ROLL
■t ^
LOCALITY OF
RECORDS
SAN FRANCISCO COUNTY
S AN FRANCISCO CALIFORNIA
■t I T L E
OF
RECORD
DEATH CERtlFICATES
A.i'
I CROF I LMED
FOR
T H E G E N E A L 0 G LC A L S 0 C I E T Y
OF SALT LAKE
C I TY
/
UTAH
CALIFORNIA
DATE
-~9
APRIL
19 7 5
PH OTOGR AP HER
MAX JOHNSON
CAMERA ■N0 2b83M ^^^ 1
VOLUME 1326
1677
904
■'♦*
EGIN
■i'
♦M/W*«*«^
,v« • « • • • • • t
III*/
FEB I i»0*^
%«»t^
.--</ "•••'•
Lib»r
DEJHIT
^
I'
' «
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
HoMnl of Hfiiltli— F No. !«; ■<'5^^^]S^ HS: I' Co
REFER TO BACK OP CERTIFICATE FOR INSTRUCTIONS
lUtfr Filed, dx^^pJb^-rni^ 100 \
Registered JSTo.
1-3S6
Deputy Health Officer
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of 2)catb
( Ta. S. Stan£>acO ) PLACE OF DEATH: — County ofO/CWu J Axv^^y^A^ct City ofO/tX^^ J AXX^rvcM.A.^C
^Ne.
St.;
Dist.; bet.
and
(IF DCATH OCCURSiTAWAY FROmIUSUAL R E S I D E N C E G I V E FACTS CALLED FOR UNDER "SPECIAL INFORMATION' \ IF DEATH OCCuiftRED IN A HOSPITAL OR IflSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. /
FULL NAME
Kk/^oaJXxxA^ ^KKk^q^^^
SH.\
i).\ii-; (ti HiK III
\<.K
PERSONAL AND STATISTICAL PARTICULARS
I COH)K
I Month )
^^
J 'titl s
<I)av)
M,»ilhf
(Veur)
Davs
MEDICAL CERTIFICATE OF DEATH
DATH <)»• I)1>:.\TH r\
(Month) \ (Day)
'i
I go
(Year)
^I\<;i.K. M.\KK1KI>,
Win* >\\'i-: i> OK i)i\« )RrKi)
iW'iitcin "-luial ilcsij/iiat ion )
I f LcxvvoudL
lURTHlM.ACK
fStatt' or Country^
v A r I n: R
^
I^in':Kl':i}V CI<:RTIFV, That r attended deceased from Xa 190H t() . UcAAX3L "^0 190H
h.^VY\ alive on U^A-^cu '^*^ 190 .
and that death occurred, on the date stated a1)ove, at I. lo M. The CATSlv Ol' DI'ATII was as follows:
■^
HIR rn!M,ArH
0|- I AlIIKR (State or Country)
maii)i:n namk
Ol" MOTHKR
HIK rmM.ACK
Ol' MOTIIHR (Slate or Coimtvy)
(YyvvJ-
Rf.iif^i! in Si!)i I'liiii
DTK AT ION y('iu.s Mouth a Days / loins
: ON T K I BUTOR Y yj>L.Cr>A^'cJk^ Ll.aAJU.^^>'vv<5 > >„v.i.x
C
SPECVAL Information only for Hospitals, institutions, Transients, or Recent Residents, and persons dying away from home.
MnlltllS
n,T
rin: auovk sT\'n:i) rKKsoxAi. tak iutlars .\ki-; tkii-: to riii': in-;sr oi- my knowij-idck and m.i.iiCF
(Infotniant
)JL^
K) XjxXa.^
O-^XvsXcJl
Former or *\ ( m^
Isiial Residence <^'^ 1 ^
Wfien was disease contracted, If not at place of death?
^AMy\JL
How long at Place of Death ?
3
Days
I'l^C^: OV nr RIAI, OK KKMoXAI. I I).\^'l-;of Hikiai. or RKMOVAI, La-^^^I; I OjL^ X T90H
INDHRTAKKR
yuJLuvA/5 Cj . O <M::LiUxx^ '
(Add
Iress 2>C)$"
N. B.-
Every item o? information should be cnrefully supplied. AGE should be stated EXACTLY. PHYSICIANS should state CAUSE OF DEATH in plain terms, that it may be properly classified. The "Special Information" for p«r-
sons dyin£ away from home should be given in e\Qry instance
1
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
noar.l <.f Mciillli -I" Nn i "^ "^T.?*!'.^' I*^'' t''>
lOO'X
Begistei'cd .A''o.
1S27
I )((!(' Filed y
DEPARTMENT Ot PUBLIC HEALTH=City and County of San Francisco
Deputy Health Officer
Certificate of Bcatb
( XX, S. Stan^arC> )
PLACE OF DEATH: — County of^'<X'T\j 0 ^xcaxc^-^lco City of VJ-0_/yv 0 /\^<x^-v^<^a.a.^
ofO
A ^
.'O
No. HO
l^Q.-
"D
(
^rv-U. WLxM^ St.; 3v Dist.;bct. ^J
IF dea/Vh occurs away from usual residence give facts called for under
SPEC
IF d^ATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREE
lAL INFORMATION" "X T AND NUMBER. J
i,h
FULL NAME
PERSONAL AND STATISTICAL PARTICULARS
si:x
^ JLTi-^XXXAJi
""■"" U)JU
:::i
, \hAJUuyx'
DATi: Ol" i;iK III
oJvt
iMoiitli^
A(,K,
cJU bo
J V'<;/ >
I Day)
M.nil/is
(Year)
Da YS
MEDICAL CERTIFICATE OF DEATH DATK OF DKATH
go
(Year)
SiNCLi:, MAKUIi:i).
\\"n>t)\\Hi) OK i>iv<>Kvj-:n
(Write ill social (U-sirnat ion)
HIKTHJM.AOK 'Stall' or Country'
AxLcrujUycL
<X/\\j^
NAM1-: (»I- I-A'III Ik
lUK THIM.Ai'K
Ol" i-Arm-'.R
(Slate or (."oiinti %•*
MAIDKN NAM1-: ol' MOTIIKR
lUR'lHI'I.ACK oi- Mo'l'UlvR (Stall' or Cotinlry
(Month) (T (Day)
I IIHRKBY CivRTIFY, That I atteiidcd dci cased from
190 to I<)0
tliat I last saw \\~rr- :alivc on" T90
an«l that death occurred, on the date stated above, at -« — M. The CAlSIv ()!• DI-ATII was as follows:
}
<X/y\A^
ore
TTATION (\
Rfsitfni ill Siin /'i <!ii( i>ri> J^^ )></»<
M,.„ili^
n,n
Tn J" \novi': sr\'n:n j-hrsonai, partkii, \rs ari-; rRii-: ro rin-;
HKSr Ol- MY KNOWIJ'.IX. !•; AM) lil'MHK
(In foiriant
a
AJUL/yv
(Address
HC^QvAM^ IWt
DTK AT ION Years
CO.NTRIHUTORY
Mo)itlis
Days
Hours
Years ,. Moiiths Days Hours
M.D.
DURATION (SIG
?)0 i()oH (Ad(lress) Ur\.fr>A_iA^ UXi
\TIC)N _ ) ears ^. Mouths Ihiys
iNED ) L^rVCroJA; 0 A)j.Uj.Xu-ay\\.c^,
Special information only for Hospitdls, InslituniWis, Transients, or Recent Residents, and persons dying awdy from fiome.
Former or llsual Residence
Wfien was disease contracted, If not at place of deatli?
How long at
Place of Deatli? Days
1M,AC]-: Ol" lURIAI. OR Rl.MoVAI
DATUo! Ill IMAI. or RI'.MOVAI, (.Vldrcss ^ ^OSGoAAMii^ \
N. B. F.very item of iiiformsition •hould be ciirefiilly HupplicMl. AGK should be Htnte<l F.XACTLY. PHYSICIANS should
state CAUSE OF DEATH in plain terms, that it may be properly classified. The "Special Information" for p«r- Ron« dyin^ away from home should be ^iven in every instance.
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
}i..Mn1(.f n<MHh I No 1. f'^J^^jutl'Co REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
Begistei'cd J\'*o,
1328
Ddir FiJol ,BjL}(Jzx^yJU^ 1 190'\
'dL,^)-A.->.^^ XtA^u Deputy Hcaltb Officer
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of Beatb
( xa. 5. StanDarO )
U/O/YVO AXX/YVCAA/C^ Citv ofO-
PLACE OF DEATH: — County ofU/O/YvO AXX/wcaA/C^ City ofO/CXA^O /\^/<X/-v^^i,^^^co
^No
.^'iS
.1)
St.
1
Dist.; bet.
and
ty\>
(IF DEATH OOCURS AWAY FROM USUAL R E S I D E N C E G I V E FACTS CALLED FOR UNDER "SPECIAL INFORMATION" "\ IF DEATH^pCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. /
FULL NAME
PERSONAL AND STATISTICAL PARTICULARS SKX QP\ ft I C01,OR
DATl-: ()}• HIKTll
a(;h
iM.jiitli) K
MEDICAL CERTIFICATE OF DEATH
DATK OF DKATH r\
2.0
(Diiy)
(Year)
4tJl(S
}'t Of .
Da vs
-^iN*.!.!-:, MARuii:n.
u in(>\\i;i> OK i)iv( »RrKi)
iWiitiiii social (hsiK'i.'itioti)
! i
lUK'rUlM.AOK
(State or Coiintrv^
FATHICR
MIRTMPI.ArH OI" l-ATMKR (State or Coiiiiti vi
m\ii)i;n NAM1-;
nl MorilFR
!UR rHIM.ACK OI' MdlHHR (St.(t< or I'oiintrv
i
^ (J
(Month) ll 1 ni{RI<:nV CI-RTIFV, That r attcMided deceased from
^0
(Day)
(Year)
2>C 190 M to 190
tliat T last saw h alive on 190
and that death occurred, on the date stated above, at
M. The CAl'SK OI- 1) I- ATI I was as follows:
OXJll AD CJ^vvv.. ^cyyy.,^
DC RAT ION )'fars CONTRIHUTORY
Mofii/is
Days
J /ours
OCCtl'A rioN
'/<X/vCmX
■}
DURATION (SIGNED )
)'ears
Mouths
Days
U
ex, U . Vflj <CVOv.q<x.tvvWo
^l iQoH (A.hlrcss) IC^
Hours M.D.
t
SPECIAL INFORMATION only for Hospitals, Institutlttns, Transients, or Recent Residents, dnd persons dying away from fiome.
Former or Usual Residence
How lonq at
Place of Deatfi? Days
Rrsidrd in S<i>i I'l iiiii i ^lUt
)V-iM c
Mnxlhy
Ihn
VUV. AHOVK ST All! I) I'KRSOWI, PA RIUT I.A R S ARI' TRI1-- To TMI- HlvST OI' MY KNO\VI,i;i)C.H AND lUlI.llll-
Wlien was disease contracted, If not at place of deatti?
(Illfoiiiirint
VxXAArtr
">ViL
(Address
'^'is'UJlLvuA.
I'LACl-: 0|- lURIAr, OR RKMOVAI. I DATl' of I?i kiai, or RKMOVAI, OA^^/WO-MH. I) ^txiU ' I ax|vfc 3. 190H
INDKRTAKHK oV^aXu ^^^ QK) <0^/OijXX/\\)
(Address 3jId1'^X ' I H tJL "Ul
N. B.
-Fivery Item of information should be cnrefully Hupplied. AGE should be stated EXACTLY. PHYSICIANS should state CAUSE OP DEATH in plain terms, that it may be properly classified. The "Special Information*' for per- sons dyinft away from home should be ftiven in 9\ory instance.
t
. ■
in
•i I
ii t
■, ' i
It I t
.HI > I
'■s ■
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
Il..;it(l of Il.alth -)• No. l^ *'|;;atf^»?;feH&l' Co
/)(f/r FiJrd,
10 0\
Begistcred JVo.
