I

Iht

^X-KiAM M \HKI! n

1 Writi ill -iHMul ill -lyti.i! -tit

I 190 H to

U,at I last saw h . alive on ^^ ' ^9°

^^^^^^ ^,^^,, .^^,,,,, „ocurre.l, o„ the .late state.l abcve, at
M. The CAl S1-: Ol- Dl'.ATll was as folUms:

H

A

lUK rin'i,\i'i"

Sl.i! ( ' )1 I ' ''1 lit 1 ^

NX Ml t»1

1 ^ ; 111 K

ItlKTlil'l, \< K

(»i' 1 Arm-'u

i st;it I' lit 1"| mil' ' v

M \I1>1-*.N NAM!

(ii M«»'i"m.K

r.iKrin'i.Nri-:
(ii Mdiin-'.H

(Statt III Cuutilry'

v

I 0
I

I
La

n n

DT RATI ON ^''"-^

CONTRIIUTORV

Moiii/is

/)ijys

SJ

^L<x^

^ i

DTRATION

, 1. 5). a

J/^ofi/Zis

Ihn'

(SIGNED) ck. cU. MlJO^^lXl.
4)ct) IS^ TqoH (A>hlre.s) hoS

Hours

Flours
M.D.

)

■,',f ; < C7^

\ IK-X.

(HOt TA IU»N

T.\, ..vuTlcll \K^ AK1-: TKfl'. l«^ '»!h

a„r.nnant (^ . Q( V\X^4^ 0 A

"special information only for Hospital
or RefeS Residents, and persons dying a.ay from l»ome.

Is, InstitulAns, Transients,

Former or
Usual Residence

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

How lonq at
Place of Death ?

Days

'i H 5 3j .v^v^fc^Nij

4-'

M

l-I KC}- nl HIUIAI, OK KKM..VAI

l»\l"l-i>f lUKlAt. <ir K1':M()VAI,

.^ .^ A..CW^V ^

190 I

' ^•'■''^•'^^ , . . ^^^.L. PHYSICIANS should

>f

' I
» I "

w

RITE PLAINLY WITH UNFADING INK

1

!!

*

1

i.

1
1
i

it

1

,

lii

aJ^'^'5:., i;»tl'i

THIS IS A PERMANENT RECORD

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

2356

190 "i

A., •■.
DEPARTMENT OF PUBLIC HEALTH

Bes^Lstd'ed JS^o,

tVLL'

=City and County of San Francisco

Certificate of ©eatb

, -a. 5. StanC»ati? )

J? %

PLACE OF DEATH:

^ . xiin 'Wi 0 ^n >vCv s. ^ City oi ^'^-^ ''^ ^ ^„
■County ot^- ''^vru ^- ^-- -^ ^n

No.

N

c* Dkf bet. c^U^^--*^^^^"^^^^^ ^^^ X

bt.t J_/1SI., UCl* ..„„rii "<5PECIAL INFORMATION- \

r-o;:;:^oc-.^vrn^^t^^^3^?-^

( V

FULL NAME ^^^

^OX^XUL. w

SI X

PERSONAL AND STATISTICAL PARTICULARS

i>\ 1 !•: Ml ink 111

M

/ w

M^ Mth I

Ki.I-

l»a'

V. »/'/'

Year

/>..M

MEDICAL CERTIFICAtt OF DEATH

DATK <H> I>KATK ^

k\^

sINt.l.J'. MAHKn't>
W tiH (HHl> <»K l»'^■' 'K^ ' •'
A • ' m «ociHl «lt -ifiiati-iii)

#i'> •

lUK rm'l,ACR

v,t,,|, 1,5 ('(.niitrv

NAMl <>l

I AT in; R

BiR'ruri.Aci-:

(>|- lAllIl^K
( state- i»r i"onnttA

MMDl'.N" NAMl'
ol MoTllHK

lUK rmM.Ai'i',

»U- MoTllKK

(State i>i r<mntry'

orri TA riox

nUST Ol' MY_K NOW 1.1 J >•■»•• ^^",^' {

.Month) <'^='^-^ _„^i^^^"^

I IfHRHBV CKRTIFV, That I atten.Wa ac-ccascd from

190 tc, ..— — - ^"...-190 —

that I last saw h — " ahve on — ^ ^ '9°

,^^^^^ ^^^^^t a.ath ucct.rrca, on the .late stated above, at
M. The CAISK^OF DKATII was as follows:

» I

DT RAT ION >V'^''-^

CONTRn'.l'TORV

.}fonihs

/)avs

Hoiirs

DURATION

Yt-ays

Months

Pars

Hours

^ \

(SIGNED) Cvv*>X^^ S.lD.iao^^.c' M.D.

Oa

T<)0

wiK, Trai

VpeCIAL information only tor Hospitals, lnstitutiy.k. Transients,
or Refent Residents, and persons d)ing anay Iron, home.

(Infounant

Former or
Lisual Residence

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

How long at
Place of Death ?

Days

ri XCHOF lU-RlAI. uR RKMOVAI,

DA 1*1% of nrRiAf- or RKMOVAI,

A — — i^— — ^— ^ ^ FYACTLY PHYSICIANS should

ATH in plain term., that It may " ^

N B Rvery Item of inform

• .tate CAUSE OF DEATH .n P'"'" —;■-.;,;„,„ ,vry instance.
sons dylnft away from home should be give

WRITE PLAINLY WITH UNFADING INK

A.?-S7t,:. !lS;V'"'i

Dull' riled. I'ctoWAJ lb

THIS IS A PERMANENT RECORD

REFER TO ROCK OF CERTir.CT. FOR INSTRUCTIONS

235?

lOOH

]ii>aistcrcd Xo.

Deputy Health Orficer

DEPARTMENT ^F PUBLIC HEALTH-City and County of San Francisco

Cevtificate of 2)eatb

PLACE OF DEATH = -Countv of6^.^ J^—' ^.ty of ^^-^

A C ,F otATH OCCURRED IN A HOSPITAL OH ;,^. ^

FULL NAME

)

-^i:\

PERSONAL AND STATISTICAL PARTICULARS

(,(»1.0R

I

i>\ri: ')! HiKiii

i

h .

MEDICAL CERTIFICATE OF DEATH

,„v,..,..,...vn, 0^

(Day)

190^

(Year)

\«.i<;

S^

5

;iav

M.niHl^

Vt :i!

/'./I

1

^IN.l.l- MAK1<n-.l>
WIlMiW 1.1) »»K DIVitK* l-.I)
iWritr in -.» i;(i .l.-i!.'i\at!'iii )

^

(Month)
I HJ-KHBV Ci-RTIFV, That I attenac-a acTc-asc<l from

S ,• ^' ^^ . TOO •

that I last saw h i- • > alive on ^ ^

a„a that ckath occurrea, on the aatc state<l above, at
M. The CAISH ()^I)KATn was as follows

n L'^-v^

e^

0? 0

niRTHPI.Xi'K

'Stat' <>r «."f>niiti y

^.■^

AMI- ... (U (7Q

ATH,..K V H ^

NAM I' nl (15

1 I

t ^

DTK AT ION ^''"'^'-^

CONTRIIUTORV

Months

Pars

Hon

rs

HiKTin-LAt »■:

01 1 AlllKK
iStatc or (.■oiiiiti V

MAIDI-.N NAMi:
Ol- MO'I'IIKK

lUHrilPLAlK
m- M(»Tni'",R
fStalt" i»i i*()Hllt^^

/yavs

s1

I lours
M.D.

(SIGNED) - . V ■ c, p QTlP ,4

— — ^ _ _i- I-. u^onif >ir IncCidiHnnc Tran^ir

<Xk

"ciPFClAL INFORMATION only tor Hospitals. Institutions, Transients,
orlefent Ments, Vnd persons dying av^ay from home.

n How lonq at

Kf^idfd n, S,n, riiUi.i>rn

M,>}itli-

/hi;

(Iiifoimatit W . --J A

.<. i

Pllif c of Death ?

u »

Days

Former or sWstsAr

Isual Residence iiou J v

Wlien was disease contracted,

If not at place of death? _ .^

— ^ ^ .. ,,i-M,iv\l DVl'i;'"! IM lUAl- or KRMOVAI,

.,,ACK or HIKIAI, c.K KhMuX AK DVi •

IXA/Y

{\nru^

I

T90 i

/t)

r X-ldrt-'^s

rsDi-.RTA'^i''^

"•"^•^^ ^ , rvACTLY. PHYSICIANS should

state CAUSE OF DE^TH m P'«'" J\7 ^^„ ,„ every Instsnce.
son. dying away from home should be ft.ve

• I

I

WRITE PLAINLY WITH UNFADING INK

.,]. )■ n;.!

,. «.rr»^i.r..<tri-

l)(,/,' l-lleil, ^ ct<rlMAj

l(o

lOO'i

THIS IS A PERMANENT RECORD

REFER TO PACK OF CeRTIFICATr rOR INSTRUCTIONS

Registered A'o. 2358

^

DEPARTMENT aF PllBLlC HEALTH-City and Connty of San Francisco

PLACE OF DEATH: — County of

I'

r:\

No.

,1?S

\,<rO„ci

(

ir DEATH OCC
IF DEATH O

Cevtiticatc of Bcatb

. ( XX. S. StanParP t

1 ^

of OxXy>v ^■'^^' ■■ ■ '■

CL

(5i^

City

)

I'

FULL NAME

PERSONAL AND STATISTICAL PARTICULARS

(^/

"N

">

^Li

1 S i I '"

DA ri". < »I I'.IK 111

\«.H

ll

M..ntli^

r,».'

l»a>

M^.tilll-

\\i\

r)

/i.f 1 .

MEDICAL CERTIFICATE OF DEATH

I)\TK <>H I>HATlt \

n.onth^ .Day) JYear)^

^ I IIHRIUW CK RTIFV, That I attonae.l .leccased from

. — 190 to

that I last saw h :— alive on "

190
190

S1N».1,K. M.\K1<IKI>
\VID«nVKD OK DIVt>Ri ID

Writf in MH-ial .Usi}j:iiati.'n>

lUKTinM.X**}',
(StaU iir r>iunti v

NAM1-; ni-
I ATI 11. K

;CV'.

„,l that death occurred, on the date stated above, at
M. The CAISICUI- DHATII was as follows:

^^>^

nr RAT ION >'<''^''-^"

CONTKIIU'TORV

\

Month:

Pays

Hours

HiR rnruACK
<H- iwriiKH

(State t)r C<nniti v

MAIDKN NAMK
01 MoriIKH

lURTHlM.ACK
111. MOTIU'.K

(Slate or Oovintrv'

(S

v^r.i.v Years JfoNt/is Davs Hours

r\

occrrATioN

k f--

' ■■ itWrts,

"ciPEClAL INFORMATION only tor Hospitals. InstitutWris, Transients,
or Refelu Residents, and persons dying away from home.

Rfsiiifd III Siiii /'"I"- '■

) 'ill >

.Mnnlh'

I his

hfsiiuii III M." ■ riiK

TiiKM,ovKsTvn..,w<K:.,v^n;;;;i,^-<---'^- •

former or
Usual Residence

When was disease contracted,

If not at place of death ?

I^,ACE()F m-KIAUOH RKMOVAI,

Now long at

Place of Death? Days

DAXl'" «'■ 15' KiAl. or REMoVAI,

V//t.t' li T90H

INDICRTAKKK

.K,

^t

I (\^V\\v^-^ "^ ^1,1 LL. PHYSICIANS •hould

...U CAUSE OF DEAT" In p...n ^_^ ^^^_^ ,„.„„.

....; CAUSE OP fEATHJ^n Xul. be ftiv.n 1 , tn-.-nc

,mt dyln* away from •<»"" ""»"'" "

» • M

WRITE PLAINLY WITH UNFADING INK

THIS IS A PERMANENT RECORD

PEFER TO RACK OF CERTirlCATr FOR .r.STRUCTI0N3

lie a i ale ml •A^'^- f^'SO\y

I III 1 1' Fi /(•'/, VC

DEPARTMENT OF PUBLIC HEALTH

=City and County of San Francisco

Certificate of ©eatb

tl. S. StanDarD )

(^

PLACE OF DEATH: — County of U^Xm. ^^

" 0 .^ I ^i!* 1 4 11 T>' i. u«* — and

V

'/if DtA-TH OCCUB3

)

St.; ^'^'•' ,t„ POP UNDER -SPtCLL l~rOR«AT10»" ")

C ,f death OCCl^HRtD IN A HOSPITAL

FULL NAME

V

I

SIX

PERSONAL AND STATISTICAL PARTICULARS

/ t

1) A ii; < it lUKTIl

M,.iith>

IMO

MEDICAL CERTIFICATE OF DEATH

DATl-; OV Dl-.ATH jj |

/go H

(Year)

A<.1-;

1/

/',

\\ n»i»\vi-:n ok i)IV<»k.' id

■ • ' ■•■n.in.'Hi

\\ ! \\f ill -.ocial il< -'

lUK riU'l, MM-:

--t.i!. ..r ' "lUiili

N'\Mi-: «>i
! Aiin-.R

Q

I iiFRKBY CURTIFV, That I =Ut.uac.l .Wa.ol from
Wc^ ^^ 190 'i to ii)^^ IH 190H

, t i'l. itp ''

tlK.t 1 last saw 1, .. ^ al.vc on _^ ^

„,„, that .U.ath occurrcl, ,.„ tin- .lat. .talcl al.ovc, at .-

■ M -riK' CAVSI- (ll- lil-lAni was as lolUms:

.wC^ '

DTK AT ION ^''"'^''^

CuNTKlBrToRV

Mo)iihs

/hiys

//oitrs

B1RTH1M.A< 1:

oi- i-\riii-K

MAinilN NAM I', 1^
OF MoTHKK

lUR rm'I.ACK
()!■• MoTIlKR
' siatf or CotitUi

DIRATION

, l.'i

occrrATioN

Ow

\Xj^

n

(SIGNED

(\

- s'^ECIAL INFORMATION o.ly tor ispltals, Ins.i.uti.ns, Transients,
„1e" Mrnh,7nd Drrsons d,in, awav lr.:n home.

«

AV>/,^/-./ >>, S,i>i ria'i.i>rn_

),-,;;

— \f,,nlh'

/!,?

„„„_„„ -bx^ (jXoJt^

Former or . ^

Isual Residence * ^

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

, How lonq at
^C ' U Place of Oeatli?

Diys

Xj lb

CK^v^X-

\XcM

OF Hl-RIAI. OR Kl-Mj>VAU

DATl-', of ntHlAt. or RICMOVAI,

190

fAddriss ^>-^^-^. ^ PHYSICIANS should

• ■; ':

i • '•

WRITE PLAINLY WITH UNFADING INK

l)„/r /••/■//''/. ^'cLtri»-JLAj

lf)OH

— THIS IS A PERMANENT RECORD

«EPER TO n.r.K OP CERTinCAT. TOR INSTRUCTIONS

2360

Jle^jisiered -jYo,

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco

Ccitificatc ot Scatb

f ^^L^^VO.^'- ■ City of OC^ l-v^Vv^C^^C
PLACE OF DEATH: -County of ^'^'^^ ^ ^^ ^ ^

, - St.; ^- DlSt.;bct. ^'„,^.spec.al information' \

V ir DEATH OCCURRED IN A HOSPIT u Aft

)

FULL NAME

A^XkX^J^

'\.\

PERSONAL AND STATISTICAL PARTICULARS

i-( 11 I »K ■

MEDICAL CERTIFICATE OF DEATH

M 1 yj.

ii \'n. »>i. lUK I II

A t , E

.1

iMniUh'

/

bH

i'.i'

T . '//

■»'i ar

DATK «»1 I'l^^'l"Jt |A

(Yt-ar^

•Dav^

(Motilh>

I ,|,;KI.:nV CI-;RTIFV, That l .tlc.loMc.va^cl fr^

i()0 — to •■• ■..■.■■—•■ ^ ''*^

' alive t>ti

luo

IM..L .

.„,Ul.at,K.al„.-co,rre.l, ...tlu. .late staU.l above, at

mN«.l.V\ MARRIKI)
WinnWJ n «»K DSVriKi HI)

Writ, in -Kial .U'siKnatu>n»

M. The CArS!< oF Dl- ATIl was as follnws:

lUK rin'i,\**i-"

N \Mi: < M-
1 ATM IK

1UKTmM,A*K
oi I Alin'.K

>-,t a! I I >i, I'l iH nt 1 y

MAn)i:N NAMK
or MOTIIKK

nr RAT I ON y<'^'"

CONTRIIUTORV

Months

I\u

\

,,, XV- I'vjj-c Months

(t)

Pays

I /outs

Hours
M.D.

r.iKi'iiri.Ari-.

(>!• MorHKK

(Htalf or Cotititi > ' y

/

/

(SIGNED) WUn^^-^

-SPECIAL iNFORMAT^f '«; J-P"-'^' '"^^'^^^"^' ^""'^"'^'
or^efeS^esfdents, and persons dying away Iron, home.

Lc\>cn^JL>

o-ts-vUk.^

(1

Former or
Usual Residence

When was disease contracted,
If not at place ot death ^

How lonq at
Place of Death ?

Days

}AA./^kCU^"^jJ /OXx,

DATl"! niRtAi. or KKMOVAI,

vni,i:ktakkk JoXW ^

N. B.-

(A.l.lress — ^ "^°~^ . . . ml. PHYSICIANS should

• •

< (

i !

N

' ;l

1

.... .... W.H ...0.0 --- ::;r=ri^

b

1D()\

Erdisfered M*o,

DEPARTWENT OF PUBLIC HEALTtKity and County of San Francisco

PLACE OF DEATH: -County ofOo.^ ^ A,0

Ccvtiticate of Beatb

J (S^

\

l^ vA K \ St • Dist.; bet.

V IF DEATH OCCUBBED IN A HOS ^

and

^e. "corrlAL INFORMATION" ^

'""^ .omVNCEG.VE FACTS CALLED FOR " 't,'^ " 3:^„"eT in D NUMBER- )

USUAL RESIDENCE GIVE NAME INSTEAD OF street *n

FULL NAME

1

d!- Ml Kin

MEDICAL CERTIFICATE OF DEATH

DA rr: oi- dv'.aih

0.t

(MontlO

il):iy^

(Year)

M. mh

\uV.

liav'i

M,,},!li

/ i. L W
(Year)

/),n

, „,.Ki;r,VCKin'IFV, Thatlat.cn.lciaov.sclfron,

190 H to

• ' 190

tlK.t 1 b.st saw 1. ^'I'vc on

.„„, ,,„, ,,„,.!, ocurrcl, -n t.K- .la.. staU-.l ahove. at
M. Tlu; CMSI. OW UlCATllwa. as follows-

WHM.WKl) OK DIVoKi l-,l>
I Writ, in -.K-ial ,l« -is^tHitiuii »

UIH rn!M,\i'i'

(Sin*- • ■ ■ nmi \

\\M1 Ol

1 \ rin.R

Of I AIUKK

MMDl-.N NAM J
<»! MoTIir.H

niUTHri.Wl".
<)! Mtirul'.K
iM;itr or Country

HHST OH MY KXOWUHUon

l)\ri ot lUKlAl. or RKMOVAI,

(Itifonnant

U,.dre.. qHi» VJX^A^^^^ ^^

, ,„,lre., 5^1 a^^^^ff^I^:;;---^^ — 7^ ...ed BXACTLV. PHYSICIANS -houid

•on. dyliift away from home » ,

190 \

>t

• »

I
I

I
, t

i

I

WRITE

PLAINLY WITH UNFADING INK

THIS IS A PERMANENT RECORD

„EFER TO .....nPCERTirlCATErOR INSTRUCTIONS

2362

Jledisiered jVo,

Ini/c Fili'tf .

DEPARTW^NT OF PUBLIC HEALTH=City and County of San Francisco

Gcrtiticatc of S)eatb

-^\ ^K ^ .. ^ ^ ' Citv of O'O^^ \ K/yj^r^y^^^^'^

PLACE OF DEATH : - County of w^^ '^ ! . ,

No.

St.;

! I UXA.

)

~ ^ ii«5iJAL RESIDENCE Gi

/ ,. OE*TH OCCURS *^»\;''?*'„oSpVfL OR INSTITUTION
\ ,r DEATH OCCURRED IN A HOSP.T

UlSt.; OCX* ,.MDER "SPECIAL INTORMATIO

- )

(\/

^

FULL NAME

lO-^n'A '

c*

'^

K.

/"^.

SKX

-;7;;^;:;;:Tno statistical particulars

\

c

M

1) \ 1 i; ( »! niK I H

I M.iiithi

MEDICAL CERTIFICATE OF DEATH _^_

^''V.W ,.j,^^y^ (vear)
(Month)

t„ O^t w.

\<.i.:

'>^lN" I I- M \KK 11. 1>
\vn>n\VKl> OK invoK* M>

(Stati ' n ' ' 'I' '>* ' "*

l>:iv

M,,>llll

\'. ;i!

/>-/

IQO

that I last saw h - alive oti
.n.Uhataoatlw>ccurrea,n„ the aaU..tatea above, at

M. TlKCArSlCC)FI)KATIl was as follows:

X^

Vj.U^'

'V

,u<.

\

J AT 111. R

HlRTinM.AiK
»>!■ I MHHH
■^tatt 'ir Counti v

M MDl'.N NAMK
<)1- M()T1U:R

lUR'l'liri.ACK
(»1 MOTHHH
(State or 0<HJ»ilryl

OCCI'I'A riON '\

jjL^

\JLXXhj

1

\^0.^\xhX)

I }):nrs ^^ Months

DlRATloN

!.4.-

Days Hours

U^lxxXu^

HrRATiON
(SIGNED)

Years

Afonihs

'^

w<XX^>xX>w

3Jb

i ^

I

Rr,idn! n, Sun /mm', /--"^

V,("

M,<>ith>

lhi\

HHST Ol' MV KNOWl.hD* 4-

(Infortnatit

Former or
Usual Residence

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

7r.ACKOKBrRIAI,nRRHM<.VA..

How long at
Place of Death?

Days

DAX'l-. of 1M HIAI. or RHMOVAI,

f Address

^10

Address '^ *- »■ ^

c^

m.ll ^ i^ (Address. »^XH QA^^^-

J aIa^-^^A^^ - ^ ^ . .FXACTLY. PHYSICIANS should

— r.H erefully supplied. AGE should ^e stated EXACT .^^ .^formation" for p-r-

rmatlon should be '^b''*'"''^ «"^'; ^^ properly classified. The
5EATH In plain term«, that, t may ^^^^

sons dying aw»y

I )

! •

* ^ i

* I

I ,'

•in

? '

«♦

WRITE PLAINLY WITH UNFADING INK-THIS IS A PERMANENT RECORD

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

)!,,:;r.l of n.;!lth 1

2363

,>alr Filcl, 0.d>U. It 100^ Registered Xo.

IfrvcL^ U -, Deputy Hcallh Q(Ti.cer

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

Ccvtificate of 2)eatb

( XX. S. StanDarD )

J? (^ J Q!?> . •

PLACE OF DEATH:-County of Oc^^ ^^CO.a^C..- Gty of Oom. ^S/m^wc^-A^

rrN

-H

No.

and

?

(

IF DEATH OCCURS AWAY f
IF DEATH OCCURRED I

St.; -^ Dist.;bet. '- v

)

UNDER "special INFORMATION" \

\

FULL NAME

UOJLL

■^xxj'yy^

k^K.

<X^~> \XX-N.

n

PERSONAL AND STATISTICAL PARTICULARS

C\

SKX

DAl'l'. <>l- I'.IK I'll

A(.K

CDI.oK

\\jji

/Ut

M.iiith*

Dav!

Mnll/fl-

V<;)i

/hi

MEDICAL CERTIFICATE OF DEATH

DATK «»1 DlvVni ,, ,

it

(Day)

/<?n M

(V(;ar)

SIN'. 1.1* MAHKIl'.n

\\\\u i\\ i: i> < »K i)';Vi iKi »:i>

. Wi it( in -<K-ial dt >iL'iu;ti' 'ii)

BIRTH PI.ACR

(Stiitf or t'oiuit r V

aAXOL<l

I HliklCHV CliRTIl'V, That I attended deceased from

0„^ ,U^ XI igo 'i to M'Cti 1.5: 190 H

tliat I lastsawh^ .. alive on U tX ^H 190 A

and that <Uath occurred, on the date stated above, at b
LL M. The CAT'J^P: Ol' I)1:ATII was^as follows:

>

aJL\hwL<x^

(JVDX<a-

N'AMI-, «>l

iATm:R

niR'nn'i.ACK,
oi' iArHi':K

I Stat' oi (."ounti y I

MMDJ'.N NAM1-;
ol- Morm-.R

Hi H Till' LACK
ttl- MoTlIHR
(SluU- or CoiuUry)

^IX

\^

.CA^TrxXJ^V o^ J^J^<X. >-.. O

i .»

nrkATioN

CONTRIIU'TORV

}'iars Montlu,

T\..^fYS^'^

Days Hours

\ \

XK. v.\.a.A.

X V -,

j I

nccri'A rioN

Rf'^idrJ in Siiii i'l <iin i>i<>

) I'll I

.\f,,uth'

I hi

TllF MU)VKSTATKI»PKK^<»VX1. I'AKTU-ri.ARS XRHTKlKTo TIIK
IJ1-:ST OF MY KNoWl.llx.J-: AND lU-.lJl-.l'

(Ad.h.ss O H H J AAj\^

^-NX.'CX*^

DURATION 9y Years .yo>i//is

(SIGNED) \Il\ '^^ ^^ , ■

/hi VS

Hours
M.D.

\Ull

icp H fAddre-;s) 5H(:^ JaaA.^ uA.

Special information only for Hospitals, institutions, Transients,
or Recent Residents, and persons dying a»ay from Ijome.

Former or
Usual Residence

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

HoH lonq at
Place of Death?

Days

PI \CF OI' IHKIAI, OR R1-:M«»VAI,

rsni'.RTAKKR

!»\ll, of ItrNiAi, or RKMOVAI,

(Ad

-CAO/^

^-C

sH.. X\H. E<Lct

.. ■ 7^ -u„,.iH he Rtnted EXACTLY. PHYSICIANS should
N. B._Hvery Item o? Information should be cnretully suppi.ed. ^^J;^*;^^^^^^^^ ^he -Special Information- for psr-

state CAUSE OF DEATH in plnin terms, that .t may be properly class.tiea.
sons dylnft away from home should be 4ivcn in every instance.

< m

-. ....» Tum IS A PERMANENT RECORD
WRITE PLAINLY WITH UNFADING INK-THIS IS A PERM

Xi.u.'^i- <■

190 ^i

2364

n#»nti*"'^

1

t t

t i i I

DEPARTMENT OF PUBLIC HEALTH-City and Connty of San Francisco

Certificate ot Sieatb

PLACE OF DEATH: — County of^OuVu vJ AAX/ v.

No,

\).V^^H^^'^

St • — Dist.; bet.

-)

I10>'^■^^ ' ,i.»3l*» " '^ ^^=.iwnrB"sPECiALiN formation"^

\\ IF Dt(

-4"o^.'!„r;,-°" o"/r.t ^^^-^f^^^o-^'-v-r-s .... ,~s.». . s....

p

FULL NAME

i t

-1 \

PERSONAL AND STATISTICAL PARTICULARS

i.«)l,t»K ■

*

i

It \ ri-.

«i! 1

_ 1 1
.IK in

I

\

>x^

\t.H

)V

5.

• lf;c

M •>!!li

\x

Year I

/'..'

MEDICAL CERTIFICATE OF DEATH

DA TK Ol' ni';ATH IM I

(Mouth)

Day)

(Year)

I |1I'K|-|!V CI-.KTII-V, TliMt I attcM.cW cleccascl from

•-IN* .1 J- M \\<\< 111*

\V!D< »\vi;d <»k i»- ' ''■^' '■ '•

it : I . 11 )

Wnt- in -

lUHl'lll'I. \*"J-.

N \\n- «»i
I AT in: K

HIKTMIM.AOK

(»i lA'rm-.K

I stall ui Cuiuitl N

maidi:n NAM1-:

«»|. MtiTHKK

luR'ruri.ACK

(Stati or Country

( nHirATlON

n.o-k^oJ-H

^^... ^^fi- to w^ .-^ -90^

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

a„a that <U-atli occttrre.l, on the .late stated above, at

UL M. The CAISK OF DK ATI! was as follows

r\yxxjx^ y^^'^^^^

nr RAT ION

(SIGNED) OX^ ^•

//ours

Pavs

AJ

^

iy'~i

^'^

//ours
M.D.

A.hlresi) 9.50^^^ i^HA^^^^..■ '

QPFCIAL INFORMATION onlv tor Hospitals, Institutions. Transients,
or Refe^ Residents, and persons dying away from home.

1 A, ;////'

/),/!

^^^iii^^^iw^^ '■" ■"'"■^

Former or
Usual Residence

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

How lonq at
Place of Death ?

Days

U.ltcss X^b'i 0^^^^'

^a.^vxL Bl

HI.ACK OF BfRIAI. OK KHM<>VAI,
rNDKRTAKKR ' ^

D\LM'o! HiKIAI, or K1-:M<)VA1,

T90H

<x^

,,,„„.. ib-i^- i^^

'^''"'^ '^ ^ "• , . . PHV8ICIAN8 should

,tate CAUSE OF DEATH .n ^ "'" J*^ ^^^„ ,„ ,very in.tance.

•on. dying away from home should be fe.ve ^^^

),

•4

RITE PLAINLY WITH UNFADING INK

THIS IS A PERMANENT RECORD

REreH TO »ACK OF cenTincATr roR instructions

l)alr Filcil. ^ct(rl^X^'

IV OH.

Reg i. sic red JVo.

2365

1 *

DEPARTMENT OF PUBLIC HEALTH-City and County of San Francisco

dcitificate of ©eatb

( tl. 5. StanDarJ? )

Q^^

J (3n

' !i!l^

PLACE OF DEATH: — County of

(XAX- ' XOAvCUtCoCity ot ^'^^^"^ "-

(^

fN

o»

St.; Dist.; bet- -^^v „^„„ 'specl ,Nrop».T.c,N- •)

,„ OSU.L RESIDENCE o..r;.CTS c.c^.o ;- ^7/|, 3„„, „„ NUMBER. ;

r

)

V IF DEATH OCCURRED IN A HOSPIT.L

.»

FULL NAME

PERSONAL AND STATISTICAL PARTICULARS

-I \

C()l,( »K

:, \ 1 i- .)!■ lUK ru

\(^K

n

, M..nth '

^!V»-. 1 !■ MAKKII-.n
WIDOW l-l> OK I>lVt»Ki"l-.n
W-it. in -Kial lU-is.' iiat i- >n )

lUKTiU'I. \i"i-:

M,)i'li

Vt art

Pas

' MEDICAL CERTIFICATE OF DEATH

DMH «)»• DKATH n . i

k.::^^ j^^ "^^'^

I in-RFBV C1.:RTIFV, That I attended deccasea from

to C)/€fc i.H 190 H

^ -< 19O * to

-t. ; '\ TOO ' •

that I last saw h alivc^ on - --

„,1 that death occurred, on the date stated above, at '■
M. The CMS^C OF 1)1- ATH was as follows:

lA rm-.K

T'.iK'nn'i,\i'K
Of. t Aiin-K

iStalc (ir *."inuit ! V

MAIDI-.N N\M1
01 MitTin-.K /

CONTRIBUTORY U^^^ K. .. a ••

Hours.

Years

Mouths

Pars

KxxXj

\ju

Hours
M.D.

iuR'rnri,ACH
01 M(»rin-*,K

; Sti'li' I't I'liiinti \

3x^L

(X^'wcL

Ur RATION
(SIGNED)

(0 +

■ SPECIAL INFORMATION only l.rH«p,lals, lnsll.i.t,.rs, Transients,

orlefe^ Ments. and persons dyin^ a.a, Iron, home.

CAo A.

^^.

«>rci r\T!i)N ^^

) - I."

/.',,' 1

HKSr OF N)^ KNi»\\ 1.1-.1><'I'- AM'

(Infoitiintit

IJ^./>^AA^

AtjL^

Aj^rO,/

Former or
Usual Residence

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

How lonq at
Place of Death?

Days

■Ia

S.li,re.s .5.X%0 dXa^

mACKOF m-KlAI^ <»K KHMOVAI.

1)\T1'. I)!' ncKlAi- or RKMOVAl,

U.ct' ■ T96H

"^ 1 - PHYSICIANS should

- i.„...i„„ .H^-^ ^";=- -^-; .e;:x^.:r'Ti:: .•«...,.. .n....... w ...

F OF DEATH in plain terms that jt n,. > 5„«t««ce.

'■ '■ SSJ^r -^t^j: :z;.;^;;"^:^-" --^ ---

»

I I

' !

^ '

WRITE PLAINLY WITH UNFADING INK

■ ! Ill .iU»i

^•o,l.*?S?*»-^''

ixih- Fih''l,^.zhr(>i^ n

190 "i

THIS IS A PERMANENT RECORD

p,.„ TO ....KOrCERT.riCATrrORINSTRUCTIONa

Ueoistercd ^'o. 2366

-*_

1 ^^ Deputy Health Officer ^ _^ .

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco

Ccvtificate ot Bcatb

I ■a. 3. StanJar? )

J? (^

PL ACE OF DEATH :— County of ^ ^-v^

City ofO<x/>v a,V<x/rvc..

« r I \ St • "^ DlSt.; DCT. -"^--^ ^^o 'QPFCIAL INFORMATION- \

V ir O^TH OCCURRtD IN A HOSPITAL O • ,^

FULL NAME

vxLmjkxa-^

ti

;^

PERSO

NAL AND STATISTICAL PARTICULARS

six

^

(.oI.oR \

i)\ri. t)i lUK in ri I

M'lnthi

\<.K

I

);;n

lo

15"

i l)avi

1 /,.»/'//'

,^0?^

MCDI

DA TK i>l" I>5"-^'1"'^

CAL CERTIFICATE OF DEATH

r\

1 Day)

IQO

(W-ai)

(Vfar!

I HEHHBV CKRTIFV. That notenad dccoasea fn.n

to A!^ i^ ^')°^

K;'')

li)cfc

! (,

at

that 1 last saw h ... alive n„

,„Hl,at.U-ath.>ccurrea. on the date statca above.

M. TheCAlSH C)l^ DKATH was as follows

up

HiNr.i.l-- M XKKIll'
\V!D«>^\ »• 1> «»1< DlVoKi KD

{

I Statt 111 v'liunti V

N'AMl- <»1
FA 111 J.K

BTRTmM,\tK
oi 1 Afin-.K

i>t,iti 111 I'lnuitrv

MAUn-'.N N\MH
>i MOTIIHK

HIR riuM.Aii-:
(>i- M(»Tni':K

(Siati III I'lmntry'

0 Qsp

i \

ni RATION
CoNTRinrTORV

MoH//is ' : />iO'^ ^^''"*''

^;-\Ja„0.

)ra>^ k» .1A'»/^>>1

occri'A TION

AV' - nfr,f in S'- ' " !'> .t r, ,^.<> ^ _,

^^^^ \iit''l'UlV I'' III''

Former or
Usual Residence

When was disease contrarted,
If not at pla( e ot death?

How lonq at
Place of Death ?

Days

•I „„(„„„:,„. h-^-^ ^

,.,....AKKK JcAXxK^^ ^^^^

I, mi:,,! llruiAl. ..r KI-MllVAI.

(Vl.lr.^s b^l '^-^^^-^'^-M - . .FXACTLY. PHYSICIANS .hould

. 'r , .„„, .„ppn.d. AGB -hould Oo »'-":; ■';''.?=;,.„, ,„Wm».lon" lor p.r-

i

WRITE

PLAINLY WITH UNFADING INK

THIS IS A PERMANENT RECORD

,,P.B TO o..xo.CeRT.nCATE.OR.NSTRUCT.ONS

236?

V

Huh' Fiii'^f^ li'cbrWv. n

It) OH

J^p^istercd JS'^o-

\ 4 1 .V4i DeDUtv Health Officer

DEPOTtIf PUBLIC HEAlJIWity and C,«nty «f San Francsco

i (

Certificate of Beatb

/ 71 ^^. i5tan^av^ )

ri ^1, 5ta^^av^

PLACE OF DEATH:-Co.ntv of a.X ^^

No.

o

^\1 <ccUv^ru

};

)X<x>

Sf cl Dist.;bet.

„TITUT10N GIVE ITS " ** '^1,^ -v

FULL NAME Kn>xCL4

and

<;♦ • ci». Dist.; bet. '''^^ ^ripciAL information- \

^ . . V . ^^ . ~ l^fxr rix/F FACTS CALLED FOR UNDER ^ffEC A gtR. /

X^ V^w S-^ I ^- "^ ' ~ .-...Ai nF«SIDENCE GIVE Fa<-i3 ^, . ^- p iwcTEAD OF STREET Anu

-^I^^^ZZn:^^^^^^^^^^'^ PARTICULARS

1) \ l■l■

\' .1

Vi I ' ii i\\ 1 1 ' ' '^^ ' '

W • ' t '

it!K rm'i, \*'i-;

st;il. k: I'.iUiUi N

1 90 \

(Yt:ii

MEDICAL CERTIFICATE OF DEATH

„,„ n„.l .;uv 1. X-V ;a.ve on ^ -^

„„,„.„ ,U..U ourrea. o,, the. ...U. SUU.,. .....v., ^.t

M. tlu. CA-SK Ol ,M.:ATn«n<.sfon„„.s:

N\M1 <>

1 A 111 i:k

r, 1 u r 1 1 r 1 , \ > * 5-"
nr I xriiKH
' stati in Cmuiti

(»1 MoTIll-.K

lURl'Ul't.ACl-.

(il. MtiTlll-'K

. • ' ", ,.\ururi \RsAKl. I HI I.

THU XIU.VK ST xTKI.rHR:^»N,'^l^^ ,;,,., KH

CoNTUHn ToHV

)V,7/^ JL. Mont In

-^

/).n.Y

J Jours

niRATIoN

) V</r.s"

Afonths

//(>iirs
(SIGNED ) V>^^CfV. 4 .
— . "":^«*i,iiTinN only lor Hospitals, Institutions,

Transients,

^CA>

lnf.,im;ml I I V V

LUAAT

formfr or
Usual Residence

When \^as disease contracted.
If not at place ot death !^

HoH lonq at
Place of Death ?

Days

.\M-

M. B.-

1

WRITE

PLAINLY WITH UNFADING INK

THIS IS A PERMANENT RECORD

BEPER TO ^..K n. CERTinCATe .OR .NSTR0CTION3.

77n 23G8

luilv l-il('<f ' ^^

l^

DEPARTNENT OF PUBLIC HEALTlWity and County «f San Francisco

^4'"

\

Ccvtificate ol Bcatb

i ^

0 ar<\j ^ \amxA <. - ' City of

o <

PLACE OF DEATH :- County of- a>v ^ ^ ^^)

(^ ir DE»TM OCCUHRED IN « HO» ,, , ^J

FULL NAME

v,'

XA^

Tl^I^l^Iin^^^^^^^^^^^^ PARTICULARS

JuX^t.

WEDICAL CERTIFICATE OF DEATH

/

IL,

I, \ 1 1 ( il UIK lii

\i. j:

'*-4

1 1.1

/',

\ , .: I

-.IN., 1.1- MAKKn-^» .,,

C^

\Ji,

luH riu'i, \oi'

-,1 iti or t'.iunti \

N \ M 1 < »!•
1- A I Hi: K

lUKTinM.Ai'K

(.1 rxriH'.K
-,t:iti <>t r.'\nit ; V

M MDl'.N N XMl
,.i MoTHHR

lUU'l'nri.Ai'V.

,t,ttt or v'lxniti N

'\

TQO ,
,l.:,vi I War)

,,,,,,, Vci^RTirV.T.at I aU.n.W...U.,va..4r,.,.„,

■ . , up

• 190 . to ^

U.it I last ..w 1. ^'""■"" ' ' , , , -

,„„Ul,al.K:.llw«H>,m-a, ....tlu d

-' t /

r^

(\

^ w^

Co.NTUllUToKV

DTK ATION
(SIGNED^

/^av.

Hours

M.D.

thka,u>vkstai;i^i;i;^k:^>nai^i^xh«;^^„;^

(Infoiiu.'int X^ *

Former or

Usual Residence

When was disease fontracted,

If not at place ofdeath^'

Tl^ACl^OF lUKlAlV^'^ KKMOVAI

A >

How lonq at
Place of Death?

Days

,vr,-.,! n< KIAI. nr KKMOVAI.

I

N. B.-

W^ L<r\7-^-0^'^^'^'^ " ' 7 1 FXACTLY. PHYSICIANS should

, —- ,„„, .applied. AGE .l.o,.ld "• •«''"4^'=f *s%„„ ,„J„rn.Btlon" «or p.r-

E OF DEATH in P'"J". "•"'•*„ ,„ .v.ry ln..."«-

-Every Item ^. ^^ DEATH in pini" """'• •■■";_" '.v.ry In.tanc.
:l:*;dy?n. aw-y from horn, -hnuU. he »

'1

,1

I

]

,L

':' t

}

11^

\ 1
1

■

1

\ ,

1 ■

1 J

'■ ■

; ' i

m

I '

:li

■fii

I ft

^p.^e PLAINLY W.TH UNFADING INK

loo'i

THIS IS A PERMANENT RECORD

p..en --^■^■^^^^C^.^T.nCATrron INSTRUCTIONS

*>-^69

DEPARTMNT OF PIBLIC HEMJH:«y and County of San Francisco

Ccvtiticatc ot 2)catb

PLACE OF DEATH: --County of ^^ ^ | ]\\ J | ,x,

No.

AcCrAJj

St. S Dist.;bet ^^^^^^c

OU, » cV.iirn rOR UNDER SPEC

SPECIAL INFORMATION- ^

('^

^"^ M USU.L ReS.DCNCE O.VE FACTS CA.LEO -;^--; 3T;EeV;ND NUMBER.

OEATH OCCURS AWAV FROM USU^L ^^ ,^^^,^,,,^^ o.VE ITS NAM

,F DEATH OCCURRtD IN A H . 1

FULL NAME

/VX'YV LCWXH-^

■71^^^^:^:^^:^'^^^^^^^^^' particulars

-1 \ ~^

',V

f<

nx I K <>i HiH in

RTIFICATE OF DEATH

vUa

r%\^

\\

\< .1

^S

i/.i/'^n

Vi ai

/ ».M

„..,...,. o.vn. ^1^

' M..ntb

lb

(Day

iVi-arl

,. ,-,PTn--V That I attcuU-.l aoca.ol Inm.

WIIM .\\ Kl» "H It ^ ". '

lUK rin'i. MM-

NAM) <>'.■
1- \ I 11 ).H

I'.IR riM't.XiV'.

(»r 1 \rHJ-.K

MMKl-.N NAMJ"

lUUlinM.M'l'.
nl- M»t'nn-,H
I Slate lit roiuiti V

orri I'A'riuN

C\

^L'-uJUaat

^M, ■nuC.ysKn.M.Kvr.p.sfon,...

■ vc^-o-'^^

A

0

DIKATION
CON

)'iar,

ATION >'-^ •

//('/^

;'.s"

Months

Pavs

/Y\J

CX^-v^A.

IflJt/ff/.S ' "-• ■

DIRATION

:Lh-- — -^ ^r,»iiATinN onh tor Hospitdl

Rr^idn! nl Son I':

Moulin

/'.M

Ho\^ lonq at

Transients,

Oa>s

ly^ (I 190H

;r^^\,^J^

AM-

\<l«lrr

N. B.-

iq d ^l.<rtl) ^^ i ' r^v4CTLY. PHYSICIANS Hhould

. ,., ' :." . AGB should be «t"'^iJ^ .rj' ' i^, information" ?or pT-

E OF DEATH in p'b " ''r^'en in every Inst.nce.

Hon* dyinft away

fii

'1

U

) I

^^^^^^ THIS IS A PERMANENT RECORD

..... .o ..CK OP CEB— -O" .NSTRUCTIONS

7fyr>H

Registered JV^'o.

/^■wO • '

■? i 0 Deputy Health Officer .

DEPMN^ PUBLIC BEALMy and County of San Francsco

Ccrtiticatc of ©eatb

"VX'

»

No.

^. 1. . 1 i VGA A%VXX and vAl i\a.v. .. .

i » Sf DisUbct. ^ -^^-; : ,,, ,N,oRM*T.oN'\

/ IF DEATH oceans AW HOSPITAL OR INSTlTUTIU

t ,F DEATH OOCURRED IN A M , ^ .,X

PLACE OF DEATH:-County of "a

FULL NAME

COI.oli

sKX

V

au

^w^

DxlK «>I' r.lK I'H

I'

W^ >
untU

/ ^

\| .!■■.

\ I

I n:tvt

\!..iith^

iWiit. in -.H-iai .UM^natK.n)

HIK rmM.AOT"

iSlaU- iir (-'"HI 111 I y

N'wn: 111

1 A rii i.K

lUK iHri.ArH

oj- I ArilHK

I statt or rmmt rv

M\1I»1:N NAN'l'-
ol' MOTHKK

niK'niiM.ACi':

(Slate or Oounlryi

OCCl TA TION

^

1

(^ KjY^

A \ \

Vral

/)./

MEDICAL CERTIFICATE OF DEATH

DATH «>H DHATH ;\ ^ i

^ ^ (Day)

190 '^ t'^

that I last saw h ... ^>live on '^^

1 „„ ftieilatt- stall ■! aliove, al • -^

M, Tlu- CMS..; t>.--l"-Vn«- as follows.

L .'-. I -

M

DIKATION

)V</;'-?

Months

Pays

I lout.

,-,,,,, J/<,;////5 5" Pays Hours

(SIGNED) ^-^^ ,^^ .^

^ ^ • '''^ ^».u. ATIQN only tor Hospitals. Institutions, Transients.

, How lonq at

Former or \\\ ^^yy^j^^M, P'«^^ "' '^'*'' '

Usual Residence U^ -^ ^ > ^^ \

Days

AV.wV/^r/ /» >•'>" /'"'""•":

)■/■(?)

Month ^

I hi

.„. (^OW."^ Vi-o.-

WL I'v S ci«.^

.?JU

„,Vri.-,..! Ili«.AI. •>' Kl'.MOVAl.

190

N. B.-

f V l.lrrss I ^^ <Lu./^^^^^<^^ --" J. . ^FVACTLY. PHYSICIANS should

(Addn-ss -^ ^^ . 1 1 k* stated BXAwi»-»' • ,, a nmv

— ^ Sullv HuppHed. AGE should »f «»«*%he "Special Informat.on for pr

sons dying owHy

\"

.r-

' 1 1

!;li!

THIS IS A PERMANENT RECORD

Wp.TE PUA.NUV W.TH UNPAD.NG '^'^-""' . ... .....uo.,0^

,— -^. i^Op-H4

j^eo'isfci-cfl ^"^"f^-

/,,,/, /•7/r'/A'.ci>Wv n

DEPOTNtI mUC HEALlwiy and County of San Francisco

Ccvtiticatc oi tDcatb

PLACE OF DEATH: -County of

^

^

X\. '3. *3tan^av^

J (^

City ofaay>^ J^*^^ ■

V'

^

No.

and '

Cf DlSt.;bet. ..^,n^R 'special information • \

'-'^•^ . rurTS CALLED FOB UNDER ^ ^^ NUMBER. /

' „,,„„ ..., r»o» U.UAt „"„^T-f,?„^ o^^o,;.".;! NAM. ..s.c.o or s...^ •

FULL NAME ^ ' ^^ -

)

^' \'^

>^,\

\

-^

V ;;;;7^;^irirRTiFicATE of death

ct

(M.nUhi

' DaV

(V.ai >

1> \ \' 1 ' "I Ui K i 11

1

Ml, mil'

\' ,»'//

/»<

• > I . . . . ! 1 1 ! ! • 1 1

— 190 -— '

,i,.,t llasl^awh ^ alive HI,

',„„...,. u..,,..,.t.u.a„u.. ,.i-..v.-,-

.5

V \ Ml < t1

I \ in 1 R

[\

01 I \ I'lil'.K

. >,t;,t,. or iNllUlf V

M \n»KN N\MK
,,1 MOTHl-.H

I'.IKl"mM,.\ri-.

<)i Morni'.K

I

1 *

^ i

n

CONTHIBITDRV

M0>t(/l!i

navi

J lour

nruATioN ^

?

Pav^

1 1 our ^
M.D.

(\

(SIGNED) ^^

\J(0^ Ik) 122J L -— 7T„, M„c„u.k Institute

pidf c ol Death ?

\ \

oicri'Xi

■'"^%

^C

Lc •

M.ni'lr

' 0

bdLMXxA.<

iHbV^' — — ! ' ■""" TrVACTLY. PHYSICIANS «houlcl

^^■''^"-^'^ (I ^ "T. . AGB should be •^V^'^iJl^^^^ciol InVormution" for p.r-

' ■ ^ . .„„,., b. carafuHy «uppl.ed. '^ ' , ,,«s«h".ed. The Spc..o

Hon* dylnft away •> ^__^

t.

i ■

11

i

I

i : 1 1 : i

J

WRITE PLAINLY WITH UNFADING INK

I'.oMiil ■■!" lU:iHli IN.

, ^^ ia!-?^UScVC<

1

^AJL\,5 LC\>M

IDOH

nw

THIS IS A PERMANENT RECORD

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

Be gi sic red ^'o. ^-O^^

DEPARTMENT OF PIBLIC HEALTH=City and County of San Francisco

Ccvtificate of S)eatb

( TX. 3. 5tnnC>arD )

City of ^-/O^v J./U CU-^A.^o4 0.0

PLACE OF DEATH:-County of X^^ ^^o^-CA^^ity

No. ^^i cMaA-^wC^^

St.; \ Dist.;bct.

and CLLu^

( ' r-.;: -cc:.%r;,"r„o".^r.t --f,?.^%r.',«"r.-.^«7 ,^^»o%* s?;i^-~o-.°::«'.- )

FULL NAME

Cm^

^J.N.

PERSONAL AND STATISTICAL PARTICULARS

cm.oK

i;. iiih

\X

ar)

A«'.l-

>-.IV«. 1.1'. MARKIH!)

\\ II)t>U J 1' «>K DIVtiRt 1 I>

W : It. it) -...-ia! (U-iLfiiat n m »

r.iu rill'!, \i*i".

. «^t,it, 111 1 '. ill III 1 \

10 )v,f<> O

XS

(Yt-ar)

MEDICAL CERTIFICATE OF DEATH

DATK Ol- Dl-.ATH . ^

1 1II';R1:BV CI:RTII-V, That I attcn.UMl dcHia-^tMl from

that I last s.tw h alive on ^ '^P

an.l that tUath nccurred, nn tlu- .laic ^^tatcl above, at
M. The CAl SI-: Ol* Dl. ATH was as follows:

N \Ml' 01

1 A in 1. R

HI K 11 11' LACK
Ol- 1 Allll-.R
(Slat. < 1! Country

MAini'.N NAMi:
(»1- MuTHKK

1

\

' J ^<A/>^^ ci^-cn-Ub LL

> VOLi^'VWOCX

7

i

I )r RAT ION )>«'•?

CONTR nU TORY

Months

Days

J Jo lit

<=>^

i ■

i

nr RAT ION

(SIGNED)

J/()>////S

Davs

Vears

HiK rnri-ACK

(»1 MnriU'^K
i Slatr i>f CouiiliA

OS. cri' \ri(>:

I

KfsiiU-<J in San /i,i>!,;'r.> \ j )>i^.'-

SPECIAL INFORMATION «nly 'or Hospitals, InsUtutloWsHranslents,

or Recent Residents, and persons d>in;) md) Um\ home.

}/n,-Ol.

THKA,u>vKsTxrr:n,M.K.oSAi^AUT,rr.AK. xkhtkih n. nu,

(Infonnatit

Formfr or
Usual Residence

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

Hew lonq at
Place of Death ?

Days

I'l.At"!' Ol' m KlAl, OK K!:M«'\A1,

oatj. (it Hi KiAi. or ki;m»)\ai.

«

\

» ^"7 13 AGR should be stated KXACTLY. PHYSICIANS should

N. B.— Every Item of Information .hould he caruVulUv -PP - " ^^^'J^;; classified. The •'Special Information" for p.r-

state CAUSE OF DEATH in ph.in terms, that ,t may be prope y

;*nl dying away from home should be ^Iven in «very instance.

i

II

!l

WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD

i.Mi.i ..r n. ,Mh !

v., ;: t"> ^Ts;.^: H8:}' Co

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

0

ct^nMA; i

lOO'i

JRo^Lsfcj'ed J\^o,

2373

\XkM cUwVU

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco

Ccvtificatc of H)catb

( TH. S. StanDarD )

m

PLACE OF DEATH: — County oldcxjy\j OXavvA:

City of ^■' CL/'W J A.Ct>xCov

y

^No. H> XtwI^Jji yWCh^V-^ - St.; - Dist.;bet, and

/ IF DEATH OCCURS J»W*V FROM USUAL RESIDENCE GIVE FACTS CALLED FOR UNDER "SPECIAL INFORMATION' \
\ IF DCATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. /

FULL NAME J ^tci. 1

t I

■- 1- \

PERSONAL AND STATISTICAL PARTICULARS

I COI.OR

Mf

1

) A ri; I ii iiiK 111

A<,i.;

rt

'M..iithl

1

Dav>

Q

}■

.)',,,/'/!

\ tat I

/hn

SINC, I,!' M \RR III)

wri>nui:i> OR i>:\ 1 »ki'i;i>

(Writ I- in '•inial di --ii' nat i<in)

0
\

BIRTIUM, \oi-;

'Stat' I IT I • iiiiit I \

N \M1-: ni

lA 111 i;r

d<XAX'

MEDICAL CERTIFICATE OF DEATH

DATl-; ol- DICATH

n

A

(MoiitlO

(Yi-ar^

.I)ay>
I ni;ki:r,V C1:RTII'V, That r atU-n.U-.l .Unxascd from

'' 190 to ■■■■ l90~~~

that I hist saw h ~ alive on — 190 — —

and that tlcath nccurre«l, <>!i the «hitc stated above, at
^^ M. The CArSh; OF l)i;.\TII was as follows:

dL<Mr'<^U-L

rtU

I i

lUK riiri. \i \i

<)l" 1 AT 1 11: K
(Statf »»r <'i>uMt ! %■

MAIIU-'.N NAM1-,
01 MoTIIKK

lUR rniM.AOH

( state I It t.'<aiiit 1 \

A\AX\J. oU' LC

(

• K *.

'ri'ATh)N 'op

k \

h'rsiiiril ni Sun f't inn t^i ><

/',n

Dl kXrinN )'tii/s

coNTkinrToRV

J/<>)////S

Pa \$

Hou)

nr RATION

)\ays

Months

A' \

/hlVX

( SIGNED iLCr'Unn^V J,\.B, LL

WCAj i'l iqoH (Ad.lress) L&V^nAX^ ^

//oufs
M.D.

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

Former or ( lu t^J' • How long at ^

Usual Residence b I A 0 0X4_^ r »\ pfare of Death? 1 1

Days

Tin*. AHOVK STA ri:D pkrsovai, rARiini, \rs ari; trii-: to thi-;
HKsr oi- MY KN<)\vi,i;i)<".K AND rii:i,n;i

'liif'itinrmt

X.lilnss 0

CXA/VW^w^^.

tl-

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

I.ACH <»H lUKIAI. OR RI:M»»\AI,

1 ,

ni)i;ktaki:k w . «^- V

DA'p: ut Hi KiAl, fjr K1.:Mo\a1,
^^ I90I

N. B. Bvery Item of inf >rin!ition should bj ciiret'ully Kupplieii. AGE should be fittited liXACTLY. PHYSICIANS should

«totc CAUSE OF DKATH in pinin terms, thnt it mny be properly classified. The "Special Information" for pur-
sons dyin^ oway from hoitia should be i^iven In every instance.

i.

: 1

1 .

'< I

I

• U n

p:

iA

li

WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD

I!,,m;,! of llcaUli !•■ N'c 1 ■; "fr^^^^^^ IKS:!' f

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

I)

((fe Filvd, y.ctvipt;

K n

ldO\

Be^j\sfcrcd Jfo,

O

374

D

^M^OO <J^ C \\

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco

Ccvtiticate of 2)eatb

( Ta. S. StanDarD )

J? QS?i ^ ^

PLACE OF DEATH: — County o{ ^^ <X/y\> ^ T\.xx.^Y\Ai\^^,j:^{\y of ^J/<X/yv JA.o >

pop % ^
^No. Lctu, V.LmjL''^y^Xu, uID(v<Ii ,.vJ a.i St; Dist*;bct.

-and

/ IF Dt«TH OCCUHi AWAY FRO** 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

^

I

1

a;

si;\

PERSONAL AND STATISTICAL PARTICULARS

I COMJR

I

I

DA 11. «tl lUKTU

Month

.\< .1-;

c^t) )V.,i

<I)av>

M.iiith

/ t i i.

(Vt-ar)

/'./ 1 .

H1N<,I,1 MARRIKH
\VII)«>\V1\H <»R I>I\t>Ki Hl>
iWiitfJn s<K'ial (lt'«i!s/nalinii)

BIRTHPI.AOK

(State or Oi)uiiti \

NAMK OI

I A rin.R

mK'i'iiiM.ArK

OI I APIIKK
(Stall or CtHintry

MMDl-.N ,VAM1<;
ni MuTiniK

fUK'rillM.AlF.
()l MOTIIKK
(Slatf or t"o\jntr\

'Month)

(Year

MEDICAL CERTIFICATE OF DEATH

DATl-; <>I- Dl". XI'II

:t II-

(Dav)

r^ I HIvRl'ir.V Cj; RTII-'V, That I attcinU-d deceased fxoiu

A^'vt? 15: 1901 to iL^tt: ife 190 M

that I last saw h'- alive on ^ ' I^ T90

and that death occurre*!, on the date stated above, at Ho 0
.' M. The CAl'SI*: OI" I)I;ATII was as follows:

:^^

"^

y.

\\]\xkKk/y\SL i jOxXr^y^.^o^'y-

Rfsitfrd in San I'latu ist'n

)'i'ij)x ^, Miiiifh<

iKn."

Tin-. AHOVK STATKU f'HRSONAI. I'AKTICr I,ARS ARK TRIK T<> THK
BUST OI- MY KN0WIJ:I)<*.K AND HKI.IHF

(I

Tifoiiuant "OX^ \jX/CxX1x)

(Address

hi

DTRATION )'ears Mouths Days

C ( ) N T R II ! r T ( ) R V Mj.J:y^f^-AS^\KM.^KA

Df RATION

Hours

(SIGNED). J

f^^ Years ^

SPECIAL INFORMATION only for Hyspitals, Institutions, Transients,
Of Recent Residents, and persons dyiny dway from home.

Former or

A

J/

How lonq at

Usual Residence HO 5^MUrUHX<UAKtu,.jlpiafe of Death?

When was disease contracted, ^

If not at place of death?

»ays

PUACK OI' niRIAI, OR RKMOVAI,

(Address .. ?)0 S^ yO^XrVX^fcoAA.

PATH of nt HiAL or RKMOVAI.

iD/ct \% 190':

Jsi^:^:^....

N. B.— Every Item of Information .hould be carefully .applied. AGE .hould b« .tated EXACTLY. PHYSICIANS •hould
•fte CAUSE OF DEATH In plain term., that It may be properly cl...lfled. The "Special Information- for p.r-
•on« dying away from horn* should be given in every instance.

',*i

4is|

I

'1

11

WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD

iT'i I- N<

luv !' r

REPER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

1 '

', )

f 4

790H

llegistcred jYo.

A.e^,.N Deputy Health Omcer

DEPARTMENT i)F PUBLIC HEALTH=City and County of San Francisco

Certificate of Beatb

^

PLACE OF DEATH: — County of C .CXa-v' J XCX^xcUccCity ofC^ <X'>^ Z KjOuyxMU:u<U>

P % P %f if

Dist.; bet.

and

\ ( ST DEATH OCCURS AwAY FROM Al S U A L R E S I D E N C E G I V E FACTS CALtED FOR UNDER SPECIAL INFORMATION" \
J V IF DEATH OCCURrtED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STRtET AND NUMBER. /

FULL NAME duUn^ \uAAX^M

PERSONAL AND STATISTICAL PARTICULARS

i)\ rr. (

l|\<xU ILkcti

>i liiKiii ^

At, I

51 s

1/

ai

/',/i.

-.|\t l.l- M \ i< H I1'.I»

U I l>« »\\ I I > < »K IM\i »K> ID

|\\'iili ill '•(H-ia; (1( vi^. nat 1" 111 i

\j

i^ .'k^cL^crvA^-i'^^

FA'l'IM.K

!!IK rill'I, \i'l-
ni- I- A 111 I'. I<

• ^tati ii! (.'iiiuil 1 \

0 Xcx^vcx

'

(ti M(»riii-;K ^ '

lUR'niiM, \«'i:

<»| MO'IIIIIR

I Slatr (It I'dinitl \

Rr uitil in Sen I i tl '

^. 1

r,w,

U,,,!f//s - /)./

111!- AUdVi-: sr\ rii> pi-rson m, i- xki'i*' i-ars ari-: rRri: nt tiik

Oil fi muaiit

ULcxo^J

f \rl.lM-.S

vCl

0^

via

MEDICAL CERTIFICATE OF DEATH

IiAll-. ul. ni'.ATH

llo

I):iv)

fMoiitli)

I m:Ri;!>V CIRTII'^V. That r alttii«UMl .UtxascMl fn.iu

C/Cfc k? lyoH tn (D/tt lb

that I last saw h Aav^ alivt'oii Vy/CXT lb

and tliat <Uath nfeurrcd, <>n the- date- ^tatoi] above, at 1 / 0
CL M^ The CAISI-: i)V l)i; Al II was as follows:

(Yt-ai I

TtpH

or RAT I ON }'r<i/s

CoNTRir.rToRV

I »r RATION — )'<r?2:.v

J/o>///is

Days

J/oiit s

'V

SIGNED) 0

M>'iths

l\

/I'V

M.D.

,1

fAaanss) Lctu fc<^V^ fe<K.AAr

1 ATI ON onlv fnr Hkpitdls, Inifitutions, Transients,

SPECIAL INFORMATI

or RfCfnt Residents, and persons d)inij dWdV from fiomf.

Former or u n a ( k /^ I T\f ""* ''""' «*

Isual Residence 1 A^ JUc^4^J )h

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

Plate of Death? 11 . Days

I'LACl't <)I- IHRIAI, OR RI.MOVAI,

1^ €5cv^

I NDl'.R r SKJ'R

IiAT^.i! m lUAi, or KHMoVAl,

ts „ —Bvery Item o? l„foim«tlon should b. c..«fully supplied. AGR .hould be «t„t.d KXACTLY PHYSICIANS should
.t«te cluSE OF DIIATH in pl„ln term., that It m»> be properly .l««»iflcd. The ''Special Information" for p.r-
son* dyinft away from home nhould be given in every Instance.

■> • •

' \

IH

I

• r

WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

376

1901

Ileglstcred JS^o,

O

Dale /v/fv^ IL ctcnU^^ 11

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco

<• »•

Cevtificatc of Beatb

{ "KX. S. StanDarD )

4

PLACE OF DEATH: — County ofO<Xnru 0 ^cu

City of

r\

<3?

IJI

l^

No '^01 U.. , St.; "^ Dist.;bet. JXLL' and

*^V» - "^ '^ " '- ,. iiciiai arCinrNCE GIVE FACTS CALLED FOR UNDER SPECIAL INFORMATION" \

FULL NAME

\\t-

^

PERSONAL AND STATISTICAL PARTICULARS

SKX ' \ !^ < C«iI,<)K \

I

\

I) A II', ol- ISIK III

\<.i-;

frvo

[Dav

M.tillis

(Year)

Ihi\.

->IN».1.I'. MAkUli:i»

u iix »\\ i:i) nk i)[ynRii';i>

Wiilt ill ^iK-ial ill -.i>.»^ti;ili<>n)

.oo\)\aj^6s^

luk riiiM, \cv.

' '^tati I ii " I itiiiti %'

NAM1-: TU-
FA 11 1 i:r

lilKI'III'LAiK

c>i- I- \ I'm.k

M \II»1*.N NAMI-:

III M(»rm:k

lUk iiiiM.ArH
III M(i'i'ni':k

(Stat, ii! riiillltl % i

IHHT I'ATION

I

Oa>v>

/O

O.i

jUxxaj

I

U jJ

w •

I

Kf iilfd III "^ i.'" / '

(///( / '/■(*

Yra,

M'lifli

hn

TUl' XHOVK STAri'.IJ l'KkSr)\-U, I' \ k TI»T I. \ H ■- AH I
IU%ST Ol- MV KNnWM-Jx". 1<; AND in-,I,Il-.l'

Tki }•; 1 ' I iH ••

rinfonnaiit J -^-M^^J. ' Ji-'V

r

a.i.ir.ss 5-cn uLUw/>

Wv u

(Day) (Year)

MEDICAL CERTIFICATE OF DEATH

(Month)
I III':R1:BV CICRTII-V, That I attcn<lc<l dcicasLMl from

... J ,90 to i9<:A. 190H

that I last saw h ^" alivton WC v i I90 .

and that death occurred, on the date stated above, at o
M. The CAT SI-: 01' Dl'ATII \v:is as follows:

DlkATION I )V'<?r.v IL Monlfis •' /></)'V //ours

CONTRUHTOKV

u

DT RATION i Vrar

I r.

(SIGNED)

'\Hrw

1(^1

J/of/t//s *^ /?r7V? • //oiir^

M.D.

/aA,hjJjLi kit

(A.ldress) Ta6 U vJ

Special information ©nly '"^ Hospitals, institutions. Transients,
or Recent Residents, and persons dying away from home.

Former or
I'sual Residence

Wtien was disease contracted,
II not at place of deatli ?

How lonq at
Place of Death ?

Days

nAi'ivu! Ill MiAi, III ki;M(»vAi,

1 90 ;

I'l MV ni in RIAL <»R RKMoVAI.

rNDHkTAKKk 0 .4\JL'^<L^ "V^^ .

n\_

^ ., , Kr%^ «Hr.,.l(l he Htnteii I.XACTLY, PHYSICIANS should

M. B.— Every Item n? Information .hould h. cnr«»'ully supplied. '^^J:;^^7/''^^^.;*^''^he .•Special Information- for pr-
•tate CAU8IZ OF DEATH in pli.in termn, that it m.iy He properly JpsmtieU. I He «pec »
HOfi* dying away from home hHouIcI he given in ev«ry Iniitance.

iai*

WRITE PLAINLY WITH UNFADING INK —

I'

I • 1!. alltl

^l

I •

t

' t
I

i

4 ^^v^u.

n)OH

THIS IS A PERMANENT RECORD

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco

Ccvtiticate of Beatb

^

, >

PLACE OF DEATH: — County of^a^' J \a->xCC<KX) City of CVo^OO; OA^^C^u^eo
We. '^JlX">^VOL'>^ XC^^rwtal St.;- Dist.; bet. and — —

r - °^-« occurs Aw.ir TBOM USUAL RESIDENCE give .acts calued '^ "^o" str e E^^irJ H^MBciT"

t IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION ^'VE ITS NAME INSTEAD OF STREET AND NUMBER.

FULL NAME

.. .Ct V<

»VCXav>v

-i \

1 1 \ 1 i 111 ii: K i

PERSONAL AND STATISTICAL PARTICULARS

% It i! < >k

<Xl

^

\

IvcLi

/ bii

Mont

\<.»-:

I

II

1/

> I ai

/>.

\\': 111 )\\i t > < »i< I '

W; it f' in » ii'ial ' \

OJxK^J^

■-.; it- . .' 1 lunt I s

\ \M)- <)!
I- A III 1,K

lUR IIIPI, ACK

(>i 1 \ rin- K

^>!,i! I- I ti itiiinl t \'l

M \ :1>KX NAMK

i! \!(rnn",R

I'.iH'nii'i.Aci-:

Ml Mo'llll'lU
^lati I.I CiiUiit t \

y

X.^^

ujJArAva^wu

^

- 7^

S,';' / I ii III .''■'''' O

M,.,ith

Tin xHMvr -r\Tii. i'Krsonai, i-nki h ikars akh run- t<> rm-
in;sr «>|. uv kn(i\\i,i:i><'. i'. and lU'.i.ii.i'

(Inf II niaiit

iAJuL

X^^^yVL/Ou-vu

n

r^,,,,.... S9vH UAaXVUAx^ C

:\t

(Vt-ar)

MEDICAL CERTIFICATE OF DEATH

i»A ri-: ni- i>! A 111 a\ ,

(Month* '!)avl

I Ill'.kl'iP.V CI-;R'rn*"N', That l aUciHU-.l tU-ccastMl from

w. /ct IS 190 i t.) t/ofc lb 190 H

that I last <aw h tVv^ alivf (Mi L' C-ij 1 ^ 190 H

ami that ik-atli occurred, on the ilate stated a])ove. at O
vJ" M, The CAJLSI'. Oh" DI-'ATII was as follows:

Dlk ATION
CON TKird '1

Moufin \

yt'i)rs Mouths I 4 /^<U''»"

Hours

DrkATK >N

A

Pav

Hours

M.D.

i-ars Mniiths

( SIGNED ^')l\ J. K00^|vk^V%>5

ii)^ lb »'>nS (Address) >^>v l.Q) UK^li/^

Special information '>"'> 'o^ Hospitals, Institutions, Transifius
or Recent Residrnls, dnd persons dyini) ,iway from home

Usual Residence I 111 ^^ H^Kl'

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

W J -\, How lonq at

(JCH^KXhA Jtplare of Death?

Days

I'LACH oi- HIKIAU OK R1C.M'>V\I

^ ii

T90

nx'l'l'.)! Hi HtAi, or Ri;.NH>\AI,

A1M1 CHS

, .. 1-1 %rf7 .^hrttild he stnteil F.XACTLY. PHYSICIANS should

,• inf.rm.Hon .houhl be core?ully HuppI.ed. AGb nhm Id ^^.^^^ /rh. •Sneclal Information" for pT-
OP DI:ATH in plHln terms, that it m»y he properly cl««..*led. The Special Information for pT

M. B.— Rvery item of

•tate CAUSE _ . ^

son* dyinft away from home should be felven in every m8t«nce.

\

^■=yzj, '

(

9

> i

-'aii«'«R??^,

WRITE PLAINLY WITH UNFADING INK

^ ■ ! V ■ .

-^, lUSil'C

L

l)(ili' Filed ,

.(ru-^>v 11

/-9<9H

THIS IS A PERMANENT RECORD

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

J?^rt'/,s7r/Yv/ ^\^0.

DEPARTMENT OF PUBLIC nEALTH=City and County of San Francisco

Ccvtificatc of 2)eatb

( 11. S. i5tanDarC> i

Si m i

v

^^

PLACE OF DEATH: — County of C CXAv JXO/^

to

City ofO'CW^ OXXX^VC

No* 3t7 1

St

Dist.; bet.

"and

/ ir nr^TH occurs AWSAY from USUAL R E S I DENCE GI VE facts called for UNDER SPECIAL INFORMATION' \
( Tf DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. )

FULL NAME

^\

KKy^y\)

PERSONAL AND STATISTICAL PARTICULARS

SHX

r< )1 .< >

^\

I) ATI t >! l;IK III

\| .1-

!),.%

■> 1 .11

I'Uis

■-IM .1,1' M \KH ii: l>

\vii»« >\\ j:i( nk i>!\ I iKni)

I'.iK rni'i, \cv.

(Stat' lit r.iiiiiiiv

N\Ml <ll
I A 111 IH

lUK rUI'I.Al'K
< It 1 \ III I-"K

■ >i;i' iti! I \

M \ii»i;n n \m I
• ►1- M<»rm:R

luk iiiri.An-:
<»r Miirm: K

( ^l:iti' I It i'l Hint I

<KA ri'.x rinx

vu

\

f-

%

L

L V

J t

Ki-litni III Silir it <!ih

Mnilf/l-

l),n

TIM- AHOVI.- ST\Ti:n I'KKsOXAI, J- \ K Tir T t.A K S A K IC T K T H To THl-
lU-.ST HI. MV KNOW I.J.IX .!•; AM) l'.i;i.I l.F

f InroniKiiit

J MEDICAL CERTIFICATE OF DEATH

DAi'i-: oi' PI-: \\\\ t' ^

(Motith)

I>av)

(Vi-ar)

I llilRl'lliV CI^RTII'V, Thai I attcn.U-.l (U'<-fasi«l fr<«m

"— ICp tn — - 1()0

that T last saw h

aUvc nil

l(p

ancLthat deatlj occurrtMl, on tht- <1 ate stated above, at ''
M. The C.M'SI-: Ol" IH-'-XTII wa^ as t"oll(.\s^:

1

o_

f--. I I I

:\l->

or RAT ION )'tars

coNTKir.rTokV

.1 '-.'-• '
Moulin

Pavs

IIoii

} s

(SIG

V ;^l.: lb ,c

DrRATK'N )V./;5 Months fhivs Hours

)0 ' ; ( A.M less) Lfe^-^^xJA.^ W.U.4..^^,

SPECIAL INFORMATION "il'* '"r Hospitals, instituHdiis, Transients,
or Recent Residents, dnd persons ilvini assas from fiome.

\v\- \

Former or
Usual Residence

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

flow tonq at
Place of Deatli ?

Davs

•I ACK <)l in KIAUOR Ki:M(i\AI.

U.J

N I ) 1 ■; K r .\ K 1". K O /<X/> V

DAXi;..!' I'.iiixi (ii ki:mo\\i.

y.t

IL

Too'i

Ik

^

rAd.ln.s 1X0^ ^IVWxsi'.OV

TT 1. I %rF should ha stated HX4GTLY. PHYSICIANS should

N. B.— fivery item o* information should he c„..fully -PPl- • „^i:*:,'^;7,L,eifie ,!^ T^ "Special Information- for p.r-
•tate CAUSE OF DEATH in plain termii, that it may »»e properly wiassitieo.
•on« dying away from home should he ftiven In every Instance.

I

WRITE PLAINLY WITH UNFADING INK —

H.,;,-,! ..f lUaltU |- So !^ '^^r.^^^^^^' ^''

Dfffe F.

4

lOO^i

THIS IS A PERMANENT RECORD

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

Be mistered JSfo, ^'^ < *'

<X.M.t'

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco

Certificate of H)eatb

( tl. S. StanDarD )

I

PLACE OF DEATH:-County of CJct^v l^a^xc. . City of Clc^^ Jax^^Cv^c

fe? t

A ( »

u

A

rN

No.

1- -^ "^ V CLl'^i"' St.; ol. Dist.; bet. V- O.. , V and

^^^ T ,,011*1 Br«:mrNCE GIVE FACTS CALLED FOR UNDER "special INrORMATION' \

( " "r'rrlT^^cc^b-ro'.^rHO.'r.i o^f^s^u" "";"xl name ,«st..o ». st»..t .no ™u»bc». ;

)

FULL NAME

4

1 .•

,\^w^K-

i

PERSONAL AND STATISTICAL PARTICULARS

SI-\

C(>1,«>K '

1

1) \ ii: « >i I'.iuTii

/ i.

iM..nth

As.H

iM

) I ) Hi I

I)av>

l/,i.////<

/'.ft

SINt.IIV MAKkll'I*

iWnlf ill •»iHi;ii ill --ii.' nat ii>n)

A

i I '^ ->

lUR rill'I.AOK
i stilt! lit (."iiiint! V

NAM I ni-
t A riD.K

HlKTHPl.ACK
OI-- I AriIl':R

iStatt (It I'ouiiti V

maii)i:n NAMH

Ol MOTIIKR

lUR I'liruArK

Ol' MOTHKK
(State or Country)

i»>-CfJ'ATI<)N ('^

1 I

i\

0 cxXx.'^c I.

Q>

x^

MEDICAL CERTIFICATE OF DEATH

DATK Ol- DKATH ,, \

if

(l)av>

\

fMotitJi)

(Year)

1 III'RI'HV Cl-RTIl'V, That I attended .krcasod from

,...,.'. up I to ^' CX: . :j TgO H

U' ^ t 1 ►^

that I last saw h - alive on w . T90

and that death occurred, on the .late stated above, at I I

M The CAI'SI-: C)l' ])I:ATH was as follows

'ill-

}'t'ars

DIRATION - --.- . .

N T R 1 n r T 0 R V U^nrsJ^O,^

C(,)

,\JxjLc<w > \^<x.t. '.,.

t

Mouths

Days

\ A.

Hon

rs

nr RATION >^ y'i'iifs

m

Jfofit/is 15" /)(7vs Hours

(SIGNED). J. i\^o-<^ <^- ] I ua.n.0 ^ ^^u M.D.

(A.ldre.s) nCO-U)^^ iv^wolttw J.

\qo

s.

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

(J^,i

rx c- [' SI t

Ne.siiifd in S,ni I 1 1

nil I'l'i)

),,i

Miintll:

I '.:

Tin- MU)VKST\TKni'HKSnNAI. I'AKTUTI.XKS AKKTKrH T(» TIU-
lii;sT 01 MV KNOWM'.IX'.K ANH Hl-.I.H.l-

(lufottnant

^\

^K\A

c

•AiMnss IbO^lX UxXaJ^'^X^

Former or
Usual Residence

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

How lonq at
Place of Death?

.. Days

ri -^CE OF lUKIAI. «>K KHM'»VAI.

S A

DATl", of niKiAi, or RKMnVAI,

a

TQO

IN. B."

U , „ ,. . 7^, ^Houltl be stated EXACTLY. PHYSICIANS should

-Every Item o? information .hould be cnretully supplied, jur. s y^^ -Special information" for pr-

•tate CAUSE OF DEATH In plain terms, that it may be properly Ua.s.lled.
sons dying away from home should be given in every instance.

•\

^

' »

D
0

»

<
H

Q w

!«■ 1
Q M

H Si;

> H

e

1 ^

5

H

Eh

H

(Talifuruia S'tatr luarft uf ffiraltli j^^^..^, R.uistcrc.l Xn._._?327fi.„

BUREAU OF VITAL STATISTICS

AfflDAVITS fOR CORRECTION Or A RECORD C'iiy and County of San Francisco

Taomae R.Carew ; of— — -A^l^_^?.^y_.^^J ?="^ Kranci-.

k' Mw ' U>.\ \ f

ikI C'<iunt\ <>i ■ ss.

.^AN FRANCISCO S

(Nanu' (if Am.int

first flulv sworn, m

he

(Address)

• •-• 'he i. 9- frienA

" " - - — ,,f-^^,,„^,,, si^eiry dfgree-^lf frU-iid or otheiwise. so state)

Peter Keanej

l3th.Ar ,, October

k ((Jl»« iinme uf T*ti\

\ \vlTO-\mT tr«^fr* I

I who (lied

S

HI

M

• , mil CiMMi;\ of San I • ;- .- ^ a

■ ihe follnwinu facts set forth mi -^ahl

er Kane, .

.^ce of- death ^l609i California. St;.

. .,,, HiMli rihli itikcr fur lioiali**

itf are n^.t correctly stated therein, to wit: _

lir Citv and Connty of San Francisco

lo_0^. as -tatcd in a certiikatc of

with the Local Registrar

lo..0>

name of docedent

F8 ther ' s" nnTne.,J:o^rick J^ane . Jjif ormant-_ Mrs^^s

ne

hi-

„ . ,,d. c v.^ 'h. true facts to be, and the changes necessary to make the record correct

attiant upon^rPT own Knov\it '1;-A .w. ..n

Peter Keajje.

16091 California St ___. ._ ^r-— -—

Fatber'ar^me: Patrick .^eane-.^.Infoir,a^^^^

:■ iliows :

Suhscribed and sw..rn to he fore lu- tin.

XlTiant) -

Si ! • iir C AI.II'OkN I \

i II \ and C'ouiiiN of

San l-'k\NCiMo

i'

n Fran i CO, Calif<irnia

ntv oi Siin l<Yai».fim«»». HUitc «rf" Califbriila

Rev , Je r poie _ B . Hann igaa

St.PJiilipa Chujtolf

San Francisco,

(Name of Afflanl)

he

(Address)

»i n^-ht^h-m knowlcd-e of theiacts hereinbefore alleged and that the
C.lu.nni. being f^rst .hdv sworn. dcpos<y and says haj-i4>e has knowU.l^ ne^ ^^^^^^ . . n vc -
'• ^^ " . / fVy^,/ ifpf^f^^^'^^/Zr^^ ^-^^.^^J^Miu Francisco. California

sai.l facts as stated therein are true.

(Affiant)

( Address) --H

Subscribed an.l sworn to before me tin

„ thi^ords "wi-re man

M„r rnTo.tUm Of a mnrrlngp rertW*-..!-. In n-;* '"r*^':5,roSirthl» blank.
l.^," o<- . ,„ay l,e Insertt-.l sptclally l.y way of ^ulmflLitlnii tnroug

I I,, I 111,' Cliv ami Ciiiinly •'< . mi^

f,:, i.rlhco StMie i»f raUfornlii

,„,. ..,,.,.nage." and ••,»..,..,..,," ■;prtest,;; "iu^lKe" or J'lua-^

1

1

WRITE PLAINLY WITH UNFADING INK

Dale /'V/r^/, li'ctc^t-^ IT

. loa

THIS IS A PERMANENT RECORD

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

Re^isfdred Jfo, ^380

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco

Ccvtificatc of 2)eatb

i XX, S. Stan^ar^ )

I

J? (^

No.

PLACE OF DEATH: — County of"^*^^

City ofOO-A^ J,h.o., ,

^^frrsJ^^fWx.

OuyxK.'. • S\

Dist.; bet.

and

-)

( " rr'o».°"occ"u%r.v,"r„o"s^prT*u r"-:"?u"o"i o-. ,t. name ,»stc.o or sT,..T .«. Nu»Bcp. ;

FULL NAME

^^

ax

PERSONAL AND STATISTICAL PARTICULARS

^! \

1) \Ti-; or HiK in

A<,1-

coi.oK ^

!

/ ij

I ^

>^IN«.I,K. MAKKIi:i)

\vn><)\vi-:i) OK i>!voKri:n

iWiilcin --."M'ial i|t «-is.' iki! u mi i

IDav

M.„ifln

Vt-ai

/Jin:

MEDICAL CERTIFICATE OF DEATH

DATK Ol- Dl-.A'PH

(Day)

(Month)

(Year)

1 Hi:Ri:nV CICRTIFV, That I attciulcd (Urcased from

^JLu n 190H to...O/ct 1.1.

tbiit I Jt saw h X^; alive on ^^ lb

T90 H
190H

\X

an.l that death occurred, on the dale stated above, at -IH5
CL M. The CATSIv C)I' 1)1:ATII was as follows:

BIKTHJM.AOK

stall- 01 I'muiti V

NAMl'. Ol-
}ATin:R

HIKTHl'l.ACK
O! I ATHKK

iStaU or Country

MAini'N NAMH
ot MoTHKR

BiKrni'i,Aci-:

01-" MoTUl-'.R

(St.-tti- iir Conntr\

III ri'A'ilMN i^

,?i

'X/rsj

0

tf

lux

>x

"vR

^KiX/C^

DIRATION Vf-'T'S Mouths />ays Hours

CQNTRIBrToKV ' . XxMI^^AaJUxX. - ^ '" ^^^ ^^

Ycays Mouths Hays Hours

nTL. LU-a. . '. M.D.

(Address) bob OkxXXjJXi ut

DIRATION
(SIGNED) J A.C

1 ■•

l(>n

R^siitfif ill ^'"1 I ' '' "' '"' ''

) , ii •

1/ .iillr

I ill 1

THK Xm>VK STAIM- n PHK^oNAl rAKTICt^I AKS AKK THrH TO
IlKST OF MV KNOW 1,1 IX. 1'. AM' lU-.l.U.l

Tin-;

(Informant

QOvv. CI

^AyYVAJ.

\.l.lr

. i/„

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

How long at ,

Ware of Oeatli? bO Days

LU,

former or p. -. i
Usual ResidenceU^CU'

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

C

n

IM.ACH OI-- HIKIAI, OR RKMoVAl, P DATK of iV. KIAI. or RKMoVAI.

(^ ft . r*^ ; U^t- '- 190':

(Addre*^?

M. B.

'> ' ,. , 7(iF should be state.! KXACTLY. PHYSICIANS should

-Every item oi Information .hould he c„retully -PP -^- ^l^X^^^-*^^^-^' T^' "^P-'"' Inform.tion" for pr-
.tflt/cAUSE OF DEATH in plain terms, that it ma> be proper y
"r. dyfn* «w.y from home nhould be given in .very .nstance.

^

')

5

I

I*-'

H

i;,,;iril of H.-allli - I- N'<>

WRITE PLAINLY WITH UNFADING INK-THIS IS A PERMANENT RECORD

,,$S^„.,.c., REFER TO BAO. OP C^RTiriCATC FOR .NSTRUCTIONS

Dafr Fih''',\J<XJ>'^ H

JUOH

Registered J^''o.

^oOA

-L

^uc^,. Ll^,. Deputy Health Officer

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

Cevtificate of Beatb

( "VX, S. StanDarD )

^

fNo.

PLACE OF DEATH: — County of^/CX/^^-u

' r -■ . City of J-V-O/^

Dist.; bet. XjLOAH^inuUJ-D^U^and >.

)

FULL NAME

Cj-iML{n\)

A^CiLC.

PERSONAL AND STATISTICAL PARTICULARS

to.'

C«»I,(>R \

v.L.(

DATK or HIKTH

A (.I-

rt

Muiithi

)■,,/»

|);1V

MEDICAL CERTIFICATE OF DEATH

DATi-: i»i- i)i:A*rn

(Month)

(Day)

I go ;

(Year)

I lIlCKlUiV CIvRTIFV, That I atteiukMl deceased fnnn

igoH

that I last saw h -'■■ alive on

©e.t

190

M,»,tli-

/hn

sl\-<.I,K, MAKl<n:i> .

WIDOWHU OR I)!VoKi'Kf> ^
iWritt in s.h ial (U '•it'iiittion)

UJ ^<L^^^o-^L/X.

lUKTIin.Ai'K

I Statf III i'i»uiUr\' '

NAMl-: O!
1' ATHHR

HIKTH PI, ACH

oi- i\Tin':K

(State or Couiitrv'i

MAIDKN NAMl.
01* MOTHl'.K

HIRTIIPI.ACIC
OI- MO'I'm:R
(State or Co\nitrv

\X)xrY^'\^o

CL^^.>^.'u

\k/l)

and that deatli ..ccurre.l, on the date state.l above, at I o C
M. The CAUSE Ol" DliATll was as follows:

I )r RATION Vt-ars

CONTRIIU'TORV

J/oN^/is ^ Days Hours

I

?

orcri'ATioN

(XxlAA.i

OjUutvxo^

h',-l,fr,f III S,IH /'l-llh

U'll i

)','i; I

Moiitli^

Ihn

THKAmn'KSTATKnPKR:.>NAI PXKT.rr;.AK.AKiCTKtK TO THK
BUST Ol- MV KNOWI.l-.lX^. AND I. hi. HI

Years

^ri>nths Days Hours

nr RATION

(SIGNED) a. e). sJUi^riaYV ,M.D.

U/Ct in lOoH (Address) I^U^^Aa^^^ V. 0.1.

SPECIAL INFORMATION only for Hosjiltais, Institutions, Transients,
or Recent Residents, and persons dying a^ay from home.

Former or
Usual Residence

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

How long at
Place of Death?

Days

PI,ACK 01* lU-RIAI. OK RKMoVAl

i(V

(Infoi niatit

(\<l(lrr

,t

D.VrHof Hi KiAl. or K1%M(»V.\I,

I go

(AtUlrt-ss

IN. B.-

^^^^^^^^^^^^^^^^.^.^^■^■iL— — ■— ■^■^"^■"'"'^■■"'"^^ t t I EXACTLY PHYSICIANS should

-Ever. Iten, o* 1„form«t1on .hou.d be cB.efu.,. supplied )^^J^;:,lJ,,ll %he "Sped.; InWaf.on" for p-.-

.tat. CAUSE OF DEATH in P'«'"f.7^:;;;« ^'.rert \n^tnZ..
•on* dyinft away from home should be fe.ven m every

'J

WRITE PLAINLY WITH UNFADING INK-THIS IS A PERMANENT RECORD

RgFER TO BACK OF CERTIFICATC FOR INSTRUCTIONS ^

.1 .,f ii.-aiih r No 1^ -ft-^^J^) luvrou

,^^\J^jJS

Der

7.9 (yS
■ ?ca!th Officer

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco

Certificate of 2)eatb

{ "a. S. StanDarD )

(^

/ wCX, >

o^s. .. City of r I ,CL/^ 0 >vO-> ^- c^cv

PLACE OF DEATH:— County ofCJCU-yX'

L tl V

FULL NAME

u

A

y.^X.LlX"

Avc

J I

PERSONAL AND STATISTICAL PARTICULARS

sl'\

coi.ok \

\]

I

DATH nf- r.lK 111

A'.K

' J

?.M

1 Month I

)V,f*.

Dav

M.in/fn

in

fhi r.v

(Day) (Yt-ar)

ftlNC'.I.R. MAKKIl'.l)

wiunWKl) OR i)ivt>K(.Kn n

iWritf i»» siK-ial cUsijrnaliou) \

BIKTHIM.ACK

fStatf or CoiiiUty^

NAMK OI

fathj:r

BlRTHI'LAiH
(If* ! AI'IIKR
(State ur Coiuttry'

MAIDl'.N NAME
OI- MOTIIHR

lUKrniM^ACK
(II MoTllHR
(Stati- or Cottiitiy)

otCl TATION -\

W

i (

w^^

ct'^w

MEDICAL CERTIFICATE OF DEATH

DATH *n' HKATH M \

^ c. w

(Month)
I HI'kr'HV CIvRTII'V, That I attcnckMl (IcHvascMl from

.:. 190. to. ii'ct^ l.S 190'^

that I last saw h i. " alive on ^ -'-^ ' ' ^9°

and that <leath f)ccurre(l, on the date stated above, at * -

M. The CAUSr: UF DIvATH was as follows:

\^C^K.<:><y^\^^:nrs^^-''^^ Crt- Q .Qrv>v;tx/cJ(v .

nrRATioN I

CONTRIRl'TORV

)'ears Mouths

(^1 ^

Days

Hours

Days

DrRATION ^ y^^ Mouths ^

(SIGNED) ij. 1 W^^' y

n>o i (Address) ll^l^^Ko^v^

Hours
M.D.

y\jJ^

*-S i' H I

Ke>iiled in San I "J"' '-<•' -^

\ r

)>■(;'

^„ .'\f,,iif/i>

/hi y>

THH AHOVR STATKU ''HK-.NA, PARTirri-AKS ARK TRIK TO T..H
IJKST or MY KNOWIJ.IX.H AND Hl-.Ml.l

(Informant Vm^O^O^OOL VM^

^0'

!A(lilr<ss

10 o"^

V

^..i ■- . ^

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

Former or
Usual Residence

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

How long at
Place of Death?

Days

I'l ACH OH lURlAI, OR KKMoVAI,

'V^-'^W^'X

INDHRTAKKR

(Address

DATHuf HiKlAi, or RKMOVAU

11 ■■' !•; i9o'(

RH.tJiK'^'t'

^S^sJ^-^OOX.

■-^-— —-----— —■—-—■■'■■'■■■■''■■'""■'"""^"""''"'"''"'"''""""""'^^iTf H Id be stated EXACTLY. PHYSICIANS should
N. B.— Bv.ry ...m o. ,„f„.„,..ion .hou.d b= cnr.fuU, suppH.-- J"^^.'/;,...,,,.,. Th. "SpeCI InWm.t.on" for p.r.
^ -. /-AiifiF fiP DFATH In plain terms, tnai 11 mwj' »*
::r;/,Cw^r »°- H.™. :H„u.d he t.v.„ .n .«,, in...»c..

'J

t

WRITE PLAINLY WITH UNFADING INK-THIS IS A PERMANENT RECORD

HEFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

,1 ..f !!.:ilib HNn i. Ir^P^ H^ »' t'-'

100%

Be^istered J\^o.

Dalo Filed }^dJ^^^ H

DEPARTMENtIf public HEALTH=City and County of San Francisco

Ccvtificate ot IDcatb

( -a. S. StanDarD )

PLACE OF DEATH: — County of

\\\

No.

Oj\j<.y^.

St.; - Dist.;bet.

City of OCunrV

and

St . - Dist.;bet. ~~" *^"" ., x

V ,r DTATH OCCURRED IN A HOSPITAL OR INSTITUTIOIM G V « A A 1

FULL NAME ^''^A^,.,cyfl v. h . -ujUfX^ku

)

'^IX

PERSONAL AND STATISTICAL PARTICULARS

• oi.oR \

\A ^

i

!)A1 1. Of JUK 111

VSrs
M.uith I

A' .H

V y

.0

n.iv

\},<Utll

\ lar

Da 1

MEDICAL CERTIFICATE OF DEATH

DATK <>1" ni-.ATH

(Month) '^^^^V^

I go .

(Yeari

1 HICRlVnV CHRTII-V. That I atten.kMl deceased from

— to

[90

^IM.I.r. MARKIKI)
\V!I)()\Vi:i> «»K 1)IVnRCi;i>

iWrittin sotial <l«-«ij.Mialion)

that I last saw h — ahveon
and that death occurre.l, nn the date stated above, at
M The CAISI'; Ol' DICATII was as follows:

" 190
190

hAAJUL

niKTHi'i.xri-:

fStnti- or ».'n\inti \

NAMH t»I
FATHHR

lURTin'I.MK
«M 1 XIHKR
'Statf or foutitry)

MAIDICN NAMH
UF MOTHKR

lUK'l'lllM.ACK
01 MOTHKR
(Stat.- Ill »,'o»uttr\

n

^ ^.

7

I )r RAT I ON >'<■<' '■«

CONTRUUTORV

Moulhs

Davs

J lout s

1
1

I

^kjIax^uwcL

nr RATION ^ >V<7r5

( SIGNED ) &. UJ- - .^^-^-^^

,ci; ^i Too'i (Address) O^O/va

Months
L.KJ

0 C),<x/vo

Pays

u

Hours
M.D.

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

Residfd ill Sail I'lam >

5 'I'a I

Moiilh)

I)a

THKAmWHSTATKU|.KR^.NA. rAR1M.rj,AKSAKKTKrK T. > TH K
iIksT Ol- MY KNOWI.l-IH'.H AND ni-UHI

(I

KK,K.

\--^\

Former or
Usual Residence

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

How long at
Place of Death ?

Days

I'UACK OF lURIAI. «)K KF.MnVAI,

(Ad.lr.-s Q/<XO^ ^

a

u

o^

DXpof UiKiAl- or RF:M()VAI,

I90H

{MhU^sH V\ V<X/>^

— ^— ^— 4t— ^'■^^■^— '™— "^ ... ^ ,^ . pvACTLY. PHYSICIANS should

Btate CALlSfc U^ i^f* > " *• ,,, w* *jv»n in avory instance,
•on. dyinft away from home should be given

'J

i' X

m

:l • (

i

WRITE PLAINLY WITH UNFADrNG INK

Boi

i,9(9'l

THIS IS A PERMANENT RECORD

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

Re^istcvecl J\'*o,

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco

Ccvtificate of Bcatb

( "d. S. StanDar^ )
PLACE OF DEATH: -County ofCW^^ Jxo.. vcc.:c City of O^X^ 0,\^^^CCCLCt

i+Jo. V.L

.t^V

^ U

/TV-ttl

,^1\<,

ii

'dV*t

Dist.; bet.

and

\..AIVA/ T ^^'-^V '^^^'^* \^J^ ' " p-VlDENCE GIVE ^CTs'cALLCD FOR UNDER 'SPECIAL INFORMATION" \

^ ^ /TS ( i N I / I )

FULL NAME

e
(

^KXH

.4

^aC

PERSONAL AND STATISTICAL PARTICULARS

sr:.\

DAIH nr- HIKTH

At'.K

u

COI.OR

N ft

I i

Moiuh)

) ,.;

(Day)

Mmilh^

I Vi-ar)

/',.•

MEDICAL CERTIFICATE OF DEATH

DATK OF I)i;ATn

SIN«.I,1',, MAKKlKn.

wii><»\vi;n OR nivoKOKi)

(Wiitf in sttrial <U nii'iiatiim)

iXoAXw'. .^

niKTHJM.AOK

(Slntf or ('..iintry

NAMl-: OI

I AT in; R

niK rUIM.ACK
<)1- lAI'IIKR
(State or Country

MAIDI'.N NAMH
Ol' MOTIIHK

a-A^tta

^ f^

^nxAxcj'u

iuKrHpr,ACK

(»!•• MOTHKU
(Stall- or Coiujtt y

DCCrPATlONrVYA

AJ^L<X vxd

ft

M, tilths

" I hi

Till- \m)V».*ST\THHI'KRS<>NAl, J'A KTHf I. \ KS A R H TR l" K To THH
lil'.ST Ol- liv KNOWIJ-.IX'.K ASn UKI.ll-.I-

: 111 f.innaiit

I Ill'iKIUiY Cl'lRTIFV, That^I attciKlotl deceased In. in
'^VvUi ' . IcjoH to ^' ^ >*^ 190 "1

that I last saw h alive on ^ C v. ' ' icp .

and that death occurred, on the dale 'Stated ahnve, at ■■
.. M. The CATSH Ol" Dl'.Vni was as follows:
UhA/Cr\AA/^ LiLhJLAyVcJu J(ryu^"^^s^^^^

Dl' RATION Yeats

CONTRIIU'TORV

Months

Days

Hours

DURATION Years „ Mouths Days

LI) \d . ^^-^^^JCol/^a.'

Address) LLLvvVAi. \

(Signed)

Hours
M.D.

i9tt

190

(

W V^. \ X.ft-\,A- a_jL.

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

Former or
Usual Residence

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

How long at

Place ol Deatli? Days

PLACH 01* lURIAI, OR RKMoVAI,

\0

DATK of H» RIAL or RKMOVAl,

rNi>KKTAlKR |t5U . mTV ^Xju^xAry^^^^^^. ^^. ,

T90H

•sJi^A uCt v*w-.

(Ail.lrcsH LD.S.jL

\AA.i^-^\

^ „._r.very Item of inWmatlon .hould be cnr.i.SSy .uppIJecl. AGE should »>«»t«ted EXACTLY PM^S'^'^NS .hould
state CAUSE OF DEATH In pinin term,, that it may be properly classified. The -Specl.l Information for per-
sons dying away from home should be given in every Instance.

11

R:

11='

I
I

■

I

i

■^

l\

i

-r

!!. ,:n.

w

I

RITE PLAINLY W.TH UNFADING INK-TH.S IS A PERMANENT RECORD

REFER TO BACK OF rrPTIFICATE FOR INSTRUCTIONS

/^//r' /'V/rr/, ii'cLcl--

2385

l<n^.. W Deputy Health Officer ^

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco

Cettificate of 2)eatb

( XX, S. StanDatO ) -^

PLACE OF DEATH: — County oiUO^yxj O A.<X>v -..^ity oi

("/

^

Dist.; bet. i-^ xU^^rv^"^

)

FULL NAME

/ — ^

r<\ '

^.V^O

-Ui

¥-

PERSONAL AND STATISTICAL PARTICULARS

• i:k

Mi

C()!,i»R \

L

i»A ri: i>i p.'K 111

Ai.i-;

U

A

Month

5H ,-,..„< t

■\l,,utll'

I 'I't-ai /

/ J,/ r.

MEDICAL CERTIFICATE OF DEATH

DA ri-, 01-- DKATH

(MonUi) 'I'-'V-

^^"^ I IllU^i'BV C1:rTII-V, That I alU-n.UMl .U-cvased fn.in

— — — TgO to

tliat I last saw h ..:— alive on

{Yfar>

190

^IN«,l,l* MAR K 11*. I »

\vii><>u i:i> *>K i>;v<»Ri i-.i)

(Wtitt 111 x.cial <U -'-nanMu)

(KXXKXXX^^

an<l that death oceurrcil, on the date stated above, at

■ AT TheCXrSHOl' Dl'.ATll was as follows

u

lUR riu'i.x*')'.

I Slatt or I "i iiilit i \

NAMK <>!■ ^

l-A Tlil-R

A

\.U^ou

L

-<5\-

I'.iRTm'i.ACi';
(>)■■ I Arm%K

I state iir I'liunti y

MXini'.N NAMl-
()1- Morm'.R

niRTUPKAlT-:
ol- MnTHKK
f Stall' 1)1 (.'oinitry

uOOfrAI'ION ^

lli

?

nr RAT I ON )V(7/-.s

Ci.N'rRMUTORV

.1/. •;////.?

Days

J /ours

a

( SIGNED ).WurraA^ J.vfc-^ U.Ca.^vA. M.D.

U. luoH (Address) Uv<nXilAA W V- -....
Special information onl> '"^ Hospitals, InstitutWiH, Transients,
or Recent Residents, and persons dyinq away fron home.

Rr-! ,!,■■! in ^.!'' /"'"■

);u!i

Mmifh^

/lav.

Xdilrt'^s CS ^''^

ifN^ Op n '\

Former or
Usual Residence

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

How lonq at
Place of Death ?

Days

I'l^ACK Ol' lURIAI, i»K R1:M<'VA1,

I>\J"1'"'>!* I'.' RIAL or K1':M<»VAI,

190H

<x^^J„Cl

Addre^H ioXn ^J^^<>-0.<U.^X^■

1-

,. . TnF sHould be stnted EXACTLY. PHYSICIANS should
IS B —Every Item of information should b. cnrefully supplied. ^^'^^^^^^ The "Special Information" for p.r-

state CAUSE OF DEATH in pinin terms, that it m«y be properly Uass.t.ea.
:':;. dytn/away from horn, should be 4lven in every instance.

) 't

]^:n<1 ..f lltaUh 1- N

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

REFER TO BACK OP CERTIFICATE FOR IN8Tf.UCTI0N9

386

i)Hfcl' Of)

Registered J\'*o.

1 1

\j(r^jj^\x'\tM Deputy Health OfTicer

DEPARTNENT Of PUBLIC HEALTB-City and County of San Francisco

Cevtificate of Beatb

( "U. S. StanDarD ) ^

r ^ H^. lie '' - Gtv of m|\<X-vVL.Lcx
PLACE OF DEATH: — County of -^^^ ^-<^^^^ ; ^'^^ °'

No

i^L

St4

Dist; bet.

— and

■ iciiAl nF«5IDENCE GIVE FACTS CAI
,r DEATH OCCURS AWAY FROM USUAL R E S I D t. N U t U

LLED FOR UNDER "SPECIAL INFORMATION- \
( ,r DEATH OCCURS AWA. ' "" "" — pTt".: O r" . N STITUTI O N G.VE"lTi NAME INSTEAD OF STREET AND NUMBER.
V IF DEATH OCCURRED IN A HOSPITAL OR INSTITUT.y ^

FULL NAME

L

si;x

DATK OI' r.IR 111

PERSONAL AND STATISTICAL PARTICULARS

COI.OR \

M

EDICAL CERTIFICATE OF DEATH

W)

.1

li

iMoTitir

AC.H

) I'ill

Day

Mmths

(V«_-ar)

na\.

DATK Ol- DHATH J

(Moiirli)

(Dav)

I go

(Year)

1 IIKRHBV Cl-KTIFV, That I attemUMl derease,! frmn

— 190

— — — IQO

190

to

"^INi; 1 v.. MAKKIKU.
\VII)()\Vi:i) «)R DIVOKi'Kt)
(Write ill '•ocial d.vi./iiat hiIi)

BlKTMTM.ACl',
(State or Ooiintrv

rr

s^

4 <

•t

\

» 5

NAM!'. «>1-

I- A r 1 1 1; R

niRTuri.AiK

Ol- lATin-.R

(Stale or c'ountryi

MAIDl-tN NAM)-:
Ol- MOTHl-.R

RlRTHri^ACH
Ol-' MOI'llKR
(Slate or Country

that 1 last saw h ■ " ahvc on
an.l that death occurred, n„ the .late stated alxne. at D- it
M The C \rSK Ol' l)l';ATn was as follows:

DTK AT ION >V<7;-i

CONTKIIU roKV

Afonths

Days

DURATION >V<7;'5

(SIGNED) u\d

.3X1 J ^ iqo (

Jf<}fl//>S

Pars

Hours

Hours
M.D.

Address)ll^.O^ ^-J- 6%s^>^

rVX^-VX.

occri'A rioN

Rrsidrif in Sun I'lan.i.^ro

X n

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

How long at

Place of Death? Days

Former or
Usual Residence

.1 /,«///;.«

lhl\:

KS AKi: TRIK TO TlH-.

[Infotmaiit

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

PI \CF Ol- lUKIAI. OR R1':M(>VAI,

I)\l'i:i.f HiKiAi. «»r RKMOVAI,

. AL'cL I'l 190H

(Address

iL,

V.

( Xddress

"■"""■"■^"""""^ ATF should be stated EXACTLY. PHYSICIANS •hould
:"'.%"nT.w°» frL ho... .hould he .Wen 1 > ."..-«•

M

u . Ji

WRI

TE PLAINLY WITH UNFADING INK

THIS IS A PERMANENT RECORD

REFER TO BACK O

F CERTIFICATE FOR INSTRUCTIONS

u> /v/f'^/, Lxtol)

yjo^j n

i

7.9(9 4

Off!

JRpeii.sfcrcd ■A''o.

2387

DEPARTMENT OF PUBLIC HEALTH-City and County of San Francisco

Cevtificate of Seatb

i ^

PLACE OF DEATH:-Co.ntv of^-^;.-— - CUv of 6a^ ^ Ax^™.

V^ ,F DEATH OCCURRED IN A HOSPITAL u Q i^ , H

>UUYVCXVC^

)

FULL NAME ^ f^^-

si:\

DAll-. »•! niRI'll

ACK

PERSONAL AND STATISTICAL PARTICULARS

Xtrrruno/CiuxlWt^

r\AXi'

A

iL)tt>

I M, ,11th)

II

I):iv>

Ron

5V

M.nih

5~

'I'l Mr)

/',n

MEDICAL CERTIFICATE OF DEATH

DATl': ni I>i:aT1I II 1 I . ,

(Month)

I I)MV>

(Year)

WIDOW ):i> OK I>lVoKr).l»

.Wot.- ill -», lal .1.-ii;t!nli..iit

HiR riii'i, \*"»'*

(Statf '•; < '•iiiit! \

NAM!' «»l
IS I lll.R

niRIIll'LACK
()!■ lArill'.K

I State iir t'dUiitrv

MMUl'.N NAMK
OI^ MO'nil'.K

lUKrHlM.AiV.

ol- MoTin-.K

( Statt- (»i C<i\uitry '

oCCl I'ATION

h\-.,\tr,f n, Sail ri,t>ii '■'/•''

I HKK1U5V CI-RTIFV, That ^ attcmUMl .U-rra^cl fmm

t,at I last .aw h ^ alive on ^^ » ^^ -^ H

a.i.l tltat .Uatb (ururrcl. n,. the- .late state-l above, at 5
(J M. The CAISI- ^^^M*'- VI U '""'' ''^ follows:

DIRATION

Motiihs o /)(iys

)'e(H

//ours

DTK AT ION

Vciira Months

/hn

.'S

//oh

rs

O/Ci: lio Toni f A.iaress)

SPECIAL INFORMATION only lor HospitaMnstitutionsOTranslents.
or Recent Residents, and persons dying away froii home.

),;i

yr,.i,th

/'..'I

^^.>y^;S^v^^l;^^^';^.r.^;^;.l:vl^r■^■''^'■^'■^■'■''^^

„„r.,., 0 JvOu^^'tXA/^ '\-V<i^

Former or
Usual Residence

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

How lonq at
Plare ol Death ?

Days

I'l.ACH Ol lU UIA!, OK KI:MoVAI.

DATi: of p.t lUAf. or ri:movai,

^du 11 190H

(A'Ulri"^^

\

, — ■ — i 7"! 77r •hould be stated EXACTLY. PHYSICIANS should

•tate CAUHi- ui ut« • • ASven In every Instfince.

none dylnft «w«y from home should be given m every

1 {

I

♦ >

M

WRITE PLAINLY WITH UNFADING INK

THIS IS A PERMANENT RECORD

REFER TO PAC. OF CERTIPIC.Tr TOR INSTRUCTIONS

Dale I'll I'd , V^/'CUrVMA/ H

DEPARTMENT'OF PIBLIC HEALTH

B,p^i^tci'(^^^ >^'*o.

2388

=City and County of San Francisco

fNo.

11 ,

;

Ccvtiticate of ©catb

( -u. S. StanDarD )
PLACE OF DEATH: — County of - cxm^ \ "^

FULL NAME iKvU^A ka>vcUa ^^^Wr>---^^J^^

'hlX

)

(Vl/ylOuuVa^cc

si:\

II \ ! v: nl ];l !M 11

\i . 1-;

PERSONAL AND STATISTICAL PARTICULARS

ft roi.iik \ f]

iM.inth'

II

n:iv

10^

fV^EDICAL CERTIFICATE OF DEATH

DA ru <>i- nHA'i'ii [/ N

ob

(Months

lb

(Year)

» >S

)

5r

/>,

slNf.I.l- M\KI<li:i>

winnw 1- 1' <•« !M\ (>k^ in
:XVtit. in -.. i:n 't< ~i"i;.iti.iiii

lUKTliI'I. \r)',

I Stall > i! ' ' 'iiull N

, lIKKKirV CKRTirV. Tlu.lJ :.lten,U-.l .leccasc-.l fn-in

n.atllastsasvht^alivcon (L'^t I b 1^1

ana that .leath ..courrea. n,, the .late .tatc.! above, at 5^
T ^j. The CAISI- or DI'ATH was as foU-nvs:

,

ii

lUKTIiri.AiH
(»!•• I AlUKK

, v|:it ( i.r I'onnt vvl

MAll'KN NAMK')

lUK rnri.Aci-:

ni Mo'lin'.R
(Slat' ' i! (.'otniti >■ I

^jYva ■^'.cl\H.u>u^

I »rR AT ION

)'(ars

'^'

Months

Pays

•" M,<.i>h^ O

/'./I

y

M.D.

"<5^CIAL INFORMATION »nlv l«r Hospitals, ^nsfifutions, transients,
or Rwni Residents, and persons dvinq away from home.

^\ob Ifc H>nS (Aaaress)^jyUm,0:\tma>

Former or
Usual Residence

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

How lonq at
Place of Death ?

Days

(Inf. i; maiit

,,,,„,,. [yxX oVuxhjw

%

DAir'n! r.i KIAI <ii Kl'. M«»VAI,

iilofc tl T90H

— — ^^— ^^— 4— — — "^"^^ IFVAGTIY PHYSICIANS should

State CAUSE Oh Ut^ » " ^ AJven in every instance,

son, dyinft away from home should be g.ven .n every

' f R

I

r. p.j^ro

WRITE PLAINLY WITH UNFADING INK

DEPARTMENT OF PUBLIC HEALTH

THIS IS A PERMANENT RECORD

BEFER TO BACK OP CERTIFICATE FOR INSTRUCTIONS

j,'ro-i.stered A'o. 2389

=City and County of San Francisco

hi

Ccvtiticate of IDeatb

I ■a. S. Stan^atO )

MJi)
PLACE OF DEATH: -County ofO<:^ .1Aa-^xCx.^

%

I

City of

-"^

X CC ^x

No.

0 *-s 1

^

St.;

Dist.; bet.

5 U^

» t

/ IF DEATH OCCUBS AW«V Fl
V IF DEATH OCCURRED IN

and ' ^

^^*f ' ^„_ .lunrR "special INFORMATION" \

)

FULL NAME

\^aXjlLL<X' 'vJ

k^AA

Sl.X

PERSONAL AND STATISTICAL PARTICULARS

DA TK III- HiK 111

\<.K

l\

5 ,

(Dav^

Mntllh-

\. al

/),

MEDICAL CERTIFICATE OF DEATH

DA I'l-; t>l- Dl'.ATll

'ot

<:r>

(MontlO

(Day

I go \

^

. 1 IIKRKHV C-KKTIFV, Thai I alUMuUM .kHvased fr-m.

mM.I.K MAKI<n-D

w iD<nvi-.D OH i):\ ' •'■■' 1 i»

t

that 1 la'^l Naw h

alive oti

1 11*14- ■ ..vvv.. .-

to iDct lb

11

IC^H

up

C^

liiK riii'i \*M-:

, '-,t:itt ii! I'l Hints >■'

^

NAM I' <>!■
». Arill.K

^3

^"VO

a„,l that lU-ath nrrurrc-.l, n„ the .laU- staU-l above, at I 0
V ' M. The CAISK (>!• Dl-APlI Nva^ as foll.nvs:^

].rurA^^o-^ Ou. ^

.^0^-

Ivin^^^

X,V>A-.C5

V \ » ~».

9

I )r RATION >''«7rA

CONTRll'.rTOKV

Months

/hn

//our

UlKTinM.At'K
(>» 1 A I IIKR
iStatf or i"(HUitiv

M \idi:n NAM1-:

Ol- .MOTHI'.K

mRrmM,As.'i%
m Mnrm-'.K
tsiaii 111 i'o>uJtry^

t

OUwU

il\

h S ^

)V<rr5

or RAT I ON

iNED) WrV>^ ^

J/oh'f/lS

/hiv

(^IGI

A-Aj-O.. .

//ours
M.D.

^

Uct li -r' ^^.MresO Mlb^ n

Ik it

QPFCIAL INFORMATION onlv lor Hospitals. Institutions. Transients,
or Rerent Residents, and persons dving and) Irom home.

;,.KKSMNAl,.-NKTirrKXK-;AKH THIK T- » T

liKST C)l- Mi^KNoWl.J.lH.l. AND m.I.IL^
{Infonnant "J '' *^^ ' r w

Former w
Usual Residence

When was disease contracted,

If not at place of death ?

•LACK Ol r.l KlAl, OR RJ-.MoVAl.

How lonq at
Place ol Death ?

Days

^1

■\.^

D \ ri

IS, 1.1 M '>t ki:m()Vai,
lijot l^ T9o1

— ■— — ^■^'"■^■"'"""'^■""■'"~'''"'''''""^'"''"''''"'" ♦ I FXACTLY PHYSICIANS should

„, ,„.o.„.«tlon .Hou.a He cn^efuH. ^uppHe.. ^^,^^^;,;7;^Um:" Th;^^«^^ .„..„,„tlo„" for p-n-

E OF DEATH In pinin term«, that .t m.> ^e Pr p

N. B. Every Item

state CAUSE Ol^ "»^^ ' " "' ^T'l^L'^Wcn In every Instance,
son. dylnft aw»y from home should be given .n every

^iV

♦ I

toi

.

WRITE PLAINLY WITH UNFADING INK

^ i .,, Depu*v '-'t^a'*'^ Officer

THIS IS A PERMANENT RECORD

PEPER TO RACK OF CERTIP.CATr rOR .N3TRUCTION8

2390

lie e! i st ered ■N'o.

DEPARTIHENT OF PUBLIC HEALTH-City and County of San Francisco

Ccctlticate o£ ffieatb

( tl. S. StanOatS )

Ar^r^' J \,<X.-yxC ■ ■ ' City of ' ) <X/>^ ^ -'^'^
PLACE OF DEATH: — County ofU.CXA^, ■> '^^^ ^

0/-

Dist.; bet.

4 ^ «>/4

FULL NAME

CX/OXA

^

1^ ^

^^}••.X

PERSONAL AND STATISTICAL PARTICULARS

MEDICAL CERTIFICATE OF DEATH

A

COI.OR '^

DAT}-: nl- lilKlH

\«.H

• M outfit

)ru,

< I»avl

1 /.<>////<

II

(Year)

/)(/>

DATK OF Dl'ATH /^

(Vc-ar)

WIIXAVI.I) OK niVuKiJ-.I)
i\Vrit»in -'nial ilf-iu'iiation)

lUKTHJ'I.StM*,

NAMi: Ol
1 ATHHR

lURTHI'l.AOK
OI- lAPHKK

I stall- or (.'oiuitry)

MAIDKN NAMH
OF MnTHF.K

lUKTIirnACF:
Ol' M()rHF:K
(State tit Cotmli y>

(Monti,)' '«»='>'^
1 in';Ui:nV CICRTII^V, That I atten.UMl .Uucasea from
' ' I^OH tn ^^ up

1- ... )i.WAv I -' igo 'i

that I last saw h- ahvc on ^ ^I ^ ^ ^

,,n,l that doath occurrea, on the .httc statcl ahovc, at ^ ^

M The CMSIv OF HHATll %vas as follows:

\\sX^.

JONTRllUTOKN A.^..-.-«

/?av

//our

r\)^

C

DURATION ^ >'''<^''-^

Jfofii/is

Ihivs

( SIGNED ).U('^-0^

^^ci

c^>\-

.CLA

Rf>idn! in San /'iiinri^ro 10 )"''

I

^r„nff^'

Dav

.n„..HovKST.vna,^K^.sM.r.JKT,rri.K..KHTK>K to tmk

IJKST OF MY KNOWI.h»«.h AND HKi.o.t

//ours
M.D.

P- I !

■ c^PECIAL INFORMATION only for Hospildls, Institutions, Transients,
or Rerent Residents, and persons dying away Iron, home.

,llr...^1U^ h^^^^^^^

Former or
Usual Residence

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

How lonq at
Place of Death ?

Days

K,<^XA\JJ\^y>^^-^

(Adfiress

1

/CX'Wx/l^

PI ACH OF lURIAI, «»R KKMOVAl.

i)ATi%<>! niKiAi, or rf;m«>vai.

J!,!11k1^^^cuu^v %!(E.^^^^'

(AdclreHHJlll ^'^^^^AA^

^ — . . , * H FXACTLY. PHYSICIANS should

state CAUSE Ot- ocaih »" f ^i^^n In every instance,

•on. dying away from home should be ft.ven In every

).

'I

>Ji

i

I
t

r

r\

'■',

n

♦ I
i »

I I

4 11

w

RITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD

Board ..f II.;. mi I N'

■?-?Si^^ U&lV C

Dff

/r AV/fv/,.li',tt^\'

dUr^<-^

n 190H

Deputy Health Officer

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

2391

Registered jYo,

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco

Certificate of H)eath

( "U. S. StanDarD )

PLACE OF DEATH: — County of

%-

H

City of JUX-wCU-Lv' •

Xmxa

Na

St.;

Dist.; bet.-

and

(IF DC»TM OCCURS *W»y FROM USUAL R E S I D E N C E G I V E FACTS CALLED FOR UNDER 'SPECIAL INFORMATION" \
IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. /

FULL NAME

.-cn^cc'^ \

^iii

PERSONAL AND STATISTICAL PARTICULARS

>.i;\

^

cnriiR

\

A

La

li

DATi" «»r- liiH rn

AC, )•;

ai

MJ.iit

II I

} t-ii t

{y.Kv

M.'iitln

ir)

/'(/ V.

SINC.I.I.:. MAKKIi:!)
WlUnUI':!) OK DIVi iKvI-l)
\\'!it»'in "social <!< -i^'natinii)

lUH ilil'I, \C\%

(Stat( 1)1 t'DHiiti \

NAMl" Of

1- A I'll i:k

HIK rill'I.Al'K

oi" lAinKK

*Sta!( .It i'ountTvi

MAIDI'N N'AMl-:
«>!• MOTIIKR

niui'in»i,Ari-;

(Stall .)! Cnimti V

i

0

0

a^v

\<X .

^)

<xx-ucl

y^

P

Lax<Tw>xx uXju

y\jY\J(\Xx/yr\^

MEDICAL CERTIFICATE OF DEATH

DATK ()l* DlvATIl

(Day)
1 Ili:Ri;nV C1':1<TII'V, That I attciKkMl tleccasc-a from

I9O to

(Month)

(Yexn)

that I hist saw h

alive »)ti

190

ami that death oeeurred, on the dale staled above, at -
■~ M. The CAISI' Oh Dl-ATII was as follows:

\..»..

ni' RAT ION Years

CONTRIIUTORV

Months

Diivs

Hour

Ur RATION

(Signed)

Years

Months

Davs

I tours
M.D.

^

),,i

^Innth^

I hi

Tin". AHOVK STMI- I) CKKSONAl. V \K I" K I r,ARS ARK TRTK TO TUl-:
ISKST (>I* MY KNn\\Ui;i)<, K AM) l!l-:i.l l.l-'

(Infunnanl UW

(AfMrcss

1,1 /^Ov>

is

"tXa ^ %\vX^-

"X

\.

I(>0

(A.hlress)

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

Former or
Usual Residence

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

How loR(| at
Place of Death?

Days

JM,AC1-: 01 HI RIAI, OR RHMOVAI, I DAIl...! lU mi.^i, „r RFMoVAI

ulDCrY^'^^ wt

m

I90H

rM)i;KTAKi:K

^■"v^w/VH

*_ N

Ad.lMss kl ^TYW-y^jt/C^tOVU^Uu 11.

1

1

N. B. Every Item o? information should be cnrefully supplied. AGB whould bo ntated EXACTLY. PHYSICIANS should

•tate CAUSE OF DEATH In plnln terms, that it may be properly classified. The "Special Information** for psr-
sfins dying away from home should be given In every Instance.

Hij

i!

I

I) t i>

'K^k-^'

I

I'l )

«t

>

h

? 1

It

[

I,

lit

WRITE PLAINLY WITH UNFADING INK —

190 "i

THIS IS A PERMANENT RECORD

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

Be^lstcrcd J\^o.

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco

^CMw

Ccvtificate of ©catb

•Q. S. StanDarD )

(HT^,

No.

PLACE OF DEATH: — County of

115 ^Jo

CL'Vu

St.;

City of 0<Xnf%^ J.XCX

Dist.; hct*

C i . > w{5-'^:\.i- and

(?■

0

(

r DE^.TH OCCURS .WY FROM USUAL R E S Id i N C E GIVE FACTS CAULED ^OR "-.DER Tj "^'*;^' Jl "°;^;J'„°
IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER.

+ -^

V \

N.)

FULL NAME

£uiA\ijy\.c

i

ii

PERSONAL AND STATISTICAL PARTICULARS

DAT!" nl- lUKlII Q,]

II

I

I Month ^

A< .1-

U

)V.i>

<l)av)

M.nitll

ALT

» tar

/;

'(/ 1 A

S!N(.i,}.: MAKKIl-'n

i\\'iit<iii --iHial (li '•is.'iiat iiiti)

IHKTMIM.Ai'H
(Statt <ir I'iMiiitt y

H I \<X.>v\.<X<L

NAM I- <)l
I'ATm.K

a\.t

V (

p.tKrupi.ArK
oi- I ai'iii;k

(Statr '>! I'diinti V

MAinKN NAMK
<>I MOTHKK

HIK'rmM.ACK
oi- MoTIlMR
(Statt' or I'DUiiti V

nCCt'i' \i'l()N

\

(

^

I iXcUvc^ ^ ' ' ^XJ ^

^hn

t\^

< n Sill/ I I ii )fi ; 'I'll

) V,i

M,,,tlli'

I hi

rnj- \H()vi- ST \ ii:ii ckrsonai, i-akiumi.ars aki-: run-: t<» tiik
lu'.sr <)i> Mv KN<»\\ i,):i»«.J-; and m:i.ii'.i'

(Iiifoi matit

MEDICAC CERTIFICATE OF DEATH

DATH Ol- DHATH

(Month)

(Day^

igo

(Year)

I m';RI';HV CI-KTU-V, That I atteiKkMl deceased from

/cfc iH 190 1 tu ...iO-ccut I.:,

190

that I last saw h

alive oti

190

ami that death .ueurrcd, cm the date stated above, at
M. The CAT SIC OF DICATII was as follows:

P .^c.<

DT RATION Years

CONTRIIU'TORV

Months

1

Days « Hours

^Ni...».

Days

Hon

nURATrOX ^'cat:s ^ Months

(SIGNED) J. U.MjUa. M.D.

/ct lb iqo'i (Address) bTH.-^^i^^^^.Lkw^,. ...

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

Former or
Isual Residence

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

How Jonq at
Place ol Deatli ?

Days

DAXi: of IHkiai, or KICMOVAI,

I'l.ACHOI" IHRIAI, <»K Hl'.MoVAK

N. B. Rvery Item oV' inform«tion .hould he cnrefully supplied. AGB nhould bo stated EXACTLY. PHYSICIANS should

•talc CAUSE OF DEATH \n plnln terms, that It may be properly classified. The "Special Information" for psp-
sons dylnft away from home shoulil be &iven In •\9ry Instance.

o*,

S3

e

I

i

■

r

if I

f ! ' '
i

tl

pmir.! ..f n. ,i,i!i ' '^■'

WRITE PLAINLY WITH UNFADING INK

^^-..^-m ■

nSiV C.J

100 "i

THIS IS A PERMANENT RECORD

REFER TO BACK OF CERTIFICATE FOR IN9TRUCTI0N9

2393

Be^istered JSi^o,

DEPARTMENT OT PUBLIC HEALTH=City and County of San Francisco

Ccvtificate of 2)catb

•U. S. StanDarD )

PLACE OF DEATH: — County

ofCJ,CL/^rt' J\XXnvC.vA'Oo City of 0/CX/^^ 3XC

?

I

I

Nn doX^^Ji^ OL ' ^ St.; Dist.;bct. and

L^iXt ^^^^^ » ''-^ ^ ,,cii»i circsinrNCE- nvE facts called for under special information' \

FULL NAME

m:.\

1) \ 1 i: I iJ !UK III

PERSONAL AND STATISTICAL PARTICULARS

coi.ok N

1' . :.

Clkv

\ I . i-:

!V./;

iUavl

M.mt/is

\ VAX

Da 1

^Ixr.I.K. MARklll)

\\ Ilx i\VI-:i> ok I>i\*t>K(KI> Cs_

11 ^o

MEDICAL CERTIFICATE OF DEATH

DATK <)!• DMATII

A

fM(.!iUi) (Dav)

I I]I*:R1;HV CI^RTII'^V, That r attended (leixased from

igo

(Year!

iQ .ct . ID

that 1 last saw h

M.

to iD^

IS.

1 ,

190

190

ahve on w '.; 190

and that <k-ath occurred, on the date stated above, at i -. 1
M. The CAISI-; OI' DlvATIl was as follows:

lUR rillM.ACK
(Stat' >»r Cmintry

NAMI-: ni
PATH IK

niRTHIM.AiK
<>!■■ lAI'llKK
I SI, it" 1)1 Coutjti y

MAiKI'.N XAMl, '*N

ol- MOTIIKK ' '

^

.1:

0

l-U

^Oj

HlKIHI'l.ACK
nl MoTHKR

( Sl.itc lit Ciiuiilt \

OCC! TATION (0

AVv/</c'(/ III Siui /'i till list-,} )ia.

/ 11 n

^f,>,ltln

r>r\.

Tin- Mi()\ K Sr\ri:i> I'HKSONAl, l'AKTHMl,AKS AR1-, IRl K 1«> 1 H h

ni-;sr ni' mv k now 1.1c ix.k and n!;iji:K

(Infonuaiit H. i

C|k;,

A.i.ir.ss. Liyvv^XnTxAj \^<X)

^

DT RAT ION }'i'iir.s

CONTRIIUTORV

I ) r R A T I ( ) N ) 'ears Monl/is

/)ays

Hours

Days

(SIGNED)

0tt

lb

lc)0

H (Address) ^'^0 3AxO_ih^ Mj.....

L

Hours
M.D.

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

Former or I -h ( ^ j ""*^ '''"*' ^*

i\jL^nt\Jjy\X} vOwV Place of Death? Days

Usual Residence

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

I'l.ACK <)1' lU'RIAL OK RKMOVAI,

nA'l'i: uf HrKi.vf, or RKMoVAI,

Cn k

INDl.KTAKHK ^J V ■ ^J

(Address iS"b' /itl 3,A^U^ t

190 \

ts. B.— Bvery iten, o.' Informetlon should be cnrefully supplied. AGB should »»« stated EXACTLY PHYSICIANS •hould
state CAUSE OF DEATH \n plain terms, that it may be properly classified. The -Special InWmat.on for pT-
sons dying away from home should be given in every instance.

)'

1

i I

,! U

WRITE PLAINLY WITH UNFADING INK

II, ,i;th

h t N. ) • •, t--r -af-3;i' !U^ I' (

100

THIS IS A PERMANENT RECORD

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

Registered J\''o.

I)((le Fifed, k S^JrLK>\j H

DEPARTMENT (JF PUBLIC HEALTII=City and County of San Francisco

Certificate of 2)eatb

( "U. S. StanDarO )
PLACE OF DEATH: — County ofd/amj ^ City of UOj>ru J Axx .

M

» 1

No 1?^C^ St.; ^ Dist.;bet. ^^ and H *

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

FULL NAME

Oj-rx) LUXr

D

^w*^.

PERSONAL AND STATISTICAL PARTICULARS

>I.\

(\

"I

Col.oR ^

<XXX

I

I , t

I)\ li: of lUKTH

\<,i-;

n

o

Ml. mill

)

(I)nv

MnHi^ ^

I Vtarl

/I.IX'.

SIM.l.i: M \RR IK1>

• Stutt ii! r'Htlltl \

1- A 11 IKK

HIHI'm'I.ACK

ni- lATIIKK

' "^!:itf ur (.'oillltl y

MAIDltN NAMK
()l MOTHKK

lUk'riU'KAC'i:

oi' M(n"ni':K

(Statt 1)1 Country'

OCCl'PATION

/y^sidfil I" ^ili' /l.lili

) V'l?/

Mnlltll^

!h! 1

HJ- \H()VI*, ST\r»:i> I'KKSONAI, I«A KTU' T I. A K S \\<V. TKri-
HI-:ST OI- MY KNo\VI,i;n<",K AND BKI.!!'.!'

TO fill-

I lufii! inant

OusT^^

f A(l(lif^<

[5^D

Q^/u-t

>u 0.1

MEDICAL CERTIFICATE OF DEATH

DA TK OI- Dl-.ATII

/QO

(Ytar^

(Month) (Day)

I III'IRIUJV CliRTlF^V, Tliat J MtteiiikMl (Icccased from

, .,..„^rvt i9o''. to ^^ct< lb.. uyo^

that I last saw h u .. alive on - ^^ ' ' 190

aiitl that (Uath occurre«l, on the date stated ahove, at

M. The CATSI-: Ol- DI-lATIl was as follows

DT RATI ON ^ '*'W ' Months IS Days Hours
CONTRinrTORV C:%,Kx:u.A-A-L\...C;. ,

DT RATION « Years _ Mouths
(SIGNED) UXO ^y. '^XXkLxj'\\.\

Pars

Hours
M.D.

K\ .1

190

(Address) H C) H

'\L

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

Former or
Usual Residence

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

Now long at
Place of Death?

Days

ri.ACK oi' inKiAi, ok ki<:movai.

DATi: of niKiAi. or RKMOVAI,

wet igoH

LaXXa-aXI'

N. B.— Rvery Item of information should be CHrefully Hupplied. AGE nhould be stated EXACTLY. PHYSICIANS should
state CAUSE OF DEATH In pinin terms, that It may be properly classified. The Special Information for per-
sons dying away from home should be given in every Instance.

V

* '^

'M

i

I

WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

Hoard ..f ll( altli !•' No. 1 1, -S^^W^ I!,Sl 1' Cu

7hf/(^ AVAv/,.y.cUt .:\. l.'L

190'

Registej'ed JSi^o,

i2395

,/(na.c

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco

Certificate of S)eatb

( "CI. S. StanDarD )

PLACE OF DEATH: — County of

I /

^

A-CU-^XCi

No.

I

<X\.Xc4.tl^.

St.;

(ir DEATH OCCURS AWAY FROM USUAL RESIDENCE GIV
IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION (

Dist.; bet.

E FACTS CALLED FO
Give ITS NAME I

City ofOCL/vu Jxolavc^ca-
I XJi\i and u \Ji\)

^OR UNDER "special INFORMATION" \
NSTEAO OF STREET AND NUMBER. /

FULL NAME

lO..''.A.l oLt

I I

.Ua-'IA-C r\>

PERSONAL AND STATISTICAL PARTICULARS

SHX (

'^t

Cf>i,ok

DAi'i; or luKin

.\<.i%

I Month)

5 '»•<?#

i
iD.iv)

Mouth

u)

MEDICAL CERTIFICATE OF DEATH

Ilk li

(Month) a)ay)

I III'RHHV CKRTIFV, That I atteii.lcl deceased from

(Year)

a.^-t . L^

/',/

SINC.I.K. MARku;i)

U ll)o\\}.:i) OK l)l\ oRi i;i)
'Wiiti in "-Ofi.'il dcsi}.' nation)

IUKTmM,A("K

(State or Counti \

NAMK 4>I-

1 ATii j:r

HIKTllI'l.AOK
OI I A I'm-: R

(Stall- or I'onnti \

MAIIM'.N NAMl

Ol MormcR

FUR rni'j.Ai'H

oj. MOTIIKR
(State or Conntrv

oCCri'ATlON

Rf^idfd ni Siiii /'iiin,niii

A^Mr^

MX^CL

/

n

190 to U'Ci' lb.

Oct, ife

that I last saw h - alive on w CX ife 190 1

aiiil that death occurred, on the date stated above, at H 310
_VA M. The CArSI-: Ol- Dl-ATII was as foll.nvs :

Dr RATION Years ^ Mouths Days

Hours

DI'RATION Years Mouths 10 /p^j'?

(SIG

ii

Hours
M.D.

^^ KpH (Address) 5

^\ri

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

) ><M * 1 I M.,Hl/l^

I hi

'\'\\V. AHOVK STATI<:i) l'KKS<»NAI, l'\RI*I»!'I. \RS A R 1-; TRTK To TIIK

ni-;sT Ol' MY KNOW i,i;i)( ,1^: and iii:i,i]:i

( Info! mail!

aJLAX^)

( \d.hcHS

I '7 %

I !■,

!■

Former or
Usual Residence

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

How long at
Place of Deatli?

Days

IJJ.ACK OI- niRIAr. OR RHM0VAr<

l>AlJ.;of Hi Ki.At. or KHMnVM

(Is

r NDi-.Ri'A K 1':k 0 <X^vvL^vNjt\» -^aO K,b- "i

(Ad.iiess ixoH Tru.v«t.4^<.->v .It.

190

N* B* Bvery Item of Information should be cnrefully Huppllecl. AGB should be stnted EXACTLY. PHYSICIANS should

state CAUSE OF DEATH In pinin terms, that It miiy be properly classified. The "Special Information** for psr-
sons dying away from home should be given In tisnry instance.

1

i'

t

I

1 1

1

y

Itr

it

I

I

I

A

WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

i)(ff(> /'VA^^/,iyoLtr4-^ n

290H

Jiegistei'ed J\^o.

S396

i

:X.d-tA,v

Deputy Heaith Officer

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco

Certificate of Death

( XX. S. StanDarD )

A

os^

(No.

PLACE OF DEATH: — County of^'o^ -J^vcv ,

r^

(^

'City of ^'Ct'-YV J X/<X.'V

X. C ' C 04)

KX

St

Dist.; bet, and

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

FULL NAME

,"0

'\jn

s I ; \

PERSONAL AND STATISTICAL PARTICULARS

DATH ul- lUKTll

Mntlth)

r-

i >

u

i

iDavi

A<-,H

^

^

}'iii I

Mntll/l^

/It..

f V.Tir)

Pa

HIN<-. 1,K. MAKkll'.n
WIDDWHI) OK DIVORk HI)
iWritt'iu siKJal ili —i^'iiation)

lUKTHPLACK
(State nr Cnnntrv

NAMI-: i»J'

FATn i;k

BIRTmM.ArK
Ol" lAlllKK

(Stati' <i! i'()iiiiti\'

t-»^^

,D

'Xc

V

MAIDKN NAMK
OF MOTIIKK

HlRllll'l.Ail-:
Ol' MOTHHR
(State or Contitrv^

OCCri'ATION j( 0

r>i

Wk.

t

MEDICAL CERTIFICATE OF DEATH

DATK OF DEATH

11 \ A

(Day)

(Mouth)

igo

(Year)

I iliiKKBV CI'RTII'V, That I atteiKle.l (leixasefl from

,<wMX... 0.1 190^ to iD/cA' [h T90H

that I last saw h ahvc 011 w i^o ■

and that death occurred, on the date stated above, at 10
M. The CArSI<: Ol- I)I':aTII was as follows:

s-

Dr RATION )Vt/;.s
CONTRIHUTORV

Mont /is

Davs

Hours

e^

P

Q

6^

y\AX ^^ I

>\jy^<X^

h'f^iif/'if ill Sim /'i a>tiist'(t 07^ ) rm ^

A/,i,if/i>

/hi 1

THK AHOVK STA ri-.n PHRSONAI, I'ARTfCn.ARS AKi: TRl K To TIIH

HHsr oi" Mv:^ KNOW 1,1: IX -.H AM) iu:i,n:i"

(1

(Address

^

DTRATION
(SIGNED)

y't'ij/'s

Mouths

Tqo'i ( Address) l A I

Davs

Hours
M.D.

SPECIAL INFORMATION only for Hospitals, Institutions, Transients,

or Recent ResidcoK and persons dying away from home.

Former or t 9 ^ IP ''"* ''"'A **

Usual Residence ^ KXA/T^ VXXA; pjarc of Death ?

(TfA
When was disease contracted, ^X

If not at place of death? v

Days

y\A) K,

PI.ACK OF IH RIAI, OR RF;MnVAI,

nATF;of lUkiAL or RF:M0VAI,

*'-t n

T90';

INDICRTAKHR AaJ A.'''V%.X» ^ )a '^ ,

(Ad«

N. B. Every Item of Informntion should be carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should

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

%\

il

i

]>,.,:>'.<] ..f lltiiUll I N'

WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD

t-t:^"^ luvclio REFER TQ BACK OF CERTIFICATE FOR INSTRUCTIONS

2-307

/)ii/c Filed, ly ct<ru-t\.'

0 ^

/r;6>s

Be^Lstcrcd J\^o.

Deputy Hf "hOfllcer

DEPARTMENT ijF PUBLIC HEALTH=City and County of San Francisco

Certificate of Deatb

( tl. S. Stanc»arD )

J? (^ \ ^

PLACE OF DEATH: — County olOajy\j ^ h.<>jy\.^i^!i ^'CxXy of <"''aA^J 0 /VXX.'^^'C ^-<t

wO

NoM l\ac^(Xv./-.^.u y /a^ .^.'.a^

> i

St.;

Dist.; bet.

and

/ ir DEATH oecU«S AWAY FROM USUAL R E S I D E N C E G I V E FACTS CALLED FOR UNDER "SPECIAL INFORMATION ' ^
( [/dEATh'oCCURRED in a hospital or INSTITUTION GIVE ITS hlA M E INSTEAD OF STREET AND NUMBER. J

FULL NAME

.QJJJXXXQ^ AXt^'

SIX

PERSONAL AND STATISTICAL PARTICULARS

V1T\

1) \ l!" < 1 1 1! I Kill

\i.j-;

?\\o

' Mmithl

'V

UOi

I Dav

A \ )'<-,u

\'i ari

Fhi

^i\<,i.T" M\KKn:i>

wiix »\\ ii» Ok i)i\( »R('i:ii

iWtit' in -iiciai ill -i(/ iiat i" III

I'.ik iiiiM. xt'i:

' ^talt '■! t '< unit I \'

NAMi: <»1

HA'nn:R

niRTHI'I, \<"H
<)I" lAIIIl-'.K
'Stair lit tNiUiitry

MAIIU.N NAM1-:
<H M()Tin:R

!UKTinM,At'l*,
ni- Mu'l'm'.K

'Stall 111 I'nuiltt \

uocri' \ri()N' ( ^

Nesidrd HI Sau JiiUhi-ni j^_ ^ ) luu

t, \r,.„tfi^

/hn

rim XHOVK STATl'T) PHKSOVAl, J'A KT HI' 1. A K s A K I'. rK! }-: in TIIH

liicsT oi' Mv KN()\vij-;i)«".K AM) Hi;i,n;i-

(Iiifiiiiiirmt

a

yx/y^^Aji ^Lt tr^^^-^>^-a.

I \ililr<sm

IQlI

0 a

O/CX^

vuAJt

(Yt-ar)

MEDICAL CERTIFICATE OF DEATH

DA ri". oi" I)1-;ath

„i,i

(Day)
1 H1';R1:HV C1:KTII'V, That l attend<(l dcceascMl fmni

.-- - I90...~~ to 190 —

that I last saw h ^~— alive on - - - ■■■ I90

fMoiitJi)

and that «Uath occurred, (>ti the dale stated above, at
M. The CATSIC Ol- I)1<:ATII was as follows

<>,J»^r^rsJsU^

o

or RAT ION Years

CONTRIIRTORV

Months

L , 1 v-ju

I^a vs

Hours

Ihn

DURATION )\ a rs ^^ Mj^h ths

(Signed) L^rVcrrcflX) J ■Jj-lv .>...,^.-

'S"

l()f) ( Add ri'ss) "wd U-ft >"\J^

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

/fours
M.D.

m

Former or . ^
Usual Residence i<^l

L

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

a^CVOwnrvWu

How lonq at
Place of Death?

ranslents,

Days

nj.ACH OF IHKIAI.J)R KHMnVAI.

a

A\^\XJU^ C>w'Ol»-^» V V

ltAJj:<)f HrRiAl. or KI:M()VAI,

T90

N. B. Kvery item of information .hould be carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should

state CAUSE OF DEATH In plain terms, that it may he properly classified. The "Special information" for per-
sons dyin^ away from home should be feiven in s^ery instance.

IM I

' f

i

1.4

w

WRITE PLAINLY WITH UNFADING INK

i5,,:il,l i<( Hr;;!lh

Xu - ^■^a^'S^i liS: 1' Co

I)(f

/. /vW,0^Xuv 1% i^^o^

THIS IS A PERMANENT RECORD

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

" ' 2398

Registered J\^o,

i^L\ If Deputy Health Officer

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco

Certificate of 2)eatb

( Ta. S. Stan&atO )

J? (!f? \ ^

PLACE OF DEATHt-County oiOOo^ J.Va .^vca..^ e. City of Ooj>^ J;vcv>v^vA^

^^

-KXAxtu, dbchAUA

1 >

St.;

[

c

\

Dist»; bet.

and

"^ ^'-'M, ,,eiiiil DCCinrNCE GIVE FACTS CALLED rOR UNDER "SPECIAL INFORMATION ' \

( '^ ^;;:t:^4'"-^- *^^^' r^f^S^^C;::^;^ - name .NSTEAO of street AND NUMBER. )

)

FULL NAME

ftxlLA.

j\jYy\xLo.r

-0-

PERSONAL AND STATISTICAL PARTICULARS

m-\ > c<>i,«>K \ .

I) All". « »i iiiK rn

AC.!-:

i

I' '

M..iitli

I 0 5V<?,

u

a)ay)

M.mlh

r t

\ t-ari

/),/ 1 >

iW'rittiii <i»ci:il il> --is-MKitii III)

I51KTm'I,Ai"K

(Stiitc or t'ouiiti y

lATin;R

ISIRTMIM.ArK

()i- i"Ariii:K

(Statf ')! *.'ijunt!\

MAIDl'.N NAMH
(»l M()Tin;K

lURTHl'I.ACK
iSt;il( (ir t'<)\uitry)

oriTl'A'lION \

MEDICAL CERTIFICATE OF DEATH

DATH Ol- I»KATH

^Wt

(Nfonth)

(Day)

I go

(Year)

^I ni':Rh:RV C1:RTIFY, That Iattcn<UMl deceased from

190 H to v^r^ 11 190 "V

VcX.

that I last saw h

alive on

T90

and that death occurred, on the date stated above, at
nJ M. The CAI^IC Ol' DlCATII was as follows

. >-> vo^^ x.<x,t <«w

ww^

(K

0

\JXJJ'

sXjy^'

-YVOw.

i\

a^

'UJLCX. ^ ^

Rr i,li<! II! S,ni I I nil, n ,,

) lUI >

yfniltfl'

Pa

Till- MiOVK ST\Ti:!> PKK^oNAI, PA KT MT I,AKS A K K TKfK T( ) TIN-
HKST 01- MV KNoWUl'.IX". J-: AM) lU'.Ml-.F

(Infnnnant \j , Vj . Kd ■ Ul<X>cJ^

(AcMrc

t

0-4KA,toJ^

I )r RAT I ON Years

CoNTRIlUTORV

I) I ■ R A T 1 0 N ^-v^ ) Vrm?

Month Si

Days

Hours

Mouths

(SIGNED)

IC)0

(Address)

uJm

/?<7t'.? Hours

M.D.

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

Former or -> . ^^ ^ M 1 ^> ♦ "•^ '""A ** » j

Usual Residence! n fluer:MJ-txX<l J I) Place of Deatli ? i Days

Wlicn was disease contracted,

If not at place of deatli ?

i)A'i'i:<)f HiKiAL or ri;m<>vai.

]'I \CK ()I- nrKIAI. OR RKMoVAI.

(A.Mress ^..H k?. My\A.A.^X^<nrV

190

.. B.-Bve.. Iten, of 1n^>..etlo„ .Hou.d be cn.efu,,. ^uppUed AGE «h„u,d be .tated eXACT^^^^^^ .rraHLt'^lo:';;!.!
state CAUSE OF DEATH in plain terms, that it may be properly classlHed. The Special Intormat.on tor p«r
aons dyinft away from home should he 4lven in ©very instance.

i!^

I

I

1»

»

[J

Mi •
I i

WRITE PLAINLY WITH UNFADING INK

!1.,h!!i !

Xo ,; ^•f'S^i; liSll' f')

THIS IS A PERMANENT RECORD

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

luUv riled, ILlclxrWv i^l

vja

Ee^istered J\^o,

.A>u Deputy Health Officer

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

Certificate of S)eatb

( tl. S. Stan^arD )

PLACE OF DEATH: — County ofOcv^v

. 0^

'.

J ^ K^\^ „ i

( ) n /%^ J (J

City of C/CL/>x^ J /v.<X>-^w^A.A,c-c

^N©.

(IfU.^^t

rt <

n t \CHLclUUi lUulu. ^ St.; — Dist,;bet. — ^"T"" and"—-

~ / I .. JcilAI oretinFNCE GIVE FACTS CALLED FOR UNDER SPECIAL I N rOR M ATIO N" \

( " VXTH"occ*'-r.V,"r„ctpVT*t o%";^n?"<,''r.'"v""s NAME .^st^.o .. s,...t .no ..«sr., ;

vHD

FULL NAME

\XX/y\JULAj

^.1-..U

PERSONAL AND STATISTICAL PARTICULARS

^l X "VN (1)1, or \

1) A 11 111 1.1 K m

iL

M.i'itl)

\^ .v.

y.ai

L
Day

.V,->////>

ai)

Ihi 1 .

sixr.l,!.: MARHI1-;H

\vnHi\vi;i» OK i)i\< •t'l j;i>

i\S'lit«ii) ^'K'ial <!( '.IL- iiali iH)

1 1

\

' Siatf <n 1 "iiuiili _\

N \\\M o|-
lATHl.K

lURlIIPUACK
oi I AlUl-.K

I Statt iir (,'<!imt! \-

MAIDl'.N XAMl.
OJ- MOTHHR

lURTHl'KAt'H
Ol" MOTIIKR
(State or r<i\tiitry)

OiHirATKIN

Resided i)i StDi I'lmnisri}

) V<7 /

yfnillh^

lh>\.

Till-: AHoVi: STATl-I) I'KRSONAl, I'ARTIcr I.A KS ARK TRUK To Till-
HKSr OH MVrtKNoWIJClX'K ANP IJb:iJi:K

[tiif.ninant Cj J<A^AJU\}

Aildrcss

MEDICAL CERTIFICATE OF DEATH

DA 11-; OI' Dl.ATH

t\.

,1L.

(I)av)

I go

(Year)

(Month)
I HI'RI'HV Cl'lRTIFV, That I atteiKled deceased from

iD.^ \b..

190 . tu V^.^^ -l.» 190

that T last saw h-£>U alive on NL.'^:'. 190

and that death occurred, on the date stated above, at
" M. The CAI'SR Ol*' DllATIl was as follows

DTK AT ION )'tars

CONTRIIU'TORV

Months

Da]

'S

I/out s

I )r RATION
(SIGNED)

i0.ot

k.1 K

IC)0

)'rars .^fonihs /hivs //ours

duOuuOiAUuL r.. M . D.

A.ldress) (K , ^K . CK^X k U ll-

(

V w

gP£;QI^L Information only for Hospitals, InstilulJons, Transients,
or Recent Residents, and persons dying away from fiome.

Former or "ow lonq at

Isual Residence Place of Deatli ? Days

When was disease contracted,

If not at place of death?

PLACE OF lU'RlAI. OR RKNfoVAL

DATHof Hi RIAL or RlCMoVAI,

UNimRTAKKR Si SJU\^\JLA^ ^^ (Iw CM^ Pk JV

TOO ■

(Address

N. B.— Every Item of Information ihould b. carefully Applied. AGE should «»« •i-*«i^EXACTLY P"Y«'f'^J,«j;'-;»;'
state CAUSE OF DEATH In plain terms, that it may be properly classified. The -Special information for per-
•on* dying away from homo should be given In svery instance.

\*i

I

t

■p*

}■

I

WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD

'Ih I- -^-'i

^ its ^*'kr^-

Dfffr Fi/rf/,{j:^:XAy^ ^%

io(r\

REFER TQ BACK OF CERTIFICATE FOR INSTRUCTIONS

-K

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco

Certificate of 2)eatb

( "a. S. StanDarO )

(5^

PLACE OF DEATH:-County of Cy<X^ J/UX^^v^ c^ City of CJ ^C^ 0 ;v<Xorv^A^ c l

and

H

TM n tl\)^ '^ I L 'W^A.A SU DisUbet — —

No* I ^ '^'^ V/V^VV Y V,\ v.. . RESIDENCE GIVE FACTS CALLED FOR UNDER "SPECIAL INFORMATION" \

( '^ r/rE:T°H^OC;u%rEV;N''rHo"s^PrAL o"r Tn^'^u'V^O^^G.VE its name INSTEAD OF STREET AND NUMBER. )

e in)

FULL NAME ^^^

SIX

DAT!-: t »r lUK IH

PERSONAL AND STATISTICAL PARTICULARS

CoI.nK \

K.

u

\

,%\

\' ,!•:

^^

1/,.,,'//.

* ' ai

/',M.

WIIH iW i: 1> t >K 1 >'• .
I Writi in -iiiKi'

.1- I'D

niKTin»nACK

iStatt or Cniitttry*

^

XXMl' t>!
1 A III IK

\ UL

niK'ni PI, ATI-;
<M 1 \ rm.:H

M \IIU:n NAMi:

Ml .M<trn)-:R

lURTHl'I.Atl-:

ni-- M(»-nn:R

(Statf or (.'ountry I

'^''

MEDICAL CERTIFICATE OF DEATH

Month)

J."
(l)av)

(Yf.-ir)

I Jli'kl-IiV CIIRTIIV, riiat I atteiKkMl <leccase«l from

*:" 190

— — — — T90 '

that I last saw h

I (p
— alive on

to

Mirn

,-Ay'W\-'<^ ^ "

Rr-iiiird in Suv /'niih "/"

Mnllfll'

Ditw

\\\V AUOVKSTXTl-Dl'HKSONAl.PAKTUri.AKs AKl-.TKIH To TIN';
IIHST <)1- MV KNn\VI,i;i)<".K AND in.l.il.l-

flnfonuatit ot O.A.>VM W i}^V>v.K.Ck

an<l that fk-alli occiirrtMl, on the «lato stated ahove, at
M. The CArSIC Ol" l>l\A'riI was as foll«nvs:

I )r RATION Ytuiis ^fotii/is Pays

CONTRinrTORV

Hours

I )!' RAT I ON ^ Yiiiys

C ft '

Mouths Pays

(SIGNED^ L<r\.trnaX' 0 ^^.UJ.AiXa ^ •

L ' ' lu- (A. hires.) U'V&^^X^ ^' vv

I fours
M.D.

SPECIAL INFORMATION on'y for Hospitals, Instltuirolfs, Transients,
or Recfnt Residents, and persons d>lng anay from home.

M I fl ^4^ How long at

OvLLa^'^ c Oh Plare of Oeatti ?

^Ol

Former or
Usual Residence

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

Days

Pl.ACKOI- lU'RIAI, OK RI-.MoVAI.

iKT.KK.O[^'^CuUU^Qfn=C&.

DATl'.ot r.i vwi. or KKMOVAI,

T90 1

.\JUX^JUr

q, -^

—"■""'"'"^ TTl ^ A AHF should be stated EXACTLY. PHYSICIANS should

N. B.— Every item o* information should be corefully supplied, ^^"^^^^^/^^^"j.'i^ ^ "Special Information" for p.r-
state C\USE OF DEATH in plain terms, that it may be properly classiticu. i ne op
sons dying away from home should be given in every instance.

I

II

i

WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD

R E FER TO BACK OF CERTIFICATE FOR INSTRUCTI0N3

2401

' i ! N'

IW^<\' C,

Dnh' rih'<l,\^<:XjA>^^ Vi

100\

Re^isfercd A"o.

<.^

\

,M , Deputy Health OfTioer

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco

Certificate of Beatb

( "U. S. 5tan^arC» )

PLACE OF DEATH: — County of

4

n.->

^

(5r\

City of O ,<X.'Vyj 0 .Kx\ ,

Tv

(

No.

St.; Dist.;bct. i — i and

VE FACTS CALLED ^OR UNDER SPECIAL INFORMATION" \

TAND NUMBER. /

\

/ ,r oCATs occuP^s AW.Y FROM USUAL RESIDENCE O.vc f-CTs called '^°« ^^^^ ^^ ^-

( IF death occurred in a hospital or INSTITUTION GIVE ITS N A M El N STEAD OF STREE

FULL NAME LCL^U^t

'^l \

PERSONAL AND STATISTICAL PARTICULARS

-s II »!.< »k

-11

It A ri: nf i;iK 1 !l

\< ,1-:

•S\ nth

1>:)%-

1/

/'.n

^ixi.i.i-: MAKKn:i>

\\ 1 III i\\ i:n <m ni\< >i<v i:!»

-U'ti:i!i.>!l)

\\

111 -' , \A

t

MEDICAL CERTIFICATE OF DEATH

I) \ II-, < It i»!'. xrii

(Month)

I

IQO

I War

may)

I IfRRHBV C1':RTIFV, That I altciuUMl <kH L-ascd from
^ ...l. Up'i tn .r\"sX '\^\.Aa,1 _ 190

that I last saw h. alive ('ii ' Ifp '

and that «!eath nccurred, on tlie date stated above, at b 1
M The C MSI': Ol' DIIATII was as follows:
^ ' Kw P . .

lUkTIIPUAOK

(Stat I- nr Cmuit 1 >

XAMl ni
1 \ III l.R

HIK I liri. MK
<)! I All II' H

• Stttl >>1 I'iHltlt! \

M \1IU- N N AMI-
"I MuTllHR

lUk ri!ri,Ari%
<»i M(>i'ni;K

iStatf or Oniuitrv

ovcri'A'rioNf^

L

Cu

S, I

"!

.%

I

,<ru w \.{r^u>v

1^

^

K.

^

/l) II

<Xa- ,
Ki-^idrd III S.n: / ' ,! n

) ,,U-^

M,nltll-

Ihn

THK XHoVKSTATKni-KKSONAl, lM<THMI.AKSAKi:TKrK To THH

ni';sT ni- Mv KNOW 1.1; I >«•.»■: and hkkii-.i-

<W:

V

r^

fA(i<iri-^s ob \J Ow^a.-'-

^

I »r RAT ION }Va^-.?

CONTKIHrToRV

Mouths

Days

Hours

DIR ATION
(SIGNED)

^

u>o

c

/)(/

)'.?

g

(Address) bob UJ^ctixNj

Hours
M.D.

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

Former or
Usual Residence

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

How long at
Place of Death ?

Davs

v.A», "*^=r I i*

iM.ACi-: oi- nrkiAL or ri-:movai

TNI > l". R l" A K K R wLtXA-m.

'U

I) \ II' of r.iKiAi. or RKMOVAI,

190

■^ 1^ 1 APP aSniild ha stated EX4CTLY. PHYSICIANS should

!S. B.— Every Item of Information should be cnrafully -PP'-d. ^^^^r;;^;^,'.',,^:^! The •'Special Information" for psr-
atate CAUSE OF DEATH in plain terms, that it may he properly wiassniea. me v
Hon* dylnft away from home should be 4iven in ©very instance.

9 — to

I

9

4

' t-

f

P

,1 .,f 11. iltli I- N

WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

<.TTr:^;JU^I'C

7.9(9 H

L^^v^ix^hu Deputy Health Officer

Registered JS^o,

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco

PLACE OF DEATH: — County of

A/^ A I ^"^

Certificate of 2)eatb

( XX. S. Stan^arD )

. City of v) <Xjy\J 0 AJX/y^^^^ ": '

u /

M Mflt ^^iAJrWj 'fc C^^i%A.t 'X' St.; Dist.;bet. ^ and

No. H I U\)- VyW. YV ^W '^'*-|^;^^ ,-_^.., residence g.ve facts called for under -specal information ■ \

( 5^ .V*D;AT°H"oc:u%;1V;N"rHo"s^PyT"At O^R^N ^ ' T U^T^O^N O.VC ^ NAME INSTEAD OF STREET AND NUMBER. J

FULL NAME

^1 \

PERSONAL AND STATISTICAL PARTICULARS

0 JL'^'^vo^'U

11

i>\ ri: « >! lUK III

\t .!•:

Lf^-

4-

M 111

I r^

l»a%

/ i-

t-ar)

Hi -

1/ ),'A

\ fa

/hi

si\( ,1,1:, M,\KKn:i)

u inowMn OK i)ivnKrj:i>

' \\ I iti ill -iK'ial ill -i;/)!;ili'iMt

lUK!" in-i, \c]-:

(stall I'l (.'"lUiitiN

\ \M1. « »1
I A III IK

lUK IHl'l. AtK

01 I \ i'm-:K
^t itt lit ^^n^!tl v

M MDi: N N \M1',
«>1 Mnl'iniK

I'.iK inri.AOK
Ml M<)rm-:K

( s(atr or i'muiti \i

nOCt TATION

MEDICAL CERTIFICATE OF DEATH

DATI-: 01 Dl-.A I'll

( Month)

(Day)

(Year)

I in':kl':HV CI'.KTII'V, That I aai-niUd «Ui-<.asc«l from

to W 'CX I'l Tip H

) iiii

.1/.. /////■

/).;

Tin- XHoVKSTATHI.PKKSMNAI.l-AKTirrUAKS NRK TKIK To TIlH

ni:sT oi- MY kno\vi,i:ik;k ani) lu-.i.n-.i-

! ■ ' ■

that Ilast saw h ■• alive oil ' ' 19° •

aiiil that (k-ath nrrurre.l, on the .late <tatc«l above, at ^' ■■ 0
M The C MSI-; Ol' Dl^ATII was as follows:

<0-V.Nw'

^'wCIa.aJC-1

i.. ,»„ >„ »■

Dl' RAT KIN

)'('ars

Monl/is

»LYV>.ArsJCA^<

Pays Hours

Xh«<i\Ui-<ow

nr RATION

(SIGNED)

Ytars

C.C^c

Afoiilfis

Da vs

I {ours
M.D.

KjO

(A<l.lress)lOl I) a-AvM\i<ia' 11.

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

Former or ,, - C H ^ ^ ^ . ' ' Sf 'T/..7 H n

Usual Residence 1 \ 5 cj - ^<s^^ vo . piarc of Death ? U Days

Wlien was disease contracted.

If not at place of deatfi ?

DATHuf H! RIAL or KKMOVAI,

^K ^ " ' I go I

1*I,ACK 01- niKIAI, OK KKMoVAI.

,.0, — nui \jfTu^.cL.^A-^, - ^

N. B.-

"~~— "— ^ TT KC.¥ should be stated EXACTLY. PHYSICIANS should

-Bvery Item n? information .hould be coretully HuppI.ed ^^llr'lll^r^^^^ The "Special information- for pT-

state CAUSE OF DEATH in plain terms, that it may be properly Uass.tie

son. dyinft away from home nhould be l^iven In every inst^ince.

^>

r)

^

^

I %

iiii

It

WRITE PLAINLY WITH UNFADING INK-THIS IS A PERMANENT RECORD

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

I)

lOOH

Picc^isfct'cd JS^o.

^403

DeDu

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco

Certificate of 5)eatb

PLACE OF DE ATH : — County of

aa^\.

*> rs

\

No.

I ? t\\

\

\

City of ''

■> \^ a ^^.

^'V\

St.;

Dist • bet ^^^

lON-
R.

)

FULL NAME

U

.m MX

PERSONAL AND STATISTICAL PARTICULARS

LX

I) \\\. < >I I'.iK IH

A « . !•:

Mi, nth ' i

1 n Y

wtixiui: n mk i)i\»»Ki HI)

iWritt in MKiiil ih -ii.'iiati(»n)

iDnv)

M ,uffi'

■»'. al

/'(/I

WEDICAL CERTIFICATE OF DEATH

DATK <)1- 1)1;ATH , \

(Month)

(Day) (Ytar)

I HRR1;BV Cl'RTII-V, That I atten<k'.l fU-rcascd from
^ -y \'^ up'; t.» . W/ci^ \% T90H

that I last saw h -S-^- alive on wcL 190^

an.l that <Uath orcurred, «>ii the date stated above, at ^ •'^ ^

lUK I'Mj'i.xri:

(Stati 1)1 r. Hint I v

NAMl<; Ol"

I A'rni:K

BlRTHI'I.AtK
OP I AlllHK

(State or Coiinti V

maii>i:n' NAMi;
oi" MO rut: H

HiK rm'i.Ari-:
oi' MoTm:K

(State or i'oiinti v

m 0

<xaK^^ ^^ '

iO

()(.A'ri'A rioN

r 1

M. The CArSI-: Ol- Dl'iATII was as follows

nr RAT ION >Var.9

CONTRllU'TORV

Months

Days

/lours

DIRATION
(SIGNED)

L-l u.

Vi-ars Months

Piu

•s

Hours

190 i

/NX<iWlo.- . ._ M.D.

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

y

KfsKtfif in Sati I'lami^rn

) < 1! •

Mnillh'

Ihn

■lM,KAm)VKSTATHIM.KRS<,XAI PAin-UMM XRSAKKTKIH TO

r 1 1 H

(Info; tnatit

n

Oc

(AddrcHS

Xj\> kLaj^

Former or
Usual Residence

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

How long at
Place of Death ?

Davs

n.ACK Ol- BIRIALOK KHMoVAI,

l)\l'i;o!' liiKtAi- or RKMOVAI,

(AiM

less

1X0^^

(y>Xv^iAA^:>A^ 11

,. . The should be stated EXACTLY. PHYSICIANS should
N. B.— Every Item of Information should be CHrefulIy -PP^'-^- JtofXclss.mcd. The ^Special Information" for p.r-
state CAUSE OF DEATH In plain terms, that .t maj »»e P^^P^"^ ^
son. dying away from home should be given .n evry Instance.

Honr.l • Ihuth

WRITE PLAINLY W.TH UNFADING INK-THIS IS A PERMANENT RECORD

REFER TO BACK OF CERTIFICATt FOR INSTRUCTIONS

2404

r^-X.-ns^vc.

100 \

Ee^istercd JS^o^

n

1 1

DEPARTMENT W PUBLIC HEALTH-City and County of San Francisco

Certificate of IDeatb

( H. S. StanDarD )

vor.

PLACE OF DEATH: -County of'^^aav .lv<V>vc^4C. City of

Q/CX^^ 0 AXX/'r

1^

\j

St.; H

lli

FULL NAME

)

jttW\_x.^v \^<x^\^

^ I , \

PERSONAL AND STATISTICAL PARTICULARS

M\l<xU

I

^

DAT!. ' <l 1.1 Kill

\r.]'.

L

HI

l»;is'

\',',if'l

all

/),,!

MEDICAL CERTIFICATE OF DEATH

DAl'K nl- DHATH h ^

(iniv>

(Year)

(Month)
I in-;ki:rA- Cl-UTll-V, That naUiKUa .Uccase.l frmn

.. la up H

f

0

■-IM I.i MAKHIl'l*
Ui ] )i iU }• I) « >R 1>'N'' ''•■' t" '•
\\ nti in -I >i-i;tl i|( ^i^' inl ^"'i i

I

ink rm'i. xoj"

-,t;lt( . «! ' I .imt I \

\ \M 1 « »:

1 AIM I'K

lUK niri, \v'K
111 ! \rm:K

si itf ■ >! i'ii>l!ltr\'

MAtT>TN NAMl*.

oi M()rni-;K

lUKini'LAri",

<»l- MO'nil-.K
(Siatf or iNiuntrv

J!: \

fl \

190'! tn

that I laM ^aw li .• alive- o„ V„ : ■ I up^ ■

aiul that ac-ath -HTurrcl, nti the date' statc-.l ahove, at o .LU

M. The- CAT SIC Ol' Dl'lATll was as follows:

DT RAT I ON JV<7r.s

CoNTklinTORV

M on tin

Days

flours

1Q\

XX uo^j^ ^

^Yl u ...

DIR \TIoN >''"^ ^ JA>;///'^ ,

/?<71',?

(Signed) ^

..'a. <

\

l^ ),ct

KjO

fA.hlrt'Ss) lib

V

Hours
M.D.

5,

\t

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

(HATI'ATIOnCJM ,

Ri-.nh-.f HI Sail I'l <■'" '''■"

Mnllfh-

/I-/'

lU-STol- MV KNOW 1,1. IX. 1-. AM) LUJll
(Info.inatU O. 1 ;.(; i > ' ^

Former or
Usual Residence

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

How lonq at
Place of Death?

Davs

I'l.ACH <>l- liTKlAI, OK Hl.MoVAl

crl

-Mr '-

I

rsDi-.K rAKi:K

( AtUlrt'ss

l)\ri,..: lirinxi. <jr R l-'.Mc >\'AI,

y,rt

t.t

190

u -Cu >aJL >

. , . ^ stated EXACTLY. PHYSICIAfNS should
f i„form»tion should be carefully supplied. ;'•••;""' .fj^j. The "Special Information" for p«P-

OF DEATH in plain terms, that it may be properly uassm

:r'iH^; »-;; w,:™'; ;hou.j .. .!«« ,« ...r, <„...««

I

I

\

m

WR.re PUA.NLV W,TH UNrAD.NG .NK-TH.S .S A PERMANENT RECORD

,111, ,'tl) I ><»• I'- - M.--^: - •

REPER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

Registered JS'o.

O

405

dwVU-Ui

19 fA
cLw^ cUakj Deputy Health Officer

DEPARTMENTOF PUBLIC HEALTH-City and County of San Francisco

Cettiffcate of Death

( "CI. 5. StanDarD )

PLACE OF DEATH: — County of

No. ^^^

et

City of

' .... •.■-bCO

^-N^

)

V n ' A ^ 1 C ' St.; UlSt., ^^* "^^ under "special INFORMATION" N

V IF DEATH OCCURRED IN A HOSPITAL OR I ^ ^

FULL NAME

PERSONAL AND STATISTICAL PARTICULARS

--lA

/'

r* ti,< »k

n^

DATl". <'t lUKlll

L.

I

iMonllO

\(,i.:

"7 ^

'l):iv

M.mtli*

'I'l al)

/)rT )•

MEDICAL CERTIFICATE OF DEATH

■ (Month) '^'■■'^'\ -

^ I mUU-HV CliKTlFV, That I attenacd deceased from

— to - ■

(Year)

— 190

sINi.i.l- M.\RHIKI>

W inoNVl-'.l) <»K l)l\ < >R« l-.l)

I \\ litt in -ocial (lt>.i'^Miatii>n)

n -

A

that I last saw h —- alive on

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

[ siv OF i)I':at

-IQO

-igo

M The C\lJ^lv OF DI^ATIl %vas as follows

A,^r>\.

lUKTmM.AOl',

'St;itc or <'iiunti V

I- All! I-,R

1

J M

n

I )r RATION >"^'^"

CONTRUUTORV

Months

Days

luk riii'i.Ac K
01 I Arni.K

(Stati ii! Oo\intry)

M\1I)»"N NAM1-, /'^

<)1' MOTHKK I

1UKTHI'I,ACK

oi- M(>rni-".K

'State 111 Cutintry)

la

\

Years Months

nd ^ i\ n

Dl-RATiON

(SIGNED) X'. to. llv^^^';'

— i...,-^DiuiaxiftN only tor Hospital?,

Davs

Hours

Hours
M.D.

"Special Information only torHosM institutions, Transients,
or Rerent Residents, and persons d>ing d«ay from liome.

( K

) , ,11

yr.nit/n

n.rs

HUST OlL^tV KNOWl.l-IX.h AM) i.«.'.

vJ /<xA'N^^>-^'^

Former or
Usual Residence

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

How long at
Plaf e of Deatli ?

Days

n.ACK OI- HVRIAI.DK RKMOVAI.

!> i

■Aa<lrt"^H T^v

)t

i> Lo.

DA ri: of UiKiAi. or RHMUVAI,

u

190

ci

lam

1 — — ^■^—n 11^^^— ^^^'^^"^"'^ J pvACTLY PHYSICIANS should

I

I

B

«<:

m

i

WR.ximv W.TH UNrAD.NO .NK-TH.S .S A P.BMAN.NT RECORD

*" TO BACK OP CERTlFICATeFORINST

,i,\ .,f llralth— t- N'-'

.. *-tJ»^n^*^''

190 ^i
h Officer

WKFER TO BACK

Re^Lstcred JS^'o,

ST RUCTIONS

2406

Dale /•V/c'/.i'^tfrtx'v 1%

Xo^'-viXt'VKi Deputy cc C Vo/i

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco

Certificate of Beatb

( ■U. S. Stan&atS )

, ^ n ^ v*^ \ - ■ City of 0<^^. i ;vo . ,

PLACE OF DEATH:— County of ^-O. ,v .

No. 5vDbb M I L

St.; I ^'"•' °^_. .„. „„„ti "SflCI.L INfO.M.T.ON ■■

t .-.

)

J Ins - St.; I L>ist.;Dei. .„: ";I".„c..l ,Nro.M.T,o«- ^

,'0

FULL NAME

kt' '^' '■ '. (jX-ctVcUj <xm.<i'

U

+

PERSONAL AND STATISTICAL PARTICULARS

« «

SKX

DATK «>I lUK III

ll:

I Ml .111

A<,H

)■,.;.

Dav)

M ,„i/,>

I

\\:i\

Ihivs

J go

(Year)

MEDICAL CERTIFICATE OF DEATH

I>ATH nl- DHATH iM i

(Month) '^^'^^-^

I m.'KI-HV CHRTIFV. That 1 aUencK-a deceased from

to ^^ -(^ "^'^■

190

slS(.l,i:, MAKKIi:!*

Wiit.in -•MUtl (U^ivrnatiiiiu

' 1

NAMK ni
FATHJCR

BIRTH ri,\iK
Ol" FAIUKK

ISlati' or 0(»\uiti y

HIKTHPI,ACK
Ol" MoTHKK

(State or Co\nitr>

^

MoTllKK J(i ^K i ,

T90

that T last saw h ••■ alive on w.'^>^ ' ' ^^p

and that death occttrred, on the date stated above, at
" M. The CArSI- t)l' DI-ATH was as follows:

G^AX'^>-<xt^^-«^^-^ ■■ ^ *-^*^^^

DIR.XTION >Var5

CONTRIIUTORV

I)IR.\TI()N >V«7;'5

On

.}/on//is

Days

.^TYy^^^y^^--^

I'

Pays

I'CX. » v-i-..

Hours

Hours
M.D.

rA.l.lr.^sliO^S d^ujiiK) d

(SIGNED)

C/Cl: i l^ H)0 — . ,

■ c;pECIAL INFORMATION only tor Hospitals. Institutions. Transients,
or Rerenl Residents, and persons dying av^ay from home.

ore I TAT ION

)', III .

Mnlllh'

/).n

(Iiiformntit

k-oo

Former or
Usual Residence

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

How lonq at
Place ol Death ?

Days

ri.ACK Ol- lURIAI. UK KKMOVAI,

to

xs* "o^jJ^kju^ ^t.

INDKRTA'^l"

jkjlXXm.

I)ATi:oi HiKlAl- or RKMOVAI,

iqJtiXi^

^ ^'''''"^'''^ ' III III PHYSICIANS should

/

i<

w

RITE PLAINLY WITH UNFADING INK

THIS IS A PERMANENT RECORD

HEFER TO n ^..^.cr^rr FOR .N3TRUCT.0NS

190\

h Officer

Jicaistcrcd •A''o.

240?

DEPARTMENT^OF'pilBLlC HEA1JH=C^^ and County of San Francisco

Cevtificate of 2)catb

<0 r. >-v^ 3 YO. >%/CA,s City of O O^-v 0 .
PLACE OF DEATH: — County of^ <X>^ J-^<^ ^^

LVve

"^l.X

PERSONAL AND STATISTICAL PARTICULARS

1 (

I

iixii-: of r.iKTn

.L,k J .

M.infhi

MEDICAL CERTIFICATE OF DEATH

DAT1-: <>I- 5>1'.A1II

ly^

\' .1-

1^

),„.)

I Dav

M.itilli

V> ai

/',

-^IN^.1,F. MARK IF I'

\vn)(>\vi.:i) <»K na "K^hi*

(Writf in -.K-ial .1. -uMnaion)

i

J HiM^FBV CKKTIFV. That 1 attended .Iccvascd from

f, Wet IH icp'i

190 . tn ^ '5-^ ^

that Ilast saw h .... alive on ^ -^ >

,„a that death occnrred. o„ the date stated above, at
•" M. The CAISI- OF IM-ATII was as follows:

( ■»

i

niKTHPLACK.

(State nr Count! v

NAMH «»l
I A rilKR

BlRTHl'I.ArK
iW I AinKR

(State or Cotinti y

M MI»»:N N'AMl-.
<»1 MoTin-.R

lURTIll'LACK
(.1- MoTHHR
(State or C<nuJtry'

oiClPATION

Oa.r\j O.^Ow^^<^^*-

CONTKllUTORV

Months IH Pays Hours

DIRATION

y lit IS

Jfot/Z/is

Davs

(SIGNED) lU_^cLWlm^'.----

IH ,00^^ (An,,n.ss)MvVulUl

Hours
M.D.

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

) 'lUI 1

M.nitif

I'^l

:.», fXRinri NRS AKi: TRl K l«> I HI.

IHST t>l' MY KNOWI.I.IH.K AM) lU.Mi-t

(Infill ma Jit

JX^

Former or
Usual Residence

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

How lonq at
Place of Death ?

Days

I'J ACK «)!• nrRIAI. OR RHMoVAi.

(0

\.«-^

SL

DA'llKof HrRlAl- or RI''Mo\'AI,

0

/\w

tmm

(AcUlresH M I UU • f \^ ^^ * ^ fXACTLY PHYSICIANS should

l!

I

1

I

iL«

w

RITE PLAINLY WITH UNFADING INK

I'-M

,,1 ,,f !i.-:n. r So. '^ ^5^^^' n^c!' c.

lutlr /'V/r^/.ljctxjrU^ ll

2.9(^H

THIS IS A PERMANENT RECORD

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

DEPARTMENT W PUBLIC HEALTH=City and County of San Francisco

Cevtificate of 2)eatb

^

(^

( Ta. S. StanOarP )

PLACE OF DEATH: -County of 6 C^^ ^ ^^Cu>x^^^Gty of O Cv^ 0 A.a^v^^^

% ^ i if.

a,s ■ 1 . •■> ' St.; ^ Dist.; bet. J Crl4.Cm^ andyO<?^-

rNSTITUTION Give ITS NAME INSTEAD OF STREET .ND NUMBER. J

(

IF DEATH OCCURS AWAV FROM USUAL RE!
IF DEATH OCCURRED IN A HOSPITAL OR

r- /

t I , 1^

%

FULL NAME

wC^

X^^C

si:x

I) Nil ( >i r.ik 111

PERSONAL AND STATISTICAL PARTICULARS

U

Ix

I

wA_

/I5'i

A<1K

Month

5'

( l);iV

M.itiUl:

\ < ar

/>,n

siNc.i.i'. M\kun:i)

lU'iitt in ^iiiia! dt^ii.' rial ii ui)

niKTinM.A'i:

(stall f»r Oouuti \

MEDICAL CERTIFICATE OF DEATH

DA'II-; «)I ni'.ATH

(Month)

(I)av

IQO '•

(Vtar)

I lIlCRiUiV CICRTIFV, That I aUeiuk'.l <k-rcascMl from

lilct ' \ icpH to iQ/^ a 190H

[901 to xy/ww y i. I90

that 1 last saw h • alive on V»^^ '^ I90

a«i«l that death occiirreil, on the .hite stated ahrn'e, at
M The CMSl-; Ol" I»1';A rn was as follows

' ' u ■ '

,\_SL W I --■

W

C '

v^A-,Lix. » wd.

NAM1-: ol-
FAT II J K

niK rin'i.Ai"K
oi' 1 \riii".K

ISlatr ()! i.'<iulltl V

ma!ih:n nami-; a
(U- MO Tin: K

HlK'l'mM.AC'l-:

()!■ Mol'Ul'.K

I "^latf i>r t'otiiitry'l

ocrrrATiDN (^XP

DT RATION ^ >'«''W
CONTRUH'TORN

I >r RAT ION 3^ Yean

I/oins

- f

(SIGNED)

nrrg

Months

IhlVS

^^\A

Hours
M.D.

190 i

( Address) T 00 (fb-OA>tUlC>V dt

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

cx/vvxL

Rr.-idfii in San /'iitninrn - ! '<"

*■ Miuifhs - l'hi\

TUl- \noVK ST\TJ-I) I'KKSONA!, PA KTUT I , AKS .\RK TKl H To TIIH
linST 01 MV KNOWIJ'.IX'.K AND lU l.Il'.K

(ItifoMnant

Former or
Usual Residence

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

How lonq at
Place of Oeatli?

Days

PI^CK Ol' lURIAI. OK RI:M<»VA1,

l)\ri of HrKi.A!. or ki:mo\'ai.

U^t V\ too'

(AddresM

n B —Every Iten, of Informntlon should be carefully supplied. AGE should ^•\^^-±^''^^2'^^^ \ . ^"""^ nLt^'lf n^I.**
state CAUSE OF DEATH in plain terms, that It may be properly classified. The "Special Information for psr-
sons dying away from home should be given in svory Instance.

iv

i

1 ti

I

WR.TE PLA.NLV WITH UNFADING .NK-TH.S IS A PERMANENT RECORD

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

li)0\

Re^islcrcd J\''o,

2409

1>v^j1wu Deputy Health Officer

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco

Certificate of 2)eatb

PLACE OF DEATH: — County of O-CLA-v v. /VU. >\ - A.ity oi

(Ho. ^^^

^u^^x^

LLvTV^vLlvCti- St

Dist«* bet* ^^^

)

V IF DEATH OCCUhRtD IN A HOSPITAL

m

FULL NAME

x^LcfXj Ocrw-koX-a

PERSONAL AND STATISTICAL PARTICULARS

^

DAil. <>l HIKTII

A<'.H

I I 5 v.,

siNCl,!'., MAKKIKU.
WIDOW i;i) OR IMVORi. i-:i)
(Writtin social (It-i^'natiutO

iDavi

M.nith^

W-aXi

/hn.

MEDICAL CERTIFICATE OF DEATH

DATK <>1 DKA'l'H ,i^

i

(Moiitli)

i I

(Dav)

/(?o

IVt-arl

I lll-KiaiV C1:rT1FV, That I atUu.kMl .k-ccasca from

Ax\ :- 1'^ 190H to i)^ ^^ 190 H

niKTin'i.xoi-:

(Statf or (,'ouiUi V

NAMl-: OI-
lA THKR

niRTHl'I.AOl-:
OI- I AlIllvR

(Stal« or I'onntrv

MAini'.N NAMI-:
(»l' MorilHK

HIHTIiri.AfK

OI- Morin':R

(Slate or Country^

0

that I last saw h ^ ' ^ -alive on

diet

T()0

aii.l that .loath occurred, on the .late stated above, at
M, The CMS!': OV UICATII was as follows

Kj \ O

or RAT I ON Vrars

CONTRMU roRV

Months

Days

Hours

,'y ' 1

O.

Df RAT ION
(SIG

Years

NED) Id. WP. Cc.

Months

Days

Hours
M.D.

Uct

iqo

(

Addns'.) \Xj^'

W-v.A^ >'V^> v^^^

SPECIAL INFORMATION only for Hospitals, Institutions, Transients,
or Recent Residents, and persons dying a*ay from liome.

OiClTAiloN

h'fsiileii h' Sill! I laihisf'i)

)rii,

Months

/hn.

run AHOVK STATKU »'HKSONAI. rARTirr KA RS ARK TRIK TO
UKST Ol-

TIIK

: ^jv KNO\vi,i:i)<'.K AND HHUi:!

^

( Xddri-ss

■\K-ii.L

Former or
Usual Residence

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

How lonq at
Place of De^th?

Days

PI \CK 01 mRI.\l, OR RKMoVAI.

cJk, J^'wN

DAXHof Ht HIAI. or RKMOVAI,
U/C^t U 190 A

l-NimRTAKKR ^JUILUX.^'^ 0^

-I

(Aclilrt«<s

N. B.— Bv.ry l..m ol t„lor„,a.lo« .hould be cr.Su.ly -"PP"«J; *°p^.Hj7l«^m'i?''Thr*8p«U< InZllfJnon-Vr pllr-
•tatc CAUSE OF DEATH In plain term., that it may be propeny ..
.on. dylnt »w.y from homo .hnuld be »Iv.n in .v.ry In.tanc

ii

B 1
H

I

HcMtn

.,f H* lUh !■' N

7R,Te PUA.NLV WITH UNrAD.NG .NK-TH.S .S A PERMANENT RECORD

-„.„ .^ ■.... nr CERTIFICATE FOR IN5TRUCTION3

J^4lo

*" j"^

;3u;U.'^i'''

Be^istcrcd J^'o.

Lv^va1-v>. Deputy Health Officer ^

DEPARTMENT OF PUBLIC HEALTIi=City and County of San Francisco

Ccutificatc of IDeatb

i XX. S. StanDnr^ )

PLACE OF DEATH: — County of

i^^» ^ . . ...,.v t-BftM us

jLla^

A

1

City of ^-^CC

k

,a.^ V\

St.

Dist.; bet.

— and

)

V ir DEATH OCCUBRtD IN A HOSPITAL wn ^ "^ D A

FULL NAME

4

-^

jiKX

PERSONAL AND STATISTICAL PARTICULARS

n^

DATi: or 1'. IK I'll

i

flA^

I M..iUh>

\<.K

bl

^IXi'.l.l", MARKIKI).
WIDtiWKI) •>»< ni\ 'ikrHI)
iWritt ill -..iKti (I'-U'iKinon)

lUHTiiri. \t'i-:

H

lie

Day

M.,tifh

fVear)

MEDICAL CERTIFICATE OF DEATH

DATI'. oi" i)i;ath II ,

(Vr:ii

/'</

(Month) "»•'>•'

I IIHKlCnV Cl.RTlFV. That I alten.k-.l .UcxascMl fmm

t,i ..^——r-r-rrr-r-:

Itp

rep

n

i

N XM 1- ' >|
! Alll I.K

luR'nnM.ArK
(u 1 A in »•",!<

'^la1l Dt I'nimti V

MMKI.N N\M1-
nl MnTHl-.K

HlK'rni'!,A(.l-,

«)i- M(>'rni';K

(Statf or ("ouiitryi

V

0

that 1 last saw h -.7— alive on — ' ^^

.,„d that <U'atli occnrrcd. nn tin- .laU- .tatcl above, at ^-
* M. The CAISIC <)1- 1)I:ATII was as follows:

^- .^C

DT RAT I ON >V<?r.9

CoN'l'Hir.l TORY

Months

Days

Hours

<X/^^^^^

jL >AV>^AC >V^

(^

nruATioN

Yt-ars

(SIGNED) ^^v^^ U). Oi"-"^

Ar,>f/i/>s /^ays

Hours
M.D.

i'^

T{)f>

ijuxtiift

M,<n(h>

n,ty.

liKST Ol- MV KNC>Wl,i;i)l-H AMI lll-.I.U.l

^)(K<

(Address

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

Former ©r \ u i /s ^ n Jt 1 , ( 1 -
Usual Residence \H 10 AKMKA.

Wlien m% disease contracted,

If not at place of death ? ^

How lonfl at
Place of Death ?

Days

!•! \CK OF lUKIAL OK KHMoVAI,

•LACK Ol- 1

DA 11/, of UiKiAl. Ol KI'.MOVAI,

^,

\Hlb- tXL UwV ^

INDKRTAKKH J /O.-Vvt'^nJL^

\,

i^B^^^w— ^^■•^■"■^■^■'"■"■■■"^■'^"'^"'^"'""^"~'^'^""*~"'"'^'"'^^^ w I 1 K t ted EXACTLY PHYSICIANS should
„. B— Bv.ry U.m o. ,„W,n...on .houM -;■-;•';'-'; ^^^^'^^'l ^1Z'^yZ»'^'>''^" The "Spec... lnW,n..i„„" .or p.r-
■tate CAUSE OF DEATH In plain tcpm.. that it may ™ ^ '
«n, dyint away «rom hom. .hould be »lv.n .n .v.ry In.t.nc

I

H

i
i

i

If i

RITE PLAINLY WITH UNFADING INK

THIS IS A PERMANENT RECORD

REFER TO RACK OF CERTIFICATE FOR INSTRUCTIONS

jUifr /'V/r^/xlcttrWv \%

lOO'i

Jlcdisfet'ed J^o^

f'-^^J — L-

Dep

DEPARTMENT (JP PUBLIC HEALTH

=City and County of San Francisco

No. ^5(]\v, ■

Ccvtificate of 2)eatb

J <n

City of O XX^.-u 0 /V<V^N

I

PLACE OF DEATH: — County of O^^a.

St.;

>ID

NS

)

«Jl«i ' *' ' ' _ ..^nra ""SPECIAL INFORMATION ' ' \

FULL NAME^ ^^"^^^

•-1 \

PERSONAL AND STATISTICAL PARTICULARS

^l

all

.IkiXt

li A 1 1 , « i! r.i K I II

A«.i';

Mi.tUli

55

\ .

Dayl

M ,>iiii'

1 Vt-av

/),/!-

MEDICAL CERTIFICATE OF DEATH

DATK nl' Dl'.ATH

1 L
iDav^

(Year)

I mU<l'BV CURTIFV, That niUonacl accvascl from

S1N<M,K MAKKIKU.
Wn>t»\Vi:i» OK 1»|\<»K* l-,I>
■\\ 1 w in -...rial dr^irnat i. >!i >

ri

I stall- oi t'ontitl V

N \M1 <•!■
1 \ III l.K

H1K riU'hAil'.

(»i 1 \ rm-.K

MAI1»»-.N NXMl
()1 MoTlll'". K

.c>^cy

\ \

<ik\jxx)

4 .

.K;.^^ i 190H to ^^ n T90H

' V „ ^'^1 •• 190''

that I last saw h ahvc o„ v. . . ^

,„a that .U-ath uccurrc.l. o„ the .late state.l ah.>ve, at

M The CAISI- OV DllATll %vas as folUms:

I )r RAT ION I ^''■'^'
CONTUIIUTOKV

I Jours

^xLo. . ^

^\. >

w

)V<,r.« J/,.;////H 10 /?^n'.s- Ifoius

lUKTinM.AeH

I Stat. Ill i'lninli N

DI'RATION

(SIGNED) V^^^^^ kO^C^a, .x.

lij.ct) \'l ion H (A.Mress)

M.D.

. NfVUA^A^>x .)i

SPECIAL INFORMATION only for Hospitals, InsUlutlons. Transients,
or Rerent Residents, and persons dying away froni home.

^r,>^^f/^'

/>,/

^^^^^in^W^^

Former or
Usual Residence

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

Now lonq at
Place of Death ?

Days

(liifiitmatit

i!i.ACH in- nri^iAU or kkmiaai

!t\'n.'>S Hi HIAI. or Kr.MoVAI,

Pl^XCH in- »i H'^'

QfU^

^U^>A.

'. t "

WM

::■„'.'-""." °. .«" Hon,. :HouM b. .<v.n > -n.

itaitce*

I

I

I

WRITE PLAINLY WITH UNFADING INK

,.,] ..f 11. '.Uli I No I- ' "'••'^•*--/ II - --

THIS IS A PERMANENT RECORD

REFER TO BACK OF CERTiriCATE FOR INSTRUCTI0N9

241^

DEPARTMENT OF PUBLIC HEAlJlWity and County of San Francisco

Cevtificate of 2)eatb

( -U. 5. StanDarO )
PLACE OF DEATH : - County of ^ .^CV^ >J ^^^ - v . C.ty

(U

l1

St'

c "n'+.iv»f o ^^ y\! and v; A. »

■n ^ Q \ K /-> ^ St4 UlST., DCI. „^.„rR "SPECIAL INFORMATION- A

)

FULL NAME

,cCtKinj^x.i 0)u

1 1 '

PERSONAL AND STATISTICAL PARTICULARS

COI.oR \

-i:\ ^^"N,

1

*
n.Mi", <»!•

liiK in

"1

-Month*

-

)'r,lt

i

%

WlDoWKD nk DiViiH'in

W ; !!'^ in v...m:>' M.-U' ii:it ■■ .n i

11

.L>V<

1/,,,'//

5.(^

( V, :ii

I hi \

I go

MEDICAL CERTIFICATE OF DEATH

DATK uF 1)1- ATH ^\ , . ,,

\j^ ^ ' - - ^

;:,■ ,,x (Davl (Year)

(Month) •

1 ni'UKBV CURTIFV, ThaM atten.Wa dcccasea from

to t^ Cfc 11. TOO H

A

ICJO

lUKTinM.AfK

( Stntf or t'onntry

NAMl" <»1*
i A IH ):k

BIKTHIM.AtH
<)1- lArill'.K

•Stall or i'ounti V

MAIDI'N NAMI-:
Of. MuTIIKK

lUKTmM.ACH
()!.• MnTllKR
(Mati or I'nuntryl

I)

3

^•'

190

that 1 last saw h alive on ^ " ^'^

ana that .U-ath orcurre.l, on the .lat. statc.l above, at ^
M. The CAlSIv Ol- Dl'ATH was as follows:

(J

0

CU>^|

\

I vJ

\ 1

I I ♦

DIR A rioN

) 'ears

Months />'n'?

.ir,)?i///s IH A7V.S*

/fonts

Hours
M.D.

5V.r/. II ■^/'"■•'^'^ '

/),/!

OCOri'ATION

Kfsiiifd n, S,ni r>>nni>^.>

BKHT «»l- MV KNOWM.IX'^ ^^'' "^^ ^

(Infurmaiil

IaxI

DIRATION >^1'''^

(SIGNED) V\. ^ ' ' '^ 'M

W/ct> !t Too't (A.hlri-^M ^

■ SPECIAL INFORMATION «nlv for Hospitals, Institutions. Transients,
or Recent Residents, and persons dying a**a> from liome.

= 1

0.0 K

Former or
Usual Residence

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

How lonq at
Place of Oeatli ?

Days

\,l,lriss 61a.

iXXAX. ut.

PKACH «)1- niKIAI. OK HHMi»VAI,

iJAlllKt HiKiAl, or KI-:M«)V\I,

'-'/cXj ' \ T90'

— ^^^^^^i— 1^— — — *— *'^'^'^***^*'^^'''^^*^ ^ I FXACTLY PHYSICIANS should

•tnte CAUSE i^r »''^'^ •" »* u u- aSv.h In avsry instance,
•on* dying -way from home .hould be given In .very

i

I'

ii

I

WRITE PLAINLY WITH UNFADING INK

I90'\

THIS IS A PERMANENT RECORD

BCFER TO n»r.K Of CERTIFICATE TOR INSTRUCTIONS

Meo'Lstcred ^'^o. -w'iXO

♦»i

I'JJ

DEPARliENT OF PUBLIC HEALTH=City and County of San Francisco

Certificate of ©eatb

^ "d. 5. StanDarD

Q^

PLACE OF DEATH: — County of Ca^^ o \

City of '^<^^ OX.CL *■

V

\ / ir DEATH or--

\ V IF DEATH

St.* — Dist.;bct.

and

)

OQpURREP IN A HOSf 1 I""- w y

FULL NAME

AXXTTAJ . . HAJ"*

PERSONAL AND STATISTICAL PARTICULARS

MEDICAL CERTIFICATE OF DEATH

\a£x

a

I

i>\ri: nf- lUK rii

I Month

l):i\

A<",K

) , ,;»

M.'iitli

(Vear)

/'..

DATH *>H ni'.ATll | \

(MontiO

(Day)

lYear'>

<IN(.1,H MARUU-.n
WinoWKD OK l)lV<.K.l-,!>

,\\n!f iti vo.ial ihslv"ali.>ti >

lUKTiirt.AOi-:

i state or rDunli y

1 ATlll-.R

HIK rUIM.ACl".

ni-- 1 AruKK
(rttatf or Oounti v

^

XXXXA

mo

I HFRFHY CKRTIFV, Tlud I atten.lca cleccased from

that I last saw h. ahvc on ^ -
a„a that .k-ath occurre.l. <.-t the .late .tate.l above, at 1
M. The CAi:SI< 01^ DHATll was as Mlnws:

DIRATION Yeats

CONTRllU TORY

Motiths

Day

Hours

[}K\.Qm yocrv

U;

MAIDJ'.N NAMJ:
OI- MOTIIKK

J!

lUK rm'J.ACK

01* MnTHlCK
(St:tti- or fouiitryl

DIRATION
(SIGNED)

\Dcfc

Month:

/yavs

3. ^. Lr^^i-o. .

//ours
M.D.

T90

(

A «ia ress)JXi221±ili

"<5PECIAL INFORMATION only for Hospitals, Institutions, Transients,
or Refent Residents, and persons dyinq a^ay from home.

oCOtl'AIION

R^sidfii III Siiv I mil' '"'•'

Mnllth-

I his.

Tin-:

Former or
Usual Residence

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

Now lonq at
place of Death?

Days

(Informant

CLL^aa.!"

V\ \CK «)!• lUKlAI, OK KKM«»VAI,

l>Ari%<>f HTKiAi, or RKMOVAI,
^, * T9O

n

^"^'^'''^'^^ .^ . * ^ FVACTLY. PHYSICIANS should

state CAUSE Of un"'" •" aiven In •v«py Instance,

.on. dylnt .way from homo -hould be ftWen >n . . »

t

I

M

■^■^i^m

WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD

nikvc, REFER TO BACK OP CERTIFICATE FOR INSTRUCTIONS

No < *

i

\%

IfJO'i

Bcgistet'cd JS^o,

r::j

Deputy Health Officer

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco

Certificate of 2)eatb

^

{ "U. S. St^n^arO )

PLACE OF DEATH: — County of a

City of a-

(•NoAttl

L 'k Urtc -y

^tu

1

\^ > » uM.

St.;

Dist.; bet.

XO- >xct,,u

and

/ ir DEftTH occults *WW*V rROM USUAL RESI DENCE give facts called for under special I NrORMATION" \
V IF DEATN OCcklRRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. J

FULL NAME

PERSONAL AND STATISTICAL PARTICULARS

^i;\

C'Ol.i »k

^

a

I».\T1-: nF- I'.IR 111

A(.H

iM.mth;

1 \

f

MEDICAL CERTIFICATE OF DEATH

DATK OI" I) HATH

ly.ct

J,

14' ar)

/hi r,s

^IN<'.I,K. MAkKlKI)

I

lUK rm'i.At'i-:

( StaU (If «'i)iiiili \

^

NAMi: «>I-

I- A III i;k

lUKTiii'i.An-;
«»|- I \rm:K

I Statf (11 iNiunt'

h

XHX ^x -ilX^C>Cr'U-^Crirx

^

MAini.N NAM1-:

<»i MoTin;K

HIUl'IUM.AC'H

• >!■ M(nHi-:K

(Statt or i'liiuittv)

A

^

I go

(Month) I Day) (Year)

I HI{R1'BV CI'IRTIFV, That I atteiulcMl .Uicascd from
"^UW.w^ 190 H tn Ji)^. 1^ IqoH

that 1 last saw h alive (in kL' t:,"u > 190 ' .

and that <Uath onurrcMl, on the date stated above, at ^

wL M. The CAISH ()F DKATII was as follows:

Q

I) r RAT I ON Years

CONTRIIU TORY

Months

/)avs

/Jours

Rr sided ill San /■> rnti t^r,) "- ) ,uj .

"^ Mntifh- ^ Ihl^

'nn; ABOVE sTA'n:i) pkhsonai. particii.aks ark trik to thk

HKSr OK MY KNOWI,i:i)(*.K AND Hin.niF

J/vCX/VsJK

VX/WA^

'Sj^

\

( A.Mri-ss

DIRATION
(SIGNED)

Ycixrs

Afoftths

X.

V.fc , s.

I()0 i (Ad<1ress)

/>avs

"W^ ) uC

Hours
M.D.

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

Former or
Usual Residence

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

How long at
Place of Death?

Days

rr^\CH Ol' lURIAI, OR RKMOVAI,

DATJ^of Hi Ki.Ai, 01 KKMOVAl,
.\Js^\,' T90 »

(Add

_ ^CMXtX-^KV

rcH. JbXkvnjJv ^.k

N. B. Every Item of Information •houlcl be carefully supplied. AGE should bo stated EXACTLY. PHYSICIANS should

state CAUSE OF DEATH In plain terms, that It may be properly classified. The '^Special Information'* for per-
s<Mi« dying away from home should be ftiven In ms^ry Instance.

I

I

\M

WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD

REFER TO BACK OF CERTIFICATE POR INSTRUCTIONS

2415

Mh !■ "^

M' r

Dff/r /'V/^r/,lL'^^lKJ2A; \1)

7f)0H

Be^istercd J\^o,

dv.^

\

Xrvulo doL\K|. Deputy Health omcer

DEPARTMENT OF PUBLIC liEALTH=City and County of San Francisco

Ceitificate of IDeatb

( "U. S. StaiiDarD j

PLACE OF DEATH: — County ofC cxyv

Ji'

^

Gty of Cj/<X/ru 0 JX-Ol vvC-L^. ^ '
jvr„ l^jHC^ Ll^'^v' ' St.; "^ Dist.;bet.WO A'v -..U and LLlu

/ ,r DEATH OCCURS AWY FROM USUAL R E S I D E N C E G I V t FACTS CALLED FOR UNDER SPECIAL INFORMATION" ^
( Tf DEATH OCCURRtD ,N A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. J

FULL NAME^VL. ■ ;, ■. . v • UUyyxXM^MA. Va. ,

PERSONAL AND STATISTICAL PARTICULARS

r(»l.<ik '

I>.\ I1-, < >! I',! k I'll

A".!-:

£Vt

II /^OH

iM.in

H.nv

C

U(J>c

M.niflr

\ I .11

f)a 1

--IXt 1 1 MAKUIHD

\\in« >\\ J-.I» ( >H I)I\'< >!■' I'D

Write in --ik lal .Itvii.. iial i' iii )

I'.IH I"H I'l, \C\-

NAMl «M"
lAI lll-.K

HI HP 1 1 IM,A(I<:

1)1 t \ I'll !•; k

(Statr ( il iDilllt ! \

maiih-:n NAM1-:

(11- MOTIIl.k

i'.iiv riii'i,A<i%
Ml- M<>in|.;k

'Stall 1)1 Countl

j

<rV>vL.ou

M.Hlth^

Ih!

Till*. AlU)VKST\Ti:i) I'KKSONAl, I'A KTIcr I.A KS ARK TRf K T«> TIN'

Hi;sr OF .Mv KN<)\vi.i:i)»".H and hki.ii:k

nnfo-maut

f \'l<lrcss

KN<)\VI.i:i)»".H AM) HK1.I1-.

4^

MEDICAL CERTIFICATE OF" DEATH

DAl'K ol- nilATII

Muiilli

( Day)

TOO \

(Vtar)

I 1II;R1:P.V C1:RTII'V, That I attended (UTeascd from

tji)^

icp'i to Vy/CA, Q up H

that I last saw h . ■ alive on \Li^C^ ib T90 ' ^

and that (kath occurred, on the date stated above, at I 0

The CAlSli 01' dp: AT 11 was as follows

ft

\JL

\M^A^^ A^ tLvM^AXX^-d^ OA-fr^-i-'^A^d^ L » w -

nr RATION

CONTRIIUTO

DlRATlnN

(Signed)

Mofi//is 1 /hns

y'lUt' s

Hours

)'iais

ly^^ n looH (Address) R^?^ "3 -JQA^

Special information only f^r Hospitals, Instiwtlofls, Transients,

.^fotiths Days

iiutions,

//ours
M.D.

or Recent Residents, and persons dying away from home.

Former or
Usual Residence

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

How lonq at
Place of Death ?

Days

PLACK <)I' mRI.U, OK RKMOVAI,

n J?

■^ 4 . ' ,

DATi:*)! Ut KIAI, or RKMOVAI,

N. B.— Every Item of InformBtion .hould b. carefully supplied. AGE should »>« -toted EXACTLY ^"YSfCIANS •houid
•tate CAUSE OF DEATH In plain term., that It m„y be properly classified. The Special Information for p^r-
«f>n« dyinft away from homo should be given in every Instance.

I

i

»^^mm

i

li

I

! lIciMh - i

WRITE PLAINLY WITH UNFADING INK

ft.i.

luV 1' r

Da/r rf7rf/,\^'fzLJoJ0\j \%

lOO'i

THIS IS A PERMANENT RECORD

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

2416

Registered J\'*o,

4^

t'^tC^

DEPARTMENT bp PUBLIC HEALTH=City and County of San Francisco

i

No.

PLACE OF DEATH: — County of

Ccvtificate of "2)eatb

( XX. S. StanDarD )

St: 3^ Dist.;bct. ) .kj<KA\ and ^<Xx%^ka

n .\a vvC<.CsCf. City of O^CX/Vu 0 'xXuw

C (

/ ,r Dr-TH OCCURS .w.y from usual RESIDENCE G.vt rACTS CAtLto ^OR "n^^" sTREtT^AND 'n umbIr^"" )

\ ir DtATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTtAD OF STREET AND NUMBER. /

il ^

FULL NAME

;\

-\

ll ,lLL*w.D r , .. \ I loy^vclxArJLl'. i .'

-! \

PERSONAL AND STATISTICAL PARTICULARS

X\

^

1» A IJ. ti[ UIK rii

Am-

a:

si I V

Muiitl;

D.iv)

v.

k t-a r )

rhi\>

!^IN«.l,H MAKKIi:!)

WIIx »n I'D nK I)!\i»Ki i;i)

'W'litt ill MM-i.il ill '"ii.' ii.it iiiu )

i»iRTinM,A*i:

(Siiit I ii; t'l Hint I \

I A i lll.K

lUK THI'l.Ail-:

ni 1 xrin'R

( Statr or l.'()Uiilr\' i

MAII>i:n NAMl
<>l- MOTHKK

HIRTHIM^ACK
ni- MOTHHK
'Stall' or Countrv

oCCrPATIOX

AArN4.tvk

Rfsidfd III Siiv /laHii.^rn ■. ^^ ),',ii^

\r.n,!ll. \ K />IT\

THK \m)VK ST^riU) PF.RSOXAl. I'A RPICr I.AKS AKl*, IRlK To Tlll-
liKST Ol' MV KNOWUKIX.K AND HKI.UU'

(InfoMnrmt

"oXxi oto "^^JLy^

MEDICAL CERTIFICATE OF DEATH

DATK OF DHATH j,

rMotitii)

(Dav

(Vfiir)

n^ I HI'lR i;i5V ClvRTII'^V, That I attcn(U'«l «Ui cased from
-~ JIqO - to ■ -

0,

up
that I last saw h .'■. • > ^ alive on KJ .ZAf. It up H

and that <kath occurred, on the date stated above, at b
. M. The CATSli Ol' ])]':ATII was as follows:

CONTRIIUTORV V

) ears

nb..ki

V^A

Montlv.

V

Ihn

'S

Hours

I ) r R A T U ) N /v^ ) 'cars Mouths

(Signed ) J

\., ' \ i i TQO

( A. 1 dress)

■U "

Ihiv

^

I 1

Hours
M.D.

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

Former or
Usual Residence

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

How long at
Place of Death ?

Days

DAT^: of Kt KlAi, or REMOVAI^
y^ JO TQOH

PI.ACK OF lURIAI, OK RHMOVAI,

A *-'

t-ndi-:rtakkr 1 *^ J\/<xa^ ^ ^<.

■^\

(Acl.

u

N. B.— Evcy Iten. oi l„W.«tlon .hou.d be ca.efu.l. supplied. AGE should •»- «*-»«^^^'^.^.^J^^^- .rrj.To^n^'lo:":;!.'!
state C.4USE OF DEATH in plain terms, that It may be properly classified. The Special Information for psr-
sons dying away from home should be givsn In svery Instance.

■

WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD

nivA'.i] i)f !!( .iltli I- No. 1=, ■'

,.tT.^^

■^■. nN.1' (•

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

«

Deputy Heaith Officer

Registcj'cd J\^o.

2417

l)„l,' Fil,'<l, VtdJoJL^j \\

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco

Certificate of "©eatb

( U. 5. Standard )

A

m

PLACE OF DEATH: — County of' ^a> v

't) . /O

U<X/vu J/

rNoXduV

).U

UrU. >xtu U

rwA

(vc

Ml

St.;

Dist.; bet*

City of '-'<VTU JXCLYXCCsl.

and

A ^ '^ Dt*TH OCCUilS *W«Y FROM USUAL RESIDENCE GIVE FACTS CALLED FOR UNDER "SPECIAL INFORMATION" \

ij \ IF DEATH OCDURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. /

FULL NAME

t i V >

^

4

PERSONAL AND STATISTICAL PARTICULARS

SKX A

A

COI.OK 1

\l

clu.

lC.!^^^

MEDICAL CERTIFICATE OF DEATH

DATI-; n|. I)i:.\TII ^\

DA 1 i; <(!■ niK 1 11

\<.i-;

Montlit

L'

).;u.

(Dav

M.niffn

/hi v.

"-IN<.1,1,. MARRJKI)
\ViI)(»\vi;i> uR I>fVi>Ki*HI)

iWtitf ill siH'i.'il (Icsijjfiiatiuii)

lilK rui'KAOK
(Statf or I'oiiiiti V

1

t ri

W

' n

(Month)

(Day)

(Year)

^ I in:RI{HV CI'RTIFV, That J atlciKkMl -lercascd from
JjLcx>. XC iooH to SJ'^ IS. IgoH

^ck:-. xk 190H to ^^ZA) IS.

that I last saw hi. alive on wcL 1 b iqq

an<l that death ijccurred, on the dati- stated above, at I JO
M. The CArSIC ()!• l)i;.\Tll was as follows:

NAM!-: ni

J ATHl-.K

HIHIHI'I, AOK
OK I ATIIKK

(Stntr or Couiitrv

MAini;v NAMJ-:
«u Moini'.k

lUkllf IM.ACI-:
<»l- MnTIlKK
' Statr- I ir (."ouiitr%

OCCri'ATIOX ^ D

^

0 I \''^

W\,'U

■'^

1)1 R.\TI()N }'tiirs

CONTRIIH'TORV

Months

Davs

Hon

rs

(\

a1

'■V "-^

ni' RATION
( SIG

}V(/;.s Months Days

Lew- , ^^

Xddress) \aX^>^v.^Kc

NED ) UJ . ^'. \J:r'>

Flours
M.D.

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

Rfisidfti ill Sati li aiu i>fit

Mnlltlu

lhl\

THK AHOV'K STATI-:i) I'KR'^ONAI, PAR rUM I.AKS A K 1-: TKIK To
HHST OF XIY KNONVI.HDCK \M) WVAAVA-

(Informant OA^tX/W^ \J^ U/ClJxi'> A.\.l. .

(Address LA^L'y>'\AyYX.<^^''w'ft-«,

TH

Former or
Usual Residence

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

How long at
Place of Death ?

Days

I'F.ACH ()!• in l^\I. OK KKMOVAI,

DArj;.,;" Hi KiAi, or RKMOVAI,
t

190*1

I ni>i:rtakkr -J WLA-A-X^ m^ VWO.,

*-*»MUdU_

N- B.— -Every Item of information should be ciirelrully supplied. AGE should be stated EXACTLY. PHYSICIANS should
state CAUSE OF DEATH in plain terms, that it may be properly classified. The "Special Information" for psr-
sons dyin^ away from home should be ftlven In every instance.

• I

WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD

li.ar.i.flt !!i ! No .^ t-^^[}t; fuVl r. REFER TO BACK OF CERTI FIC ATE FOR INSTRUCTIONS

Deput

if)(n

h OfTlcer

Begititered J\^o.

24 1 8

DEPARTMENT t)F PUBLIC HEALTH=City and County of San Francisco

Certificate of IDeatb

( 11. 5. StanDarD )

i(

PLACE OF DEATH: — County of a >

%

City of

A

d^

<X/>^ 0 ;\

N©ACtu ^UVtC^\h.iAV • . ..' St.; Dist.;bet. - and

i / IF DEATH OCCURS *VW*V FROM USUAL RESIDENCE GIVE FACTS CALLED FOR UNDER "'SPECIAL INFORMATION" N
y V, If" DEATH OCClipRED IN A HOSPITAL OH INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. /

FULL NAME Vn\>^

'■^

V

<wC^^-

PERSONAL AND STATISTICAL PARTICULARS

DA 11-: t>|- i; IK 111

c

l:

MEDICAL CERTIFICATE OF DEATH

DA'rn ()!•• DlvXTll

Mllau

M..iith)

- * -

UavJ

M'.V.

%

)V...>

M.ni'h.

/hi

SIM, llv M\RKI|.:i)

w iix >u)-;i» I »R Di\"«)Kii:i)

'\\iittiii •-.iHial ill >»ii.' Mat !< ill )

UxA^qM

St: 'i ,1 1 ', ,iuit I \

N"\MI- .>l

rATii i;r

lUK riii'i. \c]-:
<>i I A III i:i<

"ital r 111 I'l lUIlt I N

MAIIUCN NAMl-;
<'l MuTIIl'.K

lUK'llllM. \(|',
oi- MnrnisK
(Siatf i»r Ciiuntrv)

I

A.V > N\ 'X >^li

(Month)

(Day) (Vtar)

0.

I lIl'RIvBV CI{RTI1-V, That I attoii.U'il dcHx-ascl fnuii

\.KJ i ,

lip

t

u . ^ - '..

I90

that I last saw h • alive- on itp

and that »Uath occurreil, «»n the date statetl abnvt-, at 'i ^

M. The CAl'Sf-: OI' DI'ATir was as follows:

/1)n . n r:s

akLlv.

( ♦

a,A^ \K\j^K >-H ^.t

ft

n

I)r RATION

)V(/;'.9 Months

CONTRiHlTORV L ^L«jL

/Mjv

'.V

I lours

l(l._, UvLut

VlULvudu

1 w ^ L , !

I JJV^> VCL

i '^V,

<)Ccii'ationQ[^ ^ ^p

h'f'iihi! Ill Siiii /'i ilHi isi'n )'i'ilt

iC. 'X:;, Lc

Months

Pavs

(SIGNED )

^ cXi Iw igoH ( Address) LLC \-n^sui\ox.s..j.

Hours
M.D.

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

yjnuths

I hi

\'\\y\ AHnVK srATl-:i> I'KKSnx \l, l'\U iirri. \KS AKi; IK IK Tn
1U:ST OI- MY^iLNi»WI,i;i)(.K AM) WVAAV.X

Till-

(Infotmaiit

( Adflrcss

LAX^vut^l

Former or
Usual Residence

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

How loni} at
Place of Death ?

Days

PJ^ACH OK IH RIAI, (iR RHMoVAI, I DAXl.of Hihiai oi KI.MoVAI

O^ UVnL_«_

<A,i,.,..,s 3.t.73.^- IH ti -k'

190

(AD

N. B. Bvery item of information sliould be cnrelruliy supplied. AGB sliould be stated EXACTLY. PHYSICIANS should

•t«te CAUSE OF DEATH in plain terms, that it ma>' be properly classified. The "Special Information*' for per-
sons dying away from home should be given in every instance.

i

f

mmb

■^SJ?i

'«*

) i

WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD

li,,a!.l -.f H. Otl! i V,, 1. t--<-a*j;-!-J>nS^l '(.-.,

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

Dfffr Fi/(^f/, t).ct<rljL>v \%

VJO'i

Kc^iHteved Xo.

■2419

-V

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco

No.

PLACE OF DEATH: — County of

Certificate of 2)eatb

*U. S. StanDarD j

■ ^ " :, , City ofOxX^vu JAXXx-rct-LO. ^ <.

-^

0 A^a, ,

LCUl

MVAJ U V

lAaAju (:w Cy<l' VLLa.\ St.;

Dist«; bet.

"and

|( / ir Dt*TH OCCURsTAWAy FROM USUAL RESIDENCE GIVE facts called for under "special INFORMATION" "j
y V IF DEATH OCCuArED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. /

h' II ^ 1

FULL NAME LI .Uw\,a^o. > , v N UXa^

PERSONAL AND STATISTICAL PARTICULARS

'^I'X

(TlxxL.

COI,C»R

,1-

i>Ari; (•! luKiii

A*.!-;

M'-\

I go \

(Yt-ar)

M.iiith

ST' ,,.„,

Dnv

M..„l/n

/hi 1-

^iN<,i.i'. NTAkkii: i»

WIIM i\Vi:i> (»K IUVMKri'.IJ
'U'litr ill --iHi:!] lii •>!).« iiat iiiii)

I'.IK IHI'I, AOJ-:

I Stall (ii ('iHint I \

NANfl- <»!■
I A I'll I.K

lUK rniM.ArK
'n lAiin-k

' ht lit- I IT Count 1

MAIIMN NAMl.
Of Mnl'lll'.K

nnrriii'r.Atj';
ni- \!(»rni;K

{•^tati or i'ouiltiN

()» (MI'A'lloN

MEDICAL CERTIFICATE OF DEATH

(M-.iitli) 'Dav)

I III'Kl'l'.V C'I'.KTn'V, Tliat [ aUciukMl <lcceased iron

I«/) to U't.X' 1^ IrpM

that I last saw h .^>Vv alivf on ^ I90 H

ami tliat (Uath occiirreil, on the dale stated ahovt-, at ^>
M. The CAISIC ()V DIIATII was as follows:

I )r RAT ION }'rars

CONTRIlHTOkV

Mouths

Davx

II,

III} s

Rf Hit fit lit SilH /'l illh nr'il

),,ll

M,,ii//i'

Ihi

I'm: \HOVH ST All- I) l'HI<S<»NAI, I'XHriiTI, VHs \ k ),; TKt }■" lO I'ln-

iu;s'r <»!• Mi>-KNu\u,j;i)(,j-; and hi: 1,11.1

'?. (It.-

(IiifiH inant

/^

f \.l.ll. ss

vt.