J 329
^cr
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Cevtificate of Beatb
( XX. S. StanJ>arD ) J? ^
PLACE OF DEATH: — County of 0 Crrur^-VVO.- City of
«,
'^No.
(IF DEATH OCCURS AWAY FROM USUAL IF OeATH OCCURRED IN A HOSPITAL
St.;
Dist.;bct.
"and
RESIDENCE GIVE fa OR INSTITUTION GIV
'ACTS CALLED FOR UNDER "SPECIAL INFORMATION" 'N E ITS NAME INSTEAD OF STREET AND NUMBER. /
FULL NAME
^r\
PERSONAL AND STATISTICAL PARTICULARS SKX Qn jj j COLOR •
DAii-: oi' niKTii
tc
A <■.!.;
1 Month) X
\
i \ Yr.ns A
I Day)
yfoHlfis
I i'i.c
(Year)
MEDICAL CERTIFICATE OF DEATH DATE OV DKATH
(Day)
I go H
(Year)
I HF^RHBV CKRTJFV, That I attended deceased from
— to
..n
Da v:
si\(.m:. MAKi<n:n \vin«»\vi:i) OR niV(>Kci:D
(Write ill ^<K-i:iI (k-si>.»^ii;itioii)
HIKTMPI.ACH
(Stxite or Coiuitrv)
AxJL
Crvvr
NAMH O!" !• ATFIICR
niKTMIM.ACK OI' lAlIIKR (State or Country)
MAIDKN NAMK Ol" MOTUKK
tX^rv^^
^Jy\Xry>^
— ~~~ — "190 "~"
that I last saw h "■ alive on
Tqo I90
and that death occurred, on the date stated above, at IV AJ ^^r. The CAISI-: OF DIvATIT was as follows:
a /aA^c<trry.A.<<<x^ (rv /tikx U'-cX:
\t\-.^..
DURATION Years CONTRUH'TORV
Months
Days
Hours
niRTIIPLACK OK MOTHHK (Slatf or Country)
oCCri'AlION
-]\xX.<x, >vcL
DURATION
(SIGNED )
Years
^foHt/is
CI, iD. LJmx^m-
/\iys
UAAA ISO T90H (Address) "^^-^-^^XoJl^ Lcct
cIal in
Hours
M.D.
Special information only for Hospitals, Institutions, Transifnfs, or Recent Residents, and persons dying away from home.
Prsiifftf in Suti /'i am i>rt> oO )'<■</;.<;
M.nilh'^
Day
\'\\V. MiOVF ST\'n:i) I'KKSONAl. l'.\ K IHT L A RS ARl-, TRIK To TIN' HKST Ol" MV KNO\VIJ:dOK AND UKI.IHF
Former or Usual Residence
When was disease contracted, If not at place of death?
How lonq at
Place of Death? Days
(I
iiforniant HrtTKVVO
(Address ...T H WjxAj^^^^rrsj LvVN-i .
PI.ACE OK BIRIAI, OR RKMOVAI. I DATl- of HtKiAi. or REMoVAI,
QoiJLvvvA. £ai I a^t 3, 190H
t-NDERTAKER VJ OAXxA^ XcUJ.._ ^^
(Address ...
^' ^' Kvery item of information should be CBPefully 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 dyin^ away from home should be £iven in 9\9ry instance.
'■ I
"^ I
fi »
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
Hnanl ..r H.alHi I N.) 1^ *tJS^^lUS:I'Co REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
RegisteTod JS'^o.
1 330
Ddir Fil(>(l , AjL^sXxr^'rXjl^ \ lOO'i
dv<r^A.v« "ix^vu. Deputy Health Omcer
DEPARTMENT OT PUBLIC HEALTH=City and County of San Francisco
Certificate of Beatb
( xa. S. StaiiC>arD )
A ^ ■ I ^
PLACE OF DEATH: — County ofO/O/vu OAxx/vvcUyCO City of OXXa\; tS K(X/w^l\^^0
St.; b Dist.;bet.'yC)^xijim; yxxXt andNLll Uj.uix'
No. ^ 15 VjAX^veX
(IF DEATH OCCURS IF DEATH OCCU
S AWAY FROM USUAL RESIDENCE GIVE FACTS CALLED FOR UNDER "SPECIA RRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET A
L INFORMATION" \ AND NUMBER. /
>v )
FULL NAME
si:\
DATl-: (>|- lUKTM
PERSONAL AND STATISTICAL PARTICULARS
COI.OR
ACK
Is
(Day)
b 1 y>a,s oL M„ulhs K)
(Year)
n,i v.v
MNCI.l" MARKIl'.I)
w ri)<)\\ i-;i) OR i)i\< (RvKi)
' \\ I it< ill siK-ial (Usipnation)
HIRTHI'I, ACK
I State or (."ounti v^
\| iLcxaxax^
MEDICAL CERTIFICATE OF DEATH
DATE OF DKATH
(Month)
NANt)-: (M
fathi:k
BIRTH PI, AC'K ()l- KATHHR (State or Coimtry)
MAini:N NAM1-: OF MOTHKR
(Day) (Year)
I III':RI<:BV CI-:RTIFV; That I atteiKk-.l (leceased from
LIaA/O n 190 H to ULuuCv ^D igo\
that I last saw liA^>N alive on vAaa^Q ^0 I90 H
and that death occurred, on the date stated ahove, at ^ VJ^ M. The CArSl{ OF DIvATH was as follows:
DrRATION OlS" }\ars CONTRITU'TORV
Mouths
Days
Horns
M WaxKjjl OoOCOvX/CL/vru
lURTHPLACK
or MOTHKR
(Statf or Coiintrv)
/^ays
Hours
DURATION Years Mouths
(Signed) U). \J. ^^LAA/wJkxx^-^-u M.p
OX>i^A 1 Tc)oH (Address) 1 1 ^ b W (XIXulU^v 0 Jl
OCCITATION-
Special information only for Hospitals, Institutions, Transients, or Recent Residents, and persons dying away from fiome.
THl'. \1U)VF. STA'n:i) fHRSOVAI, I'A K lU' T I.A RS A R i; TR T l" To THK
lii'ST 01 MY kno\vi,i:d<;k and mkmick
Sl5Vj.etVOL Ofc
Former or Usual Residence
When was disease contracted. If not at place of death?
Hew long at
Place of Death? Days
(A<1ilress ..
PJ^CK <^I- m-RIAI. OR kHMo\AI, I I) VJ-i; of HiKrAt. or RlCMoVAI, INDKRTAKKR \K LAj. M / \xXjliA^'V\; ^^t Lo
siaJD'f xx^wlU cit
(Address
^- R- Kvepy item o? information should be cnrefully supplied. AGE should be stated EXACTLY. PHYSICIANS should
state CAUSE OF DEATH in plain terms, that it may be properly classified. The "Special Information" for p«p- «on« dyin^ away from home should be (iven in 9\ery instance.
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
lioar.lof lUiiUh I \n is ^'tj^^ lut P Co REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
190 ^
Registered JVo.
1331
I)(ffe Filed, O
DEPARTMENT Of PUBLIC HEALTH=City and County of San Francisco
Deputy HeaCh OfTlcer
Certificate of Beatb
( Ta. S. StanDarD )
(^
-Y m -^^ von
PLACE OF DEATH: — County ofO/CUYVj J/vXX-^AwCUlcc City of 0/CVY>j OAXV\v<tA^<U)
No. Tas'b. (
i/M
St
.; 6 Dist.; bet.
IF DtATH OCCURS AWAY FROM USUAL R E S I D E N C C Gl V E FACTS CALLC? FOR UNOE IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD O
FULL NAME
K
n
PERSONAL AND STATISTICAL PARTICULARS
A
and UiCLoyvrva )
PECIAL INFORMATION" N nEET AND NUMBER. /
si:x
DAI'l-: OJ- lUI-rt'll
A ( -, !•;
\
(k.
Vv>\A.
\Ay>
:x
(Montli)
X
(Day)
r% HI
(Year)
O I );a,s \ ^;,mths Xlb
Da vs
SIXC. l,lv MARKIi:i).
\\ii)<)\vi;i) OK i)ivoKif:[)
(Wiitfiii social <Usi>fiiati<)n)
nikl'HI'I.AOlv (Sfatf or Country)
«
NAMIC ()!• FAIiniR
MEDICAL CERTIFICATE OF DEATH DATE OK DKATH CS
liu^ ^0
(Month) I (Day)
/go M
(Yt-ar)
I HRRKBY CICRTIFV, rhat I attended dec ca.sed from
LLlx^ Qlj& 190 'i to LLuuX "iO i{)oM
that T last saw h -i-^-' alive on vACv/Q "iC up ,
antl that death occurred, on the date stated above, at o ■>^ M. The CAl'Sr: Ol- ni'iATII was as follows:
V^A^AJk^-^h^.^^. ofc
niRTMPI.AlK C)l- lAlllKK (St.ite or Cotintry)
MAIDKN NAMH Ol- MOTHKR
HlklMl'LACH Ol- MoTm<:K (State or I'oniitrv)
Dl' RAT ION )'cars
Mouths
Da )'.?
mNTRinUTORY (fo^ft^^-rc^crvJtLo^Q^
DI'RATION
^
Years
Months
OCCfl'ATlON
(Signed) J. J^AAycJ^x^^vv
Days
^l T()oH (
.•\<ldress) '^Sc?) VjMX J'l
I fours
\^
I /ours M.D.
SPECrAL INFORMATION only for Hospitals, Institutions, Transients, or Recent Residents, and persons dying away from home.
/hi \.
THi: AHOVl-: STATi:!) I'KKSONAI. I'A UTKM- LA KS ARIC TRIK TO TJIl-: HKST Ol- \iy KN(»\\ I,i:nc. H AND nKMl-;F
(In foiniant
Former or Usual Residence
Wlien was disease contracted, If not at place of deatli?
How lonq at
Place of Deatli? Days
(A<l(lre«.s
1'I.ACK OK IHRJAI, OK KI-:MoVAI, | DAT^! of Hikiai. or kKMO\Al,
'^ 190'!
INDKRTAKHR ()v9. <J. CJ-A.aJ(w ^<V \^
(Address 1 1^1 V rXA^^^^^-MrVV. ..Cl'l
N« B. F.very item o? informntion 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 j^iven in o\9ry instance.
M 1'^
i
'I I'
< ■
if
11
il I j(H
I'M ill
^.
^ttr WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
KoMid .)f Iltaltli — F" No. it -f'^^^ H&P Co
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
I)(f/r Filed,
I
190\
Registered J\^o.
1 332
Ov,.<n..A^A^ dU2y
Deputy Health Officer
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of 2)eatb
( XX. S. Stan^arD ) PLACE OF DEATH: — County ofCjxX/>\) N|^KX/Cl |a-^-^^; City of CjtV(JkXcrY^
^No/
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 OCCURRFD IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. /
FULL NAME
si:x
DATl-: (){•■ lUKTII
PERSONAL AND STATISTICAL PARTICULARS
COI.OR
:'>A.'