0-^^

L V,

f I K

nr RATION
( Signed )

iD^i A

f \ *

Mi'nt/is

Days

H)0

(A<l.lress)

fly for H^.

\L^

I lours

M.D.

Special Information only for HSspUals, institutions, Transients,
or Recent Residents, and persons dying anay from tiome.

Former or 's \n
Usual Residence ^ » i

When was disease confrar ted.
If not at plare of death ?

\J LoX^ . •

HoH lonq at
Plare of Death ? t

Days

I'l.ACH »>i' inHiAi. nK ki;m<>\ai

r\

DAjJloi HiKiAi, or Ki:Mn\'AI,

0^ :'\ 190 1

rA.ianss 5^1^- l^l-tL J^

IN. B. Bvery Item of Informntion •hoiihl he cnrefully muppl'iecl. AGIi should be stated EXACTLY. PHYSICIANS should

•tote CAUSE OF DEATH In pliiin term*, that it may he properly classified. The "Special Information'* for per-
sons dying away from home shctuld he given In every instance.

H..:inl «.f II' :iith \' "<

WRITE PLAINLY WITH UNFADING INK

THIS IS A PERMANENT RECORD

; Hif

1

I LA

I)

nfr Filed , \J /^iXj^^M^K> \%

lOO'i

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

2420

Reglsterecl J\'*o,

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco

Certificate of 2)eatb

( XX. S. Stnn^arD )

(^

PLACE OF DEATH:— County of a.>\ V<X ,

City of '^' Ccy^ J . Vcu^irvcv
V)'l.... and O'VO-'

/ ir DCAi^M occuBS AWAV rnoM USUAL RESIDENCE give facts called for under "special information- \

V ir D»j*TM OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. /

IVTo. \ 1 ; ' v ^Ka. St.; ^ Dist.; bct.D.O. >^^ I V..^„^. . and J \O.^X

FULL NAME

(y^,

I .n

X>H. V'.

nj.L.UL

"-l.X

PERSONAL AND STATISTICAL PARTICULARS

I) A ri-, t •! iiiK ill

M

Moiitli:

)

I

<l):ivl

M.,t,l/i

A

■t'.:ii!

Ihivs

^INi.l.I" MAKUIMl)

\vnMi\vj-;i» nK !>i\«)Rr}:i)

i\\nt<-iii vinial il»vii.'ii,it inn)

lUI' rniM. \i'l"

>t,it( . iT i 'i 111 lit ! \

Olx:^-

NAM! (M
!• ATHl.K

lURrmM.ArH

IH I AIIIHR
stall .i! roiititt V

^fA!l)l-;^' nami*:

«>h MOT I IKK V

MEDICAL CERTIFICATE OF DEATH

DAii; <>!•■ nivx'i'ii

. ^

W-C

t

Day) (Ye«r>

(Month)
I IIICRIU'.V CI';RTIFV, That I atteinkMl «k>cx'asc<l from

, . 190'! to ...L/.tX II 190 H

that I la^t saw h .^. alive on vL' cl' * ' '. 190'

aiul that death occurred, on the date slated above, at u '
M. The CAISI': OF Dl-ATII was as follows:

7} JL^ >*\-<-^-^^-u.

I )r RATION }'t'ars

CONTRIIUTORV

Months

Days

IIoii

t s

\

HlK'nil'I.Ail".
01 MOTIIKK
(Siiitf or Cuuntrv

OCCITATIUN

Krsidfd in smi I i tunisfn

} >(7 t

M.nith

Ihiv

Tin-: AiM)VK ST \ri:n i-kksonai. i'akiumi.aks aki". rKiK r< » th H
iu;sr <»i' Mv KN<»\vi,j;nc,H and hki.iiik

dress mCuuJLA ^ JjUVI ^VItM O b

4 CI, .

Dl'RATION

(Signed )

n Q!l>

qo

)>(?/-V ^ font /is

■J. -i)

IhlVS

(Address) QklH tfk)<UU,4/ J I

Hours

M.D.

SPECIAL Information only ^or Hospitals, institutions, Transients,
or Recent Residents, and persons dvinq dw<iy from home.

Former or
Usual Residence

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

HoH long at
Place of Death?

Days

I'l ACK <)I- lUKIAU OK K1:Mo\A1. I DA'J^-: of Hikiai, <.r RKMOVAI.

r.VDERTAKl

;r yb . U L^-vv^r^v- "^

N. B. F.very Item of InWmntlon .hould be carefully supplied. AGE should be stated EXACTLY. PHYSICIANS •houid

state CAUSE OF DEATH In plain terme, that It m»y be properly classified. The ' Special Information for per-
sons dying away from home should be ftlven In every Instance.

• fl

i

lil ^i

WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD

H. ,!■! .,f iiinitii r V,, .^ -A^fW--^ ji&p Co

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

Daff' Filrth V,djA>M\^ \%

100

Eeiilstcred J\^o.

2421

{

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco

Ccvtificate of Bcatb

( "U. S. StanDarD )

PLACE OF DEATH: — County of w

L

n \

No.

t

St*;

City of

CU rwV sX '> X

cll

Dist.; bet.

and

/ ir DtATH OCCURS *W»V rROM 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

A

,Sw )

PERSONAL AND STATISTICAL PARTICULARS

SKX fX^ A I COl.ciR

IjL

DA 1 J-, of- lUK 111

,1

Mr. lit hi

A«*.H

(Day

M.>nf/>-

I Vt-ar^

/',/i -^

HlNi.i.i- \fAKKlKI).

WnioWKI) <»r' DIVORiKIJ A

iW'rilt'in ^'iK'ial df'iv'iiiilinn) \ \/A

lUK rinM.AiM-;

NAMK ()1
FATHl.K

niRTHPI.ArK
ni' I-APIIKK

(StaU- or Oouiitrv)

MAIDKN N'AMH

<>i M»)Tin-;R

lURrnpi.ACK

O!' MnTllKR
(Statf or Country

C3U\.^w. r ^ I '

•\\

MEDICAL CERTIFICATE OF DEATH

DATH Ol' I)1<,ATH lA

CSUmth)

I HivRlUiV C1:RTII'*\', That I attcnckMl tlcrcased from

— to

1^7

/QO

(Year)

I9O

"alive oil

that I last saw h •""
aii.l that death occurred, on the date stated above, at
M. The CArSICjL)!' DIvATH was as follows

190

1)1' RAT ION }'t't7fs

CONTRIBUTORY

J /on //is

Days

//ours

Dl'RATlON

)'rars

f\f-iii/-if ill Saft Fnnii f^fii

) 'lUI 1

A/,,n//i'

lhi\

Till* AHovK sr \ri-:i) pkr^onai, I'ARiim.ARs ari-; tkiv. to thh

IIHST 01 MY KN<»\VIJ<;i)<".H AND lUUJlCF

(Iiifoniiant

..Mm^

'-^-y^JL

(SIG

NED) O.S)

A/i>Ni/is

\J^

190

(Address)

il

/^ays //ours

M.D.

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

Former or
Usual Residence

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

How lon(| iX
Place of Death ?

Days

ri^ACK Ol- JURIAI, OK RKMoVAl,

in'di:ri'akhr

(Addrt

DATl.ol BiKiAr. or RHMOVAI^

/ Ca ' igo'\

I

KX\^ki.

N. B.— Every Item of Information .hould be carefully supplied. AGE should be stated EXACTLY PHYSICIANS should
state CAUSE OF DEATH In plain terms, that It may be properly classified. The Special Information for psr-
sons dylnft away from home should be given In every Instance.

1IJ

i

WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD

,,f H< nlth I- Nn ■< t^^'^i^ H^l'

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

Dafr Filed, h xXA>AK> W

IfWi

Begi.sfcred J\'*(),

04 OQ

A^A^

, i Deputy Health Officer

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco

Certificate of 2)eatb

"U. S. StanDarD )

J?

rV

No. WXl

PLACE OF DEATH: — County ol^Curv^h '

Cri'dx/Vj doXo V.l\^v St.; ' Dist.; bet. CVIxo-t^A-hj

0?

City of '^'<X v\. . . A. O. > ■., C-.

\.^ o. ;

(

\T DE*TH OCCURS AWAY TROM USUAL R E S I D E N C E G I VE FACTS CALLED FOR UNDER -SPECIAL
IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET A

and

INFORMATION"
ND NUMBER.

)

FULL NAME CoAxxJa; Vx^vxA.

I

wa„

PERSONAL AND STATISTICAL PARTICULARS

"L

XryyxXkJ

DA 1 J, ( ir- Hi R Til

li),ct

M-iiith)

!l

n.iv

Ai.H

5b

\ iMl

/'(/ 1

•^iN" 1,1' M \k k ii:i>

'Wiitf ill *i>iial (Ic'.iL'ii.il ii III I

lUkTHPI, A4M-:

i St:if I 1 1! I 1 III lit ! %

d.

^

vM^Lo

NAM!' <>!
FA II! IK

nikTIM'I.ArH

«»i I A I'm; K

' state (If I'onntiv

M X ini'.N NAM1-,
<»1 MDTIIKK

lUkriii'i.ArK
'ti M(iiiii:k

fSi.tlt oi I'diinttvi

nirri'ATION 'Tfvp

7

MEDICAL CERTIFICATE OF DEATH

DA 11; <>I- Dl^ATlI (Cx

^'ct

1 \. TQO

(I)av) (Vt.';ir)

(Month^
I lIl'lKlil'V Cl'lRTII'N', That I attc-!i(k<l deceased from

t

^D^ > \; A I90'; to Vw'Aj-^. ''-.. T(>o

tliHt I last saw h ^.' alive 011 C /C<^' i« 190

and that death oreiirred, on the date stated above, at i«l
M. The CAl'Sl-: OI- Di: ATII was as follows:

I )

\.L\ ^

1

f

c\

f\f'i,l,,l It' Sail /'itjihiuii \

\f,,i,Ui'

I his

rm: AiiovK sr \ 11: n pKusdNAi, i- \k 1 n n, \kn \k i: rw i-; to tiik

lil-ST OI- MY KNi>\VI,j;i><.l': AND Hl.IJl.l'

Dilii; niaiit

MS K,Ni)\\ 1,J,D<

In It + 1

\k

\.

DTK AT ION yi'_kirs Mont In » /^<n v /Jours

C ( ) N'l' R N 5 r T ( ) R y LJx^.tTA'XA.^'^ QY^xtJ.^^Li„L^„a„l.
\l\jLKKXAwtA^ , aXA^^|V\X4A4-0^v oi LaA-La\i : ^ i.,,
DIRATION I )'i'ars ^ AfoHths Days Hours

(Signed) wWyv ^"^''A'-';^ m.d.

\j^ n TQoH (Address) bOQi^ LQjLi(A.Arv<,a at

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

Former or
Usual Residence

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

How lonq at
Place of Deatli ?

Days

I'l ACK OI' lU'KIAI, ok H1-;mo\\I, I DATl%of ISirtai. or KKMoVAI,

h^

It

INDl-kTAKl-

T90

N. B. Kvery Item of Jntfornmlion .houlcl bt. cHrefuIly supplied. AGE should he stated EXACTLY. PHYSICIANS .hould

•tate CAUSE OF DEATH !n plnln terms, that It may he properly classified. The "Special Information for per-
son* dylnft away from home should he ftiven in ns^ry instance.

•

if

RITE PLAINLY WITH UNFADING INK

r-)(n

THIS IS A PERMANENT RECORD

REFER TO BACK OF CERTiriCATE FOR rNSTRUCTIONS

Ee(Sf,sfe?'cd J\^o.

M Deput

Officer

DEPARTMENT OT PUBLIC HEALTH=City and County of San Francisco

Ccvtificate of IDeatb

( tl. 5. StanDarD )
PLACE OF DEATH:-County of ^ O^ J A<X^^.4 cc City of ^^^X^ .X<X.xc..

No. w' ^- ^^ ^^- ^<^^ ^^'-^- -^ • ^-^

St.;

Dist.; bet.

and

)

VLOwl) Cr^'AA r-^^ » ^"^"^ ^ „r=T;yMrEa,vr FACTS CALLED roB UNDER •'SPECAL , N TO R M ATK> N - \
( " -- A.°H"0CCU%Rr .rrH0"s^^.lt 0%^?^?f.?U^4rcf.;Er4 NAM. ..STEAD C STREET AND .U.SER. ;

FULL NAME

\}k i

Ur->^q- ^L-C^.>

,1.

PERSONAL AND STATISTICAL PARTICULARS

•-IX

rMi.(»K ^

i; «»r !;1K I'll

\t.inth

\' .I-

) V,.- .

^ Ii 1%

Mn,l!/l'

Vtar

/)<n.

w i!m»\vi-:i> <>k i»iv<)Rri:i>

Write ill siM'iai lU ''i^'iiutiiin)

MEDICAL CERTIFICATE OF DEATH

DATl-; «»! 1>1. ^ 1 '•

S

\J

i 1

f

(Yt-ar)

x>^<

HIK I'Hl'I, X^'K
I Stati ii! I'l lUiltl %■

NX Ml-: «>F
I ATHHR

niK riii'i.ArH

ni- l-AlUKR
'St,it«' or I'onntry I

MAim'N NAMl
<>1 Mul'llKK

lUH'rniM.AOK
ol- MiJlllKK
(Slati- or Oountrvt

I

'^

1

^Cr^^q,

w,

i J . ) uwK.

(Month) /I>''y^

I 1|I.;ri;1'.V CI{KTII-V. That I atten.kMl deceased from

.^^ ,cA 190M to.J^-^ ^-^ 190''

that I hist saw h *. alive on ^'^^ ^90^

ana that .leatli occurre.l. on the <late ^tate.l ahnve. at 6
U.. M. The CAISH OF DKATIl was as follows:

Hours

Hours
M.D.

DIKATION )>-^/^ ^'<^' /^'^'^

CONTRllU-TORV Ux:^^ '

Dr RAP ION
(SIGNED)

Yi-ays

Mouths ^ Pay^

V-
U-

I c)n

(Achlress) RH

S-JU

± '

Rr^iifn! lit Sitfi / ' <

/ II, I III

r, ,M

M,,iilln

/hn

TUK A,«)VK STATK.. .-HRSON X.MVKTU-rL XKS AKH TKrK TO THH
llKHT t)l- MV KNnWI.l'IX.H )Nl> Hl.I.ilt

( Iiifotmaiit

AJ

Xdilicss

.AJU cit

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

i "^ How lonq at

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

O^^

I) \ 11 of ncKlAi. or RKMOVAl.

T90

IM.ACi: Ol- HIKIAI, OK KKM«)VAI,

rNDKRTAKHR UJ A/>^^ J^-^ 0

— — — — — "^ .. , ArF «houId iMi stated EXACTLY. PHYSICIANS should

N. B.— Bvery Item of ln?or,«„t1on •hould be c„..^u... «upp .ed. AGB « ^^^^^.^,^^^^ ^^^ .g,,,,.„, ,„,o,.„„Uo„" fo. pr-
state CAUSE OF DEATH in plain terms, tha It ma> .^« PJ ^
^on. dylnft away from home should be given ,n even> .nstance.

r^

^

9

I

^^"1^,

WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

i i

I til

If) OH

JicH'i'sfered A''o.

^4^24

DEPARTMENT OF PUBLIC HEALTH^City and County of San Francisco

Certificate of 2)eatb

( *U. 5. StanC>ar^ )

PLACE OF DEATH: — County oiUi<Xry\> OA.XX/r^

r»

City of W/CX/Vu JAXLAa.CM->^

A

No.

t.at

<U1}

xhA Li4.Lvi'a. ) , . St.;

Dist.; bet.

and

(ir IJTATH OqCUSS AW«V FRO^ USUAL RESIDENCE Give facts CALtrO for UNDCR "special INFORMATION"
IW DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD Ol

FULL NAME

:R "special INFORMATION" \
IF STREET AND NUMBER. /

I

(XXUrrxi VIIm.

DA 11. t>J- lUK 111

.\<.i.;

PERSONAL AND STATISTICAL PARTICULARS

a

MEDICAL CERTIFICATE OF DEATH

DA TH OI' i)i:aih i

M..iitli

) ,u

: l).l\ i

M..nflis

It

fVi-ar)

/hn.

"'IN'. I. J- MAKRIKf*.

U IDoWI.I) <>K I)IVnK»J.-|) Q

'U'iit» ill vinial (l«-sii.'ii;iliiiii) ~A

IHKTHJM.ACK y

Stat< or (."iMiDt 1 \ i

NAM I-; (»I.

I ATin;K

lUKI'JM'LACH
<)I- lAIIll'.R
'State iir Coiiiitrvi

MAimiN NAM1-;

luKi'mM.Ai'i-:

<»l' MoTllI'.H
( Slatf (II roiint I \

d

(Month)

IS

(I):iv)

(Year)

, I HI-RIUiV CI-:RTrFV, That I attciKledtleccasca fruni

OX^; 9. r icpH to jQ^ 15^ TOO H

IqO
that I last saw h ;- alive oti W cL i ' j^q

and that <kath occiirre<l, on the <latc stated above, at *"
M. The CArSI-: OF DlvATlI was as follnws :

(i

W ^w-

DT RAT ION }'i'a/s

CONTRim'TORV

Months

I^a vs

Hours

(HCI rA'lloN

)",,;

yf,'iiti,.

I hi

1)1' RATION Years

( SIGNED )\X1X\xAj ^ . .

l-J/d - iQo'i (Address) Vn

/hiys

» >. w\.

Hours
M.D.

ili.U

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

'I'm", \n<)vi.: sr \ ii:ii i'HK-,oNAi. r \H I UMi.AKs AKi. rkti-; t<» thh

HJ-:sr ol- .\^V KNOW l,i;i)(.K and \\V:\,\V.\-

former or
Usual Residence

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

How lonq at
Place of DeatJj ?

Days

'I.AC1-; «)|- lUkFAI, OR Kj;M()\AI,

n

, L'uO-^v.

TQO

DV'i'i'ii;' itt'HiAi, or Ki;m(»\\i
(Achlrcs. Obl^^* tq if. .•.

IN. B. Every Item of infnrmntion should be cnrefully supplied. AGE should be stated EXACTLY. PHYSICIANS should

•tate CAUSE OF DEATH In plain terms, that it may be properly classified. The "Special Information*' for psr-
sons dyinjt away from home should be [fitiven In ^\^ivy instance.

I,

\

I

At

WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD

I! 11! 1 X.

.; l:>v!' ('■

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

Ddfr FiIi'fl.\}xiLro-^iSj \\

JOOH,

llegi^tci'cd jYo,

1*35

2^^

DEPARTMENT oi^ PUBLIC HEALTH=City and County of San Francisco

Ccvtificate of H)eatb

XX. S. StanDarD

J?

PLACE OF DEATH: — County of

.^VO. Yvc^ , City of ^/Ou-^v J^H-CX, > .

(No.

n

u. ^.--^^

y

%

Su

Dist.; bet.

and

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

FULL NAME >^i^^ ^'*-^'<-*'^^"*^

. 0;^^XlI!.

44-

■> ! V

PERSONAL AND STATISTICAL PARTICULAR^

Y\

^

1> \ 1 i: < tf lUK I'H

\<,H

Oi

I Lctu

Mi.mh

i

U.

(Day

I f

■»'i;il I

/',M

StNr.I.K MAKKIl I»

svii>«>wHi> OK niNoKrin

(Wtitein jMK-i.ii di -i^'iiati. n

X/>i^x:krJu

lUK riUM. \C\-,

' stall iir l'( iHtit I \

NAM I' ni
lATin K

XX^*^ •

w

RIRTHPI.Ai'K
OI' l-ATIIKR

(StatJ- or Cuimti vi*^

■^

MEDICAL CERTIFICATE OF DEATH

DATK OF I)!- AIM \{\

C

■k

(Month)

(I):iv>

IQO

(Vt-ar)

.Vw'

I niiKI'liV CI;RTI1«V. That XattendtMl ilcceascd from

.rl

iip H

190

\ s 190 H to

that I la^t saw li ■ alive on V

and thai death occurred, on the date stated ahove, at l v
LL :\I. The CAlSy OF DKATH was as follows:

KJL

~s

O^XA/^X-CSJ

i

(1

DC RAT ION )\'ats

CONTRIIU'TORV

Month's

Pars

Hours

P

J -^- S.' » >

MAn>i:N NAMK H)
01 MoTIIHR V.

\jYr\jYr\jOj
^OXhyWx/CX/

OlH'tPA'noN

HiK'riipi.Aoi-:

oi" MOTHHK
iStatt 111 (.'oiintrvi

^YXA)

A V>, ■"(/<••',' //' S,}ii f'l lUh isi'it

) 'tl! »

M.nttli-

Iht I

Till-: AHOVK STA Tl- I> PKKSONAI. PAKTICI- FAKS A K !• TKIK To Till-;
HKSr OI" MV KNO\VI,i;i)(.K AM) HHI.llU'

(III

I" . .Mua n t NwK/VN-^ %J O /~S~> ^ ^ ■ '^- '' '

.X.Mri.s S 00 ^ ^^aA

0

-V

}\'ars

Months

n

DlRATluN ^

NED) LLUrVMi M f\' Xou^

Pax-

's

(SIGI

Hours

M.D.

i).t

Tc)0

Addres.)^A^K ^nO'

Liu UaM

Special information only for Hospitals, Institutions, Transients,
or Recent Residents, dnd persons d)ing av*ay from home.

Former or
Usual Residence

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

How long at
Place of Death?

Days

ri.ACH oi- lURIAU OR RKMoVAI,
INDHRTAKKR ^ i . \jR<X<1

I»ATi:«>f Ht HIAI. or RKMOVAI,

(0.4 ir

T90

(Ad.lrts^ ^ 11 \J rL'

A.AAA^'>V

N. B. Every item of information .houlcl be carefully supplied. AGB should be stated EXACTLY. PHYSICIANS should

state CAUSE OF DEATH in plnln terms, that it may he properly classified. The Special Information for per-
sons dying away from home should be given in ^s^ry instance.

gS

i

f

I

I

iM^':

( T

I

WRITE PLAINLY WITH UNFADING INK

— THIS IS A PERMANENT RECORD

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

l)a(p /'V/r^/,UcttrlML^' \%

IfWi

Eegistered jYo.

24^6

^.t'VAAAi i^LXHJ

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco

Cevtificate of Bcatb

( in. 5. StanC»arC» )

PLACE OF DEATH: — County of acX-

City of U/C^C/vXXA^rLx/Tvt<i ^<X\;

No.

i W. I .s

St.;

Dist.; bet.

and

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

'M if R

FULL NAME

PERSONAL AND STATISTICAL PARTICULARS

.Kx ^

vt>I,«iK

!>.\ ri; » M i;ik I 11

A<'. !•;

M.ntli)

\ .

\x:v

i DilN I

> t a!

/hi

'Wiiti ill >iHi:il lit 'ii.' lia! i' 111 )

niRTHlM.AOK

Stntr «)r Ci>niitr\

NAMI-: OI

1 A riii;K

lUK I'll PI, ATI-:

<>i I \iin:k

•state ()i Cuuntrv

MAini'N NAMK
ni MnTHHK

HIRTHIM.ACK
nj. MoTHKK
iStatr or Country)

Ml

UX^v

^

a

LLU.

^r

I

#

MEDICAL CERTIFICATE OF DEATH

DATE OF Dl.ATM n

iMnlitll) \

15

(I>ay)

(Ytar)

I Hl'Rl'I'.V CI:RTII-V, That I attcmkMl dcctasca from

— — — — 1 90 to ■ - - I{)0

that I hist saw h r alive 011 ^ ' ___ j^ .

ami that-dtath oroiirrcMl, on the ihite stated above, at —

M. The CATSh: 0\< DICATII was as follows:

\.

XJ

nccr PAT ION

/\'n-riff(t in Siin /'i ii Hi nf"/'

) ;,i 1 >

M.nifh^

f hi 1

Till'. AHOVK ST\Ti:n I'KKSONAI. P \ K I'Ff I' I \ K S AKi; I" KIP'. l'« » mi-;
HHSr OP' MV KNOWIJ.IX. p: AM> IU 1.11 I

(lufonnrmt

( ^fUlrrsH

I )r RAT ION )'rars

CONTRIlUTokV

Monihs

/hns

Hours

DTRATiON

(SIGNED )

"^

Yiarn

Months

J . isj. Oxa^Llu,:.

Ihivs

r

at

Ilom s

M.D.

\ \ i(,n' ^ (Address) Cj <X-eV<X>>Aj. >xLo L<\ '

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

Former or
Isual Residence

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

How lonq at
Ptare of Deatfi ?

. Days

pi.ACH OP m KiAf. OK kp:movai.

DAlJ'lcjf IJiKiAl, or KP;moVAI.
w ^ A 4 190 I

i'ni.p:ktaki-k J yiXJUrcUv V iJAX^Jk^

IS. B.— F.V...V Item of l„for„,«t1o„ .hould ».e c„..*u... supplied. AGB -houl.l »».^ «»«*«:;• ^^'^.fi^TLV . ^"^«'<i'^^^^

state CAUSE Or DflATH in plnin term., that it mny he properly .lass.tkd. The Special Information for p«r-
iion» dying away from home tihould he ^iven In avery Inatance.

1R

I

I

M

I

I li; :iUh I- Ni^

WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

■,\ !

Bo^istci'cd jVo,

d^^^u^^Xju^ Deputy Hoe:thOfTioor

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco

Certificate of Death

Q^

PLACE OF DEATH: — County of ^'a >v ^- ~' >; Gty of Qo/^v J Xxx >vcl

( u

No,

^ A.,

St.;

Dist.; bet.

/ IF DfATH C^CURS AWAY FROM USUAL R E S I D E N C E G I V E FACTS CALLED FOR U
V IF DrAT>« OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTE

^U

FULL NAME

O^'Y^xiU

<X/\>L > V-.XO.

4 ^

i i)

i. and o^OJ\. \

"special INFORMATION" \
STREET AND NUMBER. /

4 .■

PERSONAL AND STATISTICAL PARTICULARS

ft

I) \Ti; 1 •! lUK I'll

\< . I-

r^hJ^

r, ,;

a. , 1 V

5

M.>>if/i

^ IN' .I.I- M \R K II'D

\\'\ t)i i\\ 1 1 1 < >R I>',\< iRi i;!>

\\t il» HI -< .. '-n .1. -.ij/iiat ioii)

MEDICAL CERTIFICATE OF DEATH

DATK (M- 1)1. ATM

V^X

15 f<,o'\

(Moiitli) (Hay) (Wiu)

I in:RI':HV CIIRTIPV, That I alleutU'd lUccasecl from

■— — I9O to "" ~~~ T9O

tliat I l.i^l ^a\v li ~ alivf on ~ " l(p "

and that lU-atli orcurrcil, nn thi* ilate '-tatt-d ahovc, at
' :^ M. The CAl'Sl-; i)V I)i;.\'ril was as follows:

iCb V

NAMl- (II

I- Ai'ii j;r

HI kill I'l. \i"j',

<>! lAlllI.K

' Sl;it ( 11! I'lilllll I \

^t \ Il»l,\- NAM!

oi .Mi)Tm-:K

lUR rm'i.Ai'j-:

•>1 Morill'.K

( Slnli III Cniuit! \ '

nicTl'X I'lnN

^

I, 1 1 1! Ill I '11

}/.,„//i'

III 1: Aiu»\i.: sr \f j:i> pHK^^nx \i, i-nk ri< ri m<^ aki, iki 1:
in:sr(»i ms kn<»\\ i.iimi-; \\i» in 1,111

i }

,vi,i,,~. '^bl- \'lU. 0%

[(]

!-

\

I ) r In A T i 0 N J 'rars .l/ot/Z/is /hiys I/oiits

CONTKilU'TORV

Viuirs Months /hiys Hours

NED) Ur*Ur>Uhj sj.yb. IJL).1ulIol> ^^

nr RAT ION
fSlG

M.D.

Special information only <nr Hospltdls. Insntuti^^, Transients,
or Recent Residents, and persons dyini) a\*a> from homp.

Former or
Usual Residence

When Has disease (onfrarted.
If not at place of deatti ?

HoH lonq at
Place of Deatli ?

Days

I'UACK <ll' lUKIAf, (»H HJ:Mii\A1,

(nu ilLv^.

rNI»i;KTAKi:R

DXl'l '! Hi Ki.Ai, or KI:M<»VAI,
^^ It T90^ ,

N. «._r.ve.. t.en, of l„»or.„„t1n« .h„„lcl b. ca.un.ll> supplied. AGF. «h„ulcl H- «t"ted RXACTLY ^^f '^'^^^t^ •»'°"'*«
•tatc CAUSn OF DI.ATH In plnin ter,„«. thi.t it mi.y he properly .la«,»h'kcl. Th« Special Information for p.r-
Bont dyin^ away from home Hhoulcl be ftiven In every Instance.

■

WR'TC PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD

REPEC TO BftCK OF CER"^tPiCfeTr FOR fNSTRUCT'ONS

/ ■

\'..

> f

'S

S- ■ i.

Deo

DEPARTMENT OF PIBLIC HEALTH=City and Countv of San Francisco

Ccvtificntc of Pcatb

w.

FLACE OF DEATH:

SC:

t t ■; [ c - t "V i I

« r t »" '

FULL NAME

PEC£CH*w ».»<D STA* STiC*L RARTtCULAWS

t

I.-

i

%XWV%^

i d cl>

\ w -. 5> K I I K r K i < ' 1 H I

^-

^.1.

v^CCn >

Citv of

DT^t.* bet.

and

MCDiCAL CER-

OCATN

SIGNED

MP

pf Iff ml RfvWrft*. iN r ''«'»•' ^''"fl **?'

Him l^«f ^

lrw^^<.

Nm

11 V, V < n rr u 1 % I > ^ i > "^i

i *

r N 1 1 1 >■ I i » '

state CAUSE OF DEATH In plain term., that It mn, He pr„^H, .••••.f«d. TM R^...l i«f • ^- - ►•

iiofis d>int away from home Bhould be fi^en In •%er> innHintc.

I

I

WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

ifJO'i

DEPARTMENT k PUBLIC HEALTH

Jie^isfercd Xo.

010

4^9

City and County of San Francisco

Gertificate of IDcatb

1 '^. 5. 5tnnDar^ )

(5?)

A %

PLACE OF DEATH: — County ofCj/a'^'v 0,rva/'>l.<X4C( City ofO/O^'^'V 0 A.<Xaa. C \.<i. e (

AOV<Lk.^v . ; St.; — Dist.;bet. -^=- and

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

(IF DEATH OCCUR^AWAY FROM USUAL R E S I D E N C E G I V E FAC
IF DEATH OCClIbRED IN A HOSPITAL OR INSTITUTION GIVE I

FULL NAME

LAjuXc

si:\

PERSONAL AND STATISTICAL PARTICULARS

(.•<il,uK \

oJjL

{L.'..d

I ■' '-_ S_-V

DAIl-; <>I IMK 111

\i.i-:

(\

iiith

L

4H

>•,■„•

(I):iV

M.,iil/i'

(W-.'ir i

/'(/ \.

si\« ,i.|- M \KRii;n

UIlx )\\ !!» OR ni\< I'Tl-r)
iW'iiti in ^itii.il (lf^i<.'iKil ii )ji)

'Statt lit I'oiintrv'

ly

'-C^^lXIAJI

I ■

I (

NAMl*. «>l
I- A 11 1 KR

?

J

L<lAAX>A.d. LLvv^xlW

MEDICAL CERTIFICATE OF DEATH

DATK OF DKATH | ( \

(Mnutli)

11:

(Dav)

I go

(Year)

, I HI^kl'HV CivRTIFV, That 1 attendod deccasctl from

Ox^\1. I'l itpi to U/et iS^ up ^

that I last saw h '■ ■ alive on w "C^U > > j^q I

and that death occurred, on the <late stated aliove. at "i- o C
xX. M. The CAISK OK DKA Til was as follows:

a

niKPii I'l.ArK
ot- lArnKK

iStatf or Comitrv)

m\ii)i;n xAMi
oi .MoTin;K

v<:.

A

HIKTHIM.ACH
OI- MoTHKK
istatf or Conntrvl

otCl'l'ATIO

Kt' sided III Sail I- 1 till

DIRATION )'car.

CONTkNUTOkV

A/ 1) tit /is

fhivs

Hon

rs

}'t'ars

I ) r R A T I ( ) N

(SIGNED) U3. Xd. Cct^aJL

Miuiths Pays

(Add ress ) LLL'"i^A.Xi.

Hours
M.D.

SPECIAL INFORMATION nnly for Hospitdls, Institutions, Transients,
or Recent Residents, and persons d>ing dw<ty from tiome.

\f,nifh:-

THl-; AliOVK STATl'n fKRHOV A 1, I' \K' rui' !,A RS ARl! I'KI'K To I'll V.
HH.sr 01-" \LV KNoWI.J-'.Ix.l-; \\I> lUJ.Il.l'

Informant

0 /vo^-»^A U- B.cJ

'W

.1

rx.l.lrcss UUL

"5

nrvvOt, i \

Former or
Usual Residence

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

How lonq at
Place of Death?

Days

^'I.ACK Ol- niKIA!. OK KHMoVAI,

V

nxri'of HJHiAr or Ki-;MovAr,
^^ ' T90 »

r.VDlIRTAKKH ytX/VV>ULft ^Iv U X^^'>%. ^i \„C

M. B. Bvery item ni information should be cnrefully supplied. AGE should be stated EXACTLY. PHYSICIANS should

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

I

1 i

■'H

I
I

1

WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD

REFER TO BACK OF CERTIFrCATC FOR INSTRUCTIONS

B«3iir<1 1. 1" IIcmUIi- F No. i-, '^f'^'^'^rnSiV C

IDOH

Regi.slevcd ■A''o.

^430

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco

Certificate of Beatb

( "Q. S. StanC>ar^ )

PLACE OF DEATH: — County oi^O^'y^ 0 Vcx.^^'C^v City ofCJ/(Xorv

3

No,

A

1

.^ \)<Xfrv M LL4.<l

St.;

Dist.; bet*

Ojfs

(IF DEATH OCCURS *W*V FROM USUAL R E S I D E N C E G I V E FACTS CALLED FOR UNDER
ir DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF

and

<^ 0

? I

A_

SPECIAL IN
STREET AND

FORMATIO
NUMBER.

N)

FULL NAME lA^^A

i

PERSONAL AND STATISTICAL PARTICULARS

■^t

SIX

^ 3

i:(>i,<>k \

a..'.-.a^

DA ri: OF' r.iKTu

.\<.K

iMoiitli

fARKIHD
U n>i»\VKI) i»K DSVnKi I'D N

i\\'iit«- ill siH'ial cU— i^'iiatii)!)) \

(Dav)

A/,>n//n

I -

'kt ar)

lhi\

MEDICAL CERTIFICATE OF DEATH

IJATK «)1" DKATH sCS

li I J

IN

(Dav

(Mnlllh)

(Year)

SlN(.!.i:. NfARKIHD

(Stati nr <."i)niU! v

NAMF (»!■
FA'nn.K

HIKTHPI.ArH

()!■• iwrnHK

(Statf or Couiiti v)

MAIDICN XAMF,
oi- MOTHF'.K

HIRrnPI.A».'K

OF m(>thf:k

(Btatf or Couiitrv)

cu

I HICRl-IiV CKRTII V, That I attended deceased from
O^t IH too' to ^KLt- IH i()o H

''-' J A 1^ ' to ^ KJ\) '1 IC)0

tliat I last saw h '• alive oti v^. -v jgo

atid that doatli occurred, on the date state<l above, at '^
-' M. The CAISH OF DKATII was as follows:

I)r RATION Yeats' Months Day^s b Hour
CC)NT R I lU'TOR V U^t<l^\Jl>\,.€rv-y\,<xL^VV<i^^....Q^^^

DTRATION 5 ):cars Months

^>^

OCCUPATION

I 0 to a 0

Rrsisfrd in San I'l ani iMn

(Signed)

Q^ II

year

Da vs

o.yyv^j^ i\)

IQO

'i (Address) 1^ U aXMa,OU\

P

Hours
M.D.

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

)

Mnnlh:

J)ll\S

THF AHOVK STATHD PRKsONAI, PAR rUTl. \KS A K F", rRFH To TJIH

«KST OF MY kno\vi,f;d(;k and ni:i,n;F

«KST OF MY kno\vi,f;d(;]

(Iiifominnt \J . 0 vO

Former or
Usual Residence

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

How long at
Place of Death ?

Days

DATF: of HiKiAl. or RF:M()\AI,

X^

PI.ACK OF nURIAI, OR kl-MoXAI,

r.NDFIRTAKKR n£^-M.^^-wKX\^ ^^ cL^V^xt

(Address. , sLbisb AjTV'Vv^^^r^X di

T9O

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

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

I

WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

i \-

4 -r-3L,, \',f^\' c.

((

B.('^Lsler''(l J\f''o.

2431

\j(f^^^^-,'^' Deputy Health Officer

DEPARTMENT Of PUBLIC HEALTH=City and County of San Francisco

Ccvtificate of IDcatb

( 'XX. 5. StnuDavD )
PLACE OF DEATH: — County of''' o. - - " City ofOxX/^v J Axx.vx-' >i -<

ISJr^. ' llAy^VuCL^'V (AT'^ \. , ' - '' ', St.; Dist.;bet. and

l^U. - -'i^ W » » ws,^ . ..ciial nr^lDENCE GIVE PACTS C*LLED FOR UNDER "SPECIAL INFORMATION- \

( '^ r;'o;:T°H"oc:u%r/o\rrHO^S^r.t r« f^sfr^^N^O^.V. .TS name ..ST.*0 O. ST«..T .no .UMa.R. J

FULL NAME

4 } 1

0 V ' ■

4

PERSONAL AND STATISTICAL PARTICULARS

^i;\

^ 0

i'< >I,()K

I V

iiAi 1-: or lUK Til

\< I-,

,U\

M..iith»

n.iv

s%

\ tar i

Ihn

'-IN*.!,!-: M.\KHn:i»

WIlx fWKD OK I»I\t iRiKI)

X\i H< i ti -'Mi:i i .1. -•iMiati' iti >

CWvA^tl^-

i; IK nil' I, \c\{

•"-tilt, ill »"')U!lt 1 \

%■ wn-: oi-

!• A Illl-.R

HiRrnpi.ACK

Of lAPIIHR

• Stair i»r Cotmtry^

M MItJ'.N NAN!!',
oi MoTIlKK

I

kSa

i

ry.

V J JC \-_ t 1

ol- MJ)THHK
' Stati- or Cimi\ti\

H-1

Rf^i.ini in San Frainisri^ ^b ?V(7>5

Tin-: AHOVK STATKI) I»KKSONAI, r ART K* T LA RS ARK TRl'K Ti> Tin-
DKST OI- MV KNOWI.IUX'.K AND Hl-J.li:!*

(liifoTinatit

M.'iilh:

Ihi

MEDICAL CERTIFICATE OF DEATH

DATi-; ol- i)i;ATn

Dav) (Vtiir

.0

(Month)
I in':RI':!5V e'l^K'ni-V, That I atteiKU-il .Urrased from
d ' ^t )S^ I90S t.) . C)ct 1^ Tc)o"i

that I last saw a ^^ alive on I90 i

and that death (ircurred, 011 the .late stated alxn-e, at VP- « o
LL ^r The CAISI-: ()!• l)h:ATll was as follows:

oW A^CXA^

-J I

CC^

I )r RATION )><7;.?

CoNTRIl'dTORV

MoHi/is

/hirs

I lours

nr RATION
(SIGNED)

Years

Months

Pavs

I()0

r.

Hours
.^_iUu > ^ M.D.

Address) OXVwUXyW ob^^«^^

00^'

<XL

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

UsuTResidence I C) 0^1 (Ib(h.^Kt^.H

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

A

How long at
Plare of Death

Days

IM.ACH Ol- lUKIAI. OR KKMoVAl,

DAXi;"! Hi KiAr. ot K1-;mo\'AI,

.ui

(Address

QfYuA^

\-^'>Xj

T^t

N. B —Every Item of information .hould be cnrefuHy supplied. AGE .hould be stated EXACTLY PHYSICIANS should
.tatecIuSE OF DEATH in plain term., that It may be properly classified. The "Special Information" for psr-
snns dyinft away from home should be given In every Instance.

i

« 1

■M

#

til

WRITE PLAINLY WITH UNFADING INK

ih 1^

•:■ -—••3^v v.SiV c

pfffr tiled n

>Xr\j IH

100\

THIS IS A PERMANENT RECORD

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

Bo^istercd J\^o.

Deputy h :!th Officer

DEPARTMENT OF PUBLIC nEALTH=City and County of San Francisco

Certificate of 2)eatb

( tl. 5. 5tnn^ar^

J? %

SI

(311

No. '^-^ 1

PLACE OF DEATH: — County

(IF DtATH OCCURS AWAY FROM
ir DEATH OCCURRED IN A H

of^'^<XA^ J A<X r\ c . , City of UXX/W 0 AXX^-.x.c.

St.; i

Dist.; bet. 0 il

' ^^ si„<^YYV«

and

5H-

o

A

r^n» USUAL RESIDENCE G.VE FACTS CALLED FOR UNDER "SPECIAL INFORMATION • \
OSP^TAL ?R TnST.TUT.ON GIVE ITS NAME INSTEAD OF STREET AND NUMBER. J

FULL NAME

JxcL

I I *

PERSONAL AND STATISTICAL PARTICULARS

f)ul

(•( >i i»k

I

>\i\- itr- i;i!< rn

A'.i-;

As

1^

Month)

l):l%

CLO' ' .

S(N<,!.I- M\KkIi:i>

w I i>i >u I i» (»K r>!V» >kr I'D

W 1 it'- ill -Mciril ill— iv' ii.it H 111)

HiK riii'i. \ri-.

(Slatf lit ('.Mint! V

1/. <

/hi 1 .

NANt) ni
l-.\T!l )H

lURTIII'I.ArH
()l* I ArilHK

ISt:iti- ur I'oUIUl V

MAIIil N N \M 1

<»i' MMi'm-.R

lURl'mM.Ail-:
III Mnrill-.R

( "^tiil" I 1! ('oullt 1 \

< )i ill' ATloX

Re^idfi! ni Suit I'l tuh i-rn

) I'll I

M,„,Hi^

TUl- \IU.VK ST\Ti:i) I'KR^ONAI, R \ K r !* f 1 , \ R > ARl' I'Rt !•

liicsr <)i Mv KNOW i,i:ni".i-; am> r.i-.i,n-,i-

1 \

Tti lill'

(Address

MEDICAL CERTIFICATE OF DEATH

i)A 11-: oi- i)i;\ Til ipx

Icl.

W

I Ntotltlll

nay)

/ go \

(V<-ar^

I ni':RI-:HV Cl-lkTH-V, That I attfii. U'd ikHHiKL-a fmm

—^ ■ — -H/l to 190 "

that I la'^t saw h ^ — alive- on -— — ~— 190^

anil that (k-alh ocriiritMl, on the date ^tate.! above, at
M. The CAISI'; Oh* DIIATII was as fyllows:

(^^^^J^J^J^^^^ - - K V ■ ■ «^AVCb JV<. j , ., q.

or RAT ION >V77/-.¥

CONTRIin TORY

Months

Pars

Hours

^TION )'rars -^ Months /hirs

NED ) LO^CPAJIK; J Ail U) lX'..'V ■ '

//on

t s

M.D.

b

I<)0

f

m. — :

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

Former or
Usual Residence

Wlien Has disease contracted,
If not at place of dealli ?

HoH long at
Place of Death ?

Days

RI.ACK Ol' F.tRIAI, OR Rl-.MiiVAI,

Qna.ti DWt

I»\r^;'if HiKlAl. nr KHMOX'AI,

'Oct. i\

rxni.R TAKl'.R

■A<i<ii«ss HC'T \3 frv

1 1 I 90 1

T
I

... ... 1-1 ikCF ehniilil he «tntetl F.X4CTLY. PHYSICIANS Hhould

N. B._Bvery Item of •.„far.«atio„ should h. c„r«U.IIy -ppi.ed ^^'f^^^J"^'^',^^^^^^ ,„for.„„tlo,.- for pT-

state CAUSE OF DEATH in plain terms, that it mny be properly wiassmeu. me 1
sons dying away from homo should be feiven in every instance.

f

«n

— -— ..ac^iina

^^W^^^V.

14

If

■\

WRITE PLAINLY WITH UNFADING INK

ard.tn':'''M !

'!'! ! V,,

t-f-S^-^: lus^r

IfJO

DEPARTMENT OF PUBLIC HEALTH

THIS IS A PERMANENT RECORD

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

City and County of San Francisco

Certificate of S)eatb

PLACE OF DEATH: — County

ofO/

^

'V

City ofCJ/Ou^ru 0XXX.OfV<^^

No. '^'XS'N (\\j^^\r■' ^ St.: 1 Dist.;bet.

^,^^. ^.. CUvTTu^i and

( " r"o;:TH"oCCUR'Rrr.\"r«0,^p"*' o%":S,.?u"on"c,V. ,TS name ,„ST»0 or STRC^ .NO ~U»B.R. )

FULL NAME UAAXXaj

-AO^W^

1 w

L

PERSONAL AND STATISTICAL PARTICULARS

OX

s

1> ATI-: ( t| llIK I'll

llA.

.mtli) K

ll)a%-)

\t .l•

sI^■(,I,^: MAKKIJ'.li

|\\iit( in v,n-i;il tli^it- iiatiifu)

I'.iH rm'i.AOj':

•-■I, (If <ir (."'lu nt I \

VAMI' nl'
!• ATlIl-.K

niKllll'I.Ai'K

oi I A I" in: R

(State 1)1 I'lmiitry

MAIMKN NAMl-
o| MoTin-.K

lURTUlM, \CV,
Ol" Morifl'.K
(StaU- or (."ouiiti y

oocri'A rioN

!/.»/'//

n

/'.?

'

u

1

,L 'Ml

oh:x^^

MEDICAL CERTIFICATE OF DEATH

DATl-. nl- Dl-ATH pCx

1 HI-;KI':I'.V CI:RTI1'V, That I attcn.kMl aeccascd from

TQO

(Day) (Vcat)

'C .cl

1 6 t; n

up I to ^ ^^ '■

190 H

that I last saw h •" alivo (ui V. ^ v < . I90

an.l that <liath ncrurrc<l, cii the date stated above, at < -
M. Tlu- CAr.SI": 1)1' DI-iATI! was as follows:

L*

^ vj

a

A

"^UOl)

1

A'/"iifr,f ill -Vcv /■'/(,•'/( /'

) III I J-^

yfi„if//^ 1 I /''

TnKAn<)VKSTxri-l)1«KKSONAl. l'NKTU-ri,\KSAKHTK< 1- Tn T H H
HKST Ol- MS KNOW I.l-;i)<'.K A M)^1•,^N■.I•

( Iiifi 1; inatit

N ,-i

DIRATION
CoNTRllU'TOkV

)V(7r? Moulin 5 /;</}, s //<>//;-.?

DIRAI'IIIN

(SIGNED

:.t I

)U3^'S).ti

}[, Wilis f^ays

I()n

(Addres.) bH'b a^Ctl/

i

Hour<;

M.D.

\

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

Former or
Usual Residence

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

HoH long at
Place of Death ?

Days

I'UACK 01-' Ml KIAI. (»R k!':M()VAI

|)AII-:i>! HiKiAi. or RHMOVAI.

T go

\L^-l

I

N. B.-

•tate CAUSE OF DEATH in pl.un tei-m«. that it may He properly wlassmeu.
»ion« dylnft away from home nhmild be ftlven In every Instance.

i\

^'

U^S^^^Ubk.

I !i

WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD

\\, ;i'l!l 1 Vo

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

Dn/r n/rf/,XJ/zL<A>^\j l^

JfUJ'i

Eegi^sleied jYo,

^434

(X.tri^^^v^

u Deputy Health Officer

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco

Certificate of S)eatb

( tl. S. StanDarC^

.^

J?

(5^

'4-

PLACE OF DEATH: — County of a^vx, <x

<* t '■. " '

^v<^^„:i

City of C)x^^/>x; uJvCSu>veA^/C

.--^i

^

N^Ix^vCvvOlL L'^x.^^Oa. .^.Cu (Ib5v-(iSi;'''.A Dist.;bct.

and

/ IF DC.TH OCCURS «WaY FROM USUAL R t S I D E N C E G . V E FACTS CALLED FOR UNDER "SPECIAL I N FO R M ATIO N •• \
( Tf DEATH IcCURiTeD IN A HOSR.T.L OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. J

FULL NAME

m

OJ\.Li

•^ r. \

PERSONAL AND STATISTICAL PARTICULARS

:'

\ri: < T liiK rn

H

/ i.

AC. I-

I O Vrai

^IN' .1.1-:. MAKHIKn

W I!h >\\ I'D OR I)IV(>Kt}.I»

'\\iit< in >.iMiai di-'-iL' tial ii m )

Dav

M.nitli

I M

(Vt-ar^

/i,n

lUR I'lll'l, \rj-:

Stall Ml ( . lunllN-

XWtl Ol

i\ riii:R

Ol I NIHl-.K
ISlati III ^.'(lUlltl v^

M\I1»j:n NAMlv
«)!•■ MoTIIHK

nikrmM.ACH

<»|- MorilKK

(Slati Ol Cnuiltrvl

nrrrr ATioN

A

\

^Wvt

MEDICAL CERTIFICATE OF DEATH

DAri-: Ol- DliATH

,■>

(Month)

w

(Dav)

I go \

I Vtal

I IIh;RI':HV CI'IRTIFV. That I attcii<lc«l (k-ccjiscd from
aX IL iQo'i to w'^ it up H

that I last saw h • • ' ahvc nii v.. C-V.- L I90

and that death occnrretl, 011 tht- dat*.- stated ahove, at n

I

1

M The CAT SI-: Oh* I H-! AT 1 1 was as follows

(? •

DTK AT ION Years Mouths

CONTRIIUTORV LLIc^X^ ..^..

Days 3s Hours

f\^feAa,s.

u

1)1" RAT ION

Years

Month.

Paxs

(SIGNED) UxMj U. \X^K^,t^\,

^/Ct) M looH (Address) lltK' "^OXci^XXM

Hours
M.D.

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

F.™er.r a0b5-(f»^vXil U. K' ^'

Rfsiiffit in San J'mmis/'n tjx- )rais

Mioilh'

n,n

'\'\\V. AnOVK. HTATl'n PKH'^ON \1, PAR I' ICT I,A KS ARK TRllC T< ) Tin<:
I!i:ST 01 MV KXOWl.lJX.l-; AM) I?!-; 1, 1 1*. h"

(Ii

fAddrt'-^s

Usual Residence

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

Death?

Days

PLACE OF niKiAr. OR ri;movai.

DAiVKo!" Ht KiAi, or KHMo\AI,

0

190

(AiMit'ss

fS. B.— Every Item of information should be cn.efully supplied. AGE should be stated EXACTLY PHYSICIA1N8 should
state CAUSE OF DEATH In plain terms, that It may be properly classhied. The Special Intormatlon for per-
son* dying away from homo should be given In every instance.

%

i

i

i

■I- «

M

H

WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

Registered JS^o,

DfUe FiJe<l,S^^d^^Osj VH ■ J^'i^l

Lcrvu^ dJUvHj Deputy Health Officer

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco

Certificate of IDeatb

( tl. S. Stan&ar^ )

^

(^

PLACE OF DEATH: — County of Ocwu ^ Kcsj-r^Z\,^^<CMY of OxXnrv OAxc^^eu^Co

1,+ ^1
No, HOC) UX a J St.; 5" Dist.; bet. \l ^ tOAU\.<^a) and H

(ir DEATH OCCUPS AW*V FROM USUAL RESIDENCE give facts called for under ' SPECIAL INFORMATIO
IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER.

i .1

+

\_ r

FULL NAME

si;\

PERSONAL AND STATISTICAL PARTICULARS

COI.OR

oJui

, J

D.Ml. <»f" HIKTII

AC K

A'X'K

M. tilth I

'iS ,

I)av>

Mnilli-

( Vt-ar)

/),7 1

•-1\<'. l.K. MAKKll-:i>

\vn)«»\vi;i» nk niv* >Rri:r)

(Writi'iii >;(M'ial di viiinatinii)

IURTHPI,A('K ,'^

I >t.itc 1 If (."iiunlrv '

L

I- A rni;R

HIRTHPI.AOH
<1!- I'ATHKR
(Stati- or I'onntrv

VDIx-rA. 0

MEDICAL CERTIFICATE OF DEATH

DATK ni- I)1:aTH tCS

it
(Day

f Month)

(Year)

I jnCRIUJV Cl-KTII-V, Tliiit J atteii.k'd deceased from
M ! 190.:^ to qX^ 10 T90S

that I last saw h '• alive on . '-jLIvL i^q

and that deatli octnirred, on the date stated ahove, at
^ M. The CAISH OF DI^ATH was as follows:

o <xCLu. cL Jca^-rvXN.xxAA.xr>v

I) r RAT I UN

\

>! A 11 ) !•: X N A M !•;

oi- M«)rm-'.K

lUK ruiM^Ai'i-:

<)!• Mo'rUHR
(Slate or Cmnitrv*

OCOr PATIO N

a)

Hours

CONTRIIUTORV

c

I)T' RATION

)'eat-s .^fontfis Pavs

(SIGNED) y.'UrrAJt UL- nDAATLKiU/
W ^t \% ,ooH (A.ldres^.) 2)b^ UAA/tLuv Ot

f/ours

M.D.

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

/\r^:iir(f ni S(:ti /'i atu isrn u L )'ra>s

M^vtli-

I hi

Tin' AHOVH STAIi: F» r»KRS()N \I. 1' \ RT U" T r,A RS ARI' Ik VV
HHHT OK MY KN«)\\T,i:i)«; H AND 1!I;M};f

Ti> Tin-

^t

'\{

IN. B.

op ^ <? "

fAd.luss 3^1 UXX/^^ NjlX^^ LLu-^...

-Every item of mformntion should be cnpefiilly supplied. AGR should be stated EXACTLY. PHYSICIANS should
state CAUSE OF DfATH in plain terms, that it may be prr.perly clansified. The "Special Information" for p«r-
«on» dying away from home should be given in every instance.

Former or
Usual Residence

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

How lonq at
Place of Oeatli ?

Days

PLACK <n' in RIAL OR ri:m<»vai

I>ATj;or Hi KiAf, or Ri;Mn\Al,

1901

^

< f

X

o>

.1

H

^'

f

, 4i^

■i!

I
i

WRITE PLAINLY WITH UNFADING INK

,••', r V

WO'i

THIS IS A PERMANENT RECORD

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

Ile^isfered .A^. ^436

DEPARTMENliF PUBLIC HEALTH=City and County of San Francisco

Certificate of Beatb

( 11. 5. 5tan^ar^ )

PLACE OF DEATH: — County of

K\y^f\^

City of U/Cucw<i.

ex.

Lu f^J

i

No.

St.;

Dist.; bet. —

and

/ ,r DEATH OCCURS AWAY FROM USUAL R E S I D E N C E G . V E FACT
V IF DEATH OCCURRED IN A HOSPITAU OR INSTITUTION GIVE I

FULL NAME

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

■-i:\

PERSONAL AND STATISTICAL PARTICULARS

ft n

H

cuc^^

(\<xL

n

1) All; < 'r i!ik I'll

\<. 1-;

MoiUlO

V, I

i i),i\

,^^i

(A

) r,n

M,,til/i>

\ tar

lh',\

'W'litriu ^(K-ial il<-.i5.'nat i'lii)

' Slat> 'It I'l iiiiitl %

NAM1-: «>I-

1 A rin-R

Oxcl

\ a

m
r r-

! i*

llIK THI'I.Ari-:

<»!• lArm-K

I stair I )I rmillt I \

M \ll>i;\ N \ MI-
CH m<»tiii;k

lUK rniM.ArK

<>1- \inTllKK

I stall- 111 t'otlllll V

utHTJ'A'l'ION

r^

R'r-iiinl III s.,-,^ /■') ,in, i-i'"

) .-.ii

^/,,ll//l'

I hi

TIN- MiuVK ST\Ti:n l'KU^«)\ M, 1' \ K lU" T 1. \ Ks AKl- TKri-
lU-.ST <)|- MV KN'oWI.Kix'.H AM) lU-, I.l 1. 1'

r%j

TO nil-

MEDICAL CERTIFICATE OF DEATH

DATl", U1-' DHATH

Day)

I go

I Year )

(Montli)

1 III'KIU'.V C!{RTII-'V, That I atlcmUMl deceased from

- to 190

190

alive on

that I last ^aw h ^^
and that death oreurred, <»ti the date stated above, at
M. The CAlSi: ()I" DICATII was as follows:

T()0

Dr RATION )'tais

CoNTRII'd'ToKV

Mouths

Davs

Hours

niRATtON

Ytars

^^o*lths

^}{\AX,\^J'

Pays

Hours

(SIGNED) Y KS.

kJ/Z^J \% iqoH (.\.ldress)Cl

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

,OL.cv^<X,

M.D.

Lu CA

Former or
Usual Residence

Wlif n was disease contracted,
If not at place of death?

flow tonq at
Place of Death ?

Days

S.l.llrvs lioO

ri.ACH oi- m KiAi. nu ki;m<»vai.

^

.\ I I', 'l! Itl

0 f P ^ )

I»ATi:..f in KlAI, or KKMOVAI,

3^0 190H

(AcMn-'Js

l)nn^ C^X

ini

Ji

^ .. 1. 1 AHF .Hniilil he stated EXACTLY. PHYSICIANS fihould

N. B.— Every Item o* InformHtlnn .hnu d be c„r.*ully Huppl.ed ^"^^^^^^/^^.^^^j^i^^^^he •'Sp.clal InformBtlon" »or pr-
state CAUSE OP DEATH In plnin term., that it may be properly t.l«Mmea. 1 ne 1 «
Hon* dying away from home Hhonld be feiven in av«py Instance.

t'i

It

WRITE PLAINLY WITH UNFADING INK

,' , < ll^ ,;th t

i;>. r (•■.

Dftlc FilviL y £l,>crlM.>v. \'\

vjin

THIS IS A PERMANENT RECORD

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

.^rvc^^

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco

Cettificatc of H)eatb

( XX> S. StanDarO )

PLACE OF DEATH: — County ofO<^^ J.Va ^yc^ ; ' City of Uxx^^.

(?m

N

o. S'iS W<^^

Wl!v

and

^ .

St.; H Dist.;bet. .

( fr ^^v^^v::^:^ -v^o^^ ^^^:^^^^-:- ^- .^^" s?:^^-Jo T;::^r )

FULL NAME

PERSONAL AND STATISTICAL PARTICULARS

'tV^A

'tX.Avo .

DATH ')! I'.IK ill

A<.i-;

d

)-,;!

iDay

MniiHi

t al

P.r V

MN<.!,1-:, MAKKIl'.n.

\\ii>t)\vi:i» OK DivoKi'i:!)

(Write in soi-ial (U«-ii.n!;itii>n)

OxA-vo

MEDICAL CERTIFICATE OF DEATH

DAII", nl Dl'.ATH

y.

(Mmith)

iQ

iDav)

rgo

(Ycar>

I IllvRI'I'.V CI'RTIFV, That I attciKlcMl .k-coascil from
oi U: TQoH to . Jii^ •' TnnH

^ ,_V. .V 190^1 to W;W*^ • > T9O

tliat I last saw li • alive on ^- -■ 190

and that death occurred, oti the date state<l alnne, at
-.i M. The CAl SIC Ol" DKATH was as follows:

(-yv^Ca^v. > N vt > u^ a.

niKTinM.Xi'K

: Stall or < '1 iitllt ! \ '

.^^'.'n'u' ^ 0 (1

•^

U ^ I

u c

A.Ou>%^d.o

niK'nii'LACH
Of- iATin-:K

(Statf or (.'otuitry I

MA 11)1*. N XAMK
OI- MOTIIKK

UIK'rHl'I.ACK
oj- MOTHHK

istatt or Country^

oCCri'ATION

KtVi

rttluW-CV i\

A'f>/iff'if ill "^ii'i /'>ini,n/-t>

)%',!!> b .■•/.»;////<

/)(/ )

rm- \novK !^t\ti:i. pkksonai, rAKTicri.AKs aki: trik to thi-

IJKST OK MV K NOW 1,1; IX ".K ANH lU.I.Il-.l'

iU'.Si 1 ill' MN K M '%> !,•.»" >»• ' *A

n

Adtlvi'ss

S-^5

A.kX

t

nr RAP ION }'iuirs

CnNTU MU'TORV

Months

Days

Hours

DIRATION

(SIGI

V,'/

A

I go

Years ^Tonths Pays

I.A 4

(Address) HuUty^^t k

Hours
M.D.

SPECIAL INFORMATION only for Hospitals, Institutions, Transients,
or Recent Residents, and persons dyini] av^ny from liome.

Former or
Isual Residence

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

How lonq at
Place of Death ?

Days

ri,ACK. ol" RrRIAI, OK Rl'.MoVAI.

)Ap%<>t" ncKiAi, or ri;movai.

r.NDlCRTAKKR

(Aatlrtss

DSl

flL,\Ji^ V

U , . ,. . .pF oKni.Irl he stated HWCTLY. PHYSICIANS should

N. B.— Every Item of Information should b. cn.efully suppi.ed ^^^^^^^^/^^^^^^^^^^ Information- for pr-

state CAUSE OF DEATH In plain terms, that it may be properly ^lassitica. 1

son. dying away from home should be given In every Instance.

I i

n

» j ( ■(

. II

Ii()ar<l

WRITE PLAINLY WITH UNFADING INK-THIS IS A PERMANENT RECORD

REFER TO BACK OF CERTIFICATE FOB INaTRUCTI0N3

„f Hinlth- 1- Nn 1^ ^-^^^^nSiVC^

100

Be<!isti'red JS^o.

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco

Cettificatc of IDcatb

( tl. 5. StanDarO j

0 ^

PLACE OF DEATH: — County o^~'a.^^' ^^'

%

a

City of O <Xr>r\j 0 ^0-^^v^.^c.cA,ec

0

Dist.; bet.

eric

(

and

fNo. Ob i I i l.\_.V „ no,, Al RESIDENCE GIVE FACTrCAlJcDrOR UNDER "SPECIAL INFORMATION" N

( '^ rF^*7ATH"0CCU%rcVi;''rH0^s1.rAt O^^N S 'l ^U^O^N C.VE KTS NAME INSTEAD OF STREET AND NUMBER. )

JX.'^^V.AA.Xt

FULL NAME

-^^ QD

PERSONAL AND STATISTICAL PARTICULARS

A 1 COI.oR

OutUj 0\D^UaXV\w

4

Xo I

I>AT1-: nr lUK 111

,1

S_«w w-^

it. null)

A<.K

bo 5V.,,

as

(Day)

M,<»tli>

\ i-ar

/'..'

siNCl.K MARRIRD.

\vn><»\vi:i) t)K nivoKs'Hn

Write in -iM-ial ihsis-'iiation)

lUH TMJ'I.AOH

' Slatt or l'omitr\

NAM1-: OI-

FATm;K

lURTHri.ArK
(>I- lArilKK
^Stalf or Count

MAIDKN NAM I'.
Oi- MOT 11 MR

mKTHlM.Ail",
()1* M(niIi;K
(State or Count! \

OCCll'A riON 'l5\P

vt>v.L V

MEdlCAL CERTIFICATE OF DEATH

DATE Ol- J)1:aTH /i ^

(Month) •!>:>>•

(Year)

I ill'lRICIiV Cl'lRTtl'V, riiat I atteiiikd deceased frum

Rrsidfif ill S,!H /'i tnii/'^/'i>

<x 1 wcL

that I last saw h ■ alive on ^^^4^ I 190

and that death occurred, on the date stated above, at
M. The CAISI-; Ol' DliATlI was as follows

\^isJ\.Jr^^\^^

^.

\„iUL<XJUL

^n

(^i

aJ.

Mouths

DrRATloN Years

COST RIIU TORY

niRATION Years Months

.NED) AJj. Uj. j KyAJ: .x

Pays

Hours

f^ays

Hours

(SIGI

w.

11)0

f

Address) %X.'5 S \ I LvA.^^^ vv

^l.

M.D.

\

\ i

SPECIAL INFORMATION only '•"^ Hospitals, Institutions, Transients,
or Recent Residents, and persons dying dway Jrom home.

M.»ilh-

/',.M

Till' \HOVK STVn-.D I'KKSnNAl. 1' A K TUT I, \ RS ARl', TRIl-: l* » TIIK
HHsT Ol-' MV K NOW 1,1; IX, H AND lU'.I.n'.F

(Infoitnatit

t\<liht-s O VO I I *" I I -'Wr

I) J

\J

Former or
Usual Residence

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

How lonq at
Place of Death?

Days

n.ACK OF HIRIAI, OR KKMoVAl,

D\T4%of iiiKiAi, or ri;movai.

FNDKRTAKKR ^S^ J<^^^V\JkjU\J ^. d^K,»^^\.t ^

T90H

N B —Every Item ot' information should be cnretfully supplied. AGE should be stated EXACTLY PHYSICIANS should
■ state CAUSE OF DEATH in ph.in terms, that it m„> be properly classit'led. The "Special Information for p.r-
Ron« dying away from home should be given in every instance.

li'l

•^^.wwi;^

f1

r
t

WRITE PLAINLY WITH UNFADING INK

.•Sf^!!S.-cH5cl'Cn

1)

(lie FiJr<!, vJclrl

yJL\j IR

vja

THIS IS A PERMANENT RECORD

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

-1

XCLC<-^ :^

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco

Ccvtiticatc of IDcatb

I 1:1. 5. StanDavD >
PLACE OF DEATH:-County ofdo/^ JAX^^- Oty ofOxX/^ ^'^^^JT^'^

No. I'iSb VJ/<XC4„i

i Vine. ^' SU 1 Dist,;bet.oU.^ - • vAAKAlyftJ ^^

b \J AXI.^ t ■■ ^roTAVlsirr r.X/r TACTS CALLED FOR UNDER 'SPECIAL INFORMATION ' \

^ 0 , I AND A

FULL NAME

^ a

AX\'l> ■ '

six

i) A I 1 « M I;IK 1 H

At,!-;

PERSONAL AND STATISTICAL PARTICULARS

C< >I,<»R /'"^

UIoJli

1^

/

H

M,»if/i-

11 at

/)„■)

(Viar)

W I now 1:1 > OK DIVoRi i;i»
'Wiitiiii -iK-i;»l (li**i^ii:it inn '

1 ^t; t ' I iT I 'i (tint I \'

NANtl «>)
I- A in IK

lUK 111 I'l, \CK

«»i I \iii»:u

' Stair or C'lmlltl \

M \I!iKN N\MH (U
(il MiilIIl.K

FSlRl'mM.ACK

Ml Mo'rHHK

I Slatf or Crmiiti ^■

MEDICAL CERTIFICATE OF DEATH

I mUilU'.V Cl'.RTIl'V, That I allen.k'cl (UiHa'^cl fn.iu

(' " ( if
lliat I last saw h ■ ' :«livt' on

an<l that death .ururre.l, «.n the .hite stated alx.ve. at
- M. The CArSI-: Ol- hl'ATlk ^vas as follows

lip

I) r RAT ION y'Ciirs ^ Months Day

CONTIUIUTORV

Iloiii s

(K'cri' x'lioN

Rfiitfi! in Siiti I i< ^

THl-AHnVKSTXTK.M'HKsONA, rXKTirrKNH.AKKTKrHTM TIN^
UHHT «)1 MV KN<i\\ l.I.IX .h AND lU-.I,!!.!'

(informant \J lUXKU -<J.

\-1.1r<

1X5^

DTKATION
(SIGNED)

)'iars

/hjvs //ours

M.D.

SPECIAL INFORMATION on'y '»f Hospitals, Institutions, Translfnls,
or Recent Residents, and persons dying dv^ay froni home.

Former or
Usual Residence

Wlien was disease contracted,

If not at place of death ? ^^^^^

How long at
Place of Death?

Davs

i'i,\ri: <)!■ Ri'KiAi, <>K ki:mm\ai.

OfPJb

l.NDl.K TAKl'K V/X

Dxiivi-r lUKfAi, iir ki:mo\ AI,

(i ct : ', ,90'

/\xn LC.

VAXl

^"'^"'^ ~ -Ho,il<l he Rtfited RXACTLY. PHYSICIANS should

—Hvery Item o* in*a.m«tion .hould b. cnrefully -pphcd ^^^'l^^^^J^^^^^^^ |„formaf.o„" for p.r-

•tate CAUSE OP DEATH in plwin term«. that it may be properly wlassiiiea. 1 nc 1

non9 dying away from homy should be (|iven In tsvery Inntance.

?;i

r

t;

// ,

f.

^u.

f

l» 1

WRiTE PLAINLY WITH UNFADING INK-THIS IS A PERMANENT RECORD

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

,1 ,.f Hinlth r N'

c-ParK^4- lUKii' r

Dale Filed , \ji€

]le<!i^ferc(l J\^o,

Deputy Hcoith Officer

DEPARTMENT OF PUBLIC HEALTH-City and County of San Francisco

Cevtificatc ot IDeatb

( "U. 5. 5tanDatC> )

PLACE OF DEATH: — County of

City of

n

CXAAJCIV.

No.

St.:

Dist.; bet.

and

.. OCATH OCCURS AWA. .ROM USUAL ^--^^--^^^^d^^l .'^^^J s^^^E^i^ D ^^^Jsi;:^ ^ ^ )

( - -*v:;:f o^cjR^vrA:<^^L ?« t^s.;j;to; oive .

FULL NAME

PERSONAL AND STATISTICAL PARTICULARS

-■r.x

A

<xU

C(»1,<»R \ A

i» \ ij; I >F 1.1 Kill

\«U'

Mnlllll 1

^

) ,„

IC

ll);ivi

M ,<rh

ar)

MEDICAL CERTIFICATE OF DEATH

DA ri-; ni- i)i:a 111

I Year)

/),;

sivc.ijv M M< i< n'.n

WlDOWl'l) OK 1)!\ ' "■ > ''>
I W'l it<- ill MK-ial .li '!■ . ' " '

U-C^XO'Ul

/

BIKTHtM.X*!:

(Stati- or t'ouiiii s

N\M1 ni-
1 A III I.K

lUHrill'I, \^ 1'.
(»1 r \ 111 I'.K

isialt 111 I'inintt %

\! Mltl- X NAM J.
(d Mollli: K

lUK'nilM.Afl-;
oi" MnrHI«:K

(Stall- I'l Ciiuntt \

I urri'A rioN

f\'fu,lr,f III S,ni /■/!//'< /"■"

VlUu V

u

/~-,

1 inCRl'lJV CI'RTIl'V, Tliat I aUcii.kMl .KHAascd fmui

— up to '^

that I last saw h - — alivf nii — l<)0
ail.l that (Irath niHurrcl, m, llu- -late ^tatcl above, at — ^
yi Xhc CAISI-; Ol' I>i:A1 11 was as follows:

nr RATION y'crs

t nNTKIIU foKV

I )r RATION

Mont/is

/hn

Hours

(SIGNED)

I<)0

Mouth:

Pay

V

I lours

M.D.

Ri

5

M.nlfh'

Ihl

■VnV MM.VKSTAlKI)l'»'HSoXAI..-AKT!i-rKXK> XKl- TKtH T. . TIIH
lll'.sr OI MA KNOW l,l,I>r.l-. AND ISlMI I

SPECIAL INFORMATION on'v •"'^ HnspitaR, Institutions, Transients,
or Recent Residents, and persons dyinq dv^ay from liome.

Former or
Usual Residence

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

How lonq at
Place of Death?

Days

ri.Ai'K <»i>i;' Ki\i, oK ki:mo\ai.

DAIJ; 'if lii in\i. <'i K1',M<>\ \1,

II \

TQO

N. B.

. . ^, A»'i Mhoulil be stnte.l liX^CTLY. PHYSICIANS nhoiild

.r.ver.v Item ol" Information should b. cnr.full.v Huppl.cl. ^^ ;J; ;^;7,'^'.^^^^^^^^^ ...Spe.l.l In»orm„tlo„- for p-r-

mntc CAUSE OF DEATH In plum tcrm«. th»t it m.iy be pr..|.crly wlBimitieci.
nons clylnft away from home «houltl be ftiven In .very InBtnnce.

3

•r^'

•Ml

4M

H

1'f

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

REFEP TO BACK OF CERTIFICATE FOR INSTRUCTIONS

..! ,,f n, lUli !•■ N'' i -

\ ' D e ^"^ u

Bci^islcrcd J\'o,

2441

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco

Certificate of 2)eatb

( Ta. S. StanfatP )

Qi;^

No»

PLACE OF DEATH:-County ofdo^TV kc^oc^c^City of ^.xn^ J ;v<X..x.^.^^

Dist; bet.

)

, ^VLCLV; ..:.. XJ^\\-'- >\'K/.-.. .S^l**.-^^^. rACTS*CALLED ^OR UNDER " ' S P EC I AL I N FO R M ATI O N ' \

/ ,. DEATH OCCURS AVVaV FROM USUAL " f f ' ^^^.^JV^^^J "^', /^ItI NAME INSTEAD OF STREET AND NUMBER. )

( IF DEATH OCCURRED IN A HOSPITAL O (^ INSTITUTION GIVE

FULL NAME n I lQ

[lla, ^K

4

si;\

DATK OF- lUK 111

A<'.H

PERSONAL AND STATISTICAL PARTICULARS

s« il .< tK

\

lA.

M.nith^

HS

r

M,,„n,

■>iar

/>./

IQO

iVeai )

-IN'.I.i: NtAKKI! 1>

\\II)< lU in «iK 1M\ « •K»i;l>

iWt itc ill -..i"i;u .l.-i;.'i!at!..ii)

iuki'hjm.aim:

I Stntf <•;■ ioiititi y

NAMl". c)|-

I athi:r

fUKIin'l.A'JC
oi- lArilKK
iSlutc or roniif rv

MMIU-'X NWtJ

III MoTin: K

iiiiniii'i,ArH

' vciti , ,1 (.'(Hint I \

n rri'ATlDN -V

K

MEDICAL CERTIFICATE OF DEATH
DATE OF DEATH [A i

I'M. .nth) *J>''^'''

1 HlRl'llV Ci;RTn-V. Thai I alUMi.lcd (Icctased from

0,t.t' !'i i,o'i t„ .A?^fc n TooH

that I last saw li alive on ^^ "' ' ' ^<^P '

an.l that <k-ath occurred, on the .late stated above, at
AT The C\rSI': Ol' 1)I';AT11 was as follows:

X ' , f

'^

5^

.Cti

-5^'

DIRATION

CONTRlP.rTORV V. I

liotit s

^

DTK AT ION )?J?'*^ Months Pays Hours

(Signed) vu u.

iD^tt 1% u,oH (Address) q%-lNf>la)vL

M.D.

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

ui^

( r)

r

M,.,itli

/>,

TUKAHoVK.TXTKnrHKSoXA. rAKTJ;;, ^. X K . A K ,. T K I V. T. ^ T. . .•
Ul'.ST oI- MV KN<>\Vl,l.I)<.h AM) 1.1 ..HI

f Infotmatil

\.Mi

1

,c

(

di

5R?^idencA3^-<^.-«^^^^^k^-^ Pll^e'roJlth ?

When was disease rontrarted, b.^f^.^^ 5l^ AnAfsK].
If not at plare of death ? l^cleXMX cM>. U>cxc4.^; ..-

Days

I'l \CK Ol- lUKIAI, OR Kl-MOVAI,

■ c

CU'^rXt

L ^ '.

IQO

!)\ri: .1 !'.<!.• I A I, or RKMOVAI,
fAcMre<*s 'Oat) wOXi

1.

^s) .. , .^^ „u„,.i,l ha fttated EXACTLY. PHYSICIANS should

*on«*d>lnft away from home should he ^Hen in every inntHnce.

51

•'I

■U'

'I

I

I
i

Is;

i'ly

1^

T^yf^irr

IPSS'^

,,f n. M'th i- N.

WRITE PLAINLY WITH UNFAD.NG .NK-THIS IS A PERMANENT RECORD

BFPER TQ BACK OF CERTIFICATE FOR INSTRUCTIONS

2,9^1

Registered ^''o.

ck.O'^^*^

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

PLACE OF DEATH: — County of

Nollu 1 mcb^xxrvM, It ^^iv da \. St.;

Certificate of IDeatb

City of jV. l ^vC v.*

Dist.; bet.

and

)

( " r"o;u"»ct%'"".:*°" ^"-.^r.t -?:?i^',^rj,;r,;iV.^«7 ,x."r^? s;%%%Ti:r.°:i"r ■ )

DC^URRED IN * HOSPITAL OR I

0

FULL NAME

-r\.Ub

cnr

•tr"^ \ \^w^.L

4 ,

sj: \

PERSONAL AND STATISTICAL PARTICULARS

0(\^.

DAi'i; tir r.iKTii

M.V.

rV

O K

M.iiith)

1\ .V,.,

(Day)

M.iii///'

/),n.

MEDICAL CERTIFICATE OF DEATH

DATE 01 i)i:ath P

64xt 11

(Montii) 'I^^'V'

/go 1

(Year)

I H1;RI:BV C1;RTIFV, That r attrn<lc.l (U-ivasod from

- TOO

— — IC)0

— — — — — —1 90 U)

that I hist saw h ■' alive on

^IN«. I.I" ^t \KKI1".I>

\\ in»»u 1 !• t>K i);\<iK»i:n

iWntr in -iH-ial ,1. -i;-- tiat Mil)

niRTin'i.x^'i"

I Stritf of i''>nnt 1 \

?

V

NAM I rtl
FATniR

lUUTm'i.MH
<»l- JAI'UHK

(Stat«- i<r v'liuiit vv

MAIDI'.N N\M1
nl" MoTIlKK

nikTIirUAOK
()»•• MOT HICK
(Suite nr cNiuntrv

au<l that <Uath occurrcl, on the date statiil above, at
M. The CArt^IC or I)i: ATII was a-^ follows

I )r RAT ION >Vt7/-.s

CONTRIIUTORV

Mi>ui/is

/hn

//()// rs

"N

\

occri'A'i'ioN -H \i

C ) 0^^ ^ ' •

Fr^idnf ni S,!ir I'l '"/i '>

I)!- RATION

y'l'jirs

■^S'

(Signed) w

T()0

^ ^fe

Months

Ctv

PiU

•s

/lours
M.D.

(Address) fCiCTr-VcWX^

SPECIAL INFORMATION on'y Jor Hospitals, Institutions, Transients,
or Recent Residents, and persons dying a\*ay from home.

)'rii I

yr,iiit!n

(liifotmrmt

1\

ai.^a.v...

Former or
Usual Residence

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

How lonq at
Place of Death?

Days

1'1,ACK (^l- lURIAl. OK RlCMoVAl.

I NIU-.KTAKKR Ck N I W ci^-^J

i)\:ri;.>! lu kiai, or khm<»vai<

190

Uxkt

3P DEATH \n plain terms, that it mi.y be properly UaHS.Hcd, I he »pew a

N. B. F.very Item o*

^o^.^dytn^/a^^y from home «houUI be J^Uen In every instance.

I

WRITE PLAINLY WITH UNFADING INK

ii.iMh r N'

Dafr Filrf/, U^cIvImA; H

7-9^? H

THIS IS A PERMANENT RECORD

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS ^

..trVAA^ :Kx.. ^^l!

«i

DEPARTMENT OF PUBLIC HEALTH-City and County of San Francisco

i

Ccttificate of 2»eatb

1 -U. S. StanDarD )

-?

(jj^

PLACE OF DEATH: — County

}(\jJ^

O^^) St.;

Dist.; bet.

and

Mn CJ JL^yW^CC'^^X' y^ <ML.']n.A/^C>-''V' J>tM t^CTS*c'itLED rOR UNDtR -'SPECAL . N TOR M AT.O N - \

FULL NAME ^

V

LccA^V*

-^i.x

i>\ ri: <>i lUK in

A<-j";

PERSONAL AND STATISTICAL PARTICULARS

n

^ W.V

1 mAiUIi)

x%

Dav

\f,<nlln

ui)

/'.M

\\

I go

\vnn»\\ i:i> <>k l>;^ ' '''■'''.'■''^

(Writf in 'filial .1. -ly nat u-ii)

^

X/^

ii

II

lUK rin'i.ACi'

"^t ;iti- I ir t'outit 1 %• '

NAMK OF
FATIll'.K

lUR I'Hl'I.ACK
i stall (ii I'onntry'

M \11H:n' NAM1-:

oi M«)Tni;K

niR rm'i.Aci-:

i)V >t<)l'nKK

(State 111- C'osuUi V

MEDICAL CERTIFICATE OF DEATH

DATK OF 1>):aTH (("\

(Month) <l>='^'^

1 III-RI-BV Cl';i<TlFV. That I atlen.kMl .leixased fn.m
Q^' i:^i<)oH to Get i% lOoH

that Mast saw h ... alive on ^^ '^ ^^''

ana that <U-ath ocmrrcl, on the date slate.l above, at il
OL M 'I'^i*-' C M'SI*: Ol" Dl-'.-Xrii was as follows:

^owkkA^^nxxX^x^ J fr->-%.^Ma„^

\.Ow4

/

1)1 RATION

> 'cars

'ar% Months '\ Pays Hours

}V<7;--V

XH

r^

Hours

m-RATIoN ^

( SIGNED )M')\ '1 : CrU^'>-^ ^ IVI.D.

Oct) 1 ! TOO (A.iaress)1:lxhyv>AXX/Vx. IdCHvVvv.Ui

t.^vv.L<x,l.

SPECIAL INFORMATION o"') '»'■ Hospitals, Institutions, Transients,
or Recent Residents, and persons dying away from home.

oCCri'ATION

)V,;/

M.nilln

In

m,sro,.>^-KN,nv,.,.....K.vN'^-'-'"

f \<lilrc»is

Former or M'^ fs

Usual Residence ^ ^^

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

Wi

\ . How long at
4rrA.A ' Place of Oeatli ?

. Days

I'l \CK <>1' lUKIAI, OK Kl:MoVAI,

DXTKof Hi HiAi, or Kl%MoVAI,

0^

ac

190

J'

,, . TfiE .hould be stated EXACTLY. PHYSICIANS should
^. B.— Bve.y Item of Information should h. c«r«Vul.y ^uppHed ^^«P;^^;-.^^j„,j. ^^he -Special information" fo. p.r-
-tate CAUSE OF DEATH In plain terms, that it may ne prop 9
'on. dylnft away from home should be ftlv.n In every instance.

m

!|

WRITE PLAINLY WITH UNFADING INK

Board ..f IKnltl. K No i« 1--~.-«^^. KM ■ —

190\

THIS IS A PERMANENT RECORD

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

He o^ist creel JS.'^o, /^444

\

11
I

«

Dale /v/r^/,y/^<rWv) 1*^

cSuji^^c^ Ajia>u. err*

DEPARTMENTOF PUBLIC HEALTH=City and County of San Francisco

Certificate of "S)eatb

( U S. Stan&atO )
PLACE OF DEATH: — County of ^'CVnrx; 0 AXX^ .tc^ .(l..ty oi

No. ICbll Mltc^.*v

... I

St^

Dist.; bet.

s

(I

1v

and

+ 1

)

^^^ A.^*.^!..^ ^-^-^ ,,wP,rB "special INFORMATION" ^

.V ,„„« OSU.L RESIDENT O.V_E/.CTJ C^.^LL.0 :°A,7o"r ST-"eT .NO NU«SC.. J

( " °,"-.r^.^=.%'-r;,':r„o"s^rt r„^?;?f,?.<=4rc^;r,;i .»m.^.s.»o o. s..^.. ..o .>.„,»

FULL NAME 0-IaX'va^Aa

A'

t (0

v\.c.

PERSONAL AND STATISTICAL PARTICULARS

'i'

i)\ri-: «)!•' luK iJi

Ai.H

aJ

H

)

iDiiv)

1 /,-;/'//'

/ R D 0

(Year)

/hiv.-

MEDICAL CERTIFICATE OF DEATH

(Month)

11

(Dav)

/go V

(Viar)

m\-«.i.i-. M \Kun:i)

NVinnUl'.K <>K I)IV«»KilJ>
iWnlt in -iK-iul ilt-i^'nati.'n)

lUKTIIlM.Ai'l".
(State i.r (,".iiuiti %

NAMJ-: <M
lATHl-.R

HIHTIMM.AiK

OI- i*atiii:h

(Stiiti- or (>'oiintrv

MAIin-'.N NAM I
()1 MoTin-.K

I HRRKHV CKRTII-V, TIkiI. I attc-n.lcl clufva-^^'l fnmi

i9^ ii 'V%. toi)-tt ii ;^;..<,oM

that I last saw h.^riK- alive on ^-' ' ^'P

a„,l that <U-ath nccurre.l, <.n the .late '.tated above, at
^^ M The CM'SICA?!' Dl^ATlI \va< as follows:

^ * ' ' V) I i 1 f . ^ .,

nrRATioN

}'ia/s

i\ font /is

CONTRIIU-TORV U^^a-^^^ nTKa.!

/)uy

J /ours

r>

•

niK'rniM.Ai)-.

OJ- MOTlll'K (\ ft

(state or CoJintryt \A U .

occri'A rioN

Rf-iiinf in San /'iiiinr',n \ ) > <' ' ^

DVRA'YIOS
(SIGNED)

}'iars Monf/is 1 /hivs

^

iD^cA. ri too'. (Achlress) 501 OAA±i£A. M

Hours
M.D.

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

Mnuth-

IIKST <11- MV KNllWI.I.D'-l-. AM)^I1I. 1.11.1

<,.,f n, QxtjOv 0" Urv^^^tA.'

Former or
Usual Residence

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

How long at
Place of Deatli ?

. Days

V\ \CF i>l- lUKIAI, (»K RKMOVAI

I»\lU:;<)f Hi lUAi, or RI'"M«»V.\I,

(Address I ill ^\\AJ^\-<nX

ct \H T90H

N. B.-

-F.v.r, I.cn, ot l„«„.n,».lon .hould be cnr.Jully -""•''«;;• *;?p^.,tTl«^Wl'"'°Th^:''*8p^cW inWn,...<.n" Jr ^r-
.tate CAUSE OF DEATH In plnin term., that it mBy Be propeny
«!!. dy*n» -w., from home .hou.d he »Iv.n In .very .n.t.nce.

|1

•;•'■♦

WRITE PLAINLY WITH UNFADING INK

15' 1

',! ..f ll(.:iith'- \' N'

■r, nSil' Ci>

1!)0H

Dale riU-'l,^^cXA>^^ 1^

DEPARTMENT lOF PUBLIC HEALTH

THIS IS A PERMANENT RECORD

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

City and County of San Francisco

Ccvtificate of IDcatb

( 11. 5. 5tanC»arO )

A

PLACE OF DEATH = -Countyof6,CV^^- ^

.City ofO^<^^-^"^ 0/MX'%vcw-^c.\.

<,^

^ \ I 0 A»-\ lex > "^ St.; ^ ^^^^** "^'* V«o HMDER -SPtCIAL INFORMATIOH" A

V IF DEATH OCCURRtD IN A HOSPITHi. wn ^ ^.-^y^ p, ^

)

FULL NAME

,<Lv-\XXAXX'

Qn>

f

V

-J

rvOL ^ \..

si;\

DAll-: t>I- lUKTII

AC!'

PERSONAL AND STATISTICAL PARTICULARS

(.1 il.t >R

i.1

V-L

M

\\ A\h)

5V.M

Mnnlfn

\

\ 1 ai

/j|! i

MEDICAL CERTIFICATE OF DEATH

DA rH Ol' Dl'Al'H

-N

\^i

NtDiith)

(Vtar)

(Day)
I ni-Rl r.V Cl'RTlFV, That I attcii.UMl aeceased from

that I last saw h - • alivi- on ^ ^••^- ' ' ^'^^ '

a„a tliat acatli nrcurre.l, on the- .latr .tatcl ahnvr, at I W
M. The CArSh; Ol- Dl-ATll wa>^ as follows:

siN( ,i,i- M \KK n: i>
wii)t>wKD oK d:v.»r< KI>

(Uritcin --orial 1I1-.1K nali' <i>

luk rm'1. \oi'

I stall . 1! t lUiiti y

>VQ ^i

.V si.VCX

I

.M . 1 lie V .\* . ■ " -■ • --S

N \\n OF

1 All! I'R

niH rniM.Aii':
01 I \ rin:K

IStatt 'a I'mnit 1 v '

(U Morill", K

lUK'i'nruArj-:
oi- M«nin".K

(Slat*' lit Country'

J .1

> V I ' ^ >

.cL

yTVQwCO.

DT RAT ION >V.?r.9

coNTRir.rroRV

Moiil/is

Ihivs

Hours

^

^K

(\JL

JUJ^

LLC

lt\

^

I )r RATION

(SIGNED)

(I

iLloi

T<)0

)V<irs .J^fonths

(Achln-^s) liiH

/hivs

'^

//oNrs

M.D.

0 (VAACr-v

\

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

) .ill -

n a

I yr,<,i!fi^ js. -} /^'"'

oCCfl'A'riDN

R'-iiffil ill San I I <!"' ''< ''

T„K.HnVRSTV,H,.,..K...N«. rU<nrr;.AKS,.KirrK,H TO THK

UKSTol' Nli' KNoWI.I-.IH.h AND HJl.ni

(liif'iMuant

^^,\^ <31

rAXX/YX >A ^

Former or
Usual Residence

When was disease (onlrarte<l,
If not at place of death ?

I'l.ACJ" nl- lUKIAI, c»K Rl.MnVAl

Now long at
Place of Oeatli?

Days

,a.in..s 5 ULox-ctc^^A.^^

D\l"i<^>i! lUHiHi «ii K1':M<«\'A1.

M

-V>A/^A^ ""^ LL

I

\ I

^■^■•■■•■^-iB^ii"""^""'^'^'^"'^'''""'"'"^"^^^'^"""'^"'"""""^"'"^"'""^^^^^. I I H t t I f'X4CTLY PHYSICIANS iihould

:".%y*n» .w°I^ "on, horn- .h h. ».v.„ y ."-..nc

;i 'I

^^

I

4

I

f

M

I*

1!,,;,',1 ,.f II. .lllll 1' No. P

WRITE PLAINLY WITH UNFADING INK

liScV Cn

THIS IS A PERMANENT RECORD

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

Re^ititercd J\f''o.

Dale FiJ('(l,\)'zkA>JLhj \'=\ l''^0'i

^r^A^ ItA^u, Deputy Health OfHcer

DEPARTMENT UP PUBLIC HEALTH=City and County of San Francisco

Certificate of Beatb

{ XX. S. 5tanDarC> )

^Ui

PLACE OF DEATH:-County ofUa>v ' VO. v\ City of H <Xo^ OAXXyxCU -

ff^o. v.. k L Idn^im^ 0 to (K i xaI u.

St.;

Dist.; bet.

and

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

FULL NAME

sl'X

PERSONAL AND STATISTICAL PARTICULARS

[YlcJU

DA IJ: < >I lUK I'll

\«.i-;

At fi I

kAJ^ 1 V.

1"^

ns

):,;i

M,,>,!ll

'i lal <

/>(/ 1

si\( ,i,i" M \RR ii:n

\\ii>« >\\ i.i» OR i)!\ » »Rtj.:n

'Write in '-mial «li — i;.'!i;tlii m)

' \

c3 £^-^ 0 ^ '--

I- AT 1 1 l.K

HiR Tui'i, \*i-:

ni I \ in I-R

i St. it I 1)1 t.1 Ml lit I %

MAIDl.N NAM)

ni' .motiii:r

niR'I'Ill'I.ACl".
nl- MO'I'III'.R

(stnti I ii ^^<lult I \i

Rr^iih'd III Si! It I') ,1 til ! ••fit ^ ^rni

X. on^rc W4.-(rr^

\,Ojyr\)

" M, III I In

I his

xnv \n<)vi-: st \i*i:i) pkrsonai, pARiiniAR^ ari: iri 1; r< > i in-
iii;sT en- Mv KNoui.i'jK.H ANj) iu;i,n:i'

(Infiniiiaiit

a)

/A<l.lri'

MEDICAL CERTIFICATE OF DEATH

DATK <)!■ I>i:aT11

TOO

(War

(Mr.iitlO (Day)

I IllvklU'.V CIvRTll'V, That I ;ittcMi<k«l (Urcascd from
I9O to T(/5

that I last saw h ■ ahvt- on T90

and that «Uatli occurred, on tht- date stated above, at o- oO
(j M. The CArSIC Ol' Dl-ATIl was as follows

« ^% %\Ki

%'^^

DTK AT ION )'tiirs

CONTRIIU roRV

Mouths

Ih}\

DTK AT ION

(Signed )

i<)n

)Vr/;.s- Mo)i(ln Days Hours

\j\jO<XAjxX.s. M.D.

(Address) Ck^XdAjtAXa ybo^^kjint

Special information «n!y for Hospitals, Institutions, iMnsients,
or Recent Residents, dnd persons dying dwd> fro.ii home.

Former or
Usual Residence

When was disease contrarted,
If not iX place of death ?

How lonq at
Place of Death?

Days

IM.ACl-; <)1- m RIAI. iiU KKMCiVAI,

DAXH"! I'l KiAi, or RKMoVAI,

iS. B.-— Bvery Item <»)f inlror«mfition should be ciirufully Htipplltfcl. A<iK should ha ntiited fiXACTLY. PHYSICIANS nhould
utntc C\USr: or DHATH in pliiin terms, that it miiy be properly cluMKh'ied. The "Special inform«tion" for p«i—
Rons dying away from home nlumld be given in every instance.

')!]

V

Hi

i

■J
%

r

Ifcl i\

J.,,;,.-.] -f It^ Mllh I N

WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD

HEFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

2447

-^'^^nJS^l'O

Deputy Health Officer

lie^i\stered jYo,

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco

Q^

Cevtificate of S)catb

( -Q. S. StanDarO )
PLACE OF DEATH: — County ofC Onrv on.o . -^.; City of

ana; tLjJUl ^ n
No. "^t^^^Wv VJHLi^X dioJA-v. St.; Dist.;bet. and

V

" ' ■•eiijii DrcinriMrr nwr facts called for under "special information" \

( " °,"„;".TH"oCCU%rc","rHo"s^."*' O^f^s'^U^'J^Vr,;! NAME ,«ST»0 O. ST«.T .» O NU-.,. J

FULL NAME

SI A

PERSONAL AND STATISTICAL PARTICULARS

IclL;.

a'

i) A li: < ii r. IK I'll

\^.\\

rlkd

MiiiiUi^

I'l

)■,,/»

Itav

M.'Uili.

S'cal I

A;

SINT. I.T' MARun:i»
WFDOW i:i) OR 1>I\ < »Rri;i)

X

ova

igo \

(Year)

MEDICAL CERTIFICATE OF DEATH

I>.\TK in- Dl.ATH

(Ml. nth) (I>ay)

1 IIICRMBV Ci;RTn''V, That I atteinkMl tkn ^ ased from

to ..•• IqO ■"

— ~— — " "" 190

190
alive oti

HiRTin'i.xoi-:

( state 1)1 CfiutUi V 1

i

Ox- ■

NAMK OI-
FATIIKR

niRTIl I'l, ATH

01 i.\iiii:R

(St.ile or Coiuitry)

maii)i;n namj;
oi- mothkr

HIR'rmM.ACK
OI- MOTHKK
(Statf or Country^

OCT f RATION \

. ^ 0"''

Kfsidfd in

Siin /'/ lUh r-rn

(1

A

\r,'nllis

/'.l^

Till" AHOVK ST\ rin> RKRSONAI, R \ R F IT f I, A RS AR1<; T K l" !•: I'o Tin-
HHST 01' MV KNOWI.ICDC.H AM) !',1:M1:i"

(\

/vv^t-^u

that I hist saw h ^^

and that death occurred, on the <hite state<l above, at

■JZT" M. The CAlSh: (>!• I)I';ATII was as follows:

W M

a..<Qj^^ en , .\ - ■ ' .

I )r RAT ION }'t'ars

CONTRir.rTORV

Mouths

navs

Hours

DTRATION

1^

Ycixrs

( SIGNED ) Lcr^unAXh^

m

MotUJis

Pavs

Hours
M.D.

^kt

\ 1

iQO

(Address) L^rXTAj^V;^ C^.U\-

uti^ns, Transients,

SPECIAL INFORMATION only lor Hospitals, Instit
or Recent Residents, and persons dying away from liome.

Former or %v^ ^

Usual Residence VI 1 ux^, »v

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

o

, How lonq at
^ Place of Death ?

Days

I'l.ACJ", Ol" niRIAI. OR RHMoVAI.

V. V

.t

DATi: of Hi lOAi or K1%M«)VAI,

NI)1;R TAKKR V-

-CU

U^^^x/cLt^XaJw

&-M.>-^Jx JX...

n

Item of Information should be cnrefully supplied. AGE should be stated EXACTLY. PHYSICIANS should
;AUSE of death in plnln terms, that It may be properly classified. The "Special information'* for p«r-

N. B. Every W

•tote CAUSE

sons dying away from home should be given in every instance.

»

I

i I

^mm

WRITE PLAINLY WITH UNFADING INK

/>^/

/(' /v7f'</,U/tLt<rlj-Ov ao

7.9^H

THIS IS A PERMANENT RECORD

REFER TO BACK OF CERTiriCATE FOR INSTRUCTIONS

Bo ^i tiered ^^o, ^448

Deputy Health Oflrlcer

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

PLACE OF DEATH:— County

Certificate of ©catb

( Xl. S. StanDarO )

J? QT^ "^ ^

Dist.; bet.

pro; V^WV ^ v. ^^^^ ^^^^ ^g^^j^ RESIDENCE o.vr r*cTS calued .c

( [^r DEATH OC^JRRED .N A HOSPITAL OR IN^UT.ON G.Vt ITS NAME IN

TS CALLED FOR UNDER SPEC
STEAD OF STREE

— and —

lAL INFORMATION" \
T AND NUMBER. /

FULL NAME

\] J\Xk.^^<i.<A VDcx.

Ill

MA

PERSONAL AND STATISTICAL PARTICULARS

r< >l,t >K

l>

L(XU

i).\ ri: or- iirtii

\ ' ■. !•:

(Month'

I I • <:

1

.1

Dav

Mntll/lS

liar)

/'..')

viNr.l.l.-. MARRli:!)

\vii)<>\\'i;i» < >K i>;\i •Ri.Ki) 0

Writ' in "-'"ill ih •~i).'nat imi )

niKrjn'i.Ai'K

(Stati or t:i>«uUi V

I- ATIH.K

HiK'niri,\t*K
oi- i-Arm'.K

(Htatt 111 iNnintt V

MAini'.N NA Mi-
ni- MdTHI'.K

iUKrniM,Ari-;

oi- MnlMKK
(Statf III i.'<)nntr>

MEDICAL CERTIFICATE OF DEATH

DATK ol- DllATII

W,ct

TQO \

(Year!

\S

^^-^f^

<XN^CL

*w^ruuou>^

Ofv

h',-^iifrJ III Sun /'niih ni-,i i

1/,./////.

/),n.

Tin- NHDVl- sr\Tl-'l> I'l-K<nN\I. I' A K Tl*' r 1, \ KS AKi: TKri- lo 1 HI-.
IIKST «)I" MY KNmvl.l-JX". 1-; AM) HI I. II. I-

(I

i

tifi>imaiit >J

ll

(MontJO (Day)

I in-:Ri:BV CliRTll'V, Tliat I atteiKkd (Uncased fruni
lD^.t \'i 190H to. ^^ 1% - 100 H

that I last saw h A. >. alive on \J <:X> 1' 190 .

and lliat death oeciirred, 011 the dati- stated a1)()ve, at H-OO
M. The CAl'Sl': Ol' Di'lATH was as follows:

.^.

DlR.xriON }'t\irs .l/<>)///is 1 /hjvs //o/ns

nr RAT ION
(SIGNED)

i ic)0

) 'ill IS .Vonf/i.s

PiU

'S

v^

(

\ddresK)Lctu V.Co Ob

SPECIAL INFORMATION only for
or Recent Residents, and persons dying away from home

tlbspitals,

//ours
M.D.

Institutions, Transients,

^

H?sH uxaAci^,l

Former or

Usual Residence ^ CM. UJtaA.c^

Wlien was disease contracted, ^

If not at place of deatli ?

How lonq at
Place of Death?

Bays

DATl'of HiKi.^l, or RKMOYAI,

..^^

cu^X.'

i

,S,„l„.s Llt^V \U. (fo M^'^.wLcx.

ri.ACK <)!■• lUKIAI. <»R RKMoYAI.

rM.KRTAKKRNnC j ^{icLl^ W \£^ 'tia'dH^ J

190

r~E)

5

r*

„ B — r.verv 1.e,n of info.mntion .hould be cnreffully supplied. AGR nhouhl be statecl EXAgTLY PHYSICIANS should
Itntc CAUSE OF DEATH in plain terms, that it may be properly .lo««lflcd. The •'Special information" for p«r-
nnnm dying away from home should be given in every instance.

I ■

m

i

WRITE PLAINLY WITH UNFADING INK

„.,nr.l of n. allh ■ F No. .. ^^^^UScV Co

I

Ihffc Fi/r(/,AjxXd>-V\^ AO

190 "i

THIS IS A PERMANENT RECORD

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS ^

2449

Rci^Lslered ^'^o.

I «

Officer

DEPARTMENT k PUBLIC HEALTH=City and County of San Francisco

PLACE OF DEATH: —

('No. '^\ ^ ^-^
(

Cevtificate of "2)eatb

( la. S. StanDarD )
County of OOLA^ aK,ao..c<^- City of OO/Vu 0 A.a

St.: 9v

Dist.; bet. Wt^J^. and J

'Y .. ••CIIAI RF«5IDENCE GIVE FACTS CALLEdAfOR UNDER "special INFORMATIO

' rF"o;ArH"oc:u%rEVi;''rHOS^p?T*At OR^^Is'^JV'o^ O.VC .TS NAMe(J.STEAO of street ANO NUMBER.

FULL NAME

. y%/CA„ si C C

AA4/t

..)

^'■■•^' Q5?i

PERSONAL AND STATISTICAL PARTICULARS

\^\v\■. or r.iKin (

L

V

AC, K

t:

I Motuhl

I 5 V,7 /

SIN«-.1,K. MAKHIl'.n,
WinnWI-:!) OK I)IVoR(Kl>
fWrifciii -.(K-ial di si.,niali'>n )

(Dav

i Mnulfn

( lUuvvOL-cL

i car)

Pa 1

MEDICAL CERTIFICATE OF DEATH

DAI"}-: ol Dl'.ATH

I ' t
i I

(Dav) (Year I

niRTHPKvci.:

(Stat? or ("ountry

VWTl' ol
!• A III l.K

RIRTinM.XCl',

()t- J \rm-:K

(Stall (II (.'iiiiiitry

MAIDI'.X NAMH
OF MOTHHR

lURTHrUAlK
Ol' MOTIIKR
(Slatf or Cntjntry)

J (rLtdU

yy\)

XXJ^^~

\

(Month)
1 HIvRlCHV CI;RTIFV, That I alloii.UMl <U'ivased from

— icp to .— ^ — — — — -Tqo ~~

tliat I last saw h ••■^— alive on 19°'

and that (U-atli occurred, on the date stated above, at
M. The CAISI*: t)!" Dl-IATil was as follows:
ijLcAJtv^ '^ M\XaJjvcJI U/txWA,A.tn;

4.^..

I )r RATION Years

CONTRIIU'TORV

Months

Da vs

Hours

Years Mouths ^ Ih

^ . ujVcrnJA; J Ah-Uj AiXc

iPtt XU TooH (Address) U\^r^a->uAlk^

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

OCCI TATION

Kfsidfil in Sim I'liiniisrn

t-

)'ra I

M.iiith'

/),i\.

THK M?OVK S'l*\Ti:n I'KKSONAl, !• \ K TI'T 1, A RS ARK IRIK TO Till-;
liKST Ol MY KNOWI.l-.lx.K WD HI-. 1,11'. F

(lllfottlJMIlt

C . a. u^^..-.

A<Mr<.ss Alb

Former or
Usual Residence

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

How lonq at
Place of Deatli ?

. Days

I'l \CF OF' nrRIAI, OR RKMOVAI. I DATF, of HfKlAi. or RF;MoYAI,

»-ni)F.rtakf:r Lv- UJ. xH^^O^AltX^ ^ ^ Lc

(Addresjn

N. B.-

-Eve.y item of in?orm«tion should be carefully supplied. AGE should be stated EXACTLY PHYSICIANS should
^tate CAUSE OF DEATH in plain terms, that it may be properly classified. The "Special Information- for pr-
son* dying away from home should be given in every Instance.

^

* 'I

•

H -i

WRITE PLAINLY WITH UNFADING INK

, fit '■', IX.. ^ t-*'-s^^, H&l' Co

ll

lOO'i

THIS IS A PERMANENT RECORD

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

Registered .Yo, «-t.>U

Dale /'V/fv/, ycl<rWv 2lO

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco

Ccvtificate of Bcatb

{ 'd. S. StanOarD )
PLACE OF DEATH:-County of 3 c^^ i^cx.vc...^Oty of O^XAr^ ^AXX^-vc^e..

,., ILN^ A K, . ■ St.; A Dist.;bet.MU,MKUru.cJfx and

No. CKIOOO ^ > > •- ocsiDENCEOlVt r.CTS CLUED roR UNDtn "sPICI. INFORM.T, ON- \

( " r,"or.T°"oCCU%7c","r-o"s^"*.U o"?»"?u"o';''o,VC ,TS NAME ,»ST„0 O^ STRICT .NO N U « B C R . ^

c

FULL NAME

U,'va1:; \-CKo\\

V

ff,.(

L^U

PERSONAL AND STATISTICAL PARTICULARS

>-l-\

QTl

1» A 1 i: OF' lUK l"I!

A « ^ H

I Montlii

111'

1 I '

il)av>

Mo,, Hi

\ larl

/'(/I

wint i\\i-:n or nivoKii:!)

(\Vrit<iii --iHi:!! .U-si^nati'iii)

BiR'i'm'i.xoi-; \

(Statf or Cimntry I -A

■¥-

MEDICAL CERTIFICATE OF DEATH

DATE OI I)i:ATn {C\

VA> ^"

I go

(Yt-ar)

(MoiitlO (Day)

I ]I1.:rEBY CRRTIFV, That I atlciitkMl dctcascul from
lD.ct. l\ I904 tn 19^ lA IcpH

that I last saw h ^ alive on W C^-- : . T90

ami that death occurred, on the date stated above, at 10 l

UA >\ n

NX Ml* (>!•■

!■ A Til i;h

U

HIKTIiri.ACK n /I /V^

Of i-Arin-K y U \m\

I stall- or Countivi -'A X< I

!IK III I'UA^ I-, A *,^

»!• MoTHKK y (XTN

Stat*' or Couiitiy^ *A w l^

M Alius N \M1-.
()!• MOT 111". K

HlRTlirUACl-:

.rLLc

J, M. The CAISK ()F4)l';A'ril was as follows

or RAT I ON

CONTRIIUTORV >.^^C

Months

/hn

•s

Ilouts

DTRATION

Years

Months

Pavs

1

Hours

M.D.

(Signed) HtMi^

('A i' u ^uvf V J 'A

iL'ct f: IQO'; (Address) i 6 IT. (jb^^^J^X^d^Ot

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

OCCl TXTlON

Kesidfd in Stui J'l aih i^<i

)'ra I

Miiiilli'

/>,'\

Tin- AHOVK STATl-n I'KRSONAl. I'A K lU T I, A K^ ARK T R T H lo T II l-

liusr oi" MY KNo\vi,i;i)<".K AND iu:i,ii:k

S (jj) ft ^ i,

A at

A(l<lnss ^bt)b

Former or
Usual Residence

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

How lonq at
Place of Death?

Days

DATi; of Hi HIAI, nr R1':MoVAI.

KjnJu a.0 T90n

(Address^ 5vC)vSAL Jt

N B — F.very Item of Information .hould be carefully supplied. ACJB should b^ -t«ted BXACTLY P»Y«>CIAN8 .hould
.tat/cAUSE OF DEATH In plain terms, that it may be properly .l«s«.flcd. The "Special Information for pr-
non* dying away ffom home ithould be given In every inetance.

1-

ID

i

W

RITE PLAINLY WITH UNFADING INK

Bon 11. "' Ill-all II I .>. ' 1 - H.^j^i^-

THIS IS A PERMANENT RECORD

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

/)((/(' Filed,

ao

190H

Registered J^'^o,

2451

DEPARTMET^ PUBLIC HEALTH-City and County of San Francisco

Certificate of ©eatb

( -Cl. S. StanDavD )
PLACE OF DEATH:-CountyofOa^0W^W City of (^ CL^ Zk^^^^...

)

V ir DCATH OCCURRED IN A HOSPITAL

OR INSTITUTION GIVE ITS NAME INSTEAD OF STRI

FULL NAME

A.C

V 1 ^^

si:x

051^

PERSONAL AND STATISTICAL PARTICULARS

A i C01,<)R

DAii: or I'.iK rn

U. *

rl-h^^

Mimth)

.\f. 1-

)'<a I

I Day

Mnnil:

(Vial

I his

MEDICAL CERTIFICATE OF DEATH

DAII-: oi- i)i;a'iii

(I)av)

(Mniitli)

I go \

(Ytar)

SI\<',1,K. MAKKll'n
WIl>n\\i:i> UK inVnRrKI)

iWiitciti ^iiiial (lisij.'iiatiiin)

HIKTmM,AcM<:

I'Statr or l,'o»u!tt > '

.V^VA^XA,

\

K ft

NAM J' <>I

iathi:k

lUR'nirLACK
ol- lAlMHK

(Slate or (.Nniiitry)

MAn)i:N NAMK

lUKTin'I.Al'K
nl- MOTIIKR
( Stall' or ConiUry

r ,

^Kx^^^o.

I lll'.Rl'BV Cl'RTII'V, That I attended <kH-cascMl fnuii

CL-^^..a . 190^ to iD/^ ^"^ T<pH

tlial I last ^awhXh. alive on ^ ^^ ^' l«P'

and that death occurred, on the <late stated above, at 3>
CP. M. The CAl'Sli Ol' DICATII was as follow^ :

or RAT ION ^X?'-- Months /hiys

CONTRIIUTORV U^

nr RATION }'iars .Uon/Zis /hn

_<

wv,-

\ I

occri'ATi<>N^\p A

A'/'ui/nf III Situ inni, n,-n i

t) )'riii V

M,:tlfll

I h! \

THK ABOVK STATHI. .•KRSnNAl. I'A KTir r I.AKS AKI- TRIH TO TUl^
IJKST {)!■ MV KN()\VI,i;i)<-.K AND HhMhl'^

« ^ p t n

(SIGNED )

T<)0

(Address) 3^50.^ " ^^^>-

Hours

Hours
M.D.

Special information on'y 'nr Hospitals, Inslitutions, Transients,
or Recent Residents, and persons dying away Irom home.

Former or
Usual Residence

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

How lonq at
Place of Death?

. Days

ri,\CK OF nrkiAi. OK kkmovai.

^ 0 p

I) \ 11: of in KiAi. or RKMOVAI,

T90H

X.ldris. ^^Hl QfVU^^\^V Jt I

N. B.-

"■"■""""^ „ ,. ,. . .^F eHnt.ld ha stated EXACTLY. PHYSICIANS should

—F.ver, ..em n» information .hould b, cnr.Sully ,uppl..d. _^'^^':^:'''t^'^^^'t^^.'^l„^^^^, Information" for p.r-

«a\?Cru"'sEOrDTA%"H"inprn. :;«;::. h.. r: m^rn; p.op.M, c....W.ca. n,. -Sp-ciai .nfo.matio„" for p..-
«4ns dyinft away from home should be ftWen in every instance.

I- 1

SI

%

WRITE PLAINLY WITH UNFADING INK

J!,,:,i<l .'f H.sOth )•■ Nil

t'-f^-ary-^.nSiVCo

I)

iilc luh^il S)AjXr^'^ ^0

i.96>H

THIS IS A PERMANENT RECORD

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

no

^j^j^j^ Deputy Health Officer

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco

Cevtificate of 2)eatb

( xa. 5. StanDatCt )

PLACE OF DEATH:-County oi^<^o. U .^* ^ City of V 1 Vuii^/>.^x

a..

No.

SU

Dist.; bet.

— and

(IF DEATH OC
IF DEATH

IF DEATH OCCURS AWAY F
OCCURRED I

"special INFORMATION" '\
STREET AND NUMBER. /

FULL NAME

U

LV<..i

PERSONAL AND STATISTICAL PARTICULARS

DAli: nl lilKl'II

\

/

Month'

AC.lv

i )Va

l):iv)

yfnfil'n

(V.-arl

I hi \\

MEDICAL CERTIFICATE OF DEATH

DATH «)I DKATII , H

(Motithl

it
(Day)

rgo \

tVf art

SIN'CI.K. NfAKkll'.n

\vn>n\vi:n ok i)!Vi»ri*i:i>

(Writfin --iKial (U ^-is-' "atMii *

lUK rni'LA''}.;

' Stat' ' ii' ' 'i itint I V

\<XKy^sJL^

I HI;R1:P»V CI'.KTII'V, That I atteiukMl .kfca^cMl fnnu

— — — — — -190 to :— 190 —

that I last saw h r— alive on — —— — r— —— - U)0
an<l that <leath occurrea, nn tlu> .late statid alx.vo. at
M. The CArSp; Ol" Di: A TH \va>^ a'^ follows:

a

OuJ<K.^'0^&J

a

a,c,^L^Ui.<v>aj

tcx'

FA I II J-.R

TUK THlM.Ai'H
«)! lATHKR
; stall 111 roiiiiirj'

MXIDJ'.N NAMH
t)I- MOTHKK

HIKTllI'LAiK
<)1' MU'rilKK
(Statv or CoMiitiy^

/CxAaaXcv J .

''^ Ml)

La,^

fXoA ^

cv Uo^c

k.

1)1 RAT ION Ytars

coNTkiinroRV

Months

Pars

J Jours

I )r RATION

(SIGNED)

II

Pars

I()0

)\'ars .Ifonths

Address) M >\'O^AtA^"^'>^-^ V-^qJlj

/fours
M.D.

^^

.Uo^Lc

OCCl TAl I<»N

1 V»r t ,

.1 /,.;.'///,>

/),n

THK MlOVKSTATKnPKRSONAI.PARTlcri.AKSARK TRIK To THH
IlKST Ol- MV KNOWM-IK-.K AND Hl.I.Il.l-

(Address

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

Former or
Isual Residence

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

How lonq at
Place of Death ?

Days

DATl", of Hi KiAi. or RlvMOVAI,

IHOS

I'l.ACK OK lUKIAI. OR RKMoVAI.

T90

(Ad(

IS. B.

-Every item of Information .hould be carefuH. .upplleC AGE .hould »>« 7**:;^f .^^^^]^^^^^; .r^Jf^L^^' Vr'^l^
•tate CAUSE OF DEATH In plain terms, that It may be properly class.^.ed. The B^^.^m^ Information for p«r
sons dying away from home should be given in avery Instance.

, «

' K

i ;

\
I

i

I

WRITE PLAINLY W.TH UNFADING .NK-TH.S IS A PERMANENT RECORD

REFER TO «ArK OF CERTIFICATE FOR INSTRUCTIONS

,.f II. Mlth I- No :. ^5[^^ H^J' <^-"

I

Dale Fih'il,

10

lOO'i

Ite<ii.stci-ed Xo.

2^53

SI

^frA.o A ^vv^ Deputy Health Officer

DEPARTMENT OF PUBLIC HEALTH-City and County of San Francisco

Certificate of 2)eatb

( tl. S. StaneacO )
J? (^ ^ ^

PLACE OF DEATH: -County ofO^UYv J\xu^^c Oty ot^ ^^

'^'^,^ !i^^. Sf Dist.; bet. C .tx ^ \1 k and kcu>V^ '

No. *^ ^' -^-"^^^^ ^ ^ , .. = ,hNr.E owe r.cTS caIled for undcr "specl ,NroRM.Tio» ■ ■)

FULL NAME

'V

K:.^ ct .,

.i:\

PERSONAL AND STATISTICAL PARTICULARS

0 x»^oAj. ^

c

DAI' I". «>r- r.IRTH

At.H

^!>

IVi

^1
Iiav

M,>„!fi>

\ tar

PiJ \ s

DATK

MEDICAL CERTIFICATE OF DEATH

in- I)i:ath (p\

IIJ tt

(Month) *I'''«y^

(Vfarl

SIN*. 1.1 MARKIl.n
WIDOW I.I) OK invoke i:i)
Wiiti in -(trial ik^ijfnation >

I HICRICHV C!:RTII'V, That I atU-ii(kMl dtn umotl fn)ni
(lLo| I T9oH toi)'CX la 190 H

tliatTlast'sawh >.' alive on ^ ^t '\ T90H

ami that (U-atli occurrcl, mi tlu- .lati- state! alx.vf, at 0- O C
M. The CArSI-: Ol- Dl-.A'ni was as follows

(X "fciut x)6 N^CCC^

luK rm'i, \t"»-: f

I Slat< lit t"' 111 nt I \ ' -''

FATHKK \ \A

niR'nn'i.Ai'K

of I A II IKK
I, Slat t 111 Cunntry

M \iI»i:N NAMi:
01 Mol'UHK

P.lKl'UPKAi-H

oi MornKK

Statt 111 I'lmntrv

i

OL'VX' ^ NXX^vCA^<^<?

A

u

rva ^

DlR.X'riON I )'''ars * Months
CONTkllU'ToKV

Days

Hours

DTK AT ION

L

)'i'ars

Months

Da vs

Hon

; v

( SIGNED ) Ox^X/ClX Ch Vft I- wk. . v M.D.

%^ H)oH (Ad.lrc.s) ID IX M iUa^^^v d

t

( )rcri' A rioN

n

R^rsiifrif ill S>in /nnirir,) y> \ ) rtti>

M,>iith'

I hi

TnKAm)VKSTXTlU>.'KKS.>NAI rSKTirriAKSAKUTKIK n. THH
HFST OK ?.1\' K NOW 1,1'. IX. 1% AM) lU I.n■,t•

; Infnrinant

(AdtlrcHS

Special information only '©^ Hospitals, Institutions, Transients,
or Recent Residents, and persons dying away from liome.

Former or
Usual Residence

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

How lonq at
Place of Deatli ?

Days

I'LACK Ol" nrKIAI, OR KKMoVAI,

DAIi: iii III Ki.Ai. i»r KKMOVAI,

N. B.-

State CAUSE OF DEATH In plain terms, that it may be properly <.iassiiicu. i

sons dying away from home should be given In every Instance.

' s

H

,i

I

i

1

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

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

1 f II ,111, !■■ No 1 ; t"'«- 3Ch»:~1 Hv'^-l' *- "

I til If l'il('<l .

10

7.9(9 1

Be^ixtcred JVo.

2454

\^^^kajs do^'Vu Dei

DEPARTMENTOF PUBLIC HEALTH^City and County of San Francisco

Certificate of 2)eatb

( "Cl. 5. StanC^arD )

1 n ^-x,' J /

PLACE OF DEATH:-County of Ooax, J;v(X > v.'-. ^ Qty of -^

0

(IF DEATH
IF DE«

Su X Dist*;bet. UCrU^q^
^ * uNoe^p

and ^Ci

IxxAn.

)

- )

FULL NAME

.C.<V'Y>^ CKXA

PERSONAL AND STATISTICAL PARTICULARS

o '

<YrL.

u:

MEDICAL CERTIFICATE OF DEATH

DAT}.; (U- ni'.A'in

(Month)

(Day)

/90 I
(Year)

DATl". OF- I'.IKIII

\r.l'.

f%'k'\

• Month)

SIN", 1,1:. MARKIKI).

U 11)1 »W 1:1 » OK !)!VnKri-:i)

■ Wiitcin HiK-ial (U -is-Miat i<>n)

I'.iu'nn'i.xi'i'".

( Statt 111 t'tiUUU y

I Day

Mnnill}

ly.-a!

/»,M.

(^ «

H V

NAMl' <>1

1 A 111 i:r

lUK rnrKAiK
of I Arin:K

' stati- iif C"(>ui)t ry

M Xim N" NAMl-.
«)|- MOl'iniK

HiuruPKAn-;

(»)■ MoTHJ'.K
(SlaU- iir Counti v '

?

?

I in;i<i;P.V tl-.kril-V, That I altetuU'tl deccascl from

IX 190 . to - '- I')0

that I last saw h .i >v-alivenn ^^P '

*

and that <Uat]i occurrcl, on the .lato stati-cl ah.n'o, at -
CF M. The CAISI*: OF DI^ATH was as follows:

DTRATION X Yrars Mont/is^ Pays I/ours
CONTKIIU'TORV LLoA-^.Xi> L.SrLcIl.4^

•^" GUiooLdL On ^ ^

R,-sitiri1 III Stin /'i ,111. .'■'■'

> 'lUl I

.\f,i)if/r

THKXnoVKSTATKni-KKSONAl.l-XKTirrUXHSAKHTKrK To TlIK
IJKST «»!-■ ^iv KNOWl.l-JM'.K AND It I. Ml. l<

(Informant CctUwMI^-NxL ^J

nr RATI ON

(SIGNED)

19, ci

u

lurs

J/ott(/is I C) /yays Hours

L.

M.D.

I<)n

'1 (

Adiir^ss) %:yV ' &A.A>4ll dt

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

Former or
Usual Residence

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

How long at
Place of Deatii?

Days

(A-Mri-ss

^-b ^

-i

\

I'^jiTb OX.

'CVVAJ

\t

l'I,ACK Ol- lUklAU OK KHMi»VAI,

DATi;i)f HrKl.Ai. or RKMOVAI,

l9c± 3k.\ 190' i

INDKRTAKKR V ^- ^ C^^:^<^^"^^ '

. . V ~~~ !• I Arp .Hoiiia ha stated EXACTLY. PHYSICIANS should

sons dying away from home should be fttven In every instance.

I

m

\ ':

III .

1

WRITE PLAINLY WITH UNFADING INK

H,,anl ■■»■ 11., ,ilt1i I- N'

Da

/(' /'V/^v/, I'ctoAKX; ^0

IfJfA

THIS IS A PERMANENT RECORD

REFER TO BACK OF CERTJFir.ATE FOR INSTRUCTIONS

DEPARTNENtIdF public HEALT|l=City and County of San Francisco

Certificate of Scatb

i -a. S. StanDarD )

J? 05? tS ^

PLACE OF DEATH: — County ofO^V^ -'^^^ ^^ - ^^'^^ °' j ^

^T "I^l- \f\^i ^ ■ St.; ^ Dist;bet.aUx^|v

No. i <^^ >^^" ' __ „„„ ..^UAL RESIDENCE G.VE FACTS CALUto roR uAd

\.,C - V v:

- r"o»T°„=rCC%%ro\"r-o"s"pyTl^%"NSnVVTTo".-0,vr,T= N.»C ,NST..O O

R 'special INFORMATION" 'S
F STREET AND NUMBER. /

andOJbrcJ'^^^^- >

FULL NAME

PERSONAL AND STATISTICAL PARTICULARS

> I", X

ni

0<»I,<»K

oJ

DA ri". < »!• r.iK I'll

AC, H

ever

/ ^

I Month I

^S

Yrat

(Day)

1/ .»/'/'

I '^'lar

/),r

MEDICAL CERTIFICATE OF DEATH

(Month)

il)av>

(Yt-ar)

^^ li;

^INi.l.K MARKTKH
WIDOWKI) OK niVoKCKI)

iWritr in social (U'^ii^imtinn)

BIK I'Hl'I.Xi'l'.

i Slatt,' o! 1,1 HI nil >

Xa^wO^

1 '^

0

N".\Ml" ni
I- AT III, K

HlkruiM.Ai'K

oi- tArm'.K

(Stair or Country)

ma!1)i:n namk

ol- MorilKK

lUK rmM.At'i.

Ol- MoTHl'K

(Statf or ^.'onnti ^

OCOITA ri«)N

A',- ■Jr.^ :>i

v

I

I m':Ri:HV CI'-.RTII'V, TIiuL I aUcnad acixasol from

190 to-— •■ it)0 — -

Hint I last saw \\^^ alive oil ^ ^*P

an.lthat death occurre.l, on the .late stated above, at

M The CAISI'; Ol'' DIIA Til was as follows:

P

DT RAT ION Vt-ars

CONTRIIU TORY

Months

Day

/lours

Uv

V .

\,n, I

/'

HKST Ol- MV KNt)\\ I.l'.lX'l' AND Hl-.I.n.l

DIRATION
(SIGNED)

Years

Mouths Pays

an 1 (Address) loOb At<^

Hours
M.D.

U -Jr

u

^

%

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

Former or
Usual Residence

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

Itow lonq at
Place of Death?

. Days

1p

(Infotniant V.AJ.

M.ACK Ol" HIRIAI, OK HI.MoVAI

I»\J'i; o! HiKlAi, or Kl"Mt)V\I,

—"— """— "■""■"'"■^ \^% %rF ahf,..l,l he Rtftted EXACTLY. PHYSICIANS should
"ans ilyinft away from home should he feUen in every instance.

t'(

I i

ii

1

I

s^

w

R.TE PLAINLY WITH UNFADING .NK-TH.S IS A PERMANENT RECORD

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

Hoard of Hialtli i ■><' ■ '■ .^..^o

lfW\

2456

,.„,-, Jli'o-is/crcd ■A''o.

Lv^^^U^^ Deputy Health Officer ,^ r

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco

Certificate oi "©eatb

( "a. S. 5tanC»arC> )

^Itv of O /O^v J

ojy\/ o.^^/<x/>x-tM^a./cc

and

•No*

PLACE OF DEATH; — County ofOo/^^ JXa^ivCvo City
(T) p V'. 5

(^ ( - ;^-:^OCcfc,;"ni^^t J^?,;?^^^^- - .AM. .NSXEAD O. STREET AND NUMBER. )

FULL NAME tdcec-.v, JUXA a. ,

)

4-

DATl', «>I- lUKTH

PERSONAL AND STATISTICAL PARTICULARS

- I Col.oR

ll

A«.K

\\ y.-iu^

5.0

(Uav)

Mntllll^

\ t-ai

/>.n.'

MEDICAL CERTIFICATE OF DEATH

DATK OI" I)I%AT1I

.t

Day)

/QO \
(Year)

I inCRi;r.V CI-RTII'V, That I attciule.l (Icrcaseil from

-yol 190H t.) 0^t; it) 190 H

\\ ii)t>\\i:n <>K i>i^"

( Wl itf ill -iiiial il< -'.

■oRiKH N

■J nation) \ s

I90H
that 1 last sasv h .'.■ alive on ^ ^*}0

and that death occurred, nn the «late stated alx.ve, at Its,.
J M. The CAI'SI-: OF Dl'ATIl was as follows:

P.IK rinM.Aci-:

' stall I ii !'' iiinti >■

1- A III i:r

mk'rnjM.AOH

01 lATIIKK
(Stall or Country)

M XlDl'.N NAMl
Id- MoTUl-.K

niK rnn.ACK

OF MOTHI-.K
(Statf or Country

>^. r »- J..C. 1

Months

VJLAXr

,t\k

occri'A rioN

W

AVwi//-,;' /'' S,7i! /■' (.''/.

) V(7/

Mnuth-

/>tir

i5i:sT oi- Mv KN«)\vi,i:i)<-.H AND lu-.i.nj-

DT RAT ION
CONTRIIUTORV

Dl'RXTION }'iiirs Jfof/t/is

Days

I Jours

(SIGNED

!U

/)^71'

)n ^

(Address)

flours

M.D.

'HdlCo JlygK^ulal

SPECIAL Information only for rtl>spilals. institutions, Transients,
or Recent Residents, and persons dying away from lioine.

Former or r n , 4 P
Usual Residence <^ -^ t) n u

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

How lonq at
Place of Oeatfi ?

Days

(InfoTinant

<r'

'A.l.lrc.s CctcN^U>. dbCh^vU^l

V\ \CK ni-- lUKlAl, <>K Kl'.MoVAI,

^1 0,L..i „

DAlU'of HcRiAi. or RKMOVAl,

190 i

rsnv.RTAKKR

(Adilrc-Hs

^

J , .. .. ^ ATF «Hmilfl he Htatetl EXACTLY. PHYSICIANS should

N. B.— Bvery Item of in Wmatlon should b. CBrefuHy -ppi.ed ^^^^fLj^^T -11.. "Special Information" for pr-
Btate CAUSE OF DEATH in plain terms, that it may be properly ciassitica.
sons dyinft away from home should be given in every instance.

1 I

l«i

1

i
I

!

WRITE PLAINLY WITH UNFADING INK

5nard i'f Hcilih- I" N-

<:S^'x?^,\\S^\'C

THIS IS A PERMANENT RECORD

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

!)((

/(> F/V^^^/, iLlclMKXi X^

190\

Re^istrred J\'*o,

3f,

Deputy Health Officer

DEPARTMENrOF PUBLIC HEALTH=City and County of San Francisco

Cevtificatc of 2)catb

( tl. 5. Stan&at? )
PLACE OF DEATH:-County of Oxx^ J^-^' ' ' ^ty of 0^^ i/^a >^c^. •
-I 4V > St- ^ Dist-bct. 5axL and '^'

)

FULL NAME

\}sinjx^

n

da

PERSONAL AND STATISTICAL PARTICULARS

si:x

Cnl.oR \

i

I) \\'V. or lUK III

.\( .1-

I

Ctti

M. m li

C )V.,

I.

!l)av

,)/,,iif//.-

3^

( \'( at

/>,7 1.

[EDICAL CERTIFICATE OF DEATH

DATE nl' I)1:ATH

( Month 1

Dav)

/go \
(Year)

I HI*:K1-:HV CIvRTII-V, That I atten.UMl (UnH-ased fmiii

190 S t(3 ii//cl. I'l icpM

alive o„ W^ct lb Tc^H

19^

that I last saw h

mN<-.I,H, MARKli:!)
WinoWHD OK DIVORii:!)
(Writt in smial (ksiKtHititin)

that I last saw h • alive o„ ^ ^^' '^ I|>^

111(1 that <k-ath ociurred, on the date stated ahnve. at CX-X^-

' :M The CVrSh: Oh' DI^ATII was as follows

KXAxxxJ

i;iK rm-i.AO}-:

(Slati- or Connti V

NAMl' »»1
HATH l.K

lUKPni'I.ACK
OI- 1 AlllHK
IStatr or Co\intry

MAIDKN NAM)
<>l" MoTllHR

lUK Iliri.Ai'K
(H Mol'Ill-'.K
(Stale or i*ountr\

( uA! !■ A riON

O^W

CUu.

Kk.^-^^^ mul*,^4^>^^-5

-^

DIRAIION )Vr7r? T J/cm////5 M?ja //<?// rjj

CoNTRinrTORV

nr RAT ION ^ JV'?'-5

\/..llfll>

k

I hi

TnKA,M,VKSM-AT,aM>KRS.>VAI PARIM.M-LARSARKTRtKTO THH
lUvST t)l- VY KNOWI.l.Di.K AND lU-.I-IlJ-

(Signed) uX.o

11.

flours
M.D.

y^ AO looS (Address) ^Ho^mavkxt

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

Former or
Usual Residence

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

How lonq at
Place of Death?

Days

ri,ACK Ol' lURIAI. OR KKMoVAI,

t

(Addrc s^

dt

UuCHi>^

DX'^'l'of IJruiAl, or Rl'MOVAI,

T90H

r.Ni.KRTAKHR U^ <X.^Ca.4-WC, U^vcUAjtoJ;

(Acl.lre.s I'll '^'Xva^^M.^'%- Ol

State CAUSE OF DEATH in plain terms, that it may be properly cla.sitiea. me op«=
sons dyinft away from home should be given in every Instance.

»,

I

1 ' .
II *

I*

i

l'i

I

WRITE PLAINLY WITH UNFADING INK

V. o

Ihifr FiJod.Vd^

Xb

Depuu

JW» . I

'♦U

Offi

THIS IS A PERMANENT RECORD

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

Registered J\^o, -^400

DEPARTMEnFoF public HEALTH=City and County of San Francisco

Gcttificate of 2)eatb

( ■Q.. S. StanOav? )
PLACE OF DEATH:-County of ^ Cv.- ivcx >.c..c.X:ity of d O^ ^^^^T^^

FULL NAME

\\

vmx )

K^K,

#

^l.N

I).\ I I-. <>!■ I'.IK III

AC H

PERSONAL AND STATISTICAL PARTICULARS

C()I,«>K \

I

\

b^

)'ra

(Day)

Mntiths

I Vt-av)

Pr/

MEDICAL CERTIFICATE OF DEATH

DATK Ol- DIvXTII

(Montli)

i;i.

a)av)

IQO 1

(Year)

vi\(,i I- MAKKIKIV
WlDoWKI) OR niVOHvi:!)
(Writfin Hociai d* -iuiiatii >n '

BIRTH »M,\^"J-: I

(Statf or r<.\nUi y ' ^

\ \M1" <»1

I AT II i;k

lUKTHlM.ArK

oi- I AriiKK

(State or Country)

MAn)J:N NAMH fO
OI- MoTIlKK

niR'riUM.AOK
«>).' MoTHKR
(State or Country)

I II1:KI:iVv Ci:rTIFV, That I atteiKUMl (U-ccascil from

. \ 190M to ...U^:^ it icpi

that I last saw h :.- - > ^ alive oti ^^ ^^ ^^' ^

and that <loatli oooiirrcl, on tlie <latc stated ahnve. at 1? ^L
M. The CAISI-: t)l- DI-ATII was as follows:

CJk:

."V^rv^-A./^

<Hyvvti/u^t\A^v<OC

c{r\j

c<j uLcL 1 vd.

OCCt TATION

DTK AT KIN i Yiars w Months Pay

CONTRIin'TORV

DTRATION

Years

jMxs^

AV>.f./ .. L, r,...^.r. 1 )Vwn. 1 yf"»f'>s A /^.n.

THK AHOVK STATHI) '"HRSONAI PARTJC(-LARS ARK -KRrK To TIlH
HKST «>K MV KNOWIJ-.IX.H AND Bhl.llJ-

( SIGNED )J^^ LL- sAX'^V

Months Days

/ClCL/->'V

Hours

I /ours
M.D.

I()0

(Aa.iress) % ^jVia^b^m. c

SPECIAL INFORMATION only for Hospitals, Institutions, Transients,
or Recent Residents, and persons dyin(j away fron home.

Former or
Usual Residence

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

How lonq at
Place of Death?

Days

<^.i).

iir.n I »M- .»i 1 i-k-- I

(Address 3>^ b\ 0 OwCNXX^n^Ji-'Vsto OX

ri.ACK OI-XWrRIAI, OR KKMOVAI

DA'XI'of BfRlAF. or RKMOVAT,

N. B.-

■""^ TT li J &rF ohmild he ittated EXACTLY. PHYSICIANS should

-Every Item o? Information .hould be cnrcfully supplied ^^^^^^^ '^^/^^^^^j^i^'^The -Special informstion" for pr-

state CAUSE OF DEATH In plain terms, that it may be properly ^lassitiea. i ne op

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

^^^'

■\

m

h

i

WRI

TE PLAINLY WITH UNFADING INK

/){if(' Fili'il.

^0

loo'i

THIS IS A PERMANENT RECORD

REFER TO BACK OF ^^-^.^.r ATr FOR INSTRUCTION»

2459

1

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco

Certificate of ©eatb

( XX. S. StanDar? j
PLACE OF DEATH:-County ofO^V^v Ja^Xoo.-.,.

0 ^

City ofC3,a/^x. 0'v<X/>^c^o<.

fNo

..b

Q.

^

\4 ^^..'j.; < _ St4

/ ,r DE*Th'oCCU«S •^^''/"^"Io^s^pVt*!: ^R^f-lsT^ITUTION GIVE ITS
V, IF DEATH OCCURRED IN A HOSPITAL u

Dist.; bet.

ind

-)

CCURS A.AV FROM USUAL « ^ S . D E NCEC. VE^ -^ ^- - ^^: 3T;^C

lAL INFORMATION" ^
T AND NUMBER. J

FULL NAME

PERSONAL AND STATISTICAL PARTICULARS

si;\

<^

DA I i: <»t lUKlH

COLOR

MEDICAL CERTIFICATE OF DEATH

DATK ol- I)i;ATn

\t..iitl»

A<.H

15

)'rii I

ll)MV>

M,,)if/r

(Vear^

(Month)

(Day)

(Year)

I HlCRl-HV CJ:RTIFV, That I aUcn.kMl deccasca from

- to

that I last saw h

-~ alive oil

rgo

— igo

Pa V

SINr.l.H, MAKKIKI)
\Vn)o\Vl-:i) OR DIVoRi KIl
(WiittitJ <.«K-ial (Itsi^naHiin)

lUKTHl'UXt'K
(Slatf or Coutitiy

rn

,„.l that .hulh ..ccurrca, on the .lat. stated above, at
J M. The CAISH OF Dl^ATlI was as follows :

t /

rx

0

lAJjLC^

\AM1 ol
FATHl-.R

HlKTliri.Al'K
OJ- 1 APHHK

(Stall or Oo(iiiti v)

I) r RAT ION )'i'ars

CONTRIIUTORV

Moulin

Pays

J /ours

I

m\ii>i:n' namk

ol MOTHKR

luR'rni'i.AOt-:

«)1- MoTHI-.R

I siat< or Countryl

1

nr RAT ION ^ Vt-ats

Mouths ^_ /?<i.v-? /Ajw/t

(SIGNED) WurwiK^ ^

ft

(Address) U\.(rvUA:0 ^M^"
SPECIAL INFORMATION only for Hospitals, InstilutiolTs: Transients,
or Recent Residents, and persons dying away from home.

t) Mn„lh:

K raided /;/ Sav i;a>i,i>ro \ "^ >''T^

UrL\c a<hJJ^r\/y^ ^^

Former or
Usual Residence

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

How long at
Place of Oealli ?

Days

PI \CH or BIRIAI. OR RHMOVAl.

osj\j\y^<^ \

DAi'l", o! IJiRiAl, or KKM(»\AI,
iD^ XO 1 90' A

vni>i:ktakkk VI V. v) ■ ^ ' \ Ji

... -lated EXACTLY. PHYSICIANS should
rnrdttn*; -w"^ "r" hen.. Should be .W.n i , .n...n«.

tf; I

I;

i

■IIMMI

I

I!

N

MM

WRITE PLAINLY WITH UNFADING INK

Dii/c lu/i'il,

\j 10

THIS IS A PERMANENT RECORD

REFER TO R^CK or CERTIFIC»Tr FOR INSTRUCTIONS

Ea^i^lerod ^'^o. 2400

DEPARTMENT dF PUBLIC HEALTH=City and County of San Francisco

%

Certificate of 2>eatb

( *«. S. Stan^arD )
PLACE or BEATH.-C~« of^^l- — ' °" °' ^^^^ ^ '>^^"n"

^0 f ri'f.tv^t ^Svdb and ^HLiv

'^ ^ '^ ti -^ ^ ' -^ St; b DlSt; bet. ^^^7,^„,V^3p,c.al .nformat.on ■ >i

FULL NAME

)

KcmxCL^;

PERSONAL AND STATISTICAL PARTICULARS

SI A

nxii.; «>! HiRiii (up I

iMDiUhl

rt»L«>R

, (1

I

(Day)

MEDICAL CERTIFICATE OF DEATH

DATE ol- Dl'.ATIl

V^

"^ r

\t,K

^.H 5''"'

Moiih^

(Vfiir)

I hi '

:^.

SIN.M.I- MXRKIhn.
WlDoUM* «»K niVORi HO

i\Vt!t.- Ill -.Liiiil <U-.i!.'":itH.n)

luK rm-i.AOK

(Stall i>r t.'imiitiy

NAMl". «)!•
» ATUKR

i.^'^l'..^

igo

(Month) ^''-^'' ^^'^"^^

"TllFRrn^V C1':RTIFV, That I atUMiacd aeccasca from

\jL\<t n 190H to t).^ ^c^ 190-

■ C ) rl. ' ^ TOO H

that I last saw h .^^ ahvc- on ^^ ' ^90

an,l that .\eath occurre.l. on the date statcl ahovo. at ^

J M The CAISH OF DI-lATIl was as follows:

rvi^U

DURATION ^ >*'''^'-^
CONTHIHITORV

Months

Days

flours

HiK'niruAOK

Ol- 1 ATUKR
(State or C<miitrv*

MAn)i;N NAMK
OF MOTHHR

iiiRTiiri.Ari',

<)1' MO I'll KK
(State or Country^

\Xxajoj

«^

Years

J ,>\ju<Uk

T(,o ' I (Aadress)

CJLUJ

OCCri'ATlON

i,/i

nrRATioN

(SIGNED)

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

uCX^AX

Hours
M.D.

^Cv

I

Former ©r
Usual Residence

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

How lonq at
Place of Death?

Days

l-I \CH <>!. Bt RIAI, OR Rl-MOVAI,

(ftlt Pi

DATK of nt KiAi- or RI\MC>VAI,

(AfUlre-^s

:r„'.%y*nt— ."y .rL ho„.. .hou... b. ftW.n In .v.r, in.t.nc..

\h

{

t

WRITE PLAINLY WITH UNFADING INK

. f II ,.1,1, -- J- Vn i; 't-*:sS-^i Hftr Co

I )((/(> Filed ,

Deputy Health Officer

THIS IS A PERMANENT RECORD

REFER TO BACK OF CERTiriCATE FOR INSTRUCTIONS

2461

Bc^istered J\^o,

DEPARTMENT OF PUBLIC HEALTH-City and County of San Francisco

Certificate of 2)eatb

( -a. S. StanDarD ) ^ .^

PLACE OF DEATH : — County of Ua-.v J .•ui/Yv<i^Xi. i..ty ot

)

l

FULL NAME A.

f

OwUl>a.

PERSONAL AND STATISTICAL PARTICULARS

COI,liR\

!)\ Tl, i>I I'.IK IH

\<.i-;

(Davt

M,,iif/t< 1

"v'cai )

/>//)

MEDICAL CERTIFICATE OF DEATH
DATH OK UttATH

{ Month)

in
(I):iv>

/90 1

(Year)

I HICRI-HV CI'RTIf-V, That I atlciukMl acccascd fnmi

.iDct lb 190M to O^t. i'\ 190H

that I last saw h ■- • ■ alive on

j^.i I

190

-^IM.l,!" MARU11',I>

\Vn»< »\V1-".I» oK DIVOR* i-:t>

^Wiitt in "-(Hial i1( Hii^natiKu)

an.l that <U'ath occurred, on the .late stated above, at -^
The CAISP: Ol' DIvA'I

M The CMSP: Ol' DIvATH was as follows:

C V

lURTIIt'I.Ai'H

(Statf or »*()tint! >■

NAM I- «>l"
I- A 11 11. K

IHKlUl'l.ACK
<»1 I \ rill'lR

' Sl.it« i>! rmuil ! >■

M mi)i:n namh

<)l- MorilHK

lUR I'ln'i.ACH
<>i- M«»'rm'*.K

I'StaK 'If Touiiti \ 1

f\ %

\

(\

/jC^vCJ^'V'^ '^^ U/ClAk^

DT RAT ION
CONTRinrTORV

)'fars Months ' /Mj'?

I' . ..

Hours

,.C

-a-'

L.

vt<X^

(>c(. rj'A rioN j

M,,ufli^

I hi

■VnV X,U,VKSTAT.a>PKK.oNA, rXKr,rr.,ARSAHKTH. H To T.IH

in>r ()i\Aiv KN')Wi.i,i>'.i-. AM) in, 1. 11. 1

in> r oi- JiiN K >' iN% 1.1,1" ...-. "''"'•"■ A »

Dr RATION >Vcn-5 Mouths Ihiys /fours

( SIGNED ) LoyvvxJuLo US CXTUl.C^ CLu M.D.

U^ l^ ic,oH (A.iaress)^nUr^<Yu

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

Former or
Usual Residence

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

How lonq at
Place of Deatii?

.. Diys

Aj

IM.ACK Ol' lURIAI, OK RKMoVAI

DATJ: of li! KiAl. ur REMOVAL

U /tX ") C 190*1

'—'""''*" , . ., , Z^n .u„,,i,l ha Mtated r.XACTLY. PHYSICIANS should

^. B.— Bvery item of information should be car.fully supplied ^^*;^^ "^^/^'^^^^^^^ Information" for psr-

state C\USE OF DEATH in plain terms, that it mny be properly Uasslliea. p-

sons dyinft away from home should he feiven in evsry instance.

; I

i

I: I

:1

i

WRITE PLAINLY W,TH UNFADING INK-THIS IS . PERMANENT RECORD

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

2^m

,.,..f n. th KN.> i.-^-t^^>H^i-c..

A Deputy Health Officer

Bcf^i^stercd -jYo,

DEPARTMENT OF PUBLIC HEAITH-City and County of San Francisco

Certificate oi 2)eatb

I ■a, S. StanCat? )

? ^ i ^

PLACE OF DEATH : —County of ' > - ^^^ ^^<^^-^ > ^'^^ °' -

No.

5 ID

(ir DEATH OCCURS
IF DEATH OCCU

St.; " D;st.!b€t::'Vv<x->x;^va

ilDEI

RRED IN'i'Ho'sPrTAL OR INSTITUTION GIVE

and

. DEAT„ OCCU -0« U_SU_.L --°,^---.^;e'7tJV.4° .'n-s-tE-.-'d-I? 3T%%'?riN 0":::= e'r" ^ ) '^

y

FULL NAME

V. ^ V

^-x

>

V

I1

/LOv. rvAAI.

Jx

i)\ 11: of- r.iR rii

PERSONAL AND STATISTICAL PARTICULARS

aJ^K

L

I

,|SM

Ml. nth'

A' . 1-

SINC.I.K. M \KKn-.i>
Wiitriti -iKia'i (Ic-iLMiatiiiii)

I D.'iv

M.nilli'

I ^ t-ar)

/).n.

MEDICAL CERTIFICATE OF DEATH

DATK 01<' 1)1:ATII

(Month) 'I>=»V*

I 111;K1:HV CI-RTII-V, That I attctHkMl <kHcaseil fnnu

rQo\

(Year)

— — I9O to

tliHt I last saw h rr."-" alive on -———--
ana that .U-ath occurred, on the .late stated above, at
M. The CATSh: OV Dl'.VTH wa^ as follows

up
up

lijL-rxlA.^xi' UAiX^A^

c' -\^ vc -J S':^

r,iK iin'i.xi'i-:

(Stati 1 >! i"| lUiill \i

X \M}' nl-
!■ Alll l.R

HiK'iniM. xri".

OI- lAllU'K

' ;->t.iti (If I'ouiiti y

M \II>i:N NAMl-
(W MUTIIKK

lUK'nn't.Aii-:
()i- M()ini;u

(statt or *,'i)untry

o(,H'11'ATI<)N(T\

ft U

?

1

?

>AxX/<X

DIR.XTION )'rars

CONTRIIUTOKV

.}fout/n

Pars

IIon) s

nrR.xTioN

)'ears

Mont In

Pav

www

0— WNjLa *^ V tt

AV.v/VMi' i>i Sail /;,/".,"' i^ ''''"'

Month;

Ih

T„KAHOVKSTVr,n..KKS,.XA. PAKTUMM AHsAK,-.-KtH TO Tin-
lU-sr 01 MV KN«)WU-,I)«.1% AM) Hll.lI.J

( SIGNED )Ur^O-vviUv J.UjUj.cMJI ' ■<_

I'D , ,

U',cL :■ ic,n'\ (Address) U^*Un\X.VO ^ -^v ,, a.

/Ion IS

M.D.

-*^^

SPECIAL INFORMATION «"•> f«r Hospitals, Institi^lttns, Translfnh,
or Recent Residents, and persons dying awd> from home.

Former or
Usual Residence

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

How lonq at
Place of Death?

Days

vJVOjtAjL

(AfUlrcf

5^10- hK.<k, '"^t

IM \CF <»1 lUKlAl, «tK KKMoVAI. 1) VTH nf Hihiai, <.r RKMoVAl,

'on* dytnft away »rom home .hoiil.1 be alv.n In .v.py Inltance.

I?.

WRITE PLAINLY WITH UNFADING INK

Boar.l of Ihaltli- »■ No

Ihtlc /v7^'^/. U^Ur^>X^ XO

2^6^H

THIS IS A PERMANENT RECORD

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

lic('>is(ei'C<l J^'^o, ^4l>0

1+ t„ r^m%r^

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco

Cevtificate ot 2)eatb

( tl. S. StanDarD )
PLACE OF DEATH: — County ofCJCunrAJ OA.^^
^T 'iq QUv^Lli SU 5 DisUbet. iitL

No. dl M L^CrA^^vTV.^ ^,,^, RESIDENCE GIVE TACTS called ^or undcr S,

OR INSTITUTION GIVE ITS NAME INSTEAD OF STREE

City of ^'^^^-^'^ vj.^ucx-kvcv

\

V.VC

and \ X X

)

r I ^ ^" RS AWA. .ROM ^U.L -fJ0E^K^^VE;^CTs'cALLED .^ U^CR ^ - C . AL . N ^ R ...K> N ■• )
V IF ^EATH OCCURRED IN A HOSPITAL OR INSTITUTION uiv

> \.l K..C \X

FULL NAME

'^h

,\-/0^/Y^

I >-

>-.i: \

PERSONAL AND STATISTICAL PARTICULARS

u

iiATi-: oi HiK in

A'.i-:

h

\ti.:ilh'

)V,n

a

l)a\ I

Mnlllln

X'h

\\a\

/hn

i)

(MontlO

(V.-ar)

siNr.i.i-. M\KUii:n

WIDoWI'.l) OK n;\«»Ki"KI>
iSViitc in -.<M ial di '-it'iial ion )

X^^ V

^

lUK rill'I, At'J'.

iS|;i!. o' t",,uiitl\'

NAMl". Ml

I- A 111 i;r

\ 1

RTR'nii'i,A< 1-:
OI' 1 xrni'.K

(Stair ol Collllll V

MAIDKN NAMI-:
<>1 MOTIII-.K

lUR rniM.Ari-:

(II- Mo'IHl'.K

I Stati o! Ci lUllt! V

i

lift" a ,

f

MEDICAL CERTIFICATE OF DEATH

DATK ol- Dl'.AllI

il):iy>
I 1II*:R1':HV CI-.KTII'V, That I attfii.kMl .U'ct a-^o.l fmm

— -— i<)0 ■" to

that 1 last saw h -r — alive on ~ "~

and that <Kath ..rrurred, on tlu- .latr ".tatc-.l ahovc, at
M. The CAISIC Ol* DliA Til was as follows

190

DC RAT ION )'i'(Jrs

CON rKii''i"i<>'<v

Mouth a

Days

I lours

Lc \ax

0

to

( )i(r!'A'n«)N

Kfbiflfd in Silll I'uifii i-iii

).,n

M,>iitln

/hr\

TI!KXH()VHS-rXTHnPKHSnNAUPAKnr.^KU<.AKKTKl K K* TIH-

(111

nrUATION >Y^ y'i;ars Mouths

/hivs

(SIGNED) 0

flouts
M.D.

Special information nnly for Hosplldls, institutions, Transients,
or Recent Residents, and persons dyinq away from liome.

Former or
Usual Residence

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

HoM lonq at
Place of Death?

Days

I'l.ACK OI- lUKIAI. OH KKMo\ Al,

DAIIiof r.iKiAi. or KKMOVAI,

\j^ *XL 190'

fA(l<lltHS

"^ . rr^ AHF Mhould be stated EXACTLY. PHYSICIANS should

N. B.— Every Item of Information should be CHr^fulIy suppi.ed J^«f; "^^/^J^j.^i^* ^he -Special Information- for pT-
state CAUSE OF DEATH in plain terms, that it may l>e properly ciossmeu. m-

sfms dying away fi-om home should be given in svsry Instance.

65)

r~b

ik«'

1 ]

I

^r

1:

I

"'mmmtm

!<'

iff

I
I

WRITE PLAINLY WITH UNFADING INK

M, ,;..!. 1 ..f ii..iitii IN" :■ •5"^:,:;^^^' Hft r Co

THIS IS A PERMANENT RECORD

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

l)a(e F//r^/, L'ct<rWv ^0

IVO'i

Rec^lsfci'ed J^^o,

Ja464

I

Certificate of IDeatb

XX. S. StanDarO )

J (^

PLACE OF DE ATH : — County

ofCJa.-w J .^a'-v-x.-^-^'^ ■ City of UXX/^v o

rNo. w.^JUU

.'^rCCaJj

1 M

.1.

Dist.; bet. —

"~ and

(IF DEATH OCCURS
IF DEATH OCCU

A^/yV£ V -^i_^ RESIDENCE GIVE ^CTS^c'tLED FOR UNDER ■SPECAL INFORMATION" \
RRE7.;THOs1.yT*A!: ^ ^N S '. ^U^O^'o , V . .TS NAME -NSTEAD OF STREET AND NUMBER. )

— )

S AW<

FULL NAME

W

\

L-Cii^ . V.4

si:n

!) XTl-. nl- r.lli III

Am-

PERSONAL AND STATISTICAL PARTICULARS

COJ t (R

Ml, nth

\ )'iii.

(Day)

Mmilli:

(Year)

/),.■

SIVC.I.K. MAKKIl-.n.

\vino\vi:i) OK DivoRv i.;i)

• Wiitiin viH-ial di >iy nation)

nikrinM.Ai'H

I state i>i I'lHintry)

MEDICAL CERTIFICATE OF DEATH

DATH ()!• Dl'.A'rn

(Day^

sl- . v».. U
(Month)

IQO i

(Vfar)

^0

NAM!' ni

J- A Til i;r

niK'niri.AtK
m lAini-.R

'Stall' m Onuntt y

MM1)1:N NAMl''.
ol- MUTHHK

I!IKT1IIM,AI"K
()| Mc)rill''.K
(Slat!- Ill i'i)unti\

A5

" rillUxIU'.V CI:RTII'V, That I atteinU'd (U-itased fruni
— — up to igo ~

that I last saw h .— alive on " H)0 ^

aticl that death occurred, on the date stated above, at "

M. The CArSI*: Ol' l)I':A'Pn was as follows:

or RAT ION Years

CONTRIIUTORV

MoHihs

/hiys

Mont/i:

A

{H

I

oi'i't r A rioN (^

A\"-ii/f'if III S'.ni I I, nil 1^1,1 -S ^' )r.,';>

.\r,»,th'

Ihn

\nv \HovH srxri i> i'KRsoNAi, I'AK rut!. \K'~. \Ki: iKt 1' ii » riM-;

lil'.sr ol MS KNOWMIM,!-: AM) lill.Il'.H

(Tnf.>;niatn

IU'RATION )'iiirs . . _^

(Signed )

i()oH (Address) bOb C}llI-U\

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

Former or o • Q \ \ \ f
Usual Residence oio lUCLA,V\c

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

How lonq at
' Place of Death ?

Days

fAtl<hi-*^>4

IM.ACK Ol' IHKIAI, OK RI-MoVAI.

r N I ) 1 '1 u 1" A i; I : R \i I mX

H. .

DVri', -it IJt HiAi, or RI'MOVAI,

U ct

190*^

fAd.lrtsH 0^0 sJLO-A-JL ^l

M. B. Every Item of Informntion should be cnrufully supplietl. AGE shotilil be stated BXACTLY. PHYSICIANS should

state CAUSE OF DIIATH In plain terms, that it may be properly wlassifled. The "Special Information" for par-
sons dyinft away from home should be felven in every instance.

.J^iilO&?

W

RITE Plainly WITH unfading ink

)!n,!nl .)f HiaUh

,^.,, , , t'-^-^'Siii U& I' C

I t

1)(

VJO'i

this is a permanent record

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

^ A Deputy Health Officer

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco

PLACE OF DE ATH : — County ofC <XTV

Certificate of S)eatb

City ofO<^>^' ^ '"^'V ' ^'

FULL NAME Ml ^/t^AXL

V)

.C > w l^

si:x

PERSONAL AND STATISTICAL PARTICULARS

i) A ri: < 'I HiR iJi

.\(.H

MEDICAL CERTIFICATE OF DEATH

DA IK OK i)i:ath '

iD.t

(Vt-art

Yr,n

(Hav)

M,,ntli<

\ I .1 t '

/'.;

■,ix< ,1 iv M \KHn:n.
\vnM»\vi;i) »»!< r>!Vi>Ri;Ki>

iWritf in MK-ial (h-ivnntion)

I", a-

I'.iK rm-i, wM-:

1 A 11! KK

lUK rin I. \' 1'.

ol 1 \ IIII'.K

I >>l,itt ' 'i I'oUlltl V

MAHUN' NAMI-,
()l Mol'in-.K

lUKTinM.AiK
ol Morill'.K

fs

It

(Month) ""=»V^

1 ni:ki:!iV CI;RTIFV, That l .Utin-Ua .Ucca^d from

tliat 1 la^l saw h - alive- m, OwA.v x Up

an.l that .k-ath ncHurrc.l, ..n tin- aat.' stated ab..vc, at l

M The CMS!'; ()!• IH.A TH was as foll..ws:

^.

,/^l

0 ^^'

~>

DrRATION >V<i/.v

c<)NTRii'.r'r()i

Months

/hiv

I lout s

nr RATION , >V</rv

(SIGNED) Jt/uJ OWUbi^

Mouths 1 .5 /^<n's

■J V -I

I lom s

M.D.

d^ujL^

SPECIAL INFORMATION only for Hospltdls. Institutions, Transients,
or Recent Residents, and persons dvinq .m^y Irom tiome.

Dicn'A'rioN

h'l-ithd III ^<ni /'iiiii, I-'''

)'.-,ii

!/,./////•

/hi

;„,- xucVKsTXTl M.-KKsnNM.rXKTUruXHSAKK TKIK D » Till-:

I'O

(lnl..:in:ii)t

Former or
Usual Residence

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

How tonq at
Hare of Death?

Days

ITAii: «»1 lU HI M, <»K R1.',M«>\ Al,

li\i') .,! p, 11 \i. 'It Kl'MnVA!,

u ,

luH... bi^l ' 'hK^^ 3i

%-

■■i««-i^M-i— ii— ^^^^^^■^^"^"'^■'^■■'"'■""""'""''^"'^'^'"""^"""'^^^^^ II h t t I BX4CTLY PHYSICIANS should

,. n.--", ..en. on^^^..-^.on .H....... .. .^..<u.,, .u.^.-W... ^^f;;,- •..°,:;: 'Vh. "^pcc.;, ...o™„U„„" .o, p-r-

:"';.."» ««"y «rom he™., .hou.d be *W.„ y >"..-«•

I

;il

< I

I

i!ii'

1

i

I

^

WRITE PLAINLY WITH UNFADING INK

l!(,u.! .>f lit allh 1- V,, '■■-. ?--;sc^:-i; liS:!' C

/>^//

f ri/r'f,^AA)JL\.^ x^

Dep

Ith Officer

THIS IS A PERMANENT RECORD

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

24 m

Be^i^sd'fed JS'^o,

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco

Ccitificate of IDcatb

( "a. £. StanDarD j

C\ ;\o , City of O'O-'^'^ ^A,<x, - -

ivr„ I'^SO VI "^ -^- ' ' St.; I Dist.;bct. J.«J(X»^«Vll and J.LcV -, ■'

iNO* 1 W V, X^ ,,eii«i orCinrNTF rivr facts called for under "special INFORMATION" \

( '^ .7D;AT°H^OCCU%rEV;N"rHo's^rT':;t o7^---o';"c.;eTt1 name .NSTEAO of street AND NUMBER. )

PLACE OF DEATH: — County of C) cxata; 0 /v.

"V

I

I

"^

FULL NAME

,"^

\^ i

PERSONAL AND STATISTICAL PARTICULARS

-.i:\ t

DATl-: MI- BIR in

K'i )!,< )

M

(\

A.

^ 1 v.^-..

/ -

lM..nlhi

\«^1-

l>.i\-

M.oilh

s't-AV

Wl 1>» »\\ I'D ( >K l)l\< »Kr II)
I Wl iu- ill - "■i.il '!• -il^ii.ili'iu)

Hiu run, \''!

'Statt -• ' ■' i!n1 ■ ^

\ \ \i i: t »i
1 A III !:r

iUK rinM.Ai'H

(>!• I XI'IIl'K

■-,!:ii . I It i'iiiinlr\

%!aii)i:n n\mi:

ol Mo'ini.K

HTRrmM.Ail',

(ti M(»riii'. K

\^tiili- 111 viiunt I \

oCCriA lloN

MEDICAL CERTIFICATE OF DEATH

UAi'lC «>I I>i: AlH

w

l^X

(Vf:\r)

(MutitlO 'Davl

I HlRI'ilV (." I'lRTIl'V, That I atUinlcl deccasctl frniii

';>_lW± ' i.,'i'\ t«) wxX' \l up H

Hint I last s.iw h ..•• ' ali\<. on ^ !")'>

ami that di-ath ncrurreil, on the date statc<l ahnvc, at 1-3
M. Thf CAT SI-; Ol" l»l'.\ Til was as follows:

L

wC_JLK.'

"C\

^vrL ^IKa^,

^\^^Q

VLby^

H (in

CONTRIIU TokV U, » >.

.}/<>////rs

Pavs

I foil) <

IGNED ) LU. J

6-^_^^Ai A.

r !

/cx^-vdj

K'- !<!i,i 1)1 ^tttl /'i ilih lu-n sj \

.1 /,,),///.

/;

Tin- \nn\!- vTMI'l) PKKSON \l, I'SHTrm \R>^ ARK VRl }■■ Vn rill
lil'ST Ol MV KNt»\\ l.i:i»(.l-; A\!> IU l.^:l•

( Iiifotniaiit

rt^

\.l(ln

u ■

I )r RAT ION

(S

f Aa.iiA-ss) r

/)^n'

//ours

M.D.

SPECIAL Information only for Hospitals, Instifutions, Trdnsipnfs,
or Rftent Residents, dnd persons dving dHdv front home.

Former or
L'sudI Residence

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

HoH lonq at
Plare of Death ]

Days

f^,K U

\ t

I'i, xri-: « >i luRiAi, i)R ri:m< »\- \i,

4 Id ^.' ■■',

,,,,,... 15'h- '^sn 5-. a I

DAri".!' HruiAi i.r RllMOVAI.

1^ B —F.very item of Int'ormaf.on should be cnrefully ^upplU-... AGi; s1k>uUI be «tntec!l EXACTLY PHYSICIANS should
state CAUSE OF DEATH in pinin terms, that it m»y be property clae^if.etl. The "Special Intormat.on tor p.r-
Hon* dying away from home should be felven in every instance.

n

* * J

I

i-

^.1

Ml

I

< «'

( I

«i «

:^A^A^.

]■ I

J

1

I
1

WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

n,i:iMl ..I Ili.tUli I' No !■> ^'^^s^^f^r.S:!' I

IDO'i

Be^lsfered JS'^o,

246^

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco

(Xevtiticatc of 2)eatb

f "a. S. StanDarD )
^PLACE OF DEATH: — County ofO,<X.^. 0 \a->-CA« Gty of 0^>X' J.vct>v<M..

It

P4e. Vjl^\tAXxJu Lo^rVx.\.m Ob CHLb^jto^^ Dist;bet.

and

FULL NAME ^ ^J-d.

LL ^ ^ vC >V

sj;.\

PERSONAL AND STATISTICAL PARTICULARS

! C(>l,i>R

tUcoU

lUJvO.

DATK or lUKTU

A ( . v.

r\

I Mo lit 10

%

} V,i

1 1).\\

Mmillis

\ lal

/hi

SINC.IJ-: MAKKIl'l)
WIDOW l-:i> OK DUoRrKn
(Writr in >.(Rinl 1< ^itnuitiuti)

lURTm'l.At*!-

(Hlatf or CoiuUi \

\\Mi-: oi
I- AT in: R

ItlKrillM.ACH

(»i 1 \iiii«:k

M Mlil'X NAM I
nl MOTIIHK

HIR Iliri.Ai'K
()|- MoTHl'.K
I Statt <ii lOiititry

n I

MEDICAL CERTIFICATE OF DEATH

DATl-; Ol" DlvXl'M j/'~\

(Month) (Day)

rgo

(Year)

I lil'iRliHV C'l-RTII'V, That I attciKk'd (Uixased fmiu
^ *■ " 190H to V, c't l^ upH

K. CL 'I icjoH to V, C't l^i

that I last saw h - . - alive on n.- v up

and that di-ath <uH-urred, on the dati- ■-latcd ahovc, at ^
.' .^I. The CAISH (>!• JUKATH ua^ as follows:

u^

v\

a

Wa.

«^

\^a.Vc .

DT RATION )'ears .)/o)ff//s Days

ONTRIIUTORV LL>wC<rK.clA.4 >Nx

//oin <i

C

/s

1)1' RATION ^ ^''^/'^ , MoHtfis Pays Hon

(SIGNED) AxxaX). J- lL^^^.-- M.D.

wot It iqoH (Address) H liv V duJAhiJUJ. ll.t

luxr ^Ituk

ocrri'ATioN (

^

Nf'-idrd n< Still /■' irih /v "

) r,ii

Mnlltll^

I hi

Till- XnoVF SiTATl'n 1'KK'SnN \I, I'A K llf I' I,A KS AKl". PR IK To

HKST o!- Mv KNOW 1,1, IX. K AND in-:i^n:K

Tin-

(hifo-mriTil

\.l<li

a

A

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

Former or ,,ur,(VVi \, How lonq at

Usual Residence hH l H 1 lt<L<iA.^ vv M Place of Oeatfi?

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

Days

ri.Aci-: Ol luRiAi, OR ki:movai,

U 1

LLu^S

>\A^AV

c

<A

l>\ri. >' 1!( i.iAi. 1)1 Rl'.MoSAU

C^ct 9.1 T90H

rNl)i:RTAKF.R

OuA

. . X

(Ad.lresH ^blS.- l^l Lk ^.

-CXX^-IX/W

N „ — Hverv item n? information should be corcfully HuppHed. AGE should be stated EXACTLY. PHYSICIANS should
stotc CAUSE OF DEATH \n plain terms, that it may be properly classified. The Special Information ^or per-
sons dyinft away from home should be ftiven in every instance.

«!'

II

1 •

11

I* <

WRITE PLAINLY WITH UNFADING INK —

I!.i,inl of ll.altb - »■

Vo. 1- -^'^^^w^^, V.SlV Co

I)(f

fr /u/e(/,\U.^iXA>^'

hj X\

100\

THIS IS A PERMANENT RECORD

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

2408

Re^l^tei-ed jYo,

KA^ A-C

Deputy Kealth Officer

DEPARTMENT OF PUBLIC HEALTH^City and County of San Francisco

Cevtificate of Beatb

( Ta. S. StanDarD )

PLACE OF DEATH: — County of

A ^

Or^

a

JAaX-v-^cu5.cc City ofCjO.^^ 0 Xcv-Nxc^^v
fNo IllC-d^^u S\A X Dist.;bet. Ml va^r^. and

'INO. I » w w ,„„„ iicilAI OFCimPNCC GIVE FACTS CALLED FOB UNDER SPECIAL INFORMATION \*

( " ,'',"o;'i,H"oCC.%r.",r°''„o"s^Pr," 0%'?«"?"o"'0,Vr,Tl N.«E ,»S,»0 O. S„..T ..f NUM.... J.

V. ^

if

C

/-^

FULL NAME

1 t -^

XA.^tLcL.\rvu

cl<

a ->^x4

PERSONAL AND STATISTICAL PARTICULARS

si:x

i».\'i i; or- lURTn

A< .!•;

r»>i,i)R \

a

.^5

i Ml. nth

5V,(

I>av

M.oifli-

■\'( a! I

Dii I .

SIN<,1.1- MAKRIl'.n.

\\ I I>» i\\ l'I> I )K I)1V< )R<l-:i>

\\ ! lit in -1 'li tl ili-ii^natiun

lUK ill ri. \*"}-:

' sta!' 1 il ' ■' lUiill %

VNMI OI*

lA rni;R

niR'I'HIM.ACK

(u- I ai'ukr

! State (If l*i)!11lt

M \ir>i:N' NAMl
«>I MdTHHR

HIR'IIIPI. Ail-;
(11- MoPlll-.R

1 State 1)1 CuUlltl N

occri'A rioN

'^ h

I on '"

MEDICAL CERTIFICATE OF DEATH

DATH (>»• DKATH , "^

(Miiiitht
1 H1':K1-:BV CI-:RTIFV, TImI I a-un-k-.l .kcva-d frail

— ■ ■ — ~~ 190 tt) - - —

that I last saw li -■:: — alive on

and that lU-ath ticcnrred, on the tlalc ^taUtl abtwc. at
"^T" M. The CAl'SI-: t)l* DIlATIl w a- a- foll.nv-

tqo

»\_«^

4hCu

S-
i

DT RAT I ON )'t'ars

eoNTRnU'TORV

nr RAT ION )'tars

.l/on//is

/hirs

11

I ',n

^ 4

( Signed ) Wur>\iAi j.^ U KcLa%xc<.

M.D.

ii:

A.hUc-;s) L(j\eAVL\6 \L-»\vw

Rrsidfif ill Still /'iiniiiu

M.. II tin

n,i >

Tin' \Huvi-: sr Aii.ii pkhsoxai, i-ar run, ars ari-: rRiK T«> Tin-

I!1:nT OI- MV KNOW l.l.Ix.H AM) lU'.l.li:!'

(InfiiTlH

„„ lo

rvyv

cLa,^ > \

\il,lr«j><s O 0 0

t

rvx^'tx JL

■ ■ ^t

Special information «"'* 'or Ho^^pitaK, lnMltrffl»ii<i. TrinMfBls,
or Recent Residents, and persons d>m;} awd\ from home.

Former or
Usual Residence

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

flow lonq at
Place of Death?

Dav

s,o:o.^.ev;»xc.t.v.

iNin'.R iaki:r

(A

nSTV.if H! KIAI m RKMOVAl.

TOO

i'ct

<

v)x>v>v ^^ u

iMns^ QlIH WcCcLcy ..\\

^, B. Bvery item of InfopniHtion should be cafefully auppUecl. A(iR should be Htnted I.X^CTLY. PHYSICIANS should

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

MkJLii

4

' i

--1 7'-*3» >. ^

WRITE PLAINLY WITH UNFADING INK —

V,i>-Ar<] uf f!< ;iUli (•■ N'').

/)((/(' Filed ,

./ejL<r\>Uv

Qkl

190^

THIS IS A PERMANENT RECORD

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

2M\B

Be^Lstcred jYo,

iL'V

Deputy Health Officer

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco

Ccvtificate of £)catb

( tl. S. StanDar^ )

PLACE OF DE ATH : — County of

(ir death' OCCUB5 AWAY PROM
IF DE<V"M OCCURRED IN A H

0^

MX^-^cu5.c^ City o{0 Q^^^ 0 Vcv^'vc.c^ ec

St.; cs.

Dist.;bet. H > LCLCl^Tv and JxXh^c'

E FACTS CALLED TOR UNDER "SPECIAL INFORMATION" "\ ^

USUAL RESIDENCE Giv

OSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER

lO

FULL NAME

\j

h

..\

/LaaXola)A.Ui

d

<X'y^\Aj

PERSONAL AND STATISTICAL PARTICULARS

SKN A A COI.UR \

DA 11. of- lUK rii

\«.i-:

/"Isc

Month)

(Diiv

M.'uHi'

Year)

Da 1 A

sINT, l.l-- MAKHIi: I)

( Writf ill Mfcial di situation)

lie.

4Kv*

MEDICAL CERTIFICATE OF DEATH

DATK ol- I>1-;ATH [ P\

l^'ct

I go

(Yt-ar'

fMoiith^ <Day>

1 HICRIU'.V ClUxTII'V, That I alttn-kd <kcvascMl fmin

tn

190

that I last saw h ": alive (Ml "

and that lUatli ncourrcd, on the date stated ahnve. at
" r" M. The CArSI«: 01* Di: AT 11 was as foll<nvs

190

igo

niRTuri, M"}-:

' Stat' (i! ' '1 mntl \

!• A I II IK

niKTll JM, AiK

<)!■ 1 All! KR
St.i'i 'It i'ii\nitry

N! Xini'.X NAM1-:
III MOTHKK

HiKTHri.Ari-:
oi- M()Tin:K

(State ui (.'ouiiti V

1 .

0

.^ ^

lOrrru li-da

.1 I -^A I

U

irnJU ^JTYuu

dU

(u*C 11' \ I'lON

^S-

\jix U c-v^^-> A.S, ■> ^- c^

nr RAT ION y'lUirs

CONTRIIU TORY

.l/o/i//is

Days

Hour's

I)i: RATION ^ Years ^fonths

( SIGNED ) llcfumjLhj 0 .Mj U) \iX

li'ctr 'XC TooH (Address) UrXtr^AJAA y

a

I/oui^
M.D.

».,C-'

h'f^itir(f III Siin /'i ,j>hi^r>

'J 1

.1/,M/,'//.

/hl^

Tin' xHovj*. sTA ri-:i) pkhsonai. tar iiitiak^ ari: rut i- lo rni-

IJHST Ol- MY KNOWI.l.IX.H \Nn lU'.l.IlJ-

(Iiifoiuiant vw

nnru

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

Former or
Usual Residence

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

HoH lonq at
Place of Death?

Days

ri,ACK OK nrRlAI. ok RKM<tVAI,

(A(l<lrf>^*

I)\XJ"'>!' ntulAl, or RKMOVAI,

. .„.^,. .i-VBllii ■••

T9O

t)

I

N. B. Every item of informntion should b.* carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should

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

«"?5s?«*r

'^m-

St

• i '1

^.uirtbr

■

^

WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

BfKinl .f H' iltli ]•' No i ^ *-^:;^^^' H5^ 1' C

Begistci'cd JSi^o.

4no

dUrvv^^ dxonu. Deputy Health Officer

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco

Cevtificate of 5)catb

I

PLACE OF DEATH: — County of CL>% J^^oxc^ax^o City of ^O.^^ J.^.<x>xcvo cu

A

No.

St.

Dist.; bet.

and

/ IF DEa/ H OCcJnS AWAY FROM ij S U A L RESIDENCE give facts called for under "special INFORMATION'- '\
V IF D • ATM OCCURRED IN A H^JSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. /

FULL NAME

,'~\

L

ft

.^1

lc>\.

PERSONAL AND STATISTICAL PARTICULARS

UAIi; nl lUKl'II

I ruxLi

.lit in

A«,|.;

)'f i/<

H

Dav

M<nillis

n

(Vear)

A? I

\\ ii>< >\\ J" It < »K i»!\« >Kri:i)

i\\!it< in -iKi.d ill -!t;nalii>n)

lUK riipi, \i'i-:

1 ! ll ' *

It: \

J?

d

CtOA.

0 .t > \oM

hJO^-ysJ^^^Ji

N WW <»1

I- A in JR

lUKinri. \t'K

O' I \ 111 l-.R

>l,U!- 1)1 ((HlHl! V

MAIDl'.N NAMK

lUK I'lll'l, \i}",
<il Mtii'lll.R
I '^InSi I ii iduiit 1 \

< H'cri'A rioN' ^'

MEDICAL CERTIFICATE OF DEATH

DATK <>l- I)1.:aTII

(Montli)

:t

^

(I)av^ (Ytar)

I Hi:Ri;r.V CI'.RTII-V. Tliat l attcnikd «leceased from

U^et \>

upM to ^ ^ l*^

icpH

that I last saw h A, - . alive on U ^t? ' ^ ,,p 'i

and tliat lUatli occurred, on llie tlulc -stated above, at
M. The CArSl-: Ol' DI'.ATM was a^ follows:

DI'RATIDN )V<7;s Months . Ihiv

C ( ) N T R 11 U r ( ) K V ^^ ^X.H/kv.O-VO'

IIoui s

L>TU

VI

J"^'

Ri'^iiifd in Siiii 1^1 atti n, n

J V(,» I

1/,M////,

lhl\

Tifi-: \M()vi': sTA'n'.n I'KR'^oNAi. 1' \K I u ri, \R-- ARi: TKn: m riii-;
iti'.sr Ol- Mv KN»»wi.i;t)»'.)-: wd Hi:i,n i-

' Info! ma til

DTRATION )'tars J/on//is /hiys'

(Signed )

ilVt ').:

M.D.

Kjo'l f

Address) ^Xo(K^.A1^>.- -^

SPECIAL Information «nly for Hosplldls, institutions, fransients,
or Recent Residents, and persons dy'nq away from liome.

Former or
Usual Residence

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

How lonq at
Place of Death?

Davs

IM.ACl-: Ol' lURIAI. OR RKMoVAI,

do Am ^6

-H

DXri'.uf in HiAl. iir Rl.MoVAI,

TOO

aMaX V

(AddrcHH Ul'J'X- 1^ tL^^A

N. B. Every Item of iiiformHllon should bj cnrefully supplieil. AGF. should be stnted EXACTLY. PHYSICIANS should

state CAUSi: OF DEATH in plnin terms, that it may be properly classified. Th« "Special Information" for per-
sons dyinji away from home should be feiven in every instance.

il!

» '■

I ,|

wC

1 1 1 1

i:i

J

n
f

\'t ii

III
u

'. i'

yi.,1

■

r

li

I

^

WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

Th(

le Fileil, i9/iLtJ>^\. ai ^OO'K

Begistcved J\^o.

o

4no

Deputy Health Officer

DEPARTMENT dp PUBLIC HEALTH=City and County of San Francisco

Certificate of IDeatb

( XX. S. Stan^arD )

St (^

PLACE OF DEATH: — County oi^^O^-r^ Ct Axx^c^^lc^ City of Q,a>X' J A.<x^xcvo c

u

No.

e-.

MJll

\Kh

^

AuA

St.;

/ IF dea/ H occJrs *w»y from usual residence GI

V IF d :»TH OCCURRED IN A H«JSPIT»1. OR INSTITUTION

FULL NAME JiA.

Dist.; bet.

and

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

N)

JLllWYxj

PERSONAL AND STATISTICAL PARTICULARS

•^l- \

I nxJui

1"<)1,(»R

MEDICAL CERTIFICATE OF DEATH

DATK OF Dl'.ATH

\x

AXJk

i»A'n; itf r.iRi H

A<.K

■'>^Jb

)',.n

\\I1H)\\ |.I» OR IMXoKD'H
i Wi it* in --(H'inl <U -.i^"^!!;!!'.!!!! )

Dav)

Miinlfi'

(War)

n

ha

Uav

lUR ril I'l. \»M"
I stall 1 1! I "■ in nt 1 \

NAMK oi
FAT 1 1 I.R

I!IR'niI'l,\rK

()' ) \ I 1! )•■ k

' state III riiaiil 1 \

\!\n>F;N NAM I
ol MO'I'IIF.R

ItlRIIII't, At i-:

ot Mo'rm-.R

< Statt til idiinti \

orCll'A rio.N/'

A'f^iifnf in San rmn.n.n

(Month)

(l)av^

(Yt-aD

I Hl'lRIUiV CI':RTII'V, Thai I atu-iiik'tl .UHxastMl from

.ct

0.

Hpi t(3 . L'€t i'l

that I last saw h A. aUvo on U ^Xj I I icp '^

ami that lUath <»{Hiit rcil, on the <iaU' ^tatutl iihove, at
M. Tlu- CAT SI-: Ol' IH-ATH was as follows:

n

DrkATION )'i'ars A/ofi/Zts '■ /\iv

vA.^VyJkA\,<(rVLhYU

//o/n s

CONTRIP.rTokV

}\ar

Months

Dav

niRATlON

.NED) UXk^JULN K XoL^

ly/cL x^ i,,o'i (A.iau-ss) ^^.oiKaa-LLu

(SIGI

//ours
M.D.

- 1

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

) I it I

M..,iih

/>,;)

Tin- M5o\ F, HTATF:n I'KR--oN \I. r\R 11. 1 I \Rs \Ri: TRIH To I'IIF:
HF:sT «>!• MV KNoWM'.lM.I-: \M) lU-. IJ^;F

( Infnt tnatit

{ \<l.lt.

Former or
Usual Residence

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

HoM long at
Place of Death ?

Oavs

IM.ACK OI- lURIAI, OK R1;M<>\\I,

r N I ) V. K T A K V. K jV^ULLu ^^ (Hp CC^ytXyyv

I» \ri: o! lUi'iAl, 1.1 R I'.MoVAI,

tS. B. r.very item otf iioOrmntloti should b.- cnre?ully ^upplierl. ACIE should be stnted EXACTLY. PHYSICIANS should

state CAUSE OF Dr.ATH in pinin terms, that it miiy he properly classified. The "Special Information" for p«r-
Kons dyin^ away from home should be fei^'C in every instance.

IV'i

4

m

r^^^'.'"

!

t

i i

WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD

no:ir<! . r lt.-:i1th- F V<

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

l)((h' Filed ,

,MA; II

VJO\

Ee^isferecl JS,^o,

2471

A'

.Crv.^^^ ckX-x^Li

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco

Certificate of S)eatb

PLACE OF DEATH:

("SO :

{ "Q. S. StaiiDarD

rNo, H n 5 vJ uUUA„^d;
(

County oV -^0^'y\J- ^
St,; t

3;

City of '■ O. ^\; 0 A.O

IF DEATH OCCURS AWAY FROM USUAL R E S I D E N C E G I V E FACTS CALLED FOR U^DE
IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD O

Dist.; bet. oUAcHxmA) and ^ ^^<XX > \ '

UNDER ■'special INFORMATION" '\ |

F STREET AND NUMBER. / ^

FULL NAME J C^UlL,

iL4.

PERSONAL AND STATISTICAL PARTICULARS

i)Ali; <>! lURl'll

Moiitll^

A«,i.;

4H

It

\
il»av

\r,,fl:

J t

4 tar

P.M

si\(-, 1,1-. %!ARKn:n
wiDi »\\ i;i» « tK i»i\'t tK.i:r)

(Writr ill -ini.il il.-i;.Miat-'.iit

lUK nil'I.Ai'K
' Stall' ')!■ r, 11! lit I %

WMI- (M
1- A Til IK

lUKTHI'l.ACl-:
()l- lAIIll-.K
(State Hi rount! V

MAIKl'.N \ \M J
t)l- MttrilJ-K

lUUini'LArH
oi- Mt»i"m;u

Slate I'l Cmnit 1 %

()rt.Tl'A riON ( u

0 ^i^OLva^vx.vo

Cu\xi.

^JVch^O; Uvt

-\

»

4 -v

Re^idf,! m Sd>i I i

M,,„th^

I hi 1 >

Tn !■' \i!«)\"i* s 1" A ri'i) rt-'RsnN w. v xki'uti.ars ari: rKti-:
lu'^r 01 Mv KNOW i,i.:im;h wd in-: 1,11; i-

ro Tui-:

(Info! maiit

A^ ^JScuvV^'^

vi,i,.~> HIS JjJUhiOo 3.1

MEDICAL CERTIFICATE OF DEATH

DATi: or ni; \ ru ■'X

(Mc.iitli) (Day)

I ni':Ri:r.V CIvRTII'V, That I atteinU-.l »lcccase<l from

\ -. I90H tn iDot 1%

that I last saw h !-.' 1 alive oil \J ''^C\j 't up

and that tU-atli «>ccnrrc<l, on the dale stated above, at ' -* -
M. The CAl'SI'! Ol" I) 1: AT II wa-^ as follows:

(Year)

1

Dr RAT ION }'rars

CONTRIlU'ToRV

Montin

/hi IS

lloilt s

DT RATION

,0

)'(■(//

I7

Mouths

Pays

(SIGNED) \:JaX/:xj ^ Ov^r>\.A

Hours
M.D.

(A.ldn'4^) IfcOyj^Jfr^icc

Special information only for Hospitals, Institutions, trdnsients,
or Recent Residents, and persons dyinq away from liome.

Former or
Usual Residence

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

HoM lonq at
Place of Death ?

Days

IM.ACK Ol- lURIAI, nR RKAtoVAl.
I NDHR lAKKR V <XX-L>aXX.

I»\i;i:.,f Hi KIM (ir KKMOVAI,

j^,,'i

TQO

Ad.lii

TsXj^ \Iq' vOJxa.^xu

IM B Every Item of inWmatmn should h. cflrefully suppHecl. AGE should be stated EXACTLY. PHYSICIANS should

state CAUSi: OF DEATH In philn terms, that It may be properly classified. The "Special InformBtion" for p»»i«-
sons dyinji away from home should be feiven in every instance.

Ill

a^ £

r

1 i!«

i.M.

Il t
rJ

ti

I

WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

l)((fr FiJod, L/^W- a.1

VJO'i

llpgisfcvcd J^o.

'^17 >

Deputy Health Omcer

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco

Certificate of 2)eatb

' tl. S. 5tan^a^^ )

\

{ I

No.

PLACE OF DEATH: — County of J ai^ vj fva . v
W "^ ~ ^l. . St.; '^ Dist.;bet.

Q^

City ofO^X^^ JyVCX^x^CA^C

and ^'

St.; bet* va7^A.*wU and ^

(IF DtaTH OCCURS AVWAV FROM USUAL R E S I D E N C E G I V C FACTS CALLED FOR U N D|t R "SPECIAL INFORMATION \
IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD pF STREET AND NUMBER. /

FULL NAME -J^a^ vcU H I laxccu '^ r \ ^ ^^

^! \

'■1

PERSONAL AND STATISTICAL PARTICULARS

i» \i i: (IF lUK rn

\< .)■

'^L;cv.u

M-iiilli

l>:(V

1 /,,!/'/,

/ 'i; 1

W [IX >U I I) • »K IMVDRCKn

'\\iit« in -mi.i! 'l»->-ii'imtiiiii)

lUH rm'i.Av'i-;

LL

I A I I! IK

HIK rni'I.At'K
<>l I A niiK

< II- MnTllHR ' I I

V. W^

A

.1 s.-.

J^*wv

ink rill" i,Aii"
<>i Mdi'iii k

n

o.H'fl'A'rioN A

/^r~-,/,:f :>• S./'' / '

\f,,,,fl,

n.t

PHK AHOVI' sr \-nit PKksnN M, FA K lir r lAk-- ARi; \V.VV. T" > rHI-

r.i-^T oi ^is' K v< >u i.i,!)'. J-. \^i> i>i;i.n i-

(T

iifuunanl J . ^<X.-% V. C-^^ ' nI K . V J L CV

\.l<ln—

(? U 'I ^

MEDICAL CERTIFICATE OF DEATH

DA'i'K < )i- niiA'ni

W,CV -'y

I lII':ki:i>V CI-.RTIl'V, Thai i alien. Ir.l <kTrasr<l {v^nn

.^X.K^K. a

A

lyO'i

In

U)0 H

tliat I last saw h .j-'v alive <>n "^ C-'. - i^o

aiiil that (k'ath tiri-urre<l, on the datt.' ^taud ahove, at i '-'
.M, The CAI'SI-: Ol- I)i;.\III \va>^ as foll<.\v<:

Ur RATION )'iais

C<)NTRIIU"T<)RV

M,'iii/i\

Ihiv

I lours

Pays

1 Inn) s

M.D.

I )r RATION ^'<'<?;a JA >///// v

(Signed ) 0 . .. clcu^

Special information onU lor Hospitals, Institutions, Transients,
or Recent Residents, and persons dying and) froni home.

Former or
Usual Residence

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

How lonq at
Place of Death?

Davs

ri,\CHni< lU'KIAI, OR KI'MoVAI,

DAIl-'of Hi H'.AI. .1 ki:M<»\AI,

ca

TOO

I NI>1:K lAKllR W

XXX^wO L<|^^t_4 \A.X3i^->^ ^ ^ ^

U 'V O "^ ' ^ ' M

1^ „ —Kverv item of Int'ormntlon should b. cnr«fully supplied. AGE should be stated KXAGTLY PHYSICIANS should
state cluSE OF DEATH In ph.m term«. that it ni„y be properly classified. The "Special Intorm.t.on- tor p-r-
sons dying away from home should be feiven in every instance.

\i

h f

I

^^««*

IM

, t

[I

WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

lut/vA^ Deputy H th Officer

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco

Crvv\^

Certificate of 2)eatb

( tl. S. Stan^arD )
PLACE OF DEATH: — County of <x-^ J.\,cl ^

i I

! r, ^ . \ 1 /">

St.;

Dist.; bet.

City of vJ tXyVAj 0 X<X ^\JQ.AM/^L^

and

(IF Dt*Trf OCCURS AWAkr FROM USUAL R E S I D E N C E G I V E FACTS CALLED FOR UNDER "SPECIAL INFORMATION" '^
IF OEAWh OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. J

FULL NAME^ClvUL

V > »

o

Is

N_».. W 1.^

n

si:\

PERSONAL AND STATISTICAL PARTICULARS

^ r<»l,nR \

vOw-W..

DA 11. iir IIIKI II

A<". K

as

M.^ml

J

tDav

1/,

» liii

/',M.

HiN<,i,}".. M\Rkn:i»
\vii)<»\vi:n OK i>i\< »Ki 1- 1)

lUiitriii >.i»< ial lU "-it' ii.it ii 111 )

^t |1 I I ! fi illllt 1 %

NAM}* Ml

FA III i;r

niRiniM.ArK

Ol' lATHl'.K

'St:(t« iir I'omitrv

MAini'.N NAM)
<>l- .MoTlll'.K

HIU IIIIM.AIK
<»1 MnTHHK
'State iir i'ntintix'

To..

1)

?

MEDICAL CERTIFICATE OF DEATH

DAI'}-: <>1 Dl'.A'rM

Uct

JX /q(} '

(Dav) (Y<ail

(M.Hith)
I lfI{RI{!{V C'l'kTlFV, That I alU-iidcd (k-ciasiMl fn.ui
IQO '1 to ^ ^A.

in t

tliat I last saw h !- ^ alive on ^- ^ i»p

and that (kath ocunirred, on the dati- stated above, at
Os M. The CArSl\ ()!• DKATII was ;,s follows;

J _.^ , .. .

DIU A lloN

}'i(irs

Monllv

na\

llOHt S

CONTK im Tory

DIR ATMiN

Signed

)'cay$

Months

l.ti ■^Hflu

IhJV

Nout^
M.D.

L

I J

OCCll'ATION

Rf-idtii III S,nr / t ,1 III /'I'll

Miiiilli'

ihis

rill-: xHovH siATi:!) i'Kk«»nai, 1'\k rhri.xK-- aki: ii<ri'. r<> Tin-:
HKST «)1- MV KN()\VM;I)<".H AM) in.i.ii;!'

f Iiifoimatit

ck . C^" <0^

f \.l<ln

\qV\ vy ruHxxLLAKxu dt

^ ■ .. w

litdls, InsU

".5 i<,o^ (Address) gtAJlla\X{^ '^6^h^-X'

SPECIAL Information only for Hospiu

or Recent Residents, and persons dyinq awav Irom home.

tutions, Transients,

k

Former or \ a

Usual Residence C^iOCVa-YVv^wU

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

How lonq at
N Place of Drath ?

Days

rt.XCJ'tOl- IHKIAI, <»K RKMONAI,

I>\l!of !l! KIAI in HI-.MmVSI,

-I

I no

M. B.-

». I 1 1 i; 11 «i!^.i %nF ehriulil be stated r.X4GTLY. PHYSICIANS nhould

item of 1ti?armBtlon should b.- ciire^ully supplied. A«iti sUouHl '»« »l»«eu i. %^w i u

CAUSE OF DKATH In pinin terms, that it mi.y he properly classified. The Special IntormMl.on tor p.r-

-Kvery
state Qi
sons dying away from home shouhl he feiven in every instfince.

;•

1

SUfs™^^

ir

Ir

U

\

WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD

I!.,., V.I of n-tltli I- No 15 **^^^5^. H&I' Cc

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

Bogistered J\^o,

O f ^ f

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

Certificate of Beatb

( Xl. S. Stan?arD j

^N©.LL

PLACE OF DEATH: — County of^ aix< '

City of C'CX NV

V.

^L >xtu, IX^ 1 > Vs.. , : '.514

Dist.; bet.

V* •

and

F DEATH OCCURS1AW»V FROM USUAL R E S I D E N C E G I V E FACTS CAtLED FOR UNDER SPECIAL INFORMATION

(IF DEATH OCCURSIAWAY FROM USUAL RESIDENCEGI
IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION

GIVE ITS NAME INSTEAD OF STREET AND NUMBER.

)

P

FULL NAME

0

PERSONAL AND STATISTICAL PARTICULARS

.aa

^1 \

A

t*<>i<»k '

aXx

Lv

I> A 11-; «»I lUK 1 11

%!..iUh

I>av

ACH

^1

1/

iW'tittin >«iMiai lic^i^'ialiiiii >

luk rin'i, Aoi'

' stall (i! t'l 111 nt I \

N \M1 «>|
I A 111 l.K

luurm'i.Ari':
i)\- 1 Arin-;R

i ?it;iti lit i'niint vy

M\!m:N NAMi-;

nik 11! I'l.At'i-:

<»1' MoTHl'.K

' State 111 Coviiili yl

a

f 1 (\

^ 1

,-> -i

I

^OJ

<>AJuLol/'>'

^'-^XK

tHCVVATinS

A'f :i/ri/ in SilPi /'i mil /^"'

ii I

M,>uth

I hi

THH AllOV!-: STATi: Ii !'K Ks( )N A I, 1' \ H lU' i I.A K-. AKi; IKrK l' > TIIK

lucsT <)^• iiy KN<)\\ i,i;i)i'.i-: \n!> i'.i:i,ii:i-

(Informant 0 XCUvJk Lv- O /ZM^TY^^^

fX.Mnss LA^V^^'^-A^

>
1 1

^\.^r^'<Aj^

MEDICAL CERTIFICATE OF DEATH

DAIH <U' DllATH

Month)

; i

(Dav

I(;i1

(\'t , 1 1

I III'lkl'HV Cl-;kTll"\', Tliat I atttu.U'.l lUctasiMl fn.in

'„jL/C :i \,fy': to U^c^b 1% i(,on

tllHl I last saw h :.. . alivr nil ^CW *. i,jn

ayd that (Uatli nccurrttl, on tin- dati,- stated almve. at J -"^
M. TIk- CAISI' Ol- DIIATII \v;is as follows:

CONTRIIUTORV

1)1" RATION Ycar^

(SIGNED)

Months

Pa

\s

//<

'out s

.V,>i/f/i.s

/hi

J.s-

/ft^tlfi
M.D.

%J^ It rooH (A.l.ln'ss) LAX^r^o^

Special information onl> for Hospilah, Insfilutions, Transients,
or Recent Residents, and persons dyinq a^as from home.

Former or
Isual Residence

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

HoH lonq at
Place of Death ?

Davs

I-I.ACF. <)1 IHl

I>\rj: .f lU KiAi or RKMnVAI,
Uot ^^ IQO''

N. B.— Every Iten. of l„.,.n,..t1on shou... He .nne.uM. suppfeC. AGB should »>« «7'^:;^f .i^^^^^.^^; jri^lfiLt'-V'rJr'
•tate CAUSE OF DEATH In plain terms, that It mny be properly classitietl. The Spec.al ln*orm«t.on »or p,r
son* dying away from homo should be ftiven in every instance.

if

i

.1

ii

H

■^r'^A' 1

,r

1

I

-'^

WRITE PLAINLY WITH UNFADING INK

THIS IS A PERMANENT RECORD

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

Bcgisfered JS'^o,

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco

AA^

Certificate of H)catb

( 11. S. 5tnn^ar^ )

^

PLACE OF DEATH: — County of

^

n

City of - a^ >\^ O/v

No.

6

II

(

St.:

DIst.;bct. oL XA^jxr

.vt

and

If DEATH OCCURS AWAY TROM USUAL R E S I D E N C E G I V E FACTS CALLEID FOR UNi>ER "SPECIAL
IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET A

INFORMATIO
ND NUMBER.

~ )

FULL NAME

I"

> .-">

n

--lA

l» A 1 I < li

PERSONAL AND STATISTICAL PARTICULARS

u

IM'

l):i'

\ < ■. 1-;

5 ,

•^iNi.i.j' MARHn:i>

\\ lln i\\ I'll «)K 1»I\« >Ki"i:i)
'WiJti ill xKiai di — ii-nnt imi)

«^^^a

HiK I'm'!, \i"i-:

St.itt ■ i! < ■' 111 lit i \

s

Aj 'J , V

4^^

NAMl Ol
I ATll IR

®

(^

n \

\J TVCL^xCLC^

Cl.CC; V'^

HIKTIII'I. \ii-:

Of I \ III IR

I "^t;it«- ii! riiitiH! V

M\ii)i"N ^A^tK :)

Ml MciTllKR -^

HiR rmM.Aci',

ni MoTiniR
I Slatf 1 ir c'ounlJ %

n.rrrATiox

t.cx,^u.

^

MEDICAL CERTIFICATE OF DEATH

KATH of nilATH

Mmith)

) i\-

, I ifHRHHV CI'IRTIFV, That I atti-inlf.! <!< < < a^t <1 frnm

l<;n'\ to 1(^3 ■

that I last saw h • " ali\t' on l</<)

ami that <U'ath occurred, on the «lalc ^tatiil ahow, at

M. The CAi SI-; (ji- i»i;,\rii wi- as follow

,La^ tXV^i.

Aw"

,V^\

DlRArioN )'cius \ Months

CONTRIIUTORV

Pav

Iloii

t H

nrRATioN*

( SIG

)\'ars

.1fi>f///iS

Ihiv

NED ) A. dJ. ^ *XC-

ca o . .

Hours
M.D.

aaa4X4\- ' >^o^

K \

^LUCi

Kf^idrd in S,n; /'i,iih

) .ui

M, 'II til

I'

\\\V. AHOVK ST\TI- It IM-R^nXAl, I'AR I' Ii r I.A K> AKi: IR!}.; Tn 1111:

i!i;sT (>!•• M^ KNi >\\ i,i:i)''.J'; AM) !u:u.n;i'

Oil fnitnant

\,l.lri-ss lO I 'J

?^ i ' i

*.

I()0

X.l.lre^s) 1 0 3 UO^C

%

SPECIAL Information only 'w Hospitals, Insfltufions, Transifnts,
or Recent Residents, and persons d>inq dw-av from home.

Former or
I'sual Residence

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

How lonq at
Place of Death ?

Oavs

n.Ari'.or BrKiAi.uk rhmoxai.

n \ ri: "' Hi Ki \i .1 RHM<i\Ai,

I no

(Adairss 15XS. 0 A^O vL.i^'Lt ^v

... - It I- ,1 AHF shniilti be statecl EX4CTLY. PHYSICIANS should

IN. B. Bvery item oV Information should h.^ carctully supplied. A(.R shoul.i l»e stoten n ,. ^' ,„tfop,„H.-.o„" for dt-

»tote CAUSE OF DEATH hi plain terms, thot It mny be properly class.t.cd. The Spe..n1 lnU>rmHt.o„ *or p„r
«on« dyin^ away from home should be j5;ivcn In every instance.

t »1

!•)

1.1

* *J

1^'^

I

I

WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

!)((

^ X\

VJO\

Bc^isiered JVo,

i'y m -^/-»

Oy^^O-^A^^ cXX'

'\Mj

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco

Certificate ot S)eatb

( XX. S. Stan^ar^ i

PLACE OF DEATH: — County of^^O. >

-<-\

'No. 11^ ''-^

St.;

(IF DE
IF

ATH OCCURS AWJAV PROM USUAL R E S I D E N C E G I V E FACTS CALLED FOR UNDER "SPECIAL INFORWA
DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER

City ofUCLT^j 0 X<Xo\c^-<

TION- \ (1

Dist.; bet. X' \ a > v rA.o. , . and i3 \c^ ^

I

)

FULL NAME

H

v.. ',

(XlVvO

PERSONAL AND STATISTICAL PARTICULARS

I»A I1-: Of lUKlll

AC. H

i !,

I Writt III -1 Hi. I

luk rui'i. \»M".

St.ltr I ir I'.MItitt \

NXMi: 111 /'^

i

lUK rui'l. Ai H
<)l I \ in IK
IStatf i>r *.'i)iiiit! \

M M 1 > 1-; N N A M } ; (^
«>1 MOTHKK l^

!l.l ! 1- ill

V K

M

\J\jrKkA^k^^-\.<x.

MEDICAL CERTIFICATE OF DEATH
DATE OK DKATH

(M.imh' il)ay»

I HI{R!{i;V CI^RTIFV. That I attt>ii.U-.l >Umh a-,,.! fmni

V. . ..... i(p . ti) V, CL' ^\ i<»oH

that I last saw h •■ ' alivt- nn ^ wl.

aiiil that iKath ocrurrcil, nn iht.- ilali- stat<.il ahnvt i'
,M. Thi- CArSI-; <>I 1»! Al'II wi- .(-. follows

A

i<('

>vl^<X ^xtv^A^

v^

1)1 R.xriON ^Ytais

CoNi Rim'lOKV

Months

Pav

Ilotlls

Df RATION

i Signed ^

Yiars

Mouth

lUK iiiiT.Ari:
«>i Mirnn'.K

(St:it»' or (.'ouilttv

(A

Ok-

nCClTATloN

f\/'^itfr{ III ^t! II I'liiii: '>»•''

1/ -,''//

I his

Tin-: AHovK sr \ n-i) iM-K^ns \i. i'\k rini. \rs aki-: iKri", r<" Tin-:

nnsT o].- NIV KNOW I.l IH.l', \M> lUI.Iljl

(1

(Address

O^^-^-xA > V

iqo

"1 (Addrfss

/hivs Hour's

M.D.

Special information "nl!" *of Hospltdls, institutions, Transients,
or Recent Residents, and persons dvinq A'f^i^s from home.

former or
Usual Residence

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

How lonq at
Place of Death ?

Oav"

I'l \fi-" m in Ki.M. «>K Ki;M<t\ u,
O'L0wL^O-/^rA/

1>A i

Mii\ \1.
I Qc^

Ad.h CSS b X^ Cr. v<hOwctcA.-ixu ...'

... .! 11 I".. I AHF sHniild he stated EXACTLY. PHYS1CIAMS should

!N. B. Every item of informHtion should be cnreVuIly supplied. AGE should '^^^.^-Y'"" ^ ^f^ |„t'„rmatmn" for D,r-

«tate CAUSE OF DEATH In plain terms, that Jt may he properly v;la«8.t.ed. The Spc.al intormat.on *or p,r
«on« dying away from home should be feiven in every instance.

Vo

i \

* Ij

[H

I

H

^

WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD

HoMVl ..f llrnllh r

ti-i-^3e'.<^~j% i;<vl' ('

***Nj4r-*

REFER TO BACK OP CERTIFICATE FOR INSTRUCTIONS

Dfffc F/Z^'r/, l^/^t{r

Brgi\sfrrp<] JVo.

*"l f -^^-^H

,(^\.KAJ>

J UV„«i

Deputy Health Officer

DEPARTMENT OF PUBLIC HEALTH-City and County of San Francisco

Certificate o£ Scatb

I "CI. S. StnnC»arl> i
PLACE OF DEATH: — County of " <XT\j ^ XCL'Y\.C\ACcCitv of ' CL I V " \ <X .V. s

No.H

t WW-
( " 7

^uM-vA. >, St.; Dist.;bet. and

rnoM^^USUAL R ES I DENCE Givt facts called for under special information'

DEATH OCCURRED IN A HIOSPITAL OR INSTITUTION GIVE ITS NAME 11

ATM OCliuRS AWVAY

FOR UNDER "SPECIAL INFORMATION" "^
INSTEAD OF STREET AND NUMBER. /

FULL NAME

I

--1 \

PERSONAL AND STATISTICAL PARTICULARS

'\

;i

It A I 1. < <l I'.IK 1 II

M .1

I).

\ I . »•:

"^INt .I.l- M \K l< I in

U llx >\\ ! 1) < »K I I X t M> ) ! »

iiiKruri.x*'!" \)

(Stntt (it I . Ill nil \ _A

r^

XjY\ ^

Oo.

NAM I <»|
I \T!I IK

HI KT IIP I, \<'K
Ol* lAlin-'K

i St^ltr 1 i! C- ,\\ lit ! \

M \iiii:n n \\t 1
<)j .MMiin.K

luurm'i.Ai i:
<>i \!<»rm;H

f Slutc ur fiitJiiti \

orrri- XlioN-

AV. /,/r,

1 /

-A

aJ n

MEDICAL CERTIFICATE OF DEATH

i» \ II-: I ii Di: ATii

1 hi-;ri;i;\- ci:rtif\\ That i ntu-iuU-.i .h. , ,
i(p tt>

thai I la--t ^a\v h alivi- oil

a?l<l that ih ath « trcii rrtal. nn tin- datr -talt.<l aliovi', at
M. 'Ilu CAl SI- i)V hi ATI! was a- tolloss-

jCL,y\j

1 II I,;;,' / / I', I

riii; MS(>\i' sr \ ri-n i'kk-.<>\ \i, r\R rin i, xks a hi; i'k! }•; ii > Tin-:

inCsT ni M\ K N< iW 1,1 IX , I-. WD iU l,li;i-

!nfi>'maij!

nrkAl'loN )V(7;v

Mmiiiis /hns

Ihuits

1

DERATION Vn^

V '>ilhs /hivs

Hours

f Signed ) ^A.liA-^cL

% ^ - _

1

M.D.

I.,', ( Aili

r«'sv 1 - '

SPECIAL INFORMATION "nlv liir Hospitals, Institutions,
or Recent Residents, and persons dving dwdv tnni liome.

Transients,

former or
lisual ResMenrp

ItoM lonq at
PIdf p ol Death ?

Days

When Has disease rontracterf,

If not at place of dcatli ?

ri.ACI- «)I in HIAI, itK RJ^Nfo

\-.u.

1 1 \ i 1 . ■ 1 ; 1 H

IMt '\ AI.

i

INI) 1-: K 1' A K i: K ' ' ^La. UL<.

IQO

A.M!.—

w 1 .,

^ ... ... I- I \vv shnulii he Rtntetl RX4CTLY. PHYSICIANS hHouIcI

B. hvery item oV hit'orm«tion «hr>ulcl be cnre»uM> suppi.ecl. A(,f. shm.Hl "e.^*"*^" J' '^^^ » |„»'....„..,„,n" tor D«r-

• tatc CAUSE or DEATH In plnln tcrm«. thpt It may be prcperly class.t.ed. The Sp...«l Inturnu.l.un tor p-r
lions dying away from home should be given in every instance.

>

>

z

/ <)l >

N . a! •

:

vx\ f'riitn

I < (O ' .

iip

^'1

* I

<1'

'.;i

v«

,\1:s^i^w

■ 1

,;'

ri

■ f H.

WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

•■^^i^^B&PCf

n^ffr /-V/^'^/.t ctc-l^h. 1\

1

VV^^wV'li

\^^U

Der

jfTicer

Registered A^o.

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco

Certificate of 2)eatb

( XX. S. StanDarD j

No.

PLACE OF DEATH; — County of ^ cx-.v .

St.;

City of L cc^v V Vcv ,

Dist.; bet.

,=? 1 1.

and W

(ir Dt*TM occurs AW«¥ rnoM USUAL RESI DENCE give facts called for under "special information' \
IF death occurred in a hospital or institution give its name instead of street and number. /

FULL NAME

a

il

I ) X ,^ ^

^v

PERSONAL AND STATISTICAL PARTICULARS

J

H^

v_

\l 1

|j.

\< , 1

) ,,/»

S1N<,!.1-: MAKHn-.l»

WIlH .U KII t>R Ii'\-. iRiJ I»

Wtitt 111 kiiK'irii (It ^ii" iMli- Mi '

A

n

L-

stall 1 1! I '■ 111 II t : \

N\M1' III

1 x'i'ii j:k

HIRTIIIM.Avl.:

<>i i.xrm.K

■it iti (It i'ljiitit I \

M \ !i>i:n n ami-

t»l MnTin-.K

HiK riiiM.Ari.;
<>i' MornjiK

■^t.itr (It I'liimt! \

oirri'Aiiox

f\'f/il/if III S,;n I

^.

MEDICAL CERTIFICATE OF DEATH

DA TK <)I PKA rn

'Month

I>av

I Year)

! Ili'KHnV CKRTIFV, That I atlouiU-.l dii i us.-.l fr.mi

190

to V

that I last saw h

alive oil

ct

lt)0

ami that death occurred, uii the date stati-d above, at II 01^
^' M. The CAISH OF I ) I! ATI! was as follows:

'■ \ vc>

or RAT ION Years

CONTRIIU'TORV

Months

Ihiv

//oil) <

DIRATION

SIGNED ) J

)'('ins

Vout/is

/\n

»0 , i^.

U-.

^

-i)

(X^YV

^ I

D

I /

Tin-: AHOVK STA'I'l'n PI* R SOX \I, I' \KT!iMI,\KS ARl-: I'Rri-: T« > THH

lu-'.sT «)i-' MS' KN( t\\ i,i;i). . I wn hi-:i.ii:i

(Infonnaiit

OlWfc

.'V-^

m

\.i.ir,.s SlH u criA<rv>x.

-^^^^

\ i

^ . igo'l fAdilress) l o U^v

//ours

M.D.

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

Former or
Usual Residence

When Has disease rontrarted,
If not at place of death ?

HoH lonq at
Plar f of Death ?

Dav

ri,A<'i:'»i luRiAi, OR ki-:mo\ai,

0'

fUt ^-L.

DAri;..:* IUkixI .11 Rl.Mo\M,

Ifiol

t N I ) I ; u i A K I-; R

In ':i

A.Mi.-ss Whl ■][ iXv^L-O^

r>x

Bvery item of infor.n.tion hHouUI be ...refully Huppliecl. AGE Hhoulcl be stutecl EXACTLY PHYSICIANS should
rtat7cAimE OF DKATH in ph.in term,, that it m».v be properly classified. The "Special l,u„rm„t.o„" *or pT-

N. B. B-

state _- -

«nn» dyinft away IrVom home should be aiven in every instance.

iri

'■ !

• I
I

J.I

r:^i

WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD

If
i If

I

:it

! I th I- N>> 1^ '^''^y^'"''--'- -'^ '' ^''

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

Dff

h' Filed , L'cLMj

>^o\, X\

lOO'i

s^ «

Eegi^iei^ed jYo,

^Q

tV^^<i

ENTO

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco

Certificate of IDeatb

TX. 5. Stan^arc*

PLACE OF DEATH: — County ofCJCX-^x ^ Xa ixc .
Ne.^ ' J ^ 0%V->^cL^L . • .'..^K^ .:. ■ St.; - — Dist.;bet.

A. „ ^

City of^^^''^^ 0.n.<X'>xc^.

(IF Dt«TH OCCUBS AWAV FROM U S^ U A L
IF DEATH OCCURRtO IN A HOSPITAL

WAV FROM U^UAL RESIDENCE Givr facts called for under spec

and

OR INSTITUTION GIVE ITS NAME INSTEAD OF STREE

lAL INFORMATION" \
T AND NUMBER. J

FULL NAME ^ ' 0

s... U

PERSONAL AND STATISTICAL PARTICULARS

ft

!i \ n t »r i'.iK ill

^ l\i .1,!" \l \K Iv II !i

\\ ! 1 t' i\\ I !> I iK 1 I • ^ I ti- It)

HiH rin'i. \ii-

\ \ Ml 111
I \ I II 1 K

lUK III I'l, \«F.

oi I A I'm: K

I Stat ( 1 ii (.'(lunt I %

MAIIM'.N NAM I
nl MOTIIHK

HIR III I'l.At"!-:
Ol- Moiiii-K

(State o! t'luiiu 1 \

ni » I !• \ ll»»N

A'' >/i//'i

MEDICAL CERTIFICATE OF DEATH

DA IK <u Di; \Tn /('\

^/cfc

TOO

(Vrai >

I 0

J ^

!^t<>ntb■) iDavi

I HI:K!;P.V l I, RTII-^V, Thai I attt-n.lf.l •kiia'^ca from

that I hi'-t -^ INS h ■■■ alive- on l«p '•

aiitl that iliath i irrnrrcd, on the daU- slaud ahisvo, at ^

M. 'llu- CAT SI-: Ol'" IH-:.\'i'lI was as follows

vl <x V cL^^Xz-c.

rVCv^ iXCA-i

1)1 l< A'lloN

)'car

Mini i 'is

^

y

c < » N T k II s r r < > k n* w>x<y^>vaw.

/A/l'.s- T Hour

%<>Xj u.^'|v...

Mouths

Hav

DlkATinN Years

(SIGNED) ^ K. d \nU>' s '^'..

[A ^ ^

\1'/Ct IH i.,nH fAddn.s)3.S0D JxAlmx£A

1 1 tin is

M.D.

Special information nnl^ f'"^ llospildls, institutions, Fransienls,
or Rccfnt Rfsitlents, and persons dyinq hhhv from home.

/'.

in: \H(>\ I'* ST NT I- h I'KRs,. )\ \i, i'\K rue I. XK'^ \Ki; THri-:
lu^Toi. 2''v KN(t\vi.i:i»<.i-: AM) in i,n:i

Tn \\\V.

Cm

\.l.lr< S-,

r^\^t

Former or
Usual Residence

When was disease (ontraf ted,
If not at plare of death ?

HoM long at
Place of Death ?

Days

I'J \l'H «)I' HI KIAI, OR RI:M«»\ Al

I M . 1 : r t a Is 1-: R AjlLaJCU ^^

XIKoS in uiAi. or ki:m(»vai.
^/Ct Ski TQOH

... 1-1 KCr uhoulfl he stated F.XACTLY. PHYSICIANS should

N. B.— Bvery Item of Information ehouhl b. cn.cluHy suppi.e, ^J^^^^l^^^f^^^^^^^^ ..s,,,-.-..., ,„form„t1.,„" for p..-

•tote CAUSE OP DFATH in phiin terms, thiit it mn> he propLrl> c,lHS8Hieu. in*. i

iif^ti* dying BW«y from homu should be ^iven in every Instance.

«l^

1

i

m

•"^Ww*

WRITE PLAINLY WITH UNFADING INK

THIS IS A PERMANENT RECORD

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

Dfffr riJcfL Vl.'cl<rVO

vj X\

I9n\

Re^i.sfcfpd JVo,

so

4'

C<oO

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco

Gcvtificatc of IDcatb

PLACE OF DEATH: — County of

CVV\

'\

City of ^J<X>^ 0,^cx , ^4 Q ^

\

iNo.

I luxA,cgu.U.Li

\

1 1

St.;

Dist.; bet.

and

/ IF DEATH OciuRE. AVWA, .ROM USUAL R E S I D E N C E G I W E FACTS CALLED FOR UNDER "SPECIAL INFORMATION' '\
V ir DEATH JcCURRCD IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. /

FULL NAME

t.v^^

)

V > V i

PERSONAL AND STATISTICAL PARTICULARS

^

.< 'k

^.

xX.^.^^

1' \ rr < •! luK rii

M-.nth

s<.i-

•-INi .1,1' M \K K UH
U I 1 »i i\\ I I > ( Ik

U iiti^ in - H ii' .,. ■

N \ M 1 i»l
1 \ I II IK

lUH rm-i, \< J'.