^
Jl^O
iMoiitlil
(Day) (Year)
A <■.!•:
O "O ]'i(iis
%
Motilh
<^ ^ Da vs
SIXCIJV MAKKIl-:!)
wii)( )\\ i:i) OK i)i\"()Kr }-:i)
(Wiitiin s(M-i;il ik*.i)^u;it iuii)
HIK'nn'I, vol'! (Stiitf or Country^
\AM1-: ()!• 1- ATII }".K
FnU'nU'I.AOK <>l' I'A'rHHK
'State or C'o'intrv)
MAinivN NAMH ()]■ MOPHKR
HIR rHIM<A(^K
'•I MornHK
(Stall' or Couiitrvl
MEDICAL CERTIFICATE OF DEATH
DATE OF DEATH
(Day)
r,H
(War)
I HEREBY CERTIFY, That I attcMick-.l .Icciast-.l from
I90 to — — — ic^
that I last saw h ■^^^"^ "alive on k/d
and that death occurred, on the dale staled almvc, at ~
The CAUSE Ol- DIvATII wa^; as follows:
Axxtx M K X) (TVUxLcL
DERATION Years
COXTRIIiUTORY
Mouths
Days
Hours
MiDiths Pays
CLyV^/^w8.V<r>A..
Hours M.D.
OCCT'I'ATIOX
(?.
'^'V.
<L
DERATION Years _^
(SIGNED) \. 2)^ oU
VAAVC^ 'M K^ol f.\.l.lrt-ss) OX^KOlkAAVu V<XV
Special Information only for Hospitals, institutions, Transients, or Recent Residents, and per>ons (lvin.j ,m.i> from home.
Rfsidrd ill Sax I'l tun isro «. )'rnr.< ' M'i:iffis * /)a\.
TH1-: AHOVK ^.TAI'l'l) I'KKSONAI, 1'A ki" IT T I,A KS A K l". fRll-: To THH
HEST Ol- Mv K NOW I, ):nc.E AND Hi;i,n;F
(In
foiniant JVXXJOL ^U Kyir\\.0^-
(A<1<1
Former or Usual Residence
Wfien was disease conlrarted, If not at place of death ?
Hew long at
Place of Death? Days
I'l.ACH Ol' lUKIAI, OK K1'.M<»\\1.
'ctIm-C
l>\l^-;of niKiAi. or RHMOVAI,
)ji\s% \
r.NDi-.KTAKi'-.K kX^WaXX/O^ \X/\\/kjiAXA\MJJ\'',
T90M
N. B. i;very item of Information should be carefully supplied. Adli Hhojld be stnted KXACTLY. PHYSICIANS should
state CAUSE OF DEATH in plain terms, that it may be properly classiltied. The "Special Information" for per- sons dyin^ away from home should be £iven in every instance.
i«niMii«»a J
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
j?,,,,nl..f Hcalth-FNo. i > 1«^^^ U& I' Co REFER TO BACK OR CERTIFICATE FOR INSTRUCTIONS
I
Da
fe Filed, 3
V 100 \
Deputy Health OfHcer
RegLstered J^o.
1 3;5.3
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of 2)eatb
( "d. S. StanDarD )
J? Op A ^
PLACE OF DEATH: — County ofU/Cu^^ JAxXy>vCx^CM. City of O'CU"^ J ^cu-rAya<.,^L/CLx*
No. 5H"l CjAXA.'-0>VLtrvv
(IF DEATH OCCURS •F DEATH OCCU
St.; H
Ka\)
Dist.; bet. ^ A^^ and 1 A^ b
S AWAY rROM USUAL RESIDENCE GIVE FACTS CALLED FOR UNDER "SPECIAL INFORMATION" "N RRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. /
FULL NAME
PERSONAL AND STATISTICAL PARTICULARS
(^
SKX
DATK (»1- HIKTU
COI.OR
VJrUvv
iMimtli)
^kctl
(Day) (Vfar)
ACK
^11 iri
VI );,ns \ .^/otilhs O ^
lhi\.
SINt.i.K MARKIKI). WinoWKI) OK DIVORl'KO
I Write ill '^•u'i.'il tlf^i>.'iiati<>n)
lukTm'i.ACK
(State or Country)
LcvX>vOL<iw
111
if
NAMH Ol* I- A Til KR
HIRTin'l.ACK < ) !•■ 1" A r ! I K R (Slatf or Coinitry)
maii))<;n xamh
Ol- .MOTIIKR
iurthpi.ack
<»!• MoTHKR (State or C\)utitrvt
MEDICAL CERTIFICATE OF DEATH
DATE OF
dhath r\
\kkAui
(Month)/
(Day)
(Year)
I III':R1';BY CKRTIFV, That I atleiKkd deceased from \.l J^CtM- iQO 0 to vLu^/CL M 190H
vXm-CL '^^ti
^Oaa 190 0 to that I last saw h -^.-'v. alive on V\.VA-Ol -j^-ti icjo
and. that death occurred, on the date stated above, at L V Al. The CAlSIv OF DIv^TIl was as follows: ^w^'w>vaJ!a.^C>-^.a^ ot dLxyxM^
di;r.\tion contriiu'tor
} 'ears
n
Months Days
J lours
V \-<<XAxLA,./tXyC. U\).\^.V:i^J.^JX<<rVv
IH'RATION ,. Years
^00
OCCUPATION fJvP
Rfshifd in Sati f'l a in isro \\))'rn i s i }fiiiiths
Mouths
( SIGNED ) vJXjuI Uj- 0 M>-'
'h\ iqoH (.Address) 'XV^
Pays
Hours
Special information only for Hospitals, Institutions, Transients, or Recent Residents, and persons dying away from home.
Former or Usual Residence
How lonq at
Place of Death? Days
ihi\.
Till'. AHOVK ST\'n-:i) rKRSONAl. TAR riiMKARS ARl*. TRrK T« » Til )■: BKST OI' MV KNoWIJUXiH AND MKI.ll'.K
(IiifoMiiant
r\.1(l
ress
When was disease contracted. If not at place of death?
rL/\CH OI" IHRIAI, OR R|;MoVAI, I DA'p-;.)! HiKiAi, or RKMOVAI.
•NDKKTAKKR H. • Vj . U L^T^V^TVO^ ^*<- L^ (Address 1. io 1 VrrVva,^.V^-vv 01.
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 p«r- .^ons dyin^ away from home should be jjiven in every instance.
d)
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
li.xml of Health- »•' No. i<, "^'^^^^^ UScV Co
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
RegLstered J\'*o,
\ 334
l)((l(> AV/^v/,dxJpXt-.^U>Jt>v 1 100 H
"l.cr\.v^:^ duiAvu Deputy Health Omcer
DEPARTMENT OFPUBLIC HEALTH=City and County of San Francisco
Certificate of Beatb
{ 'CI. S. StanC>arC> )
St
PLACE OF DEATH: — County of 0 CPn^ir>-vA.<X; City of OxX^nJlOj VJI^Cj^^X-
No.
(IF DEATH OCCURS AWAY FROM USUAL IF DEATH OCCURRED IN A HOSPITAL
- St.
Dist.; bet.
-and
RESIDENCE GIVE FAC
OR INSTITUTION GIVE I
TS CALLED FOR UNDER "SPECIAL INFORMATION" \ TS NAME INSTEAD OF STREET AND NUMBER. /
FULL NAME
^a
PERSONAL AND STATISTICAL PARTICULARS
SJ
DATH ol lUKlH
AC.H
rVA^Xx
Ntuiitli)
la
(Day)
(Year)
'li
) V w
HL MnutfiS 0
Pa vs
•^Ixr.l.H MAKKIl'.n. WIDOW l-:i) OK IH\'»»k( I'.I) iW'iitiiii >«(Kial lifsivrnatioii '
lUKTHlM.ACK ( State or (."oiuitry)
i,
\\M1", <)!• I ATHICR
HIRTHJM.AC'K <)I- J-AIUHK •State or Country)
MAn>I%N XAMK Ol- MOTHKR
IJlKTin'LACH or MOTIIKK
(Slate or Countrv)
OCCT'PATION
Uu"kA.Ajtj
MEDICAL CERTIFICATE OF DEATH
DATE OF DKATH /O
(Mouth) K
^0
(Day) (Year)
I HRRI{RY CERTIFY, That I attended deceased from
'.' 190 - to 190 ~
tliat I last saw h -• alive on ~~ 19O — -—
and that death occnrred, on the date stated a!)<»ve, at M. ,The CAl'Slv Ol' DlvATlT was as follows:
M. The CAl'Slv Ol' 1)I';ATIT was as fol
Dr RAT ION Years
CONTRIBUTORY
Mouths
Days
Hours
DTRATION Years Mouths
(Signed) o^\j\rL^ (i^o-^^x
Pays
Hours M.D.
vAA-^Q ^\ iqoH (Address) C3/CX.^»atxc vlW^UX V<xJL
Special information only for Hospitals, Institutions, Transients, or Recent Residents, and persons dying away from liome.
Rfsrdfd in Sttn I'l <ni< isro
)'iii I .
- .lA>/////«
/)<n.
rm: ^Ho^•l^ statiid phrsonai. i- \k iumi, aks aki: TKn-: To rm-: uKsr oi- MY^ KNowM,i:i)(.H AM) iu;i.ii;i-"
(lufoMuaiit C/VJ) . (JKS> L.^XV'O:^
Ai,i:i)(
W
(AMd
rcss
(is?
m
Former or Usual Residence
When was disease contracted, If not ?♦ 'lace of death ?
How lonq at Place of Death ?
Days
INDICRTAKKR
(Address
^
K Ol-' inKIAI, OK RI;moV\1, J DATilof HiKiAr. or RKMOVAI,
/0./WQ
3 /ol/vx^^(x vJW^o^ \L<xX.
N. B. F.vepy Kern of informntion should be carefully supplied. AGE should he stated EXACTLY. PHYSICIANS should
state CAUSE OF DEATH in plain terms, that it may be properly classified. The "Special Information" for per- sons dyin^ away from home should be feiven in every instance.
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
Hoard of lUaltli - l" No. i<^ "^^J]^^ J''&1' Co
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
I M
M'
i)(f/(^ /v7^>o^ ...dx^pix^ JL^ I I'jo'i
Deputy Health Officer
Eegistered JSTo,
1 335
dC^O^^^^^^A^
,1
DEPARTMENT OFPUBLIC HEALTH-City and County of San Francisco
PLACE OF DEATH: — County
Ccvtificate of H)catb
( "CI. S. StanDarD )
o{^iOjy\) J Axxaxculcc City of Ooyvu J a^cxax/CxVAam:>
St.; X Dist.; bet.
(IF DEATH OCCURS AWAY FROM USUAL RESIDENCE GIVE FACTS CALLED FOR UNDER SPECIAL INFORMATION" "X IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. /
and <=UAA^^^yWA^A )
FULL NAME
S
PERSONAL AND STATISTICAL PARTICULARS ,KX (X\ A I COLOR
■r\Aj..
n.\ ri". oi" iwK I'll
AT, H
iMoiith)
» \ JV.;;>
(I)av)
Monlhs
(Year)
MEDICAL CERTIFICATE OF DEATH
DATE OF 1)1
•"A
30
(Day)
(Year)
A/1
siNc i.K. makuii:d.
WIDnWJ'tD OK DIXOKi" Kl> iWiitiin sorial tlfsiKtiat iuii )
lUKTni'i.Aoi-:
t state »)r C.uiiti v)
k'
/C^
'
III,,'
m
WMJ' <)l I- A 11 1 I.K
HIK I'HI'I.ACK
<)i- I A rm-:K
(Stat<- or Coiuitrv^
MAinilN NAMK
<»i m<)Thi-:k
IURTHPI,A('H <>l' MornKK (State or Country)
lLvJk/>
^\.xrv\rvu
O^^-x^
cL
- tux
(Month) K HHRIUJY CERTIFY, That I attcMKU'd (Icceased from
to vXwCL
X^.Acp^ to UvVS^ 2>0 T90 M
tliat I last sfiw h-t-^- alive on \Xw^ ^ Dpi
and that <leatli occurred, on the date stated al)ove, at 'A XO ^X M. The CArSl-: OF DlvATH was as follows:
vVvtrv\.A/c..