< U' 1 \ III J K

' -^t if ' I il • . Sillt 1

M MDl N N \M)

<>l' M< I III IK

lUKI'mM.Ai'l",
••I Mo'l-HHK

I '-t.ii I < ii I'liii lit I

1 1

-\

1 ' LcvVv^cd.

n

« >i < 11' \ rn)N

LxL^VAjto^l- ■

Till." \HOVI- STATl-l) l'KKS«»N U, r\K rin l,\K^ AKi TKl 1. T' » I'll',

in->r»>i M\ K N« lu i,i: !)< . 1', \m» inijii

f Infiirtn.-int

<X >^A- t^^v^

N.Mr.... 3s IH LcLa<

MEDICAL CERTIFICATE OF DEATH

1>AT1-; ol Dl-Ai 11 \

v

4

M.uilhl

Dav^ I Wat

I H1:R1;i;V ri'.RTII'V. 'riiat^I att«.'n<k-<l <lec-cast.Ml frniii

U'l

i«)0

that I la-l saw h .... alive on ^ CO i u T()0

and Hiat .liath uci'iirrc<l, <>ii tlu- ilats.- statnl al)<»vc, at
M. Tlu CM S1-; Ol' Dl'.XriI u.!- as fdlli.us:

mRAIMiN Years

roNTRIIUTOkV

Mouths It Dav.s

I lout

DT RAT ION
(SIGNED )

)V./r.?

Mouths

fhiv

J\jllU

M.D.

Ill

(

Aililre^s) I2»0b J ^L4,<n>v 0 ,1

SPECIAL INFORMATION on') f"!" Hospitals, Insfitutions, Transients,
or Recent Residents, and persons dvinj anav from home.

When was disease contrarted,

If not at place of death ?

Oavs

J'l.Ari.-, <»l ni KI.\I, OK Kl'.M'iVAl

^'

i>\ri;

il: ,n u

k i'M< >\ \i,

IQO

rNDKKTAKKK Y(X^^^-*U. H [^ \}a.>v^X. "

' , ,. , .pc «u„,,i,i he -mteil r.XACTl.Y, IMIYSICIANS should

N. H._Rver^ Item ni inf...„..t Ion Hh.n.hl b. c.re^ull. Ha.ppl.ed ';^^'^^^^^%^ .^,e.,„l Intonn.non" *o. p..-
•taU- CAimi: Ol Dl ATM ui phnn terms, thni it may he propcrl> wlas^meu.

Ron* dyinil away innn homu h

IiouIjI be fe'iNen In every in-stancc.

t

«r

t

m

\

i»i

: k

i

w

I

I

i

WRITE PLAINLY WITH UNFADING INK

Hnar.l -'f H- ■Ml

5, V,j ,:, ■*.S^^^HS.l'Cn

I)

dh' Filrd ,kj<::XjAj

K.K.' ^l

lOO'i

THIS IS A PERMANENT RECORD

REFER TQ BACK OF CERTIFICATE FOR INSTRUCTIONS

Bes^ustcred JS^'o.

cL^-CCL

Deputy Health Officer

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco

Certificate of S>eatb

( X\. 5. StanC»arD

No

PLACE OF DE ATH : — County

ofCj<X^rv J Axx-rxeui^ -City of ^ <^^yy^ ^ ^'^^

XCCO cc

.. Let

.i

St.;

Dist • bet. ^^^

FULL NAME >.--... t'' J OK/^vKo. v , v-

PERSONAL AND STATISTICAL PARTICULARS

^

sj:\

ni

i«»I,< (K \

I 0 ^ i

1) \ ri: » M i;iK 111

\i .»'.

UwLM

I Motuh

si\i , IJ' M \Rk !1 1»

Wllx >U 1 I> OK I>!\t>K*. Ml)

(Writ, ill MK-ial lU "^is/nsition)

l):iv

.1/,, »////.

/hn-

MEDICAL CERTIFICATE OF DEATH

DATH t>l" Di: ATH

I'ct

1 1

(Day)

(Year)

^

ij.udc

lUK rniM, XT)-:

Ntifi ' 1! I '■ 111 nt ! \

III

n

NAMl' <U

FA Til i;k

Qir^

0

IvuXO^rru J .CL^iv' v<X

niK I'm-!, \rK

01 1 \ IHI-.K

iSt;it« . '! I I unit 1 V

M \ii»»;n n \mi 1 0

Ol- Mollll K >

A

\

a K

) ^ V

L^i'vr>\x

^ a

lUK ini'i.M 1-;
n|. MtHiiiH

(St»t« I'l Sunlit I %

« U'C I

X,iw.

M.iill,

lht\

TIIH \HoVKSTXTKn''KKsnVAI.1-AKTirri.VHS \K1, Tin K Tc TIN-
UHsTMh MV KN(.WI.i:i>.^K AM) l-J I.D 1

[ 1 11 f. 11 mafit

( Month >
I ni;Ul':HV CI^RTII-V, That I attciKkd (kccasctl from

;\L>A>. XT- igo'1 t.) ^ ct a Tcpn

tliat I last saw h .. alive «»n ^ cL 1 ■ up ^

ami that dcith «.ccurre»l, 011 the <lat.- stated above, at ^) ' '
OL M. Tl^e CAl'Sh; Ol' Dl-ATII was as follows:

DIRATION )V<?;v

CONTKIIU'TOKV

Mofit/is

Days

Ho tits

.V()Hi/tS

fhiv

DTK ATH )N

(SIGNED) UJ Xp. L-^-V^Lo- )%^
lUcfc IH ic)oH (A.hlress) UJl -y^X^L W wcc^ ■

f fours

M.D.

SPECIAL INFORMATION only 'o"* Hospitals, Institutions, Transients,
or Recent Residents, and pejcsons dyinq anav from home.

Usual Residence

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

^ Place of Death ? ^

fttys

l'I,\CK «»1 HIKIAI, OR Rl MOVAI,

CfUt

V.'l'.

liATi; ot III KIAI, c.r Rl'.MoVAl,

€,ct Q.-^ T90H

( Xil.lii-^-

0O'A^.4\_.<'

IN

UVOOUDL Wc|%'

r\<l<li. s'-

Ttate CAUSE OF DEATH In ph.ln ter.n.. that it m„y he properly .la^shleU. The bpeclal lnW.n»t,o„ for pT-
«ofi« dying oway from home hHouUI be given in every Instance.

r

r-'

i

^

I
I

WRITE PLAINLY WITH UNFADING INK

1 )((!(' Filed J

n
J

\

1'

lOO'i

THIS IS A PERMANENT RECORD

REFER TO BACK OF CERTirrCATE FOR INSTRUCTIONS

2482

Bc(!istere(l J\'*o,

<

Deputy Health Officer

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco

PLACE OF DEATH: — County of

(Tettificate of H)catb

( X\. S. Stan^arD )

^ ^ + y I r

ity of "J K.^^O^'\:rO^^^ kXLX

a

a.

City

No,

St.;

Dist.; bet.

and

( ■' r."»;"..°"occ"u%*-r;,':r„„",^r.i r^^^-.^j^^";'-;.'"! 5,v^" r..".o

UNDER "SPtCIAL INFORMATION" \

OF STREET AND NUMBER.

FULL NAME

f

m

\oj\jcx. o^vxX

jU^yu^'>iA^">>'v.<n w

PERSONAL AND STATISTICAL PARTICULARS

I» \\V. « >I I'.IK I'll

C()1,<»K \

I t

/^1l

A 1.1.

Ml. ml!

J w. )'lil>

->I\< ,1 1' M,\KKIi:i>
(Write- ill -.■H-ial .h-^s/nit !■ .ii)

niKPuri. \ri

< Statf 11! I I in III! \ '

J^jy^

I):IV

M,nifh>

c^

I Vi-ari

n.n.

NAM I. <»!
I- ATI! l.K

BiRTm-i.Mi.:
oi- 1 Arm-K

I Slati <i! I'dlUlt! V

maii'i:n* namk /-^
i;k / ,)

H

<Ojyy\XM J

J aXia.^^

;x^

(»1 MoTIll';

lUK rnri.xcK

ni MoTHI'K

(Stati Hi V I ■lint I \

<)t(ri'\ riON H

\6 Kjcdxixi) d JuAaxLow-^-v

C>KJU

I

i

MEDICAL CERTIFICATE OF DEATH

dath <>i- i>i;ath n,

/go

(Month) 'I>«>'^ •''''■'''

1 lil-RIUJV CICRTH'V, That I atteiKkMl ilcif asctl from

-— — — -190 to •. igo ""~

that I last saw li alive oti '<P ^

an«l that «kath occurred, on the date stated above, at
The CArSfC t>l' DlvATII was as follows:

•4

Dl'RATION y'tuirs

CONTUIP.rToRV

Von //is

Pars

Ilotit s

I )r RAT ION

)>7r?

Months

/hlYS

(SIGNED) "3. vfc. JbO-

v. , >

//ours
M.D.

iqo

(Address) W<0^HA.CO^d- S, a.i

SPECIAL Information flnly lor Hospitals, Institutions, Transients,
or Recent Residents, and persons dying av^ay from home.

)'ii! I

yr.nith

n<i\

THH xnnvKsTViKnPHKsoNAi PAKTirri.
(I„f..n„,u,t \. ^- 3a.W</>^

\Rs AKI-; TKrK TO Tni-;

X-^/VVV/VVv-OO v^^

^ -x ^ ^ J

Former or
Usual Residence

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

HoH lonq at
Place of Death?

Days

I'l.ACl': <>!• Bl HIAI. <)K KF,M<»VAI,

DATl! tif lii KIAI. or K1%M<>VAI,

Oct ax TOOH

TQO

INl.KRTAKHK WoJjb-rCtt nTTUXA^w^^XU

(AdclresH 15 XH

Wu

'C-^¥LS-fr%%^

N. B.

state CAUSE OP DKATH \n plnin terms, that it may be pfoperly wiassmeu. c m

fiTns dyinft away ?rom home should be given in every instance.

'ft

1;

f

iM

ri'

'V

4

WRITE PLAINLY WITH UNFADING INK

^

Dfi/c ri/p(/X'AA>xK) x\

100 "i

THIS IS A PERMANENT RECORD

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

No.

DEPARTMENT b? PUBLIC HEALTH^City and County of San Francisco

Ccvtiticate of Beatb

( tl. S. StanDar? )
PLACE OF DEATH:-County of^CU^ l^aTvCw. .City of C^ . .V^o-c.c.ec

j«?!Dqi J no ,__

' r,".;:r°"occu%"r;,;"r„oTp"*' "fMs'Tu""; cv.^s name ,nsT..o or st„..t ... Nu«=.-. ;

(

FULL NAME

si:\

PERSONAL AND STATISTICAL PARTICULARS

nrs ft coi.«»K \ A

1. \ ! i; It! r.'iR iH D

r'\

(Day)

\».i-;

V.,,. Cclrt I M<nnh~

I 1 ai

/',.'

< St.itt III t,'inint I N

NAMl' «>l

I AT in: R

RIKTiiri, \ri-:
()! 1 \ I II »:k

i^iiatt Ml riiuntiy

MAIDHN NAMl
(tl- MoTin'.R

HIRTin'I.ACl':
«U' Mn'rilKK

i Slatr or I'muiti \

< uiTl'A ri«>x>

/s'riJrJ til S,i» I 1,111. '-'•-»

MEDICAL CERTIFICATE OF DEATH

DATH t>l-' Dl'lATH

1^1 igo'i

(Day) (Year)

ilct

(Month)
I IIICUIU'.V Cl'.RTII'V. That I atti-mU-.l (Uccascd from

lL),cfc ^^ 190' \ t.> : ' ^^p

that I last saw h-^' alive on U^^ ^^ I9O"

an.l that ck-ath orcurre.l, <»ti the .latr -tatod above, at
* M. The CAISI': Ol' DI^ATII was as follows;

I )r RAT ION Yiiirs Months

Day

J/om^

^C:

DT RATION Vi'drs .Vof///is^ /hivs //orns

NED ) Jh\. o ^ mIOxdiaaI^li m.d.

(SIG

I()0

(.'

Special information on'y '<»r Hospitals, Institutions, Transients,
or Recent Residents, and persons dyinq dway from home.

) ,,/;

M»iilli

/',/!>

THK vHnVKSTVlKI>l"KRSnNAI,rM<TUT!.AK^AHK TRIH To THH
' HHSToi' MV KNnWI.HlH^K AM. nKMHF

ni;si ni Ml K.N'iNv 1.1^" ■■•
„„r ^ 1 M^\.X^A.^VXXU-

( \<Mi< ss <7^*^ 0 V

A^-x^Vi ji

Former or
Usual Residence

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

Mow lonq at
Place of Death?

Days

I>I \C'K (»I- IHRIAI, OR K1;M<>\ AI

r.MM.R lAKHR

nKTi: iif ijiKi.M 01 ki;m<>v\i.

\(l,li,^H obTX^ I L A^K.

"""""""^ . .. , Trv «H»..ia he fttated KXACTLY. PHYSICIANS should

son. dyln4 away from home should he j^ivcn In every instance.

n

\ 4,1

1

r>,:

^ I

n

(♦I

n

■'1

I

WRITE PLAINLY WITH UNFADING INK

!!,,ai<l ..f II^mUJi 1- Nc I" t-^^^it) V.S^VCn

I)i

(ffc /v7^'^/, UctcrU4A- X\

lOO'i

THIS IS A PERMANENT RECORD

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

.<S\.K.K '

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco

Certificate of ©eatb

PLACE OF DEATH:-County oi^^- : ^l/Va^acv^c. City ofOc^ 0 A-O-o-c...

^No.

v., C '-

, + III

^I^^lM J: '.-^ ..St.;

Dist.; bet.

and

)

V IF DEATH OCCUI

:.^r: :::ios%'f... o^ ..s..;u%To. o.vr.Ts name ..stc.o o. st«,

FULL NAME

-L

PERSONAL AND STATISTICAL PARTICULARS

DAll-; ill lUKl'll

COI.OK

ac;h

s^V

I Driv

M,,,i!li

■\r.'t 1 )

I hi

sl\. ,1 1-: MARK I1-. I)

iWiit! Ill -•Hial i|tsi(.Mi,it iim)

MEDICAL CERTIFICATE OF DEATH

DAIK «>I- Dl'.ATH

(Mi>iitli>

(Dav)

igo

(Year*

I Ill-klU'.V Cl-.kTIl-V, That I atteii.k-d (Iccrasfd from

■ ,^H to 0-t 1% icp^

Hint 1 last saw li - alive oil ^' ^ - ' ^ ^^P '

ail. I that .k-alh (KTurred, on the date state<l ahovc. at ■
'. M. The CAl'Slv Ol- Dl-ATH was as follows :

iJ AxLt ^^^>

V\i

HiK rui'!, A'M-:

St:iti "t »'' Hint 1 ^

NX Ml" Ml
1- \ I" H V. R

lUU 111 JM.ArK
(>l I A nil' K

I State (ii I'dillltl N

maiih:n nam I

ol- MOlin'.K

lUK'rniM.Ati-:
<)i- m<»tiii':k

(Slatf or Couiili ^

A

KJ

M

oaA

i^

4 ^ i

CO 'w'VCw

XX^w^^

X'"\>\aJLcxA/

'u

DC RAT ION Years

CONTRIIU'TORV

Months

Davs

Hours

nr RATION

,}fonths

(SIGNED

)'rars

/hj VS

Hours

M.D.

oCCri'ATloN

h'r^iiirJ III S,ni /ntini>t'-i ) '<'

'- .M,-,,th- " /''"

T.,KA,U,VKSTXT,U>iM^Ks.>NU J-AKTirt.XK. M< K T K r K in T,,..:
JJKST <'»;Ji'V KNOWI.I-JX.K AM) in-,l,n.l

(I„f..nnant J AX^.^^^^ ^- *^^

f \ l.lr> —^

LAJL'VyxxiJ(v<:

i<>o

f

A<l«lress) KjJ^ >

SPECIAL INFORMATION only ^"'' Hospildls, Institulions, Franslfnts,
or Rrtcnt Residents, and persons dying away from home.

Former or
Usual Residence

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

How lonq at
Place of Death ?

Davs

ri.ACH Ol miijAi. <»H Ri-:MiiVAi,

C^'

l)\ll ,' li! uiAi. Ill KMMOVAI,

I go"

I NDHKTAKHR

(A.l,ln.s. 3b1X^ l^ V,. ^^^

■— ^ .. , 4,1 .\„.,.l.l he Htetetl I.XAGTLY. PHYSICIANS should
N. B.— F.ver, ..en. of ,„f.,r,n„.ion .h.ul.l ..-• crefuM, -.pn .e. ^ ;;_.•;;■• '^'„^°^^ ^h. "Speci.. lnWn,..ion" .or p.r-
■tate CAUSE OF DHATH in plain terms, that it mii> i»e prupwr y
"n* Hyinft away from home «hoi.ld be feUen In every mHtance.

1'.

u

ill

'■♦

I

Ml

I

I

WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD

REfeR TO BACK Of CERTIFICATE FOR INSTRUCTIONa

;i,:ilil 111 ll'.iiin I ->i. a^-^^-^m^^

lie^istercd J^'o,

•I •- f\ 9

j-u Deputy Health Officer

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco

Ccvtificate of Bcatb

1 U. 5. StanDarD )

4

^

PLACE OF DEATH:-County of^^^ OA.a^- ^. . ^. City of O^^ J.XO, ,^<...^c

No.ot ma^u:^ A:^^.;\do

U .

St; -

Dist.; bet.

and

)

U^njJ/i A, ^>^.l WWW.^^ ; orS^ENCE GIVE ^CT^CArjcD rOR UNDER SPtCAL INrORMATION ' ^

/ ,r OzAh occurs AWY -^"O*" ^^SUAL «f SJDENCE^GJV^E ^FAC^^ ^^^^ .^STEAD of street and NUMBER. J

\ IF DfATH OCCURRED IN A HOSPITAL

OR INSTITUTION GIVE ITS NAME II

\U

FULL NAME

y

Vt iX a.

HEX

PERSONAL AND STATISTICAL PARTICULARS

« ( »1 ( )K \

a

lL^

w -^

DAl'l-. « 'I I'.IK 1 II

At. I-:

,%%\

Mmith

"kl

1 l);iv

M.-mHi

f%'t ai

])a

sIN< .l.H MAKk 11 n

\\II»< >\\ 1- I) nK ni\< »KtKI>

<\\iit« ill -'nial (1« -»vintt!'>n)

lUK nil' I. \'"»-:

<-,tat > n: • • iti n! ! \

\ \M 1 ( »r

!• A III IK

lUR I'll IM, Ail-:

oi I \ 1 11 1; K

ist.itr <ii Cnuiilry

NtVini'lN N\M1

oi Mnrnj;R

HiK'i'uri.ACi';

n|- MoTHl'.R
(Statr or Country'

MEDICAL CERTIFICATE OF DEATH

DATK OI- i>i;Arn

l^

Dav)

(Year)

I III-:UI;HV tlikTIl-V, Thai l atUndca (leci-aseil fn.ni
7^ put i' UK.. to ^^ i^. TonH

OX\vL 1. up- to "^'^^ ' ^- ^^

that I last.awh . • alive on C wU I l icp

and thai .Uath ocrurrtMl, m, the daU- staid ahovo, at 1

M. The CAl'Sh: OI- l)h:ATIl was as follows

dL^..

i Kn

XJlhJ{^f*VOL'L * *

nrk A'lioN
coNTiuinroRV

'm

^

Hours

-.j,„«

I ) r K A r M » N >3''' '"^ '^^' ' '' ^^' ''" -^^"^ '

(SIGNED) M\.1J- nIiUVv^
i^ rt, . ic,o i fA(hln>ss)qi>.^' ''--

V

I /ours
M.D.

\j xjYU<jOjy^

,d

tnJCl TATION

3<3LX,WX>

) - ,,

y/ iiffi'

THKAm)VKSTAlM.,.rKUSnNA. .AKrUMMXK.AHHTKrK To THH
HKST OI- >iy KNoWIJ-.lx.h .K>I> M-.M' t

foTtnaiit vJW,- ^-^

(In

A.M'

4XH

SI

OJ\K<A,inX'

SPECIAL INFORMATION only for Hospitdls, In^itufions, Transients,
or Recent Residents, and persons dying away from fiome.

Davs

Former or
Usual Residence

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

AA-O

How lonq at ^ ^

Place of Death? ^

ri \CE oi- m Kl.M, «»K RKMOVAI

nxjilof I'.i KiAf, or ki;N!<»\ \1,

. - t .

c^i

T9O

A-OsA^

N. B.-

■~— "■—"■■"■"— """""""'""'^ TT^ AfiE should be stated EX4CTLY. PHYSICIANS should

-Every Item of Information should be cnretully -PP'-f* p^.^-ircla^sified. The "Special Information" for pT-

•tate CAUSE OF DEATH In pIhih terms, that it m«j bu properly

sons dyfng away from home should be feWen in every instance.

. n

•^> ; ^.

: #u

WRITE PLAINLY WITH UNFADING INK-THIS IS A PERMANENT RECORD

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

Mil

Registered ^'o.

O 1 Qf^

Dale Filed, {).^XA>^Oso W lOOH

Ifrvo^liL^ Deputy HeGSth Officer

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco

Certificate of Beatb

( 11. 5. StanDar^ )

^

No

PLACE OF DEATH: — County of CX^% VC

City of O^CX/^^ J/u<x >A.au4

L. C L

'}c\\n'A^h:^\\d<^ ' St.t Dist.;bct.— and

LCVXU/^ a, IVv.. ^Vw oesTdeNCEg.ve rACTS called .or under •special .nformat.on • \

( '^ r/±T°H^OCC^%r;.;"rHO^s1.r*L 0^".;™0^ CVE .TS name .NSTEAO O. street A.D NUMBER. J

)

'A

FULL NAME

^l.X

PERSONAL AND STATISTICAL PARTICULARS

. r( >i,t)K ^ A

171.

1) ATK « 'I HI R I'll

L

I

I

.^^i

M-.tuh

At.K

'XO 5

(Dav

M.,)i!li

Vtai

r>a\

•^IM .! V M AK 1< 11 I>
WinnWl-.D <»K DIVoKiKI)
iWiitiin -iH-ial ilf>H''iat ii>ii )

0

i I

MEDICAL CERTIFICATE OF DEATH

DATK Ol- DKATH

(Montht (Day)

(Year)

I 11I':RI:BV CIvRTII-V, Thai I attciuUMl (IccLascMl from

\ . up ^

that I last saw h ■ alive on ^ ^^' ' ' I'P

aiul that death occurre.l, on the .late -tatc<l alx.ve. at H

I i

HiK rm-i. M'K

( Stat< ' >: ' '■ Hint ! ^

N \M1- I >l

I- A rin-.K

lUKTHIM, Ai'J-:

<>i- lAriii'K

isfatf «>t c'o'aiitry

\t \11>HN NAMl.
.11 MuTllKK

lUKIinM.Arl-;
Ol Mdl'IlHR
(State or Ccjtintryi

0 .c^xLa^ • '

t I ^^cx

or ;1

M The CMS!': Ol- hi- A Til was as follows

c'.k^■wk d.

DTRA ^I^N

Yea

Ur.l'TORV "^"H]

Mouths ^ Pavs

4 .

Hours

0

Llv^Ubt

OCCll'ATlON J I

L >A^OU

Kr.^iJe'd III S,i>i /'iiDh ,'>-*.»

5

M..„lh:

lh!\

BEST or %U' KNoWIjUx.h -V^J) l'»-.l.J''

(Informant

a. OL

>VA,' CC^

I ) r R A T I ( ) N > /'^'-^ Misfit /is /htvs

( SIGNED )..M\.dO. Mri<

.^AXA.^.<nx;

f A*Mress)C

I lours

M.D.

SPECIAL INFORMATION only for Hospitals, InMitutions, Transients,
or Recent Residents, and persons dying av*ay from liome.

Former or ^X T^^ ^^^ ««« '«"« «»

Usual Residence

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

Place of Oeatli ? ^'

Days

I'l ACK nl lUKIAU OK KHMOVAI,

pAi'i of iiiKtAi. ol ki';m(»vai.

t^^t

^ 1

TQO

J?

,„,,„.„ H XI (JO ahJvc4.irrv

; t

ua.h.ss MM ^ oJUU^v ^ oil Un.^

atate CAUSE OF DEATH in plain terms, that it maj be propeny w
»ons dyinft away from home should be ftiven in every instance.

i

I

WRITE PLAINLY WITH UNFADING INK —

H.cir.l ..f Hialth I' N

,,. ,^ '?.-?"ri?.X^l',.'vr I

■r:">^;

l)((fr Fih'(l,VfduXx.\j X\

100\

THIS IS A PERMANENT RECORD

REPER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

S486

Be^i'Stcrcd Xo.

Deputy H

»*^N

ORlcer

DEPARTMENT OF PUBLIC HEALTH^City and County of San Francisco

Certificate of Beatb

( 11. 5. StanDarD )

0 ' r?n

PLACE OF DEATH: — County of

r>

■ City of ^JXXA^' 0 K<X.^ \. f:

':^

%

No.

J
n , St.; Dist.; bet. ^3 CrViK- Ll'

Dt*TM OCCURS AWAY FROM USUAL RESIDE

IF DKHTH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE

and

CX.^

)

. = «« IIQIIAI RrSIDENCE GIVE FACTS CALLED FOR UNDER "SPECIAL INFORMATION • \

( '^ ^"-^."^°"_^.r^Ar.\!.''?^.„''.lV.1|- Tp^nStitution GIVE ITS NAME instead of street and number. ;

n

FULL NAME

1

cx^o^qt - ^ .CLV4

44-

-i:\ (

PERSONAL AND STATISTICAL PARTICULARS

J

Xt>xcv

DA ri: «>i- lUK in

Ll

)

Mnnth

(I)av)

\ 1 , 1-:

Ht

'l.

1/

H

'/i;iri

/hi l.N

i\\iit» ill --.H-i.n .1. -ivn.,! .Ill

I'.iK rin'i, \i'i"

St.ltl- I IT I 'i 1(1 lit I N

N \\1 !• OI

I A rmcR

lUK 111 ri. At}':

OI I AllIKk

(St.itf III i"(»uiitrv

MAIDl-N NAM1-;
OI- MoTin-.K

HIKTIIPI.ACK
«>1' MoflllvK
(Stall- or Cuuntiv

,-U

I V I ^"w -— ^- ■

OCCri'ATloN

2)

vhv

^\.^cx ^

(Vt-arl

MEDICAL CERTIFICATE OF DEATH

I) \ ri', < )i- ni'.A rn

^ .;

1 ni:Ri:i?V CI-RTIFV, That I attcii.k.l .Uriascl fmtii

^. cA. : up'' toi^-^ '^ 190H

that I last saw li >^w alive on ^ ^^- • • ^'P '

anil that (U-alh occurred, on the date stated above, at
. L ^r. The CVrSI-: OV UKATH was as foll«>\vs:

DTK. XT ION )'('(irs

CoNTKllirTORV

Months

/hivs

I/Oltl s

DIRATION

)'iiirs

Months

Pax

I . rs

» N 1

M.D.

(SIGNED) \}\ ^ U

Oa^ at) K>o-' (Address) ^^ibMlXrvxto^M^^ ■

SPECIAL INFORMATION only for Hospitals, Institutlorfs, Transients,
or Recent Residents, and persons dying away from l>ome.

1

Kfsiilfd III Sail /'i.nhnio Ob ^ '''■

M.mth-

I hi

■nU: X..nHSTATK..l-KKS<,NA. PART.rr..XK-^AKHTKrH To TUH
liKST OI- My_KN»)WI.l-,I)<.h AM) l.l-.I.H.f

(Info.mant J ryy^<X^<^ X^X<XtrVA^O '

fx,i,irt-<s ^'^i '^y"* -^M

Q

«

4.

Former or
Usual Residence

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

How lonq at
Place of Oeatli ?

Days

IM \CK OI- niKlAI. OR KHM«'X AI.
TNDl'RTAKl-R U /QJLX'^>^^Xx

15 XH

DNXJ'oS ISfRiAf, of KKMoVAI,

\_

■t

<X\a. > v^

(AtMifss

<r^

ysjk

atate CAUSE OF DEATH in plain terms, that it may be propeny
son, dying away from home should be feiven in every .nstance.

ill

U

■•'il

'if

•i .

:-Hl

r^f^.

•"^•^

I lb'

WRITE PLAINLY WITH UNFADING INK

^"-'■'•^

u

..VI' r

THIS IS A PERMANENT RECORD

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

IfJO'i

Be^isfcred jYo,

O %c^

DEPARTMEN?OF PUBLIC HEALTH

City and County of San Francisco

Gcvtificatc of IDeatb

Vi. S. 5tanDarC>

X

PLACE OF DEATH: — County of

No.

^- i k

'':(Xy\j oAXXv^c^^eo City of
St.; ^ Dist.; bet. V-O^UA ,

U N Dt f

rV^rVca. and

or. TH OCCURS AW.Y rROM USUAL R ES I DENCE G. vt facts ^*l^," ;°" ^^^^J

ir DEATH OCCURRED .N A HOSP.TAL OR INSTITUTION GIVE ITS^NAME INSTEAD kXF

FULL NAME Xtrv^ccCLCu %0^t^

"special I

STREET AN

NFORNIAT
D NUMBE

ON' \
R. /

PERSONAL AND STATISTICAL PARTICULARS

■<ii."'k^ ^

I) \ r i: < >! HI K III ^

/ ''-

\\

A« ,i-;

W f I )• i\\ !' ! • < tls I • V' •'•' • >■ !>
■U lit. Ml ~,H :..: .!< ^:-:;.,'; .!l)

lUK rn ri. \i"i;

^' • I)! iiiimti \

ll.lV

\r,titii

I A ill i: K

^ M

La^vvl:

t 4

luk rni'i.Ai'H

r)!' 1 A IIIHK
i Stati or I'outitt \

M \I!»1:N NAMI-:

t»i M(»riii:K

lUKTIII'I, \\ V.

<M mi>iiii:k

iSlaU- III iOuutt \

occirAriuN ^i

aqt

n

/ ■» ( i

MEDICAL CERTIFICATE OF DEATH

DA ri-; t >i iii.A'i'ii

M-.nllii

i)av

iVtnri

1 ll!:Rl';r.V eiKTIi'V, riiat I altfinlcd tkHxascd from

up

, , _ t
til at I last saw h ' alivi- <iii ^

and that «U-atli (K-currcd, on tlic .latt- statcl aln.vc. at ^''^

y M. The CAISF': OF DKATII wa-- a^ follows:

Dm jviVvvc 't X

Ari

DIRATION ^ }'''<ns

CK\v

Ihiv

Hours,

RATION Jl^ r*

(//'.V

Months

I^xv

(SIGNED) vJA.<XAV

\aA,ca

<kcui

Resided m Sax I > ati. ."

^

Mntlth^

■,Mn^XI.nK.TX,M^prHR.ox^KrAKT10ri XRSARKTKrHTn
in-ST «)l- MS KN'iW !.l IX.1-, AM) lU-.l,!!.'

(I

nfnnnant U -COw^-VVA- U ' • ^^

lUd.

l()n

M.D.

SPECIAL INFORMATION ""!> *nr tlospitdls, ln\fitutions, Irdnsients,
or Recent Residents, and persons dying andv from home.

Former or
Usual Residence

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

How lonq at
Place of Death?

Days

v\ \ci-" (>i- m KiAi, <»K ki':nu»vai

■ ; 0

DA 11! of Ht HIAI or KI:M0V\I.
wet. ^a TOON

I

/>"u^

'""—"'—"■"—"'""■■— ""'"""""^ rrr^ ,. ,, ahF should be stated EXACTLY. PHYSICIANS should

J,. B.— Every item oi inWmation should b. --«- '^ ^^""^^'^t propeHy classified. The "Special Information" for pT-

state C4USE OF DEATH in plum terms, that it mn> be proper.y

so^s dyini away from home should be ^iven in every .nstance.

.^^

r

ifl

iV

■

I
I

WRITE PLAINLY WITH UNFADING INK

!)<(((' Filah CxtcA.^^' 5Ll

10()\

THIS IS A PERMANENT RECORD

REFER TO BACK OF CERTIFICATE FOR tNSTRUCTIONS

Registered ^'o, 2488

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco

Certificate of 2)eatb

( tl. %. Stan^arC^ )

m

PLACE OF DEATH: — County of C\ >-^.

No,

' -^ , -^ ' V - City of CJ Ojy^ O XXX > \- CA^-i
St.; 3v Dist.;bet. ^ XXKM and

,.o,,«i RFCSIDENCE GIVE FACTS CALLED FOR UNDER "SPECIAL INFORMATION ' \

■. s

)

If

0^1 i

FULL NAME J <X yv^^u^

PERSONAL AND STATISTICAL PARTICULARS

n

It \ 11-. «>i" lUK ni

\<.i-

%;

.L.

I>:t\ I

M.m'h

\v\\\ i

;i

(/ 1 .\

-.IN< . 1.1 M \K N n-l»

WIUOU I ! lit)

<Wt ill- in --» .f'lii'

ki

,t\HrVcjLcL

r.ik rm>i. \i'i'

■-t.it • ' >' ' I -n !it 1 \

NAVfH «>K
I- ATHKR

lUK I'll I'l.ACK

<)!■• I Arin;k

I St;i!r III i'liuntl V

,0. rv' J .V

LU^tc^x

lA

A

MAIDKN N\MH (iCS
«)1 NU)Tm:U U|'

I5IK rm'i.AOK

f Stntf or t'otiiiti >

\xk>: \itrvk M^

ij

0

OjJ

l^aXjtvv) C

^vdL^ilv

orcn'ATlON I

TMKA,M>VKSTXT.;.M.KRSnNA. PAKTUM^KXK.AKK TKtH •,-.> THH
HKST OF MV KX.)\V!.KI)<W% W 6^^ 0

' \.l(lrcss IHOL

MEDICAL CERTIFICATE OF DEATH

DATH ol- DHATJI , . '^

(Month) 'I>='^-^ <'^'''-''"^

I IIl'Rl'P.V C1':RTII<'V, That I altcn.lc.l <lci-t asc.l fn.ni

„ ^ ~ 1 c^o t« . — -^— TOO ■

that I last saw h ahvc on ^«P

aii.l that .U-alh ..ccurrt'd, oti tlu- <laU- statc-.l above, at
M. Tlu- CAT SI-; (»l' Dl-A'PII was as follows:

DT RATION y^-'DS Mouths Pays

CONTRIIUTORV

Hours

( SIGNED )UA.^mJtH^' J ^^ ^^ ^ M.D.

SPECIAL INFORMATION onlv lor Hospitdls. InstiMiHons, Transients,
or Recent Residents, and persons dying dwdv from home.

Former or
Usual Residence

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

How lonq at
Place of Death ?

Days

I.ACH OK niKIAl. OK KHMO\ AI,

Qui. ULLA-^XO.U^i

INDICRTAKKR M V

-H

DAXl". "S Hi HIAI <ii K1':MoVAI,

U,c.t -^ 190

(Ad

A-'-CLA^,

^\

^tl

(lit'ss Ow D^ o w t

W-4-4^

tXk^

>t

^ vx InE should be stated EXACTLY. PHYSICIANS should

N. B,— F.very Item oS information should be carefully «"PP»-^- 'I'^^J classified. The -Special Information" for pT-
state CAUSE OF DEATH in plain terms, that .t ma> be PJ^J^^J'^
;in. dyinft away from home should he given In every .nst.nce.

' J

a

1^

Hi

I

I
I

m

k

WRITE PLAINLY WITH UNFADING INK

Unanl

11. lU). ! N

i.X !' I'll

HJOH

THIS IS A PERMANENT RECORD

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

O f QQ

lie^isfercd J\^o. J*f

^ , ^ Deputy Health Officer

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

Cevtificate of Beatb

f XX, 5. 5tan^a^^ >

PLACE OF DEATH: — County ofU/O.^'

i

N r\

City of C' Oy^-v-

m

No. 1 b ^

(

St.; 1 Dist.; bet. U/^rvun\' and

"' P .V .o^« IJC;UAL RESIDENCE GIVE FACTS CALLED FOR UNDER 'SPECIAL INTORM*

" rr'dTH'ScCU%rEV.;."rHO^S^P^T*AL O "ns'tJV.O. C.VE .TS name .NSTEAO OF STREET A.O .UMB

TIO
ER.

FULL NAME

/I

— ^

>

A i

PERSONAL AND STATISTICAL PARTICULARS

'-l-X

%-

I < ii.' 'k

u

V

.. 'J

\! ,nth

A< .K

.1/

W I 1>« iW I 1 > ( t|.' I > V« iKl"!:!)

I \\i lit \n - > 1 i: •>■• -i I.' nut it 111)

MEDICAL CERTIFICATE OF DEATH

DATH OF I>i:Aril ji ^

(M..ntli) 'I>'ty^ ^^■'■•«'''

I HI:K1:1'.V CI-RTII-V, Tlmt I aUen«k'«l tU-ix-astMl fnnn
^s:X: ^ > up' to aD<:* 9^1 T«pi

tliat I last <aw li alivi- on ' ' ^<P

an.l that <U-ath occurrcl, nti the <lali- -^tatr.l abnvt-, at >- oU
.,1 M. The CAl'SI-; OF DKATH wa- as follows:

Cjx^v^

lilH 111 J'l.At"!'.

'-.tilt" iiT ',*« MHlt : %

I- A rilKK

niK inri.ArK
(M" I A iin-.K

^t.iti ii! iNiutitlv

-\ r V

^C

1

J I ■ ■ -^

maii>i:n* n\mi: (^

L

lUK'i'mM.Ari.,

'Stall 111 i'mmtiy'

.-D

-^v

^OJjJr^ tx'^a

nicri'ATioN

u

)V,;

}/.,,!///•

/):

T 1 1 1*. \ H( )V K ST \ T 1-: 1 ) »• H R -^< • N \ I . i' ^

KTI'TIXK^ ARI-; TKIK T* » THK

Hi:sr ()i< MY 5i^«>\vj,i:i)r.K an > i.mjii

(Inforinatit

n

c«w'

I) IK. XT ION

}'r<irs
1

Months

Pa

vs

I lout s

CONTKIlUTOkN

cjr^x.a

DIRATION ^ >V</^

Mtiut/is /hi\

r SIGNED )n(^- UjX\:Uic

Hours
M.D.

.a.lress) l^ia^^l<V^^

SPECIAL INFORMATION only lor Hospitals. Institulions, Transients,
or Recent Residents, and persons d>ing away from home.

Former or
Usual Residence

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

How lonq at
Place of Death?

Davs

I'KACK «)I- lUKIAI, OR KKMoVAl.

i)\rj- .; lUKiAi. or ri:mo\ Ai.

^'€t

vS.

T0<^

\(lilrt".s

5X1

Xolv«-VL

t

A

r N

N. B.-

— ^ "T! 77a 7\\\ should be stated RX4CTLY. PHYSICIANS «hould

„f information should b. cn.ctuHy f"r»P ^^j^" p..' erly -lasshMed. The -Special Information" ?or pT-
E OF DEATH in plain terms, that it mnj ht pr.,periy

rSin'i^'w^; «r:,;;hon;'^ ;ho«,., H. »•„.„ >., ,.=., in,.„nc..

«HIW^

■^li

M

1

•A I

-:f'

f

I t

I

WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD

I V

* -^U-A'.s^Vi-

Dft!

Deputy h

IDO'X

REPER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

'3490

Be^isfet'erl JS'^o,

,(r^^*-^

h C

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco

Ccvtificatc of IDeatb

No.

PLACE OF DEATH: — County of "\.^^ ^

St.;

^4-

City ofl'oyvv 0 ^o^

n ■ \\ ^

I rUAAA^<rY\^ and C Ctl

Dist.;bct.N I \AAAxJry\>

"■ "" i.ciiAl DTQinrNCE GIVE TACTS CALLED TOR UNDER "SPECIAL INFORMATION \

A

FULL NAME

i

CUUj Ck^t^CC<LA

A)1:CU'

o

PERSONAL AND STATISTICAL PARTICULARS

r< ii.t ik

i> A 1 i: » »r i;iK 111

^ H^

M

M

\' .i

<,INm,K. MARHU !>
\\II»()U'1'I» <iK " * ■

•- \\l it' HI ~iH'l;i;

1 ! >

MEDICAL CERTIFICATE OF DEATH

MATH '>I- I));ATH

^c

Nf.iiuhi

»av)

iYtar>

I JIKREBY CI.U'riI'N', That I atU-mlcl deicaNc.l fnmi

tliat I la-t saw li -.' alive oil V. tv s. up .

nii.l that death ncrnrrcl, on the date stated ahove. at

M. The CArSh: Ol- Dl'ATH was as follows

r.iK I'll j'l, \*'i".

S,t;ltl 1 i! t'l 111 llll ^

X \M1 < »!
I- All I )■ K

'^

i I

^fLativo.>v vbo^ldix

niR rm 1. \eK

(>! 1 \liIlK

SI

! 1 \ I' 11 IK '^i

^Vvt^v

»>i Mitrm: K

luK I'll I'l, \ci<:

(Slat*- or Count! ^ 1

t V c ^

rvTu

r

ovhtpai'ion*'^ (\

0^ 0-uuljU.o^" ■

V.0

h'fsidt'li III S.iii I ' '/' ■ i-i'"

^f ■'/;

Tin- xm,VKSTATKl.PKK...NXI.l>AKn;;rUAK^AKKTKl H Tn TIIH
in:sT ni- MY KNiiW M.Iit.l.; \Mi hl-.l.H-f

( Iiifutiuaiit

A.l.ltH-s SS^b ^ 1

oli\) U

t

DT RAT KIN

}'t'(irs

Miiiiths \ Pars

Hon

IS

CO

NTRIIHTORV ^a.N.CL^C^C

„Lk

}'r<rrs

lf,>^///is

/hiv

a.-

is

M.D.

DIRATION

r SIGNED )

^',cA^ .. i<(o

SPECIAL INFORMATION only for Hospildls, Institutions Transients,
or Reicnt Residents, dnd persons dyini) .iw.)) from home.

A. 1.1 1

es-

xo

,L'

Former or
Usual Residence

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

How lonq at
Place of Death ?

Dass

i'l.ACK OlJU^fHlM. "K K1:M<»\^'.

1^ f^

.,.„ ^i Xdx^ ^ ■0^ '^"*^^

i»\ii" li lii HiAi. or ki-;mi>vai,
C),ct

ir)0

,. , TaE should be stated EXACTLY. PHYSICIANS should

of hiformntlon should b. curafully fuPP''^;". ^^^'f^^^ ,„„-,fied. The "Special Information" for p.r-
F OF DEATH In plain terms, that .t may be properly ^las

HS:^r ^^^ :;;;;;.; He .Iven . .^.y instanc.

•i;

•1}

.(•:

r^

Wili*#

^J^tv

\

,,;,,.! ..f 11. :nth»- No .. *^=«J^H&P Co

R.TE PLAINLY WITH UNFADING INK-THIS IS A PERMANENT RECORD

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

I)(f/r Filed, vl'cA>i>-^Uv- ^l

Officer

Re^lsfeied J\^o,

2%ni

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco

(No,

PLACE OF DEATH: — Cot^ty

Cevtificate of 2)eatb

( "CI. S. StanDarO )

ofU/CXOA- J \aA^C<-t^(- City of Oo^^v 0/vcv > vc.oi.cc

Dist.; bet.

and

^iJJ^ V y V\^VUA.'>^V\j^ ..^/iTt RrsTDENCEG.vE facts called for under 'special information- \
( '^ I^^V:;:^ Ic^jfci^i't.i^^t ^^V.l^.'^^.^soV^^. .ts name .nsteao of street and number. ;

FULL NAME

lb- ^l.-A

'^

<.i:\

i)\ri-: <»! liiRiii

\l.l-.

PERSONAL AND STATISTICAL PARTICULARS

! cnl,<>Ki

xo

/ o

Mmithi

(Day)

MnUtll-

\ lari

/><n.

S1N(,1,1*. MARKIl'in
WIDoWJ: I) <»K l)i\<>Kr)-.I>

iWrittin -<K-i;iI .It-ii'tia! i< >ii )

lUK riii'i, Ai'i-:

I St;it( tit I'liuntrv

n

MEDICAL CERTIFICATE OF DEATH

DATK Ol' I)1:aT!I

I

A.

Month)

(Day)

IQO

(Year)

I Hl':RI':nV CIIKTII'V, Thai l atU-u<UMl .U-.-cascMl from

•• — — -fgo tr) "■ —————— ————r, 190

that 1 last saw h -— alive oil " 19° "

(\

\0

k

NAN! I <>!
1 A'i 11 IK

lUR IHl'l.M K
<)I- I\lin-K
Stall .11 rduntiN

MAIDl-.N N\M)
01 MmTHKK

HIK TMl'l.ACK
01 MoTIIHR

(stat< iir (.'outitiA

ovcrrA'rioN

h'r-i,{fi! til Sa>i I- 1 1!

Qj oxcy'

xo

n
(

X- V \-

?

ami that (Uath nccurrcMl, mi the date ^talid ahovc, at
" M. The CAl SIC C)l" ni^ATIl was as follows:

\

DTK AT ION )'i'ars Afontfis

CONTRir.rTORV

Davs

Hours

Dl'RATION

Years

^rontlls

Days

( SIGNED ) .L<r\.tmJA 0 Vfi. u) ^JlL

: i(,o ^ (A.l.lress) W^^^^^J^A^ ^-h4w

Wtl

•m-

Hours
M.D.

Special information only for Hospitals, Inslltutwn^, Transients,
or Recent Residents, and persons dyinq away from home.

)■,,?,

M,,>,lh'

l\i\

HKSToV MV KNOWI.KIX.K AM. lUlJll

^

informant G)^.^^rXi-^.^ L-Uw-.^.

(A<l<lt.

Former or u,/ H^ I -^ ^U ""* '"!I'J'^.,

Usual Residence " * V5 ^KaMj^>SJu \ ^i^t of Death?

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

Days

ri ACK «H- lURlAl, OK KI,\1t>\AI,

Nft^xOU"nJ-<bL

I)\ri"of H' HiAi, of KHMoVAI.

ik

INniCKlAKl-.R

^'Q^

190 ^

'^ dtnv

N B —Every item o^' Int'ormnf.on •houlcl b. c„refu„y nupplled. AGE should »>,« «.«ted BXACTLY PHYSICIANS «h^ld
.tate CAUSE OF DEATH In plain terms, that it may he properly classified. The "Special information for pr-
son« dying away from home should he given in every instance.

i

1

I
1

I

i

WRITE PLAINLY WITH UNFADING INK

H, ,;.!.! ..f II.nl!!r I- No :< :^--;^*!^ BS: PCo

THIS IS A PERMANENT RECORD

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

pfffc Fi/rf/,X.xXc

100

Registered JS^o,

2492

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco

Certificate of Beatb

( tl. 5. StanDarC* )

PLACE OF DEATH:-County of6xx^^^ 0;vO >. r. , r City ofO^O^ 0 Vo.^ ^
,^T h ' * - St.; ■ Dist.;bet. U ^ "^ andvrv^,.

fNO. ''^ - "- „ ,,e,,Al PrSIDENCE GIVE FACTS CALLED POR UNDER SPECIAL INTORMATION' \

( '^ r;;;ATH"oCC^%rEVi;''rHo"s^PrT"AL 0%"r;STmf4'/0.VE .TS name I.STEAO or STREET A.O NUMBER. )

)

FULL NAME

PERSONAL AND STATISTICAL PARTICULARS

m:\

111

COI,OR \

KjCkXx

UVW. of- r.lKTIl

.\ < ■. 1-:

LI. ^v

0 r,

I M()tUlt>

5',„'

( I^av

M.niths

■.tar)

Ih

SINt-.I,!- MARKli:!)

\vn)o\vi-:i) <m niv»tK«.Ki>

(Writf in -o.ial il- -'-naliDii)

HIKTMPI.AOK

'Stati' or Ciuintrv

»• A ril IK

niKTiiri.xn-:

oi' lAlHl-'R

! sta!' « '' (.'uuntl ^■

MAini'.N NAMJ'
ol MoTMHK

lUR riiri.At'K
111- MO Pin-: K

i.

Ol.

A.UL<X

\ \

MEDICAL CERTIFICATE OF DEATH

DAPH i>i-" i)i-:ath \

L'cfc I'"' I90-

(Month) <l>»y» <^'f:«'^*
I HlvKiaiV CI'.RTIFV, Thai I aUciKki! .UvchscmI from
.L^^yI; aC IQOH tn Cix^ X^ icp S

that I last saw h i- > ' alive on ■ -^. , ' 19O

and that lUath occurred, on the (late statcil above, at H

M. The CAISH OV DI'.ATII was as follows:

DT RAT ION )\ar5 Mout/is \ /)a\s

CONTRIIHTORV W.-^^^^•^t^ -Ct(xt„t <Xm .' ^

nrRATioN

Hours

1 U V 1 ^ \

Years

A

{ SIGNED )

I(>o

(Address) I5 9w^

Pars

\x^^

Hours
M.D.

ortTI'A riON

- *i)

0^vAA,y>

-\ V rt "TV

h'r.Mjfif m S,nr /'xuhnr.) .''L > f'.?

M <„!l,'

Ih!

TUr xnoVKSTXTFUrKKSONAl, FXKTIcri.XRSAKK TKIK To T!IK

lil'.S I 01- .-.1^ rv >..,..,.

flnfoonant U CU^CC lv U Ij C

0 '^

X.lilii

11% Bt vllcr^u dv

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

Former or
Usual Residence

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

How lonq at
nareof Death?

.. Days

r^ACH ol- lURIAI, OR RKMoVAI

indi-rtakhrTTI O.C1L4L<L«/>v M U vh\.

I)\rj-:.)f r,t Ki.\i, or RKMt>VAI,

Q ♦

til

'I

«'J;

■ l(

^fil

^>

(

c

. \

7-

t
■'i

3

0

'.I

N R —Fver^ Item ni information should be carefully supplied. AGE should b« stated EXACTLY PHYSICIANS should
I;at/CAUSE OF DEATH In plain term., that it may be properly classified. The "Special Information" for p.r.
sons dying away from home should be given in every Instance.

I

WRITE PLAINLY WITH UNFADING INK-THIS IS A PERMANENT RECORD

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

Hoanlnf lUalt^r ! No. ■ , T^^Wr^ii) HS: I' t o

D((fr Filed,

100 H,

Re^isto'cd J\^o,

•**^ » • / ' J

Deputy Health Officer

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco

Certificate of Bcatb

( "a. S. StanDarD )

(^

PLACE OF

'N

DEATH:-County of Oc^^ i^<^-^ -^ ^c^Gty of 6 ^^ J A^-^^^cc
M ~ \'k\K St.-,? Dist.,bet. 'i^aVvti,r, andJKAC,-

O. 'I 1^^ W „ ,,.,,.1 BCSIDENCEGIVE rACTS C.LLED FOR UNDtR "SPICIAL ll-irORMATlON- -J

( " rr"o»T"oCC;R'Rr;,"rH"s^RVT'!;t o%"-:"tu"o";"o,.E ,TS name ,»ST..0 or =T...T .MO nUMB.R. >»

' 0 ,(^' ro D

FULL NAME

'1 X {

! \

JlM

m.

si:\

DAIi: r>J- ISIK Til

.\<,H

PERSONAL AND STATISTICAL PARTICULARS

UC

U

r%\!^^

M.iiithi

);\t>-

I):iy>

Mntll/l-

( Vtari

/',/).

^iN. ,i.i: MARK n:n

I \\! ill in -H ial .!< -iiMi.tli'iii)

MEDICAL CERTIFICATE OF DEATH

DATE Ol-' DKATII

X

fM(Hith)

Day)

(Y.'ai)

I III'RI'HV Cl'RTIl'V, That I iitUndf.l don asod from

.ct 9sC:

i()0 H

IX.'

iUK riMM.ACH

1 St:iti- i>r I'ltiiiit lA'

NAM J- <>l

I A III i:k

I'.IKTIiri.Ai'K
Dl- I A rui'.K

tStali III *,'iiu!!ti\'

MAII)1:N NAMl-
«tl' MO'IIIKK

lUKTlll'I.AiH
ol- MmTHHK

(State 1)1 I'duntrv

U

^\X)aX

L

lb 190 H to

tliat 1 last saw li '-^ • • alive on L ctJ ' - 190

and that death ocrurred, on the date stated above, at H
L\. M. The CAISI-; Ol' DICATll was as follows:

om I'A rioN/ u

'f'^ii1r,i III ^iiii /'iiniri^r,! Ou ^ >'•'

, f

Mnllth

I hi

rnv MM»vK sT\TKn i'KKs.,nai. iak . l , i. \k- ark tkik t-. TIIH
liKsT ni- >-iv KNowi.i ix-.K AM. irri.n.i-

(Infii'inant

II- 1?^ tk at

Ur RAT I ON Vi'iU-s M 0)1 1 /is H Davs

CONTR IHI'TORV L.<XXXM^<X/<^ UJ JLcX-i^^ v

DT RAT ION IV^j-r.? Mouths Pays

I lout s

(SIGNED )

\L',^ca^ '.^^ 190

(Address) 15'X

Hours
M.D.

„Q)

uA4.c-e-v-w J w

Special information only t«r Hospitals, Institutions, Transients,
or Recent Residents, and persons d>lng av*ay fron home.

former or
Usual Residence

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

Hov« lonq at
Plare of Death ?

Days

i»\Ti >; I!! KiAi «>i ki;m(»vai.

190

\.lilrt'-<

ly.ACi: nl- lURIAI, OR RKM«»\AI,

(AcMn-ss Ull \r^rUxUU..<n w tit

N. B.

""■"^ ^. .. !• -I ATF ahniilcl be iitated EXACTLY. PHYSICIANS should

-Kve.y Iten, of Information should b. cnreVully «uppl.ed ^^^^^^^'^^^^^^^^^^^^ ..gpeclal Information" for pT-

state C\USE OF DEATH in plain terms, that it may be properly wiassiiiea. • nc ^

Kons dyinft away from home should be ftiven In every instance.

^;.

1

f\

■ri

1

I

m

I

ft
■

>*».-.<.

WRITE PLAINLY WITH UNFADING INK-THIS IS A PERMANENT RECORD

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

/)((/<' Filed ,

n

X\

lOWi

Ko^istered ^V«.

"L^i iL^n. Deputy Health Officer

DEPARTMENT OF PUBLIC HEALTIi=City and County of San Francisco

Ccvtificate of 2)eatb

( H. S. StanDarD )

PLACE OF DEATH:-County of^Ct^^^ Oxaw - c : < City of^XX/^A. lva.vc_>

\ i

/— f

/TVi IMl %an\.«'i'^ St.; 4 Dist.;bct. bXiV. and

rMO. IV \l vV V^, V, V ..V. . „^„ uc.,,*, orSIDENCE GIVE FACTS CALLED FOR UNDER ■special INFORMATION • \

( '^ rF"o;AT°H"oCCU%';rEV.;THo's^PrAL o"r ?ns'tu"o"n"gIVE ITS NAME INSTEAD OF STREET AND NUMBER. )

,UA ,\ . VA\(1 fCs

\.,.

)

FULL NAMEv.

^ ^CUC^VA.^.

H

si:\

PERSONAL AND STATISTICAL PARTICULARS

m ft ""•'''' ■ '

i» \ 1 i; «»i r,iK 111

A'.l-

4

) 'lii I >

fS r7s

( l>;ivi

M.,>/t/i'

\ carl

/*./

sIM.I,]-. MARkll'.n

wnx »u }:it OK nnoKij: I) y

iWiitciii -oiia! (l<-iL'n,iti"n)

MEDICAL CERTIFICATE OF DEATH

DATK OF DKA'III ^ "^

U.cX

(Month)

(Day)

IQO

(Year)

I Hl'RlUJV CI:RTIFV, That I attciukil dcccascil from
JD/Ct' "^.f 1904 to ^ ^ ' ^ 190 ^

tliat I last saw h * alive on ^'P

and that tk-ath occurred, on the dale slatetl ahove, at
M. The CAISIC ()!•" lilvATIl \\ns as follnw:

(Statf 111 (."iiuiiti >

NAMl <H-
lATlll-.K

lUK I'HI'l.ArK

()!■ I xriii-.K
( Stati III Country

MM!»i:n NAMl,

01 Moriii'.K

nmriiri.ArK

()|- MnTMl-.H

( Statt i>r Cmillli v

\

i

.^wC^

lilvATIl \\ns as follows

DT RATION Years

CONTRIIUTORV

Moulin

/hivs

I/our

KX^"- slLvwci

^ Sjy\KKxXX^Oo

■^

^

«H rri'\ rioN

AVw,/^-.7 III ^tiii /'I'lii, .'■.('

nr RAT ION

)'t'iirs

MuHihs

/hjV<

(Signed) ^. iX ^

//ours

M.D.

I()0

Special information only for Hospitals, Institutions, Transients,
or Recent Residents, and persons dviny avvay from liome.

) III I

\l,,„Hi

I hi

TIIK M?,n-HSTATKI)1'KR^oN\I.l'\KTirri \KsARKTKrK To THK
liKST OF MY lCNo\Vl,i;i)C.F. AND HFFIll-

(Info! inaiit

dv^'^^U-^^ ^

\.l(lH-^S 10 \\

Former or
Usual Residence

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

HoH lonq at
Plareof Deatfi?

Days

J'J \CH OF ISFKIAU OR UF.MoVAI,

(A. Muss U'U ' 1 I '^^^-Uxnv Ut

i> A IF ..' I'.i Ki.\i. tit rf:movai,

V„ 1 \_ s.

TQO

'"'"'"^^ TT ,. , AHF ahniild he Rtnteil EXACTLY. PHYSICIANS nhould

Bon» dying away from home should be given in every instance.

J »

1

.%^<:^%^'

I

I

1

1

WRITE PLAINLY WITH UNFADING INK

Ji,,:n.l .,f Health \ "<'

r 1»

♦^''j-rv^.

.- I', i"?

) iuS.1' Cn

I)(f

te Fi/rffX',€tdyMsj X[

100\

THIS IS A PERMANENT RECORD

REFER TO BACK OP CERTIPtCATC FOR INSTRUCTIONS

A^

A

M<i

r^r

\ ^ ' \ K

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco

Cettificate of H)eatb

( Ta. S. StanOarO )

4

PLACE OF

(^

DEATH:-County of^.CLAV Jxa , .c..^ -,. City of O CC'>V JAcv^vC^CO

M^

». ^

■Ki ^ I ^ n KkX r\. ^. C ^ St.; ^ Dist; bet. ' ■ -^ UsZMXXi->i^ and

FULL NAME^'^^

,WNl-

sLLU

PERSONAL AND STATISTICAL PARTICULARS

SKX A^

CDl.oR

M

,A

nATi-: «)!• luK 111

AC.K

I

^^

iMoiith

} -.(

I Dav

.U,i»////>

V.-ari

n,i V.

•%

ii— ii

«;IN»'.!,K MARKIKli

un)n\v!-'i> OK niv»>Rri:n

(Writiin -iiiial iloiiMuilinii I

HlKTHl'I. %*l-

d ^^-vCv^

(Statf ill i'iiuilll % A

o.

1 A riii'.K

^

; U

HIH rill'l.AOK

oi' 1 xriii'.u

ISlatf III *.'i>»iiit'. \

MAini-.N NAM}.
i»l- MulUKR

lUU iinM.ArK
.»i M<>'!in:K

I still ' ii I'tinuti \

m ril'ATluN

Kru/fif in Sil>l I'l ini. '-"•

wl

\[\.

MEDICAL CERTIFICATE OF DEATH

DATK OF I>i;aTH

XJ^ ^^ r9o'^

(Month) <I>:«y) (Year)

I in':Ri:HV C1:RT1FV, That I atUn<UMl actvasea from

©ct XL I90M tn ...LC*^ M

that I last saw h J-^>'^ it+ivc oti W /cv „^a.

and that tUath occurred, nn the date stattd above, at

M. The CAISIC OV I)i: ATll was as follows

1

I(>0

,V^^^<

^^%

A^CSwV.*.-.

, t

I -1

1)1" RAT ION
goNTRIl'.rTORV

Years

CM

MOHiJis

/hn

I lout

kX\-

X !<:

DT RAT ION Yiius

■V ^

(Signed ^ j.cW^-^

Months

fhlYS

VV/v Si .' ^-KJ

Mrtllll^

I hi

IMF MU.VKSTATi:ni'KI<snNXl,l-XKTU-ri XKSAKH TKlH T. > XWV
llHSTol NKV KN..NVl.i;iM,)i^AM. HI 1,11. 1-

^. i)c.^.

(\

Uigurs

M.D.

ICJO'I

(A.hlress) V\Xv 'kfc>^--^

fitffis,

SPECIAL Information «nly lor Hospitws, Inslitutions, Transjfnts,
or Recent Residents, and persons dying awrf\ from home.

Former or
Usual Residence

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

NoH lonq at
Place of Death ?

Days

I'LACl-: (»»•■ lUKIA!. OK R!.\!"»\ Al,

i'l, AL I*. « >r III 1^

DXIJ ■'! i'.iKiAl, <»r KKMOVAI,

t at a I 190 H

^

ISI.KKTAKHkV a I j^O X^NVV

^_ V c

AU,h..ss IS^H Ol^^klc,

state CAUSE OF DEATH In ploln terms, that it may be properly ^lo»»meu. v

nons dying away from home should be feiven in every instance.

m

> ,

'i

r

il;

'isW???*^

WRITE PLAINLY WITH UNFADING INK

1!,,:,:.! of !l.allh V V'). I' -S"-;^*^'.-* HS:^_<£^^ «^«_«-.— — — — — '

I

THIS IS A PERMANENT RECORD

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

I)

lle^itilcicd JS'^o,

2496

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

Certificate of Beatb

X

( Ta. S. StanDarD )

4

(?ri

PLACE OF DEATH:-County of 0,0.^0 ^^^n^^^^^* City ofCJtV>%. OAxx^ovcv^

D

fNoAAUj

I

^ru/v\AA

.1

r^\.;i.

I

St

" Dist.; bet.

and

.* r^:.: ;.om^usual resTdence_o.v^,^cts c^l^o .-^^^^^ .;;i^rij?'^::^c;::"' )

I ( '^ ^^i;:;;f^cc$«^v,r^":.i^r;;. ?« t^^;;:;t<;; o.v. .ts name .nst.^o o. .....^ .

FULL NAME

VOs^^^^-^cLov AjV.a.4. ^ ^ ^-i.^^ ^

PERSONAL AND STATISTICAL PARTICULARS
^j;v; /x ^ I COI.OK

m

<xU

i.:

DA IK <>!• HlKril

A«',H

,|\,c\r

I \)A\ I

M.nilh^

! Year I

n,n<

MEDICAL CERTIFICATE OF DEATH

DATK OF DHATH ;, -

Uct

1 . /Q(y

(Month) 'l>:»y> '^■'■•"'

I in':Ri:P.V CI:RTI!"V, That J attcncU-.l <kHxase<l frmn

QjpAAA. ci.b lOoH tn i'ct 1% IqoH

190

siNr.i.i" M \RH n;i>
NVinowKD OK i>iVMKri;n ,

iWrittiii '■ocial lU -i v tuitiim) \

lUKrnri.AOK

iStat< lit (■(iniit!\

Hlo-Y^v

that I last saw h ^. ■ - alive 011 ^^ '^^ ^ ^
and that (k-ath occurred, on the <lale 'stated above, at -l i 0
0. M. The C.\rSI<: Ol" 1) MAT 1 1 was as follows:

V" '

\

.t. > VA-

NAMK 01
FATIIIR

HlKl'Ill'LAiH

C)l- ixruHK
(State or louiit! y

MAn>l';N NAMl-

Ol- MoTin-:K

HlKTinM.AOl':

01 Morm-.K

(Slati- or Country

ovOtl'ATION

XX4 ! >^ '-\ V

-^1

0

DT RATION

CONTRIBl'TORV X C^^i >A.v.

)'tuirs 5 Months ^'^ I^ay^ Hours

Years

Months

Kisidfd III Siin /'mil, I-

) 'ra I

M,,„lhs

Ihi

HHS-r^.H^ MX^NONVUl-DoK AND IU-l.Il-.l-

DIRATION ^

(SIGNED) . lU. to. Lc^v.A..^

Pays

Hours
M.D.

IC)0

(Address)

\AXi<;L'

SPECIAL INFORMATION only 'or Hospitals, InstiluUons, Trdnslfnts,
or Recent Residents, and persons dying away from home.

Former or
Usual Residence

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

Now long at
Place of Death ?

Days

(Iiifoni\aiit

-3

AX^

\.Mr>

k a. ^.'

(1 "^

4

PI \CK 01 lURIAI, OR KHMoVAI.
I NDICRTAKKR

DXXl'"' Hi KIAI. ot K1-:MoVA1.

0

<* 11

TOOH

state CAUSE OF DEATH in plain terms, that it niB> he propcny 1.111
sons dyinft away trom homo should he ftiv.n !n s»«ry instance.

ill

i

^

'V'Y

ill
-lii Jill

WRITE PLAINLY WITH UNFADING INK-THIS IS A PERMANENT RECORD

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

ii.^r <:

Re^ititeicd -^o.

•3197

\ dou>u Deputy Health GfTicer

DEPARTMENTiliF PUBLIC HEALTH==City and County of San Francisco

PLACE OF DEATH: — County of Cct^

'0 I

Certificate of S)eatb

( Xk, S. GtanDarD ) ^

- Cic* City of Ci-o/^^ 0 -^-cv > '-^

A

"i

jsj^^ iH LouWCLrL- ^

I..

* ^,^ ^.,,rn FOR iAnDER 'SPECIA

and ^J ^

nvLli

c )

X^'^^v^:;^--^^- ^iv^^^^:^^^^" ■^---—' >

FULL NAME

cux DsmvLtclo.

(1^

PERSONAL AND STATISTICAL PARTICULARS

ri

I.

l)\ II" «'i' i;ik III ^

a.kLti

(Kl..nth\

(Uayi

A< ,i-;

It ,

1/,,

( Win

'\n:

MEDICAL CERTIFICATE OF DEATH
DATE Ol- DKATH l^

I Month*

(Day)

iVtari

"^I HIkl-HV Cl.RTIl-^V, That I attended decease.l fmn,

C\,.., , ,„.H to ^'ct ^0

I

up

s

>^i\< ,1 I" MARK n:i»

wiiMtwij) <)K l»:v« .!■•' I'D
i Writf ill -ocial il' -'" 'mI^'" '

lUR rm'i.ACK

(Statf or C'luiitrv

X \Mi-: oi
I A rniR

lURTHIM, \i K

oi- i\iiiI':k

I stall- 1)1 rixnitrv

niaiih:n NAMi:
t»J mdthkr

0

Lcur

^rtX-v^'vLC

190H

that I last saw h •■ alive n„ ^^ ' ^^P^

and that death occurred, <m the d.le stated ahove. at ^^0
Q M. The CAl'SI' OI' DI-A'PII \va^ a^ folh.ws

Q.l

^-yx,^^ wC

il AA^^.x-0\.OL^CC^ ^.U^

vilt<l ^

Kx.

HIR rillM.ACK

oi M<>'rin-:K

(State <»r Cotjiitry*

oCCfl'ATlON M^ 0

ft
n ),;,,. 1 v,">ffi^ 1 0 run

U /T i XX./-V^ U.-' XAv-

DURATION 5V<7;s

Ct)NTRIl'.rToKV

Mouihs

Pav

Hon

IS

.^

//ours'
M.D.

Kf^i.1r,f III Su>i I nni, / v
liHST OF MV KNO\Vl.lU)(^K AND lU.l.U-h
(Informant M ^U^

nURATION )V.7rv

( SIGNED ) I I ^^'

^ ,-. U)nH (Address)

SPECIAL IN FORM AT ION onlv for Hosplldls. Institutions. Transients,
or Recent Residents, and persons dying away Irom home.

Former or
Usual Residence

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

How tonq at
Place of Death?

Days

^CX/O^A^

i)\ri'. of i',i HiAi 01 Kl^^!<»^'^'.

^^^_^^^— ^B— ■— — — — , FVACTLY PHYSICIANS should

r. <

"ips"'

.1

i

M

I

I

i

I ifiH

I

WRITE PUA.NLY WITH UNFADING .NK-TH.S .S A PERMANENT RECORD

^^ p^rCR TO BACK OF CERTIFICATE FOR INSTRUCTIONS

JS.,;i!.! .if ll< ;i!tl\ ' ^'^ " -....^^

J?

/>rf

cL

t!A.tl.A

•L,

V^U

Depu

f^■ t-»

190H
1 Officer

Jf('o/\sfercd ^\^o.

2498

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco

Ccititicatc of Bcatb

( XX. 5. StanDarD )
PLACE OF DEATH:-Co.nty of^^ i /UXwc.cc Gty of ^O^^ lvc.>. .

a

n

. 5^ Dist,; bet. ^\ ^

md

■>-'. ■>

4

"' ' '' T'■'1=^■rs™^"r..•"^^^■•S?J.r

FULL NAME )(^

XL -

PE

RSONAL AND STATISTICAL PARTICULARS

IN

n^

(.« tl.oK '

IJATK OF UIKTH

L

I

/UH

M.iUtJi)

\t .1-:

x-ut HO ),

|):iVl

1/, ,»'//>

( » lar

/',/

DAIK ol- DKATH iH

MEDICAL CERTIFICATE OF DEATH

(Day) (V.aii

I III

(Month)

{KKBV fl-RTIFV. That I atU-n.U-.l .Ui casd fn.,n

— — lip "■

up

t(»

'^IX«.ii' %t\Hkll'I»
\VIH<»\S I I» «»K I>1\< •Kill)

I Wi itf 111 ^iHial '1' >u'n;it 1' m I

lUR run, \<'i'

' stati ( ii i'l iinil i \

N \M1 nl

1- A 1 II 1 R

lUK rin'L.xrH

c)|. I AIHKK

(Stall I ii i'miiiti \

MMDI'N NAM1-.
(»|- MOTIIHK

inK'niPhACl"*.
ol MoTHHK
( State 111 (.'ounti N

that 1 last sawh —^ alivi-nii

a„a that -Uath nrct,rrc<l, on the .late ntatecl ah.^vc. at
M. The C.\rSI-: Ol- I>i:.\ni was as foUnws

I9O

DTK AT ION >''''^'''''

CONTklHl'TORV

Mo fit In

Pays

Jloins

6^

Ilk.

JX

Iloiins

M.D.

-i^i^L INFORMATION onU lor Hospitals, InstitW. Transients,
or Rercnl Residents, and persons dying av^ay from home.

/

\l,.nlh

/',-■

DIHTI'ATION

in%ST ol- MV KN'»N\ l.I.!"'' ^^'

(infonnaut L<fUrY^X^^ ^i^

Former or
Usual Residence

When Has disease rontraded.
If not at place of death r

HoM lonq at
Place of Death ?

Days

,.,.ACK ni- BIKIAI. '»K KKMoVAI,

I 4 . V^

,,M1 ,; Hnuu. or K1:M»>VAI.

Q ^ .

' ^'^'^'^"'^ , M L PHYSICIANS should

1»,

, I

i!^

I

4

\

B<KI1'

WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD

f n.MUh J No ;. ^•^f'.^.HM «• . REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

/)(f

Ir /7/rv/, IiWUIrv 3.1

loo'i

Be^/.sfercd jYo.

'^ ^ 09

,<jA^A^X>Q

n

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco

Certificate of S)eatb

( XI. S. 5tanDar^ i

PLACE OF DEATH: — County of JCXTV JXu .k^s..<-. City of a.>x. J AXX/i v

w

q.-

/O

Ld^u,^^ ^wCWixA

Dist.; bet.

and

No. V,C^U, ^V.CUci\.\.u - St.; , --- .

^^ / ir DCATH OCCURS iwAY TROM USUAL RESIDENCE give facts called rOR UNDER SPCC.AL . N TO R M ATIO N ' \

( "death OCC^R^TeD in a HOSP.TAt OR -NST.TUT.ON GIVE ITS NAME .NSTEAO Or STREET AND NUMBER. J

,Tr>

)

FULL NAME

I.X

PERSONAL AND STATISTICAL PARTICULARS

A

li Nil". « •! r.IK 111

M nt

\ * . ):

"•Wi.l.V. M\KHn.I>
W \\u »\\ I- l> « iH I)"''

U ! lt» 1 !1 -I n ill

I»,iv

\/. ,,:'/,

I hi 1

1 ')

I

K.

I- A in i;k

MIR rillM.AiH

Ol* I AIHKH

I Slatr i>r t'mi nt i v

MAIin'.N N\M1

HIRTIIlM.Ai'K

<u- m«)Tiii:k

(Statf lit OdUiiti \

A

c

II

^

U^j \

^

\

, iv A.

<>rcri'ATH)N X

Kf^idfd in -"<,! II / I ii III

) ,;/

M„<ih^

IhlM

Tin* \i5ovi-. sr \ ri:i> i»kks«>\ai, i'nk ru' ^ ^k

lUCSr (»!■ MV KNOWl.i:!)'.!-; AM) lu.i.ii.i-

I

-^ AKi: iKn* ro rHi<:

(In fn- iniuil

'\

JL^

m

MEDICAL CERTIFICATE OF DEATH

DAi'i-: ol i>i;atii

cA.

(MoutlO

Dav

/90

iN'cat

I HRRRP.N' CliRTlI'V, Thai I altciuli-.l <k'ccav<.'(l from

t,, A.'lLt 11 Kp't

I

:i

T90

that I last saw h

allvf nil

190

aiuLthal death ncciirrcd, on tho .late stated ahnve. at H OO

I \

J M.

The CAISI-: Ol- l)l';Aril was as follows;

Co\,v.i\.b-^'

DTK AT ION )'rars Months

C ( >NT R 1 1U'T( ) R V Wi\^*

Pars

J/oiif s

nr RATION

(^

)'i\ll

Monlhs

fhivs

(SIG

NED) 4XC<1 Vj. L^ O V

I/oni y

M.D.

!C)0

■.J i^

ON only '*"■ Bospitiils,

SPECIAL INFORMATI

or Reient Residents, and perbons dyinq dnav from home.

/^
( V HoH long at

5^^'X ^ ' PI'J'-Pof Ow^h-

Institutions, rransients,

Former or
L'sual Residence

Ddvs

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

ri.

0

ACK Ol- lUKIAI, OR R1;Mo\AI.

'\

J,,,.:Kru<,.:K Vv'^'%-0, ,

\) \ 1 I , ' i5i HiAi- 111 ki;movai,
'3.1 igoH

E OF DEATH In plain terms, thnt it may be properly wlassitiea.

N. B. Every Item

state CAUSE OF DE , . :„,.«„ce

son. dying away from home Hhould be g-ven m every instance.

1

, I

I:

■I
ftf

I ■•«

,|Vl

«#«l^

1

WRITE PLAINLY WITH UNFADING INK

juinni of n

Xi.v.i^v ^'-"

0

\) X{

]f)OH

THIS IS A PERMANENT RECORD

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

DEPARTMENT llF PUBLIC HEALTH-City and County of San Francisco

Ccvtificate of Bcatb

PLACE OF DEATH: — County

m

Nt>.

.t-

i^-

i

^

%

City of ^' ^^^"^ ^J AXi^^^'^UL.Oc

and ^

FULL NAME

-•I A

PERSONAL AND STATISTICAL PARTICULARS

^

t

a

iV

/ ^

\( .!■;

•>I\< ,1.I- M \H k 111'
WIlH t\\ lit < tK 1»'\ I I'l-'' 1 !'
Wi iff ni • t "H

1 \ ihi;h

P,1H ill I'l, \»1"

Ml- r \ I'lii-.K

stall I >; I . iii l\t ! %

M Xini-'.N N AMI

lUR rni'i.Ai. H

t)l MnlMll-.K

1 State iir i'oiititi ^

\l..„:ii

MEDICAL CERTIFICATE OF DEATH

PATK < 'i- 1)1' ATH ' \ .

11:.

I):iV>

.;r|;F.V n-.KTIl-V, Th.ii I attcn.U-a .Urca-^ol fmtn

Muiithi

1 III- ■

_- - l.,n -In - -'—up

tlial I last sasv h r: alive otl ^'>"

iNl .1!

a I

aihat.leathnrourred, n„ tlu- daU- ^tatcl abovo. at
- M The CMSI- Ol- ni'lATIl was as fo!l<.ws

nr RAT ION ^''''"^^

C< (NTkll'-rToKV

Months

Pav

Iloto <

I )r RATION . >VcJr^

lU-ST <)!■ My KN<>\VI.l.n«-l'. AM) Hll.i'.r

(SIGNED) ^^^ ' -\^-^^

Hours
M.D.

Special information onlv f«r Hospil-ls InstituH^s, iransients.
or Refent Residents, dnd persons d^inj ana) Iron, home.

Former or
Usual Residence

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

HoM lonq at
Place of Death ?

Oavs

J.I soF nl^ IHKIAI, OK KKM'.VAI

INI>1:K I'AKI-.K

W^^^

TQO

r\

CuAc

<\ t4v

"^""^"^ II , I |- PHYSICIANS should

' ' ^ulcl b^ carefully supplied. AGE should b« ^J-t^jJ^^.f^^^.^ |„|-orm«f.on- for pT-

„. B.— Every Iten, «* A^^-Tf^S^fpTj^ ;r^" that It muy He properly cla.s.ficd. The 8pc
state CAUSE OF DEATH m P«"«" fV^ .„ ^^^ry Inst.nce.

««n, dylnft away from home nhould he ft.ven

m

1 'P

.1 > .

i I,

If»

''it

(

^1.

H<.:ii(

] wf !I. ;iUh J- No

"wmTE PLAINLY WITH UNrAD.NG .NK-TH.S .S A PERMANENT RECORD

REFER TO BACK OF CERT.r.r.ATE FOR INSTRUCTIONS

'^50 1

••«' «r "-".

343 HS:1' Co

Re^lstcrerl J\^o,

/.././•7W,0ctX^ a.1 190^

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco

Certificate of S)eatb

( XX. S. StanDarO ) ^^

^ . -T^rT r .^ ^f ^ n.-fv 0 AXXA^C \,4.C City of ^ ' <^^^ ^ -^^^ ' ■
PLACE OF DEATH: — County ot C\.^^ j ^ ^^^

Tic^OXA ^ ^^^^^J^^^^ ,^,^ ,, J USUAL H"'.?5.NCE^-- -74 ^N'^A^i," Tn^s^ e7o° ^ J St%"e% ano number. ;

-)

1 ( - [;^i;:;:f ^-i^vrs^ii^^^ -f^?^?^<^^;^ .^J w^^ .^s.ea. o.^s.ree. ano n.^ser

FULL NAME

cuu.^

PERSONAL AND STATISTICAL PARTICULARS

■ 1 \

DATi: OF 111 Kill

,\<'.K.

C<>l,t>R \

iijJvsi_i'

Ai^x

I Month"

\

-\\i.\ V M AKKIl.n

\vin«Avi:i» OR nivoKCKu

.\\'iit» ill vH-ial ik-i^fiiHtmn)

,1 1

(Dnv^

M.niths

Year!

/)</i.^

MEDICAL CERTIFICATE OF DEATH

DATK oi' i)i;A'rii „ , .

(Month!

iDiiv)

igo I

(Yt-ar)

-\

niurin'i, Ai)-

(Stat* or I'onntrv

NAMK 01
lAl'in-.R

niRTIU'LAiH
OK l-ArilKH

(Statf or Country

MAIDI'.N NAMl-
,)I- MOTIIKK

HIK rili'l.ACK

oi' Morni.K

(Slatf or Con nil y

I III'RIUiV Cl'RTIl-V, Thai I Mttcn.UMl dcTcascMl from

OLI^o, IO. upH to ,)D ti^C) looH

that I last saw h i- ' . ahvc on ^ ^9"

■uu\ that .Icath orcurrol. o„ thr- -latr stakd above, at 'I-HS

M The- C VrSI* OI" DI'.A'ril was as follows

^O^^v. t 1 A^> ' ' A,^L^-^

j^Lu-o.!

(^

\\j:^\.o^

Y\j \Xj

o

I) r RAT I ON yciJis

CONTRIIH roRV

J/on//iS

/)iU.

II oil PS

<x

a.

m

/'[)

.t

.->

c>sXiL^<x>vd

OCCri'A I'lON

)',iji

M.iHth

/hn

,... -.,.,, .,-,,PKK^oNM,»-AKTIcri.AKS ARK TKIK To TlIK

'-mw^cj

(Informant \J • ^^ •

(SIGNED) i^ kjOjd:

U/t^ !(,() I fA<hlross)

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

SV^J-iV Jvci^^"' X'Ka- ^T.D..

Wlifn was disease contracted.

If not at place of death ?

'I.ACK ni- lU'RIAI. OR H1;MoVAI.

\<l<lrt'

XcQ %CHl^^t<x'

DAT]", of lUKiAi, or KI'.MOVAI,

o

^ ' 1 90

l^ot.

www ^^-v wV^"^'^
VNDHRTAKKR iJ<XC^^.<A^

Addre.. .111 QTl^<t^Un% at

rs. B.

^ ,, . TfiF should be stated EXACTLY. PHYSICIANS .hould

-Bvery item of Information .hould be c«ref«lly -j;j>":^^; ^^J;;,^ cl«..ifled. The '•Special Information" for pr-
state CAUSE OF DEATH in pla.n term., that it ma> "^ P J
^nn, dying away from home should be given .n every instance.

t

♦;

I .

^•11

rt-rr'

I i

f^^ff

w

RITE PLAINLY WITH UNFADING INK

iv,,r.l ..r H. (Mh r V.

IfJO'i

THIS IS A PERMANENT RECORD

BPPFR TO BACK QF CERTIFICATE FOR INSTRUCTIONS

Deputy Health Officer

DEPARTMENT OF PUBLIC HEAlTH=City and County of San Francisco

Cettificate of 2>catb

( "CI. 5. StanDavD )
PLACE OF DEATH : - County of 0 c^ C /va, . , - ■ . City olOc^^ ^

FULL NAME

^

No.

i

{ ' ^

--i; \

PERSONAL AND STATISTICAL PARTICULARS

\

DA ri: <»i liiR 111

At.i;

A

~r\

M.,ulh

I 1.1 vi

M.>,'li

J I

\'.:i1

Iht^

v IN.-, 1.1- M \Kkii r>

wiiM i\\ i;ii « iK p ' *'' 1 n

, W I iti in -H : r '"

UKTiiri. X''i-

\.<UU^

(N

'-^

N\M1- or

i^\ Tin K

niKTUlM.KtK

ni- I \;in-:K

M \!1»J:N N AMI".

oi- Mt>riii:K

iiiK rni'i, \vK
(>! M<irin:K

, -^t;ii ' ■ >; Ciitintrv

nru

MEDICAL CERTIFICATE OF DEATH

I.ArH <)1- nKATH A

^si Kjn'

.Month. l'^'^' '^■^•='^'

1 in-:ki:i'.V Cl KT1I"V, That I attin.U-.l .leceascd fnmi

^ — \.p t.. itP "

that I hist saw h - alive on ^'P

an.l that .U-atl» ncrurrcl, nn thi- dat.- ^tati.l above, at
\T Thr C VrSIC Ol" ni'ATIl was as follows:

/ , ^ ^ '(in y

DIRATION Yi-ays

CONTKIIUTORV

M on tin

Pax

Hours

nrRATioN ^ )Vr?i-5

( V

/)<7l

flour's

M.D.

XjULo. vxd.

met TAl'IoN

n

•si

r. 'J>.'

s ■ , I /

5 )v<?

yr.nith

/',n

,,,,,,,VK.TVrK,>1.KK:..XU PAKT,c-rKAH.ARKTKtH To T..H
in>T ol- MV KNoWI.KIx.h AND HhKni

ilnfinuaiit

C

Ailfhi'ss

55 CoA^

c

4

( SIGNED ) ij^f\Jiry\JOv J AD \^. kXj

SPECIAL INFORMATION onJ* 'or Hospitals, InstitunbK Transients,
or Recent Residents, and persons dvinq dv».iv from liome.

Former or
Usual Residence

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

Hov« lonq at
Mace of Death?

Davs

I'l.ACI' ol' lilKIAI. OK R1;MoVA1.

rsi.i.RTAKKK W-v>-JL4 0b^<^^x

I> \ ri: ..: Hi HI Ai, i.r RHMoVAI,

190 *.

^UL ^^

■ TTZ AHE should be stated EXACTLY. PHYSICIANS should

•in/dying awy from home should be given in every instance.

it.' !

i-''i

f

1 .

V'A

I
': i

i

w

mXE PLA.NLY WITH UNFADING INK-THIS IS A PERMANENT RECORD

REFER TO BACK OF CERTIflCATE FOR INSTRUCTIONS

}*(ia!il lit 111. 111!! ' ^•'- ■ K.-'v^t ■

190H

Jleo'isfrrerl jYo,

O

503

A \ . » >

^ Deputy Health Officer

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco

Certificate of 2)eatb

( xa. 5. StanDar^ )

A

PLACE OF DEATH: — County of -^ ^'^

^

^No, 5'5'T uA^fr^.^

St

City of ^J.<X^

i

i

>\.C^

^ Dist.;bet.UcX<xxrv<X' and

lA-A

)

(

/\/CA>V ,,.,,., RESIDENCE OIVE "CTS CtLrO FOR UNDtB "SPCCI

AL INFORMATIO
AND NUMBER.

")

(5?

FULL NAME

m

jtOVCJj

(Jt^^-^xc^-vq/i :^

PERSONAL AND STATISTICAL PARTICULARS

^'■m

(•(>1,<)K

^>

DAri. «>I I'.IKTH

Ai.K

A

vMonth)

)■

. DmvI

M,,u'li

Vt-ar)

/'in.

MEDICAL CERTIFICATE OF DEATH

Ii\iK nl- DlvXTII

Uct

Month) 'I>='V)

"~^I HI'Rl'BV Cl-RTirV, That I atten.le<l dftcasea fnmi

u.cL 190 'i tc, 190

rgo

(Year)

SlSr.lJ-:. MAKKlK.n
WinnWK.n <»K DIVoKChl)
iWritciii •-•Kial (l.-iv'iiatinii)

that I last saw h ^^«^ alive on ^

atul that .Icath ..ccurrcl, nn the .latv stated above, at
(j M. The CAl'SF-: OV 1>1:ATH was as follows

IqO

-,|:,t I I .r < '')U1ltr%'

NAMK «H
I AT I IK R

HIR IMI'LAOK
f)l l-ATHKK

iStatf or Cotinirv

MAIIH.N NAMK
ol-- MOTHHK

nl Mt.TUHK
(Statr III i'ounti V

orrri'A i'n>N H

r^

'^

<^

n

1 I

K.^^

I )r RAT ION Ytars

CoNTRIl'.rTORV

Months

Dux

'S

Hon* a

DURATION >Vc?rjy J/<m/Mx

( SIGNED ) Ua^MVv M lUX-^V^

Pa

VA"

LI

J

li^

^cu^^^xL

c< *. I()0

( A.hlress) b 0 5 cL<xq^v^xa-

SPECIAL INFORMATION only «or Hospitals
or Rrrent Residents, and persons dying away from home.

s Insnlutlons,

flours
M.D.

it

) I'll I

Mnilfll-

/h!

TUV MU>VK ST XTKI. PKK.ONA1. I'AKTirri.XRS ARK TRIK n» Till-

(lnfo!iua!it

Former or
lisual Residence

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

How lonq at
Place of Death ?

Transients,

Days

PI XCK <)1' lUKIAI. OR RHM«>^ M
qkn A /^

c

rNI>i:RTAKKR

i)Kri'-.f 111 KiAi, or REMnVAI,
aJ'^X' -. : 190'.

V^<t^t^

*«n/dy1«g «w«y from home .hould be given In evry In.fnce.

! !

I

!

t

I!

t

' \

W.'

iv;

<::> '•

P%J

1^

' '1

4 <l

11

■itfU.

't»I^:

f

l»

it

w

RITE PLAINLY WITH UNFADING INK

uS:!' C

THIS IS A PERMANENT RECORD

«EFEP TC 3^C- 0-- CEPTir,CATE FOR INSTRUCTIONS

])

ute /'V/r./.L,ctcrl

,V-t\'

A t\

1U0\

rfj XO.

•3.-04

DEPARTMENT OF PUBLIC HEALTH=Citv and County of San Francisco

Ccititicatc of Bcatb

:^

PLACE OF DEATH: — County of-<x^^

No.

City of 1 <^~>^ -^ ■

and

(

IF DEATH OCCURRED IN A HOSPITAL OR IN^tmu ^

)

FULL NAME

\

X.

- 1 . X

PERSONAL AND STATISTICAL PARTICULARS

I *

> \ i j: <»i lUH rn

n-

\' .!•:

HI

M.mlh !

!V,/'

I

i > !\

MEDICAL CERTIFICATE OF DEATH

I>A 11.

i; Kill

%!

(I)av^

/0">
I V carl

1

'^

I- M \K I- 1! I>

. I I , , ,|; 1 ilN'i iKt' i: l>

I m-Rl-nV Cl RTIFV. Thii I atu-n.U-.l .Ur. a^c.l from

K, w W £- .

icp

that I la-t saw h -" a.ivc .>ti
.,„a that acatl, .H-ourro.l. nn tlu- -late .tal.-d al.nvo. at
V.W M. Tl'C CAl S1-: ^»l- ni.Alll ua- as follows:
C . . J*

-, .. M 1 "I
I A rilKK

I'.ik'nu'i.^*!-'.
(i! I \rm',H

■^t ..! I . ,T li ill lit ' S

M \ii»i:n namk

()! MOlin-.K

|;1H rill'l, \i 1,
(ii \i<rrill'.l<

I st:,!> 111 (iiUllt I S

nia ri'A ri<»N

/,V hh,l III ^^•t'l I ' ••'

.AJ^u

m K \ riON )V.ir.

^ .*> \ /hl\ S

I /oil I >

!M U \

< \ r ' I ^ "V

\

\K 1 |. 1 i ^i':

I I 11 i ,• llUIIlt Sw- . v_-

\in nu i

i SIGNED^ ^ >

/>.n

Hours

M.D.

SPECIAL INFORMATION onh lor Hospitals Institutions, Transients.
01 Rfcfnt RfvidfBts. and ^m«s rf^nj a^.^^ tr.ni homf.

Ho^ lonq at
•«^"»fV". Pla.f of Dfath? Oay^

WIlfB *i^'' disfjvf ionfi.»<t{Hl.

II m\ at Natf «»' df^^h ' >___^_ii^— ^— — —

a:is M il.x'v K .i

i< \

^\^

V
o

! KlMoXAI,
IQO

0 "xcXv. sv

S . s ',

\ M

k >. *.

N,»^^.«-^ ^ "-

II . VuU » ^ .ii«i'l'" •'

IN.

M.I.CAIIS, Ol m Mil I.. ,....!.. ,. .^- • -

I

!■ (

. (
I

I!

i

1
^

4

i

WRITE PLAINLY WITH UNFADING INK

'-. \' S'

^X-rs.^i: V.S^V C-

\

Dnh' /'V/r^/.L'ctcrt-t^ VX

]U0\

THIS IS A PERMANENT RECORD

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco

Cevtificatc of 2)eatb

0 f?^

A

(p

I PLACE OF DEATH: — County of^^^

City of C'<x/^ru o A^o^v^^^A^c

No.

I Qf ^ Dist • bet ^^ ^^ ^^^

)

FULL NAME

.{rv'N.v.

(iijd

■^v.s

PERSONAL AND STATISTICAL PARTICULARS

^ v;t»I,(>K\

i.\ 1 i "i i;!i< I'll {\r\s

IL

M.iTiih '

\« .K

m r,..,... 1

1>.1V

M..„'!,

\s

WAV

I hi 1

\vn>< »Nvi i» < 'K i»ivnRri-.n

Bik run. \>'»:

^t.iti Ml I ..'int! \

MEDICAL CERTIFICATE OF DEATH

DATH OF DlCATll |^

(M.mlh) '^*='y^

I III'KIFA- CI-RTIFV, That I attrti-k-l dcH a^eil from

tliat I last saw h --' alive on - -^ "^^ ' ^^ '

a„a that .U-ath ncrurrcl, en the .lat.' stal.-.l ahnvc. at 1>
CL ^I. The CATSIC t>F Dl^ATll was as follows:

J

1 Alii i:k

1UK IIMM. \*'J",
ni- 1 \ ni I'.H

iSlati 'II r.i\uit'A

MAn)i:N NAM!-:

<)i- M<)Tin:k

lUKTlIlM.A*!-:

oi- M<»riii-.K

I St:itf 111 CduiiIi y

tAvU^.A.A,...^

DIRATION >'';"^

CONTHIIUTORV '

, 1^ "w »- I

u I

-Uax, QkoJu-'^ '

I V

oci. riA rioN

h-r i.liil III ><i>i / I <!»• '•'" ^ V \ ■

DTK AT ION
(SIGNED)

Miuiths
Miiiillis

\ /></rs

Hour

l\}\

^\

/fi>urs
M.D.

I<>n

Special information onlv fcr HospUdls, institutions. Transients,
or Recent Residents, and persons d)ing <ih,.v from f«ofne.

How lonq at
Plare of Dcatti ?

Days

(Iiifi);inruit

\.Mv

•s>i CK (Ak "J

ii

Former or
Usual Residence

When was disease contracted,

If not at place of death ? ^ . _ —

(Ad. Ill

I

^^.^_^i^— — — — i^— ^"^^ "^^^^^^^ I pxACTLY PHYSICIANS should

state CAUbE Ol m a .^ ^^^^^ instance.

sntis dying away ^rom home snomu i.c »,

m

n i<

ii

M

WRITE PLAINLY WITH UNFADING INK

l)((fo Fi/rfl, v_

190H

THIS IS A PERMANENT RECORD

REFER TO BACK QP CERTIFICATE FOR INSTRUCTIONS

Ecs'i.stcred ^'^o. ■— '>vlO

DEPARTIIIENT OF PUBLIC BEALTH=City and County of San Francisco

Certificate of ©eatb

( XX, S. StanDarD )

i

PLACE OF DEATH: — County of O.O,

^

'S

City ofCJ/Cx^/w. O/vcv. .

rttn^V^^H , »i;= .v^.Y TROM USUA

Sf Dist.;bct. ^*^^

RESIDENCE G.WE TACTS CALLED '■°« 7^"^; st%EEt";ND NUMBE«.
OR INSTITUTION GIVE ITS NAME INSTEAU

" )

• bt.; L>^1SI.; 0%,l* u„DEB "SPECIAL INTORMATION " ^

FULL NAME

m

\j

I \

,-i

^co•.^

t

^i:\

!, \ 11. oi lUK rn

A<.H

PERSONAL AND STATISTICAL PARTICULARS

)

MnuHv

\'< ;ir)

Ha

MEDICAL CERTIFICATE OF DEATH

DATE OV DKATIl i( ] .

wet ^ ' ^

(Month) 'I'^'>-^

^Year)

" I lll-KPIiV Cl^RTll'V, Tl.at lattcmlc.l.U-cease.l fn.ni

l(p<b

\VIl)«t\Vi:i» OK I>lV.»Kv 1.1

iWtlt. ill «Hi:.l ,UMiMl;H!..ll)

IUKTIiP!.ACK

Statr or Oonnli >

NAMH <>|
KAIHlvR

RIKTHI'I.Ari-,
Ol- lAIHl-.K
(Stall- or Coniiti V

MAn»KN NAMl-r
OI MOTHKK

lUK rUlM.ACl".
ol- MOTHKH
(State or (.Nniiitt >

190 M

that I last saw h •'.- • alive on '^O

and that death .ccttrretl, .>n the .late stated above, at »
M ThQCAl'SI' Ol' I)I';ATII was as follows:

^

u

.^r^j^^

CONTRlI'.rTORV

Mouths

Pnvs

Hants

\xn^^^

Years

Montiu

Pa vs

TqO

(Address)

Hours

M.D.

Y\:

)',•(! I

DIRATION
(SIGNED)

SPECIAL INFORMATION only tor Hospitals, Institutions. Transients,
or Refenl Residents, and persons dying away Iron, home.

%v^\

/)<7 1

^^^TltlSi^^

"^m

Former or
Usual Residence

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

How lonq at
Place ol Death ?

Days

ri.ACK<^K Bl-RIAI. i)K KKMc»VAI,

DAl'lCof Ht KIAI, or KHMoVAI,

(Aa.i.4is.n^i O'

o. . .

f ^'l*''^^^'' ^^ , " ' I I I I I I I r PHYSICIANS should

ii
I

!

H

»M

tl

' {

Ml

.-Ji.

Mi

WRITE PLAINLY WITH UNFADING INK

,M,,1 .,f 11. 'I'l 1-

VHJ\

THIS IS A PERMANENT RECORD

REFER TO BACK QF CERTIFICATE FOR INSTRUCTIONS

i \1 ,, Deputy Health Officer

DEPARTMENT OF PUBLIC liEALTH=City and County of San Francisco

Certificate of IDeatb

( u. S. StanDarD )

PLACE OF DEATH; — County of O

J

City of C ' CU-v-v.

am

m

No. j;^^^"^^

-N r -U UW L^V — ' ' St.;-— DlSt.;bCt. .spj-c.aL iNrORMATION- \

^

A

FULL NAME

PERSONAL AND STATISTICAL PARTICULARS

.1 N

*( i!.< >k

MEDICAL CERTIFICATE OF DEATH

I)\ IJ t •! iUK 1 il

^

i V\A

M-.nt'' ■

/ t

i >.l N

> ( ;i

r)

\ t . I'

/hn

DATK »>1 ni'.ATH

(Dav)

Year)

I llKRKTn- CKRTIFV, Thay atU-n.K-.l <Uo a^.a fn-n.

Vw^

liiO

' I

t„ iDct ^^.

SIM ,1 !■• M \KK HJ)

W1I>. .W ID MK I):V<»K> I- I)

\\ ■ 't

BIKTIIP1.A0I

I A 111 J K

lUK I'll iM. xri-:

Ul 1 \ IHKK

(Stati ( ir t'ouiit '. ^

MA!1»J:N NAMl.
()I- MOTHl.K

lUK'I'HIM.All'.
ni- Mn'lHJ'.K

I )t . r r \rn )N

\ ;.>ii

B\<XKK^ ■ -^

cl=

I<)0

that 1 la^t -^aw h - alivr on

,„athat.Uath.KTurre.l. nntlH-.laU^tat.a alnnv, at

M Tin- CAISK oF HKATH ^^a-, a^ folLnvs:

Hours

X

\

nr RATION ^ 5""^
(SIGNED) ^^V-^^^ J^

Months

/hrvs

KjO

fA.Mrr^-) iOD^U^giXvwCA

,-0^

Hout s

M.D.

SPECIAL INFORMATION only for Hospitals. Institution.. Transients,
or Re«nt Residents' and persons dvinq a.ay from home.

s -

Former or qqallnl. .

Usual Residence 1 i '^ V ^UA.

When was disease rontrarted, ,
If not at plare of death? 2_

How lonq at
PlHff of Death?

w.

Diys

I'l ACH OF in KIAI. «.K KKMoVAI,

/'6

I ni)1-.k'iaki;h

i)\ri . ■

!' H I H I

K l.M< i\' \I,

Ci>>C^-v

Qf>U^

.^s^^TYV

■m

'^1'^''^'^ ^ '^ " ' I I I I I I r PHYSICIANS should

m

r,

I ,

■r
I!

li

>!i.'

li

M

It

m

WRITE PLAINLY WITH UNFADING INK

THIS IS A PERMANENT RECORD

REFER TO BACK OF r.rRTIFICATE FOR INSTRUCTIONS

Dfffr /•V/r^/,l!J/ctM>t^' I'X

IDO'i

Be^Jslcved .A"o.

O^

07

Deputy Health Offlcer

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

Certificate of IDeatb

I XX. S. StanDavD )

-^ . City of

((^

xa_

J X o ,

PLACE OF DEATH: — County of

{\ I , , ■ , <:*. ■ Dist • betM il^^A^.^nv and U^OA- .

mr ^ U ^-^^ dl k I ^ * ' ' '^f'* L^lSt., DCU ■* „^„_o "special i n formation- \

FULL NAME ]"■ ' [ ^^ .

• 1 \

PERSONAL AND STATISTICAL PARTICULARS

<( »I < iR

mIIcuU

i».H ri: ' »i

\< .l•

-. I \| , 1.!- M \ K I- n i>

\\ I 1 M .\\ 1 1 • t "K I I ' ' '

lill' I'll fi x»'i"

1 \ 111 1 K

ink I'll I'l, \ii-:

oi 1 \ I'lII.U

(S(;ilt i>] I'. .11111

M \II>I.N NAMl'
111 Miil'UMK

lUH in ri, \ii'.
( >i- \!< t rn i-'H

>^ t . 1 1 I 1 I i i ' I 1 11! 1 1 I 'i

( II ( r 1' \ ri< >N >

M.intli

l»:i\

'l ■ l!

TQO

(VL'ar'

! \

A 1

C3 K^r^O^^

MEDICAL CERTIFICATE OF DEATH

DA IK t>i- i'i:\'rH I \

(Mi)nlh> ''*''^

1 HI^KKBY CKkTIFV, Thai I altnuU-M -U. .a.ol fnan
upH tn . ' J'^

that I last .axv h iliv.-.-n ^- ^'^ "

a„.lthat.Uatl,.uvun.il. ..nUu-aaU-.ta.c..lah..v., at IMS

M 'KXxK.- CMSI'-. <>l" ni'.ATll xva-^ n-, foll.ms

^

aa.%

{)

^1

Nj

i,cubU 43j^xy^>vi>vycxlA.^v c^

+^

I )r RATION
CONTRir.lTORV

, 0

i .I/<'/,'Mn

/></!'

Hours,

\j^j\J-J^^^.^t^>M.

VC' > > wCLa

^.cxq^. ■

CL^'VCm

DIRA ri"N
( SIGNED )

Yiars

I J

M tiths

Day

I/lUttS

M.D.

s. '-',. ■ ^ <

I < (1)

f A.Mr. --)

a,

^\4

<..J A..

xxaW^-^cj^'^^^

f^ru.lfl in S,iu I

,. HO ).."

1

/'

, ,, \ i> I r u' 1 1* I < • III I'
HKs'r <>i MN K^'»^^ i.J.n'.i ^ -I • -,^

SPECIAL INFORMATION «»!> I- "«?»"^. I"^'''""°"^' '""^""'^'
„, R^eM Wrms' ^"4 P"-onv d,i«, a.a, Iron. ho^r.

Nrmcr or
IsihI Residence

When was disease contrafted,
II not at plarc of dealli ?

lo\* lonq at
Plaif of Deall»?

Days

,.,.XcK OF lUKIM. ..K K»:M..VM.

(Inr(i!iiK<nt

iiff;.

^11* C!L^^

INKl.K'l' \KKK

fA.iai.

,(1

U

!

I in \i. "I K1:M«>V Al,

I

rjAxxu

S5^- ^^'^ ^^'^^-

^1'"^^ '" ^ iiYAGTLY. PHYSICIANS «hould

'ill

i

ii

r

fT*

WRITE PLAINLY WITH UNFADING INK

THIS IS A PERMANENT RECORD

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

i' •.!

I)((lv /v/f^^/A cIctIma^ 9^^

WO'X

Jlec^Lsh'iPd JS^n.

0"-:^Q

DEPARTMENtIiF public HEALTH-City and County of San Francisco

m-

PLACE OF DEATH: — County of

Ccvtificate of Bcatb

14t). t>

'II

• ^ D'ct ♦ he^i and

,X,(rr>XCUi ■ W C>N^, VV -J^ ^J'ii^rr n.V. rACTs'cAUtrO rOR under SPCCAU ,NrORMATK,N- \

FULL NAME

L

^kLo^AX^ UXi->v\'vV

PERSONAL AND STATISTICAL PARTICULARS

I> A

(>! i;ii<ril

U +

/ 0 L I

\ < . 1 ■

WIlMiWKU «»R I>t^ '

\\!'!- ill - ■ i' ■ ''

niRTHI'l.\>'K

MEDICAL CERTIFICATE OF DEATH

v.- a I

N \\1 1 • >1
I \ I'll ) K

lURTliri.SrK

( M ! \ I'll \:\i

■-t.ltt I'! ^1.11111

M \!1)1 N N \M 1
OS Miilin'R

HIR riHM,\CK
(»| MorilKK
I ^t ii t 111 i'liuntt y

(Ki'ri'X TION

:t\

\\

I in^KKHV . KRTIFV. That I Mtt.n.U-.M-.va.cd \vnu

that I la-t -;nv h ilivmii ^ " ^''''

,„ath:.l.Ualh.KH-urrc.l. ..nth.aat.^lal.a al...vc. at

M, The CATSK OF Dl-ATll ua^ a. toll.u^;

■ :>^

<X^x

-O

' (^ ^ ■">

l»r RATION

CONTKII'ITOUV LlwU'

.1/,"////

/hiv

//our

-\

^

A

,-> V I,

^rn>///ls

CO 1)

\ *

dtk at i on >'■'''''

(Signed) ^

/?.7t

/ /outs

M.D.

CM„lL<X/'v-ucL

n f - W I < f ' < ' -— ni -^M^-»«^ '.'III'

kii^AL INFORMATION onK t«r Hosp.Ws, Institutions. Transients.
orl^M Mi;.!^ and l>ersons d.inj -h.> fro:,, home.

Formfr or i ^^ '

Usual Residence ' '- ■

When m^ disease fontrafted,
If not at place of dcatfi ?

HoM lonq at
Plar e of Death ?

Oau

J.,, UK -'K lUKlAl. OR HKMOVAI.

l>A

i;t HI \i 1.1 R1M»»V \1,

inn

CDl.K I Akl-,H H > \. s^

\(M;t<s

' \ , , pvACTLY. PHYSlCIA^iS should

%TH 'n pin-.n termn, that it may ^^ [»

N B —Every item oi int'or-m

II

• l!

Ft

i

-■

11. *?

H

I

W

R.TE PLAINLY WITH UNFADING INK-THIS IS A PERMANENT RECORD

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

;>v r !■

IWWiW^i"

Duir rih>(l \)cXaA>^^ ^3.

/^OH

Baiislerod jYo,

^\^KJ^

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco

Ccvtiticate of Bcatb

XX. 5. StanC^av^ )
PLACE OF DEATH:-County of^Ct.. J X<X-c-^- City of-C^^Axx . .

'-V„trVLixL

St.;

Dist.; bet.

and

FULL NAME >

-TS^CALLED TOR UNDtR SPECIAL . N FO R M AT . O N • ' \

;t1 name instead or street and number. J

PZ

RSONAL AND STATISTICAL PARTICULARS

--1 \

MP

1) \ 1 1, 111 i'.M< rii

\^C

v^\

.WW

\< I

•^IN. .Ij; M \KK II 1'

It 1^ r 1 1 1' I ■* 1 ■ 1-

MEDICAL CERTIFICATE OF DEATH

!>;1V

I Month >
HFkKBV CKKTII^V. Tl.at I aUcn.K-.l.kHva.cl fi-.n,

1 \ 111 1 U

luK rm'i. \i !
>r 1 N rin K

-,1 ' . , ,! I 1 in til ! >.

M \ ! HI N NAM
(tl MoTin'. I<

I'.ik'niri, \^i.
«>i' \to*rin:R

I Stiti i»r <.'(iniiti y

^0

^ »

tbal 1 la>^t saw h alive- on

,n,lthata.ath..r.ur,XMl. nntlu-.lal.^tat.a alnnv. at "

M. Tlu- CATSK OF 1 u; All l^xva. a. fuil-.u^:

ItjO

nr RAT ION >'''^^^

coNTRir.rroRV

Months

Ihix

Hour

'\ ^1

A

I )r RAT ION
(SIGNED^

}V„'/

n n/Z/lS

/hn

M.D.

f

+■

«Ki I'l- XTloN

/,>,■, ,,/,-J III "^i"' I '

Iiif.i-r.Kint

^

XU IKTl.NK-- \K

IKl 1' 11

Tin- AHOVK ^' ^' '\1' ' ' 'Vim f' \N|. ni*l,lK

<A.