1)1" RATION CONTRIiaTORV
)'cars O ISIoulhs Days I /ours
X.
V^V.\.<! >.\
}'('ars
^^
cL
OCCI^PATION
Months
Da vs
)oH (Ad.lress) S.Ol'i cU-eA>ULaxlj2\X) Jt
Hon IS M.D.
Special information «nly for Hospitals, Institutions, Transients, or Recent Residents, and persons dying away from home.
Rcsiiifif in \<in I'i atnisro
'S'luxi f
M.^utln
Ihivs
VMV. AHOVl-: S'rA'n:i) I'KRSOXAI, P \KIICII. \Ks AKI", tki }■; To TH 1-; lJi:ST Ol' MY KN(>\VIJ;D<". H AND lU'.I.Il'.H
(Infoiniant
6
UA^CutjUx)
(Address
<\.
b I 0 ViJj A,A.^i:Jk LLv-C
Former or 0 ( ri
Usual Residence "^b G/VCA^^X^
When was disease contracted, If not at place of death?
L -V , Hew lonq at ^, vil/w-tiU"A Place of Death? 1
Cmj^L. INjys
ri.ACii OI" in'KiAu^oK ki:movai.
(TW V\
DAT^'.of IJi HiAi- or KKMOVAI. ^ TQOS
k IM , o: III H
i:ndi:i<'iakhr
(.
%
Xddreis . V'l () "1 C) <VCA-^P^'>'WX^>X^ s.'.t
N. B. Bvery item of informntion should be carefully Hupplietl. AGR should be stated BXACTLY. PHYSICIANS should
state CAUSE OF DEATH in plain terms, that it may be properly classified. The "Special Information" for p«r- sons dyin^ away from home Khould be [^iven in o\cry instance.
i-
» I
M
II
(
'1
t « ;
)(
1,1
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
)?n,inl of n.;.lll» I- X... !^ -^.^|^:>I!.vI'Cm
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
1
Registered *A^o.
1336
/(' /'VAv/, dx^vtx'v\vLen. 1 100^
cLo-i-v^ dJL/v-u Deputy Health Officer
DEPARTMENT OFPUBLIC HEALTH=City and County of San Francisco
Certificate of 2)eatb
( XX. S. StanSar? )
^
PLACE OF DEATH: — County of O/Ou^^ JAXX^^^^cuUMi City of Cj/CWV JAXL/TVCv^ci
■« 1
No.
Cm^'
(IF DEATH OCCUrt^S AWAV FROM IF DEATH OCcluRRED IN A H
St.;
Dist.; bet.
and
USUAL RESIDENCE GIVE fac OSPITAL OR INSTITUTION GIVE
;ts called for under "special information" \ ITS NAME instead of street and number. /
FULL NAME
'YW
si;\
PERSONAL AND STATISTICAL PARTICULARS
I COI.OR
'UJ
I
JvaJaji
!).\Tr: oi HiRrn
\ ' . I-:
)l<
v.,
Month)
ss
J I a I
$
V
la
(Dav)
.\r.ifitlis
(War)
1^
A; r>
^ixr.i.iv MAKun:i). wiin t\vi:i) OK i)i\« iKii'.n
iWiitiin '-ocial <l(>-iLMi.ilii 'ii)
lUKrHPI, AOK 'Statf or Coimtry'
N\M»'. OI' 1 A'lll ).R
lUK'nUM.ArK OI lAIMKK (Statt" or Country)
MEDICAL CERTIFICATE OF DEATH
DATE OI- DKATH /O
(Month) K I IIIvRI:BY CrvRTlFV, That I atleiidod <lecease(l from
?)0
( Day)
i9o\
(Year)
\'X 190 H to
that I last saw li i-"^ > ^ alive on
^ 15.0. ^U)oH
and that death occurred, on the date stated above, at i \0
JX M. The CAISK OJ^DICA'I'll was as follows
MAIDllN NAMK «>!• MOTH MR
lUKrilPr.ACK OI-- MoTHHR {Stale <jr Country)
CUV\,A
7
DTRATION ]'c'ars
CONTRIBrTORY
M 0)1 ills
Pays
//ours
(Signed) J.
?
i
occi
\J JUk^<kXjL\)
Resiitfii ill Sim /'i ii m /.iit OO )V(7/f
.\f»ll//lS
n.ir.
vnv. AHo\i<: sTATi-: I) I'KRsr )nai, i-ak rue i.ars ARi; TRri-: ro 111}-:
HHST OI' MY KNOWI.J'.DC H AND IU':I.11';K
(Infotmant V^ . V) . <AD . OL
A
(A (1(1 res
AwCtu,
'CXA-VM^i
/^ays //ours
M.D.
.1
SPECiAl Information only for lldkpitdls, institutions, Transients, or Recfnt Residents, and persons dyinq away from home.
Former or ■^^Uxxa.^v^ ^"^^4, "»^ ^m at . ^ ,
I'sual Residence vty^-^x/^^^^wCA.^CA.xOl . 01 piare of Deaffi? ' v \ Days
Wfien was disease rontrarted, If not at place of death?
T90 t
,^ri,ACH OK lU'RIAI, ok RHMOVAI, I DATI': of Uikiai. or RKMOVAI.
IN. B. Kvcry item of ln?ormntion 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 given in every instance.
ill
IJi
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
nonr.l ..f Health F No i > 1^?^^. H&l' Co REFER TO flACK OF CERTIFICATE FOR INSTRUCTIONS
Registered J\''o.
1 ^17
Ihili' /'y/('</ , J3jiJ^sXjUy^JiM^ I I'JO'i
i-fr-u^ ioAMJ Deputy Health Officer
DEPARTMENT rfp PUBLIC HEALTH=City and County of San Francisco
Cevtificatc of Beatb
( tl. S. Stan^ar^ )
PLACE OF DEATH: — County of O-O/^rvj J AXV>vcaa C( City of Oxwv; d/UX^CA^'C<
(lii^ ft
No. Hoik
(i
KXA^'^O;
and
O^, St.; 1 Dist.;bet.
ocqu
H Occurred in » hospital or institution give its NAME instead of street and number
J /CuXtX'
/ 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 rtrrilRRFn in a HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. /
ISTIT to
FULL NAME
.\aX dui/^VTVU
PERSONAL AND STATISTICAL PARTICULARS
SK\
DAII-: <)l- lUKTII
\<".H
COI.OR
.1
4i'>iitiii K
(I)av)
(Voar)
(Year)
) 'i\i I
.1/. .»////>
0.1
/><7 1 ,v
S|N»,I,K M.\KKIi:i>. WinnWKI) OK I)l\( )R< i:i) 'W'ritiin vooial dt- siirnatioii)
lilRTm'I.At'K ' Statf or CinuitrV
NAM)-, <)1 f A r H H K
Hik'nnM.ACK
<»1" l"\rHHK (Stat( or Country^
maii)i:n namk
()l MoTHKK
HiK riiri.Ari-:
ni Mo'IUKK (State or Cotiiitrv)
occri'A Tiox
ft
,MwA
X^v'>x
0 JUWvV€u'>
MEDICAL CERTIFICATE OF DEATH DATE OF I)K.\TH /^
iWct M
(Month) K (Day)
I HERI':BY CKRTIFV, That I attended deceased from LAXCCL Ov^ 190H to VAAa^ /bl 190 H
tliat T last saw h -^-''■' alive oti U-0-/CL '^^ 190 'i
and that death occurred, on the date stated above, at ^ M. The CAl'SI': OF 1)I':AT1I was as follows:
CONTRIHrTORV
Mi)}iths \ Days
Hours
DC RATION (SIGNED )
Ycixrs
J. Vj\. oijoo
Af<ynths
Pays
I/ours M.D.
X^O.
OXWy\XX'VL<.L
f\fsi(if<i ill Siiu /'i iii/r/fro "" )'riii.< \ .l/";////> oC (^ /^<'i'
I'm: A]u>vK STAT)" I) rKKsoNAi, PAR rur I. \Rs \Ki: rKii-: lo rui: HKST oi- Mv K.Nt >\\"ij:i)<", H AND iu:i.n:K
(Iiiforniatit
-Z/W.'yy^
(A<l(lress 1. V^ i ['K VSj /CCVA,
HOlU
St
ULvvq '^M IQOH (Address) ^^l
Special information only <"r Hospitals, Institiitlons, Transienls,
or Recent Residents, and persons dying away fro:n home.
Former or Isual Residence
Wtien was disease contracted, If not at place of deatli?
Hew lonq at Place of Deatfi ?
Days
ri.ACl-: OI" lU'RIAI, OR KKMoVAI,
DATIiof HiKiAi. or KKMOVAI, i 190^
(Address
N. B. Rvery item of information should be c.-.refully siipplieil. AGB 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 dyin^ away from home should be 4'*'*" '" every instance.
Ui
il
rffl
im^
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
IJoanl of Mcalth-I' No. 15 "^'^L;'!*^ J'-^'^ <^'o
J)(f/r Fi/rff,
I 190 \
Deputy He^^r. ^ Ticer
Be^istered J\^o. 1 ooH
DEPARTMENT ()F PUBLIC HEALTH=City and County of San Francisco
Certificate of H)eatb
( Ta. S. StanC>arD ) PLACE OF DEATH: — County ofCja>'V' JXXX/>'VOL4.C{.City of *3^€L/Vu 0 AXXavca^Cc
rNo.
w lb
D
>^^A-trv\,
y
.. CX'-CL^,
St.; I Dist.; bet.
."LcYV
(ir DC*TH OCCURS AWAY FROM USUAL RESIDENCE give facts called for under "special information- \ IF DEATH occurred IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. J
and oUXC'VvCrv'XV )
0
FULL NAME
WA/WJX)
<X/Y\^^.
s )•: \
PERSONAL AND STATISTICAL PARTICULARS
^ JL/-yv\^^(xXjL \xA\.kX^,
DATJ-; Ol- HIK in
x*.!-:
Get
iMotith)
MEDICAL CERTIFICATE OF DEATH DATE OF DKATH
Si
(Day)
fVtar)
'[
siMijv m\kuii:t)
fWriUin social (lesiv:nati<m )
HIKTHPI, AOK Stall' or t'oiiiitrv*
NAM J Ol
I- A III i:r
IUkTHIM,A<K • II- I AIIIKK (Statt or ("ountrj')
MAIDKN NAM}-: Ol- M or I IKK
HlklHPI.ACK Ol- MoTUHR 'Stall- oi rouiitrv
/hn.'.
(Year)
(Month) A (Day)
I HI-; R J-:HV C l-: RT 1 1' V/ That I attcndcMl deceased from
LWx:j X^ icoH to lU^.CjL
X^ lyoH to
that I hist saw h «i-^vj alive on
CL.
io
190 H v^ i)^' 190 H
and that derith occurred, on the date stated above, at H ^•v \^ The CAlSh: Ol- DhiATII was as follows:
viD K/s^^y^A^^ \J/v>jlw\>v^'vnwa^.<^
DCRATION CONTRIP.UTORV
I) I' RAT ION (SIGNED)
]'cats Mo)iths o Pays I/oiirs
r.VOAu
Years
Mo)itlis
Pa vs
AV
OC'Cri'ATlON
Rrsidfii ill Snii f'l tun ism
ol^cux O/CuyVrvwwc
rm-; aho\i-: srAri-.n i'Kksonai, tar i hilars ari-; irik to rii j-;
IlKST Ol- MV KNOWl.KDC.H AND M1-:M)-;F
(Iiifoi iiiatit
\j
1
fAdd
n-ss
II
IXa VA^-tryyu M Xxx/CA-
J
//ours M.D.
t\^q '61 TooH (Address) 5 Hi? d-U^L\X\) it
M 61 T()oH (Add res
;IAL INFORMATION
SPEClJiXL INFORMATION only for Hospitdls, Institutions, Transients, or Recent Residents, and persons dying away from fiome.