VpEC.AL information o.ly .«r fepilnK Instit^li.ns I^sie.ls
or Remi Ment., and persons Mn ''■'^ I'"" I-"""'

How lonq at

former or Q i ^ I ^ n i ' Plare ol Oedth ?

Usual Residence \\o ^u^

When was disease contracted,

If not at plare of deatti ?

XCH ol^ lU RIAL MR R1:MmV\I.

Oavs

i 1 ^^^

v^Co. 'dtcv^V

-J v

Rl

1 AiMn'-^

DA 11'

i;- in At .11 R I'M' »VAI,
TOO

X.i.ln.s WV.V.M _.__— — — — — """^ ^ 1 FV4CTLY PHYSICIANS nhoultl

.tutc CAUSE Oh ^^_ATH .„ p.B.n^^ ^^ ^.^^^ .^ ^^^^^ ,„,,„„,,.

•on* dyinft aw»y

^l^i^-^^

tVom home should be ft

y^y^if..

,1

'i' •

1

'

^i (

it

**w

ii

im

WRITE PLAINLY WITH UNFADING INK

THIS IS A PERMANENT RECORD

REFER TO BACK OF CERTIFICATE FOP INSTRUCTION^

ih,fr riir<L ^ clt^l^V 1^

I'JO'i

Megisterrfl .V^.

opti n

KA -L^x

^

Deputy Health Officer

DEPART^IENT OF PUBLIC HEALTH=City and County of San Francisco

Certificate of Beatb

n. 5. i?tnn^ar^

PLACE OF DEATH: — County of
No. 'I !

City of ^ CV. >

V

■ ■ ' ' ^ ■ St.; DisUbet. ,„„.. ,..;\"l,o~. >,

FULL NAIVIE JVoXOl

PERSONAL AND STATISTICAL PARTICULARS

11

); \

MEDICAL CERTIFICATE OF DEATH

], \ 11.; oi in. \ III

i Da yi

\ ■

!!!!■■ ill

M XRKIl

\'" !'

1 \ri! I K

lUH Til IM, \i!-.

->;,', , • . nnt! v

M \l 1>!'N XAMl

« u- Mi»rm: K

luiri'ni'i.xti:

urrr\ri»»N

d

I IIFKKBV CI-RTIFV, Tl.at ! alU-n-U-l .K. . as.-l Ir mu

,„.lthat.U,.h,KainT..l. ..nt1u.la'. .aU-.l ab..ve. at I I
(J^ ;^j '1-lu- fAiSI-: <»1- l»i;.\ ril ua^ as foU.ms:

ink \ TH >N )■<,//<

J/, '!////<

fhns

/fours

DIKA Ti* >N
f SIGNED 1

/),n^

I loui <

M.D.

.X IMOH

A. Mia

0

\jj^<:x.'s\^

'^ ^

,, ..,uib I = XK- \KKTHrK T-. THH

SPECIAL INFORMATION ' '- "-Pi'-'^. '"^'""«»"^' """^'"'^'

or tocnt Residenls. M person^ d^ini .i<>h> Irn, h»w.

Former or l| ,.

Isual Residence h^k^^^ > ■ , '

When Has disedsf ^nlrafted, il .

How lonq at u ,

Phireof Death? ^^ R^^^

II not at plare of deatli ?

: III fi >• ni.-mt

rM>i:K r AKi'.K

i.\ n: >' H' i-^i

^^''"'' ^r^ 7( TirWCTlY PHYSICIANS Hhould

;S. B.— F.very Item ot" '"^'^^'^^i^" f„ " j„ t,„„s. thnt it m:.> he properly .loHS.I.ed.
stote CAlJSn or DHATH .n '' " \^"^ ^^„ ,„ «very mstance.
«nn, dy-.nS away tVom home should h. ft.

( 1

,1

f

ii

1 ^*PJ:

«>

I

■

m

WRITE PLAINLY WITH UNFADING INK-THIS IS A PERMANENT RECORD

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

1. F V

^^ :^.xK, Deputy Health Officer

Jle<sisfrrp(l >jYo,

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco

Certificate of Beatb

( xi. 'l'- il'tiiiicav:

^lr^ :

PLACE OF DEATH: — County of

0

M ii

rN

I

Nu.

M

St.;

Dist.; bet.

City of O CX.^' 0 V :>-

and

^IlED rOR UNDER SPECAL INFORMATION- ^

-' a.

,MoM USUAL RESIDENCE ^^'VJ J^^^X! ^M^AmV mSTEAD of STREET AND NUMBER.
NSTITUTIO^

FULL NAME

PE

RSONAL AND STATISTICAL PARTICULARS

--i \

T^

I iK

~\

N \ M i 111

I \ ! II 1 K

A ■\

^K

MEDICAL CERTIFICATE OF DEATH

1) A ri-: t >1- IH-.A TH

, m^kl^UV Ci-RTIFV, Thai l:,tU-n.k-a.k.,:.-a fp.ni

thatl'la.t..wh-e^ aUv.nn i^^ -^ ^'>°^

,„athat.U.uh,...urrca. ..ntlu.lat.^tat.a alu.v.. at I I

lX M Tlu f AI^l^ '^1 I'l Vni vva. as loll-ms;

M,>ut/is

Ihi

// .,>

U

lit'

(U Mnriii;K

lUH riiiM, \< v.

t»l Mi»'ilU', K

«u 1 I 1' Xl'li >N

K,

TllK \n()\l* -.

f In fii- 'uatit

A

niKArioN

f SIGNED ^

Ts

^ h ,■->

lhl\

M.D.

Ki'iH

\a.iii

When H3S disprt^f Antrartfd, M o- /
II n«f .It (»I<<<P "' <!"**' ■ ^^ '

I \\, oH HJ' M'i\ '^i.

SPECIAL INFORMATION on»'«' ""^Pi'-'^ '"^l"»"""^' "-"''■"'^■

\\m lonq at g

rnrmpror 11 ,. ^ •. clkt ot Dfdth? A\ Pavs

Usual Residence M4^^<-

iu:m<i\m.

^ ''^"^ T n . IIWCTIY. PHYSICIANS Hh„uia

ftiT-*

1 !

II

•Ii

I 'I

I ti

.1

^m-

M

WRITE PLAINLY WITH UNFADING INK

Honi.! .f H^a'tli t

Duff rUr'L yctcrlr^v %%

li)(n

THIS IS A PERMANENT RECORD

REFER TO BACK OF CERTI FICATE FOR I NSTRUCTiONS

]^e^>i shared J^o.

,^\wCO

Deputy Henlth Officer

DEPARTMENTOF PUBLIC nEALTH=City and County of San Francisco

Ceititicate of Bcatb

PLACE OF DEATH: — County of O.o%'

ft A -, ■ h

^'V

City of CJ Cu^v -J A

'^ ^ , St.; Dist;bet. „„ „^„.p special iNroRMAx. on- \

( ,r DEATH OCCURRCD IN A HOSPITAL OR INS^ ,^

FULL NAME

Ll^mJa.

^W

< I

>-i.x

PERSONAL AND STATISTICAL PARTICULARS

>

;»\ IJ 111 lilH 111

i< .|•

SIX. I.I' M XKK n"i>
U I IM .\\ ) I I * •!< ^

/

i)\ n; <>i- DHAiii 1,^

1 \ I

MEDICAL CERTIFICATE OF DEATH

'Oct

/on

N'.H!

:k nn'!. ■> ■ »

I \ 1 II I K

niH rni'i, \' K

ol I NTin-K

M \ii»j:n n \mi:

«)1 MoI'lll.K

lUI'iIi I'l. xi H
.11 Mollll K

I ■-( ;,t I 1.1 ti lli ill 1

{\

H.

0^

(Month) "'^'^■'

I ilKKKHV Cl-RTIFV. That I attcu.U-l -Uhh asd tmm
t L UP'^ to Let .MoH

Uial I la^t .axs h -■ alive on '^ ^ -

^,„.n|,,,t.Ualh.Kaurrc-.l. ..., tin- .laU- .taU-d abnv., at
M. Tin- fAlSK oF 1>K.\TI1 was as foll.-svs:

.Krr>

w

/hiys

Hours

Ihns

SIGNED

\^*^

Hours
M.D.

I:

i^i^T^iTl NFORM ATION onh lor Hospitals, Institutions, Transients.

\t,.,i'ii

Hnt'

or Refeln ResVdenls, and persons dvin^ a^..s Irom home.

p /7> How lonq at

former or ^x IK. ^^, d ' ■Pt«re«ol Death?

Days

When was disease rontrarted,
II not at plar e ol death ?

/Cx/v\)M w^v

vQ

M<^^A'

,., xn 01 nrK!M-"H hi m..vm.
rM>HHTAKl-K H^ ^ . ^ ^:

I, A IK,,' n-Niu ..I hi:m<>\ A

3^H

T90H

N. H.

'" ^^ ^ PHYSICIANS Hhould

' ••' "r;j'r:r;v:,;^s:':~:-:; r:;;t ,.:;:-XS:r-;;; ■- ; ■..,. .-

«tHU CAUSE Ol Dl ATM "1 Pi"'" ^ Instance.

;'n. .lying nwny from homo Hhould be ft.sen

i

,1
•i

" 1

,1

'II i

I

w

RITE PLAINLY WITH UNFADING INK

THIS IS A PERMANENT RECORD

REFER TO — -'- rrPT.nCATE FOR INSTRUCTIONS

nfx4 o

It \ 1 1

IffO'i

Jico'i.slei'pfl «/V7>.

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco

Ccvtificatc of IDcatb

PLACE OF DEATH: — County of CJ ex.

City of

U a^'>'^

ii

No.

Sf Dist.;bet.^'cicv.^<^ and ^

)

St.; UISTm Del. ^^^ „^_„ -spt-clAL .NTORMATION \

A ftp u ^ 1

FULL NAME

l/(>4_.C,

PERSONAL AND STATISTICAL PARTICULARS

^

-M

\

vl)^>

i( il.t >K

, \ 11.; I .i HiK rn

\1 . Ml

MEDICAL CERTIFICATE OF DEATH

I, All; i>i i.KA Hi

\« .K

1 r M \KK iri»

^

I HKKI^HV CI.RTIFV, That I ,.it.n.h-.l .U. .a^..l in-n,

t1,at I laM ^au h al.vc- ..„ "''^

„„l,hat.U-all,...a-urre.l, nntlu-aaU..ta,..l ah..v., at .

' M. TlK- C.\S--K <»l I'l^ ATI! Nva^ a. UAh'^^.^:

6tdX Q>b^^d^^^<

'\X^.AA.' •

^

H ri. '<■)

^»

CJOs^^X; J )VC:

Mi < '

, ; 1 i i 1-'

I'.n.' Ill I'l, S' !■:

•,1 ll . I i! 1 1 .11 III

M \ Ml) N "-' \ '^l
Ml MolHl-.K

ink iin-i, \rK

(.1 Mnrni'.K

-,t lit' 111 r.Huiti ^

t), ,1 1' A IK tN

"I

>

\

'\

A

1)1 K \ rioN

)■/ (// s"

Monlhs

fhn

Hours

H

^xi' '^n

,^

.a.Lc%^'^

I )r RATI on-
Signed )

) ',,11 s

)r,>ni/i

I hi

\\A.\

N

M.D.

f < )"

\.l.lr

■special INFORMATION o"lv 1^' li-^'l-'^- '-»'»"»'»-• '^-"^'^"♦^'
„,1^M mJ^I^ -nd P"-"^ rt)in^ a..n Iron home.

W I

» 11

' I II fi i: mUit

rwTv

^i) .

Nrmpr or
lsu.ll RfMdpnre

WhfB w.is disrasf rnnfrdclffl,
II not Ht plat pot dpatti'

Hfm loni| at
pirfif (it Ikdih?

Oivs

i>>

I- I Ml

1 <■)' >

\.Mh -•-

aiH

y

i

, 1 1 1 1 ' r \

I

/tX/^^

N. B.

" . IIX4CTIY PHYHICIANH Hh..uld

- r,;;^;;"Svr;;;:" :;::-:: ~;:t ,;...^; i-;" -• --'

«^n« «i>-.»a »^"y *••"•" *'"""'

,t

»'

WRITE PLAINLY WITH UNFADING INK

J)

((/(' /u/rff,^.QXjXhiJ\j "XX

iva

THIS IS A PERMANENT RECORD

WEFER TO BACK OP CERTIFICATg FOR INSTRUCTIONS

Registered *A^. . i o

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco

Ccvtificate of Beatb

( H. S. StanDarC )

^^r>

(?n

PLACE OF DEATH: — County of ■

City of C3x5^'^^ ^J.'vo ,

St

Dist.; bet#

and

-)

(

' ,Vor.TH"oc"u%ro',"r„o"s'pr.t o%"n"?u"o';"'c,.. ,T, NAME ,«ST„0 C. .T.e.T .»0 NU-«.. ^

^^

FULL NAME

PERSONAL AND STATISTICAL PARTICULARS

■ KN >^

•i >I <)K

O

1» \ 11. <»J HIKTII

Mont!-.

Ai.K

' 1 )a V

1/,, »////»

( Vcar)

Da v.w

HIN«*. 1,1-: MARUn l>

WIIX t\VKI» <»K I)i^■• (RtKI*

i\\!itf in >.iH.ial ilt^ii/nat ii lu)

BiK rm'i.Aoi-:

(Slat I- or t.'Dunti ^

MEDICAL CERTIFICATE OF DEATH

DATK 01-" 1)I:ATII I \

(Month) <I>ay^ ^^■^■^"■'

1 l!I':KHnV CI'IRTIFV, That I attcmkMl deceased from

———--190 to 100

that I last saw h :t— alive on ^*P

and that death occurred, on the dati- stated above, at
M. The CAl'SI': t)I' l>l':ATIf was as follows:

!• A rin;R

JUK IHJ'l.ArK

(M 1 A iin-'.R

iMatr oi t^ ouiit! V

MMHl'.N NAMK

01 MirniHK

niK riii'hAi !•:

«»|" MnTHHK

(Slati- ur iNiuntiA 1

(HAll'A riON

\/,>l!'h-

Ihn.

T.iK AH.>VK STXTK.. ''HRSONA, P XRTUM^J.AK. AKK TRfK To THK
in'ST ni- MY KNOWI.I.IX.H AND IShl.n.l

(Inforniant

I )r RAT ION >V.7r.?

CONTRIIU'TORV

I )r RAT ION }'i'in-s

Mont/is

/)lJ\'S

Hour

^fonths

A \

Pavs.

(SIGNED) KJ^XJry-J^^S^. Uw ^^ 'y - *
U^t ..,; looA (Address) U^^fr^v>^^^^j

M.D.

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

Former or
Usual Residence

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

Hov« lonq at
Place of Death?

Days

I'l \CK nl- HfKIAl, OR RKMoVAI

\

' JU^^-Vv-vvi. w .^xXJ>.

n

DAI) ot Hi KIAI ot RlCMoVAI,

I 1

^

tuA) .-s

T90

ci.

( \(l(ln'>-'<

INDICKTAKHR s/ wLA-AJUu "- -^ ^-^^

(AtUlri'Ss. OVJ L • k ^

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

U

I

1 I

i I

P I

I'

WRITE PLAINLY WITH UNFADING INK —

r H- "Uli !■ ^

, .. '*^?^^>;- IKS.!' I'u

lorn

THIS IS A PERMANENT RECORD

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

Eeglsivvcd jYo. -

kA ciX

.:::t,

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

Certificate of IDeatb

( TJ. S. Stan5ar6 )

: OS?

PLACE OF DEATH.- — County of . J.\.o, GtyofCJ.O-.^

No.

OAX

St.;

-Dist.; bet.

/ ir DE*TH OCCURS AWAY FROM U S U A I. « t » 1 l^ t i'. w ..«..- j---- " ~ " " " -
C ,r DE*TH OCCURRED IN • HOSPITAL OR INSTITUTION GIVt ITS NAME

-and

.«OM USUAL RESIDENCE cv. .ACTS C....O .-"^-OCR ^'-^^--,'--;3---- )

X \

FULL NAME

PERSONAL AND STATISTICAL PARTICULARS

\

^111.

roi,< iK

i)\i I, <»f' I'.IK 1 II

Nf.itith »

1):.V

\ I . I-:

J ,,/

(Vear)

/>,/!,

sisr, 1,1' MAKKn:i>
\vii>()\\ i;n < »K i)!\< iHv J J)

iWiitt iti v.Kial (It — i^MtaiMU '

HiRTini, Acr:

NAMl- «>i
FATHl-.K

HIKTH»-l,AfK
ni- l-AIIIKR
I St;itt or (."iiiititlA

MMDl-.N NAMK
<>1 MOTIIKK

HIR rUPUAOK

ni- MOTHKK

(State iir Country t /

nccri'ATioN

Rfsiilfd in Stin /■': iin,

)'rit I

\!..,,fll:

I hi

THH ^noVKSTXTl-IM'KKSnNAl.l'AKIHTI.ARS AKi; TKIK T<> THH
IlKST Ol- MV KNnWl.l.lx.H AND r.I.l.nJ-

'D

('AfMir

MEDICAL CERTIFICATE OF DEATH

DATK OF I)1:aTH ,r

(Month)

( Dav)

(Year>

~~ I HI:RI':HV CI-:RT1FV, 'niat I alteii<UMl «lecease.l from

___ — __ _- — — igo to .- ■ 190

that I last saw h ~ alive on ^9^

and that .kath occurrecl, on the date stated al.ove. at
M The C VrSp; Ol' Di-ATH was as follows:

Dl" RAT I ON )'t'ars

CONTUllU TORV

Month's

Ihiv

flours

(SIGNED )L(rVrvxX>v o.vfi.lUcix

(Ad.lress) Ly^.^^"^-?■*^- ^- it

Hours

M.D.

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

Former or
Usual Residence

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

How lonq at
Place of Death ?

Days

PI.ACK Ol- lURIAI, OR R1:M"VAI.

rNi)i:RTAKi:R

(Adtlrcss

DXTKuf IM KiAi, or RKM<»VAI,

Oct -

I90H

— — — - ,. . Top ^^„„,d be stated EXACTLY. PHYSICIANS should

N. B._F.very Item of informBtlon should be cnretuHy -PP'-^' ^^^^^ ,,assi«led. The ^Special Information- for pT-
state CAUSE OF DEATH in plain terms that .t ma> ^« P^^P^*"^
sons dyin^ away from home should be g.ven .n svery instance.

>

d

1

«

i

\x:

—^ 1 '

1

? '

*i

i m

'

'

i ^

'

littii

#

»M

m^-

I). *

WRITE PLAINLY WITH UNFADING INK

i?,„,!>:

,i IK;tUh 1

\-o ■•> **^^i*HS:

:l' •.".)

THIS IS A PERMANENT RECORD

R^PEPI TO BACK OP CCRTiriCATg FOR INSTRUCTIONS

I)a/(' Fi/rf/X dj^M.^ 11

190H

Jicgl^fered A^o.

0^9 f^

Deputy Health Officer

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco

Ccvtificate of Beatb

( XX. S. StanC»arC> )

PLACE OF DEATH: — County of

J? ^

City of Oo^-N^ J A,o.

No.^

„ St.; Dist.;bet. and

ED FOR UNDER "SPECIAL INFORMATION" "\

NO NUMBER. /

FULL NAME ^

A>-UxtiA.'

A

six

KAIl-: nf. lUKTU

PERSONAL AND STATISTICAL PARTICULARS

i

1

Mi.titli

/v.

X < . H

I'll 1

sIN<.i,K, MAKHn:t)
WmnWKI* <>K IHViiKi 1 I)
|\\'iit» ill *inci:ii ilr^sk' u.il ; iH '

stat» 111 •■oimtry

MEDICAL CERTIFICATE OF DEATH

DATK OI' DHATH

il>ay

(Yfiir)

NANH ni-
!• A in IK

!UK rniM.Ai K

MAIDKN NAMK
01 MOTIIKR

HIR rulM.ACH
«»1" MorHKK
I st.itc or Countt %

/

/

<>i

CII'ATION CV\^

MR

M.'ii'li

/'.n

aiif..nnrmt V^Cj-^-^O^^' V,<^ W '«

Ks AK1-: iKiH r<> rin-.

\<\A-

(M(inth)
I H1:RI:HV CI:RTIFV, That I atten<U-.l .Uixa^tMl from

^ - 190 - tn - — Uyo '

lliat I last saw h ^ alive on ^9°

and tliat .kath occurred, on the date stated above, at
M. The CAISI^ OV DKATII \Vfis as follows:

DTK ATI ON y^'^f^

CONTRIinroRV

A/on //is

/)a\s

Hours

DT RATION

f^

Ycays

Mouths

/hws

SIG

,TOIi).1jLv,^

NED) \,^t\Jry^\.>

H)0 (Address) L-t ^

Hours
M.D.

SPECIAL INFORMATION only for Hospitals, Instityttohs, Transients,
or Recent Residents, and persons dying d^dv from home.

How lonf at

Plaff of Oeatli? Days

Former or
Usual Residence

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

I'I,ACK MI- lUKIAI, OK KK%f«>VA!

a.

)X^'y\^'>r

Dxri: ')t I'.iHiAi, '•! ki:m<»vai.

I M ) J*. K r A K K K

■il

V'=

<i.cy-o

1X%v

fA<iaT(>,s «iW I ^^

I

TT n^ AGE should be stated EXACTLY. PHYSICIAINS should

InWm.tlon should be —;""»; «"^'' "^^ ^.^^^Hy classified. The 'NSpeclal l„»orm«f,»n" tor pT-
stote CAUSE OF DEATH in pb.ln tcrmn, that ,t m»> !»^-_ n;;;»'f ^

N. B.— Every Item o\

.on. dyin» awa^ s'ron. home »l.o„l,l he ftiv.n In .v.r, In.t-ncc.

I I

;>

iT

WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD

REFER TQ BACK OF CERTIFICATE FOR INSTRUCTIONS

! \.

\

l)<,h> rilr'lXJAAHA} XX

jfjo'i

Jifo'/.s/c/ed J\'*o.

1/

\i^K^ XjiA.'^^ Deputy Health Officer

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco

Certificate of H)eatb

•U. 5. 5tanC>arD >

PLACE OF DEATH: — County ofCj£X^\

>3l^

(Ks

City of " '^ v^'

r-i

^i^ n

No.

St.; '< Dlst.;bet. u\D &iA/<>A_a and

iiciiHi Drcinrisirr nur facts called roR under ' special information ' \
( '^ .VrE:T°H^oc:u%ro\;''rHo"s"rAt ^^^lir.ru^'ioTl.T.ll name .nsteao of street and .umber. ;

)

((l\l?

FULL NAME

^

a.

4

PERSONAL AND STATISTICAL PARTICULARS

i I 1 1 , i • K \

u

;i Nil I ii HI

N!

■^IX' . !.J M \ k K i 11'

\\ I I )( 1 W I I 1 1 )k ! 1 ' 1 •'■ i t I

]

LU^oLcv- ^

h' I ' M IM \i' K

\ \M I ( tl
I s ! I 1 ! I'

P.I R I'll ri. All-;
oi ! \ III i: R

M \!I»i:n %■ NMl
ni- MoTlUR

lURIIll-I, \i I.

• u Morm-R

■-1 :iti ii! riiiint t \

•HTl 1' ATIoN

/^^>

\\

Vj crLcx

fl

Jlvvcv,.

,;,/ /

\f,,i^*//'

h.:

Till- \HC»V1* sTSTJ-I. IM-R^ON \I, P \ k T L' r I. \ R - ARP IRPH T« > THI-

p.i.s'i'di MS K Ni i\\ i.i;i»< . p; \^i' p.pp" '■

(Info- !ii ml

a

S-IiIh -H

1^1% \

'-yx^ r\ it

X^"\ OC

'1

MEDICAL CERTIFICATE OF DEATH

I) \ ip; t >i I'p' \ III

■ Month t

I go

(Vt-ar)

.l)..v)
1 IlKkKHN' l I-KTIFV, Tliat I • tiinU-.l .lectasea frnni

■ u^, In V. -^ Xi TOOM

that I last <a\v li ■ alive- on '^■- ' -■' I<P •

.ukI that death .u-currea, cii the .laU- statt<l almve. at '^
M. The CAT Si'! Oh* DI-^ATII wa-^ as follows:

^X?J"UC^'^-Xr

o^*.

DTK AT [ON )V<7rv

CONTUIiUTukV

DIKATION )'-"v

Months

fhn

-L

1 1 oil r^

Mnuili^

fhns

SIGNED

M.D.

-A

l<)0

A.Mress) HlH O.CC

SPECIAL INFORMATION on') J"r HospifdK Institutions, Transients,
or RfCfnt Residents, and persons dvinq dvtav Irom home.

Former or
Isual Residence

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

How lonq at
Plare of Death?

Days

'!, \i'V. <»i P.PHPM* «►!* rp;m< >^ ^^-
■npi;kiaki;k Ml vi >v<XA.y

DATP'.i)!" IP HIM- "t KP:Mi>V\P

TOOH

J

(AtMusv

^sS'b- 'isn

■"— "^ 77a aGH sHuuia be stated RXACTLV. PHYSICUISS should

item «V int..rm.,tlon should b. car«tuily suppi.ed. ^t ». « ^.,„^^5,^Sed. The ^Special InformHtum" for pT-
C\USK or DI:ATH in plH'.n terms, that it may be properly wlass.tie

N. B. Rvery

state G/llJf9l- v^r «-»»--» • - , l„„#«nre.

•on. dylnft away from home should be J^.ven .n «very .nstance.

«

I

>

d

i5

0

^

■- "^ «

WRITE PLAINLY WITH UNFADING INK

riald Mil

Dnfr Fih'fl , t ct^lHL>v XX

r^o'i

DEPARTMENTS PUBLIC HEALTH

-THIS IS A PERMANENT RECORD

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

Jirjj'i.s/e/'cd -jYo. ■ ; f

City and County of San Francisco

Ccvtiticatc of Bcatb

PLACE OF DEATH: — County of

. ■ City of Jcc>x J va >^c' c

J M

M a St.: Di5t.:bet. Vtiv and -^^^

*-^0* •-- ' ,,e..Ai orCinrNrE rlWF FACTS CALLED FOR UNDER SPECIAL INFORMATION \

( ' frorjrOCrun7.'u\r.los%'!^.': ^^':.^f^^^^Z.rJ^ name .NSTEAO of STREET AND NUMBER. )

FULL NAME ' ^

)

PERSONAL AND STATISTICAL PARTICULARS

YS^ '^ ...!...k N

I) \ ri; <u i;iR ill

C'

\».i-;

^i Ni .1,1' M \ Kl% II '

\\i Im lui.ii t »k i»;

I'.iK rn iM, \i" 1

(St:ii 1 I iT i iimi ! s

1 \ III IK

I'.ik rn iM, \. I

I M I \ I'll 1 U

A

L^^

QCLl

m

V

U lit 1 s

M \ I ill \ N \ M 1

liiR rm-i, \i r

<>1 MoTlll K

- ' '■ ' • t n lit T \

m

cv vv J Xa

I

J -vo.

r>

Lo

S,ni /■/ i!ii. '•' .-'

i^ ft
[J

) r,i

rm- MsnVKSTXT. l)PKR^..NM,I'XUrhMl.\R^AKnTKri^ TO TllK
lU'sT <)! MV KNOW 1,1. IX .K AND lU-.lJl'.!-
(\ W

YCL/Y>xiL"5

niifiiTmaiit

I

\(l<lrt— *-

51H H<^A^^^

MEDICAL CERTIFICATE OF DEATH

l> \ ri' ol- Dl'.AI'H

Dav

(Month'

/on i
War)

I ni'.RI'.r.N' C JlRTIl'V, Tliat I alUii'kMl (knca'^iMl from

i^ ^t luO I ti)

f(,n I to I^P

alivf on T^P

aiul that .U-atli occurrtMl, on tlic .li.tL- -taU-.l above, at

tliat I last saw h

M. Tlif CAr>I-; Ol' IH;.\ Til wa< a< follow

l\^.o^cw

>duuuL to £^A.^aj.<X4-CcC

1)1 k.XllON )Va/v

CONTRIIU lOkV

M<>n(hs

/>./!

1 1 oil) \

(SIGNED

Month'

Pavs

O.t . ...

Uout <

M.D.

H)0

A.Mri-O 15' I -^ '^-v C

SPECIAL INFORMATION "niv lor HospltdK Institutions. Transients,
or Recent Residents, and persons dying dwrfv from home.

Former or
Usual Residence

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

How lonq at
Place of Death ?

Da\s

1» \XI" ii: Hi

!■! \CF «»i IM KI.M- OK RKMOV.M,

,snKKT.iKR lUv^X^ lUxxUni-

(Address %bb QfYWL^^^^r^V Jt

ki:mo\ .\i.

too':

il . .• I \CT should be stated EXACTLY. PHYSICIANS should

n. B.— Every item of inform;.tio« should h. cn.eVuIly f"^* -^. ^ ' ;^ ,,aH«5fied. The "Special InformBtion" *or p.r-
•tate CAUSE OF DEATH in plain terms that .t niaj '^ J J
■on. dying oway from home should be ft.ven .n every instance.

; t

J.

1 .

t^

2y

.,..*:

«i!'l

WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD

I !!■ .;il: ! N<

lOO'i

REFEiR TO BACK OF CERTIFICATE FOR INSTRUCTIONS

Jicglsferrd ^Vo,

I . -

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco

PLACE OF DEATH: — County of

Gcvtificate of E)catb

( "U. S, Stan^arD i

\ O . ' V City ofO/<x/w jAX>.

f\

No.nirRj&U-- St.; ' Dist.;bet. "'t^ and ^J^

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

0

FULL NAME

4f

PERSONAL AND STATISTICAL PARTICULARS

m

a

toJUi

t»l ink III

.1

I

+

/ 3

SIN. I r M \k k nn

ri'i. \»'i-:

1

Ml < u
I li i:k

lUK I'll I'l. \ri:
<•! r \ nn-'k

■^1 it ! .1 I'l lU lit

M \ 1 lUN N \M 1-
'M MiillllH

'•I \T<)'riiKk

■I K'i llillt 1 \

-\^ ^

l1

^

< >t'* r I' x'l'loN

/s'r-n/rif m .S,;ii I'lanii

1/.

/

•in: \I5()\■l^ sT\Ti-i> I'KRs.txM. p\KTn ri \K- AkK 1 ki !■• i" I'm-
in;>>r oj. mv kx< i\\ i,i; ix.i-; am> m.iji

i"' ' iniiiil

\j 1 .

U ^ X

a?

. '1 ^

MEDICAL CERTIFICATE OF DEATH

i»A ii-: «»F i>i: \Tii ^p\

(M.,iitl,) -nayt iViai'

I II I'lk i;i'.N i. IRTIl'V. Tliat I attcii.U'il .JtHiast'.l fp.iii
,■ . , .. . iqnH to iU'^ ^^ ImoH

that I la-t -aw h ■ ■ alive nn - ' I^P

an.l that .Uatli nrrurte.l. .ai the .latr M..'<-.1 ahnvf, at <©
U M, Thf CM SI-: (>!• I)i:A'rH ua'- a- t()ii,,\v^:

IiIUATIoN )'iajs

e < »N'rK inrroKV

Mo)Ulis

Pax

Hours

DIRATION
(SIGNED)

Pav

\

Hours
M.D.

r\

ofc

^»

i()oH

A.Mn-^s) 3-lV auJH-C'

SPECIAL INFORMATION onlv for HospildK. Institutions,
or Recent Residents, and persons dying av»a> from home.

Former or
Lisuai Residence

When was disease confrafted,

If not at place of death ? ..

I ACK or nrkiAi, '•!< k!;M<'VAi.

HoH long at
Plar e of Death ?

Transients,

Davs

r.XIU'.kl'AKKR

i;

i» \ r

Mit\' \I,
IQO'

7^ ^^

Aa.ifl^s 30 5" QTV^awLc^'i

IS. B. Rvery item of informntion shauhl l»^ -••r

stole CAUSE or DF: \TH in plinn terms 5„«,„„ce

sons dyinft away from home should he ^-ven ni every instance.

"TT n MIF. .'io„I.I he stated RXACTLY. PHYSICIAINS should

afully supplied. '^'I:'^;"; ^^i^..^j. The "Special lnforniM5..n- for p^r-
. that it may »»e pr«.p'^«'"y classmeu.

I

J

1

6,;

^"'tlH,

if

1 1

^ II

<>

il

•i

il^^j^-:

WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD

H,,.i.i •■ n^

V,, ;- *.^^ -. ;.^.i

DEPARTMENT OF PUBLIC HEALTH

REFER TO BACK OF CERTinCATE FOR (NSTRUCTiON3

licgialeft'il oVo.

City and County of San Francisco

Cevtificatc of IDcath

11. 5. t?t^n^ar^ j

PLACE OF DEATH: — County of -Ccw . \ -r^ . . City of ' ^v OAXX^
fS^,. vC a,LAx<vk '' St.: Dist.:bet. and

FULL NAME v.<r\h.L^ —

PERSONAL AND STATISTICAL PARTICULARS

^^

*( 111 >K

Xk>

Hik rn I'l. \>-i-

X \ M 1 « M-
1 All! IK

ni.'Tii ri. \i'i-:

1 » ( 111 lit ! \'

M \ I Ill's X \\11

til Mi>riii;u

i;!K riiiM. \K ];
' •' ^•| > I'll i;k

oi'iTl' \ IION ^

1 '•' ■ ! I )

. C

1

11^^

1 1

\o

,ct>v<x<L<x,'

u

\ %vn ' ■ 4

U

AV /,/,-./ /,' .s,/»/ / 1,1

^ v

- 1'

■rin% \H(»\'i-: s'l' xri: d pi.-r^^on \i, r \i< ri. ri \K'- \k i
ini'^roi Mv KNowij.D' .1'. NM> in 1. II I-

H I K I ' • t " •■'

■»:illt

S). a

f

,cu.

+ !

Xildrt-ss *i..' ,-A„J\^/

MEDICAL CERTIFICATE OF DEATH

^

^4

\'.uithl

I».'V

( Vrar

I IIIkl-l!V ClKTIl'V, That I itlcuikMl ikrrasc.l frutu

that I hi^t -aw h

I </J

,,Hven„ ^Ct 11 190 H

,11, ! thai .Ua-l! .KTUMa-.l, < m th. -latr -tati.! alx.vc. at '
M. Thi' CA' SI-: <)1' I'rlATll was as follows:

1)1 k AI'ION )V<7/.v

coNTKinr rnkv Oa

(SIGNED) > w

^ ^-.

^•v

.1/f'////'^

/>,/r

Hour

1/

/)(/!'?

I<»'

A.ian

1 1 OH Is

M.D.

f

SPECIAL INFORMATION «nlv l..r Hospitdls, InMitiitions, rrdnsienfs.
or Recrnt Residents, dod persons dvin) ,mdN Irom home.

Former or { K , ^ t . ,
tsiial Residence xiJ-^-A^/ rw*^

When was di'^ease contrarted,
If not af plare of death ?

How lonq at
Plare of Death ?

XN^'^x^^-^H ^^

Ddvs

I'l.ACl- <»l- lURIAU OH i:i;M.»\ \I-

X

1'^ ^ ' ^ vVi-^

I>\rK .-: la lU M "I RKMoV \I<
0.t:t; a^^v iqoH

Atl.ln

N,

»-" ^!^ Mlf s'ln.M be stHte.l EXACTLY. PHYSICIANS should

B. r.very item of i«for,n,.t5on Bhoul.l b. cnr^tully supphed. '^ '^ Ui.HHiticd. The "Special Int'ormHlion" »»r pT-

«t«tc CAUSE OF ni:ATH Xn pl«in terms, that .. may - ^^"^'"*
sons dylnft away from home should be a'.ven .n every mntHnce.

^ I

P

-i^'k.'*.

WRITE PLAINLY WITH UNFADING INK

I ., '. |- \',

u " — "*

f iik:' (■

I

^'^

Date /•V/r'^/,lL'£tcrl-t\; ^^^

lf)()'i

THIS IS A PERMANENT RECORD

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

Jfes^is/f'rc^/ jYo,

,a:

Deputy Health Officer

DEPARTMENT W PUBLIC HEALTH=City and County of San Francisco

Gcvtificate of H)catb

i XX. S. 5tan^ar^ '

PLACE OF DEATH: — County of

^

-^

City of

<X'

V '^

No.

St.;

Dist.; bet.

and

..<^ii*i DC-e:in*FNrr nwr FACTS CALLED FOR UNDER SPECIAL INFORMATION" \

FULL NAME

.all

X-tVCX/^-V' ;■'.

PERSONAL AND STATISTICAL PARTICULARS

\< ,

-I V. .l.K M SRR II
W ! I )< . -A r I ' I »K 1 I

r»

L

wA.

MEDICAL CERTIFICATE OF DEATH

I Vral I

I II !•' U 1:P.N' C'l.Rril'N. 'K\\.k\ I iUlmuK-.I iKnHa-,c(l Inmi

- — — — — i(,o

up I'

— alivf on

that I la^^t saw h —

ati.l thai .Uatll .Hrurrcl, on the -laic -^tatL-.l a1.<n-c. at
M. Tlu CAIM' (4^ IH;.\ ril was as follows:

\<.p

yxAx J-c<^v

i 1 r 1 \ I ' 1 •

1! I \

u >

X \ M I < > 1

i A 111 i;k

lUHTHI'I, \> 1-:
< »' I \ 111 !■ K

I SI ,1' 1 . i| I . Ill !ll ' V

Ml MdlJIlK

lUU III I'l.Aii:
'I 1! ' 1 <\ i'oniit! \

'All' \ TION

t\fsiiifd HI ^.m ! I >'■><

) , ,7)

\ f. , It'll '

\'\\v. M'.ovi*. SI' \ Ti: n i'^*Rs<>\\i, r \K II'' ' I ^'<'^ '^
mc-r 01. MS' KNnwi,i:i)< .!•; \ni> lui.ii.i

Ki: THri' r<» I'li

inntit

DTK AT ION )V,://

CON Tkii'-r roRV

M,>uu>s

Days

I/onts

DTKATloN 5V<//A

"1

SIGNED

Mont lis /hn

I lom s
M.D.

1 1 )' >

f

SPECIAL INFORMATION «"!> for Hospitdts, Institiifions. Iransirnts.
or Recfnt Residrnts, dnd pfrsons d)inq .m.iv Irom homf.

HoH lonq af
Former or p, , ^^^^, n.ns

Usihi! Residence

When was disease fontrarted,

It not at plat c of deatti ? ^ . _—

iM.ACi' 01 iu^KiAi. <•!'! ki-:m<>\ai.

u

i> \ ri

too'

' ' ■ , . ,. , Zw .'inula he Ht«te.l nXACTLY. PHYSICIANS should

N. B.— Jivcr, item »V inf„r.„„tJon nhnuhl h. ....n.lly ^^^^^^ J^ ^ .,„H«Wlecl. The S^^M lnform..t1.>n" tor p.r-

•tat. CADSI or 1)1 ATH in pinin Ur,„H thnt .t m.y ' ^^^

«nn, cfyinft «w«y from home nhould he ft.ven .n ever, .nHt»n.e.

4 i

' (

>

2)

^^J

|i

ii-

•» J,

^"

/^'

WRITE PLAINLY WITH UNFADING INK-THIS IS A PERMANENT RECORD

Hoard. . f !l.i':l' ' "-■

r >•'

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

Dale /•V/r^/Aci.C^K. VX

^

\ '^-\XXA

Deputy hi

h C

Boillsicrrd 'A^o-

riPTO

1

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco

PLACE OF DEATH: — County of a.-YX

Certificate of Beatb

J 05^

. C{ty of C) <X.^r^ J A,o

.1 s o

lU

^,u,. , ^ Sf ^ Dist.;betXt>TV'. ' and .A./j

)

ft

FULL NAME

\

I K > \..0

PERSONAL AND STATISTICAL PARTICULARS

^w W

|i \i 1. t i! !',IK I'll

M.MiSh

'I

Pas

,Rta

>,!%. ,1 I' M \K k IK!)

.< . ■, - ■ i! i. Ill >

(I)a\'

(Vtarf

.1 »

i',n>: !'H »'i. \^■^■

\ \M I- I >!

HIKTHPI, AiK
<tl I AlllKK

\t \il>l \ N \ Mi-
ni Mnrill-.R

luR riiPi, \(i:
<»i- \t(»ihi:r

I stall tir r.nilitrv

(\

Cc.

.Va.

\.

-^U

L

( )i iTl' AI'ION

V

.. X

MEDICAL CERTIFICATE OF DEATH

II \ r }■" ' 'i' I '1' A ru

iMMlltll'

1 flKRKHV CI'RTIFV. That I atU'i.-lcd dctvaso.l Inm.

that \ last saw ll ^ilivt' ^ii ^'^"

a„.l that .Ualh nrrurrcl, .mi the -lat. stal.-l al.nvc, at
M. The CAISIC Ol- I>l.\ I'll wa- a- follows:

DTK Xl'lON' Yrars

CONTRir.rToRV

S,^

^

.^fouths

Pav

Hours

DIR A rioN

)'<ars

MoutJi

'is

/>r;r

i

(SIGNED) J .'viLOJ^V^t,

Ilouts
M.D.

, r

I.' i

' ! i

' I
I

td

I<)0

f .\«Mn-ss) bub

a.

SPECIAL INFORMATION ""Iv f»r Hospitdls. Inslitutions. Transients,
or Recent Residents, and persons dvinQ d-<*dy Iron home.

/'^

)',-ai

M.oith

TnUA,M>vKSTxiMnM-KK...NA, pxktum;kxksakktk. K in

lU-sT ni- MV KN-nVl.l-.lx.l-. AM> LIL''

( Info! tnaiil

\i1(1m s*;

.OUL\

Former or
Usual Residence

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

How lonq at
Place of Deatlj ?

Davs

IM XCH OV I'.IKIAI, <>K Kl-.MnVA

^

rNi)i;KTAK»:H N i ^

TQO

O^^ ^ ^t

CAilili' '-

3

it

^^^^— Jnm^— ^— ^■^^^^'^'^'^'*^'"*^^ , iv%rTI Y PHYSICIANS should

state CAUhfc Ot- wt'* ' " ** , , . . Aiv^n in every instance.

Hon, dyinft away from home nhouhl be ji-xen ^

4

WRITE PLAINLY WITH UNFADING INK

n-

N

Dafc Fifrf/ ,\J^<T\>-^^-^ '^'^

n)o\

THIS IS A PERMANENT RECORD

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

kj&\^'^-^^

DEPARTNENT ot PUBLIC HEALTH-City and County of San Francisco

Ccitificatc of ®catb

PLACE OF DEATH: — County of

^

City of ^ <^ •

\cx >

V

Sf X Dist.;betX OxX'vV^LL and

I

•1 '

)

mr f l ll I n St.; ^ UlST., DCI. '^^ ,__.„ .SPECIAL INFORMATION \ i

V IF DEATH OCCURRED IN A HOS^-M-i.

AM \

FULL NAME 0£l^<x1x; >aA-vc i^xxo.-

PERSONAL AND STATISTICAL PARTICULARS

!•, I I I

M ,i!th

I) >

■» < .11

\< i-:

b D

}

MEDICAL CERTIFICATE OF DEATH

DA Tl-; i>l DKA'l'n

1 >T.)ntti'

(Day

(Vtar^

I iiHKKBV CKRTIFV. That J atun.k-.l .Uv. a.ol fnm,

that 1 last saw h

alisr oil

<J c:l

up

- !\i ,1 1" M \KK 11' I >

\

^„,., .1,,t.Uathor.urrca, .,n tlu- .laU-tatca aln-v.. at ^
M TlK' C\rS!{ OF DKATII was as follows;

3»0

LU ccL^^^^^cL

lUK rin'i,\«'i"

I St. ill ( >! 1 1 lunt I \

lURTll I'l, \i*!"
Ml I \ nil- K

. >t ,(t I lit i'- lint • \

M XIDl.N NAM 1

oi M()'nn:K

JUK IHl'LArH

(>!• M(i'rm:K

I Stati tir Country

t )icri'A'rioN

c

L>^at c

'"n

^1

CK^v.0^^^^ Ml^Aix^ctui

IHKAI'ION Yi'iir^

CONTRllHTokV

U- A

^rontf!x

Pays

I loU} s

^

L

''>V<

e

DIRATION

C
(SIGNED) AA. ^W

l*U,t

}rnnth:

/hivs

Iqn

Hours
M.D.

SPECIAL INFORMATION «nly for Hospitals, institutions, Iransients.
or Rerent Residents, and persons dyina anav from home.

■>

) , ,;

Mnll'lf

Ih!

Till- MicVHsTATHUPKR^^nNAl^XK K 1 ,x

f ItlfoMllfUlt

U)AiXoou-^ Lc^v>^

(A'ldvess

lu

<\^"k

1

Former or
Isual Residence

Wfien was disease contracted,
If not at place of deati) ?

How lonq at
Place of Oeatli ?

Days

Uct.

,., ,\CF OI 111 KIAI. ol; k!;M<i\ Al.

TQO

^^^-^— ————'— '*'""**** , FYACTLY PHYSICIANS should

!1 1

0<

pi

hi

I

i

WRITE PLAINLY WITH UNFADING INK

'•, I N'

/ -V 0 \

l)iifi' I'iU'il \ <^':Ay^^ 3vl

DEPARTWENT OF PUBLIC HEALTH

THIS IS A PERMANENT RECORD

REFER TO ...n-r.r.CATErOR INSTRUCTIONS

=City and County of San Francisco

Ccvtificatc ^i Bcatb

i

(9rN

No. ^^

PLACE OF DEATH: — County of

City of

c\. ^ V c-

St.; Dist.; bet.

RESIDENCE GIWE FACTS CALLED r

and

( " r";»,°"ccci/.ro-,"°:c"s^r.t o%^t:s.-o. c.. .s ..«. .

.OR UNDER -SPEC.AL ' « ''O ^ "^f ^!' ° ^ ' ' )
NSTEAD or STREET AND NUMBER J

FULL NAME

>

PE

RSONAL AND STATISTICAL PARTICULARS

W\

1 1 1 i 1 K 1 1 1

L

\» ,i:

w

""" MEDICAL CERTIFICATE OF DEATH

DA IK "1 I''" "^'I " :

AS
il)ay>

i\'«;irt

111

K,:nV Ci:KTirV. That I atUn-U-l .U.va.ol rn.,u

1 1)')

^

Y M Ms k I 11

that I last -aw h ^^>w alivr ..H ^

;,„athal.Uatbnrrurrc.l, nt, the -lal

I()0
It;')

r -^tattd abovi', at

M. Tin- CAlSi; 111- I'l \ni ua-;,- l-n-"-

:i ri^ \'

NAM I <M

I- \'i*ii i:i<

I'.IK 111 IM, Xil'.
*»l 1 \ III I'K

I SI il t I it ^'i lUIlt 1 N

M Ml»l N NAM1-;

(»i M<»'nii:R

ik rni'i.ArK

il \1oillHH
■^t iti ii! I iiuiitr

o

1

M.nilhs

l\i

HoHt

/uwcLcu-

nruATioN

(SIGNED »

} V./r.v

M.nith

fhw

M.D.

r.\<i'ir

^

Li'^

"qpECIAL information ni> n- "-
jrlefen^ Ments Vnd persons d)inq h.„> Iron, home.

ON ""Iv tor Hospitdls, Institutions, Translenis,

li

.r.Minr.nl JA^O^%aJK

m ki»:i

Former or
Isurfl Rpsidenre

When was disense contrarted,
If not at place of df atli ?

How lont) at
pld» f ol Oedth ?

Oavs

\CI'. Ol- P.I KIAI, »)

R )<KM'»V W

::.,.„« lUK'^.

f Atl'It*'*'^ Ov Lii.

' K'l-l.c'^'^ UJ^Vu4yVV&-VC^LX. ^ ■ , , V4CTLY PHYSICIANS should

«nn, cfyinft away from h«m« ^.hnuUI bw g ™fl^^^^M

^fcta

L )

1

. -^

»i

k t

w

RITE PLAINLY WITH UNFADING INK

f. -: -ar ,-., ;;X: 1' i

/)n/r /7/r^/,y.ctcl

1>X.^ S^^

lOf^'i

THIS IS A PERMANENT RECORD

REFER TQ BACK OF CERTIFICATE FOR INSTRUCTIONS

DEPARTMENT OF PUBLIC HEALTH-City and County of San Francisco

Ccvtiticatc of ©catb

^ , f n rx ->A. o ' X o.^^e^<^c^ City of c) <^^ ^ '^ ^ > ^^
PLACE OF DEATH: — County of^cx->A. . - /

and

-^

No. .^

{ ,F OE^H OCCURRtD IN • HOSP.T.I- OF N5T

FULL NAME

St.;

0

Dist.; bet.

TS C^LED ^OB under' 'SPECAL ' ^ "^^ "^^f *^ ' ° ~ ' )

tJ name instead of street and number. J

^sj,^^ 4 I v-O-X^-

PE

RSONAL AND STATISTICAL PARTICULARS

n

^

, K

\i

^

M.Mll !l.

M

EPICAL CERTIFICATE OF DEATH

DATK ••! I'l'ATH

(Miintli'

fun

).!'

Kl.nV ri;RTlFV. Th,.r ! m.,,,1..1 .Ut. a...l Inun

\i .i:

1 M\KI<U n

1 t>

' IM'I. \i

N \M1 I U
1 \ I n IK

v.\ in 11 i'l. \fK
11! I \ riu- K

luu riM'i, \> 1,
(>r %!< >'rii i:k

1 1 )0

It)')

-111

lat I la^t --iiw n
,!„,:„ .l.M.h...urre.I, n„ tlu- .Ir > -.:n-l al-vv. .n

\

^

DIRA rioN
CoNTRlin roRV

)'i'ars

^font/is iG /><n'

IIOUK

^

JLpVOL^vco X<rW>^^'<^a.

Former or
Usual Residence

•,Mn^xH,>vKSTvrrn,-KK.nsx. PNKTP^rrxK. ^KKTK^K m r.n

HKST Ol- MV KNO\VI,ri>'.l-. AND MM''

DrKATION
f SIGNED )

)V</

^

M,nilh

IhlV

'n%'

f fours

M.D.

IijO

Aa.ln-^O i^lt)

— — ^^nriT^MATION onl^ l«r Hospiyh. Institutions, Transients,
or^efen^ isfde'-nts.nd persons dUni ...,.> Iron. home.

How lonq at
Pld< e of Death ?

< I.

„,,„„.3,.,.W«.<u.^x;$^'«"-V.

^uUi^*^^^ ' ^^

■H

^H In plain t^rms thnt it mj >

N. B. Kvepy Item o* !nV'.>rmut

1 1

)

(

WRI

,>.K.r. iMi€ THIS IS A PERMANENT RECORD
TF PLAINLY WITH UNFADING INK — THIS \^ M ri.

^^ 1 p.P.B TO BACK OP C-°-.^.^-^Tr .OR INSTRUCTIONS

^ ' Deputy Health Officer

DEPARTMENT OF PUBLIC HEALTH-City and County of San Francisco

Certificate of Scath

"U. *3. Stan^ar^

J? ^

PLACE OF DEATH: — County ofCJ,<x >

J

No. HIS U

St.; 1 Dist,;bct

IDS

NST

FULL NAME ' CLc^^^^ -^

City oi^^

1 V,

n

and

)

V IF DEATH OCCURRED IN * HOSP.T

. ^

■■I

———'—~~~~ _ ^^.-ricTir Al PARTICULARS

PERSONAL AND STATISTICAL PAhii

I ( il.i >K

I

V

1 1

;^ED,CAL CERTIFICATE OF DEATH

DAIK ol- I'J ATH , '

'Mi.nth'

1 >..%■)

■V. :,1 1

! !'

\H K !l !'

U • It.

to wet ^^X I'>"^

' 190 ^

,,„Ul.:...U.Ml,,.o.„rr.,l,,.„Uu..l:.U.....>M.l..-..,.„
a M TlK. CArSi; nl- lil'.ATM u..--lon,..s:

^a.4tK.o t^vU;

1 \ I

1 \ in IK

I'.iK IH ri, x<'V.
i)\ 1 \ rm.R

\i \nii:N' N AMI-

(»1 MoTlll'.R

lUK rm'i.xfi".
<»i M<>rni'.H

(State ot I'ltUllt 1 \

(KAtl'Al'loN

K ,1

0 /CLcwl'

i

■\

CoNTKIIirToKV

}/onl/is

/hiv

//.'

HI V

.ik

„ V, >

(Xw

,c1

c

(\

Ul)

DlRATIoN
( SIGNED)

Years ^f'^"ff''

/>,71^

Hours

M.D.

('AiMri'-'-) ^''

%> -^

/O^'^v

— irTlN FORMATION »"ly I"' ""^''■"■"^' '"^"'"'""''' '"""''""•

xxXaX^^^^'w

AV- , / drd III >'!■''/ / _ ^ . J .

T,n.Ai.>vK.Tvr,^n.K.-'-,)V^,l!,;,k^"^^ '■

Hl-ST Ol- MV KSnWl.l-, I )«.!•. AM' i.»...

(Ill f.i- ntnnt

Former or
Usual Residence

How lonq at
PIdi e ol Death ?

Days

,,Vn{.,; iw uiAi, or KKM<>VA1,

I NI)1:H1 AKl.K ^ /Y\

<\a.ln<-. HIS" ^MaJ.AA,-W-A^ -- ^ ^_ ; , , FXACTLV. PHYSICIANS »hould

,„, .„.c.-un, -upplt.... A..B -'^"^''.'wud? TH?-'«n.c-,B. .„.-o...U..n" .0. p.n-

„au- CAUSE OF p> ATH m pl" ,^^^ ,„ .,„y ,„„.n... .__„,,

iE^::^-r;i^^^:e -=•--' —

3
)

WRITE PLAINLY WITH UNFADING INK

Xi, li^.!' ('■

THIS IS A PERMANENT RECORD

„.P.R TO c.rPT.nCATEFOR.NSTRUC^ONS

/

ii)(n

J^voislcred ^^,"0,

DEPARTMENT OF TOLOEALTH-City and County of San Francisco

t '

Ccctificate of S)catb

(7n

^

PLACE OF DEATH-. — County of

City of5.Cc/^ l\AX.>^<-^^-''

^

5 II

V

and

I t

)

No.

' St* Dist.; bet. ^ ITJ -^cpecial information '\

( ,F DEATH OCCURRED IN A HOSPITAL ^ , (\ ^ C^ f|

FULL NAME

\^

.L*.c..

^ a\

'-N

PERSONAL AND STATISTICAL PARTICULARS

^ .'^-

\ > :n

\t 'Uh)

;;;;7^,CALCERT.FICATE OF DEATH

i;iK •MUM, \v"l'

-,',•, , ,; I '1 Hint! %

N \ Ml < M
I A 111 IK

!UK IMllM, X»'l",
1 »l I \ 111 !• R

i --,t:it . ; I I oint 1 ^

MAim.N NAMl
01 MU'lMll

lURTiiri.Ari.':

up

that T last ^aw h

M TIkCAISK <n- 1.1. ATM ... n. follows:

-A

DTK AT ION ^'"'^^

lf(>>>//lS

/hn

//(i/U s

Ihiv

f fours

M.D.

L?fv - ' ^ -^

TuXoyv

6

<»r<Mi'A'n»)N

.f7T>

m;'^!' nl- MY KNi)\\ l.l-.l"-'- ^ '_

Former or . ^fe

Usual Residence ^^ o

When \^as disease contraffefl,
II not at plare of deatti ?

'J^A^K^

How lonq at
Place of Oeatti

Days

f!

\\V,^\ nl- M\ K.N«'" '.' _ ^

H

I»AT1- -M !;■ HiAi. ..I KHMUVAI.
Oct ^^ TOOH

I NUlK'l

oudxLi^^

^'(E

Aje<^^'

f AilMn

.tjon^

N. B.-

M1"-^ ^DIC Y^ ,, Y PHYSICIANS should

.t.,u- CAUSE OF DEATH .n >•!• "^' ^^^„ •„, ,,„y l„»l»ncc.
,,n. dylnft away !rom home »h....l.l he s.

I ;

i 1

! ;

;>

<r

f

;!.

)

WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD

I,, ,;,h I V. , ^^^«;^ !:>vl ' REFER TO BACK OP CERTIFICATE FOR INSTRUCTIONS

l>nl (' nii'fl , - "-^

/ D 0

Begh.icvcd jYo,

% •-' >

De^.

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco

Certificate of H)eatb

( "U. S. StanDarC>

\

PLACE OF DEATH: — County of

City of

\-

"^

^

1^

No.

(

St.;

Dist.; bet.

and

IF DtATH OCCURS *W*V FROM USUAL R E S I D E N C E G I V E FACTS CALLED FOR UNDER SPECIAI. INFORMAT
ir DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET «ND NUMBE

N )

FULL NAME

'Ci ^^

i \

PERSONAL AND STATISTICAL PARTICULARS

' <\ !,1K III

A

H

i%\

MEDICAL CERTIFICATE OF DEATH

DAiK iu iu;a'i n

(Motith)

!l):iv)

IQO \

(Vt-arl

\^>V.

M \KK III)

i ! I 1 I K t , • , , 1.- , ) ( )

HiH ruri, \oK

■ I ' Ml 111 I \

^ ^ Ml i»!
t \ 1 1! 1-.K

iUH'l'Hi'i. \i K
■^t it. , ,1 r, Mint I \

M M1>1'\ N AMI
"I MnTIIlK

'•ll< rill'UAi'H

"i m<>'i'iii:k

O^^n^ J Xcwv^

t)l

L

V

\ A L I

:1

L

<XA

I III RI;HV l i:R'rirV, Tli.it I attcn.Ucl «kH\asLa fn>iu
V up i to W wU .^^L Itp 1

that I last saw h alivi-on ^ I90 ■

aii<l tliat ik-atli occurrt'il, on the datf state*! above, at
M. The CM SI", <H" i»i:.\i'll uf- '.\^ fol!o\N<:

'^^'x^rvvQ^wv

Umh^'

, \

J

A. A i

I'f Itifii ill Sutl I litlli

I»rk\ri<>N Years Mouths

C<»N rKllJI'I'oKV

I ) r R \ r H » \ ) V</;a , ^ M, mills

( SIGNED ) Lv vl' ' ' ' -

/>./rs

I /ours

/Kn

I lours

M.D.

t

IC)f5

(Address) It JAi K'ltli.'a.a.een

Special information ^ '••'^ llosijitdls, institutions, Iransifnts.
or Recent Residents, and persons d)in;) dwdv from tiome.

I O.

\ >

iH J-: \n»»vK STAT in phrsonai, pxk riiii, \ks aki: iki j. r<> rm-
m.sTni Mv Ksnwi.i iKji". \M) iu;i,n:i-

(Iiifiitmant

Wv. i.

J r. s ->■ o

n.Mkss IbHb y

D^cycU.

I

Former or
Usual Residence

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

HoM lonq at
Placed Death?

Di)s

n.Afi'Oi lUKiM.oK ri;m<'\\i,

I ni)i.ktakj:k

i)\i'i:.if iHHiAi. 01 ki;mo\ai.

n

/ •

(Ad.lit Hs

'1 P, ' I

•tate CAUSE OF DEATH In plein term., that it mii> He properly wia.eiiicu.
■on* dying away from horn© nhould be given In .very Inntance.

o

s

tr

>:

J

J

! I

I

D

WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD

11, ,it)| IN'. J ,» ■?^ar»<-(-4) Hi*^: I' *''

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

10 0\

Bp^i^sferpfl J\^o,

* > f^ i >

,tr^cc4

/VM,

DEPARTMENT bp PUBLIC HEALTH-City and County of San Francisco

Certificate of 2)eatb

^R

n. S. StanCar^

i

PLACE OF DEATH: — County of wG-

X a_

Vs-

I

Wo. - ^ J V t ^<

u

I v^V-

St.;

Dist.; bet.

J? QTI

City of 0<xr^\j J Ax^

and

r - , = ^« lt«IIAI Pr SIDENCE GIVE FACTS CALLED FOR UNDER SPECIAL INFORMATION ' \

FULL NAME

PERSONAL AND STATISTICAL PARTICULARS

'J A

On-

I <>i,(»k

r t tf lUK 1 II

I>..v

\'.|v

w I ill >\\ i:i> « »k i»i\« iK II)

'.\ ; it ' 1 11 --I H'i.i I ill »it'ti,' t 'I ill >

(^

L

cv

HIRTIIPI.ACH

N \Mi: ni

I \ ri! iR

lUK in I'l, AtJ.:
"1 I AlllJlK
^'l.iti III rinintt V

M MIM-.N N XMl'
<>l MnTIIJ.K

I'lK niiM^Aii-:
"I Morm-.K

' "^t:ili lit I'oullt I Vl

Mi'cri'A rioN

A'r'Mi/fi/ ill Siiii /'i ail: I •! <i

Qj ,C ^'^A wi

L'.i.ci.

i»\

MEDICAL CERTIFICATE OF DEATH

III Di: A I'll

' I

I go

(Year)

I iiHRKHV C IkTiFN', That I attriiiU .1 «it . rased frotn

that I last saw li ■ alive nn ' Kp '

ail. I thai .U-ath .Kaairreil, nis the ^lale -tale.l above, at
M Thi- CM SI-; <>I' hi, ATI! wa-. as follows;

Ww^

C'oNTRll'.rToRV

I )r RAT ION >''<7/v

( SIGNED ) M I LCTvLc

Months

l)a\

Hours

Mofilhs

lhi\

/lour a
M.D.

)', ii I

M,<„lh-

lhi\

Till'. MJOVI-: STAIl-n I'f-KSMNAI. I'AKTfCt I.XH-- AKI t K I l- To TH»'.
1»KST (H-- MV KNoUl.l.lx.l-; AND 151. 1, HI

niifiiinumt

\ .AsJ^^A^Js..^^

( \fMif s).

I<K'

Address) H XO ^C

SPECIAL INFORMATION nnlv tor Hospitals, Institutions, fransients,
or Recfnt Residents, and persons 6y'm »^^y '^"^ home.

f ormff «r
Usual Residence

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

HoH long at
Place of Deatli ?

Days

CJ-U^Y

i> \ ii: ..: i!( KiAi. lit ki;m< >vai.

C)-C^>^^-^'^ W /ClAJ(.

INDl-KTAKKK vULaA-M^ ^

(A.l<lr<-ss Ob iX' l". XU

IC)0 \

,. , 7j;p. „H,,uld be stated EXACTLY. PHYSICIANS should
of Information should bs corefully supplied. y^ classified. The "8|.ecial Information" for psr-
E OF DEATH In plain term., that it may be prop.rly .lass.»iea.

N. B.^— Bvery Ite

•tate CAUSE v»r E#i-« ... — f - . . ^..„,..

s'in. dyinft away from home should be given ia •vry instance

P

^

ur

5<

/

I I

ii

D

. '=.:

#

WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD

I

I

I \'

■=c^-i.i:. n^p (■

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

L.^L/v^ Deputy Health Officer

Ee^Lslc! I'd J\y),

*"»'*' '^O

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco

Gcvtificatc of E)catb

"U. S. StanDar^

jt

PLACE OF DEATH: — County of Jo.

City of

r'

,0^/'^X'

h <n

k .X ^^

No.

\

(

St.;

Dist.; bet.

and

ir Dt*TH OCCURS Aw*v F p o M USUAL P E S I D E N C E G I V E facts callcd for under

IF DTATM OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTCAO OF

SPECIAL IN
STREET AND

FORMATION' \
NUMBER. •

/^->i

FULL NAME

PERSONAL AND STATISTICAL PARTICULARS

ii .1.1 iK

(\^

Kin

LL

^f \R k I! I»

• • ' i»Kr|.;i>

L'tUltiiHl)

X

M F 111

I 1! Ik

^V, N I N_'

li'i. \i}-

ill \u.

•I i I lU 111 I

"1 M..i'in:i<

iHR riiiM, \. 1-
'>! ^ti»•l•|ll;R

'^tat, .,1 I'tnniti

MEDICAL CERTIFICATE OF DEATH

;» \ri: t»i- i>i; \'rn "^

(Veari

I HIKl-'HN' Ci;R'ril-N', Tlial 1 alu-nli .1 .k<^ a-^cd from

tliat I la-t -aw h A^^-^a ali\<- on

aii.l that ilialli . hmii rrf-l '"> \hv dati- stntt-il a!)nve. at
^r. TIr' CM'sl, Uv IM; AIM ua-. as follow^

I<lO

DC RAT ION

Ki •NTKUUTOKV

.1/

Ihus

//•■ii^

' >* >. I !■ \ rio.N

,o

11

f^'-iiir.f III Sun I

niRATIoN

SIGNED

)'(•<//

1/-

I\Us

\

\

n

I lours

M.D.

AXjXj^i^ '-'•^^

SPECIAL INFORMATION on') f*"" Hospitals, Insmutlons,
or Recent Residents, dod persons dvim] .mdv from home.

How lonq at

Plare o( Oedtti ? \

1 / ,/ 1

lA

UK \!5

)\ I' '-r \ III) I'KK'^ON \I. l'\K lUMl, ARS AR J 1' K T 1 ' 1' • 1111';

iH'>i' <(i- MN K.Nuw i.i.ix.i-; AM) bj;i.ii:f

' III I'M iisatit

li.ia.^

1 ^,

Urld'

former or (\D

Isiial Residence ■ '

When was disease contracted, /^ ^
If not at place of death? \J ■ k^ \

Transients,

Oavs

I'l \i\' ()1 lURFAI, OR RI'MkVAI,

I) \ ri-! Ill m KiAi, f>r K

;MnVAI,

1. ^ An ,.',.,iiUI he stiite.l F.X4CTLY. PHYSICIANS should

N. B.^ Every Item of inform»t!on should h, .orctuHy supplied. ^^'''r.; T' "^n^d The ^Special Informafmn" for pT-

statc CAUSE OF DEATH In plain terms, that It m»y be properly classH.ed. He »p
sons dying away from home should be J^iven in every instance.

o

^

9£

r

r

1

I I

1

'J

C^'

m^'

! ' ', IN

WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD

■ - ;uv.i . . REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

Be ^isf ('!'<'(! jYo.

'?5.'?n

•H. ^-\ •

Deputy Health Officer

DEPARTMENT OF PUBLIC HEALTH^City and County of San Francisco

Certificate of IDcatb

Xi. S. JIitnn^a^^ ■

City of O CL-yx

PLACE OF DEATH: — County ot

X.'^Xj

^feXia^.a a\Xc x '• ' SU Dist.;bet. and

/ ,r DtATM OCCURS .WAY fBOM USUAL R E S I D E N C E C I V E FACTS CAtLED roR UNDER ' ^ ^^ <= I A L I N FO R M AT I O N ' \
{ "death OCCURRCD in * HOSPITAL OH INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. J

i 1

FULL NAME

.L^'

Uc

PERSONAL AND STATISTICAL PARTICULARS

^

I'l il.i iK

' I '! i'l i; I 1!

%\

"^ 1 Li

bS

II

i •*"■« iK I I)

' \ M I or

1 X I ill R

lUK rn I'l. \i I-

'1 \ : 1 il \ NAM 1
'•1 M'tlHilK

t'.lH rm-i.An.;

""' i'' I >! Ci mill! \ I

' » ■>■' r A rn )X

/\'' :,iril III SiUi I'l iiiii ni ,1

U ^\ . i V/^

rn

0

MEDICAL CERTIFICATE OF DEATH

DA 1 K <>1 1»K \'rif

' M.iiithi
I 11 KK V:\\\ CHkTU-V, Til 11 \ a\u\vV

thai I \A<i -;i\s li •' alivi- nil W :v .... i,p ,

and that -Kalh .hcumi'.I, mi \\\v .late statud abuve, at

\\ Tlu' C \rSI'; Ol' I'l'XXril %^:i- as fnllow^:

u

1

DiRATlnN *^ )Vr/rv
C<»NTKIi;r I't'KN'

Months

Pa

1 1 on I ^

\)\ \l\'K\ < > N

(SIGNED )

)-ra,

Mouth

Ihjvs

c

/VJ\±J

d. I

w ■>

I

n

* ■,',,■ / -

\'..,'lh

in'.sT III Mv K\o\\i,i;i)(.i-; and in:iji;i'

'Iiif.i-mrmi

n %v

■^ ■ .

I \.l.lrtv.s XO

^%^rcA.t(n^ '^^-'

^rs\) \Xf\> ■ .

-N

Hours
M.D.

Kf'i

SPECIAL INFORMATION ""'^ l'"^ Hospitals Institutions, Transients,
or Recent Residents, and persons dvin-] .ih,iv from home.

^ %^ \\m lonq at

PI,iif of Deatli? Dd)s

Former or
Usual Residence

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

|» \ ri' ot' III KIAI, (II K KM<>\ AL

KJ :

i

IQOi

lA.Mi

N

... \r,r. s'v. .1.1 be stated KX4GTLY. PHYSICIANS should

■ B. fivery Item of information should h-- cnretully suppnf . i„„;iied. The "Special Infonniitinr' ifur pur-

stote CAUSE OF DEATH m plain terms, that it may i»^ propcrl, wlass.t
sons dyinft awoy from home should be feiven in every instance.

o

'>

1 es

' \

I

H '

g

;

'iWs&-

0"

WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD

I , IV'

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

jhf/r /•7/f'^/,Let<rUt>v XX

n^oH

JU'Lii^tcred JVo,

>-T*^|

dLX^

Ut

DEPARTMENT OF PUBLIC HEALTH

City and County of San Francisco

Certificate of Beatb

.A

i 11. S. StnnDarD

PLACE OF DEATH: — County of^ CL^^ JX<x^^^Ui.c<)C{ty of ' <x->v

1 ;

y

No

5il

\

D£«TM OCCURS AWAY
IF DEATH OCCURRED

(

I T

St.; ■. Dist.;bet. -

FROM USUAL RESIDENCE GIVE FACTS called for under

N A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF S

\ o

and

SPECIAL INFORMATIO
TREET AND NUMBER

N )

FULL NAME

J cn">v

n

si%x

PERSONAL AND STATISTICAL PARTICULARS

• r uiKi'ii

',*

S

\\ 1 ! 11 'A r 1 t « >K 1 ( ; \i

1 ' I 1

J(

«'♦

1 \ III IK

lUK riMM.srK
'»! I \rm.:K

"^t;lt> .1] I'ouiitrv

I'.lk lui'LACj.'

<»l Miil'UKH

I State 111 (.'ountt \

'U

MEDICAL CERTIFICATE OF DEATH

DA ri'. Oh DIATH

M,,;i;: fl)ay»

I HKi<i:i!N' Ci;KrilN'. rinl I allcn.U'.l <lr<. i-.<m1 fnnil

that I la^t saw h nlivc mi i^p

aii.l tliat .Katli nrciirrLMl, on tlir d He ^tati'd a1)..ve, at
M. The CAISK OF I>i;AriI wa-^ ;i< folL-u--:

A.e;.

C^c^c t<

-A

' I'^^-^-y^W

C_<y r..^v

DlkAlloN y''<^'

CoNTRII'.rToRV

)'i (US

M,n///f<;

Pa

IV

Hoius

M^^uth

Pav

'HHTl'ATloN i* n

A'c ■•/(/;•(,' /;/

/

/

in: M'.ovi-: srA'nuM'FRsoNAi, r\K in I ' xk> aki; ik' »' i" ''•'■
u-.s'i* oi MN KN< iwi.rix .1-; \M) lu-i.n i

iiif,

tnuant

t

%

\ \

or RATION . ^

(SIGNED ) J 'J ^<^ ^ ^ ^

iO C^ X\ looH (A.hlrrss) bOb : UaX Uh. jI

M.D.

SPECIAL INFORMATION only for Hospitdls, Institutlnns. Transients,
or Recent Residents, and persons d)inq dwdv from liome.

former or
UsudI Residence

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

How lonq at
Place of Deatl»?

Ddvs

I'l.xi'i: <>i I'.i KIM, OK ki;m<»v\i.

A

3 ,cc>x/ '^ i w-a

nu'i

wCX

• 1- I'M or Rl%MO\' Al,

IM)1':U r \K1%K VI

'^

Ow/^rs/ J c

A, Ml ess Civj L.JLcu

n

kJ

^n

i^r^

?

r
7

J ,. , ^.pp should he stnteil f.X \CTLY. PHYSICIANH nhcuild

IS. B. Every 'item o»' InfTm.itJon shouhl be ciirut'ully supplied. A . , ■ ^^ *'Speciol Intformrtl'ion" lor p*r-

stutc CAUSE OF DEATH in pluin term«, that !t may he pn.perly .luHH.^.ed.
«nng dyinft away ?rom home Hhculil he ft^en in every instance.

I > I

5

. -to'

CJ

WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD

I V.

t"- w-^v USil- Co

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

Ihffr Fi/fff, U/tl^-lMA' 1^

IfJOH

liei^islered JS'^o.

2532

1

^v.c<^ Cc\>t{,

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco

PLACE OF DEATH: — County of X

Certificate of ©eatb

->v J,MX\xcc<lco Gty of '^^CU>v J ^^

CL'V^^C^.^.^ 0

No.

L

St.; H Dist.; bet. I fla vklt

and

\r vn

ptATH OCCURS AWAV TROM USUAL R E S I D E N C E G I V T FACTS CAtLCD TOR UNDER 'SPECIAL INFORMATION' \
,ir DEATH OCCURRED IN A HOSPITAL OH INSTITUTION GIVE ITS NAME INSTEAD Qt STREET AND NUMBER. /

t

FULL NAME

Lc^q^c<r>\j )

riTUTION GIVE ITS NAME INSTEAD Qf

PERSONAL AND STATISTICAL PARTICULARS

A * ri»l,<tK >

llcul

I

UikJj.

MEDICAL CERTIFICATE OF DEATH

I) \ ri; I ii- i>i;a rn

,c,t

lilK 111

M,,'!li \

/i)^0

\i .1-:

14

\

II. I \

M. ii'li

I hi

■-l^< .1,1" M \K k 11- I>

uilHiWHIi «>K 1 1 ;\ I tpr f.' t)
'Write in •mki.,1 tli^ii'iiatii>ii J

Mit t \

lUHrnv

1 x rm-.K

Hiki'iiiM.ArH
'>i 1 xrin-.K

' St ifi (ir I'oiiiiti \-

^! \ii>i:n- n amf
<'i Mtrrm-.R

Ill Md'lIIl'.K

' '^t.itt ,,t Countryi

4 I

1

(Yt'iiri

I HI';Ui:i5\ (.l-.RTJI'V, 'i'!i:ii I atton-kd dcrcascl fr.Mii

U at' "XX 190H t.i .. :t 3>X i()oH

that I last saw h^A^x alive oil i:^ 9.:^ SO^OllNfYL iqo 1
an.l that .k-ath .xTurrcd, nii the «lalc stali-.l almvc. at 10 60
LL M. The CM "^1; <>!' l)i: A Til was as follows:

a

1 A^'

-vUvu LiA-tXrV^Li

Dl KATION )V./r

CONTRIIU TORY

)V</rj

MouthR

Pavs 1 3» Hour

X

Pax

s

//oNf.s

/yy^<ry\A>

'HC\-i'A rioN

/\r' !iilil 1)1 V,,i>; /'itlllil

AAxwvx^

cu

- )■,•,,, ^ ^ yf,.„'ln

/hn

nrRATioN

(SIGNED) U,/a,LL<3u<:^ b. ^'in^txttcr>v M.D.

SPECIAL INFORMATION (*nh lor HospitdK. Insfifutions, Transients,
or Recent Residents, and persons dying amy Uom home.

'in: Ai'.uvK sT^ri:i> i'j.:ks()\ai. r \r rur!, ars aki" ikth t«> thh

lUCST <)!• MY KNOW 1,1; IX '.I-: .\NI) Hi;!,!!'.!*

(Infotinaiit

jjU^tpw 'h. n<>«rtt

^i

Former or
Usual Residence

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

How long at
Plareof Death?

Days

Vl ACK <)l- niRIAL OH ki:M<»\AI,

n

INDHKTAKKK UW

DAIi; ,1? lu Hi.vi, or R1-;M()VAF,

IQOH

(A(l(li«.->*s

i9^ XH

^0/

l) ,. , 73,p «u„,,i,| he Rtated liXACTLY. PHYSICIANS should

IS. B.—Every Item of Information should b. carefully BuppI.ed J'^^^^^^Z^^^^^^^^^ ..gpe.lal ln»orm»tlo„" for p-r-

state CAUSE OF DEATH In pliiln terms, that it may be properly ciassmcu.
«?>ns dyinft away from home should be ^iven In every Instance.

! I

1 1

1; I

r )

WRITE PLAINLY WITH UNFADING INK-— THIS IS A PERMANENT RECORD

1

■h IN' ■■ 'r-l' ■»•■'—« 1'.^ l ''"

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

'n

IXtfr ri/('f/,V^tAMXj 1%

IDOH

Uvilislered JS^o.

533

i.*.w^ \

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco

Ccvtificate of IDcatb

11. S. StanDar^

-<

PLACE OF DEATH: — County of ^

City of' '^

V^

"%

No.

•^ J WW

f

(Q

v., u

±\

St.; ^ Dist.; bet. n Ov and

/ ir Dt*T4< OCCURS *vwiiy from USUAL RES I DE NCE gi ve rACTS called for under "special information • \

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

Xi) i-k

FULL NAME

+

(H.*..

HI S

PERSONAL AND STATISTICAL PARTICULARS

» f I i , I I K

-t

\ lUK r

M

Ii:i%

\«.i-;

'11 M \ k i< n I

>| |\\ 1 I > < IK I I

^\ : it ' It) >«i M la ! ■ ,

0

It

.111)

HIH I III'!, Xi'l-

N \M1' ( i|
F \ 1 II IH

I'THI'I, Ai'H
I \ III KK

' '■ • ' i! t'tiiilltl \-

M Ximx X AMI-
'>! MolIll'.K

I'.'H III I' I. Ail-;
"I MoI'llMK

— s.

^

r^

O.'

r^xj Ji

^

ct^.^i

> ^^<1j

(Vf-ai •

MEDICAL CERTIFICATE OF DEATH

I) \ t'l: (>i i>i:a rn

\i,iiu!i> (Day)

1 IIi;Ui;P.\' Li;kTll'V. That I attiiuUa .U-«nasr.l from

tliat I last -,a\v h wH* alivf oil W.C.4J 3^3^ Kp'^

aii<l that (liath < »(riirre<l, < m thi-diitr Ntatcal ahovi-, at i
M. Thi- ( AISK or I)l'.\l'll wa--- as follow^:

I)( R.\ TK 'N

y,,,,

Months tl /hn"^ HoHts

wW >\jL

if

_ , w4.

r^

<>^ » I I'Ai ION

l\f>hlftl ill Siiii I I iiii

zx?U^<

n

CdNTRIHrTokV \/U j^wK/wlXa^ , <X , ^

^ — ^ I

1)1' RATION Yiiirs ^louths Pa

(SIGNED )vd^e-0 ■ ' ■^>

rv

/ fun IS
M.D.

SPECIAL INFORMATION "ilv fnr HospUdls. InsMtutions, friinsipnts.
or Recent Residents, and persons dyinq dv^dv Irom tiome.

> ,,/;

»-' M.iiith-

III 1 \novi sr \ ii:t) i'Hksox w, fXKTirn.ARs a hi; ikih i<» iin;
\n'.wi' ()i_Mv KN(>\vi,i:iK.i-; am> iu;i.ii;i-

(Inf.,

inatit

' \

.MrcsH Q*Db(p Jj .h.^cy1X^v\X OXI

Former or
IsudI Residence

Wlien was disease contrdfted,
If not at Blare of death ?

How lonq at
Place of Deatfi ?

Days

i'i.acj: ni luHiAi. <iK ki:m<>vai.

nsri", (it lliKiAl, or KlCMoX \F,

ni.i;ktakhk U a..U/n±l rrLoAA.-ru^ ^< V^

(A.Micss IS 3.H c\t^^

"""""""""""""""^ TrF .Hnuld be stilted EXACTLY. PHYSICIANS nhould

N. B. Bvery Item of informntfon ahould be cnrefully HuppI.ed. ^i^n s^ ,|«„if|cd The "Special Informati.m' for p«r-

•tate CAUSE OF DEATH In pli.in term*, that it mnj be properly UaMifica.
nnn% dylnft away from home Hhoiild be 0sen \n every Instance.

I'

■fell

#f

WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

Dftfc File<l ,

a?^

190H

Rp^i.slervfl A^o,

2534

I

1

Deputy Health Officer

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

Ccvtificate of IDcatb

( "U. S. i5tnn^ar^ i

PLACE OF DEATH; — County of a/rv 0Xa^\.cc4Cc City of " vv J ^a^rv^^ixi^o
No. ' S ^ CLK St.; R Dist.;bet. K ■ L^ad^Ao and'/BA^cil^^ek )

(ir DEATH OCCURS AWAY rROM USUAL RESIDENCE Givr facts calltd tor under "special INTORMATION ' N
If DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. /

FULL NAME

^1 F\c\4^ LLywtu L

PERSONAL AND STATISTICAL PARTICULARS

Ul ..Xl

3

&y

'•1 HIKIH

A

M,.mh>

(imy)

/ DO t

A ".I-;

1 1

)V.;

n

M.„i/i

I hi

-iN<.i.jv M\Ri<n:i)

\ Mm .\\ I'!) UK iJiVoRTKIi

lUNTiUM. \K'V

-n «,

X^

.4

%_ <w s.

N \M1 <)1

1 A rHi:R

"' 1 AIHKR

~-l ill ,1! I', Hint! V

".' m<iihi;r

'HR IHIM.Ari--
"i MoTllKk
Mati oi Coumr\

'^VCCL;

(Mnlltll)

(Y.ar)

MEDICAL CERTIFICATE OF DEATH

I) A l'l^ ( il ni' \ Til

il):ivi

I 1I!:RI;1!V CIIRTU'V, Th.-it I atlciidcil (Irria-tMl from
•.A 190H to iyct XX i.pH

that I la^t saw \\JJ\j alivi- on ^~ cD %,% itpH

aiiil th;it death (UHnirred, (Ui llie datr stated ahovf, a1 I oO
U. M. The CAI'SK OF DKA I'll was as follows:

^<jt\XLl ^kjtax^^c^' t - t.

rvx)

} 1,1,

i\

. i

c

^ \.>

?

vxXl

DC RATION

Mouths

/h2\

'.V

Hours

ii

< KAll

•AllUN^

r' W W U O.

L \ SJX.

Dr RATION Vt'ars

(SIGNED) U

Months

/hivs

i]X.% ^ L-vv

(0 1

I louts
M.D.

t^ %% iqoH (Address) (3 15 iaA^frtl^M<iq

Ions, Transients,

SPECIAL INFORMATION onlv for Hospitals, Instituf
or Recent Residents, and persons dylnq awdv from liomc.

Ihr,^

Former or 1 , . -1 li J
Isual Residence 1 1 0 i w^

/aVx \%

HoH long at y

Plareof Death? 1

. Oavs

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

i)Ari;iif m K'lAi. or rkmowai,
iLct IH IQ0I

I 111 Aijovi-: sr \ 1) n i-kr«>nai, i'\k i rrn.ARs ari; tri k i'») thh
in-.'si'Dj. ^^^^• KN( )\\ij iM .J.; AM) in;i,n:F

^u.i.h.s. ilOL \;oJA nt

N. B._Kvery item o? i„?„rm«tlon .houlcl be carefully supplied. AGE should be stated EXACTLY PHYSICL4NS should
•tote CAUSE OF DEATH in pinin terms, that It may be properly wiosslfied. The Special Information tor p«r-
«nn» dying away from home should be ^iven in every instance.

I'l.ACK OI" lURIAI, OK K1:M<)VAI,

I i

ji !

\\

i ,

s7^

• -^

I . ij^L

•1^

»f

imi

'ii

t '

r

J

T

WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD

,), J N-,> ^T*^-; l!M'< o REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

/hf/r /'VA'^/.lLet^rlMA.. a^

hjoh

Ju'oisf crrd JVo.

^585

X<r^c^ Deputy H^-^'**^ /-.«^..^..

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

Certificate of IDeath

PLACE OF DEATH: — County of o. >x

r

10 City of ' O

A.

iNo. .

at

tTY^w.0.

St.: ^ Dist;bet.

i *■ .-

and

^Ol.4.C0

I t '

(IF Dt*TH OCCURS Aw«v TROM USUAL RESIDENCE give facts called for under special information \
\r DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. /

FULL NAME

. .{rr

PERSONAL AND STATISTICAL PARTICULARS

) ' '! i';k i 11

rlX^

1 /

N! \R Is ii:i»

1 I • I iR I> i\'UK I !

'! I'l. \i'K

1 A in IK

niR IHIM. Ai-H
' " I X I IIKK

""■'■■ • it *'i mti!! \

A' Mill N WMF
"1 MoTIII'.k

MEDICAL CERTIFICATE OF DEATH

!■ \ ij. 1 .1- III: \ I H

,-» I 11 "-J

A» • /on \

M nth' :< . > iV- !!>

I IIKKKHV t i:rTII'V, That [ attiMKh-.l .!v .-a frnni

that I la-t h;i\v h —— alive nn Kp "" —

aiiil that (Uath <Maiirre<l, nii tht- <! ati --tatcil above, at •

~ M Till- CWrSh; <)1' Dl-; ATII wa-; as foII.i\v<:

K. 'XXxn.KXaX, )b_^<x>xl> i^.^cu^CK-AJL

'•IK rillM.AOH
"1 Mot I IKK

\,tL<x-vxd

DIRATION )'riirs Months Pais

fONTKIUrTORV

DTK AT ION Years Mouths Days

llotd s

( SIG

NED)L6^^viA; J ^i^.Uj-ixLa^^

I/i'UI s

M.D.

\ ' A

__ /\f:ii/t'if in San / i ,; ii, / ,-,i ^0 ) > '" * *"

I Hi: \m)VK STATi:i) I'Kk'^oN \l. I'XKTIiri.AKS ARi: IK! !■: T

•n-.sT <u mvkn<>\vi,i;d(,i-; wd hhmi:f

'' ' " f"' '"■' nt J AX)L^Ok A rvv^.>^y-

r^d. I<)0

H (Achlre^s) L^\,e^wUxA L 4f-t.>gX

SPECIAL INFORMATION o"') for Hospitals, InstifuHtffis, Transients,
or Recent Residents, and persons dyinq av»dy from home.

M.'f'h

•JO \\\V

^\<lclrcss

Usual Residence I Ul

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

.. Days

I'LACi^ <>I^ lU KI\r, <»H RHMOVAI, | DATK of HrRi.u. m KHM<>V\I.

Uvo-^^

X'h

IQOH

/o

INDKRTAKKR

^'(Lm,VU

rAd.hvss ix:?^^ ^yutxhjkd. t

*. „ ... Af F «ho,.lH he Atated EX4CTLY. PHYSICIANS should

N. B._Eveny Iten, of Information should he CBr^fuM^ «uppl.ed ^^^f^ J^^^/^^,,^^^^^^^ .8,„,ia, Information" »o. p-r-

•tate CAUSE OF DEATH In plain terms, that It may he properly ciaasiTieu.

iion« dying away from home should be ftiven In ssnry Instance.

I I

Ii

' i I

Ii

^

rJ

^\

S

WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD

i V. -^■-■■'v^i. ]:K]' r.

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

^,<

A

M

ill

DEPARTMENT OF PUBLIC HEALTH

It('gi.sl('i-C(l v\V;.

2.^

536

City and County of San Francisco

Certificate of Bcatb

( XI. S. Gtan^a^^ i

Q^

PLACE OF DEATH: — County of

a^rxcc^ec City of' ia.y\> J VcXwac-^Uio

JVa

No, KXyy^sXh^,<xX L-\>f^juxx^\-^<ii,^ fi^. St.; Dist,; l^t. and

(ir DtiiTM oc«uBS *«M>Y TROM USUAL RESIDENCE give facts called for under special information "^
ir DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD Of STREET AND NUMBER. /

rv

FULL NAME

PERSONAL AND STATISTICAL PARTICULARS

« '< »i.t Ik s

M 1 LclL^

■ iUK I Jl

i

■ '^r\KKx^ WoXXxXL

\

1\

r%X?s

I N! ARH 111)

■ 1 ' < »H 1 i;\nKi*i-:f)
• Mia ; ,1, ^i^fiatititi)

%

lA

IT

r

m

■ ^ M 1 I IF

ink iiii'i, \(K
"! I \ 111 Ik

' * I >iiiit t \

M \II>i;x N \MF
<»1 .MnTlli'k

'Hk Illl'I.MK
J'l- MuTHHk
^tsit« i>r Cotuifrv

'• ' I i'\ riox

n

^

MEDICAL CERTIFICATE OF DEATH

DA 11, t li |));ATH

\i Mill il):ivi iNVari

I H I'lR i;i'.\" (, ! RTll'V, That I .iIIi'IkIlmI .lt-<va--i'd frniii

, — -lip— to — -— — ICp —

that I la'^-t ^a\v h :-^ — - aHvt' on - — — ■ Itp

and that (k-atli iirrisrrcil, on thr datr state. 1 ahnvf, at
M. Thi- CAISI-; (>1 I)i;AriI wa^ as follows:

. 1 /n ( Kit

•„ C\ ^- > U-i-^VXX^

<xXA^a' k tA\,t

,<vA.

i

U

UjUL4jlLu aD ClLLi tt

^

jj O^^fer^x^'M ilctC4.

1)1 k.\ri<»N )v,//s

CnNTRflUToKN'

MoHlhs

fhtv

Hours

Ihn

-\ J

V<XuJ-

c

K,

(SIGNED )Le\e>\JA' 4 ^MA: J-cLo-vwci

/foia
M.D.

SPECIAL INFORMATION "nly for Hosplfa
or Recent Residents, and persons dyinq dWHv from tiome.

Ifafs, Inslinjftons, T

Former or
Usual Residence

/qX

,>CL.t:A

CJy L j HoH lonq at
IU.IKX.1 Place of Death?

Transients,

Biys

h'fhh'ff III Sun I'lnmint 5S )>'<.'<> M.oilh

Inn

nil; sijovK SIX III, ckr^onai. i»ak ikm-i. aks aki-: tki k t<> thi-:

IU;ST ()!■ M^- KNn\VM.;i)«,H AND lU'.I.Ii:!'

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

I'I,A<'i; "1 lU KIAI, OR Ri;M<t\'M,

flnf.ifinriut

^

c

UXX-uXt

I»\ri .,'' lit KiAi, or KHMu\'AI,
VDKRT A K H K ^J t ) >VCU 1 ^ V V^

fAd.uiss ^S" ?:i - "iSl

■.),Ci_

.. , Ar-F _h«,.lrl he -tntecl EXACTLY. PHYSICIANS Hhuuld
OF DEATH In plain terms, thnt it miiy be properly wiaMiiieu.

N. B." Rvery Item of

•tate CAUSE _. ^

•on* dying away from home should be given In ©very Instance.

\

sd

f

t
{

WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

P.oat.l i,f il. -Ith ! N".>^ i^ •$-T'^s^^ uScV Co

Da/c /'V/^^^/A'ct<rt-t\; li

190 H

Regi^lcred J\'*o.

2537

CV^HwCU^ dLtAj-t

\jL

\

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco

Ccvtificatc of 2)catb

XX. S. 5tanC»arC» )

(^

PLACE OF DEATH: — County of '^ CbY\. JXCL/WC/^CC City of^<X./y^^ J \.<X/^^'<Xxlco

Hi

Wu

, Lctc, ^ K.t\.<.rJuA. ?o CM^kAi:

CL^

St.;

Dist.; bet.

and

S AWAY FROM USUAL RESIDENCE give facts called for under "special INFORMATION" \
IF DEATH OcduRRCD IN A HOSPITAL OH INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. •

FULL NAME

H

.L±\

\}

YX VUO^^Uj

o.

PERSONAL AND STATISTICAL PARTICULARS

Hl.\

1 »!.( )K

> . r VVCVU

^Li

nAi"j-;

nl IMKllI %

IS-

M.nthl I.

(Day)

rll'l

MEDICAL CERTIFICATE OF DEATH

DATH Ul< DKATII

il'ct

A«'. J*.

•J }|■,u^ ^

M,,„th^

1

War)

Pa

SINr.ii- \!AKUIi:i»
'Uiittin -^iiiial ih --iv nalinii i

10

ccMrMj-<^

A

luK rin'i, \rj"

I St.iti- I ii * ■ III nl ! s

N \M! <»I-
I- ATI! )■ R

HIKTm'I.ACK
(H- I'AI'IIIR

istiitt' 1 .1 r. .uiit I \

<>i- Mo'nn-'.k

HiR rniM, \ci-;

<»l. Mn'inilR
(Stall' i»r loiinHy

(HHTI'A'l'lON

IL' ,et 1 D

%% /QoH.

(Month) (Day) (Year)

I lll':Ki':BV CI'RTII'V, That I alteiuUMl .krcascMl from
190'^ to w cfc 2.x ^ifO^

that 1 last saw li-\' alive 011 ii/ ct XX upH

and that (U-atli orciirre<l, 011 the <late stated al)ove, at D oO
L\ M. The CAISP: OI- !)I:.\'I"I! was as follows:

U>''Y%J„U^

s-^^

L Ol >x dc

or RAT ION )'tars

CONTRIIH'TORV

."i/oni/is

t^tK^^X^

£>m's

Hours

<xJj....^jjaA

%

xxM^o^y\j

\.L-L<xaa^

DTRATION

(SIGNED )

Yjiars

Months /hivs

//ou

rs

C.et 3.3^ iqoH (Address) UIm H Lo

fe

M.D.

^M-'

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

xt

ransients.

Former or ,
Usual Residence I b

rt

OJvXXj ^t

How lonq at

Place of Deatli? \X Davs

A'/'Mii/'if lit Sill) /'i ii 11, /--iir \0

M.'uth^

Ih

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

Tin; \ii(»\i\ sr \ I'l'D I'KRsnNAi, I'AK'iii'ri, \Rs ARi; iRi 1:

liHsT 01 MV KNnWM'JX'.H ANF) \\\'.\.\V.

!IiifM!iiiant

111 IFIK

( \(Mri-«H

Uiii '■'^ Lc fe CKA\.AjLa,l

INDliRTAKHK M/l 0 A./y\/W Jj.

TQOH

I'l.^CK OF ntKIAT. OK RKMoVAI, I DATi; of Hi rial or KKMnVAI,

(Adc

N. B. Kvery Item of Informiition mHouIcI be cnrefully Kupplied. ACJR should be atnted EXACTLY. PHYSICIANS should

state CAUSE OF DEATH In pinin tcrm», that it may be properly classified. The "Special information** for per-
sons dyin^ away from home should be i^iven in every instance.

mm

I '

)1

n

•#

m'

WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD

l; :,!,! ..f II. iiMh \ N<. i- ^'^.71:^^ i'^

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

Dff/r /v/^v/, ALict^rUtA-. a^

IfJO'i

Jieffis/ej'cd J[^o.

2"^

538

^

<5UCA.

.VHJ

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco

PLACE OF DEATH: — County of a

Certificate of S)eatb

( U. 5. StanDarD )

J? ''-1 -f I P I

'^<tci^ LL<XH.<X' City of oL^<i' '-l/tCto-^ LaA)

No.

St.;

Dist.; bet.

and

/ IF Dt*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' \
V IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. J

FULL NAME yCl'»vi<i. \D, jLiA^U5AXtr>\;

)

- 1 \

PERSONAL AND STATISTICAL PARTICULARS

(MioK

^^]

IxU

J-

'XjJjL

liAl'l-: < il lUK 111

M, iillli

JV,/

I):i\'

M„vlln

(Vt-ar)

/5./ I A

H!N«- I,K, MAKH Il'H
WinoWl.'Ii OK D'Xi iRiJJ)

(\Viit< ii! -(Ri;il iltsiviuitinii)

,L

HIK I'Hl'l. \i*K

( State ct »"' intitr\')

NAM J- ni.
J- Al H KR

HIRTU I'l.ArK

<)i i\rm:K

I Sljiti <n I'duiit! N

M Aini'.N N \\\\\
<>l MorillCK

niK'ni!M,A('K,

of- M()iiii-;k
(St:it<' or Cinintiy

MEDICAL CERTIFICATE OF DEATH

DA TH ill- 1)1;ATH .

(Month) (Day) (Year)
I HF.Ri;m' CI<:RTIFV, That I attciKkMl (U'ooased fruiii
Kp to IqO —
til at I last saw h alive on Itp
and that death ocnirrcd, <«n the dati- stated above, at
M. The CAl SI-: OF DICATII was as follows:

Q^hoJLo. .

Lcd.(

0^

\XKKjy\X

i

^A

1)1 RATION Years

CONTRIiaTORV

Motiths

Davs

Hours

DTRATION
(SIGNED

Years

Mouths

Pays

Hi

ours

,4iQrn":,..lU[l

r()0

(Address) <X,d-0/ J/OXo-^ K.<uL

M.D.

'(Xa'ucL

ov'cri'A rioN

C,

/\'f^it/fif III Stnl /■') ilHi irn

) I'll I

M,;,ll,'

fhn

THK AnovK ST \ ri-.n pkksonai. p \h rieciAKs arh trtk to tiik

H1-:ST Ol-' MS KN«»\\I,i;d<',K AND lU'IJlU-'

i\

(InrDtmant

%.

r-vciAX^rw

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

Former or ^ M 4 if ^^^ '*'"'' **

Isual Residence '^^ J/CU^O vCtA^ piare of Death?

Days

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

ri.ACi: Ol* lU RIAI, t)R R1:m<i\AI, | DAri;..f nimu or rkmovai,

&^ a.H 190 H

'flU^(^iu, Ia,

INDKRTAKKR

A

V - o /cUXoc^ 'VA.il^ Co

(Addtess \J XO- S tJLL-Jl

N. B. Every Item of Information should be carefully supplied. AGB should he stated EXACTLY. PHYSICIANS should

state CAUSE OF DEATH In plain terms, that It may be properly classified. The "Special Information" for per-
sons dylnft away from home nhould be given In every instance.

|! I

^1

)

£1

K1

J

tif

I

WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD

M. !li IV'

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

Dff/^' ri/rf/,VckA}<> '^.^

IfJOH

Be^istcred J\^o.

25

539

^

L^cc "". M Deputy Health Officer

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco

Cevtificate of "Death

( "U. S. StanOarc* j

No

PLACE OF DEATH: — County of' a-rv J \xxJy^J:AAJ^ City of ^^ tx^^ J Xxi/vxecA/Ca

Dist.;bet. and

USUAL RESIDENCE give facts called roR under "special information ■ \

~ INSTEAD OF STREET AND NUMBER. /

St.;

/ IF DEATH OCCURS AWAt FROM USUAL R E S I D E N 1 1 G I V E FACTS CALLtu
V IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME

FULL NAME

.y

^

mx-

^1

{S-tkl«^K;

PERSONAL AND STATISTICAL PARTICULARS

SI- \

{w

DAii: t>i lUK ni

COI.oR 1

rvo

L

M.mth

At,H

uU>t bS"

3k^

1/,»,/,^l

M^

\ ('at

/),/l^

HINT. I, K MAKHIHD
\Vn>(>\Vi:i» OK 1>!N'»»R> }'f>
iWritfin -uial lU— is.'nat inn '

r

>v<:i/

BiR rm-i. Xi'i-:

'Sf.iti or I'lMintiy

^•\^T^• oi

1 Alii l.K

HIKIHl'I.AOH
OI* I AI'IIKK
•Statt' iir Couiili >

M \ii»i;n NAMI-
Ol' MOTHHK

lURTm-i.ArH
OK motiii;k

(state or I'luuitrv 1

MEDICAL CERTIFICATE OF DEATH

DATli Ot' DKATH 1

f Mouth) 'Day) (Vfar<

I HIUslU^V CliRTli'V, That I attcii(U«l iltMH-aseil from
L- Cb 1^ 190 H to iL^/ct -Xl \cp*i

that I last saw h-inr)r\ alive on ^ cfc X

l)0 1

Tip

and that (k-alh occiirrt-il, on the dati- stated above, at ^
'J M The CATS!' OI- DKATII wa^^ as follows:

?

'XXXrY\ju{

^

3Jk.M^^y>-

X\/YW<XA

1

DT RATION )'t'iirs J/ort/Zts Days

C ( ) N T R I BUTO R V ^Xa^lOAX^ J iXudxtuJ^

//ours

DIRATIOX

)'t'ars

(Signed) \lil J 'lfc^fvluA^

W/cJt . iqnl (Address) ^J-JA^vwam/ lljO-^utaE

//ours

M.D.

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

Rf^iifni •>! S,;n /■> <iiii>u-i) — ) ''i?

*" M.infh^ " I

Tin- \HovK sr\'n-i) i-kksonai, pAKrurLAKs akI'; TKrK To rnH
liKST Ol' MV KN<>\VI,i;i)C.K ANI) i!i:i,tj;F

(Iiifoiinatit

h

XWWCL,

VN.

\.l<lli'

\ , now lonq at
t Place of Deatli?

Former or .A^ln f« ^J- How lonq at

Usual Residence b JLO Uja^-^Vwxi

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

Days

iM \CF t)i" mi^iAi, oR ri;mo\ai, I i)\ri:<»f lUKiAt, or rkmovai.

INDl'.R TAKI-.K

■ Muss 11 5H ' mjUAA,fr>v "dt

N B —Rvery item of information should be cnrafully Mupplled. AGE should be «t„tcd RXACTLY PHYSICIANS should
state CAUSE OF DEATH In plain terms, that it may be properly damnified. The "Special Informat.on" for p.r-
sons dylnft away from home should be j^lven in every instance.

> A

i

jn*^

WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

Deputy Health Officer

!.»'

Re^istci'cd J\^o.

2539

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco

Cci'tificate of H)catb

( "U. S. StanDarD j

(^

^ 4 -^ 1 c

PLACE OF DEATH: — County of Hl^^ J \.a.>vCL4cu3 City of ^ CV>v J V>ct'>vcui.cx>

No.

V\JY\\,<Xy\j

\D 0"M vCtxx^

St.;

Dist.; bet.

and

(IF DEATH OCCURS AW*1f FROM USUAL R E S I D E N C E G I VE FACTS CALLED FOR UNDER "SPECIAL INFORMATION' \
%f DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. /

FULL NAME

.0

(YYXj C

<KL

.Lhj

PERSONAL AND STATISTICAL PARTICULARS

I) A ri:

>i HI Kill

.Mouth)

XX

\' .1-;

^4>t (dS

) ■»•(,• t » "■

M.mlln

M'x

\ I a I

fh,

(Year)

^INf.l.l" M \KH n:i)

\v n >t I \v i; I » OR 1 ) i \'( » K I ■ i: !)

HIKTHl'I, M'l-:
'Statt- or t'l Hint i \'

NXMr: iH

I ATIIKR

luk rm-i, AtH
Of 1 A rm-.K

• st.'iii- or I'liimt 1 \' '

M MDI'.N N'AMl-;
<)1 MOTIIHK

HIKTMl't.ACK
or MoTHHK
fStatf or Conntrv)

<tCCri'Ari(JN J? ft

MEDICAL CERTIFICATE OF DEATH

DATK OF DKATII // A

Dtt ii

(Month) (Day)

I m^RI'HV CI;kTII'V, riiat l attiiKliMl .UMvascd from
L- Cti )3> lyO H to \i.'/0t ^l loot

that I last saw h L'V*\ alive on U.CAJ 2.1 190 S

ati<l that iKatli ncciirrcd, on the date stati-d ahove, at b
'j M. The CAfSIC (>!• DKATII was as follows:

1

1

niRATION

CONTRIIU "I

) V(/;\T

Months

Days

OKV cL

X.OJ

I lout s

) cats

Kf sided ID Salt / iiitni rii *• ) lii

DTK AT ION

(SIGNED) Xjll. J. 'otc^vL
vlMlij %{ T90H (Address) O,

Mouths Pays Hours

Kjy\A M.D.

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

Former or / « . j n | « "!^x How lonq at

Usual Residence

bXO

Place of Deatli ?

Days

M.nilh^ - lui

Tin-: AHovK sr\ri;T) i'Kksowi, pxhtu ri, \rs aki-; tkih 10 rm-:
I'.Hsr oi- MY kno\vm;i)<.h and in:i,ri;F

(1 11 forma nt

h

X>wvs.^x,

y\

ulo CH^^a.,tQJb

r\(Mics« —f?

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

I'I,ACR OF lU KIAI, OK KI;MoVAJ, I liXIJ of IJikiai, «.r KJCMoVAI

N. B. F.very item of information ahnuld be carefully supplied. AGE nhould he ntnted EXACTLY. PHYHiCIAINS nhould

state CAUSE OF DEATH in pinin terms, that it may be properly classified. The "Special Information" for per-
sons dying away from home should be given In 9\9ry instance.

( ,

t

3

•I'

w

WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD

if H<:ilth- !•■ No

«w^%.

I'.i^V c

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

Dff/r F//('(/,h^itA)

>~t\j X%

190H

gistevecl JSTo,

2540 1

Deputy Health Officer

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco

(

F DEATH

Certificate of Beatb

( XX. S. StanOat? )

QST)

L,' 0

A R Dist: bet. 0 .Utt-

i

J

PLACE OF DEATH: — County ofUcuru Jxcxy^vc^NLCc City oi -o^^^^^ h^xx^^c^^uiycvo
No. 5 m • W q Jc St.: R Dist.: bet. 0 .Utl'YWOVi and luL WtiK^

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

" )

(B

n

FULL NAME JiCXAxx.

]

,Uu^

t,

vvt^A^cnv

SIX

PERSONAL AND STATISTICAL PARTICULARS

h

i> All. ( )i liiK rii

l0Jv.i^

^A^l

(Year)

\<.i.;

bS

)•,-,/

{,

1 I):iv

M.niiln

I Vtar)

Aj i:

'-IN'. I, I". MAkHIia*

W 1 1 >« > W }•■ I > OK I > I \'« > K V ■ i; I )

iWlMiin ~iirial ^ 1. -,! v> ii:il n ill )

\(:sSK^^^^<i^

HIK rUlM.AOK
(Statf or Ciiuntrv

X\MI MI
1 A in IK

lUR'nilM.ACH
')! I ArilllK
' Stat I 1 ir l"<)uiilr%'

MAiniN NAM1-;
<»I MoTHllK

IHRTIIIM.Al'H
<)1 Moi'UKK
' Stati or I'oniiti \

oi'cri'A ri()N(7tv>'

rs

% CMjX^no. M I 1/Ol^^

MEDICAL CERTIFICATE OF DEATH

f>!imtli) (Day)

I Ill'kl-I'.V Cl'RTll'V, That I attcn<lo<l (Uocased from

ifWj C CA/ ^l upH to 190

that I last saw h-^^' alive on vLvCAj 3^,1 I90 H

ami that (U-ath ocrurred, on the clat«.' statetl above, at

S5^

M. The CAISI-: OI- DI-ATII was as follows

Jx4.k;

^

<XUu

I) r RATION }'t'(irs

CoNTRinrToRV

Mouths

Days

//on

/ \

9-

\

^

DIRATION

Wars

Mo)ith>

/hns

(Signed) ^i LAj. fltD-u^irru>u

iiicfc 13l iooH (A.hlress) X'S'l'me^Lt k

Iloni s

M.D.