Former or Usual Residence
When was disease contracted, If not at place of death ?
How long at Place of Death ?
Days
I'l.ACK Ol-' lURIAI. OK kI-:M<»VAI.
DATFo! I'.iKiAl. or R1-;M0\AI,
r
(Address , 15" XH. UXAr^LkX>try:u Bl
!N. B. F.very lter« of information •houici be ctirefully supplied. AGB should be stated EXACTLY. PHYSICIANS should
state CAUSE OF DEATH in pliiin terms, that it mny be properly classified. The "Special information" for per- sons dyin^ away from homo should be £iven in every instance.
.t
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
M....i.l..nir:,ltl. 1 No i^^-^'^^"'^"*^'"^ " REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
l)(t
h' Fi/r(/ , 3jLJ^\XjL^^\AM/yj i IfJO^
Be^isfci'Cfl J\^o,
1 339
Deputy Health Officer
DEPARTMENT OT PUBLIC HEALTH=City and County of San Francisco
Certificate of IDeatb
( "a. S. Stan^arD )
PLACE OF DEATH:
No. \\
ri^ iLa"^
County o{Oouy\) ^ KjOu^\j^kA<:a. City oi^OJTs) 0 /vCXyv-vc^wAl^c^
^
Dist.; bet.
(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
PERSONAL AND STATISTICAL PARTICULARS M.X A . f\ I COI.OR
A.>My>^,-^
■cJu
LL'J^ujtx
DAIl-; i)l IWKll!
\ < ; V.
(Dav) (Vfjir)
S^
) 'tUt I !•
1
M.miii^
^t
Pa 1.
STN(.1.1-. M.\KUIi:i). WIDOWl-:!) <»K DIVDKrKf)
'Wiitriii «)ri;il <!< -iv'iiat ii m)
!UI< IMI'I.AOK ' stati- or (."ouiitry)
NAMR OF
iATm:R
lUk rniM, AiH
ni 1 Alin:R
I shitf or I'onntry)
MAIDI'.X NAMI-: <>l- MolIlKK
luk rui'i.ACK
«)1" MOTHHR fstatc or t'ouiUrv)
OCT !* PAT ION
MEDICAL CERTIFICATE OF DEATH
DAT}', Ol" Dl'.ATH r\
(Month) A (Day) (Year)
J ni':Rl':HV CI{RTIFV, That I atteiKkMl .lecoascd from
190
to
that I last saw h ~ alive on
I90
atnl that death occurred, on the tlaU- stated above, at ~~ M. The CATSlv Ol- DI'ATIl was as follows:
1)1 RAT ION )'L'ars Mont /is Days Hours
CONTRIIU'TORV
DIRATIOX _ Ytars .. Months (SIG
NED) L^iVrrLUv 0, Vij ^■
Pays Hours
Ola'vxL M.D.
^f.Olt/f'
Pa 1.
Ill I. \Il()\-K STATl-.D IM-: RsON \i, V A Ri'Ur I, A KS AKl". TRll': To Till-:
in-.sr ()i- MY kno\vij:d(". !•; and in:i.ii:i-"
(iiif
^'KJJyJi
' Xi'.dress ..
Ij^Vvt) I iqoH (Ad.lress) L^\-^-vA,£A^ Wi^^ SPECIAL Information only for Hospitals, Institutians, Transients,
SP_
or Recent Residents, and persons dyinq away from fiome.
Usual Residence 1 1^ ^ ~ H IL WxM.
Wfien was disease contracted. If not at place of deatfi ?
How long at Place of Deatfi ?
Oavs
V\ \QV OV lURIAl, OK K1:m<»\A1, DA'I1I% ot lit KIAI, or RKMOVAl.
(Address .
N. B.-
-F.
8
ivery item of InWmaf.on should be carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should tate CAUSE OF DEATH in plain terms, that it may he properly classified. The ' Special Information for per-
sons dyin^ away from home should be given in every instance.
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
)(,,;, 1. 1 -f H.'iMii •■■ ^■" i> t"t:'*':;^'"'^''^"'>
/)((/(' hailed ,
\
lf)0\
Rpgisfcrod J\^().
<340
j-^ Deputy Hcnfth Officer
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of H)eatb
( "U. G. StanDavD )
PLACE OF DEATH: — County
ofVJCL'-ryj 0 .^XXoO/CAAOo City of vJCUTv 0 A/O^-x^CA.^i. ci.<j
-I
No. ni^i M ll/OXLCAV St.; 1 Dist.;bet. 0 .MX^i and UAXCtnO;
/ ir Ot»TH 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 tEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. /
FULL NAME
KAXhj
>\-.\
) \i i; (ii r,iK 111
PERSONAL AND STATISTICAL PARTICULARS
xJa
I Moiiih I
U
(Day)
A^\
MEDICAL CERTIFICATE OF DEATH
DAi'iv t)i' i)i:.\Tn
\<.i':
'I 1,1
bS r,„.;. O
.^filHlllS
ao
'Year)
Pit V.v
W !!>( »\Vi:i) nk DIVoRTKI)
Wiitciii •^iKinl il<si>.Miati«in )
itiK rniM.AOK
Slatf or Country)
FAT II IK
lUKini'I. \(H <>|- |- A III }-:k
f "^tatf 111 v'onntrv)
maii)i:n NAM1-:
oi MOTIIHK
luk rmM.ACH OI" M()Tm-:R
lStat<- or Coiintrv)
UXVWX€L/YVU
1 •
Moiith' [1
< Hay
(Yt-arl
I m{Ri;P.V CI'RTII'N', That I atlfii.lr.l «Iccfaseil from
tliat I last saw h -LTk^-v alive oti Vw^AA-O sS U k^ "^
and that (kalh occurred, on the date stated above, at " VJ - M. The CAl'SI' Ol- DI-ATlf was as follows:
I) r RAT I ON )V<;/.f ^ Mouths b Days
CONTRIIU'TORV Qj OrsuO^^rv^^^KXj^Ary^
Hours
I
occt
TATIOX (\
\
Rfsidetf i)f San /'i uiii isro — )V(/;y "~ M<'nfh^
/hn.
Till-: \lto\-l-: STAT)'.!) I'KR-iONAl. I' \R iUT I. \KS AK i: T k I l'. To nil':
iiivsr OI- Mv KX()\\"i,i;i)<". I-: and ip.'.ij)-.!-'
' I iif' .: maul
fA.Mress Ill?> Ni f\yCLA.<rVyj
■^
1)1' RATION }'cars ^ Mont/is ^ /^ays Hours
GNED) LUL^A-jUL L^OoWLtNj M.D.
Xj\<\y I TQo'i (Address) HHCO ^ \'\ U\^ cJt
Special information onlv for Hospitals, Institutions, Transients, or Rffpnt Rfsidpnfs, and persons dyinq away from home.
Former or Usual Residence
When was disease contracted, If not at place of death ?
Hew lonq at Place of Death
Days
190 t
ri \CF OI" lU'KIAI, Ok kl-;MO\AI. j DAJl'.of l!i kiai. or kI-;M()\"\I
(AtMrcss
N. B.
-h
8
ivery Item oV informHtion should be cnrcfully Hupplied. AGB should be stated F^XACTLY PHYSICIANS «houId tate CAUSE OF DKATH in plain terms, that it may be properly classified. The Special Information for p^r-
sons dyinll away from home should be ftiven in every instance.
I
il'J
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
. r„ uh ,. vo i.^-^^^ H^l'^" REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
Dale hailed ,
\
10 (J\
Hegistered J\^().
1 34 1
Depu
t' *icer
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Ccvtificatc of IDcatb
tl. S. Stan^ar^
QfD
PLACE OF DEATH: — County of 0 0.-.X -J .►UXz-vvca^c^ City of ^J'Cv->^ O/vawtA...
f^
iv)
f4o;rVaYtC*A^ ^^'-'-^VUi. vxi^l i-( I St.;
-tu, V
«i I i)^
Dist.; betr
and
-)
I / iiciiAi Dr<; I nrisir F nwr facts called for under special intormation ■ \
( '^ r/rc;T°H^OCC^%Tot~"° --"' 0^'?^^f.Tj;U'^O^r.;i name ..ST..0 O. STH..T ..O .UMB.. j
FULL NAME
Ll>vt<rv^w^C)
L<xcL(5
V^^c^v
si:\
DAT!-: Ol IlIK 111
PERSONAL AND STATISTICAL PARTICULARS
/
rVO'
Ic
M.)!ith)
\'.i-.
Hfc
)'rai
may)
M.,ntln
(Year)
Da\>
- \ , ; 1 M \kH ll-:i).
U 11»< tU i;i» OK DlVoHt l\I)
Wiitfin >.<Ki;il «U >i>.'iiati'>ti>
liik 111 i'l, \>" )•:
•~t.-it' or < •niiiliv^
N \Mi-: »>i- 1 \ rii i.K
I'.ik riiri. \i i-;
<tl l-ATin-.K ^t:it( or Cotiiitrv'
\i miii:n n ami
"I MuTlU-.k
lilkTHlM.Xri-:
<'i" Morm-.K
'St;itf or C'o\itUr.\
MEDICAL CERTIFICATE OF DEATH DATE OF DEATH
.^Q
(Day)
igo'[
(Month) /J 'l>:iV' (Year)
TTThrI^RV CHRTIFY, That I attciulcl deceased from
to ■ ■ I9Q
IgO
that I last saw h-tr— alive on
190
an<
1 tliat death orciirre<l cii tlie dali- ^tati-d above, at M, The CArSI-: Ol" Dl'-ATII was as follows
1) (x.i'xr^vXccv TOJL<x\t) ^^\jUL<x.<i'-
"S^y<X-\>-trX^' >v.'
oOCrPATlON
AVu'i/rif III Sii n I'l aiii i>fo
).,;,
\f.'iilh' ' /*'"
riM- \i!(.\i- ST ad: I) i'kknonai. r\KruTi,\K^ aki: luri-: ii» rm-,
r.l -r<»! MV KN< t\\ I.l.IX.i'. AND BHl.li:i'
Info; ni;inl
<UL
^\.l<lr.
I) r RATI ON y^'f^y^
CoNTUinrTOKV
Mouths
navs
Ho 1(1
Years
Months Pays
f SIGNED )...L8. \h- \Ax>^ U^V>i> LKS>yA T,o'i fAd.ln-s<) vrunvi^^
Hours M.D.
SPECIAL INFORMATION only lor Hnspitdls, Institulfo^. Transients, or Rerent Residents, dnd persons dying awa) from fiome.
Hov> lonq at
Piafe ol Death? Days
Former or Usual Residence
Wfien v^as disease rontrafted, If not at piai e of deatti ?
,., \(,-V <)!•• I'.rKIAI. <'K ki:m"NM-
^^iAL.^%y^_
!)\llJ\ot' HiiUAr. or RKMoX'AL
Q) jJfCX. '31 T9oH
>V
■' »N —— 1—11— —^—^^^—■■—'—^— —"""'— "^^ f t cl FiXACTLY. PHYSICIANS Hhoultl
!N. R. p.very item oV inform.ition should b.- cnrefully HuppHecl. AGh «''""'; l^.V %he "Special Information" ?or p-r-
•tHte CAUSn OP DKATH in plain tcrm«. that it may he properly U»»*«.>.
«on» dyinft away from home Hhould be feiven in every instance.
it^
I
iV
m
m\
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
n.,,Mr.l of HcMlth I- Vo 1^ ■'"tS?^"^ I'^'^l' <-*"
Registered J\^o,
134^
IhUc W^v/, dx\^te>^JLjLrv I 100\
\j^,^^j^\!U\j^ Deputy Health OfTicer
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of 2)eatb
( Xl. S. StanC>ar^ ) PLACE OF DEATH: — County of Oo<jy\j 0 /u<X/>^cv<i.ccCity of Occ/v^ 0 Axx/>^t^^A^
No.
IXo
X'O'
(
St.; A Dist.; bet.
H
d
ir DCATH OCCURS AWAY FROM USUAL 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 STREE
sil
lAL INFORMATION" "X T AND NUMBER. /
and
FULL NAME
oJU.
V
OlVm
SKX
DATE OF lUk 111
PERSONAL AND STATISTICAL PARTICULARS
I Col.ok
' Month I
(Uav)
(Year)
MEDICAL CERTIFICATE OF DEATH
DATK t)I- 1)1;A TH / 1
\AX^'
Montli) [T
1^
(I):iy)
IQO 1
(Year)
a«;k
I ex )'(/;
Motil/l!:
/><l\.
siNr.i.i?. >JA K un: I >.
WinoWKD OK IHYoKklU) iWiitt in siK-ial .I'-^iv'iiati'in)
lUK I'Ul'l.ACK (State or Country^
NAMI-: <)J !•• A I' 1 1 } : K
RIRTHPT.ACK
<)!•" J AIHHK t State or (.'oimtrv
MAIIu:n NAM)
oi MoTin:K
lUR'nilM.ACH OK MoTHKK (Slalf ur founti \<
I in<:KI<:r.V CIvRTII'^V, That I attendcMl (leocasc«l from lb 190S to LitA^ XH 190 H
that I last saw h LiJ\ alive on V^^^VCL. >- \ up '\
an.l that death occurred, 011 the date stated above, at ""
^ ^ M. The C^\rSl': OI' I) I-; AT 11 was as follows:
,i/un CixM. . . . ...v ».-
DC RAT ION I )'t'ar.<! Mouths J^y^
CONTRIIU'TORV UAJkx\AVrL.atMA^ oUx<Vt\vt\
Hours
OVlvCtilVOZ^ ^ JsjUcaaaJlmiK' LLb-
DIRATION
Years
Mouths Pays
V^Vivtcck
A J
y^6^
OCCUPATION P f\
/-
'\,-iJ/-if m V,/;,' }'i (111, i^<-.> \/^ Will
M.nilh^
/',
IHI-: \HOVK STA ri'I) I'HK^ONAl, l'AK'rii"l'I,\KS AKJ: TKI}-: 10 THK
iu-:sT 01 MY K\o\\i,i:i)<-. i-: and Mi:i,n:H
(Infoiniant
^ X'ldrcss
.^Jl/3
XC)
f SIG
^J</>/\\Xh
, NED) liMrVy^Jl U
Llu^Q ^.>l T«,o'i (Addre<;<) '^^H Oa^CIUa; Oi
OIAL INFORMATION
Hours M.D.
SPECjIiAL Information on'y for Hospitals, institutions, Transients, or Recent Residents, and persons dyinq away fro-n home.
Former or IJsudI Residence
When was disease contracted. If not at place of death ?
How long at Place of Death?
Days
I'l ACK OI- UrRlAI, OK K1:Mo\AI, j DA'I'J'ot IJiKlAf. or Kl-.MOVAJ, rNDl-.KTAKHR \'^' ^ LcTWWtjV "^Lc
(Address 1 io^ \J rtvQ-^L/S-^CVv '^'k
Rv<ry Item of information •hould be cnrefully Huppliecl. A(]B «hould be stBted F.XACTLY. PHYSICIANS should »tate CAUSE OF DEATH in piiiin terms, that it may he properly classificJ. The Special Iniormat. >n lor p«r-
<^_-
N. B. F.I
utate CAUSE OF DEATH in pi
«on« dyini^ away from home should be feiven in every instance.
ii:ii
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
I!,,,uM ..I ll.;ilt)i 1' V<«. !^ ■^T.'^i?''' '^'"^ '' '^^
/)((/(' Fi /('(/,
\AAy^
m
lf)0'\
Regisfei'cd J\^().
\ .348
,^^ Deputy Mc2irh Officer
DEPARTMENT OF PUBLIC HEALTH==City and County of San Francisco
Certificate of IDeatb
( *a. S. 5tan^ar^ ) PLACE OF DEATH: — County of C' Ow/>\; 0/vcv^vi^\^ccCity of C3/0^-r^ JX
^^%\t
1^ ytrCLJLfJk^ LU.uA,cc>>^ St.; Dist.jbet.-- and ■ —
/ IF dAjth occIurs away rnoM VSUAL R E S I DE NCE give facts called for under "special information • N
V IfIIoEATH occurred in a HbSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. /
m ft -1 ^
FULL NAME J A.CLO'XCu> v) (AX^w^aa^^-ocuL a
si:\
1 1 \ I I". <»i HI kill
.\«.i-;
PERSONAL AND STATISTICAL PARTICULARS
1 C<iI,(»K'
AA.^
U
MEDICAL CERTIFICATE OF DEATH
I)AT1<; ol" Dl.AI'll
d
(Moiitli)
(Day)
l9o\
(Year)
( Day)
(Vear)
) '(•« ; .
J, M,;it/is ... V.
Pit \s
sTNf*.r,T?. M.\kKn:i>.
WIDnWKD OK ni\<)KrKn
iWiitcin '^cK'ial <U>*i>.'^nat ion)
lUKIIirLArK Staft- or Comitrv)
^^^jL/dLcL LoJj
I' AIH 1 R
111 .
ill t
I
lUKTllI'I.ArK
oj- I Ariii:K
(Statf or Ciiiintrv^
m\ii>i:n NAMK «u- .Mi>rin;K
niUIHl'UACR
nl Mo'nil'.K
( Statf 111 ("()niitr\-^
I III<:RI-;HV C1';RT1FV, That I atU'n.Ud <lc(vasc(l from UvVaXX. I90'l i^^ .XXkaJIIX^ "hS \(p\
that T last saw li '->^ » alive on \Aaw\^o. :5l uj^'\
and that death occurred, on the date stated alxive, at
^ M. The CAISI-: OI* DIvATII \\as as follows: , \J AJt^k^»^^^CCtvv>vX mB-OvXJ^*
1)1" RATION Years • Mont /is
CONT R I lU'TOR Y ..™..... .-
Days
I lours
)'rars
nrCT^PATlON
f\f>itl^il in Sii>i f^raMCis^o..
Y,,ii.
M.<},tli>
/;,;
rm \i!u\i-: sr \ri:i) pkr^^i^x \i. r \k run, \ks aki-; rKiH to riii-;
lU-.sr OI' MV KN( »\\M:I)(". 1". AM) Hl-l.n-.F
(h
DTRATION (SIGNED) UJLVUA
IX^; 1 i(,o'i (Ad.lres.) ^^Ovi\.V\.li
Months Pays
Hours Wu M.D.
Special information only '<"■ Hospitals, Institutions, Transients, or Recent Residents, and persons dyini 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.AClv OI- lURFAI, OK kl-:MO\Al,
i)ArL;<)t" HiKiAi. or ki-;moval CJjJ^^Xi 3v T90H
rXDKRTAKKK J\jJCXu ^ OKj CVOy^CV^V
f information should be carefully supplied. AGE should be stnted FiXACTLY. PHYSICIANS should OF DEATH in plain terms, that it may be properly classified. The "Speciol Information" for pt.r-
M. B. Every item of
state CAUSE
sons dyin^ away from home should be feiven in every instance.
%
111
It
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
U...-ir.! ..r ll.Mltli I- No. Is lJ-«i;''af^»?^l<S:l'C.)
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
■I.
':il
i' :
I •
I I
1!)0H
Uegistcred J^''o.
1 344
Deputy Health Officer
IS;'
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of IDeatb
( tl. S. 5tanI>arC» ) PLACE OF DEATH: — County ofCjCL/Tu 0 AXV-rvCA^<x^ City of 0<Xa^ J.VCU'ivCv.^tU)
P^.
dt^V^^ LLa.^ 'Jf'.^A-^vSt.; Dist.;bet.
and
•)
(IF DB»TH OCCpPS AWAY FROW Op U A L R E S I D E N C E G I V E FACTS CALLED FOR UNDER ''SPECIAL INFORMATION' N IFJ DEATH OCCURRED IN A Hol(^PITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. /
FULL NAME
a>tu.
PERSONAL AND STATISTICAL PARTICULARS Sl-.X OPS A I CCH.Ok
i>\ii-; oi itiK 111
%^olXx
.\c.K
llMiith>
)'/■(?».
(Day)
(Year)
.OLh^aoAxt
>vcrl
OL^vcrai)
WEDICAL CERTIFICATE OF DEATH
DATE Ol" I)i:ATFr
(Montli) /
(Day)
(Year)
1
Months \ t Days
^IN<",l,i:. MAKkll-:!*.
\\ 11)1 »\\ i:i) OK ii!\< >Rvj; n
'Write in xii-ial fK-sit^uat imi)
■ Statt or l."i milt 1 y)
NAMl- OF' KATm;R
OI" l'ATUi;k
•Statf or lOuiiti v)
m\ii>i:n' x.\mi-:
ol MolHHR
MiK ruruxrH Ol Moriij':R
(Statf or I ()\intrv)
C)-c/w<yLl
?
I irRRr'HV CIvRTlFV, That I attended dcroa^ed from
U^^-cv XO 190I to LVw^ 'iA i(p*H
tliat I last saw h ^^ alive on O^Vc^ oC 190'!
.-md that death occurred, on the tlate *^tated above, at M. The CAISI-; Ol- 1) I! A Til was as follows:
VwAvcrLL^^cw Ov>w^x^vt.v^^--
V-^ArJ ..
I
(OU(\Axyy\.^
nr RATION .--. Vi-ars Months It) /)ays
CONTRIiU'TORY U-^'v^t'Lovr%.,«r:v^.»n«(V.
Hours
Years
%
DURATION
d.' ' TQo'i (A.ldress) ^XO \K.\\. Lt
iNED ) AM1\X^
IX'aJ
1^
Hours M.D.
Special Information only for Hospitals, institutions, Transients, or Recent Residents, and persons dying dway froii home.
/),M
iMii. AHo\i.: sr ATI" I) PKKsoNAi, I'.XK rii'ri,AKs .VR}-; rKiK r< > 111 )•;
In-;ST 01 MY KNOWI.I.DCH AM) lUvl.li:!'
(InfoinuMit
(Add
cwy\.
Former or Usual Residence
When was disease contracted, If not at place of death?
How lonq at Place of Death ?
Days
I'l.ACH OI- IJl KI.\I. OK Ri:.Mo\-.\I.
n.XTJ'.o! Hi KIAI. or K]';Mo\A1,
(Address 5i^^lX- \^lA/v Jt
ijjji^ll
IN. B. Every Item o* information should be cnrefully supplied. AGK should be stntetl RXACTLY. PHYSICIANS should
state CAUSE OF DLATH in plain terms, that it may be properly classified. The "Special Information" for par- sons dyin^ away from home should be j^iven in every instance.