J cuAJKvaAM.'>v irLcm^

0 ^^K^'UJ^.KrdUi

f\'r-itli',f III Sail /•iiiiiii'-f'n jV ) i d i

M.niths

Ihiv,

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

former or
Usual Residence

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

How lonq at
Place of Of atli ?

Days

THI-; ABOVF. ST^Tl'Ii I'KKSONAI, I'ARTICr I,A KS AK V.
ni.:ST Ol' MV KNOW'M'.IX'.K AND iu:i,n.l

IRIK To TIIK

(I

nf...ina!il 0-^^ vj^. \j\J<XXX/S\xkX''y^'

(Arid

rcss

SOI

u (^-ULcav 0 xxXx LIaM.

Pl.ACE OF niRIAI, OR RKMOVAI. I I) ATK of niHiAi. ,.r KICMoVAl,
l-NDHRTAKKR ot Aj . " J XLUv4jbVu

(Adche... ail QfH' (]LlLu.tiA, ii

N. B.^— Every Item of Information •hould be carefully supplied. AG6 tihould be stated EXACTLY. PHYSICIANS should
state CAUSE OF DEATH in plain terms, that it may be properly classified. The "St>ec!al Information'* for psr-
sons dylnft away from home should be given in every instance.

:>

. «i

A

V

i ■

WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

Hnnrcl of Hcalt h I " No. \ ~ ■*T.^«ii%) I'-S: P Co

/)((/(' FiJet/ ,

(

.Cruu^

>^J X^

r.^

WO'i

Besjfis/r/'ed A^o.

2541

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco

Certificate of 2)eatb

( "a. 5. StanDarD )

PLACE OF DEATH: — County of XUyv J AXXAA^*_<u^o City of ^^/CU^v J ,»

J( (1^

>L/<X/W<X4XU)

No. 1 ?5 5 J XXckX lU^

iL

f

'St.; 5^ Dist.;bct. 3-0 t^u

I-

and

ai^i:.

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

FULL NAME

.try\.CL/s

%/0^'

d.

PERSONAL AND STATISTICAL PARTICULARS

CL

L

d^A^jJjL

MEDICAL CERTIFICATE OF DEATH

DATH <>i- j>i;atu

:» \ I!-: or hiki-ii

ACH

Moiilh)

bl

)%

3)

(I):ivi

M.mfh^

A\^

■:ir)

I'l

Iht

'^IN'*.!.!" MARRIl-.U
\VFH(»U i;i( r»K l»!\t»Ui HI)
IWlit' in -mial il(-tK<1l»tion)

lURrill'l, \»"1-.
'State or <.i.imti \

(Month)

la

(Dav)

(Vear^

I III':RI:i;V CI{RTI1'V, That I atteiukMl deocased from

m\\ojv 'i 190M t.. li)'C^ "kX lyoH

that I last saw h-L/Vv\ alive oil U'C-tT Xi 190 H

ami that (Uatli orcurrcil, on the date stated above, at 11 H^
Cx M. The CAISK ()!• DKATIt was as follows:

NAM I' OF

I athi:r

HIRTlM'l.AOK
«>|. lAPHKR

(Stiiti- or Coufitrv)

MAIDHN NAMH
<)!• MOTIIHR

HIRPmM.AOK
<)»• MdTHHR
(Stall- or Cotuitrvl

UCCri'ATION I U

UXi/).<x/vvc)u>u \J iV LuA.

DT RATION Years

CONTRinrTORV

DTRATION )'cars

(Signed)

Mouth}

Davs

Hours

Af()Nths

/hivs

Hours

1 Jfl Ur>v>viAX M.D.

vLkt XX rqoH (Ad.lress) lOT OAA^llicK. Ot

<xjy\Aj

Rffidftf in Sum f'l aiiii^rn O O ) '("

\rr,„th>

Ihl\^

Special information only for Hospitals, Institutions, franslfnts,
or Recent Residents, and persons dying atvay fro.n home.

Former or
Usual Residence

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

How lonq at
Place of Death?

Days

THH AHOVK STATl-J) I'KRSONAI. PARTir f I, \ RS A R l', TRl K TO TIIK

hkst of m\lknowijvI)c.k and hkijf.f

(Infoitiirnit

AfUlrcMS

TiS \hJUoX

n.ACK OK RfRJAI, OR RHMoVAI. I DA IF; of Ht kiai. or KKMOVAI,

rXDKRTAKKR VJ ^WsX^yV ^ -OAX LLvwCLb Lo
(Address ^t D^ \irnAA.^U,.A^V W A

N. B. Every Item o? Information should be CHi*e?ully supplied. AGE should b« stated EXACTLY. PHYSICIANS should

state CAUSE OF DEATH In plain terms, that it may be properly classified. The "Special information" for pri-
sons dying away from home should be given in svery instance.

< ,

t I

ffl

I

1 ;>

WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD

Hoar-! f H- ilth 1 V., •- '^"^^,^J:;0i H^il' fo

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

0

1^

4^ 1

190'i

Begislrrcd J\''o.

2542

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

Ccvtificate of Bcatb

( XX. S. StanOarD j

i

^

^No.

PLACE OF DEATH: — County of cX^a-' ^' >v<x/y^J^\A^c City of ^'O.av J \,C^->a.cuiXl^

^^^ C\ ■ % I ■ 4 i

J 1 U; • ^isA.<n^ ^10 O-Mvcto.4 St.; — — Dist.:bct.-— '- and

('\|F DEATH OCCURS /iwAV FROM USUAL RESIDENCE Give FACTS CALLED FOR UNDER "SPECIAL INFORMATION" \
y IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. /

A

FULL NAME

urrxAryX'

r^\

.U

CTV

PERSONAL AND STATISTICAL PARTICULARS

^^i;.\

Ol

t<»l,t>K

OJJL

i'VC

t^

1) A I}-; <»! IJIKTH

A<.i-;

.^^^

MEDICAL CERTIFICATE OF DEATH

DATE Ol' D1:aTII

X\

Vfar)

rgn

M..nth:

5-C- ,

Day

\f.>utfis

\ (MI

/J,7 1

siNr.ij.: %!AKRn:i>

w r 1 )« » u } . I ) ( » K i> [ \< > K * ' i; I )

'\\iit< in -(nial (h'><i>.Mia! i- m )

cuuucccL

lUKTHPI.ArK
' State (ir C<»iuitr%'

N" XMl", oi-
1- A'lIIKR

HIK TUl'UACK
Ol- I ATHKK
fSlatt nr Count! V

MAIDKN NAMK
OF MOTHI'.R

HIRTHPLACK
OF MornKK

(Slate or c'oiinttv

OCCri'ATION

I

(Nfonth) (Day) V

1 HfCRlCHV CI:RTII<'V, That I atteii.k-.i ikctased fmni

1

iy.ct; 1^ 190 H

to w'ct Xi

190 H
that I last saw h.*-'Vn. aUve on 'C <L\j 3^1 190'i

atid that death »)ccurrc(l, oil the Mat*,- stated above, at i(
\X >T. The CAISI'; l)F DICATII was as follows:

\t

^^A/\

h)

U/vJk'-

nr RAT ION )'ears Months S Pays Hours

CONTRIIU'TORV

DIRATKXN

(SIGNED)

Years

.'Sfouths

Days

dUU) ow . \J fLtA/vvcrv-v^

}

I

K) XK-^yy^^<x.'

Krsidnl ni Sati /'i <iH(isrit [^ )'roi.

k)j^ 1?^ 190H (Address) ^01 Qj<.Jduju J t

1

/fours

M.D.

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

1 /,);///;>

Ihi\s

\\\V. AHOVK STATKD PFKSOXAl- PAKTUTI.AKS A K I". TKl K To TIIH

linsr oi' Mv KNo\vui:n<". K and ni-;i,ii:K

[111 forma lit

fAfldrt'ss

OiS'i. m ^ojvxxAA^YK, nt

A

Former or
Usual Residence

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

How long at
Place of Death?

Days

ri.ACK 01 lUKIAI, OR RKMoVAI, I DAlllof Hi kiai. or RIC.MOVAI,

O-wvi. I ^^ ^"^ Tool

10

rj.ACr. OI- JSl K l.M, Kl

INDHRTAKKR

(Address

N. B. Every item of Information «houIcl be carefully Rupplted. AGE should be stated EXACTLY. PHYSICIANS should

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

WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

Hour.! . f U.-.,U1i T No ;- ■^'^■■■;af'^. uScV C

'X^s^KAj^ doiAHj Deputy Hcc:::h Officer

Registered JSFo,

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco

No.

Certificate of Beatb

( tl. S. StanC>arD )
PLACE OF DEATH: — County of ^ CX^x' J/UX.>x>cx4.co City of Cj/Cu>% J A.<X/ryw^^c4.-cuo
\ 1^\ MU A.ULK) St.; \ Dist.; bet. Jt XycLi and

(IF Ot*TH OCCUPIS *WAY rPOM USUAL RESIDENCE give facts called for u4dEB "special INFORMATION" 'S
IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAQ OF STREET AND NUMBER. /

FULL NAME

L

o^^ywj^

PERSONAL AND STATISTICAL PARTICULARS

SHX

0 ^j'rsx.oJ

IM

D.\TK OF HI Kill

A(,i-:

' C(»I,(IR \ A

MEDICAL CERTIFICATE OF DEATH

Month)

1

) 'ra >

Dav)

M.inUn

(Vtar)

na\

Ik

(Year)

SIM'.I.K, NfAKRlKl)
\\ri)o\Vi:i) Ok DIVoKiKI)
tWritt'iu MK'ial <k'>iKiiiiti<>ii)

BIRTH PI.ACK

(Statf or CcHuitrv

UArroCyVi.

■4

NAM1-: ni"
FATlIl-.K

HIRTHI'I.Ai'K
<>|.- lATIIKK
(Statt or I'ouiitry

M\I1)1-;n NAMl'.
HI MOTIIICK

HIRTHPLACK
<>l- M()THI:R
(Statt- or t'ouiiti>

rAA'

3v3v

(Month) (Day)

I HI-Rl'HV Ci:RTn<V, That I attendeil ileceased from

LL^?uJC 190S to iL/ci: aSl^ 190^

that I last saw h X^V aHvc on Uct 3^^ 190 H

uikI that death occiirrc<l, 011 tin- d;iti- slattd ahove, at I-2».U

Cr M. The CAI'SI*; Ol" l>i:.\ril was as follosvs:

%

DTK AT [O.N Years L Montha Days Hours

) N T R I in T ( ) R \' L i v<r Vt^Dj cx i^i. ^hIt^^uJLahj

DURATION Years Months Pays Hours

( Signed ) JL U). gijLAJL>urcuttr M.D.

i %% iqoH (Address) JRI UXitlxhj ot

Ou

()t'Cri'A'l"K)N

R'-yiifed in San Finn, ism ( )',iu s .^/nnf/is

/>,n

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

Former or
Usual Residence

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

How long at
Ptare of Deatli ?

Days

THH AROVK STATKn F^KRHONAI, I'ARTHM' !,ARS AKH TRIK To THK
HHHT OF MY KN'OWI.KIX.KnAM) HHMHK

(liifn'iiiaut

(Addrt'ss

KN'OWI.KIX.KnA?

PI.ACK OF niRIAI. (»K KF;m«)VAI. I UATKuf Hi riai, or RKM<»VAL

n^. ...

iqoH

rNi)F:RTAKF:R V (<X^yxfc^rciA; MjA.-^k^..

(Ad.lrvss \X^^ \f)f\A.M,^\^^^\ Ut

' U'

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

state CAUSE OF DEATH In plain terms, that It may be properly classified. The "Special Information" for psr-
•ons dyln4 away from home should be given In every Instance*

I I

\'

^

\ ■!

O,

I

WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD

HoMtl . f lUulth I No i^ :$^^^-)U&l'Co REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

Ihtfr /vVrv/, lD,^tc4>XK' X\

190H

Registei'od J^'^o.

2544

,^ Deputy Health Officer

DEPARTMENT ob PUBLIC HEALTH=City and County of San Francisco

Cettificate of 2)eatb

( xa. S. StanC»arC> )

PLACE OF DEATH: — County of

City of v]l,C>-U)

ATU

^No.

(IF DEATH OCCUnS AWAY rROM USUAL
IF DEATH OCCURRtD IN A HOSPITAL

St.;

Dist.; bet.

and

RESIDENCE GIVE fac
OR INSTITUTION GIVE I

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

FULL NAME

SH\

PERSONAL AND STATISTICAL PARTICULARS

j COLOR \

-x/ys:

Lh

4)wL

u.

DATl-: nf- lUKTU

AT,!-;

(Month)i

0

t3

) ■(•(/ 1

Day

M.iulln

( \f;il

/',/:

^

MEDICAL CERTIFICATE OF DEATH

DATK OF DHATH ,/ \

^''ct 11

(Month) (Day)

I in;Ri:!5V CliRTn-V, That I atteiKkMl .Icccased from

igo .

(Yt-nr)

^IN<".I,K. MAKKFI'.D

\vin< »\\ i-:d or d!\< >w<i:i)

(Write ill sfM-ial di sivnat ikii)

B!K Till' LACK

'State or Oouiiti \

LL A ^J^

H

190

to

that I last saw h ^ — alive on

"I90
T90

and that death occurred, on the dat«.- state«l ahr)ve, at
' ■ M. The CArSl<; OF DI'iATH was as follows:

HcUv

<k.i>

'i

^^A.

Kkx

<x

NAM!-: «>I
HA I II I.K

IUklHI'I,A» K
01 lArilKK

(Htati- or t'oiiiitrv)

MAIDKN NAM1-;
Ol- MnTIIKK

HIKTIIPLACH
OF MOTHKK
(State or rotintry)

f HO r FAT ION

Resided in San Ft am ism

1)1 RATION Years

CONTRIHUTORV

Mouths

Da vs

Hours

> u

0;

)'ciiys

t

Mouths

f^avs

Ul' RATION

(SIGNED) \J . .i\D. U) O-CkU,

^/et; 3^3. Tcjo (Address) VjIxax^ MU/u

Hours
M.D.

) ea I

Mnllth-^

I>a\

SPECIAL INFORMATION only for Hospitals, institutions. Transients,
or Recent Residents, ind persons dying dway from liome.

Former or
Usual Residence

When was disease rontrar ted,
If not at plareof death?

Hoi¥ lonq at
Plareof Death?

Days

T 1 1 V. A Ii« ) V R HT \T 1: 1) P K R HON A I. PA R T KM' I. A R S A R H P R T V. T< > T H K
HHST OK MY KN'OWUHDOK AND nKMHK

(Informant

(Addresi

PJ,ACE OF niRIAI, OK RKMnVAI, | I)\TKof HtKiAl, or KKMOVAI,

T \ ^^s

INDHRTAKHR ^ i '

1 00

KJ

H

(Adilrt-sM

35 5 \i JVfr>xlci.v',

^

N. B. Bvery Item of Infopmatlon should be cspcfully aupplled. AGE should b« stated EXACTLY. PHYSICIANS should

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

I I

J

,'V'?

WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

H..,,i.] .,f !I. aUh IV.. 1= ^'-VJ^Si, Hftl'C'

luUr Filcil, .. /tJ>fM>v 9^4

WO'i

Registered J\''o.

2545

n

dwd' LC-

W< /

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco

Certificate of Beatb

( tl. S. StanC»arD )

PLACE OF DEATH; — County ofO/O/^v jruX/VLCUu>0 City of Oxx.^^ o V<x ,xcUl^ '-.

1 M 1 ^

St.;

(ir DEATH OCCURS *\w*Y FROM USUAL RESIDENCE give facts
IF DEATH OCCU

IRRED IN A HOSPITAL OR INSTITUTION GIVE I

Dist.; bet. ^* and

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

FULL NAME

v. >«i*^ '*»

0 ^

PERSONAL AND STATISTICAL PARTICULARS

si:\ A - A '"' '!.' '^f

DAI 1-; i»!- HIK I'll A h

Kn

\xXxi

(^l.itith' i

\«.H

JV,?>.

I).,-. I

M, mills

%\

(\\:\x)

l\l\.

"^IN<'. 1,1 M\KUIi:i>
(Wiitr ill -(Hial ill --iL' natiuii

BTRTHJM.M'l-,

'State (ir I'ount i \'

NAMK <)I
FATiniR

RIRIHl'l.A* H
Of 1 AlllKK

(Statf iir (.'mititi v)

MAIUI-.V NAMK
(H- Mnrill'.K

niKTHIM.AlK

Of Mn'i'lIKK

( State or «."iiuntt y!

OCiTl'AIlON

(W-nr)

MEDICAL CERTIFICATE OF DEATH
DATK oJ- DKATH .A

(Month) <I)ay)

I IIl':RI';nV CI-:RTIFV, That I atten.kMl deceased fmtu

.- ■..^.v;— .:—.- 190 ^ to —^'.TTr up

that I last saw h ■ alive on '■-■ Ttp

and that death occurred, oti the date stated above, at
M. The CArSIC ()!■ I)i:.\TII was as follows:

Y

rvxxx- r w

J\.A^ii \ i.

n I

nr RATI ON }'t'ars

CONTRIIUTORV

Months

/\iv

Hours

/hivs

DURATION Years J/on/As

/l£fc 19. iQo'l (Address) Kj^<ry\AA^t

(SIGI

Hours
M.D.

\

*, \^\,,.^^

Special information only for Hospitals, Instlt^tyons, Transients,
or Recent Residents, and persons dving dHay from home.

Rfsidfd ill Sim /■inii,n,:> )>,ii f ^ .t/,»if/is i. 'j /Mia

r\\}- XHOVE STATHP PKRSONAl, PARTICl'I.AKS A K i; TRIK To TUH

HKST OF MY kno\vij:d<;k and nHi,ij:i'

nnfonnatil

i

i-vW Kju^^^^'^^-'

fAd.licss

Raa- lb

Xm w

r\>,ji^

Former or
Usual Residence

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

How lonq at
Place of Death?

Days

PI,ACK OF niRIAI, OR RF:MoVAI, j DATi: of lltKlAf, f>r RF:MoVA1.

^H 1 90 H

(Address ^HS Ss M /\\AAa,^tv . )t

N. B. Every Item of Information should be c«r«ffully supplied. AGB should be stated F.XACTLY. PHYSICIANS should

state CAUSE OF DEATH m plain terms, that It may be properly classified. The "Special Information'* for psr-
sons dying away from home should be given In every instance.

1

1 f

*

t

1

'

(J*

I

D

• o'

: I

i

ill'" I

• I

r

WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD

l!.,ar(l c.f II, alth )' V

Vii 1^ "^'f^^r^. lU^P I'o

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

Da/r FiJvd, \V'^

,<rlA,^->0

K %\

U)0\

JRo^isfcvod JSTo.

S546

Deputy Health Officer

DEPARTMENT'OF PUBLIC HEALTH^City and County of San Francisco

Ccrtiticate of Beatb

{ Xa. S. StanDarD )

J? 01^ -^ <^

PLACE OF DEATH: — County ofCJoyvu ^Xxx.^>^-eUieo City of CJ/Cl^tv J ^^cl/>x.<:^..^^o

(^ n

No. oS. ^x.

xc^{m\„c

St.;

Dist.; bet.

\\-'

\}

and

K^

\

(IF DCATH OCCURS AWAY rROM USUAL R E S I D E N C E G I VE FACTS CALLED FOR UNDER "SPECIAL INFORMATION" N
IF DEATH OCCURRtD IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. /

FULL NAME

\}

xrryxixo

•^%

PERSONAL AND STATiSTICAL PARTICULARS

Ml^OuU

\ ^

WkXsl

DA ri: m- lukiii

\i.|.;

MEDICAL CERTIFICATE OF DEATH

DATK <>I- DHATH // \

(Month)

as

(I):iv)

igo H

(Year)

Month'

1 v.;

^

s

(Dav)

M nl'h-

It

/'./

SIN<,|,1.: MAKklHI).

WIDi »\\ i:ii OR IMVoKrKI)

lUiitcin ^(Mial dt -.i^'nat inii)

k

,]

f

M

luR I'll I'l. \ii-:

(state or riiinitl \'

N'AMl- OI"

iatiii;r

nikTMIM.ArK
OF lArilHK
(Statt or Coiiiitrv)

MAIDKN NAMl'.
OI- MoTJIHK

FUHTHI'r.ACK
<•!•■ MOTMHK
'State or Countrv

I HI'ikliHV CIvRTH-N', That I atltii.kal ileccascd from

tcfc ia \<pH to y c;b a.3 ,goH

that I last saw h -L»-i aUve on L ' CX 33. lyo *i

and that death occurred, on the dati- statccl above, at CX\)iKvt7
11 d M. The CAlSi: (>!• Dl-ATH was as follows:

XL^ru

If uxMm)uIi

Dr RAT ION Ytars Months H^^ Days Hours

U

nr RATION 3 Years
( SIGNED ) V ll^rVuU

Mijtit/is

/)ays

Hours
M.D.

^ruLhj

di

(

3^3 i«)o'^ (Address) SH JKv^.dL

SPECIAL Information only for Hospitals, institutions, Transients,
or Recent Residents, and persons dying at^ay from home.

r

OCCd'ATHIN

Residfil i» Still limit !>,■,> *" \'iilis \ ^f.niths \ ^ lhl\.

Tin-: ABOVE STATI I) PKKSONAI, I'AKTHM L\KS AKl*. TKIK T( ) TflH
nKST OH MV_K.NO\\ l.l'.Ix.K AM) WV.X.W.V

(InfoTtnaiit

-w^

\.M,,ss %\ \i) lAA/>xnrA-t Cji7

Former or
Usual Residence

When was disease rontrar ted.
If not at place of deatli ?

How lonq at
Plarcof Death?

Days

rLACi-: ni m RiAi, ok ki:M<>\ ai, | Dxri.of ni kiai. or hi;movai,
LfrUju Uu>^^L4, I ^^ ^"^ T90H

(A.Mitss in I N»\AAAA.e>\ Ut

N. B. ^»M^ry Item of Information should bs CBf*e?ully supplied. AGE should be stated EXACTLY. PHYSICIANS should

state CAUSE OF DEATH In pinin terms, that It may be properly classified. The "Special Information" for per-
sons dylnft away from home should be ^iven in every Instance.

( J

I

fit

\

I I

I i

:>

i I

H m1 ..f !!( -iHh - \- No

WRITE PLAINLY WITH UIMFADING INK — THIS IS A PERMANENT RECORD

]\ScVCn REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

, ••£.

^

If)OH

Ihfh' Filed, UtiurW-N; V\
0 u

v6v„A.A. Deputy Health Officer

Registered J^'^o.

;2547

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco

Ccvtificate of 2)eatb

PLACE OF DEATH: — County ofV'-<X>v

"Kc

CL )-vCU^

City of OxX/^-v dx<x>

XCa.^^

^ 3

No.^lC) \1 ll-O^xto,: . > ■ St.; ■■ Dist.;bct. Y^^-^''- ' and\J.<XC

/ ir DCATH OCCURS AWAY ^ROM USUAL RESIDENCE GIVE FACTS CALLED f** R UNDER SPECIAL I N EO R M ATI OM" \ j,

V IE DEATKJ OCCURRED \*i A HOSPITAL OR INSTITUTION GIVE ITS NAME I^^STEAD OF STREET AND NUMBER. J \J

(t

FULL NAME oru'U/^^-o

,00

-I \

PERSONAL AND STATISTICAL PARTICULARS

Cni,( )K ' ^

w .\j Y y wCX^

DATl-; OF IiIKTH

Ai.H

L.'

M.iutli'

bS

3 r

(Diivl

M.nith

\ (.'iir

/)./!<

MEDICAL CERTIFICATE OF DEATH

DATH OF I)1:aTH

(M.mlh)

(l)av)

IQO \
(Year)

I ]II-;kI':HV Ci:r<Tn'^V, That I altfn<UMl (UMvast.Ml frnui

4.. \.,\,.\,.

190

'^IN'.I,!". MARK 11!)
U I!»< tWl- I> UK li;\i iRii:[)
Uiitf ill -.Dri.il ill •'is.' iiali"i!i)

luk rm'i. \i'i-:

(Stat- i.t I .Hint 1%

Hi

OJ\)\xj

t^x

!• ATII HR

lUk flllM.XCK
01 I XIIII'R

I Stal (■ 1)1 I'lxmt t \

^T\lI)^;N na%!1-:
01 .m()Thi;k

niRriMM, \CK
n|- MoTlIKK
(State <»r Countrv)

OCITI'A TlOX *'\i?

i>x

Q^xjo^Aj

(^

to w ZXi I90 t

that I last saw h • ' alive on ' - ^ ' T90

and that tU-ath occurred, on the liatc state<l abovi'. at

M. The C ArSIv C)|<" Di; ATII was as follows

_ _t.A_^..

^

XAJo-*J\.'^i.KAj^.

Yi

DrkAlloN ' )cais
CONTRIIU'TORV uXa-^

v

&AaA-UU-^ '

Rridfd in Sijtl /'i d >n /.•>fi> J^L ) ' il i

\f.„iHl^

I),) 1 »

DIRATION
(SIGNED )

\^jCX« •*.'i 1 90

Months

Months

Ha

r.v

I lours

.<^,o

Pav

I,

rs

Hours

M.D.

Address) 15%- H 0 KxX'>\t ^£XdLc

i

Special information only for Hospitals, Institutions, Transients,
or Recent Residents, aniJ persons dying m&s from liome.

Former or
Usual Residence

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

How lonq at
Place of Death?

Davs

TIIH AIIOVK ST \'ni) l'l''RSnNAI, I'A KTUT I. \ RS A K l'. TRIK To THK
BHST Ol- MY KNO\VI,i;i)<".H AM) HI.Mi;!'

fill Tot mail!

xHVx; Lo-o-i

A.ldrts.s. %l C)

yxX

^

lU.ACK OF m RIAI, OR RFtNfoVAi, j DA IF: of HrwiAr, .u KKMOVAI,

190

(AtldKss

N. B. Every Item of informntloti •hould be cnre?ully supplied. AOB iihould be stated EXACTLY. PHYSICIANS sbould

Btote CAUSE OF DEATH In plnln terms, that It may be properly classified. The "Special Information" for per-
sons dying away from home should be given in ^s^vy instance.

I

51

• o

I

* I

I

WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD

H..;inl ..f il. iMh IV.. " "?'«' ^■?.- H^ P Co

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

190 H

Re^isfevcd JSi^o.

O^

548

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco

Certificate of IDeatb

( XX. S. Stanc>ari> )

*

No,

PLACE OF DEATH: — County of 'CL-yx- J .n.ou'vccULOO City of O^C^-u J /V<X/>x.C>uutU5
L O^KctoLA." St.; — Dist.; bet. - ^ .......-..-.- and-

r

,{)

(ir DEATH OCcUrS *W«Y FROM USUAL
IF DEATH OCCURRED IN A HOSPITAL

RESIDENCE give fac

OR INSTITUTION GIVE I

FULL NAME

iXJLAj

AAA} :

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

'"XJ'XJLhj^MYXj

PERSONAL AND STATISTICAL PARTICULARS

COI,i»K

i'Aii-; or- liiKTH A^

1 Month I

1 rllX

1 ):l V I

A' , I-;

%!

)V

\%

(Vfarl

/),/■

MEDICAL CERTIFICATE OF DEATH
DATK OF DHATH d \

u

Month)

3.1

(Dav)

(Vrar)

U IDmUKU ok IMVoRrHI)
Wnte in social «ksiK'iation)

lUR rni'i.Ari.:

(SUiti or ' ■nuiitr\'

NAM J- Of-
I ATllllR

MlklllPI.AfH
<H- I ATHHK
Stat* or fonntrvl

mmi»i.:n namh
<»1' motiii'ir

HIKTm-i.ACH
Of Morill'.K

f Stall or i'ounl! \

1)

O^LTLn^l

I

I HI'kJvHV ri;RTlI'V, That I atleiKlcl dct tascl fn)ui

-L'tt iio T90S to 4^>ct ax

that I last saw h>C/Vn alive 011 L ct X^

UfO H
190 H

aii<l that (U-atli ()C( iirrcil, 011 the dalt' statuil ahovi-, at boO
^ M. The CAISH OF DHATH was a> follows:

.Ui

DC RATION )'cars Months I SL Days

CONTRIHI'TORV n^ — ^ d^A> VOJ Cr^ AxA^X^i)

(mo

nccrpATioN

Rrsidfif ill Si! 1,1 / i diii isrii •- )V(/i

,1 r

duration
(Signed )

)'rars Mi'n(/is

Days

)o H f Ail(lrtss)

u

o-<l

I /ours
Hours

M.D.

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

Former or

Usual ResidenceClVvCXK

K*^ VXiAJ-adow plaf e of Oeatli ? ^

yr,intii.-

IhlY,

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

Cl|vu.A.'rx,^ N ^J^'^J^K^^u0^n»t of Death? ^ .. Days

Till-: AIU)VK STATKI) PHKSONAI, PAR P IT f 1,AK> A K l-! TKIK To THK
HKST OJ- MV KNOWI.HIX'.K AND H1;IJI:F

(Itifoimatit

^.%.^|

(Afhlrc-s

rOl^.>QyCrA^

l%l5'^ \jYLv(tiU.^ra at

I'l.ACK Ol" ni'RIAI, (IK RKMo\ AI, I DATI" of Hi kiai. or KHMoVAI,

r M ) 1 ; K r A k i: r 0 /rVwt.o^<r\> oL' AX>wvi^

(Atl.lrrsH ^$^1

ta ^X <^<r>v Q

N. B. Bvery Item of information should be cnrefuliy supplied. AGB should be stated EXACTLY. PHYSICIANS should

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

I I

Ir !

Hi

I

H

3

J

:>

*
«

I

i

n

f

rf*

WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

Unnnl (if Ilralth I' No. le, 4«^»t^H&PC»>

Reglstet'ed J\'*o,

2^

Dufe Filetl,\j/zkjXjO\j IH 1^0^

i^tc^/^lxvM Deputy Health Officer

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco

Certificate of 2)eatb

( "d. S. Stan^arD )

^

:\

PLACE OF DEATH: — County of V 'o.^ rv J A r. ,— . City of J.<X/vu JX.cx>a..c^A^.
^No. 5t ^: \ : St.; Dist.;bct. = * ^ and

(ir DEATH OCCURS AWAV FROM USUAL RESIDENCE GIVE FACTS CALLED FOR UNDER "SPECIAL INFORMATION • '\
IF DEATH OCCURRED IN A HOSPITAL OH INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. /

FULL NAME

ji.

PERSONAL AND STATISTICAL PARTICULARS

^i:x I

!>\T1-; or lilKTII

M.V.

I'OI.nK

/ '- i

M,.iith

):-a>

(Dav)

M <n//i}

\ tar)

/hn

MEDICAL CERTIFICATE OF DEATH

DATK <)!• DlvATH

(Motitli) ri)av)

/go '

(Year)

'^IN'.l.l-: MAKNIi;i)
wiixiu'i;!) OK in\» >Kij-;i) n
'Wiifcin MMinl lit— i!.Miatii»n) I

ISIKTHIM. XCK
(Stall or Counlr vi

NAMl OF-
!• A'ni i,R

nTKTHIM.ACH
Ol" FATIIKR
(State or Cuiiiitrs

MAFDl'.N NAMH
oi MOTHHK

HIKTMIM.ACH
OK MOTHKK
(Staff or C»)uiitryi

ni-cri'ATl()N Oj\p

h'fsiiifi! in S,m /'i a III I -it

I HRRRRV CI-RTIFV, That I atteiulcd den ihscmI from

■ ■ 190 in ^....:.: nrirn:: ,." up

that I last saw h aHvc on jijo

and tliat death occurred, on tlie <latc stated above, at

M. The CATSH Oh' I) I- AT 1 1 was as follows:

DIRATION i't-ars

CONTRIIUTORV

Months

Da v V

Hours

Wars Months

nrRATioN

(Signed ).L(f\^\%jUvv^ j w*.

W ^ I<)0

Pay

Hours
M.D.

fArldrt-ss) Wv^ ,

SPECIAL INFORMATION only for MospiUls, Jnsmufions, Iransieits,
or Recent Residents, and persons dying away from home.

M.mlhs

l>,i 1..

Former or
Usual Residence

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

How lonq at
Place of Death?

Days

THK AnoVK sr\ TIJ) i'HKSONAI, I'A K T Kl' I,A K^ AUi: TRl K TO TH K

(I

HHST OI" MY KN0\VIJ:I)(,|.: AM) HKI,n:F

nfotmant \| iWC-JxXXjUL Q A^WxHX'

1^

'Y\i

fA.Ulrr.s 5"% V^TYXAM-AjL-ft. ^^

l'I,.\CK Ol' lUKIAI. OK RKMOYAI, I DATICof Mi kiai. or RKMOVAI,

INDICRTAKKK LC'V\aA-Ma_ IX'VV'CiXKjt.O.

(Adclr.ss ^ (0 1& ^ YXa.XMWw.'^'Vu J L

N. B. Bvery Item of Information should he carefully supplied. AGE should b« stated EXACTLY. PHYSICIANS should

state CAUSE OF DEATH In plain terms, that It may be properly classified. The "Special Informstlon" for psr-
sons dying away from home should he given In svsry instance.

I I

I!

^

II

I

M #

fr

m

.ji*

«f

WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

It, ,..!,! of lUalth'-l-" Nn ;>; '^*;.^!S^' 1'^'' •-*"

I)(t

fr /vVrv/, yctK)-Ovi

XH.

190K

Registered Jio.

OK^

550

cLma,a^

Deputy Health Officer

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco

Certificate of H)eatb

( 'U. S. Stan^ar^ )

i^G

4 Q^

PLACE OF DEATH: — County of Ocl^a^ ^.a City of Ocx.>v ^

/ / ir DEATH OCCUWS AWAV Fl

y V ir OCATH OC^URHtD IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STBCET AND NUMBER

St.;

Dist.; bet.

and

ROM USUAL RESIDENCE GIVE FACTS CALLED FOR UNDER SPECIAL INFORMATION" N

FULL NAME

PERSONAL AND STATISTICAL PARTICULARS

SI-;\ fs^ I COl.nk ^ ,

^ I i > ■

^\ ^ ■: :

I)\Ti: nr lURTH

\*-V.

)\,n

I Day)

M.'Htll

— y.

MEDICAL CERTIFICATE OF DEATH

DA'IH Ol-' I)i;atii

's A

I I

(Year)

(Year)

Diiv

HIN«.i,K. MARUIKl)
WIDnWi:!) OK r»I\< iKi'l I)
iW'ritftii siK'ial (l(si),'iiiiti'i!i)

UA^

HlkrillM.ACK

(Statf or Country)

NA\fl-: Ol

I athi;k

HIRTHIM.AtK
Ol- I-ATIIHK
(Slat«' or C<iui)try)

MAIDKN NAMK
OI- MOTHKR

HIR'IHI'I.ACK
OH MoTHHK
(State or Country)

V^'

tJac4"

I

(Month) (Day)

I HI:KI':15V CICRTII'^V, That I attendtMl ileccased from

— -— — — - igo to iQO ~~~

that I hist saw h .: ~" aUve oti ^^ 190

and that dt-ath occurred, on the date stated ahove. at
M. The CArSI<: Ol- DIIATII was as follows:

1

^ >-^|a.>vt at dLcrttu. lu

/O. cR ,

DTRATION Years

CONTRIIJUTORV

Mouths

I hi \'s

Hours

\K,kX C^ij

%J^'\ \. r

rs

I liur ^a-tju^

Mouths

Days

Hours
M.D.

DTRATroN JC^^ars

(SIGNED) J.Vj\.. i\.

^^. ^H 190't (Address) Ulu ''' ^A.

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

OCCri'ATlON

/^fsiiifd in Siiif /'i itiii isi'it

)'ftit

Mitnth:

thiv.

TIIK AHOVK STATl-.I) I'KRSONAI, I'AK riCII.AKS AKi: TRl K I«> IHh

HHST Ol' MY kno\vm;i)c,h AND ni:i,n;F

(Informant

^

-L<rX<yt

f A(lclreM««

Cdt^"^ C<H.A./V\tu hbAkKAX'^K.

.\/v\tL

Former or
Usual Residence

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

How loni] at
Place of Death ?

Days

in \(K 01 nrKIAI, or RKNfOVAI, I DATKof Hihiai, or RHMOVAI,
INLHRTAKKR KjxXaX ' NKixi^'<t<Jl U

(A<l.h

N. B.— Every .ten, of l„fo.„,atlon .hou.d b. can.fu... -upp.led. AGB .hould «-•*«*«- ^''.^f^^,^; .XTJllLll^' lof^i-t
•tate CAUSE OF DEATH In plain term., that it may be properly claaaifled. The Special Information for pmr-
(»on« dylnft away from home should be uiven In mxery instance.

I I

5

3

^m^'

-r'

,- rr

'mtfi'-m^

WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

n .i!.l .if H,:t]th F No. !> ■*"f--7K?is:^ JiS:!' (.

m

liJO'i

Registered jYo.

2551

O^^iXKKA

DEPARTMENT Of PUBLIC HEALTH=City and County of San Francisco

Certificate of S)eatb

( m. S. StanDarD )

PLACE OF DEATH: — County oiOo,^^ jA^O/^cvv . City of 0,<xyr\j JX<X >x.

op

J;

i

(No. bH'-s Jc'- ' .. St.; ^ Dist.; bet. d JLC^^rx-ctj and sU

/ ir Di«TM occuns *w»v rROM USUAL RES I DENCE give facts called for under "special information" \

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

A

e

%

FULL NAME Ld^^ru^y-^d^

.a.L

I I

PERSONAL AND STATISTICAL PARTICULARS

si;\

I.

C<»I,nR

I>ATi; OF IslKTH (TX

LCi^j..

Month)

MEDICAL CERTIFICATE OF DEATH

DATE OF DKATH , A

(Month)

I Day)

(Year)

A<.i.;

b ^^ )>,?/>

10

(Dav)

.1/,'wM'

fVear)

A? I J

«iN«.i,i.: MAKHn:i»

\VIlJ(i\v|.;i> OK niVnKOKI)
(Wiiifin siK'ial iltsis/natiuii)

lUkTHIM, \(*1-

st.it f lit ( % Mint I %■

M rlouvvLixl

N\\t]' »»!

lA riii.K

lUKTIIIM.ArK

'»! 1 A IIIHK

< Stat* 1)1 I'ojititi V

MAn>i:N NAMH
nl MorriKR

HIRIHlM.AlH
nf- MOTIIHK
(State or Oc)tnitrv>

I

(^

■\l

)

I in{Rl-:BV CI{RTIFV, That I alteii.kMl dtcrascl from

.\J^ XD 190'i to . Ux^t X^ 190S

that I last saw h - ^ alive 011 A^- tX XX i^o ' i

and that (Uath occurred, oti the date stated above, at 5 iC
M. The CAISI-: OI- DI'lATII was as follows:

CLccCti %9 J.^voJbci\^

A

1)1 R.XTION

^'W

CONTRIIUTORV

\A^^-\.Ajfi.

^! out lis ^ Days ' •^ Hours

yfiXaXaii.^i-^^

LuAXX; W

iU\

-^(UA^ c ' ^

DURATION 2s 0 Years
(SIGNED)

,'^f out/is

d,c4 ,

fhus

M j

I /ours
M.D.

U ^0 W J

da X% 190H (Address) 1^6 OlD^t<Na>u-i

CJLAX^^Jl^

oceri'A'noN/

R/^siiffif III Satf / iiiniifi'n K, )iuji

Months

rhi 1

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

T{1H AIU)VK ST^ri'n PKKsoNAI, I'A KTICT I.A RS A K K TR T K TO THK
BKST OK MV KNOWLKIXIK AND m'.\AV>'

(Infonnant Mh^O-A.MjLX dv . UJ /CXA^-VlOA. dxXxuJ\^

Qfl^

(.^ddrejss

bH.^ "3 CriUu^rrru ut

Former or
Dsual Residence

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

How long at
Place of Death?

Days

PLACH OI" niRIAf, OR RKMOVAI. I DA U^: of HfHlAL or KEMOVAI,

rSDlCRTAKHR

(Add

1901

N. B.— Every Item of Information .hould be carefully supplied. AGE should »^^»«-*«d EXACTLY. PHYSICIANS should
•tate CAUSE OF DEATH In plain terms, that it may be properly classified. The -Special Information for psr-
sons dyinft away from home should be given in every instance.

i

t

1

t

«

-f

1

dI

^

I

^

II

WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD

tT.l ..f II. :ilt!l (•

'. ■V":---sg^^ Hit!" C

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

/hf/r /'VAv/,yd:(rlMA;lH

190H

Regisferofl JSfo.

i^OO**^

(Mcc^ i^\ , Deputy Health Oflflcer

DEPARTMENT OF PUBLIC HEALTH=Clty and County of San Francisco

Certificate of H)eatb

( 'U. S. 5tnn^a^^ )

m 4

^

PLACE OF DEATH: — County of "^ <X>\; JAXX.YLCxA.coCity of CJcu^ru J TUXwcuLeo

^No. JXV^^VOu'^X' Ik 0^\xc£oJi

St.;

Dist.; bet.

and

(IF DtATH OCCURS AWAV FROM USUAL
\r DEATH OCCURRCO IN A HOSPITAL

RESIDENCE GIVE fac
OR INSTITUTION GIVE I

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

i !

A

FULL NAME

CrtlXuJir J L -co-rru

'-l.X

PERSONAL AND STATISTICAL PARTICULARS

I> All-: <»r lUKTH

iricLlji

\

^.

.ivcU

31

i I);iv)

,^57

\<.i-:

(d1

5 V<j *

I

.1/

\\

fVoar)

l\i

T0o\

(Year)

n

^IN«. I.J- MAHHIi:i>

wiin i\vj;i) OK i)i\< (Kr i:f)

•U'lit*' ill --m-ial ill ^lu'ii 'I'lit'

7\xXhA^CcL

lUK rui'i. \i'i-;

• '>t.lt( (II I'.iUtlll V

NAM}- ()1

I- A in i;r

lUKTHIM.Ai'K
OI' lArilKK
(Sta't or Count! V

MAn»i:N NAMK
<>l- MoTHKK

HIRTHI'UACH
OH MOTHKR

(StaU- or Couiitrv)

MEDICAL CERTIFICATE OF DEATH

DATK OF DKATH 1/ \

(>!.)iitlO (Day)

I III'RI-HV Ci;kTII-V, That r atlcii.kMl .krcasc.i fn.ni

I90M to . Al C V ilS. H^H

that I last saw li ^.^m. ahve on U/CXi 9.S. T«p1

and that «U-ath <>(uiirre(l, <>ti the ilatt- stated above, at <->
CX M. The CAISI-; OI- |)i{ATII was as foil

^^ \\

ilWS

JJT^-

Dr RATION

} 'ears

Months

?

coNTRiBrTORV bLLc^cnruT-lA^

Par

^

DTRATIOX
(SIG

Years .^fouths Ihivs

iSJct

NED)MTl 0. ibft-jvk

A.\\J

5lX tqoH fA.l.In-^s) ^JIHAV\XU-A/ ^t»-4.

^

Hours
Hours

M.D.

Kr.-iilftf HI Sun /'niniiWi) \Q 5V-(7/>

occri'ATioN Q_r

M,„if/i^

/).n.

SPECIAL INFORMATION only for Hospitals, Insmytlons. Transients,
or Recent Residents, and persons dying av»ay from home.

Former .r ,^^^. | J tl, Cl ^ """'""''

Usual Residence

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

^^ 0. Place ol Death?

Days

THK AHOVK srA'n:i) I'KKSONAI, I'A KTICl' f.A KS AKI-. TKIH TO THH
HKST Ol- MV.KNOWTJ-.IX'.K AND UKI.ll-.F

(Itifo-niatit

(A«Mrc>;s

'S%% - 15

^k)i\j livo^u.

PJ.ACK OJ- liTRIAI. OK RKMOVAI, | DATlio! Ill wiai, or REMOVAL

0\J w. J. v^XLi>\au^\4i

i'ofc %S

I90i

fA.lilKss

N. B. Every Item of Information should be carefully supplied. AGE should be stnted EXACTLY. PHYSICIA.NS should

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

'I

D

♦4
• Si

i

I

4

I

Iff

WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD

ih ( V.

'-.- -art .--a, .M\ !' t"

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

Dull' Fih'd , li cUrW\

'^

4

190H

Jleo'l6'te/'C(l A^o.

553

.^V,i <

A

r

Deputy^ Ith Officer

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco

Certificate of IDeatb

( *a. 5. Stan&arc» )
PLACE OF DEATH; — County ofCJo^ J\.oxc^^eo City of OOyVU J XOm^CUl/ao

N«,

.1 UX- . '^^ Ui^ 1 \tu k CK. \\.d OLA.

(ir DEATH OCCUaS AWAY FROM USUAL
ir DEATH OcBuRRCO IN A HOSPITAL

St.;

Dist.; bet.

and

L RESIDENCE GIVE facts called for under spec

OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET

IAL INFORMATION" "\
r AND NUMBER. /

A

FULL NAME

<!:\

PERSONAL AND STATISTICAL PARTICULARS

CLL*.

a

f

vet

X.'

DAI'}.: cil HIK III

\' -H

\\

MEDICAL CERTIFICATE OF DEATH

DATK oi- i)};ath

A

Mi)tnh>

5

Dav)

A5X

(Vt-ar)

H

■W'

I

O J* ) tii > ^

U,,Nf//<

n

Pa

"-•IN'i.lJ'. MARHIl-D
'U'litciii -..Hi;il (1. -iu* iiatiKii)

)

Ic^va'V

A-

f * . .-

HIRTItl'I.Ai'K
( Statt (ir i.'iiuiUrv

NX Ml- Oj-
JATin-.K

lUK rn I'l.AiK

<>i- I \rin:K

I st.iti' 1)1- v'ounti N >

MA I DIN N \MH

lUK riflM.ACK
•»»• Mo'I'llKK

'Stitf (11 i'ollIltlV

/"\

(Month ) fDay) (Year)

I lfl{RI{BV CI:rTIFV, That I attciKlcd dcnaso.l frmii

iL'/tltj IH 190H to ...iL/CLt 3.3L up\

that I last saw h-UV^-s.Mlivo on W Caj %'X U)oH

and that death (>ccurre<l, on the date stated above, at 0^.0
U^ M. The CAI'Sp: Ol- DI'ATII was as follows:

Lixx»xAxv

0 11

H

/

'trt'UX^va.'^VQj

^ I A

?

Dr RAT ION y't-ars

CONTRIIUTORV L.iX\.0

Months Pars Hours

1)1' RATION
(SIGNED)

fl;

M.'Hths

axXxxtvcL

occri' \rioN

Keuded 11! Sav riiuui^r,< SO Vrnt- - .Mntli^

Davs

i)/tt^ Xh TQoH (Address) Ictu HXU Ju^^ijit

ffnsi

I lout s

M.D.

SPECIAL INFORMATION only for Ifnspitals, Inslilutions, Trinsicflfs,
or Recent Residents, and persons dying away from home.

Former or ^s ts C: ^^ ^ . \->t~ ""* '""' '* 3.

Usual Residence ^ v D J ^ \ v . L Place of Death ? O

Days

/J,M>

TMK \novK sr\ ri:i> pkrsonai, i'xktismi. \k>^ aki* tkik to thi-:
Hi-isT OI- MY KN«)\vi,i;i)<*.K AM) ni:i,ii:i-

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

(Inff^nnant

PI iCF Ol" niKIAI.DR R1-:M<»\AF, J DAII ,,• IP Ki.vf, or Ki;.M«t\AI,

(Address 451 Ol V^Xi.4. ^C ) . Ot

190 H

rNDHKTAKKK 0 /ixX^^rCV-^^^ «L>.aJAH

N. B.— Every l.e^ ot <nW„.„..on .hnuld be cr.fuM, .uppl.ed. AOB .h.u.d b. .,»..d F.XACTLY PHY«,CUN8 .houW
•tat/cAUSE OF DEATH In plnin tcpn,.. that It may he properly cla..itled. The Special Information Tor per-
•on« clylnt away from homo ■hniild be ftiven In every Inetance.

\

I

J

^->

I

WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD

!!■ M :

V , ., ^^rr?^:! HM' i'

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

fhifp F//r^/, K.\XAsVv SLH

IfJO'i

Regisfri'od jYo.

2554

.^^^A^A^

VV

I

No

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco

Ccvtificate of H)eath

PLACE OF DEATH: — County ofO'CL/TU J A.<Xy>vCU:t>(X)City of C'/CL/^x JXxX^rU^c^cX)
. Hi \J Li\^<Xxla; LLvM. St.; k Dist.;bct.L<l/OmX\.OLXdLaJ and Ucrvctixxilt

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

aTb)

FULL NAME

. LcLm-^x m I Lct\xvo^5

>x.

<kK

CO

PERSONAL AND STATISTICAL PARTICULARS

"^I'N \ . C(>I.i>R

lU

^KaI^

i> All-; or i;ik 111

\ ' . 1-:

let

Mi.iilh)

!

%

(Dnv)

1/,. .////>

(Year)

Ci

IhiV

^iM.i.K, MARun;i>

\^'II><»\Vi:i» nR DIXnKi'Hn

'\\'!it' in --"H'ial ilt^ijj'natiiiiii

luk j-ni'i, \«i'

I Stall or riiuulrv

N'AMI-; (M- ,^

I'A rilKR I

MEDICAL CERTIFICATE OF DEATH

DAi'l^ <»1 IiJiAlll ||

fMiiiitht (Day) (Vear)

I KI'iRI'r.V CI-RTH-V, That I attcn<k'<l deceased from

L/otr 1% 190H to vi cfc 'xa. u^\

that T hist saw h A/^n. alive on ^ ob 2^ i^o^

and that death occurred, on the date state«l above, at I

M. Tlie C ArSI'! OI- DIvATII was as follows

lURTHIM.ACK

«)|- lArUKK

I Stat< (ft t'ounli V)

maiiii;n namk
<il' MoTHKR

Lex ^ uL

nrkATION Yrars

CONTRIIU'TORV

Months i-i Days

//ours

/h

utrs

•.IK'I'HI'I.ACH /

>l' MnTIlHR t r\ A •

Stati- or Coiiiitrvl ^ \\ U

Aj

/wdb

I )r RAT ION )Ver;-5 Mont /is /hiys

(Signed) .*AJuiJl. U. ^ic'rvvut M.D

Ucfc 3LH ino H (Address) L^Ltoj^L^VOL^rvK^nic

^

iK,a

Special information only for Hospltalsf; Institutions, TranslenH,
or Recent Residents dnd persons dying away from home.

niori'ATioN

Krsulfil It! Siiir /'iijihi^/ii

)'iiii

Miiiith^

Ihn^

THIC AIU)VK ST\ri:i) I'KRSONM, I'XRTirtl. VRS AR]-: TRTH T< >
HKST OF MV KNoWM'Dt'.K AND I{i;i,n;t"

(Informant \J fUXl^VaXi J\X/\^>clA^el?.
fA<1.1n^s \X hUaKXxLcU LLaO/

Till-;

Former or
Usual Residence

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

How lonq at
Place of Death ?

Days

I'l.ACK ol* ru RIAI, OK RKMoXAI, I DATK of HfRlAi. or RKMOVAI.

N. B.-

-Rvery item of informntion .hould b= carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should
state CAUSE OF DEATH In plain terms, that It may he properly classified. The "Special Information" for per-
sons dyinft away from home should be |ti>en '" "very instance.

I

I

1 ^

I

WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

Horn 1 , f II, illli i'V., ■ ■^■F'sr-'i^-inSi.l' C,

Dff/r /'77^^^/X .ct^nlj-'

t\, DvH

IfJO'i

Registered J\^o.

2555

.,■4'^

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco

Certificate of IDeatb

( "CI. 3. StaiiDarD )

O^ 0

PLACE OF DEATH: — County ofU <X-va^ JA,a>^^' v, Qty ofO/tx^-u JX<x.>x.o

u

No.

-'^^")X ^ St.; Dist;bct. . and i

(IF DCATH OCCURS AW»Y FROM USUAL RESIDENCE GIVt FACTS CALLtD FOR UNDER "SPECIAL INFORMATION" ■\
IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. /

FULL NAME J A-

■>j:\

PERSONAL AND STATISTICAL PARTICULARS

\\\\

i> \ ri: or iuktu

AC-K

Mi.nih

) V „'

iri-

(Davi

.1/.;/.'/).

/ >.

(Vfitr)

Pii 1 .

SIM.ij:, MAKKIHI*
\\II)<)\Vi:i> OK I)!\i H<ri:i)
(W'litfiti siK'ial (]( ^ii'tiatioii)

luk iHPi.Ac'i-:

• Staff or Cijiuit! \

NAMI-: ()l
FATIIICK

niKTMPKACK
<>|- lATIIKK
(Statf or Ouniifrv)

MAIDHN NAMK
(>I MOTIIHR

niKTIIlM.AOK
<H- MOTIIHK
(State or Cotuitryl

OCCri'ATlON V

MEDICAL CERTIFICATE OF DEATH

DATK OF DHATH < A,

III I

V^

(Month) (Day)

I ]fF:RI':nV CI-;RTIFY, That l attcn.k><l .kicased fruin

V..-'- 190'i to y^ ».a.

that I last saw h ^-^^ >n alive on V_ ct ■ ^

/go \
(Year)

iqo

and that death occurred, nu the date state«l above, at H 3 0

^

M. The CATSK Ol- DliATII was as follows:

I

OjLc

)

xx^y^ ^' .\<x v\ c

0 ,

DIRATION Years

CONTRriUn'ORV

Months

Da ys

Hours

n

.D'ulo

3^

nrRATIOX Years ^ Mouths Days ffours

(Signed) LL. U J.ccsi.(, M.D.

ili^ ^c. iqo"; (Address) 3.X5 5 H t U4s^\.fc^v jt

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

Residrd in San Fiamtsi'n A?> )>ats \ M,n,th>

/hnf

Tin.; AHOVK ST\IK,I) F'KKSOXAl, r A KTIOr LA KS A K I-. TKIK Ti > THH
HHST OF MV KNOWLHDC. K AM) HHI.IKF

(Informant ^ -CO ^ U L ^ • . L

f Adilres"^

Former or
Usual Residence

When was disease contracted,
If not at place of 6(athl

How long at
Place of Death?

Days

I'I.ACF: OF BFKIAI, OK KKMoVAI, I l>n*Kof Mikiai, or KF:M0VAI,
rNDFRTAKKK (H? • J ■ U A>w4a^ '^^ W<j

(Adihf

\,4,A.A-t

N. B. Every Item of information should be carefully supolied. AGB should be stnted EXACTLY. PHYSICIANS should

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

D

I

WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD

Brvird .if HiMlth I" No. u ^?*^«^ I'.&l' C

RCPCR TO BACK OP CERTIFICATE FOR INSTRUCTIONS

Rpgistered JSi^o,

;!3556

.^lA^Ui

.+•

dOyvMj Deputy Health Oflficer

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco

Certificate of Death

( "a. S. Stan^ar^

4

No. '

PLACE OF DEATH: — County of ex.

»\

City of '--' <x.y\j JX,o^ ,

/ l!

w u u v. I

I
t

St.;

Dist.; bet.

and

(ir DCATM OCCUMS AW»V FBOM USUAL R E S I D E NC E Gl WE TACTS CALUeO FOR UNDER "SPECIAL I N TOR M ATIO N ■ \
ir DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. /

FULL NAME

srx

PERSONAL AND STATISTICAL PARTICULARS

COI.OR N

LL^ixxt..

DATi-; (ir iiiK rii

Ai.K

Mi.iithl

(Dav)

W^ 5V.n

1/-

t V<>ar)

/'..•

SIM.I.i:. MARKIHI*
\Vri)n\VKI) OR niVoRtKI)

W'rittiii v(Kiiil ill •^i^'iialHui)

niRTniM.Ai'i:

(State i>r (."omitt v

L i^cL^^u

MEDICAL CERTIFICATE OF DEATH

DATH Oi- DKATH

(Month) (Day)

I IIHKI'HV CICRTirV, Tluit I attcuckMl <lcrcasc«l from

rgn \

(Year)

^,

I9O

to

190 H
that I last saw h -• alive on U Cs up

and that death occurred, on the date stated above, at l
M. The CAISK OF DICATH was as follows:

U-, -

A-

I

I A riii;R

HiR rm'i.ACH

<)l" lATHKR
(Stati- «)r C(nuitry

MAII>i:n NAMK
ni- MOTUHR

inRTHIM.ACH
OK MOTHKR

(Stat*- or Ci)untr\

<H cri'ATION

Ur RAT I ON

Yeai

?

Mofiihs

Day

CoNTRIin'TORV L^Vvr>AA^ ^JiA^:>\.ci
Dl'RATION Years Months Pays

(Signed) . Y- ^ ■ ^^^^^^^x

^' el

Hours

Hours
M.D.

\ \

Rf>iilfit HI ^,111 I I <: >'< I '■

) V'lf >

M,.nth'

I hi:

U'l uyo'l (Address) kX^ w CV^Cl^j^ l j

;, iRstitnlfRS,

SPECIAL INFORMATION only for Hospitals
or Receot Residents, and persons dying away from liome.

former or
Usual Residence

H'iS

) i^KA^

H«w loRf at
Plare of Oeatli ?

Transients,

Days

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

THl-: ABOVE STATi:!) I'KKsmNAI, l>\KTIi'ri. SKs ARIC TRt K l'< » I HI-
nHsroI'MA" KNOW I,}: IX, K and HIIJIJ

(Informant ^ K^^t^JUrs^ UU {HL^V.\ '

( \.l.lr. -.-

I'l.ACK 01 HI RFAf, MR RKMOVAI, I I>Ali;..t llf KIAI, nr RKMoVAI,

w S-, 190 .

rl.ACK iM HI KlAi, MK Kn.>n*v

u

f '

Utyv

N. B.— Bvery Iten, of i„f«r«.tion .hould be c.fu.ly supplied. AGE should »-..««-*«^^EXACTLY PHYSICIAN* .h^

state CAUSE OF DEATH in plain terms, that It may he properly Uassitied. The Special information for |»sr.
sons dying away from home should be given in svsry Instance.

I

2J

J

I

WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

.1 .,t Jl. aitli !■ No 1- -"t^p^lii^' HS:!' C;

Dnfc FilviL 1 .ctHOA; V\

100 H

Be^lstercd JS'^o.

2557

^

(K^u^-^Ui

Deputy Hc-fth QflFicer

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco

Certificate of 2)eatb

( m. S. StanC>avD )
PLACE OF DEATH; — County of O/v^^ J/vcu-^vCa.

City of Uxx^x* 0 A.

4^

^

St.

Dist.; bet.

and

No. W\Ajyv\^<X^

/ ir DtATM OCCURS AWAY FROM USUAL RESIDENCE GIVE TACTS CALLED FOR UNDER "SPECIAL INFORMATION" "\
V IF DEATH OCCURRED IN A HOSPITAiL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. /

FULL NAME

^1 \

PERSONAL AND STATISTICAL PARTICULARS

Qf)\^L

n ^

i> \ I »; «<i- niKTii

\ ( . I-:

viTic

1

hj

MEDICAL CERTIFICATE OF DEATH

»ATH OI- DKATIi ,r\

\

Dav)

(Year!

M.iith)

^i\< .1.1' \i \KKn-:i>,

UIIxiU l.;i» OK IHVoRTKr)

'W'rift- ill «4CM'inl <l<sit.Miat ioii)

Dav

M.nilhs

It)

l)ii\.

BiR rnj'i.Ac »•:

I Statf or t "(Ml n 1 1 \

NAMI-; <i|
lATin.K

HiRTni'i.Aci-;

OI I AIIU'R
( St;it( or roiint rv

M A I I > v. V N A M 1'.
«»| M<)Tm;K

iilkTiriM.Ai K
<)|. MnTllKR
(statf or Coiiiiti\

<HTt PA riox

Li

<LiLA LL •

I Hl';Kl':nV CI^RTII-V, That I atti-n<lf.l ilcccased frniii

— — — — — 'T igo ■" to - .-- ~ ■ lyo ■

that I last saw h ... — - aUvc on ~~ _— ___ j^ ___

and that death occurred, nii the elate stated above, at —

.^r. The CAISI-: Ol' DIIATII was as folk)ws :

/cO-^olXA IfsjfYYSj mXrrrs^'

H

\Jnj^

y\Oj

I)( RATION J'O/'^" Months Pay

C ( ) N '1' R I lU "]■ n R \' V t CAA.\,<L4_«>^ (% . ........

/ fonts

Dl' RATION

^

i'liirs

Mouths

I\i\

]

iTi^Q

\ I

~- I

(SIGNED) J \X'dXKA^ ^5. La. , ,

U/tli D.^ UfoH (Address) isOb UAA.tU^. J.t

/A Hits
M.D.

<

r^^

(

.L.

S

.

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

f\r-id,',l in SilPt / iiliiii'

) ,,ii

\r.,uih^

I hi 1.

Former or
Usual Residence

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

Now lonq iX
Place of Death ?

Dtys

rm.; An<»vK sT\ri;i) pkksonai, i>ariicii.\ks .xri; triic to thJ';

Hl-;sT ni- MV KNoWI,i:i)c",H AND WV.X.W.V

a

(Iiifotniant

Y\AyY\J

XfMrt's'-

UI.ACK OI-' JHRIAI, OR Ri;Mo\AI, | DAIKot liiKiAt, or KIINfOVAl,

i9tt XH looH

I N I) j: R r A K K R sXJ X/y\^<X (^ A.*

fA.Mlrss % i°L

N. B. Rvery Item of Informntlon .houlcl be carefully supplied. AGB .hould b« state.l EXACTLY. PHYSICIANS should

state CAUSE OF DEATH In pliiin terms, that it mny be properly classified. The "Spetlal Iniormation" for p«i-
softs dylnft away from home should be ^iven In every instance.

i

f

<->'

(fr.

I H

WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD

H. arl of If. iith I No i^ 1^^J^^lutl'C^ REFER TO BACK OP CERTIFICATE FOR INSTRUCTIONS

IDO^

Bogistered JS'^o,

?2558

A,. -M D. .

DEPARTMENT ^ PUBLIC HEALTH=City and County of San Francisco

Certificate of H)eatb

( "a. S. StanDarD )

i

V\

'No.

PLACE OF DEATH: — County of (Jcx^v o .^.a. ,

4 ' I ll 14

^

St.;

Dist.; bet.

City of w /CX>^X; ^ .' v<x

and

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

J(

FULL NAME

XA%-yX\.^

SI.X

PERSONAL AND STATISTICAL PARTICULARS

I COI.OK \

w

C\

DA TH or lilK I'll

.\(,H

MEDICAL CERTIFICATE OF DEATH

(Year)

/ t

M..iitir>

)..;

;Uav»

M,>Hlfi'

I Vrar)

J>,

SIN«.l,H MARHIl-.I)

\vn»n\vi:i» nk i)i\<»K«i-;t)

(W'litcin Hofial (li~i>.'iiat inu)

«. >

niKTm'i.ACK

fStatf ur Countrv>

A

(Month) (Day)

I HICRI'IHV CI'RTII-V, That I attoiuUMl <lecoaHe<l from

190 i

I90 't to

tliHt I last saw h ■■ alive on ^' ' icp

and that death occurred, on the datt- stated above, at i
CL M. The CAl'SI': OF DJ^ATII was as follows:

AJJY^^'UUXX^'^'^ >j .Yvv '. '

NAMK nl- A

FATMJiK ('

HIKTHIM.Al'K
Ol' lATIIHK
(Statf or (."ountry

T

DTK AT ION )'ears

CONTRIP.PTORV

Months

Day

Hours

)^,«it_

-H,

MAIDKN NAMi: A

«>!• MOTHHK I I

HIRTIIPI.ACH
OF MOTHKK
(Slatf or Country

(1)

-cx/^^x:^

occri'A'noN ? ,

ResiiUit III SiiH / I iiiii i>rn

DTRATION Vt'ars Months

( SIGNED ) UAAJ\-^w<Xi J . M ) I

/hlYS

Hours
M.D.

H>0

SPECIAL INFORMATI

or Recent Residents, and persons dying away from home.

(Address) ui; M fWuM foM.^lni
NATION only for Hospitals, iRsntntions, Transleits,

J fii I

Mimths

Ihi

TH1<: AIUn'K STATJ-.D I'HKSONAK J'AK rUT!. \KS A K !■; TK! K To TIIK

»KST OK MY kno\vi,i:d«'.k AND iti:i,ii;i-

1^

(In

fornjant H 'VvCi XXx

\

l^JUU^

Former or Uxn 1 .

Usual Residence 1 1 ^ ' i ^^

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

How tonq at

Place of Death? I Days

1*1, ACK OF ntKIAI. c>K KK%fO\ AI, i DAT f: of Ht KiAi. or KF:M<)VAI,

,T\!l

INDFIRTAKFK

}kXj

1 u

190H

N. B.— Every Item of information .hould be cnr.fuHy supplied. AGE should ^^•*«««i EXACTLY PHYSICIANS .houfd
State CAUSE OF DEATH \n pl.iin term,, that It may be properly classified. The ''Special Inform.t.on" for per-
Hons dying away from home should be given in rnvrv instance.

Dl

^-:>

I

f

WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD

RCFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

Hoard of H.iilth l-Vo it. 1:-f-^'Z.>. i;SiV C

Dale Fili'il. y

\j IH

lOO'i

Megistcred J\''o.

!559

2r^n^

OF

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco

Certificate of H)eatb

( n. S. Stan^ar^ )

-?

PLACE OF DEATHS— County ofQ<X>

V

n

J *

City of U <X/Ysj 0 huOWYXJ:^.'^

fNo»

fc

(\T Dt»TH OCCURS
ir DEATH OCCU

St.

Dist.; bet.

s 4w»v FROM USUAL RESI DENCE GIVE facts called for under ""spec

RRCD IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREE

and

lAL INFORMATION" "X
T AND NUMBER. /

FULL NAME

/(X/cyi "> •

{

^1 \

PERSONAL AND STATISTICAL PARTICULARS

I rcii.oK

LtxU.

MEDICAL CERTIFICATE OF DEATH

DATH Ol' DKATII

UATK nr- lURTII

A<.1-:

ai>t /

I Moiithl

Hq )v

(Dav)

M.nilfl^

/',/i

u'n)(»\vi:ii OK n!\<»Kii:i)

'Wiitt'iii social ilrsi^fiiatioti)

lUHTIII'I.ACl',

1 Stat. .,T I '.iimti \ '

I

NAM I'. Oi'

»*atiii;k

?

HIRTIIIM.ArH
OI" KATIIKk
(Statf or Ofiunti y)

I

MAIDKN N'AMK
OI- MOTIIKK

7

HlklHIM.ACl.:
Of- M<»Tin':K
fStatf or i'oiiiilry)

I

orcri'ATiON

Rrsi,ff,t

in Smi /'i am i>»'n ,/% U )'t'<iis

(Month) (Day) (Yiar)

I m-KI'HV CKRTII'V, That 1 atUii<kMl acivased fn.iii

— — -190 tu ^ —- Tcp

thai I last saw h rrr- alive on icp

Mild that lU-ath ncciirrcil, uii the ilatt- stati-«l ahuvf, at
M. Tlu' CAISP: OI' l)i: A'ril was as follows:

DlkATfoN

JVa

'ars

CONTRJIU TORY AT V\<X->xXltl<L Ihw^ i^ y

Davs

Hours

vclC^

nr RAT ION >V<?r.? Mont /is /hiys Hours

,NED) Lcr^^-CPru^V J.'fcll ' ' . - M.D.

(SIG

' rt: %^-i

I<>0

SPECIAL Information only far Hospitals, InstUyftths, TriBsleiits,
or Recent Residents, and persons dyinq A-^xi from home.

M„iith-

lh}\

^.

Former or 1 p. ,
Usual Resldfnce^AJ,<x,^dwe^

Now long at
nare of Death?

Days

Wlien was disease ronlrarted,
If not at plareof death?

THi: AHOVK STATI'J) I'KKSONAI, I'A K T KT I.AKS AKI. I'KIH To KWV.

HKsT OF MY KNo\vi,i:i)<,K AM) hi;i.ii:f

Informant \! MwlX^VXJ. \l rW^^^

ri.ACK c)i. Ml KIAI, OR KKMnVAI, I DATltof III hiai, or KHM<»VAI,
fNDHKTAKKR > W. O <Ka.^^t '

N. B. Bvery Item of information •hould be carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should

state CAUSE OF DEATH in pinin terms, that It may be properly classified. The "Special Information*' for per-
son* dying away from home should be given in svery instance.

f

i

I

^

,5

WRITE PLAINLY WITH UNFADING INK

D<f/r /-VA"/, t|ct<Xov ^H

J90H.

THIS IS A PERMANENT RECORD

BEFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

Registered J\''o.

2^

560

OK. Deputy Hen.'th Oflficer

DEPARTMENT 0^ PUBLIC HEALTH^City and County of San Francisco

Certificate of IDeatb

PLACE OF DEATH:-County J<xJIx<x ._.,_,. cuy of ^,^. J^f-.o , .

( <r DtATH OCCURS AWAV TROM USUAL RESIDCNCr ^^*** ^** "• ^^'-"^^CrVi and LUX^

FULL NAME Ut..L.,v mTLc

C4 c c

V V

)

SIX

PERSONAL AND STATISTICAL PARTICULARS

■^

n

' U I

1 n \l

DATK or- lukin

x<.j':

I

i^

4.

M.iiitli )

H3 ,,.„,.

Wri)(»\\ |.;i, OR I)l\oKv-l-l>

'\\Mfr III ^.KJMi .i.-si^r,u,ti,„l)

It

'Dav

M.inth- O

MEDICAL CERTIFICATE OF DEATH

DATK OK DKATH ,^

IQO \

(Year)

K. 1
(Vear)

A? 1 ,

, Mii.:u,.:iiv c,.:rtifv, tiw„ ,„„.,„,..,, ,,„.o..,...,i f.„„

niRTHPl, AOK

(Statf- or Count! V

N'AMK Of
I-ATIIHR

lUKTHPI.ACK
Ol- l-ATni:H

'Stat, or Count! v)

o| Mo'l'llliK

T90H t.> Ut:,t ;xi ,,^.,

that r last saw h / r.livc .m iDcl -

».„ltI,,-,t,U..,lho..o,nTc,l, ..„,|,,,|atc.|Mt..,l V.-, ;,t lC>il

M. TheCArsi; or |„.:.vril was ,.. foll„„s:

y,x.>v<^ Y tiv<d Jv^ ,U^ L^ Q_^^^^

^La.l .,'„.,, ,,»| tiu %iavt ou. ^ ■ \ , ■

dir'ation

) ('lU s

Months

Ihi

Is"

Ji

(SiGI

//t>iirs

.NED) J 4v<yo 09. J^ux^cytXA^

niK rifi't.ACK
'»!■ Morinik'

"^t:it<- or Couiiti V

V

r^ P

U

-t

fcjO

/tout 'i

M.O.

.rl^en^Zu' I'^SDf f.^'^* ?l'Lr""'' '"^"•^"»"^' '"^^

1/,.,///,,

3. n.

Formfr or
Usual Residence

When was disease confrar fed,
If not af place of death '

How tonq at
Ware of Death ?

Oavs

(Informant \XX ■ .Lx-V U- I ^ ^^"^^^X Crt U-C<X-Q^ I ^^ ^H

J (1

N.Mr.s. RlX' IS lix.

TQOH

N. B.-

A.i.hv.s 3iq U"acc».'v^L

■.';;V/c'ru'"8E'oFtE;^^^^^ !:;;"^nH"^ :'"^''"^*'- '^«R «^-«i h, ,.„te.l exactly. PHY«,CIAN« H .7

* i

^

^
>,

I

t

I!. ..ml i.f Health !■■ No. k :S'$^^^

WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD

f" :ar!-~ti> lu^ J' Co _

REFER TO BACK OF CERTIFICATg FOR INSTRUCTIONS

Re^isfet'ed J\^o,

790H

ow<H.M^ L| Deputy Hecith Officer

o/x

DEPARTflENT OF PUBLIC HEALTH-Cify and County of San Francisco

Cettificate of Death

( Ta. S. Stalt£>ar^ )

PLACE OF DEATH: — County ofaay>^ d^cx_ , vacc. City of

^(1

^"(Ta

^>

-V

CX/>x.^ 0 ,\,<X > vc

CC>a

n)

U A ^,

No.

\h

St; ?. Dist;bet.V_<XLLlC^

\A..a.. and Oxxc\.a *

f "" f/rr*'..!.''*'"''^ *'*'•'' ''''°"' USUAL RESIDENCE GIVE facts called for UNAkR ■'specal inform'1t,««^^

\ IF t>EATH OCCURRrD IM A uncDi-rii «= .^c^,,-. .. • unif^H SPECIAL INFORMATION'

.T„ occu-.co ,„ . „„,,„., o„ r„s",j;v« o,;. ,Ts nVme° .'."s'Tt.",,^? srV/.Ti.'o";"::."-"'"" )

FULL NAME

ll) . ,

si;\

'4

PERSONAL AND STATISTfCAL PARTICULARS

HATl-; nr- lUklH

a.

MEDICAL CERTIFICATE OF DEATH

DATK Ol- ni;A'IH

^

il^ct

/go t

(Year)

/

A(,i-:

JV„

Q

( I)a\-

Moulin

■ 1 -
(Vrar)

I),j\s

"^IN«".l,i:. MAKUII'I*
WIDOW I.; I) OR DIXDKfi.:!)
' \\\\U- in v.M-ial d. -ii- iiat inn >

HIRTHIM.ACH
'Statf or I'unntrv^

K

^ I HHRHnV CKRTIFV. That^ [ Mttcmlcl .IccLascl from
^■^ SI. lyo , to AOt± 2.3, iQoH

that I last saw hw'A. alive on w ^L _?, .,_

and that *Uath orrurrcd, mi the date stated ahnve, at

c<

M. The CAISH i^V ni-ATH was as follows

I

{]

'<r>"w^^^-^^-4-,v<n'^-Q O <>

o

NXMi: (tl
I All! IK

lURTm'I.ACK
<>l' I AIIIHR
<Stat« or I'oiniti \

MAII»j:\ NAMl
<>l .MoTllliK

lUKTnpr.Ari.;

<H MnrilKK
(Statt or Cumittv

&ttX\/^'d

^ i

I) r RAT ION );,/

CONTRim roRV

; A

I

X\ > .

DIRATION
(SIGNED )

.^ font /is

'K fhivs

Hon

rs

/yavs

dJ ^

Uf^H rAddress) \^{i^ ob <H.U-0LKJL .. jl

f fours

M.O.

Special Information only lor Hospiiais, insmuHons. Transienis

9r Recent Residents, dnd |>ersons dying away from home.

orrrPA'iioN

J rt! .

M.oitit

I >,! 1

Till-; \Hn\H STATi:i) I'HKSoXAI, I' \ R I" KM' f. \ K-^ AK Iv TK T H To Till-'

Hi-;sr OF AiY KNou i,j;iM,K AM) Mi:i,n;i'

(liifoiinatit

Former or
Usual Residence

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

NoH lon^ i{
f\vt of Death ?

Davs

190 t

I'l.ACK Ol- FHKIAr. nK RKMoVM, I DATl-of Miniai or KliMi.VAF.

' A.I.I, .s. 112,1 OTUa

N. B,.

-Every Item of inforrtiHtion •houlii be cnrePully nuppMed. AGK •hould be iitnted BXACTLY. PHYSICIANS should
•tate CAUSE OF DKATH in plain terms, that It miiy be properly t^lasalffled. The "Special Information" for |»er-
aofie dying away from home nhould be given In my/try inntance.

^

(r-A

I

■
1

1

^^m^-

/*»V»«^*-"»

li'

11

WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD

■i l|.i!ih-l' Vo '■ ■f—yc_.^^.uf<}-c,. REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

SLH

o^\^<.KJsdJLA>u Dei

WOH

Jfr'o'/.sfe/'ed JVo.

25^^-'

6^

DEPARTMENT OF PUBLIC HEALTH=City and Countj^ of San Francisco

Certificate of Beatb

( *CI. S. StanOarC^ )
PLACE OF DEATH: — County of ' City of

No.

St.;

Dist.; bet.

^V>/Cr>^

and

(ir Dt*TH 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

tu

<XhA.i

m

PERSONAL AND STATISTICAL PARTICULARS

DATl-: Of lilRill

I

L

I

A<,K

LI

MEDICAL CERTIFICATE OF DEATH

DATK ol* DliAIM

I>,i\ I

M^nilhs

\ car

(Month)

Dav'

rgn

(Vi-ar)

n

1 in-:RIiBV CI:RTIFV, That r atteti.k-.l <lf. rased from

!>IN«.I,i:. MAKRIi;!)

\\ II)n\\i;i) (»K ni\«iR('Kr) ^

(Wfiti'in social (lc-iv^ii;iti"in) 1

lUKTHI'l. \i'K

■state (,! < , iimtr\-

I- Ai-in,i<

lUKTUF'I.Ar}.:
<>I- 1-AIHHK
' Stale (ir Ooiintrv

MAIDI-v; NAMK
<»l Mo'lIIl-R

lURI'mM.ACi;
<»f Mo'I'lIJCK

'State ( It (.'(HI jitrv"

oCCri'ATION

A

ii'/t.t 3sO iQoS to

that I last saw h — alive on ~

^^ A

and thai <k'atli Drciirrcd, on the date '-tatid ahovi.-, at
" M. The CArSl- Of' IHi.XTII was as follows

^

I )r RAT I ON Years

CoNTRimTORV

Mouths

Ihivs

//(iiirs

DIRATIOX

(SIGNED)

)'i'ars

IT

Mnnth.^

Ihxvs

ii),ct.

/fours

M.D.

Xc T9o'l (Address)

SPECIAL INFORMATION only for Hospltab, institutions, Transients,
or Recent Residents, and persons dvinq awdv from liome.

Krsiih'd in Sitif f ! iiiii lyt'i*

)•.-,! I

M :-t)l'

l>i}\

former or
Usual Residence

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

HoH lonq at
Place of Death?

Days

THi-: AHox'i-: sr \-n:i) !'krs(i\ai, pARrict!, \rs ari-:

UKST Ul- MV KNoWlJ.IX'.l-: AM) liKMI!!-
(Informant ^X ^ '.'■•-. H^ lL'

TKI K TO Till-;

Acldru^H 0 C)1

i'l.ACH oi" mKrAi, OK ki:mo\\i. i i»\ri;,,t

(is i

I C)0

Ad. h CSS s^bbb y JX

-wQ^Avir*

IN. B. Every Item o? information shoulfi be cnrefully Hupplied. AGB should be stated EXACTLY. PHYSICIANS •hould

state CAUSfi OF DEATH in pinin terms, thnt It may be properly wiawslfied. The "Speglal Information** for p«r-
fiins dying away from home should be given In ovory instance.

I '

^

I

c9i

i

< k

ir

'♦■

WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD

RCFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

1

Be^Lslered JSI*o.

^56;

ioo\

^Hj Deputy hiealth Officer

DEPARTMENT OF PUBLIC HEALTn=City and County of San Francisco

3

■6^\A-<i

Certificate of 2)eatb

( tl. S. StanDarC* )

PLACE OF DEATH: — County of O/Cu^^ 0 a.<x

A

n^

vc

City of

i

o

Q^-^v^

No.

St.; 0 Dist.;bet. \XX\, and ^ I

(ir DC«TM OCCURS AW«V FROM USUAL RESIDENCE GIVE rACTS called for under "special INFORMATION" \
IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER )

%

FULL NAME 1 I

^1 X ^

PERSONAL AND STATISTICAL PARTICULARS

t:c)i,«)R \ s

J X^^^CcA„

<

DA n-; nr lUKTii

Ai.K

(Moiith>r

(W-ar)

^

0 J,-..,

I Dav

M,,Htb>

» tar)

/>,/ 1 .

■^IN'I.K MARRIHIJ.

N\ IDnUKD OK I>lV«>Kri:i) ^

iWiiti in MMMiil »l<>«ii.'iiatii»u)

lURTIII'l. Ari-: /-v

(Statt or r.niiiti \ [ y\ %

VlKJad

NAMr (H

I A 111 j;r

-I

MEDICAL CERTIFICATE OF DEATH

DATK ()!• DHATIl ,^

(Month) (Day)

^ 1 I[I:RI-:BV C1;RTII-V, That r atten.UMl ,ltHvasc<l from

' " Kp -■ tn L' C^t 3v3 IqoH

that I last saw h ■•■■ alive on L-' cJj ;i o loo i

and that dcatli occurred, m\ the datt- stated aluivc, at
_" M. The CArSl- OI' DIIATII was as foll.ms-

!,,_ .... , ,

Hik run.AiH
<n' I Arm.'K

(Slatf or i'luintrv

lUR ruPT.AOK
(Statt or Couiitrv)

t)CCri'ATU)N HjV

C\

A^-yr^JJsJ^K K

Dr RATION X )'ra/s ^i^otit/is

A

a

<XKk

CoNTRinrTORV

or RATION b Years

/)avs

I fours

(SIGNED

Mo)iths

KX.K \ X..)

fhiv

Hours

M.D.

l<>o

(Address) 113.1 JU JtA>vC. o. d. i,\ c .3t

'\jbCa^iv<x

Special information ©nly tor Hospitals. Institutions, TrinsJeBts,
or Recent Residents, dnd persons dying away from home.

^

Rfsidfd lit Sail /■ I iiHi isi'o

);.ti

M.nith'

I hi

Tm; Ai?()\'K s*i'Ari:n pkksonai, tar rirn ah-^ ari-; rKri*: rn tiih

HHSr Ol- MV KNOW I.i;i)»',K AND HHI.Ii;i"
(Informant \1 'VvO JV.o<X l

Former or
Usual Residence

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

Now lonq at
l^ace of Death ?

Days

I'l-ACl-: «»l- IHRIAI, c»R RKM<i\AI, I DATJ-o' Ht kiai, or Kl-'MOVXI

I ni»i:rtakkr OcHLc^ut^rw u itXAJt UL'w.r*^

. N

T90

N. B. Every Item of Infopmatlon should be cnrefully supplied. AGE «hould be stated EXACTLY. PHYSICIANS should

•tate CAUSE OF DEATH in plain terms, that it may be properly classified. The "Special Information" for psr-
sons dying away from home should be given in 9vry Instance.

mm

I

I

m ■

I

s>

. -to

j c^ »

'SW-^

WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD

Sm.ii-I . f Ilinllli I- Vo : - •«'t-:^3^; WS^V Co

REFER TO BACK OF CERTIFfCATE FOR INSTRUCTIONS

Dfif,- FiJ,-<l. h.A.(X

0 V ^ A

M^h

.*. ju,

Deputy Health Officer

Ee^istcTed J\'*o,

2564

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco

Certificate of H)eatb

-?

PLACE OF DEATH: — County of cl^^ ^ ^^

h

City of u ex

.v'a:

No. I (: S C 5.L.\..^4\.

St.;

1

1

(ir OtATH 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^ /

Dist.; bet. AXO. \ " <^ > ^^^^^

FACTS CALLED FOR UNDER "SPE
GIVE ITS NAME INSTEAD OF STREE1

FULL NAME J L6\.a^

and V '

0

{

PERSONAL AND STATISTICAL PARTICULARS

"^1. \

lOl.OR ^

'1

I 'All-; ol- lURTH

At.H

/kt

Mnllth

D.i

/',/

^!N<.I.I-: MARK IID^

UF DOW 111) (»K U!\< iR> l-l)

niKTHIM, AC}-:

' stall (ii ("..iiiitl \

t

MEDICAL CERTIFICATE OF DEATH

DATK OF I)1;A'I"II ,; \

Vi'ct It

(M(iiitli) (Day)

^ I HHRKHV CHKTIFV, That I atten.lfd dcioascd frnm

L. cL u 190H to ' t

tliat F last saw hi. alive on w '^ . * '.

TOO \

(W-ar)

190

aiiil that (U-ath nrriirred, on tlu- date state<l above, at I i
.' M. The CAISH or !)j;ATn was as foll.nvs:

.K.\^',

Kr-

f^l

•il

NAM I* 01
I'ATIUIK

HlRTmM.AOH
n|- I AIHHK

(Statr ni I'outitry

maii>i.:n' xAMi;

oj- MoTHKR

HIRTHPI.ACH
Of MoTllKK
(Slatt or Conntiyi

A

M

DIRAIION '^ }'iiirs
CONTKIIUTORV

.Vinit/is

Day

Hours

\v

N

DIRATION

(Signed

)\iiys

Jfi>n(/is

/)av

■,n

~N

Hours

M.D.

KjK

i. 'Xl I

90

( Address) i5 15 ^ihx.cCJ. I

"H'Cfl'A TIOX

\^K

Rfsidrd ill Siiii /ill

) 'lUI i

1/,,»M.

n,

Special Information only ^or Hospitals, Instifutlons, Translenls.
or Recent Residents, and persons dving away from (ion»e.

How lonq at
Plar e of Death ?

Former or fJ N ,

Usual ResidenceMDaAXv-r-w<;'u^ /

When was disease ronfracfed,

If not at plare of death ? 5 A|,4<xM ^m:^

Days

Ayw

rill.; AHOVK STATHI) t'KRSMNAl. I'A K TFC r I, \ R ^ A R ! ; TKIK To Til).; PI.ACK Ol- lURIM, OR RHMoVAI, I DATJ-'.f Hikim. nr KKMt.VAI,

liiCsT oi" ,Mv KNOW 1.1,1 ><■,}.; AM) in;i.n;i' /t) < I 1 _»

1

(infoMiianl US . U XtX^^ M K- ot)

0 J>

LuA%AX*i^

N. B. Every item of ir.form«t1on should be cnrefully supplied. AGE should be stated EXACTLY. PHYSICIANS should

state CAUSE OF DEATH in pinin terms, that it may he properly classified. The "Special Information ' for per-
son* dying away from home should be given in every instance.

^

; J^\

I

I

19

II !!i 1

WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

VJO'i

X^^^^ ; ,, Deputy Health Officer

Registered JSfo.

(^^\^

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco

Certificate of S)eatb

K "a. S. Stan^arD )
PLACE OF DEATH: — County of U<X^^ JXOAUvUyC^ City cA^^Xp<\j Ja^Cuwc^l^oo

C CK. isti^tcLli Dist.; bet.

and

IF OtATH OCCURS AWAV TROM USUAL R E S I D E N C E G I V E FACTS CALLED FOR UNDCR "SPECIAL INFORMATION'
IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER.

)

FULL NAME

KUXj \

\XXX^

PERSONAL AND STATISTICAL PARTICULARS

i>A ! i; or lUR rn ^'\ a

' iuJL

t

MEDICAL CERTIFICATE OF DEATH

DATH <»1 nilATH /, \

vtcLu

Il:iv

\< . !•;

bl y

M.

\vri)ii\\Ki) OK nn'oKn I)

iNViiti in social <lt -ij.'ii.it!i i!i '

BIKTHIM. \0K

fStatf or I'uunti % '

lU^ccL

•'•ths 'X^^

^XaT

W-at)

n,n

(Uct

CMonthl

ix

(Day* iVcar)

^kolu

I HHRI'HV Ci;RTn-V, riiat.I atteiulcMl «kc-.asc.l fmm

that I last saw h-t>v alive on (L-ot %% I90H

anul that (loath occurred, on the d.iti- -.t ate.l ahove, at 10 ID

aiju;

y\. The CArSI'! OI- I)i:.\Tir was as follows

AJ^Af

ruQL<i

»A l!I }.K

HIKTHIM.Al'F
Ol- IAriIl-:R
'Slat! or Count!

m mdix x ami'
<•!■ m<)Thi;k

lURTinM.AOK

«>»• M«)Tin:R

(Slatt or Countrv)

oiATl'ATlON

c

e>ta.

I)

DTK AT ION )'t'ars

CONTRIIU'TORV

Mouths

Davs

Iloitt s

%

ic^l

DIRATION Yiars Afont/i.s Days //ours

(Signed) J L . iLoyif.xx-^vcLi^ ivi.D.

Special Information only lor Hospitals, lnsHfutl»Bs, Translciits,
or Recent Residents, and persons d>jng dHdv from home.

AV' I,!, ,f I II Si! I! i'l ,!

n , - w f »

'- 1/,. ,//;>, *" 1>,!V>

TH1-: AUOVK SIA ll'D I'KRSDN \\, 1' \ R IIC T I, A R S AKH TKt H T< > THK
HlvST C)l-' MV KNnWI,j:i)(;K AND Hi:i.n;('

Former or
Usual Residence

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

How lonq »{
Place of Death ?

Days

lliifotnjatjt

^.Q

Oc- a^rx^y^^^ A^A.A^

(\«l.lress

5^01

oU-'UM^A^^rv

<X 6t

PI.ACKOI" ni'KIAl, <»R RKM«»\ \l, I J>\r}:..f HiKiAr, or Ki:MnVAI.

c^i^cdoc^^ I ^^ ^^ .90H

(•NDKRTAKKK U /tXJwV VS-tC \I |VoA^C/VA^ ^J-^ WO
(A.Mr.s. 15 9.H 6i<^^Jkt4>A 6t

N. B. Bvery item of informntion should b- ctirefully supplied. AGB should he stnted EXACTLY. PHYSICIANS should

state CAUSE OF DEATH in plain terms, that it may be properly classified. The "Special Information** for per-
sons dj-ing away from home should be given in 9\mri/ instance.

3*

k^

\l

..#••

WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

7)afr Fi/r^f,^d^J,j<K^ X^

lOO'i

Begisfcj'cd J\^o.

2566

.{y\,c\^.

"^ \ * A

Deputy Hcaith Officer

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco

PLACE OF DEATH: — County ofua.-v^

Certificate of S)eatb

( "U. S. StanC>arC> )

City of 0,cuw

J A,.

CA^

m

No. ^CCr>

1

and

C\ aS>.; — Dlst.;bet.

(ir t)E»TH 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

PERSONAL AND STATISTICAL PARTICULARS

SI \

?

I>X 11, .tl' lUKlH

A«,H

■<)I,nR^

LI

?Jxkt,

siNf.i.i-: MARkiKn

u iiM >\vi:n itR i)i\nKi'i:n

•Uiit'-in -.iii-i.-tl iU'^i).'?i;itii 111 )

in

I l);tN '

M,<t,lfi

/ 4 0 H

(Vt-ar)

/>,i

t

CoJx.ou \.lLx_L >

MEDICAL CERTIFICATE OF DEATH
DATH <n<' DHATIl /A

(Month)

(Dav)

/go

(%■< al )

inRriiiM.AO}-:

'Siati or (■tanitrv

N \Mi-: III'

1' A IHICR

mRTHI'I.ACK
0» lAlIll'R

(Stall or Count! v)

MAlIUvN NAM1-;
<)!• MOTIIHR

151 RTH PI, A OF,
OF MoTHJCR
(Slatt* or Coutitrv

oOCFl'A rioN

D

I HI'kl'HV CI-RTII-'V, That I atteiicltMl <lc( rased from

^ Zk up. to AJ^ti XX

that I last saw h-w.' alive nn ^ " ^

aii<l that (leatli occurred, on the date staled above, at
M. The CAI'SI': <)!• DIIATII wns as folhrns

icpi

Ttp

e

XI

"i- '1 v-O.. i

r ;l I

^^

^4vYv UVlc

I ) r R A r I ( ) N > 'cars Months Pa vs

CONTRIIU'TORV U AX-^-^^cCtv^^x.^. .:

I )r RATION Years Arniit/is /)avs

(Signed^ y%^ u '^il/N. oc .

A-ldress) ^ 6 t CJ A^-CLuw Ul,

Hours

Hours
M.D.

Kj^Xj

IQO 1 (,

Special Information only for Hospitals, institutions, Tr««sifBts,

or Recent Residents, and persons dying awiy from tiome.

Qj

u

Rrsiihii HI SiDi I'l ,-i>u i -I'll

)'rii I

M.xifh-

/hn

Tin-: Afun'K stati'I) pfr-sonai. i'AKTicti,ARs AR1-: TRtH r<> Tin-;

IlKST OP MV KNn\VIj:i)»'.K AM) HFI.Il-F

Former or
Usual Residence

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

How lonq »i
Place of Death ?

Days

•^ \

190 I

ri \CF <)I" lUKIAr. OR Ri:M<t\AI, j I)VTF:of inHiAi. or ri;m(>\ai.
INDKRTAKFR W oX^tx^- ' ' '

N. B.— Eve.y item of information should he carefully supplied. AGE .houid he stated KXACTIY P" ^81 CIA N 8 should
state CAUSE OF DEATH In plain terms, that It may he properly classified. The S,»eci«l Information for pr-
sons dyinft away from home should he ftiven in 9\9ry instance.

, S)

: -^^

I B

>^m-

(#

WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD

f II. alth I' No !~ "*-^^!-'^>H5il' (■

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

Ditie Filed ,

9.H

100 "i

Registered Jfo.

2567

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco

Certificate of 2)eatb

i "Q. S. Standard )

PLACE OF DEATH: — County of

No. ^^ IH (/LKo^-..-

City of Uc^y^^K<y.

%

St.; b Dist.; bet.

IH ii

\.

and

(

IF DEATH OCCUHS AWAY FROM USUAL B E S I D E N C E G I V E FACTS CALLED FOR UNDER SP
IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STH

ECIAL INFORMATION' \
EET AND NUMBER. /

FULL NAME

a..,

'1)

xou

X V\A.'

PERSONAL AND STATISTICAL PARTICULARS

DAIl or HIRIII

k

WMonth)

Ac.H

IS ,V.,

M

(I>av)

M,.f,th>

n

\ car

Pil vs

MEDICAL CERTIFICATE OF DEATH

DATH Ol- I) MATH , \

\]^\.

(Month) (I):iv

I go 1

(Yf.Mr)

HIN<-.I,K. MAKkIKI>

\V 1 1)( )\y i: I ) o K I ) I \i > K i" H f>

tV\'ritfiii •H(>ci:il <ltsiv»iiati()ti)

LI ^.-^W^^^

BIRTH PI, M'l:

^Statf or I'diiiitry

NAMl-: ni
1 ATHKR

niRTHPI.AOK
OF l-AIHKK

(Statf or Count 1 \

maii»i:n namf
<H' m<)Thi;r

lURTHl'I.ACK
«»F MoTHKR

(Statf or Country)

I-

I III'IRICHV CIvRTfFY, That I atU-ndtMl (ktvastMl frr)m

'.: ;'' lip . i<) *c tX C\3 190H

that I last saw li •■ alive on ^ '• - I90 ',

and that death occurred, nn the date stated ahove, at i

a

:\r. The CATSJv t)!-' DIIATH was as follows:

n

%

-v^X

VV^CU

\ t'

.,.,Ah>u^<2Lt_j_L/txj-u -U^-O

1

+ ._'

DT RATION

}'raf

S

Months

Da vs

Hours

t -
ft

CONTUinrToRV

1)1' RATION Yiius

\.\

Mouths

(SIGNED)

UA

4X0 w

rD

"^%

.o/L"

OCCl'l'ATK

fsfsiitfii ill San /■ 1 iiiii i>' <'

\_ ... vi

a, ;,

(Address) "^SQ-i

/hiys Hours

M.D.

XD^tk It

Special information onh for Hospitals, Institytitns, TransieRts,
or Recent Residents, and persons dying away from liome.

) ,ai

Mnllth.

I >l! I

Former or
Usual Residence

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

How lonq at
Place of Death?

Days

THJ-; AHOVK STATl'l) PKRSONAI. I'ARTICC I.ARS ARl! TKIH T< > THH

MHsT oi' Mv kn'<)\vi,j:i)<;k and in:i,ii',i"

rv

(Informant C> ^ ^ Kxt-OT

PI.ACK 01 in KIAI, Ok KICMOVAI, I HATi; of lU RiAt, or RKMOVAI,
I- N I ) K R T A K K R v) (tLcLCAV ^ OJilj Ll ^ u O >

(.

Qrrw.

N. B.— Every I.em of ,„«„rm..lon .hou.d be .nr.fu.l, .uppl.c.l. AGE .W.1 "• ••'•"•',^''.*«ILV P"^''';;,*^,;;!:;.*!
.tatc CAUSE OF DEATH In ptain Urn,., that it may he properly cla...U.U. The Special Information for per-
aont dyln* away from homo should be (tiven In every Instance.

^i.

. 4=f

I

"■

WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD

IlrKi rd . , f H .-n 1 ! Ji V So. i% *rV[^j> 1 US: V C ,

REFER TO BACK OF CERTlFfCATE FOR INSTRUCTIONS

Iics^istcfcd J\^o,

2568

ludr Fii,ui,^.iz)zA^Jc\^ an IfiO'i

d.Ji\XAA dJL\yM Deputy m--.;.*, oflflcer

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco

Certificate of IDeatb

PLACE OF DEATH:— County of .A ^^ ■ v City oiOoyr^ -^ Ko w cc^.c

St.; : Dist.; bet. U /CULtAAyC^^XX and Jaa„Ov

/ ir DEATH OCCUnS »W«Y rnOM USUAL RESIDENCE give facts called for under "special IWrORMATION" ^
V ir DEATH occurred IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. /

FULL NAME VA.\n^^ vUc

No. Id 11 qU-J^cxXJc : ^^

si:x

i' \ri". nr lUK Til

Ac-.K

PERSONAL AND STATISTICAL PARTICULARS

0

C\

IL^.t

M..nth'

)V

(Dav)

M.»:ih^

i'>'tar»

Ar

(Year)

•^JN'.l.K, MAKklJ.n
(NVriti- ill Sim iul clrMiKniitHtii)

C)

HIKTIIIM.AiM':

( Stat I- or i.'iinnt i y

<^^-Ma^

NAMi; (H
I'ATII1:k

KKJ.

MEDICAL CERTIFICATE OF DEATH

DATE Ol- I)1:aTH "X

Uct

(Mciitli) (Day)

I HICRIvBV CI'RTIl'V, That I atU-inkd (Urcascd from
C ct .-.f: I90i to C'tJ: Xh looH

that I last saw h a. . . nlivc on U ct^ .4cs igo "^i

and that cleath (»ccurrc<l, on t Ik- date stated above, at t iO
M. The CAISIC Ol- DllATII was as follows:

nr RAT ION

rD'\-"r\^

FURTHIM.Ai'K

<H 1 A iiii;k

fStatf 1)1 i'<ntntt V

M XIDi; N N AMI-

niRTII!M,Ai.H
of MnTllKK
(State or Comitrv)

k^Oo G

\ ''.

)V</;-.v Months H /?^7j'j

C^ 0 ,

CONTRIIU'TORV L vl\-tXA.4^^Lv^fe^ .

Hours

flu

OCCri'ATlON

Resided in San /'> int</. <■!'<>

[)r RAT ION
(SIGNED)

)'i'ars Mouths

J. CJ,4JUC'

l^avs

Th

r\/YV

<JL-C U v'

ours

M.D.

i<»o

(A.i.ircss) amio ■ n

Ik, It

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

) ViM >

Mmitlo

/>,n

Former or
Usual Residence

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

How tonq at
njre of Death ?

Oavs

Tin: ABOVE STATl'I) t'KKSONAl, PA K I'li't' I,A KS AKl", TKlH T» > TIIK
HKST (H- MY KN<)\Vl,i;i)r,K AND lU-.I.n'F

(In f..i n.ant ^ SJUdULSjuZAX \K^^ K-b C \. > ^

PI \CK OF lURIAI, OK KK\foVAI, j 1)\1 l.-t Hi kiai. or KICMoVAI.

(Address

wa.,>:l^ <w^ > \.

., .. 1- A ATF .hould be stated EXACTLY. PHY8ICIAIN8 iihould

sons dylnft away from home should be given In every instance.

■

i'

y^V*»WW .««

i^

cs.

PERSONAL AND STATISTICAL PARTICULARS

WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD

""^ REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

190H

Registei'ed JSt'^o.

S5G9

Deputv H--:", Officer

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco

Certificate of 2)eatb

( "U. S. StanDarO )

PLACE OF DEATH: — County ofUCU-rv^ J h^aoxc . City ofvJ<Xy-^ ^ K/X-

/7\

Dist.: bet.

KXA^-^-X)

and

V.J

/ \r Dt«TM OCCURS *(^*V FROM USUAL R E S I D E N C E Gl Vt FACTS CALLED FOR UNDER "SPECIAL INFORMATION" \ !^
\ IF DEATH OCCURRtD IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / I

^

FULL NAME

y%.a

n i

) \ I 1 <tr HI K Til

l.\

D.iv

4

) V</ » .4

M.,uilis 0

%

\ tar)

Da 1.

MEDICAL CERTIFICATE OF DEATH

DATE OF DKATIl

U^Lt

IQO

(Year)

>^IN<.I,K, MARKIKIV

wiixnvKn OR ntvoRiKi)

(AVritcin -iKial di^iL'nat ion)

A.-> wO

HiR rHPi.AOi-:

IStatr or Ouuiiti V

NAMK <>I

F \thi;r

HIRTHF'UArH
OF l-ATHKR

(Statf or Country)

MAn)i:N NAMK
<>!• MOTIIKR

lURTIIl'LACK
OF MOTHKR

(State 1)1 t'nuntrv^

(Month) (I)ay

I HIvRI'BV CICRTTFY, '1 liat I attcudcd deceased from

K^tX 1 : 190 ; to Dc±. ..a.S .. 190H

that I last saw h w alive 011 ^ .^ X% lakL^Ji. i<p ;
and that death occurred, on the «late stated above, at oJ^
Ji.w.' M. The CAT'SH OF DHATII was as follows:

'>A4

iVU

<LlaJL -Lo JbQA-^-^%. Q c , j X. . . ^ ::

Oco_ V

kLcxLu

1 ^ i

0 L

DI'InATION )V</;-,? ^ Mouths Pays

CONTRim'TORV llj XoJi^rUU^ xt^

Hours

)'i'(irs.

Mouths b /Jrti'.s-

,^ •■ iH

L^tl

u

occipA rioN

DIRATION
(SIGNED)

ill-atj IH IQOM (Address) S'C?> \l KOI vt^,^

Hours
M.D.

H

SPECIAL INFORMATION only for Hospitals, Institutlotis, Transieits,
or Recent Residents, and persons dying andy from home.

sitird ill Sail /'lami^rn ^ Vrai^ 0 yr.uiths b /^<m.

rHK AMOVK STATKI) I'KRSONAI. PAR T ICF I,A KS ARF: TRIK TO THH
nnST Ol- MY KNOWl.KDOK AND HKMHF

i P

Former or
Usual Residence

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

Now long at
Place of Death ?

Days

(Inf<nniant

(Acltlrc'

^%% MJ A..d<Mi^AMX4^

ri.ACE OF niRIAf, OR RKMOVAI, j DATIlof Bcrial or REMOVAI^

INDFRTAKKR

A<l<lrc<«<("

3.06" QrlV&>xI.^ U^^L.

of information .hould be carefully supplied. AGE should be stated EXACTLY P»Y8»CIAN8 .houid
E OF DEATH in plain term., th.t it may be properly classified. The "Special Information for per-

N. B.^— Every Ite

state CAUSE

•ons dying away from home should be ftlven in svsry Instance

^

1
m

I.

I

^1^

r'

.1

'it

WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD

Honrd I'f ITealth I V

^■■, — •

REFER TO BACK OP CERTIFICATE FOR INSTRUCTIONS

190^

Registered J\^o.

?3570

XJ^

r\>M

DEPARTMENT of PUBLIC HEALTH=City and County of San Francisco

Ccttificate of 2)catb

( XX. S. StanC>arD )

^^

PLACE OF DEATH: — County of Jcl^x;

City of 0 ,<x.>-v

^

^

P4o. LClu X V^C ..A. ) ^ V-l- 1. ^'>-^. <i-^ v^ ■ .St,; Dist.; bet.

\ ( ir Dt*TH OCCURS AWAY FROM USUAL R E S I D E N C E G . V E FACTS CALLED f^ UNDER
* V •»■ DEATH OCCUBRrO IN A HOSPITAL OH INSTITUTION GIVE ITS NAME INSTEAD OF

and

SPECIAL I
STREET AN

NFORMATION' \
D NUMBER. /

FULL NAME

I '- w

-1 \

i>.\TH Ml- r.ikiii

\y.V.

PERSONAL AND STATISTICAL PARTICULARS

^

iMc.mh

I I I

RINf.I.R. MARRIKD.

Unit in «K"ial df-iy Ti;itii)nl

( Day

1/ ififh-

I Viar)

Pa 1 .

I ^tat( ■ ir I'l lunli \

N \Mi-; <»i
J A Tin: R

mR iMi ri. Aoi-:
<H I" \ 111 i-;k

i stair (If i'laujtry

MAIDKN NAMi:
ni- M«)TnKR

lURlHl'LAC-H
nj. MOTHHK
(Siatf ur Country

OCCri'A riUN

I

A )

I

'\ \ i

,ttc Cic!

A

J.

UJlA^i

ruT\AJ.

1

MEDICAL CERTIFICATE OF DEATH

DATK Ul- I)i:ATn ^

(Moulh) (Day)

(Year)

I HIUnIU'.V CI:RTIFV, Thai I atteiKkMl (kiiascd fru

HI

>^

to L zXl

1<)0

190

tfiat I last saw h alive 011

Mild that .kath omirred, 011 the .late stated abnve, at i I J
M. The CArSlC OI' l>i: ATII was as follows:

DT RAT ION ' }'<'ifs
CONTKIIH'TORV

Months

Day

I /ours

1

DT RATION

)'iays

} > ^

IXK^»vO, i

Residfii in San /'nun 1^1 n

) 't'li 1

M.nllh^

/hi 1 ,

(Signed) tU. \d . L<rYvL

Mouths

Pavs

Hours
M.D.

(Address)

rv\rsJiiM.JrKjaiJ^

SPECIAL INFORMATION ^nly 'or Hospitals, Insfilutlons, Translfiits,
or Recent Residents and persons dying d*»dy from home.

THK AHOVK ST\TJ-I) I'KKSDNAl, I'A KT ITT I.AK S AKK TKIH TO TIIK
BKST f)l' MX KN<)\Vl,i;i)<".K AND IU:i.II;H

(Informant 0 XXX-^'^ CL, O .■cJk'>->-V^i

>

(Acl^lre^s

LAX'Vruuv^o^

v,«a_-'

Former or
Isual Residence

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

How lonq at
Place of Death ?

Days

V\ \CF OF in KFAI, OK KKMOVAI. I DA^-H of B. kiai, or KI-Mc»VAI.

T<)0

,<~\ '-■^ -~i

N. B, Kvery item of lnform«tlon .hould be c«i-«fully supplied. AGE . ^^ "Special Information" for p«i-

state CAUSE OF DEATH in pinin term., that It may He properly cla.sitiea.
aons dylnft away from home should be ftlven In .v.ry instance.

Isi^^

I

hi

WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD

li.iiiirl of ll.Mlth — I- No. !^ T^^^yii^.V.fkV Co

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

Jieo'/,s/('j'('(l jYo.

2571

Dale Filed, M^<Xj^\>^0\> IH I'-^O'i

X^\AA^ dUl\Hi Deputy Health Officer

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco

Certificate of IDeatb

( H. S. StanDarD )
PLACE OF DEATH: — County of CJctoO/ 0 XxX/woL^ccCity of (Jxx,>^ J A>Ct>V'C^>-A.c^

(N

o. 5^1

^

St.; v) Dist.; bet.

*TH OCCURS AWA>

DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE V

\\ 1

\\j

and

G

4

. r V

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

FULL NAME

Ox

axx

v„

PERSONAL AND STATISTICAL PARTICULARS

DATi; or- lUK rii

IC ^> cU

MEDICAL CERTIFICATE OF DEATH

.. AAi

M.iinii

\«'. i-;

70

)-,,i,

(Dav

M.,>,ihs

rVh'i

13

'Vrai)

/)./!.

'Wiit'iii --mi.i! ill -i(.'niili'»ii)

MIN illl'l Xri-
IStatt 1 il » ouilt I \

\ \M I 4)1

I- A rilKR

Hiurni'i.ArK

<»! I AlUHR

(stall iir iduiili V

M MltlsN NAMl-;
()»■ MOTHKK

lUKTlIPI.Ac i:

<ii' M(»inj:K

(Stall lit i,'utinlt%

l\

DATE <)«' DllATH \

Ilk

(M.iutli)

(I>ay)

(Veai)

\ UliKI'I'.V CIlkTII'V, That I attcii.kMl .Itreasoil fruiii
,V^W ^5 u>oS to ii'llfc XX . icpH

that I Inst saw hX^' aHvc- on U/ct. ^l i«P H

and that (Uaf h IK (urred, oii the datt.' statr«l abovf, at H^O
0^ M. The CArSI-: Ol' DliATII was as follows:

ccMx^yvvtx^

C(h

'vK^^YV^

ICv^cvCo^^ya /ds

Ihn

'%

//.

out s

I) I RATION % Yeats Months

CL/>V"WO^

'V\;

I uX\,^i/va/vv'

^

nori I' A rioN

M.nilh^

Dii

DIRATION )Vf/rv S ^Tonths /hiv< Hours

i.U). iLlLtm.^ M.D.

( Signed )

L'ct

H)" 1

A.h

Special information »nly 'or Hospitals, Institutions, franslfnts,
or Recent Residents, and persons dying away Iro.n home.

Tni': \novK st^tj:i> ckusonai, i'aktkm f.ars aki; tki k r«> riuc
ni-:sT ui- ?.iv KN<»\vi,i;i)c.i-: and iuj.ii.i'

(ItifiMtiiatit

,\Arv^vva ^J ri o/oc^ yv

\,i,h,-.s 6 1 I

^3\jJ\k. C

Former or
Usual Residence

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

Now lonq at
Place of Death ?

Days

nxri.ii! I'.i KiAi. or '< i;m< i\- \i.

I'l.ACl*: Ol IHKIM, «»K ki;M<»\\I
fA.I.|t«Hs 3lH%s5

^ H

N. B.-

-Rvery Item of liiformntlon should bs cnrefully Hupplied. AGE nhould be iitnted F.XACTLY. PHYSICIANS •hoyld
state CAUSE OF DEATH In plain terms, that it mn> be properly classified. The "Special Information" for psr-
fff>ns dying away from home should be itiven In ^s^ry Instance.

• %

\

*0\

l»

>l

WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD

jianl ..f H. alth 1 X-. i. 1*.^^^ i u'v I ' ( -. REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

7)afr /'V7f'^/, \L//a:

4^

tcArV

hj c< V

UWH

Registered J\/'o.

2572

a^.Ciuuu

. ., Deputy HcaJth omcer

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco

Ccrtiticate of IDeatb

( XX. S. StanDarC> )
PLACE OF DEATH: — County ofO/aa^ ^J K<X/>\^<AAU> City of Ooy^V' OX<x>\ r v

A

No.

^

^V„4-.nL

St.;

Dist.; bet.

aniJ

and

.,\L

S I

; w

/ 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 ^
( .F DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. J

FULL NAME

■V Uw ex.'

i f

PERSONAL AND STATISTICAL PARTICULARS

si;\ A ft cui.nR ^

h

a

I>A'ri". <>l- 1;IK i 11

.\<,i.;

^xv

Mouth

} I tu

I)a%)

M'iilln

\ ! al

/).7 1.

SINi.!,!-: MAKKIKl),
WIDOW i:n «)K DIVoKv'HI)

(Wiitf-in xiH-ial ih '•i^.- uat mfi >

lUK rui'LAri-:

(Statt iir I "iiuiit I N

NAMi; <U-
FATlll.R

HIR'lHFM.ArK
OC I AI'HHK

(State or t'ountlA*

MAII)1;N NAMi:
<)I MOTIIKK

lUKTIII'I.Ai'K
(U MnrilKK
(statt- i»r Country

XoxxoucL

i

i

MEDICAL CERTIFICATE OF DEATH

DATK OI- Dl-XTll /A

\ I

(MmitlO

t

(Year)

(Day!

I II!';Ri;i'.V CI:RTI1'V, That I uttcn<k<l (kHcased fruni

that I last saw h - alive on W/ T90 ■

and that death occurred, 011 the date statid above, at -. j 0

M The CAl'SI-: Ol- DIvATII wa^ as follows:

1 \ V •'^'

kxxJ. '.

I) r RATI ON )V.//v

CONTRIIUTORV

'I
Mi>}iths O Days

Hours

Yra

rs

Months

PilYS

\

nr RATION

(SIGNED) .u L^^vtUuiL,

ilcl IH iqoH (Addre>;s) 3)^0X' ^H IJ. J

Hours

M.D.

^ >L^.<^ \AA>i-C '^ \^

vKjdj^AjuL

^

Kfsidfd in San /-i.tu^nm

) 'rti I

h'.'uf/r

Ih

Tin- \IU)VKST\Ti:i) PKKSONM, 1' \ K TU' f f, \ KS A K l, TK I K To THH
ni:ST OI-" MV KNOW! llx. H AM) in-.IJl-.l-

^W.

ij . Id. Co-^

b

A

%

i

,,1,,rcss %%X1 M I \A.^L^uA..<m, Ui

Special information nnly for Hospitals, Institutions, Transients,
or Recent Residents, and persons d>ing away from home.

Former or
Usual Residence

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

Now lonq at
Plare of Death ?

Days

190

e\CK <H in KIM. OK KI;MoVAI. I DAll ..! IUkiai. .»r KHMoVAI,

N. B.-

■"■"""""^ , ,, ,. . A,rF ahniild he Mtated EXACTLY. PHYSICIANS should

-Every Item o* I«form,tlon .hould be cnrefully supplied ^^f;^*;^,'^*,,^'^^^^ ..g";,,!., ,„formBtlo„" for p-r-

state CAUSE OF DEATH In plain terms, that it mny be properly wiassitiea. me p
sons dying away from home should be given In svery instance.

:>

ni,.ii<l i.f 111 iitli I- ^''i !«^

WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD

,s^^,.^„ REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

" '^573

^

f

l)<(fr FilaL ^/ct<rls^>v ^H

VJin

lieiL^tcred J\'^o.

-?

.^r\JU^ ^^< \f-

1

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco

Certificate of Beatb

i XI. 5. StnnDai^ )

PLACE OF DEATH: — County

of -^^^xx^v 0A.a>\cc4e^ City of ^^^curu J A.xx.ym^^a c o

*

No-A^^^

tu'VV

^^L^rV

t

±

Cy-^',v\Xa(' St.:

Dist.; bet.

and

— )

L __.- iiciiAi or « I nr Nr r r.ivr facts called for under special information* \

( '^ rF^orAT^H^OCclr.r/N^rHo's^.yT*!: 0%'?n|^?U^tVn"0.VeTtI NAME INSTEAD OF STREET AND NUMBER. )

FULL NAME

hJX.y\Ji\ Lla.L^ix'Ucvv

PERSONAL AND STATISTICAL PARTICULARS

s!:\

COI.oK

au

DA ri; ni I'.iK 111

\< .!•;

^

^^

.Us

X

M ,>,'h

•Vt-ar)

/),?

\\ ii)(»\\ Ki> »»K i>iv< »Krj:n

(Write in --tK-ial (li-.i-iiatiiin)

niH riiiM, \i"i;

(Stati 111 I ■.lunti \

NAM J" "»i
PATH IK

I'.IR rill'I, \i »•;

<>!•* lA rm:K

< Statt oi I'tiiint ! V

tXCCLwU.C '\;

MEDICAL CERTIFICATE OF DEATH

DATH 01- I>i:aTH . ^

(Ml. nth) il>ay)

r Ifl':k i:i'>V CMIKTIFA', That J alUii<U<l <lt«x:ist.Ml from

(Year)

U)0

ItjO

that r last saw h i-»^ alive on vl 'CAj ^*.

ami that <U>ath occurred, on the ilalc ntntecl above, at O >^ 5^

U' M, The CAl SI-; OI' Dl'lATII was as folhnvs :

DT RAT ION )'tars

CoNTRinUTORV

Moulhs

l\iv

Hours

U-i>V^V<X>AX4
OCOVl'ATION ^ (1 , H

MAini'.N NAM1-;
<>1 M()Tni;K

luurni'i.Ai'K

(»»• MOTIIHK
(State or Counti y)

yr<»iih-

n,i\

TnFAI«>VKST\TKnPKKSnNM.rAKTIit!.AK-AKKTKl K K. TIIH
HKST «)l- MV KN<»\VI,i;i>«.l-. XM> in-.IJl.f'

(liiforniant

(\<l.lt.

4

MthjcUx.

1

Jb

DTRATION
(SIGNED)

."Sronths

/hns

Hours

M.D.

A,l<lress)LUa^^Ui .^. 0^44\A.LCVI

SPECIAL Information only forllospUdls, institutions, Transients,
or Recent Residents, and persons dying a*ay from home.

Former or , ^ , ^^ i s i

Usual Residence I C^ H LLcVwv^

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

> ^J Howlonflaf q

U ^cV vvv^aX Ot Place of Oeatli ? "

Days

IM.ACK c)|- m KIAL<»R Ki:M'»\Ar, I I>\TJ:..t Ml HiAi. or KHMOVAl.

lit± a^ I90S

LNJl/ry\,CLt«\Ml

'I ,. , .-,e «i„„.i,i K- .tated EXACTLY. PHYSICIANS iihould

•tate CAUSE OF DEATH In pl«ln term., that it mny be properly clawitica.
Hon. dying away from home should be given In .very instance.

D

5l

A

1!,,ar.l <,f Ht alth I V

WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

f^*^ 4 "dr.

lS-?^»?>*> fiSc I' ^'

f

Deputy Health Officer

Registered JSTo,

Dute Filed X

DEPARTMENT 0^ PUBLIC HEALTH=City and County of San Francisco

Certificate of 2)eatb

( "a. S. StanDarD j
PLACE OF DEATH: — County of

City ofO^^-'^*^ kJ Kql -,

No.

%.

+ . ,

\\'~^r\\Oiiy !i\l' ('-■i.iV..' ~ ' St.: - Dist.;bet. ^no

1 U^ r I VAA^ . ^ V. V- I „.,,.. RESIDENCE OIVl r«CTS CLICD »OB UNOCB 'SPICIAL , N FOn M«T10 « " \

)

i',

FULL NAME

',. /w Vf\»*.. -

V

L.a

PERSONAL AND STATISTICAL PARTICULARS

M \ '>

^

COI.oK >

3xrTr\j>Xx

U

1).\T1-; nf IIIKIH

\<.I-'

<>,

M..mh

i Das

M.nilll

lhl\

sIN«.l,I-: MAKKIIJ*
WIlMtWKU OK IHVoKiKU

iW'litcin H(K-i;il "h "-is-'ilaHiili)

liiK rHPi.Ai'i-;

' st.ite or Count t y

(A

li.:->

NAMl- <)1
J A 11 1 I.K

HIK riiri.Ai K

(II' lATHHH

'- State lit I'ollllf r\

MAiliKN NAMl.
Ul MOTHKK

lUR rnI'UAt H
ui- MoTHHK
I Statt or Country

MEDICAL CERTIFICATE OF DEATH

DATK OF DKATH , r>

Day)

I mCUICl'.V CI-;RTIFV, That I atU-iukMl (ItTease.l from

(Motitli)

Kp

(V.arS

ujo'-i

that ! last saw h '-^' alive f)ti ^^^ T90

ami that cU-ath omirred, mi the (late stated al)nve, at I
^f. The CAISI-: 01' DlCAin was as follows:

DrkATIoN Years

CoNTRlHrTORV X' Q-^-sM^.

Months

Day

//our

X

C V LK.

J^A^i,

L

Jl..

oCCri'ATloN

Re s hi f if in Sun I'litii' /

) . ,fi

M.nllh

/*,,'i

TnKAm,VKSTAT.n.-K><soNA, PXKn.M-jXK.AKKTH.K To T.IK
IIHST Ol- MV KNOW l,i:iH.h AM» l-l'Ml.r

^

(Infiinii.utt

lu..^4;t

f \(l<Ir«'Hs

wLy,

J

Df RATION

(\

}V(/;'A

Mnulhs

fhiv

(SIGNED) Vwl

/lours
M.D.

(Address) iC

Special information onl> J»^ Hospitals, tnsntutions, Fransleiifs,
or Recent Rebidents, dnd persons dying away from home.

Former or
Usual Residence

'Hail

uhju^>

HoM lonq at
nm of Death ?

Days

When was disease contracted, (^ ^ \ ^ ^^^^j ["^4 ^ ^ ^
If not at place of death ? \JU.<UAHmA^ U^ ^o^^^

IM^ACK Ol" HCKIAI, <»K KKMoVAI,

DATi: <•: ntKiAr, or KIMoNAI,

U.t.1

190

n

rNl)i:KTAKKK

(Ad.lrc.sH RHb MyWL^^CT>v .1

M. B.— Bve.y Item of Information .houM be c«refull. .uppHecl ;;;;^;;,;":'4t«^n:i?''Thf '^^^^^^^ In^oTJlTon" fo" ^r-

«tate CAUSE OF DEATH In plnln terms, that it m»> ne pr m
Ion. d% .w.y from home -hou.d he giv.n In .vry InM.ncc.

^

^

J

at

♦ I

♦ I'

P

<IM#

i ■ '1 '

m \

(»

WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

I'.o;..!.! of HiMltb 1 Vo. 1- 'S-?'^>,T^]US:I' Cu

I)/f/r Fi/('f/X^ tX r ^^Ji:

J/

K C' \ k t

Dept-^- ; «

Jf}0

h Officer

Be^isfrrcd J\^o.

2575

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco

Certificate of 2)eatb

1 H. S. StaiiDarD )

PLACE OF DEATH: — County of ' Cu^rxj - ^\. o

p

City of 0/CL>v 0 Ko

iSf,^

Dist,; bet.

and

(IF Dt»TH OCCUBS 4w*Y FRo4l USUAL R E S I D E N C E G I V E FACTS CALLED FOR UNDER SP
IF DEATH OCCURRED IN AJHOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STRE

eClAL INFORMATION" N
EET AND NUMBER. /

FULL NAME

^ 1

lOJx.

II

L- L.W 0 > \.,

■-.iix

PERSONAL AND STATISTICAL PARTICULARS

fl

1) \ 1 j; t >r liiKTii

A«.K

n

1 Monti!)*

I»nv)

M'-nth-

/hi

i W'l ite ill ^1 Ilia 1 1 !i ■'Ii.- nat ion )

Ml

I'.iK riu'i.Aoi-:

stale ot roimti \

NAMJ-: Of-
! A rilllR

lUKTHI'UArK
ni' lAIMIKK

(Slati or t'oimti %■

M \iiu;n- nam j;
<>! m(>tiii-;k

iMR'rmM.Ari';

( Stall- or I'oinit 1 N •

MEDICAL CERTIFICATE OF DEATH

I)AT1«; u|- I>i:\TM

(Viar)

(Month) (Day)

I HF'kllBV Ci;kTII'V, That r altt'ii.kMl deceased from

— lip to — ---- ^^ — —r^ Up

that I last saw h alive on — — lyo

and that death occurred, on the date stated abovi', at
— ^ M. The CAT SI-; Ol' DI-ATI! was as follows

q^

CLA,^ ^'vCN

•^

\,

A,'_ •„

4

I

UVucJuxn^

coNTkinrToRV

Months

Days

Hours

<^

^\.KX

K UIjouO^ux,

L

\A

DT RATION

i Signed )

0

)\'iH %

n 1 m

PiU

Hours
M.D.

fA.ldress) 1<^V(^

cu

iMrri'ATioN /O ,

h'r^liit'il ni Si:ii I i iiii

KSr^,/>^^*xtx,

yf,.,itfn

/',M

rill': AMovK sTAi'i:i> i-kkson \i, i'\K rni I, \K-- aki: I'KrK m rwv
incsT Ol- MN' KN<»\\i,i;i»< .!•: and iii;i,ii i

Special information nnly for Hospitals, Instituffons, rranslents.
or Reitnt Residents, dnd persons d)ing dwd> from liome.

Former or
Usual Residence

4

How lonq at
Place ol Death ?

Days

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

(Info'inant

Ofw % C.iuA,.

:x

Vl.XCV, Ol* ni KfAI. OR K|.:m<>\\i, I OAII;..! IK kiai. ur KlCMnVAI,

190

rNIH.K'IAKKK

A^^^X

N. B. Rvery Item o? Infformntlon should b* carefully supplied. AGR iihould be utiited I.XAGTLY. PHYSICIANS should

stiitc CAUSE OF DHATH In plnin termw, thnt it mny be propeHy classified. The "Special Inl'opmution" for per-
sons dying away from home nhnuld be given in every Instance.

I 1

)

?

I •

m

P

WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD

i!:.nl. f Htalth » No 1 T^-g^^jiiS:! I.. RE^ERTO BACK OF CERTIFICATE FOR INSTRUCTIONS

K' as

JfWH

Be^Lslered A'^o,

*yrz^.

i576

Dfffc Filed ,

DEPARTHENT OF PUBLIC HEALTH-City and County of San Francisco

1

CXM^

Certificate of S)eatb

( Ta. S. StanC>arO )
PLACE OF DEATH: — County of Cxxoa. J.*\a v^r , .Qty of C'O/yvOa.cx ,
(No. LuLc* ^Wvc'Yvt^i L\-l->-» ..v. kcv .. ..St.; Dist.;bct. and

1 / ir DEATH OCCUnS AWAY rnOM USUAL RESIDENCE GIVE facts called tor under "special INFORMATION" \
J \ IF DEATH OCCJjRRCD IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. /

FULL NAME b

e

.1

^1 \..K.

sj;\

PERSONAL AND STATISTICAL PARTICULARS

C01,0R \

o.

I) All: «»r luKi'ii

Ai ,i:

>

M..mh>

)

b

Dav

MEDICAL CERTIFICATE OF DEATH

DATK OJ. Di; ATH \

(MotitlO

(Yt-ar)

1/m;/

n,i r.

^iN<.i,i' Nt \kk III)
WIDOW J.; I) (IK ni\MKri;u

iWtitfiti suciai <|t <.i^Mi.iliiiii)

HiKTniM.Ari.:

I State III <.'r)nntr\'

NAMK OF
FATin:R

niRTIII'l.AiH

oi- iATin:K

fStatr or t'oiintrv

MAII>i;n NAMK
<)I- MOTIIHK

ItlH llII'l^ACK
<H MOTHKK

(Slati- <>t t'liiiiitrN

f\

^

^

(Day)
, I III':K1':PA' CIvRTII-V, Thnl I MttcniUMl <U( lasc,] fmni

A))L<Xi.-^ /X::\ up. to t'ct ^2.

that I last saw Ii ^ > alive on ^.. '

Up 1
Xi)0

and that dtath ncciirrcd, on the date stati d above, at
Cf M. The CAISI- i)V I>i:.\TII was as follows:

QJktl-

rX.v./ii,wj \^-.c*„'., t , wC

,u.

n)

I )r RATION }'t'ars H Months TVl Days

t'oNTRIinTORV

Hon

rs

\A^0yO^

I

U

A

L.

(H'Cri'ATION ■

AV'/,//-)/ /II SillS / I ,!Hi I'lii

Dl'RATION

(Signed)

it t

.U,>////ts

/hiv

Hours
M.D.

(Aililress) xXXrvy^^Mt^ \.K.^

SPECIAL INFORMATION only lor Hospitals, InstitufioBs, Translenls,
or Recent Residents, and persons d>ing aMay Irom home.

) III I

M,'ii!U^

l>,l^

Till-; AHOVK STAII-D I'HKSOXAI, I'AKTUMI XHS AKi: TKIH To Till-:

in;sr oi- m\lknowi,i;fm,h and ni:i.ii:i

f InfiHinaiit

V a.

O/cl

( X-LIk"-*

former or
Usual Residence

When was disease rontracted,
Ii not at place ol death ?

How \m% at
Pl«-etf Death?

Diys

I'l.ACK ol- nrklAI, OK KHMo\ AI, ( I)\'n;..f m kiai. or KKMOVAI,

0C\_ ,,

Mm

i . W\jl/Y>UXl ''

W,

TQO

N. B. Every Item of Information .hould be carefully nupplled. AGE •houlcl be .tated EXACTLY. PHYSICIANS iihould

•tate CAUSE OF DEATH In plain terms, that It may be properly classified. The * Special Intormatloa ' for per-
sons dying away from home should be given in every instance.

I I

:>

If

M

WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD

I'.m;it.1 .,f ll.nltll I" Vn : - t-'^'^S^) ]',Scl' C,

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

Begisicrcd JVo.

;^577

4

\H| Deputy Heafth Officer

DEPARTItlENT OF PUBLIC HEALTB-City and County of San Francisco

Certificate of Scatb

( Ta. S. StnuDarD )
PLACE OF DEATH: — County ofCj/<XAv 0 Va.>xec4.ac City of C'xx^^ J AxXyvuec4.<U)

N

o. oL I "i i >. J JL k ct >^xcu

St.; S Dist.;bet. ?\<i

and

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

Ht;

FULL NAME >m'Tu LI.l.cUou>>^ ll.c^^xW

^xinjA-

PERSONAL AND STATISTICAL PARTICULARS

t

^Rcvu

i> A 11-: I ii' liiK i II

\ ' . !•:

M.iiith) t

t

I v:^

\\

Dav

rWl

V\

s

\

IK

uii)i tui. n ( >k n :\ » ii'i j n
( Writ*' i II •>!« 1.1 1 ill --iu' iiat !< ill i

XC

a.

!• A I 1 1 1 . R

nTKTni'i, ACK

<»I IXIIll K

IMtMtr Of IdUlltl S

maii>i:n XAMI-;

<>!■ MorilllK

HIR rilPF.ACH
»>» Mn'I-HI'K
(Stati- or Coiuitrvt

^

MEDICAL CERTIFICATE OF DEATH

nAi'i: ( 1 1 miAi'ii i

I III{R!:i?V CI:RTIIV, That I atlondcd .ItHvascl from
190 H tn C ZAj XX u^H

that I last saw how. alive oil l.i tX XO^ i,p H

iind that <Kath orcurreil. mi tin- diti- stati-d al)<>ve at 10

L^ R

rf

M. The C.MSI' Ol Iij;.\rn was as foil

LLccJtu.

4

d^CiiXkSj

1< >\\s

^ X^xtrvx ' V cx<i

DIR.^TION }\ars

CONTRHUTOKV

1 v-K. CO > x.e > w-CL'

Mouths A /?,/i,s- iloii

$ s

DI'R.XTION

Yiars

Mouths

i

Pavs

oceri'A riuN

tccctj

( Signed ) vlAc-Uk Lrlt^^^XL

w Caj ^-X. iqo'I (A<hlri'Hs) l5 i »- u '.sl^ >>

f font s
M.D.

\

SPECIAL INFORMATION only for Hospitdis, InslifuNons, rransients,

or Recent Residents, and persons dyinq dH<iy from home.

XA, t.4_4X'W

KfMtiiii I II '^,11! / / ,,';'i /»*'f» 1 Q J f'<

•(/; , — \f,,iit/l^

/),n

TH i; \I)« tXJ.- SI \ 11 II l'Kks< »\AI, I'XKrUT!, \KS AK1-; rKll-: 'I'l

HiCsT (»i MN Is \» iw i,i;i)«.K AM) iu:i,ii:i'

r 1 1 H

Former or
Usual Residence

When was disease ronfrar ted.
If not at plare of death ?

How lonq at
l^are of f)f ath ?

Days

IiifuTinant LoJUKJ-N.*^ VU. LL-^^VVA^Wx

(5?

X.l.lross c*.l3 '3s. J X4

t

lOAvca;

at

ri.Aci: <>|- luKiAi. (»K ki;m<>\ai, | i>\ii

.^ , sL/ct XS^

^ d

INinK TAKl'k

HI \r. i.t K i:M( i\ \i,

w v-Aj c^o T go 1

•u

'jLt .

N. B.-

-Rvery Item of Infoi'rtiHtion should he cnrefull}' MuppUed. A«B should be stntecl KXACTLY. PHY8ICIAIN8 nhould
state CAUSE OF DEATH in plnin terms, that it may be properly classified. The "Special lnt»riii»ition" for per-
sons dyinft away from home should be given In every Instance.

D

3 p

WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD

Hon..!..ni.;.!.h FNo .. '^'ii^'^iUikVCn REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

l)a/r F//rf/, lD.ct<rU;

I

>v IS

i

d^c^v^.c-^ X.X. vq Depu*

10 OH,
Ih Officer

Be^isfcTed J^'^o.

;^578

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco

Certificate of IDeatb

PLACE OF DEATH: — County ofOo^^v JXa'^vCUi.'C^ City of ^^amj vJA.CLTvec4/ao

No. ^ ' loX<^^k_^ a. k^ L MivCtA.1 St.; Dist.; bet. — antJ

(ir Dt*TH OCCUBS AWAY FROM USUAL R E S I D E NC E G I V t FACTS CALLED FOR UNDtR "SPECIAL INFORMATION" "V
IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. /

FULL NAME

A f ^+

tXL^-VfXLU'

A

wi-tHMXX/TVV (m)

•^1 \

PERSONAL AND STATISTICAL PARTICULARS

0^

I

I) \ri or lUKTJi

A< .1-;

I

All

Ml, nth 1

as

lias i

1/ ,.;//

'i I ,'U I

(S'fiir)

SINr.lj:. MARK III)

W J r >« »\\ J.' I > ( » K I ) ; \'i I K I 1 ! I

•Wiittiii siuial lit '-uMial 1' 111 '

0

x>

L

ll

nil-' rifiM. \i-»-:

^1 !t- , -■ . ,.int I %^

NXM). (»|
I- A III IK

HIK rilPI. \( K

ni" I \rm:k

(StMtt (ir I'liunl T \

M XIUHN NAMK
til- Morill'K

lUK iiii-r. All-;
oi- Ml I'm I-: k

(Stntc or Couiitt \ '

MEDICAL CERTIFICATE OF DEATH

DA IK « »1- Dl-; AlH I j

L' ct a 3

(Muiilh) il):n>

I HJ'RIU'.V t i:kTI|-V, That I alti'U.K'.l .K-rtasiMl fnMii

lliat 1 last saw ll C^n alivf on \i' CAj 3.3 igo*^ XjD

and tliat iliatli nccurrcil, on the datf statvil ahnvf, at S» T

T M. The CAISI-: OI' I)i:.\ril was .,s folI,,us:

3

J

i^

■^

I )r RATION )'iijrs I .IA';////,s I S /;,/, v //ours

C ( ) N T R I J '. r r () K \' > > \X,ULtc-/vCut LL^4/CX4A.

»

0

AwCla^

?

//<

ONrs

A

I'll- \ rioN Qfn

^/D^^\AXjy\>

nr RATION }'rtjrs I Mn,it/is b /)^7v?

(Signed) vD n 1 LxxiAA^<j.ouvUj M.D.

Special information nnl) f«r Hospitals, Insfifullons, Transienfs,
or Rftenl Resldpnts, and persons dyini} anav from home.

Former or

AV.Wl//// //' S,;)/ /'l ll Hi ll'i) "

.»/.

././A> 4 3) i^'i

\ \.\ 4^1' y How lonfl a* g -a

Usual Residence cL.6-0 UO^vfr^ v<XV PUe of Deaf h ? I J

Wfien was disease rontrarte^, -^ \i k^ i /v »

If not at place of deatli ? rMM^ J <XM^' wQJj

Diys

rui'" AHovH ST \ ii:i» i'KK-;(>NAi. i'\K rii'ii. \K- m- r i ki »•; i " > in K
HHST oi' Mv KNOW 1,1, I)<;k \m> in;iji;i

(In fitfin.int

\.Mi. V.

5 0 S dLJ,vw^<r>vt Ot)

II \<1' iH- lUklM, iiN |.;i:M<i\ \I, I l)Ari:.it lUvwu it UHMnVAf,

\

x\

N. B. Every Item of Information .houlcl be carefully mipplicH. ACI. «h.n.UI ba «t«te.l »'XACTLY. PHYSICIA^IS .hould

State CAUSE OF DEATH In plnln term., that it mit> he properly cfomilfled. The Special Information for p«r-
iion« dytn£ away from home nhould be ftiven fn m\9ry Instance.

ijfi

WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD

I!i.;ii<l ..f M. ;tUh »■' Vu :■^ t'^^-sst-J^ uSiV Cn

REFER TO BACK OP CERTIPICATE FOR INSTRUCTIONS

,^

Du/r Fi/r^/XzL^i>JJ\) ^H

790H

Bp^i^stcj'od JS'^o.

579

<X^'^_CC^J

• U L

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

Certificate of Beatb

( "U. S. StandarC> )

PLACE OF DEATH: — County of

1 1

m

^No.

3 .^xx^'X'CUi/Oo City ofU-CX'-^'v J Ax>.
hIk' / ^ -^'Z , . • ■ St.; \ Dist.;bct. OAXt^m.m.CK and L^T> '

(ir Dt»TM occvBS AWAY fHom USUAL RESI DENCE GIVE facts called tor under "special information • "\
IF DEATH OtCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. /

.-^ ' J

f\.

A

FULL NAME

i f i

n -

ii

PERSONAL AND STATISTICAL PARTICULARS

haih (»i luk lii A ^

MM..iitli ' ICiN'

\ « ■ »■;

MEDICAL CERTIFICATE OF DEATH

DATK OI' I)}:aTH

(Month)

(I>;iv)

(Vi-arl

I I1I:KI-:P.V CIIRTII'V, That I atlen.U-.l <k-,i:i>iMl from

1/ .).

/),/

•^iSt .1,1-: M AK k 11 I»

u iiH »\\j;ii <ti< ii:\nRi'i:t»

Uiitf 111 "^iHKi; li ^ij/natii 111 1

niR riiJM, \i'i-

' *-t it I I • I I 111 nl I \

NAMl.; ni

HATni;K

nikrnpi. \cv.

fit I \ III YM
iSt.iti <ii (■( iiiiit

mmih:n nami, ,0

<»l .MoTIII'.K L

a_

rs

K^

rs

I

that I last saw h

I <>o .
alive oti

c

,, ♦

and that dcatli nccurrcd, on the date stati-d aliove, at
M. The CArSI'! Ol' I)i: ATI! was ;,s follows

I ) r R A r I < ) N

)'t'il/ s

0

t'ONTRflUToRV Lfe-i.JL<X Ovt^t l>

u

Mii)iili% I Pax < Mom \

^J^

^

cv

iivJ

DIRATION }i<irs

(Signed) > J

Months

/hi

vs

\

wY>xrYrux.

lukiiii'i.Aci-:

ol MnTHKH
' Slate tir (.'ouiiti \'

I
jy\j 0

/<X/YV o.^ucx

< H'l ri'AIIoN

fsfsiilfif ill Still I I ill), lu'if

) ■/■(?;> ^ji. Month

r>j

rilHAHi.VH sT\TKl.I-HK-oNSI.l'\kTH Ii.\k-.AKi; ll<l F To THK UlLArK..F fit klAT.ok kKNfnVAI

iqo*. (Address) HbO VirU^AlcL\.

I/oNrs

M.D.

Special information «nl> '»r Hospitals, Instilyflons, TranslfBts,
or Recent Residents, and persons dvimi a^») f^"^ h^mf-

Former or
Usual Residence

When Has disease fonfraffed,
If not at place of death ?

HoH lonq at
Place of Death?

Dtys

iIkst «)i- mv know i,i;i)«.1'; and i'.i:i,n;i

(Iiifot innnt

v.^

f \ft.!rfss

SO

>\X<X<5

> w t/x^i

I) \ ii; ..! Hi in u I.J ki-;mu\-ai.

iqo

•tate CAUSE OF DEATH in pl«in terms, that It m„y he properly cla.s.t.ed. The Spec.al Intormat.on for pr-
«r»n« dying away from home should be given In avery Instance.

:)

1

WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD

Hi.ar-l if It, aitli 1- N'o. i =; *'r'-^«r<«t} !kS:l' Co

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

Dnfp Filed ,

oLCrvcUi

as

190\

Regisf creel JS^o.

^3580

Deputy Health Officer

DEPARTMENT OF PUBLIC HEALTII-City and County of San Francisco

PLACE OF DEATH:

Certificate of 2)eatb

( Xl. S. standard )

-f

0)^

County of QCXA-\J JAy(X/VV-<^aLCC> City ofO,a.Av J "xo

i

- <L

i-

No. V. ciu ^ u>CrL\„^

^

and

, - ' < - _CV.l St.; Dist.;bet.

/ IF Ot*TH OCCUIJS «W*V FROM USUAL R E S I D E N C E G I V C FACTS CALLED FOR UNDER "SPECIAL INFORMATION \
V IF DEATH OC<jURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER /

FULL NAME ^ ^<x.vK

PERSONAL AND STATISTICAL PARTICULARS

"^'■^ A •, I oil >K N

1) A'n; . .r iuki ii

a

Month

\<".K

15

(Dav)

M.,uth

(Vtai

/>.;

MEDICAL CERTIFICATE OF DEATH

DATH U!- nivATIl \

(Month)

(Davl

I (^(t
(Yf.n)

u n)t)\\j:i) OR i>i\<»KtKr)

•U'lit' in *;«KHal diKi... luit i' ni >

lUa.

I in-:ki:HV Ci:RTn-V, That I attin.U.l deceasetl from

tn H'ct

lUKTMlM.AOK

i State <>r Cmuit rv

N'Wtl- OI'
F- A Tlil.K

HIKTIIl'l.ArK

oi- I Aini-:H

(State ■It I'oiuiti V

MAII»i;n NAMl

lUKTHI'LAri-:

<)i' M()'i'm:K

(State oi Coniitrv

ry

\ I LL.

WC^'fx

c^ '< 190H In v: Cb 100 i^

that I last saw h •.• i»v aUve 011 ^' ct ■ X k^q

and that death occurred, on tlic date stated aliovc, at
M. The CM SIC OI- DI-ATIf was as foIUms:

r\jrs\,*^^ W<X.>wt

u:

Dl" RATION

)'tars

Days

^

Mouths
C ( ) N T R 1 15 r T n R \- ^ V Ci^A^dvo J.a.x.u.i„ > >

/A.//

/,s

Dr RATION

Ihl

ix

r'l

UCCl'l'ATlOX QTiP a I'l

/\'f'Mif,''if in Siiii /'mi/, .' 'I ii o ) ViM

Hams
M.D.

"1

(Signed) J _ __ „.._

Ucl AS^^ iqo t (Address) UluXiVC) I) O^Ux-d-O. I

for Ifo'

Special information only for Ifospltdls, Insmutlons, Transients,
or Recent Residents, dnd persons d>ing dwdy fro.n home.

Former or
Usual Residence

'T^ '^

bSb ulo^M

How lonq at
Plif e of Death ?

Di)r$

M,>ii(h'

lhi\.-

THH AHOVK Si'Ari'.n I'KRSON AI, !• \K rim, \K-, AK1-; TK fK T< > THK
IJKST OI- MV KN'()\VI.i:i)<. I-; \M) Bll.n !■

(Infonnant VJ . V v\D . wL

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

<X^(>M

MbKwA.<\i

X,<^,'

T90

IM.ACK OI" lU KIAI. (»K KHMnVAI, I I)ATi;..r I!i hiai. or RFMOVAI

I'J

t'N

N. B. Every item of informntlon should be ciirefully supplied. AGH should be stilted BXACTLY. PHY8ICIAN8 should

state CAUSE OF DEATH in plain terms, that it may be properly classified. The "8|>ecial Information'* for p«i>-
sons dying away from home should be fti^^n In 9\9ry instance.

:>

c

w

RITE PLAINLY WITH UNFADING INK

H..aia ..f n. -.'.th ■ I- No :^^^:';^^HS:l'Co

T)((h' Filed ,

iO

15"

100\

THIS IS A PERMANENT RECORD

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

Registered jYo.

2581

\A Deputy Heatth Officer

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco

Certificate of Beatb

( H. 3. Stan&atS )
PLACE OF DEATH: — County of U<x^v J /v<x .wc^^ <. Oty ot

f4o.v.^^-

U

^C^rV

Jir

11' C^^.

4

n I

St.;

Dist.; bet.

- and"

M USUAL RESIDENCE GIVE FACTS CALLED

( '^ rr"o;:T°H"oc5u%*«"cV.« r^oTpTTAr o« ..ST.TUT.O. O

FOR UNDER "SPECIA
IVE ITS NAME INSTEAD OF STREET

L INFORMATION" N
AND NUMBER. •

FULL NAME

^0 iJtcLUv^^

-4

tU'

-w-

PERSONAL AND STATISTICAL PARTICULARS

A

SHX

DAI i-; «»I lURl'll

.\t,H

C< >I,' »K N

Month

)■

n.iv

\l,„!h

I Vt ar)

lhi\

-, INC. 1,1 MARKIKl'

\\ n»<»Nvi i» OR niy»»Hv i-.i>

tWiitt ill -iK'iaS cli-sii^tial'i "ti )

MEDICAL CERTIFICATE OF DEATH

DATK t)l' DllA'i'JI

(Month)

Day)

IQO

(Y<-ai^

1 lII-kl'BV C1':RTU'V, That I altcn.l.a .leciascl from

UvX. y^

190H

that I last saw h -^ • aHvc on
ana that .Uath occurrcl, on the .late- ^tatt-a ah.m-. at
(? M The CMSlv Ol- Dl^ATII was as follows:

% _ M H^

lyO
190

i / I

BIK TIHM.AOK

'Statr or (■(Hiiiti %

NAM)-: ol
FAT II IK

id-

kXjXXi^^

HIK rHPl.Al'H
0|- 1 AIMIKK

(State or Coutitrvi

MAIDl.N N\MK
nl- MOTHI-.K

niRTin'i.Aii;

Ol' MoTHHR
(Slate or I'otititrv

\

U

U XV \ > \

IXc^Ow>v

^7s

« )(.(.- tl-ATION "w

J Xcu-v

ex.

>v.<

\.

Ur RATION Yeais

CoNTRIlU'TokV

Mouths

Day

Hour

DTRATION
(SIGNED)

Vcnt'S

T)

^r,}ut/ls

/hiv

'i\ a. %

Hours
M.D.

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

.OJf^^

Rfsuff,1 n, Silti riinn,^,n \ "> ' ^"

\J,,tiih-

- /),M

ih'ST Ol- MV KNOWI.HIX.J-. AND in 1,11.1

(Iiiroiinaiit

(A<l.lr«'^s

(!du"'-<C{,/%

11':'

Former or
Usual Residence

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

-. i

t

How lonq at
Place of Death ? o

D#ys

n.ACK Ol- lUKIAI. OR RKMoVAI,

t NDKKTAKKK JVXAAJU^ ^ -' ^ - j ^

nA'i;i!i>'' Hi Hi.Ai. 01 ki;m<ivai,

iy,c^ ^b 190M

Adai.-H ^^I'a' I I

"^^"■^^^^■'^■^'^^"^"^'''^"'"""'"'''"""'^"~'"'"^" I I h t t I FX4CTLY PHYSICIANS should

„» i„f„rni..tion .hould he cnrefull,. -PP''-^- „^„^p^:H!;7l«,-Hled? Vh^ -Special Information" for p.r-
E OF DEATH in pt»1n terms, that it m»> ^e P^^P

N. B. Every item

iif)

)

y

\

WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

Bnnrd of Heoltti— IN-. ■ - -w^^iu^ I'.Si V

l)(ih> File<h IJ/obvi-Ov XS

190\
Deput* »-J^a!th Officer

Re^isteTed JS^o,

2582

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

Certificate of 2)eatb

( la. S. StanC»arC> )

A

PLACE OF DEATH: — County ofUa-r^ X<XAAXi<.-^ City of 'J<x^^ J/vo^a wc^^c<

I'D (% '"^ ^ ft

fI^.LLLu^L<^<-'l^u Ob CHlk.\1l<xl St.; Dist.;bct.— and ~

\ ( ir DC*TH OCCuAs AW«Y FRdM USUAL RESIDENCE GIVE facts called for under "special INFORMATION" \
% V 1^ DEATH OCQURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. /

FULL NAME

M Rc<J^\.oJUj L

ux

PERSONAL AND STATISTICAL PARTICULARS

S I . \

DA 11, OF- IIIKI'II

AT. !•;

ri»l,(»K

a'

f

MEDICAL CERTIFICATE OF DEATH

DATK ul- I)1:aTII

f^

n

)V,.',

(Dav)

M.I, I til

r

\'tar)

Pa

SIN«.i,K MAKKIKD
\VII)<»\\ 1:1) OR I)IVoKi'i:i>
(Writi ill -"IK i:il (it'si<.^nati«>n)

\ nxsXKuA,

niRi'm'i.ArH

fStatr or Country)

NAMK Ol-

FA rni;R

niRTni'i.ACH

Ol' I ATHHK

fStatf or Countryi

MAIDHN NAMK
OF Nf OTHER

hirthpi.acf:

OF" MOTIfF:K
(Statr or Country)

n

i."', I

(Month)

1 ^
a)av)

(Year)
I HURUBV CIvRTlFV, That I atteiuk-.I .kctasc<l from

■^c± 3s3

that I last saw h

I90'; to A^'/C;t c^N^cS 190 H

alivf nti ^. C\ liyo

and that death occurred, on the date stated above, at i- 6 0
- ■-- M. The CAlSlv iW Dl-ATH was as follows:

a

'Vh^-<rvA„w

<;l \j rlA.^>acUs^i. V

DT RATION Years

CONTRIHUTORV

Months

/hiv

Ho lit

Yi-a

rs

Mouths

I\n-

k ♦

AXAAAAXXnTX"

Resided in Sun f'iau,isrn .*sb )>(?/>■ t Months I

OCCri'ATlON Oi\ X „

IhlS

DIRATION
(SIGNED) Uj. W

i/ct X3 TQoN (Address) LcU^ 'HtL: qlDo^^xda

Hours
M.D.

SPECIAL INFORMATION only for Hbspitals, Institutions, Transients,
or Recent Residents, and persons dying dHdy from liome.

Xi^^

Tin- AnoVK ST\TF*n PKRSONAI. FARTIcn.AK^ ARF: TRTF: TO TlIK
IJKST OF' MY KNo\VI.F;DC,H AM) HHMHK

(Iiifomjant WT\,<X,« V 0 -*-* •

\(l(ln

) 6-4.'VXaX<

■1'

Former or
Usual Residence

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

i How lonq at
,c^-AA-.e>\ ; ( 9\^t of Death ?

Days

T90H

PI \CF: of IURIAI, ok RKMoYAI, I da if: of IHkiai. or REMOVAL

rNDKRTAKKR\l»^ j CtdAiAV M fl y^/uLO.\lu ^ K
fA<i<inss I ill NjrrU44x-<rkv ol

N B — F.very Item of information .hould be carefully supplied. AGE «houId be stated EXACTLY PHYSICIANS •hould
state CAUSE OF DEATH In plain terms, that it may be properly classified. The "Special Information" for per-
sons dying away from home should be given In ^s^v}/ instance.

3

:>

WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD

I',.. «!il i)f 11- .lit!)

•?■- .•si-^ M&r Co

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

Tht

fe Filetl,V/zLj^-\>XK^ X^

lOO'i

llegislcrcd jYo.

2583

.MA^V 5

\ (

\

'"^Icer

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco

Certificate of IDeatb

( tl. S. StanDarD )

n

1^

\ .

,->'X; J;v<X>\ f^ <_<i

PLACE OF DEATH: — County ofCJcx^ ^ ^ n -<c City of Oa.->x; J/
'^No. 1H%^ .' ^ V. '. St.; 1 Dist.;bct.l£))uyd \' /. and ^ "^

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

% +4 Fl ^ t ^

FULL NAME Jt <xrUx Li^va.A>-<..l .

^c

SI \

PERSONAL AND STATISTICAL PARTICULARS

mi, ok \

i)\ ri: or iuk rii

a; ...

K-^J

h

Mbtltll I

A< .J.;

Vv

) ,,/!

D.ivi

M.n,fll-

/',/r

srNc.i.K, MAKi<n:n
winoui-:!) OK iMN < ii'i in

i\\iit< ill viKJal ill --ii' iKit 1- 11 1

lUR rni'i. \i"]-:

' state 1 It t 1 Mint I %

,Oj\K.Kj^6^

A

MEDICAL CERTIFICATE OF DEATH

DATH <)1" DllAIH

IkX

Mmii;

(I)av)

igo

(Year)

1 ni;i<I';HV CIIRTII-'N', Tlmt I atteii(k-<l <k'tcasc«l from

tliat I last saw h •■•.' alivf on KJ -"^J^ *c l up

and lliat (U'atli occiirred, on tlu' date statetl above, at
M. Tlu- CAISIC Ol- Di-ATIl was as follows

X \MI ni'

I A in i-.K

MlkTIIPl.Ar!-,

• u- I ArHi;K

'siat( ')T i'ljuiilrv'

MAini-.N N\M1-:
<>!■ Mnrni'.K

lUk I'lll'I.AiK
Ml MOTItHk

iSlatf or t'oiinf 1 vt

\U

DCk ATION I }'tuirs
CONTkllU'TORV

Months

Pays

I /ours

orcri'A'i'ioN V

Kf silted ill Siiti Fiiiiiii'^in i

Dl'R ATION I y'turfs J/o////ts

'^ If i"^

(Signed) -j . LI

'C^ 'XS iQo'i (Afldrcss)

/hn's

m

Hours
M.D.

J XjsJiJ

'V%u0'ul O.l

S FECIAL Information only for Hospltdls, institutions, Trdnsirnts,
or Recent Residents, and persons dying away from home.

M„iith^

l).:\

Tin- AHOVK STXTHI) PKRSONAI. J' \ RT H" f r.ARS A K I- TklH TO TIIK
BHST <>1 MV KN«)\VI.i:i)C.H AM> ni.i,ii-;F

Former or
Usual Residence

Wlien was disease contracted,
tf not at place of deatfi ?

How long at
Plareof Deatli?

Days

V\ ACE OF HI RIAL OR KKMoVAI, J DATi; ..t HtKi\r, ..r RIIMOVAI,

11H i)4/vhvAOL,>cUxt J,t

< A(Mress

.tate CAUSE OF DEATH In plain term., that It may be properly cla..if.ed. The Special lo.ormalion o p.
■una dylnd away from homo should be »lven in .vory Instance.

)

i;. .:i!

WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD

,[,,,,,, , ^v, i..^£'^^-.:.]'.ScVCn REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

du^^cu^ oLLohM t^eputy Heolth OfHcer

1\

Re^isteied J^'^o.

;2584

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

Certificate of IDeath

( "a. S. StanDarD )

J on

\ 4

PLACE OF DEATH: — County of Co. >a. J^a^%^CA,a

City of Occ^r^ J Xcv

I \ CA,.

(ir DI^TH Ol
I* DEATH

"w-W

vK'^ w'^si.u,u,cc ^ ,

St

Dist*; bet.

and

■URS AWAY FROM USUAL R E S I D E N C E G I V E FACTS CALLED FOR UNDER "SPECIAL INFORMATION- \
OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. /

FULL NAME

x^

CLLuQj \mc

\.

PERSONAL AND STATISTICAL PARTICULARS

m: '\

'V

i't «I • tk

DAI'l'. <»r ItlK 111

LLcM

M..iitli

\ < . V.

)'i at

V

(Dav)

M..u(/n

I . al

Pa vs

\\ ini t\vi:i» OK i)!\t>Krj;i)

Uiilf ill vinial (li'-is/nat i'ln I

lUKI'lll'l, \rv

(Statf or T' 111 iiti >

I ATM l.K

lilRIII I'I,A»1-:
<)I I AIIIKK
(Statf or Country

MAIDI'.N NAMK
OF MOTHKR

I'.IUl'IMM.At'K
ot MoTHHK
'Stall- or Coiuili vi

MEDICAL CERTIFICATE OF DEATH

DAPK (»!•■ Dl'.ATH

<^3w /go H

€t

(M.)jith) fDayl (Year)

I IIl^RIiBV LI'iRTIl'V, That I attoiukMl lUaxascd from
' -; r ,,^{ to AQ^ 2L1 190H

190 \

i<^-t;

that I htst saw h ^'\ alive on ^ " "^ ' ' I90

au«l that death occurred, on the date stated alxive, at
M. The CACSP: Ol' DIvATIl was as follows:

XV>'

nr RATION Years

\\

CONTRIIU'TORV

A/onths i X Days

Hours

Months

DTRATION Yi-ars

( SIGNED ) LLt|^J^ M fV iw

/)</

I'S

,<Xa_\,<X V ^, L\, , y

Hours
M.D.

I()0

( A.1.1 ress) (K iK . %i.^UluU^

SPECIAL Information ""'y f*"^ Hospitals, institutions. Transients,
or Recent Residents, and persons dylny awd> from liome.

oCCri'ATION

Kfsidfif itt Silt' /■></)/- /w"

)■/(/<

Mmilh-

Ihi

THK AnoVFSTATI-.DPKKsoNAl. I'A RTIi-f I.AKS AK l- TK t K To THH
HKST Ol' MV KNoWIJJX'.H AND lUlI.II-.K

(Itiformnut

Afhln-ss H I IX) Oh ■

VA-O VV'^^^VV

r\\.

Former or
Usual Residence

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

Now long at
Place of Oeatli?

Days

DATlCof 1!' KiAt, or KKMOVAT,

f'K oi' mKiAi. OK ki:mo\ai
J f ^

ud<h.ss Hw\x^ \^xk at

190

State CAUSE OF DEATH in plain terms, that it may he properly UOMitie
•on. dying away from home should be ftUen in every inntance.

)

5t
t

WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD

F?.,;,-.i ..f n. ,;t!i )■ S(, !c -i..^jr^; MScl' r

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

/)

((fc tl'li>(l X'X^J^A3<}\J X^

790H

Registered J\^o.

-^^OoO

.>CKAA^

Aj-u Deputy H -'^h Officer

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco

II

AA.^

PLACE OF DEATH:— County of ^ a

Certificate of 2)eatb

( "a. 5. StaiiDarD )

.^ City of '/Cc>v OA.cc > wcv^CLi

■^

"> \ '

*\ o

'No. H^

1

>-' * I

b+ ^^

^ f

L I A^ • Si; Dist.; bet. b A. K and

/ ir Dt»TH OCCURS AWAY FROM USUAL R E S I D E N C E G I V t r*CTS CALLCD 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

. iOI.siR \

Vl)lo '

I

X

II

I> \\\- «»F- 111 Kill

A(,l-

Q'-

11

\t..nthS

)

(n;iv>

Mm III:

\ I al

lhl\.s

SIM. 1,1:. M\KRIi:H

\VIIH>\VM) OK I)I\ « iRt 1 i»
(Wiitfiii social ili sj.j iiat t.ni >

C'X>^

lUK rUlM.ACH
stall or i'ontitry

NAMi: 01

I- A 11 1 i;k

niK TmM.M'K
01 • I\ri!HK

(Statf or I'oiinti \

MAIDI'.N NAMI
Ol' MOTIIHK

HIKTHI'I.AlH
ol- Mnr!!l-:K

( state or c'otiiili v!

^^

MEDICAL CERTIFICATE OF DEATH

DATH ()»• DHAIH \

ll 1 4

TQO \
(Year)

V5Al

(\

io.-,.d.

OiOri'ATlON

/sfMifrd /If Siiif l'i,i>iii"'>

(Month) (Day)

I HICRIUJV CI-RTII'V, That I atteniU-<l dci-cascd frnm
— ._— __^ ^ J^p -- — to :r— ric)0-

that I last saw h ■ alive on " Up

atid that death nrcurrcd, <ni the dati' -tated alxu-i-, .it
M. The CArSI'! t>l" DIlA fil \va>. as follows:

I ) r R A i" It ) N > 'e ll I X Mon ths I hns Hon rs

CoNTRim-ToRV aXv\,\.il^k "m^V-^.^k

^\!

DTRATION

l\ivs

Years Mouths

( SIGNED ) . Wurv-vXH; v . Mj LU, c

((\ p [1)0

ly/ct 5sH luoH (Addres<.)Ld\.e>xeM W I

Hours
M.D.

*

iW

Special information only l«r Hospitals, Insfitutions, Transients,
or Recent Residents, and persons dylnq dwdv from home.

) .,})

\ J, mill'

Diis

Till- \HovK sr\ ri:i) pkksonm. i'\k ihii xks aki- tkih to tmh

lil'.ST ol- MV KNt)WI,i:i)i'.H AND lUJ.HJ'

\,l,lt.sv; 1 L

kU^.d. J I

Former or
Usual Residence

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

How lonq at
Place of Death?

Days

I'LACK OI- mKIAI, OK KKMOVAI,

^lO^ '

DAX»'^«»f 111 lOAi. or KKMOVAI,

TQO ■

l9.ct :u

fAd.lrrss ini VnW^^fr>V '

AX<Xh,tu ^H, g.^'

■'■■■^"" TT . »np .k»..l<l he Rtatetl BXACTLY. PHYSICIANS should

N. B.— F.very I.em o( tn!or,.,».lon .houl.1 be ...r.fully .uppl,.d ^-^^Xtt^i''^^^^' "S^'-'-' ""'"-..Ion" .or p-r-
state CAUSE OF DEATH In pinin term., thnt it n.1.5 !■« P>-"l"!rly cia.sii c
.an. dylnft away from homo «houl<l be 4iven in .very in.tance.

D

I

WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD

Date Filed ,

REFER TO BACK OF CERTirtCATE FOR INSTRUCTIONS

llegistered ^'o, ^586

JIA; aS^ 100 "i

; Deputy Health Oflflcer

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco

Certificate of H)eatb

( tl. S. StanDarD )

1
PLACE OF DE ATH : — County of :x ^

si

Q

City of cUh^

r

No.

St

c

s

i

"and

I., Dist.; bet. — —

(IF DEATH OCCURS »WAV 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. /

^ ^ ,0

FULL NAME

^n^..,.n

•~v.\.u

L

CC'>'^\.

i ! \.\. \

PERSONAL AND STATISTICAL PARTICULARS

six /

loi ( >k

4-

i» \ ri; of I'.iK TH

4

MEDICAL CERTIFICATE OF DEATH

DATK C)l' DlvATII {f\

(Mouth)

I

IQO \

IDay) (Year)

\!<.nthl

\(,i.;

5 0

) '*•./ 1

(I);iv

M.itilh^

\ t-a 1

/'i? 1

\\ iix twij) OR r»i\ »>Kri.:i)

Wiitfin -iM'ial 1' - I'liat i' iiO

( 1

niKTIll'I, \('V.
(Stat* (II I'.iiinli \

namj: t)i

I ATHl'.K

niKIIIlM.ACK

<M' iaiiii:k

(Statf or i*i)uiitrv

MAini'.N* NAMK
c)I- MOTHKK

lUK inri.Aci-:

OJ- MOTHI'.K
(Statf ()! »."<)untry

^

jCYV

1 IIHREBV CliRTIF-V, That I attended (krcascd from

— ■ 190 to ~ IqO "

that 1 last saw h-:- alive on " 190

and that death occurred, on the date stated above, at
M. The CArSF-: Ol- DI^ATII was as follows

DTK AT ION Vrars

CONTKIIU'TORV

nr RAT ION rears

(SIGNED ) /X. '.^ . ^ ^

Mouths

Pay

Hours

otcrrATioN

/\f Mil fit III San I' I nil'

.'\ronihs

k Q

nivs

Hours

M.D.

l;a:1 li Kjo (Ad.iress) <L^4 U^^rucuXu La.i

Special information onl> tor HospUdls, InsHtutions, Transients,
or Recent Residents, and persons dving away from fiome.

) lii I

\r<'iitii'

Ihn

rm- AnovR stati'.d pkksonai, rAK'i'irfi.AKs ark TRrK T»» rin-:
liiCST oi'" MY KNowij.ix.H AM> iu;i,n:i"

(IiifoMiianl U

I)

J > V KA.L A£/Yw<ru- cx..'^ .

(A-ldrcss

Former or
Usual Residence

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

How long at
Place of Deatli ?

Davs

I'I,ACK OI- lU RIAI, i)R RI;M<)VAI,

LV A.C

I)ATi;<)!" Hi HiAL Of KKMOVAI,

0.ct 15 T9o'|

^

vCc

INDJCRTAKKK Ll

of inWm«tmn should be carefully supplied. AGE should be stated EXACTLY PHYSICIANS should
E OF DEATH in plain terms, that it m»j be properly classified. The Special Information for psr-

N. B. Every Item

state CAUSE

sons dying away from home should be ftiven in every instance.

D

^Vi'^miipir

WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD

n..,r l.f n ,;.h i n, - ^-^^i i.fclM , REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

Deputy Health Officer

Registered JS^o,

?358?

n

.<KAy<cX5

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco

Certificate of Beatb

PLACE OF DEATH: — County of O a.

City of ^^'ccw JXo.

:'^

\ vCt O

No.

St.; 3^ Dist; bet J O.^'Lex,

A

and

/ IF Dt*TH OCCURS *WAV FROM USUAL R E S I D E N C E G I VE FACTS CALLED FOR uAfOER SPECIAL INFORMATIj^N ^
V IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTE/ib OF STREET AND NUMBCH^ J

)

'U

FULL NAME

u

lJ^^^^K

~>

uwL ) V, wi, , A

PERSONAL AND STATISTICAL PARTICULARS

^i:\

i<ii<»k N

Hll

i

n \Ti: or ink ru

A< .!•;

V.

L:.j

MEDICAL CERTIFICATE OF DEATH

: 4 - ' I

C^

(Yfar>

v!T

ICX

M..!i!!i'

I):ivi

I Vi-ai )

n,!

W !!•( lU KI> I iK niN'oKi KP

|\\!U« in ^(Kial .It^is-'TKitiuii)

II! ^d

OUJK.C

d

HJK 111 1*1. \i'l-".

■ Stat' "T •'■.uiitiv

NAMI-: «»J
I \ Til IR

HIKTHPI.Ai 1-:
i^\^ I AIHKK
i Statt or t'liiuit! \

MAIIM-.N NAMK
(il M»)rilI-:K

BiK iiiri.Ai i:

Ot'* MnlllHK
(Stall or Cotinti v^

f I

I I Lc

CVO

\UwLcl^v

t

ill.

w

n

(Month) I Day)

I H i;k i;i'.N' (.liKTU'V, Tlial I aUcu<U-<l (U'«xastMl from

ct

^',€t ;^H

icp to ^ tAi c^n i<>o 1

that I last saw h-' alivr on Hp

and that death orciirretl, on the date statt-d above, at it '
M. The CAUSK OF DHATII was as follows:

V- A,... v^vCX,'

1 .. (XWl

Dl' RATION }\'ijrs

CONTRIIUTORV

UJ\J

M on tin

CU5

Ihns

tiU

DURATION )V.7r5

(SIGNED ) C ^

^ft)H(/lS

/h7V

4 . S -^

Hours
I /ours

M.D.

,d

occri'A rH>N

iiifii il' Sati /ninii^i-ii OW ) - <?

fS .1/-;;///.

Ih!\>

THK \mn-F sTMi-i) PKRSONAI, PAKTirr I.AKS AR K TRIK To OH-;
linST Ol- MV KN<)\VI,i:i)<".K AM) HMJIJ-

L

(In forma nt OX.<l\/<M.

(k. LcCYV.A^^^^^<^'»^-

X-Mro'is

rYs\XK.<.<i

ii..-t

K

H)n

fA.ldress) V^'h \)->..a\.u

Special information onl> for HospifdU. Instltlrtions, Transients,
or Recent Residents, dnd persons dviny dwdy from fjome.

Former or
Usual Residence

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

I'l.ACK (»1- HIRIXI. OR RKM«»\Af,

How lonq at
Place ol Dedtli ?

Days

1

<X vwCV-

I>Ari;of niKiAI, in RKMoVAI,

w ca- .-w

i -

rSDHRTAKKR ^R- U A^Ow^A, ^"^^^-j^

TOO .

A.lill^

a .. !• ^ AfiF -hauld be i^tateU EXACTLY. PHYSICIANS fihould

of information .hould be cnreVully supplied ^^^^^^^/^^^^^j^i^'Vh^ ..g ,., ,„formHtl.m" for pT-
E OF DEATH In plain terms, that it miiy be properly ciaHsmca. i n«s t*^

N. B.— Every Item

state CAUSE OF DEATH In p

Hons dying away from home should be given in every instance.

5

U,

WRITE PLAINLY WITH UNFADING INK —

!)(,lv F//rv/,liJ,ci:JGJ2A; %^

100\

THIS IS A PERMANENT RECORD

REFER TO BACK OF CERTinCATE FOR INSTRUCTIONS

2588

Re^istcrcfl JS'^o,

Deputy Health Officer

DEPARTMENT OF PUBLIC HEALTH^City and County of San Francisco

Certificate of Beatb

( tl. S. 5tanC»arD )
PLACE OF DEATH: — County

ofCW-YV 0 A.O^nA^^AJiXX)Gty of

CC'-^X) 0.\.CVA-

No.

w^^

I !(■

St.;

Dist.;bet.^^

hc^tLC

V

(

ir DEATH OCCURS AW
IF DtATH OCCURR

u.Y rROM USUAL RESIDENCE GIVE FACTS CALLED FOR UNDER
ED ,N A HOSR.TAL OR INSTITUTION GIVE ITS NAME INSTEAD OF

SPECIAL IN
STREET AND

and ^i^l<^

FORMATION" \
NUMBER. /

.^ ^ >

FULL NAME

'W

m

jx.i 0 l\.^^\

PERSONAL AND STATISTICAL PARTICULARS

I

i> A ri; < »r luu rii

iDct

\1..nth'

A<,H

I

^»

f^

) ■(■'(; I

(I):iV

M,.uih'.

( Viar)

/',/

MEDICAL CERTIFICATE OF DEATH

vL'cfc

i Dav

IQO \

(Year)

0\

(Month)
I III;R1:HV CI;RTII-V, That I altciidfl <lt'«<.ase.l from

1()0

SIN* .I.l-: MARK 11- 1)
WilinU i:n OK IHX' >I'i II>
\\ ! it( ill v(»,iai tit -.:s-'ii:.t i- ml

itiKrm'i.An-

I Stati- I ii C'tiuut I >

.1) CcLtr

\xr

NAMi: «>F

I A rm-.R

HIKTm'l,A*K

oi lArm-.K

(Slatr lit Oouiitrv'

M Mill N NAMi:
Ol- MOIIII.R

lUKTm't.At'K
ni- Morm'.R
(state or Country*

(H iTl'A'riON

C>aLLa >

^

AV-/</^(/ /'/ Sni! I'tatu

)'r>ii

M,,>itfr

Ihi

ni-,ST OI MV KNMUl.l.lX.I-. AM) iu-.i,n.i
(infonnant OaA^cX^-^ IUo^^C^-

that I last saw h -■■'■ aUvt- on *^ ^'P

an.l tliat <U-atli ncrurrc.l, on the date ^tatc-.l above, at li I
M. Tlic CAl'SI': Ol' Di; ATII was as follows:

CYV.,

CONTKIIU TORY

Mtnilhs Pays /fours

|>r RATION ^ >''</'v

Miiuths

PilXs

//on

IS

(Signed)

k:.\c

4

L'i i()o'

f

Vl.lrr.s) ^l^a \J|lui4.c^>A ol

M.D.

\

SPECIAL INFORMATION only for Hospitals, Insntutlons. Transients,
or Recent Residents, and persons dyintj dv*a> from home.

Former w
Usual Residence

When was disease r onfrar ted.
If not at place of death?

How tonq at
f»lareof Death?

Days

l-I.ACK <)|. HfKIAL OK KI-MoVAI.

I>AT1% 'it Hi I'IAI or Rl-tMoVAI,

(

r, .

INDHRTAKKR ^ 'tX ^"^C - ■

N. B.-

■^p.i^— i^-^"^""^"^""^^""""^"'^"'^^"'^"^*^^"^^"^^'^"'^"''"'^ I Km t t I FXACTLY PHYSICIANS nhould

-Bvcry ...n. ot l,.*o.,n-.ln„ .hou... he c-afuM, .uppl..d. ^;^;^;:^„„»J. Th; •S.-co.! i.fa.,n...o„" lor p.r-
. * r AllSF OF OrATH In pl«in terms, thot It mii* i»e Pf-"!* J'

5

t-.

f II. alth »•■ No

WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

2589

USlV Ci,

700 '{

Registered JS^o,

A

\A.*

! Deputy Health Officer

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco

^

Certificate of 2)eath

( tl. S. StanDarD )

PLACE OF DEATH:— County oi^O^-,-\j J,V<x^v<^cv City of Oa/vv

No. O.J. 0 Crvc ^ vcL L

S^Y^O^ LL^\/vCi. s

St.;

DEI

STI-

e

Dist.; bet.

and

4 »~L iiciiAi er Qinr NCE nivE facts called for under special information \

FULL NAME

i

\

L<.;

Va,';.^;

PERSONAL AND STATISTICAL PARTICULARS

Owii

u

1) \ I]-: < »! HI urn

A».i-;

li^ct

M..!ith

} ■,■,?

il):iv

Mnulllf

ov (^

(V.ar)

ATI

mNT.i,F. MAK«n:n
wiix t\\ i; i> ' »K i)'\' i!< 1 i; I)

(Wiitcin ^iKJiil di -iriiiitKiu)

niKPiir!, \0K

(Stat» or I'oiinti y

lAin ) R

niKlIllM.AOK
Ol- I AIHKK
(Slatf i»r Cniiiitry

MAiniN NAMK
Ol" M«)'lin:R

lUK'I'HIM.All-;

<»»■ M()rni':K

I state iir rinuitrv

CJ/CL^ru vjA^CU ,

e-'-"

OCCri'ATION

Rfsi,lfd III San /'inn, isr,}

)'i\i ,

Mnlltll'

Pin.

TliHAn()VHSTATHnPKK^ON^. rAHT,rr.,AHSAKKTKrH T< . THH
BEST OF MY KNO\VFi:i)<.K AND nil.n.J

(Informal

VjflfXxXXA^

(Ad.m... aSOO s^^lL^^^OlBt

MEDICAL CERTIFICATE OF DEATH

DATH Ol' Dl'.ATH

et..

(Month)

Day)

rgo i

(Year)

I II I;R I'lI'.V Ci;kTII"V, That I attcii<lcd «UH-ease«l from
IC 190'* to ^/cIj ^S. KpH

that I last saw lit.- ■» alive oti w wu A! 190 :

and that (Uath occurred, on the <late stated above, at '
M. The CAl'Sh: OJ' DI^ATfl >vas as follows:

Ccuvti,^<x.<i ^'

^v-c^y^

DTK AT I ON JVrt'-?

CONTRIBl'TORV

Months Days 1-^ Hours

Years

Mouths Pays

ft

(SIGI

flouts

M.D.

Dl'RATION ^ i\, K ^

INED) 3ll\ 3. N [WvAiA^'.

il'.tt XS upH (Address) 9.500 JAlJUweXxsJl

SPECIAL INFORMATION only '"^ Hospitals, Institutions, Transleiifs,
or Recent Residents, and persons dying away from home.

Former or
Usual Residence

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

How long at
Place of Death?

Days

ri^ACK OK IHKIAI. OK RJlMoVAI,

i

\)axL

DATl". of ISf KiAi, «»r REMOVAIy

lytJt x^- 1901

,...„.,..,.l ikALu, V %

(Address q(p*I?^

^>\1

,, . Tpp .houid be stated EXACTLY. PHYSICIANS should
I,. B.— Bve.y Item of Information .hould be carefully euppUed. J^^^J^Z.^.m.^. The •'Special Information" for per-
.tflte CAUSE OF DEATH In plain term., that It may ne pru|,«. ,
:". d^faVaw., from hon,. .hould b. ftlv.n In .v.r, In...nc..

D

U,

!li..i'.l 1

WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD

,f,,..nh rvo. i.^?i^n^>'^'.- REFER TO BACK OF CERTIPrCATE FOR INSTRUCTIONS

2590

Registered J\'*o.

^ WO

Deputy Health Qflficer

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco

PLACE OF

Certificate of "Seatb

( "U. S. StanOarO )
DEATH: — County of 0<Xax^^*^^^«-^^<^^^'»-^^ City of CJO.'Yxj J.N.O. .

Ne

^ U - vj . v'

C^^w^c^v

r»

V.\.-v^A

St4

Dist.: bet*

and

, „ liciiAi QTCinrNCE: civr facts called for under "special information" "\

( " rr".;ATH"oCc"u%r:."rHotp"T'i:: o"r"nSt'.?J;^o';"c.VE .TS name instead OF STREET AND NUMBER. )

FULL NAME

Q

crlhixt fc (X >->

\u

DAT!' < t! r.lK Til

PERSONAL AND STATISTICAL PARTICULARS

L'

axkfc

Dav

\r. 1-;

)'>'dt

WIIx i\\ I'D < >k I>'i\( tKl'KI)
(Wilt'- in ^iKial (Usi^»n:ilii)ii)

lURTIllM.XiM',
I Stntt (ir t'ountiy

NANtl" <>l'
lAIUl'.K

oi- 1'ATiii<:k

(Stair or Ciiimtry)

MAIDIIN NAMl'.
<i| Mo'lMIKK

lURTHI'l.AOl-;
f»J" Mo'l'MHK
(Stall- or t."(HiTUty

<X>-v ^

f

^S

.■■■•r)

/J,7 1,

■^VT

OCCri'ATION

Rfsiifed in >'<?»/ I'lmtiisrit

)■/■<//

M nil tin

]h!\

TnKAm,VRSTATKI>PKKSnNA, rAKTUM^.AKSAKHTKlI-r.) THH

^JTLcxXA^i^^C^Uw

1500 \^^lJyy^M^x

MEDICAL CERTIFICATE OF DEATH

DATK OI' DKAPH

(Month)

%

(Day)

!Vear>

I Ill'RI'HV (.I'.RTIl'V, That [ atteiKkil (leoease<l from
v^^rt ID 190 H to w/cl - Kp .

tliat I last saw h •■ ' '\ alive on w- Ct I90 ■

and that tlcath occurred, 011 the date stated above, at • I
Q M The CArSfv Ol-' DIIATII was as follows:

Ua.A-<i^'-<^

C C ■< rw^C

1)1' RAT ION Ycani

CoNTRIl'd'ToRV

Years

Mouths

Days

Hours

Mouths

DT RAT ION

( SIGNED ) . mII d. M lloA^

11/ ct i<)o'i r.\ddr>-^s) '. ■

Pavs

\^t\.^ - w

I lours

M.D.

t

SPECIAL INFORMATION onl> 'or Hosplldls, Institutions, Transients,
or Recent Residents, and persons dying away from home.

Former or
Usual Residence

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

How lonq iX
Flare of Death?

Days

I> All. m:' I'.- I'lAi, or KICMOVAI,

C ct V. 190 t

PJ,ACR f)J* niKIAI. OK KKMo\AI,

I-NIH-KTAKKR XUXUjL ^ d^l CC|yCC-v

^,„^^,^„iBi^^^^Bi^«^ii^— i^— "i^"^"^^"^^^"^"^"^^^"^"^""^" .J EXACTLY PHYSICIANS should

IN. B.— Every ...n, o« .„.„rn,«.lon .hould be c«r..uM, -upplted ^^^^^'I.^J^^J, The "Spec... Inforn....on" »or per-
state CAUSE OF DEATH In plain term., that It may ."" P' ^
«n. dyin* -w., from home .hould be given in .very .n.t.nce.

9
^

«o'

^)

RITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

w

Hnanl uf Ihiilth I- Nu i . ^-^^^i) l!5c I' Co

Reiisteved JSI^o,

o^i^Y

h^K^

L,^^ 1l^)^ Deputy H..-.th Officer

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco

Certificate of 2)eatb

( "U. S. StanDarD )

i

PLACE OF DEATH:— County of "^ CX.^ J ■vcxv.t.a- ^Gty of ^Kx.y^ . /va.->^

^

Dist.; bet. ?b C. A ' ^^ ^ •:..c;v \. and V.* ^ Aa < --

■ •(•iiiti or c I nPMr r r ivr FACTS CALLED POR UNDER SPECIAL INroRMATlOW \ \

( " r,"o;".,°„"occ"u%;"v;."r»="»^pr.t ir:.i^r.5^.or..T^\ name ,»sr„o o- ..«.. .»» nu-.c. ; j

FULL NAME

Ql^P

\w,.^\.*AA^;

t

PERSONAL AND STATISTICAL PARTICULARS

sKx AA , v:^'i.">i^

11

LUa.C

H

\<.i-:

V.ci

M,nii/>:

'\ tar

Ih!

SINi.I.K MAKUn I>

\vin«>\vi-:i> nK i)i\< >k4 j:i)

U'litcin -(K-ial .1( -ivtiali'inl

lUKTIlTI.Xri: A /-x f\^ ('7^,

(State ..r CuimtiN ' I \a f m

\ \ Nt » < U

I- A in !:k

HiK'rm'i.Ai'K

«)l- lATHl-.R

(St:it< or iNmiiti \-

MAI!)1-:N NAM).

( » I' M ( )'r I IK K

lUK'rni'i.AOK

oj- MoTUHR
(state or Country

L o-cLc^

%,

),',;/

1/ .,/'//

//.,'

OCCri'ATION \

HHST Ol- MV KNOWM-.IM.h AM) Hl,I-il »

U J L

r^iifrd III S,nf / lUii.'-xi c^*-

v'A-q ■

MEDICAL CERTIFICATE OF DEATH

DATK Ol- I)1:a TH

A

'Month)

'Day)

(Yt-ar)

Wdu

I ni';RI':rA' CI:RTII'V, That I atUMuUa «kc eased from

s:^n:ju • . luo to w \:.u. o^r? 190S

that I last saw h A' alive on -^ - -^'^ ifpt

aii.l that death occurred, on the <late stateil ahove, at ' ■
M. The CAISE OF DI^ATH was as foll.nvs

Lft /\Ar>^OrvA.xxJL J n

\_i.

DTK AT ION >■'<?/?

CONTRirdToRV

Moulin

Pax

Hours

Ycays Mi>>iths

NED ) Ldctk ^ ■ li A„M.

Dl* RAT ION
(SIG

e

Kp I

f

Address) Wh I

l^ays lloui s

M.D.

iaL*,ix.c\,(A Jt

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

former or
tsual Residence

When was disease rontrac ted,
If not at place of death ?

How lonq at
Place of Death ?

Days

I'l ACK ol- nCKIAI. <»R RKM<t\ AI,

c^.lD,

0 ^'

I)\Ti:uf Mt KlAl, or RKMoVAI.

T90H

^<k. ^i

r.NDl.KTAKKR

Ad.lP

UA^

UCi^i-^^ *^ *-

^„^^^^^i— «^— ^^^■^'■'^'^■'"■"■"■■"^" IH h* t ted FXACTLY PHYSICIANS nhould

of l„form«.ion •houid be carefully -PP»-f; „t?p^eHr"l -stifled! TM " Special I„for,„«tla„" for pr-
F OF DEATH In plain terms, that it ma> he proper.y

:SH"xrJ'h::::;Hou. .e ...n <

r*

f

r

WRITE PLAINLY WITH UNFADING INK —

.^,1 ,,f n.a!t]i rv.^ ,■ **^.5:^>i»^''*-"

4

lOO'i

THIS IS A PERMANENT RECORD

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

DEPARTMENT Ot PUBLIC HEALTH=City and County of San Francisco

Certificate of Death

{ tl. 5. 5tan^ar^ )

PLACE OF DEATH:-County of '^x.v " Aa .v... City of Oa.^v J\<x...c.^

CPfc. ^'C^

wi ^'^M

i\

St4

Dist.; bet.

and

— )

FROM USUAL RESIDENCE G.vt r*CTS called r

rOR UNDER "sPECI*t INFORMATION ■ N
NSTEAD OF STREET AND NUMBER. /

^ if..

FULL NAME

(^,

PERSONAL AND STATISTICAL PARTICULARS

4

H 1 LCLtX
i»Ari'. or uiKi'ii

,^WH

M.mlh'

M.v:

ipc

Day

M ,>illi

ar)

/>■/ IS

WllHtUHDcm I>!\ oKi i:i) j \

\\l !tf 111 HI KM a I

(Htate cir i<>untt\

NAM I", n|-
lAI Ill.K

{^V iai'h»:h

(Statf i>r (.'oiiiiti \

MAini'N NXMi;
(»l- MoT Ill.K

lUR IHIM.ACK
K\\: MOTIIKK
(State or i"oiiiiti \ '

ot^tVC'-

MEDICAL CERTIFICATE OF DEATH

DATE ol- 1>!:ATH '^

iVear)

(Month) ''>•'>■'

] ni';K!':BV Cl RTII'V. That I attenao.l .UitmsimI from

— — - — - — 190 — —

-~ 190

-■■■ . — I9O to

that I last saw h t:— alive 011 -

au.l that cUath occurrcl. on tin- .late -tatc-.l above, at
M. The CAI'SI-: ()1'\I)1':A ril wa^ as follows

'^c^*-^
^ ,,

\ . ,

CONTRIIUTORV

Mofi/hs

Diiy

Hants

//(>nrs

'-^/

KryiJfit III S,ni /'«'

) ,,.'<

M.<i>tli'

/i,,M

.PII^^H,>VHSTATK^PKKS..^A..^KT..^,.U<.AK^,TH^K TO TUH
HKST OF MV KNOWI.I.IH.K A^" Hl.I.IM

(Infoitu.itit

0 ),CX. c

0'?

\<Mn*'«

,,r RATION >v<^/-^ ^'^^"'^^ ^ ^'*'''

(SIGNED' J (Is UO cUX<:c%\.cL M.D.

v^ ^

^.(E.WLL.vA.

aa.

SPECIAL INFORMATION only lor Hospitals, Institutilrns. Ir.nsifRts.
or Recent Residents, and persons dyinii away trom home.

Former or f

Usual Residence

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

How lofl4 at
Place of Death ?

D<iys

pi.ACK Ol- in KiAi. <»K ki;m..vai.

I

KXl'I'if I'.'HIAI. or KHM«)VAI,

IQO

'U \.i

^ I rVACTlY PHYSICIANS nhould

I

Bonnl ..f 111 nUh I- N" ! =

WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD

^,S-=;v^,,^,,,.„ REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

Dale Fi/<''/.\i'<:XM>^i>v 3.5"

^ i

190 H
Deputy Health Officer

PiPi^lstercd J^^o,

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco

Cettificate of S)eatb

PLACE OF DEATH: — County

0 [\ !

( "a. 5. Stan^ar^ )

J? on A ^

'..-U

^Ne.

UhulWx^

a

St.;

Dist.; bet.-

and

TH OCCuIrS away F
CATH OCCURRED I

'."ri^r.t :-^?'?;^"u'=.^rj,v7"r«-«" r,.".ri: s?;^=;-.'o'r:e-;r ■ )

FULL NAME

"^l-X

PERSONAL AND STATISTICAL PARTICULARS

\ COI.OR '\ "\

h

^syxXA Ktc

a.^.

I 1

i>\ ri: tti I'lK I'H

I Mi.iitlil

A' .1-;

r.-.f

(Day)

)/ ,nt/n

% i-a!

/^<n

iWiitf in -<" 111 -i' -i/ii.HHiii)

MEDICAL CERTIFICATE OF DEATH

DA 11-: «>K DHATII j, N

i:^

n

igo .

(Ytai)

(Munth) '»'*'V>

I IlI-RI'iHV Cl'.RTIFV, That I attcii.U'.l <U-ivaHtMl from

iQct IH 190 ^t to ii^^ 3^a icpH

that I last saw li ^.>. alive on ^ ^t .^3 190 H

au.l that .It-ath occurred, on the .late stated above, at

M The CAISI- Ol- DlCATi! was as follows:

\

HIK rHJ'I. Ni'l'.

! Sf:i!t .It I*. Hint! N

N \Nf 1-; 01

I AT II i:r

lUR rniM.Ai H

( stall or i'tiunti V

maii»i;n namh

Ol- MoTHl'.R

inKTiiri.AiK

t»| MOTIII'.K
(Slate or OcHiiitryl

oiit r\ rioN

Kr^uU'd III Sun / i,nn ii<>

WCUw

N \

! V,/ /

.\/nnf/n

/ hi I

^^^ii^^y^i^^^ ""■■■

(Iiift»! tiiatit

■.:%.

.„„„.,.„ ^it

DTK Alio N >Vv//.?

CONTRinrTORV

Man tin '■^ /^tns

Hours

nr RATION
(SIGNED)

Yi'ius

Months

na\

^Vl

,<X-V.CC

1

0 .^b :X^ ,.,o-, (A,Mr...s^A^Vutivll.-

/fours
M.D.

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

Former or
Usual Residence

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

How lonq at
Place of Death ?

Days

n.ACH <>|- in KIAI. OK KKM«.VAI,

I»)Ji:<>; UiKiAi, <»r RKMOVAI,

Y>\.

^^^^^.^__^— jj— ^^^— —— ^f^^— '^^^ . pvAcxLY PHYSICIANS nhoulfi

state CAUSE OF DfcA inn p ^^ ^^^^^ i„«t«ncc.

•f>n« dying away from home nhouiu oe gi

I

m-

\

I

WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

Bonr.l ..f He;. 1th K No i; "^■f^^^O) lU<v:l* C

190H

Registered JS^o.

2594

uju^ K-. VH\ Deputy Hea!th Officer

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco

Certificate of Beatb

( H. S. StanDarD )

Jl

m

PLACE OF DEATH: — County of '<x-*v ^ \o. ^^c^. - City of ^^ Ov 0

A.Ow >XC^^

rNo. UH ... .'_.. St.; 5 Dist.;bet. - ' ' - and JlUac^^C

(ir DCATM OCCUBS AWAY FROM USUAL RESIDENCE GIVE FACTS CALLED FOR UNDER "SPECIAL INFORMATION ' \
IF DEATH OCCURRED IN A HOSPITAL Oh INSTITUTION GIVE ITS NAME INSTEAD Sr STREET AND NUMBER. /

A

FULL NAME Ml

'1

La'^^M- ^^-

k.

\

si:\

PERSONAL AND STATISTICAL PARTICULARS

^ 1 1'

LL

DA ii; or r.iK in

0 ^

iMoiithM

M.V.

1 ^N

iDav)

\l,itilfn

car)

» ca

A/'

s!\< .1,1-: M \K l< 11 11

\\ IlXtWi: II OK IMVt iK* 1 I)

(Writfin >-<Mi:il lit -.i',> ii.it :> i", )

X

cL<rUc^

niKTHl'l. \i J-

f Stntt lit < ' unit I %

FA 111 KK

BIU I'lMM.Ai »■;

oi- 1 Arm: K

(Stall or Count!

MAn»i:N N\Mi-:

<)1- MOTHKK

lURTHlM.ACl-:
<)»• MOTHKK
(Statt or I'otuitry

'Xc^t^i\A.a >

n

\J<y\J^:^ '.VVCL

\

MEDICAL CERTIFICATE OF DEATH

DATK OF DKATIl

m

(Day^

rgo \

(Year>

I 111":R1';P.V CI;RTII-V, That_ I atttu.K.l .Ur.ascl frf>iu
.. LL\^*wC\ L 190'J to V <Lt '-s\_ 190 '^

that I last saw li -*. alive <»ti -^ CU .-. \ i(p

an<l that death octurreil, mi the date stated aV)uve, at i^i- ^'-i
. M. The CAISI-: OI- 1)|;ATH wis as foIUnvs:

I)rR.\TI<)N 1 }V<7/v

et>NTkiiuT(>kV

Mouths

Ihxx

I lours

DTRATIoN

)\ays

(SIGNED )

^1

.Uou/Z/s

/></1S

//ours
M.D.

+

AAj^L^lX^^XX

(Hcn-A rioN

A'r^iiftif in Sill/ /'i ,; If, '>'•■<

I

1/,,;//^.

/>,.

THK AHOVK STXTI'D I'KH S( in \ I. r\K rUTI.AKS \RV. TKl H To IIIH

iIkst «)i'" MN KNOW i,i:i)( .1-; AND Hi:i,ii:i-'

(ItifoTumiit

\.l.lr.

I5ii ^

IxA-C*. k

1 1)0

r Address) 1 iq- 10 li

Special information cly for Hospitdls, Institulions, Transknts,
or Recent Residents, and persons dying d¥,i\ from home.

Former or
Usual Residence

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

HoH tonq at
Place of Death ?

Days

PI.ACH 01* niKIAI, oK HI:MoVAI, j DATK of Ht kiai or KI:MoVAI,
CrA.- VS^NA. I ^ ^' ^*^ T90^

'W Cvo-^<i.

INDKKTAKKK OCt>>^C^\^^

\

Xr

A<M,-ss IXC^l Q lf\\.^^A^ >\. H

.hould he c«r«fulUv supplied. AGB should be Mated BX4CTLY PHYSICIANS .hould
„ plain terms, that Jt may he properly wlassiiricd. The Specl la»orm»t.on for |wr-

N. B. Rvery item of Information

•tate CAUSE OF DEATH i

«Ofi« dying away from home nhould be given in every instance.

I
i

WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

B4,.i-.l of ll.;ilth I- N.< : '^'C.Hi.^'- ''"^'' '^""

I)(f/<' F/h'f/ ,\^' ^

X5

190'i

Bcgistcfed J\^o.

2595

k^cn^A.' ' ■ ^^M Deputy Health Officer

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco

Certificate of 2)eatb

( tl. S. StanDarC> )

J? QD ^ m

PLACE OF DEATH: — County of Oo<jyyj 0 A,<x ^m-^^^ <^' City of Cjcu>v JA^o.^ v ^.v. ^

No. ^\H - ': Xl. St.; '' Dist.;bct. ub CrwiXN^'d and JCTV^ ' .-

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

FULL NAME

11 V

LLvtru

x.u\

•^! \

^

PERSONAL AND STATISTICAL PARTICULARS

DA IT of I'.lRlll

\>.

Ll

MEDICAL CERTIFICATE OF DEATH

DATH <)!• DKATH \

^ ■ ct X\

(Moiilli)

Dav

igo \

(Vt-ar)

• Mi. ml)

M.r.

)'ra >

lUav)

M.iiiih^

fV.Tir)

I>av.s

u iix »u i:i> mk f)ivi >Ri }■:!>

iWiittiii -.(H-ial ill ><iL'ti;it :> 111)

X>^^

L

lUKTHIM.AOH

(Stntf or Coiinti V

\\Nn-: «»i
}'A riii'K

HlK'lHIM.Ari-:
<H' I Aini-'K

• St.lti III l"ol1lltl V

M \II)1:N NAM)

Ml- Morm; R

lUR'niPUAlK

«»i m(»i*hi:r

( Stati or I'ounttA

ocrri'A'iioN

<X^

\j

Xo.

i

CX-ry%^ ^^ \K.\

r

I

XJ

I HIvRHnV CI'RTII'V, That I atleiKk-.l (k-tvascd frnm

Al' at I i9o3 to W ^^ -'i up

that I last saw h alive on ' ' I90

and that death orcurred, 011 the date stated ahnve, at
.'. M. The CAISI-: Ol 1)I;ATI1 was as follows:

1)1' RAT ION .K Years
CoNTRlIU'TOKV

DIRATION ^ )\ius

A

Moulin

Pay

Hour

.'S rout /is

Pa

vs

^^^'W i

1

\

AVw,/^,/ it> Siii' r'niiiif'i,)

);„i

yj.nlth^

/',/)-

THJ- Mi.iVKSTXTJ.:nCKKS..NAl. I'XRTU't 1;^K•^AR1•:TR1 H T< > HIH
jij:ST <)1" MV KN< »\\ I.l-.IX", K AM) HhldH^

'Iiif'Hinant

(Signed) ,

il
i I t >*

Hours
M.D.

(Address) IDH'ia.' b Uv .it

Special information only for Hospitals, institutions, Transifrts,
or Recent Residents, and persons dyinq a**a> from tiome.

Former or

Usual Residence

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

Now lonq at
Ptareof Death?

Days

ri 4CK <>i' lURiAi, OR ri:movai, I i>\r»:<.t iti hi.^i 01 kkmov.ai.

"■■"■■"" ' , „ ,. , Ai^p ■Ho, III ha atAted EXACTLY. PHYSICIANS should

N. B.— Every Item of lnform«tlon should b. cnre^'uMy -ppi.ed ^^;^;^l^'''^l^^^X^%^^ I„form«tla„- for pr-

•tate CAUSE OF DEATH In ploln terms, thot it may he propi^rly wlassifiea. \

«on« dying ow«y from home should he given In every Instance.

6S

P-

rJ

■^

^

WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD

l!.>:ir.l .,f II. nllh J- No \^ T^^^^y^^j V.ScV C',

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

I)(f

fr /v/r^/,lycfcKHl>v %S

1f)0\

Regisfcj'ed J\''o,

25^ >^^

D6

trU.^<N

S ' / s-

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco

.

Certificate of H)eatb

( "a. S. Stan^ar^ )

\

No.

PLACE OF DEATH: — County ofO<X^-v. Vex >vc
-» vet ^\j ^ ^- i> v^ ' ^- v-t. a. I . St.;

,L ~L City of '^^^"^^^ J .VCL.^va^<i.ci

"and

^^^ _ _ _ . . _.., — - Dist.;bct.-

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

;n

FULL NAME

CL^\,

\\\^./'

s I-, \

PERSONAL AND STATISTICAL PARTICULARS

\\

DAIi: <»I lUKlll A

\' .!•:

\; nthi

15

inav)

l/.,./M>

k t-;

■ar)

r>a%.

SiNC.i.l- MAKKIl'.n

\\ IPi >\\ i;i» t>K I»I\(>K( HU

(\\ tit' ill ^u.ial ill -;yii.niiiii)

CCicrL<.^<.(^

lUR Illl'I. \*'l'

I Stall iiT I '.>!lllt I \

\ A 1 1 1 >• K

HIK IIIIM.AiK
«)l- I Al'in-K
(Statt 111 ri>niit!\

MAIDI-.N NAMl
CH- MOTin.K

HIK Till' I.AC H
iH MdTllHk
(State nr Codliti %

orcii'ATioN

Kf!.iiird 1)1 S,ni /'urn,

^JU^^-Y^CK

) I ii I

M.infln

l>.

THHA1M>VKSTXTKnPKK.ONAl rAKT.rtM XK.AKKTKtKTn TUK
niCST or ,MV KNoWi.I.lM.K AND l?i-,Ml.l

(liifnrniaiit

^-^ XSjXY\j'Ouy\j

\ 5-^Vh-^.

( Aililu vs

MEDICAL CERTIFICATE OF DEATH

I>ATK 01-" nHATH .. N

(M()iith>

I>:»v)

(Vcari

I Ill*'Rl''nY C1;RTII''V. riiat I iittcinU-.l deceased from

IgO 1 tn 'W'S„ V > i. up N

that I last saw It .. ' alive on - ' • up

and that dt-atli orcnrrctl, on tlic date stated alxnc. at I 0
LI M The CAl'SP; OI- DI-ATFI was as follows:

^ /^ ' '- ^

[ ^ *

nr RAT ION )'iafs

CONTRIIUTORN ^^

w<r^

J)av

Hours

">vL.^ X*^

♦ \

DIRATION
(SIGNED )

■Cfc *^'i rqo

Years M,uitln

navs

K

■+ <1 '1,

^

HoHt s

M.D.

SPECIAL Information <»nl> 'o^ Hospitals. InstltuHons, TranslfBts,
or Recent Residents, and persons dyinq Afii) from home.

former or
Usual Residence

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

im '*Um,' >'\ri.

Now lonq at
Place of Death 7

kys

D.XTHof nrKtAi, or RKMOVAI.

U-Ct %k 190H

I'l \CK 01/ lUKIAI, <>K ki;M<>VAI

— ""^ TT AnF «hould be stateil RXACTLY. PHYSICIANS should

jS. B.— Bvcry Item o? l„Vorn,«t1on shoul.l be ^"'•"^"'•y f^^^'J^t properly classified. The "Special Information" for pr-
state CAUSE OF DEATH In plain terms, that .t may be PJ«P«'-'y
««ns dying aw.y from home -hould be given In .vry instance.

il

WRITE PLAINLY WITH UNFADING INK —

it n<:iUli S- No iv -^^^-^i^JlUS:!' Co

THIS IS A PERMANENT RECORD

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

I)(ifi> Filed, ii'/::±.cr4-i^u V^

100\

Eegistei'ed J\i''o.

an

97

DEPARTMENT OF PUBLIC HEALTII=City and County of San Francisco

^

Certificate of Bcatb

( XX. S. StanDarD )

PLACE OF DEATH: — County of '^ cx^-v o A/cx^ > v tv^ c^ c< City of '^ vv ' vc^^x^r< o -

j(

No.

'I^ A<\-\vao..

St.; 5^ Dist.; bet.

\\tL

and

in t \

)

/ ,, OI.TH occu.s .w., fRO» USUAL BEsTdENCEGive "''"'\%%° ■■°"„7°" _f "^i'i '^'^^^^^

I IF Dt.TH OCCURBf D IN • HOSPIT.L OB INSTITUTION OlVt ITS NAME lNSTt»0 Or STRtET «ND NUMBER. /

^ t

FULL NAME ' ^^^ La x- <

L

\-4

JUJiKA.Ly\j

S I-. \

PERSONAL AND STATISTICAL PARTICULARS

I C<)I.<»R X

■i\\

LL

1) \ I'l: OF- UIK IH

A< .H

Miinth

S ,

Da VI

M,»itJi^

'1 '^ f-
1 Year)

Pa

^!N<', I.i:. MARK IK I).

W ll>o\Vi:i> Ok DlVORi):!)

\\?!t(iii ^iK'ial ill -.iLMiati'inl

lUKTIU'I. \ci:

iStati- '>! r.iiiiiti %

ns

w rv

, t V^A.V,^w

NAMV ol
lATin K

HIRTHIM.ACK
Ol 1 AIHKR
(Statf or (."ountry

MAIDKN NAMH
(»!• MOTUHR

HIK rill'UACK
OF MoTllHK

(Statt or v'imtitrv)

OCCri'ATION

^v^v

Ic

d^u^cLc/w

-CC

I

A C )

0

CjMMxLi/

•yx)

/hi\>

run AHOVK STVI-K.) '"HH-^NA, rAKT|Cr, XK. ARK TKrK To THK
HKST t)I- MV KXoWlJ.lx.K AM' HI.LH.l-

Ax.'

(Month)

(W-ar)

MEDICAL CERTIFICATE OF DEATH
DATE OF UKATII

(Day)
I Ill'lRICBV ClvRTII-V, That I alteiKlv.l dtrcased from

~.-,_::,j,.— , :-.■-■ I9O tfl * IQO "~

that r last saw h alivt- oti - T<P

ami that death Dccurretl, on the date stated above, at t^
tX M. The CAT SIC Ol" DllATll was as follows:

Ldhi^^^^^^O^ Jxy^C.Li..C. sJ,CX.vv^i^v<rvvA
DIRATION )'{ars A/o/Z/rs' Days I/outs

CONTRIIUTORV

DTRATION

Vi'ius ^ Months

^ 'is \V

( SIGNED ) ^\j^yjlx) J Ad. Uu

ly/tfc Q^H iQoi. ( Address) UX(r%>wi\^

/^(7VS
OUAVCL

flout S

M.D.

SPECIAL INFORMATION only '«r Hospitals, Instrtunons, TraRsifRts,
or Recent Residents, and persons dying away from home.

Former or
Usual Residence

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

How lonq at
Rare of Death?

Days

I'l.ACK OK lU KIAI. OR RKM<»V\I. DXX!:-; H'HiAf m RKMOVAI,

■Xl.KRTAKKK ^ ^1. ^Xtx^AX^^

190 S

■^ p K I I h t itecl BXACTLY. PHYSICIANS should
of inforniHtion .hould be carefully supplSed. ^*^^ l!^"!'. .l^j" The "Special Informnfion" for p*P-
E OF DEATH In plain terms, that It may be properly Ua^.tled.

N. B.— Every Item

!•,, cl .,f n. :iltli 1- N')

WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD

^•f'^^nfkVCn REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

Jteghte/'cd A^o,

V/M<. Deputy Health Officer

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

i

I

I

a
f

i

(Tevtificate of Bcatb

( XX, S. StanDarD )
PLACE OF DEATH: — County ofOa.^\. 3 Iux.^cv.n co Gty of OxX'>v. J.Va.>^.cv^ cc

n A

Na

St.;

Dist.; bet.

^nXat-nxJ^M and JLiCCviAA^

vl V, \„\^ W N^-^Y "- ,.eii«l orfSinrNCE Givr FACTS C*tLED rOH UNDtf* SPECIAL r^NFORMATION- \ A

FULL NAME

T

^YV^

La-^.'...o VJLcuac^/

d.

PERSONAL AND STATISTICAL PARTICULARS

>-J.\

1

ri»I,< >K

I» \ ! i: < >I 1! IK I'll

At .K

iDct

I M.itith

>-lNi.I,1' MAKHIl I»
WinnWKl) <»K 1)I\ i »RrKn
iWiittin -;<Hi:il ih'-is-'tiat n iii)

niRTIUM.AOK
(Statt .'T '.Miiittvi

t l>av

M,»,th>

( ^ tan

Pa vs

h\K(\\''

(^

MEDICAL CERTIFICATE OF DEATH

DATK Ol- 1)1:ATH a

(Month) • !>;«>•' ''*■«'•"■'

I lllU-iMBV C1;KT11-V, Ihat I altciKkMl <UTertsc(l from

ij^A± 1 S 190 H to ii).€t -XS TCP H

that I last saw li

alive on b d ^3

itp

an.l that «kath occurred, on the date state.l above, at \ ''
M. The CAl'SI*: OV DICAI'M was as follows:

nTv 1

X

A^C <.

Lu-

~i

N \MH t)l
lATHKR

lUKTlllM.ArK
()! lArin-.K
(Stiiti lit rniintry

MAIIU-N NAMi:

oi Morin'.K

HIKTm'l.ACl-:
ol MoTHHK
(Mali or Conntryi

/

Wi'V^v u lO^^^

(k.-v

t\

Cfw-c

U'

^

^qJ^u

()t, CI" TAT ION Qr\p

Pf. Miff if in >•''!" /

; ii If, ,''''

) , ,!

M,>i,fh'

/hi

T,,HAm>VESTATKnPHRSONAl rAKTirrLAHSAKK TKrH T-
linST Ol- MV KNc)Wl,KI><-.K AND Hl.Ml.l

IHK

f AfUlrt'ss l,Xo

V

9=

' f

nr RAT ION

CONTRIIH'TORV

) 'ears

Months

Pi

/rv

//oiu s

M

DIRATION
(SIGNED)

)V<7;-.? 3- ,)/<)>/ t//s

LAct

7)^7 1-

/OmCCIc )\:(xK,'

//ours
M.D.

iD^ XH T^^nH rA.hlr.ss) t^il L^Uiu Jt.

lilals, In^ti

SPECIAL INFORMATION only for Hospil
or Recent Residents, and persons dying a»*dy from home

titutlons, Transients,

Former or
Usual Residence

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

How lonq at
Place of Deatli ?

Days

l'I,ACK Ol- lU-RIAI, <»K RKMoVAI

DATJCnf Hi KiAi. or KKM<)VAI<

Q,^ 15 T9o'i

fA«l<lrt'«^'«

^^^__^_^__^^^M^^^M^^^— A— i^M^^"^^^'^*^^^'^^*'^^^^^^^^ - FXACTLY PHYSICIANS should

jS. B.— Bvery Iten, o» i„for«,«tlon .hou.d he carefully .uPpHed J'^^'^j;iZltmVl^^^^^ "Sl-cl-'i .nfo...»f.o„- for pr-
state CAUSE OF DEATH \n plain term., that It ma> "^ P ^
•*'. dyini away from home should he ftlven In every Instance.

*

WRITE PLAINLY WITH UNFADING INK —

J?ofir

(1 .,f n. :'!H) F No ;- ■^•'T^^W^V Co

Dulo FiJcilXJi^jXAh^ V5

U)0\

THIS IS A PERMANENT RECORD

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

2599

Re^islei'cd •A^o.

\.^K^ \jj\}M Dcpu

- alt h Officer

DEPARTMENT OF PUBLIC HEALTH=Cii) and County of San Francisco

PLACE OF DEATH: — County ofO/CVru dAXX.'>xC\

Certificate of IDeatb

{ Xk, 5. StanDarD )

^ City of U<X/"ru J /ucx. >vc\,s^ ^ ^

,c"fi

A

^fcW^^^-O^^

St.

Dist.; bet.

and

If"

FULL NAME

s.,Q^X-\0. U C.

PERSONAL AND STATISTICAL PARTICULARS

DAii: or liiRin

\r,H

C< >I.«>R

ll i.

Motini)

(Day)

M.niiri'

5.M

\ rai

Ihl^.

^INT, I 1" M \K K 111'
WIDOWJII) «)K Hl\ 1 .Kill)
(NViilf ill '^•H'ial <U->-is.'iiatioti )

^!.(t( or t'oiuit I ^

J,'

MEDICAL CERTIFICATE OF DEATH

DATK I'l' Dl.A III

lii.ct

I go \

(N\-art

UJb ^ N-C

y

1

I.' CU^f^

V O

NAMI-: <>»•'

I ATI! IK

lUKinri.ArK

<)!• 1 A II IKK
(Strit< i>r I'uviiiti V

MMDI'N VXMK
ol- MO Till. K

HIK'rmM.ACl-.

(►I- motih:k

(SlaU- or Ct)tiiitry)

XX^

">

Monlh) 'I»;iv)

I lll'kl'lHV Cl-RTII'V, Thiit I atUMi.kMl ilecca^ed fn.ni

w :;.l . . iKp'x to LL' ci, IhH. 190 H

that I la<t ^a\v h Vv alive on ' ' I<P

1,1 that (Uath ncriirrcl, 011 the <hitc stated ahove, at
" M. The CAISIC Ol- DlvATH was as follows:

at

c

I) r RATION )V(/r5

CONTRIIU roRV

.If on //is ^0 /)ays Hours

Ihiv.

nr RATION VriU's Motilhs

,,,n (A,hlress)U\Ai\- 'A.W'-

(SIGNEI

Hours

M.D.

/

OCCl'I*Al'H>N

Rr-iJrJ ni S,n! /*/ .

in, /-/■'

);;ii

\l<,l,th-

HKST Ol- MV KNoWl.J.lx.h AM) liJJ.n.l

(liifoiniaiit

(A.Mnss NlIUJ Ut)

ui

i<.S, ^ >'

SPECIAL INFORMATION only for Hospitals, Insntufions. Transients,
or Recfnt Residents, and persons dying HWdv Irom home.

Former or
Usual Residence

When \*as disease fontr.i( ted.
If not at place of death ?

HoM lonq at
Place of Death ?

Oavs

I'l ACK OF lUKIAI. OK RKMo\ Al,

DXTI'ii Hi KIM, <«i KI-;M0VAI,

(Address OAi) i, a*.

N. B.-

—^ 1— ^—— »——'—— '^^ iFVACTlY PHYSICIANS should

^ * <-Aii«P OF DEATH In plain terms, tnai n """j^ »

state CAUbti Ut- uc« ' " » ^iven in every instance,

sons dying away «rom home should be given .n eve y

P*^^ m'< 'M^ ■

^

it

WRITE PLAINLY WITH UNFADING INK

I-,,;,T.l , f 111., hi! i N.i i^ ■*'^:^r;;^H&P«.

/hf/r /u/ef/,^<:JzAhl\> X^

VJOH

THIS IS A PERMANENT RECORD

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

2600

Jlc^isfercd J\''o.

DEPARTMENT dp PUBLIC HEALTH=City and County of San Francisco

Ccvtificate of "©eatb

( 1:1. S. Stan^arD )
PLACE OF DEATH: — County ofO<:u^ J /^<x.^voui^ City of O^-v Ja^vv<^.^c.

rNo. "^^C)!^

'T>'Va. > w^ <. .

St.

Dist.; bet.

and

>^\Ji^ y t V,*^ » w^V^ . .,^,,^, DccTAVlMrE nvr FACTs'cALLED FOR UNDtR "SPECIAL INFORMATION' \

( " r.^i;iT°H"o^ru%rcV."rHO^S^VT'lt o"R'?^?f.?u"4^."o.;cT4 name .NSTEAO O. SXREET ANO NUMB.R. )

FULL NAME

^<ixv' >

I

i

g \X<x<5\\j U.u>v<it

r> ^ "

PERSONAL AND STATISTICAL PARTICULARS

1 \

r<>i,< >K

M I La V .

\^\

(lM,inth

A<.1-

r,-,/ >

H

^5

iDavi

.V,>,,/A

ai)

/'./

slM .1 1' M \KK 11-' I >

WIIH (Win « tH I'X ' >«<'»• I>

i Wi i!f 111 -.. ; i' ■!■ - -• •1" ' '■ '

J

MEDICAL CERTIFICATE OF DEATH

I go

(Vt-ni i

1UK run N^'i"

NAMI* <H
FATiniR

HI HI" 11 I'l. \<.K

(ii 1 vrin-tK

Statt 111 Country

MMUJ-.N NAMK
ol Morm'.K

lUK riiri.ACR

(Slatr .'! Ciiuntr> I

n:

<X^^

ft

.u-xLc '^

^yw

<X , ■.

O^Aj/u^'

/^

,^^X3u \J )\AJ^^<^

. t

I !1I:K1':HV C1-:RTII"V, That I aUcn«U<l «U(Ha-.«.<l from
- , . -t u^'t to ^''lP>

that I last saw h .i- ' alive on w ^A,. .. i.^o^

an. I that death occurre.l, on the date stated above, at *- 3 ^-
M. The CAISI' OV DI'lA'PIl was as follo\\s:

DT RATION Viuiis Months o /)aYS

CONTRIIUTORV M>l<UL^^^ W^ U C^-v

DTK AT I ON )V<7r.« 1 .Vo'fths /><m

(SIGNED) >ujLcv^ ^ L' ->',•:

I /ours

iL' .

KjO i

fXddress) \^^"^ ^0 i^^^

I lout \

M.D.

SPECIAL INFORMATION only (or Hospitals. Institutions. Transifnts.
or Rfcent Resldfnts. and persons dying away from homf.

oCcri'ATioN

4 \f'»ilh'

IJKST or m£knowi.i,1)..i-. and hi. Ml. I-

(Iiifonnatit

.UU>

MX

Former or
Usual Residence

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

How lonq at
Place of Death ?

Days

U ttj

n.ACH (-1 BIKIAI. "K KIMuVAl,

!)Ai;4C')!' liri'iAi. <»t KKMOVAI,
•'. TOO

^ _-^ ♦ 1 FXACTLY PHYSICIANS shoulcl

•tate CAUSE OF DtA in in i» « «vepy instance,

noti. dying away from home should be ft.vcn .n « e j

Hi

ElMD

L

/m

♦ ■^.

I..

A

y.

1.-

LOCALITY OF

RECORD S

SAN FRANCISCO

COUNTY

S AN FRANCISCO
CALIFORNIA

DEPT

T I T L E

DEATH CERTIFICATES

OF

RECORD

I

M I CROF I LMED

FOR

THE GENEALOG ICAL SOCI ETY

*

OF SALT LAKE

C I TY

UTAH

CALIFORNIA

DATE

•

APRIL

1

1975

PHOTOGRAPHER MAX J 0 H N S 0 N I

CAMERA ■n02683B f^ED 1

VOLUME

YEAR

2600

I

*. f

^^m

mmm