• ■
^i
h
h
n .
I'l' ■ ,1
'tpl
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
i;.,,n.l "f flcaltli J No i^ ^^^. nSiV Co REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
Eeglstej'ed J\^o.
1 341
Dale /'VA''^6-^vLo>-.^J^-t^, 1 1!)0'\
lu,^^^ 'L.v^ Deputy Health Omcer
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Cevtificate of S)catb
( *a. S. StanC>arC» )
J? ^ , ^ ^
o
PLACE OF DEATH: — County ofUa^u OiUX/^TLCUiCoCity ofJ/a/rv J.>va/>^o<.^ao
'No.^
it
(5])
cy^'
l-vJ^;
Xl;
St.; Dist.; bet.
-and
(IF DtATH OCCURS AVVAvIfROM USUAL R E S I D E N C E G I V E PACTS CALLED FOR UNDER "SPECIAL INFORMATION ■ ^ IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. /
0
FULL NAME
XX' v-cn v.u<;iCL'
/Oi-XO-CrvXi.
PERSONAL AND STATISTICAL PARTICULARS
DA II. «)!• Hlk 111
COI.OR
'\xXjl
I M-iiilh)
At.K
Mb ,■,-„,, "i
(Day)
.V. -»///>
(Vear)
IH
An.
MEDICAL CERTIFICATE OF DEATH
DATR OK 1)1;ATH 9
(Monlh)
1
(Day)
(Vi-ar)
SINC.I.lv MAkRIi:!).
\vii)i »\\ i:i) (»K i)i\< )Kri: I)
iWiitciu •soti.il ^I^■^iJ.'n:llioll)
lUK'nn-i.ArH
(Statf' or (.""Miiiti v'*
namt: oi-
FA'III J.K
inkTuri.ACH
OI- lAlllHR
( Statt or Country^
M MIO'tN NAMK or MoTUHR
r.iK riiPLAi')-; <»r M(»rm-;K
( Sl.iif or r<)uiitrvt
?
I Ifl'RKRV CIvRTIFV, That I nttcnrled deceased from
hv 190O to ax^tj I up'i
IM..L 1 .<..^t saw h-i^A' alive on UX^vt I T9o'i
and tliat death oceurred, on the datr stated above, at o • H o CI SI. Thr CAl'Sfv Ol' l)l«:.\'ni was as follows:
1)1' RAT ION y'rars 3> Mouths '{ Days Hours
C< )NTR IIU'TORV \^lKA^Crvu\-^ A^
DURATION
)'rars^
J/ou/Zis
IhlYS
I
occri'A rioN
h'fu'i{r({ in S,ni /'i a 11, isri>
_ OX\yYWa/>XU,
) '(•(//
MouHn
/),/!
rni: nhovi-: stati: d i'Kusonai. i- \k iuti.aks .\k i; iKri". ro rn i", iu;sT OI" MY KNOW i,i:i)('.i- .\M) in:i.n;i''
Hn fii; luaiit
.VM..SS iHiw GlIJLit^ c^t
(Signed) .sJxcx/i (lb . VJUy^yrcU'val)
1 if)oM (.xd.lnss) b?>bli),a>vj;vat
Hours M.D.
SPECIAL Information only lor Hospitals, Instifulions, Transients, or Recent Residents, and persons dyimj away from home.
Former or --ro^Vl/l/l^
Usual ResidencelMl 1 1 L UXJUaaIAj ut Place of Deatli ? H ... Days
When was disease confrarfed, If not at plare of death ?
ij,ACi<: Ol" m Ki-Vj, OK ki;mo\\i, j d
INItl'.KTAKl'.K
(Ad<lress S Hb
I u 1 Ai, or K i;m» >\ .\ I, ^ TQO'i
v^orW)
d
N. K.
ivery item «V inform,.tion •hoi.hl bs cnrcfully Hupplicd. AdB Khot.lcl be «tnte.l F.XACTLY. PHYSICIANS «houId t«tc CAIJSF: OF DFATH in pliiin terms, thnt it msiy be properly claHsiticcl. The Special IntormHtion *or pi.r-
«on« <lyin^ nwny ?rom home should be ftiven in every inHtance.
c
1
c
. .*
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
,,,,,,.1 of ll.iltli VSo. y^-^'f^^^li^VCo REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
ill
r.
m4
., I
Ihf
to FiJpd, dx^Atx^JLvv I lOO'X
Registered J\'*().
1 346
D e p u t r aji h "O • f "^ ^ ^
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of 2)eatb
( Xa. S. StanDarD )
PLACE OF DEATH: — County ofO<XA^ ^ K<xrY\^<AZ^ City ofO/OA^ J Axl.-wca.<l/c o
No.
O-di-^
-vc
txxl'
St
Dist.; bet.-
and
fls AWAY rhoM USUAL R ESI DENCE give facts called for under special informatio
CURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER
- )
FULL NAME
PERSONAL AND STATISTICAL PARTICULARS
S}:\ A (\ I C<H,<)R
V-Q;
\)\V\-. Ol- lilKlIl
|
1 |
7 |
|
1 Mmitlit |
(Day) |
7^5 t C/rar)
a<;k
HI
} Vi/ >
M.nilfn
/>(!•
sINCI.K. MARKIi:i)
w ii)(>\vi:i> OK Divouv i;i)
<\\tit«in social <ltsi>^nati<)ii)
i
lUK rUJ'I, At'K ! State or (."ouiitrv^
NAMI-: <>I" I- ATni:K
niKTHI'I.ArK
()I- I'AinivR
< Statt or Country)
maii)i;n nami: of motmhk
lUR'l'Hri.ACK ()I MDTHHK (Statf or (.'onntrv^
4 ^ 9
0 A^CrUw^cLCoAX)-'
MEDICAL CERTIFICATE OF DEATH
DATK OF DKATH /H
KM
(Mcinth)/]
(Day)
fgcA
(Vt-ar)
I inTRrvBY CKRTri'V, Tlint T atlriKlo.l (Icoeased from . iXcuq. .1^ 190H to LIa^^ 'il T(p H
that I last saw h X'Vva alive oti VX<^v.-<^ 6 1 190H
and tliat (K-ath occurred, 011 the date stated above, at v-o5 CL M. The CArSf'! ()1< DIIATH \va^ as follows:
^X'\...>crv%A^
4tAix<xi %xWaixt^3 Ib-JjAvO O/CJU V^-<J^2
DT RATION )Va;.? Mouths Pays Hours
CONTRIBUTORY LlVCXJL'^'VXA^tX
duration (Signed)
^
Mout/is
Hours M.D.
oc
:cri>Ari()N 0 [) A
rm: \iu>vi-: spAri-.n i'Krsoxm, i'artuti.ars ari: iRri- I'l rm-: i}i;sr OF MY kn<>\vij:i)»", F and Mi:Mi;f'"
!/,/»///.
/ 1(1 1 ^
I}i;sr OF MY KN<>\VIJ:1)»", F and VAAJi-.l [nformant Vj . VJ . cKo . \jL<X.<Ji
"t
A.l.lrrss . LcLu ^^ ^ ^ Ch^vd.OX
QjL^t; I TQoH (A.l.lress) LAt<.i\cG (UD (H^ v|aa t<V.l
Special information only for liospitdls, institutions, Transients,
or Recent Residents, and persons dying away from home.
"-^ I Hew lonq at , .
tux. Place of Deatli? IX
Former or u . m
Usual R sidence i » v
When was disease contracted, If not at place of death ?
Days
I'l \CF ()!■ lURIAI. OR Rl-:Mn\Al. j DAIFiiI IMkiai. or RF;M0\AI, rNDKRTAKKR U <xLlAatx V] |\^DL\^ ^ L<)
IS'XH Ot/CrtAl^OA. al
(AcUhcss
N. B.-
-v4;
H^t.
-Rve sta
rry item o^' informntlon «hould be carefully supplied. AGE «hould be stated BXACTLY. PHYSICIANS should te CAUSE OF DEATH in plain terms, that it may l>e properly classified. The Special Information tor per-
sons dyin^ away from home should be j^iven in every instance.
\ %
1 tu
r ^
" '' , HI
llli
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
I
liegLsf creel Xo,
134
No.
DEPARTMENT CrP PUBLIC HEALTH=City and County of San Francisco
Certificate of S)eatb
( TH. S. StanC>arD )
J? op ^ ^
PLACE OF DEATH: — County of^)/CX/^^' 0 /uX/>vCa^ Cc City of OxXA-v 0A.CX>vac4.r (
b IX V^'CA^Cov St.; 1 Dist.;bet. obxJ|'Ur>xt and jVtOJv>xu.
/iTlF DEATH OCCURS AWAY FROM USUAL RESIDENCE GIVE FACTS CALLED FOR U N ti E R "SPECIAL INFORMATION ' \ \
\\\ IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / ij
FULL NAME
o.^\>.
\\^y\^A
SIX
i» All-: < ti iMK rii
PERSONAL AND STATISTICAL PARTICULARS
, coi.ok
(Moiith)
I
^<r
MEDICAL CERTIFICATE OF DEATH
DATE OF DKATH H
(Day)
/ 'J.s ^)
(Year)
ACiK
^^ » )V,M« ^,
Months
Duvi
^INCl.I*. MAKRIi:!)
\\ jDi luj-'ii OK i)i\<»Kri:i)
(Write in sofial (h >-i}.'iiatii m)
L..
HIKTMl'I.AOK
(State or (.'oniitry)
NAM1-. <)!■ FAT}n;R
UIKTHlM.At'K
Ol" IATHKR
I Statf or Coviiitrv)
MAIUFN NAMK
«»i- Mi>rin-:K
lUK'iniM, \C\', <»r MoTlIJ'.R (State or CfWHitiT)
C' X^^i^^/Dj
(Montli) \
?»C IQO^
(Day) (Year)
I Iin:RP:BV C1';1vTI1'\', Tliat I atteiKU-d dcooascd from
.'.' !(/) to — — — — -~ —190
tliat I last saw h.trtrrrrr alive oti — •••" • ~~' 190
ami that doath ocmtrreil, on the date <tatt'<l above, at M. The CAISI-: ()I« 1)1':ATII was as follows:
1
DTRATrOX Vrars Months /hns //oi/rs
CONTRIBrrORV
aa
DTRATION-^ }'ciirs
^00
J/o/z/Z/s /fays Hours
<X/Wa VX.A < M . D .
<X
OCCrPATION JP 0
h'ryidfif ill Snii Fi(Uir''^,-n 'o )\-,ii< *" .y/"i!f//< ' /l<ns
I'lii", \HovK siAri-:n i'Krsonai, i> \k iim.AK^ aki: TRn-: 10 11 1 1". iU';sT oi- MY kn()\vm:dc.k and Hi:i,n:t-*
(A.MrcKs
10b
(Signed) OAX/cUi^vok 0. u^^ . .. . —
LLvq.'^l Tc)o'i (A.l.lress) IgOl^ UXxAlx^v ^1
PEC^IAL Information '•nly tor Hospitals, Institutions, Transients,
or Recent Residents, and persons dying away from home.
Former or Isiial Residence
When was disease contracted. If not at place of death?
How ionq at Plare of De«th ?
Days
ri^xcK oi" ijiKiAi. OK Ki:\ni\Ai,
rxni'.R TAKl'.K
(
DATlUo!' HiKiAi. or K1:M<i\\1,
151 K ] \l. I >K K 1 . \n '\ w,
vT/VcxtiU) Co
N. B.-
•F.very item ni information should be cnrefnily supplieH. AdR s-^ovhl be stated F.XACTLY PHYSICIANS should state CAUSE OF DEATH in plain terms, that it may be properly classified. The Special Information for p-r- sons dyin^ away from home should be fiiven in every instance.
P
r
^
r^
m
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
H,,:,t.l <.f !I<:ilth »•• No 1^ ■^*?^«';r'«^ "^ »' <■"'>
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
i V
. I
I
/)(ff(^ /vVrr/, QX^pX^L-^wU-Uv
nJO'i
llegLstercd JS'^o,
l.">4«
,^u Deputy Health Officer
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of IDeatb
( Ta. S. StanJ>ari) )
PLACE OF DEATH: — County
ofO/Qyvu 0 . VCu^ v'C.^^.^yco City of C'CV^v^ J A/X/^tv-ol/Q^oo
No. ^\'^ X^ C^<3-\Jc.<i St.; 10 Dist.;bet. \X ry^<L and 1'^ AycL
(IF DtATH 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
OyK/CrTVL/O^^CtyAxi^k; \XJoJL<i^AJj
•>i:\
i).\ri-; •)!• Ill Kin
PERSONAL AND STATISTICAL PARTICULARS
I
MEDICAL CERTIFICATE OF DEATH
(Day)
/IIS
(Vcar)
AGK
l^^
)Vl7» >
.?0. M,ni
l/i>.
x-b
n,tv.
sixc.Mv M\kun:i)
WIDOWKD OK I)IV«>Ki }•; I) (Writfiti social <ksi''tiatii)n)
'Statr or «,"oiiiiti v^
i^
0<yy\j 0 /uCO^K^^./CA.<i^'C>o
DATK OV I)I;a TM
(Month)
(I)av)
IQO 1
(V.'ar)
I irrvRHRV CI'RTII'V, That I atteii.U-d .Icci-asod fn.iii
I f LCtu X.\ up'l t(i LAa^XX .'Bj I i()oH
I last saw h-^ Viv alive on V^vvv^V '■*-*-^ l<)0 *
that I last saw h-^ Viv alive on L/'LV\-<5l ' -^-^ I90 \
aiul tliat death f)cciirrc(l, on the date '^tati-d ahove. at V» ^ M. The CAl si: _(_)!' DI'iATIi was as follows:
y^ X.<X/W\^^.^^r\-^^JX)\JUi .vj -CVA>4-NyCwL^r-<!M^
\,-\j:xhJji
II*
I, "■'''■.
JyfurwttxA \. Uj,<xX' OI- rATiiKK y (Tpy
istat* ot Coiiiitryi -A \f['
ocrtX
0/OUT\j 0 ^^<X/>vt,>^ CO
Dr RATION
JV(7r.? 3 Mouths \0 ^Davs ? /lours ^
MAIDHN NAM}-; OF MOTHHK
itiRriii'i.ArK
01 MnruHR >
(state or Country)
occur
k'r'^lii^if III Si! H / I It Ih I -III ** *"
C ( ) N T R I lU'TO R V Ca n('\XjULA!^A^^v'v^<oJL 'J.AA.lN^A^CA-uL<^i:i-u"5
dU AwX^AA-.rOl/Ow» . „ 4- 0 V ,
)V(r;-:f o Mtinths Vo /?(;]■.? Hours
NED ) \( IxxUruxAV
I) i; RATION (SIG
X^> I
i()0 '\ (Ad<ln'
M.D.
ss) 5.0 w i oj\KXjX dt
Special information only tor Hospitals, Institutions, Transients, or Recent Residents, and persons dviny away from fiome.
) 'rai
M.iiilh^
/'</ 1
III i: AHovi: SPA ri;n i'krsoxau tar tutlars ar]-: rRri-: m rn i-;
lU'.sT oi-iiN' KN'(»\vij;i)c.i-: AN' !ii:mi:k
'■(^'
Uiifonnrnit
d y\j(XyvOf< VJ . LO oJLcxrttj
\.1.1th>.s H i C5
\X4. dtj
Former or Isual Residence
When was disease contracted, II not at place of death ?
How lonq at Place of Death ?
.. Days
I'I,.i^(.:i'; < >1- lURIAI. OR RHMo\Al, I DA Ti: ->!" HnuAi. or R1;Mi»\A1,
i NDHRTAKKR \l lUrvuxJkxx-k^ U (fc/OAxx^^^ Lo
Ulrcss dl'^HV N ]'\A^,^,^^J.^^,.^J-v^. wt,
(AcU
,«tion should be cnrcfully supplied. AGB should be stated EXACTLY. PHYSICIANS should ATH in plH>n terms, that it may be properly classified. The "Special Information" for p«r-
N. 15.— — Hvery item of Inform
Btate CAUSE OF DEa I H in p
sons dyin^ away from home should be 6'ven in every instance.
■>M>i
w
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
! ;. , . I .
of IK alth I' N.'
\o i> ^-r^^^^iJ US: I' 0.)
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
♦
I
■U^:
iff'* ,1
I.
i)(i/i' Filed,
I'JO'A
Registered J\i''o.
1 ;i4f)
•Wa^v^
Jjl^ Deputy H ". - "^
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
PLACE OF DEATH:
T^
Ultcv^Ur^^
^^^-^^cu
±.
Cevtificate of Beatb
[ 'Cl. 5. Stan^arD j County ofUayw J;v<XAV'Cul,'a.( City of OcuTf^ ^ n^O^ry\.'Z.\^^^0
%
r\
0^
Kct
<xlSt.:-
Dist*; betr
and -"
>ccuRS aiwAY rROM uisUAL RES I DENCE give facts called tor under -special information- \
f^ I _ __ ^^ ^^p NUMBER. /
h f ir DEATH occurs /dwAY FROM MSUAL R E S I D E N C E G I V E FACTS CALLED FOR UNUtK !. f- 1 1, U V IP DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREE
FULL NAME
'Xuy^j... LLa^cLcLcox^^l^"^
V:
-^I:\
i*\i i; »>l UlR IM
PERSONAL AND STATISTICAL PARTICULARS
; c<)i,(»K >
iDixJwt
vj JLAT S' /"fj^X.
M.-iilli)
tl):iv)
AO«
\\ )V,?»v b M.mihy X\
(Vtar)
Pars
^I'SniM. MARKIEn.
u iixtwi'!!) OK r)iv»»RrKn
\\iit« in Horial dt-^i^'nati'Mi)
(State or Cmiiitry^
NAM I" Ol FATHl-.R
I'.ik iiiri.ArK
(>!• FATHI.K
' stale (tr l"<)\iiiti \ '
f
kJxAjx^
a^trvA^
^fATI)^*^* nami*
Ml- MoTHKK
!51kTHPf,ACR ••I- Mf)THi:R (State oi t"i)iuiti\ I
Cj/aA.oJa^ JU(>vvkLcI
<X^l'^A
OCCl
^""■•"""•U)..tJ
A''' tif-d III Sit U I I il III I
yt, l!'Il■
l '.■'I
MEDICAL CERTIFICATE OF DEATH
DATK OF I)l". \'\'U r\
(Month » jf
(Day) (Vtar)
I IIKRin'.V CI:RTI1"\', riiat r attended deceased frmii
CL^VO, lb UpH to LLw^^ X^ Up\
that I last saw h^/Y>\ alive on VA^v/O >v-\ up \
atid that «kath occurred, on the date stated above, at H.H 0 CL M. The CAl'SIv ()!• dp: ATI! was as follows:
i
nrRATION Years Mouths
C( )NTR IIUTORV =
Pays
Hours
(SIGNED ) J .
Mouths.
Pays
Hours M.D.
vXv^
%
^' ' I <
;o"
{
X.ldrcss) Lj^yVCo ^O^V^t Tospitals,
riir: xnovi-: sr \ ri.D i-kksonai, far ruri, xk^^ akk 'Mti'K Yu iiii. in-'sroi- M\- K Nt »\\ i.i.ix.i-: and in:i.n:i-
'Inf.i; niatit
' N'Mi.ss
SPECIAL INFORMATION ""'y ''••^ nospitals. Institutions. Transients, or Rnenl Reslilcnts, and persons dyiny away from home.
former or /s , ;«( 4- M "*^ '""•* ^* I 1
Usual Residente^b Ua/C^wa/VVU^^xU Jvpidre of Death? I A Days
When was disease rontrarted,
II not at plareof death? _^^
I'l \CV Ol J!I KIAl, OK KI-.M' 'V \l
DAT;,'.'); Hi K \i. HI K I-:M< »\AI,
X. 190 H
rXDl'.K'I'AKllK (
Address. 3bli- l^ tL df
V ,. , .^p „},,„. Ill he stnteil fiXACTLY. PHYxSICIANS Khould
N. IJ.— Hvery Item of inform»tIon .houlcl be cnrefully suppi.ed. ^^J' "^^T^^^ ^he "Special Information" for p.r-
8totc CAlJSn or DI.ATH in ph.in terms, that it may he properly claHH.^.cU. nc T»i fions dyinft away from home should be feiven in every instance.
' !►;
^^
;#
iff
if
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
l;, :,,.! ..f n.allh 1 N'o : -. ■^'^'J^^l^' liS<.V C
Dnh' Filed , Q
CA^^^X/V^
I /.96>H
Deputy Health Offin^"
BegLsiercd JS'^o.
I 'ITyO
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of 2)eatb
{ *a. S. Stan^nrC) )
i on A ^
PLACE OF DEATH: — County of Octox' J AXX/^yvCuiLCxCity of Oclo^^j J \.(Xo\ov<i.c<.
No. Vl^\^ ^^ WVLAAtu --- ^<Jf\jJ^OJc St.; ^rr— - Dist.; bet. ~ ----r-r--r--— --- and -— :
ft / IF DC«TH OCCURS 1*W*V FROM USUAL RESIDENCE GIVt FACTS CALLED FOR UNOtR "SPtCIAL INFORMATION" "\ 1) V "^ DtATH OCCUttRtD IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. /
FULL NAME
rx.Qu'rxrs-^Os.^.
vl/.uLk
u>\A..{rvx/.
SKX
PERSONAL AND STATISTICAL PARTICULARS ^
! Cni.oK
J
I).\TK oi I'lK 111
(vJu,,
r%%\
(M.<iilli>
\<".K
It,.
* V } tin .<
I Day)
M.'ulfi^
(Vcar)
An
U IDOWI-.I) OK DIVoRrKI)
Wtit' ill •^i>i-i;il (It vi^Mi.-itioii)
lUKTHPT.ACK
Statt or Country*
VAMH OF
»Aiii i:k
TUKini'i. \rK <>i- i'.\ihi-:k
state or Coniilrv)
MA1I)1:N NAM1-:
()!• Morni-.K
BTRTHPr.ACR
<)l- Mo'fHHR fStatf or Countrv)
a
U.tcc^K
-0
MEDICAL CERTIFICATE OF DEATH
i>ATi-: oi' in
U-vLO
(Month) K
(Day)
(Year)
I II1':R1:I!V Clik'niV, That I attended deceased from
^)^v<> X\ 190^ to UwM^ Ji-O. 190 H
that I last saw Ii .«-V alive on U-*^<^ M 190 'i
and tliat ikatli i.rcurreil, on the date stated al)ove. at U.-.^O.
0 M. Tlu- CM SI-: OI' DIv.ATH was as follows:
e.
i^
-cvxx
V.W^<»v.
CONTRinrTORV
Jfo/i/Z/s
xct'^vn(va>
^rp
}-
OCCUrATlOX
Rfsidr,! in Sail Fuiiniu-n aX )Vr/; v *■ \h»ilh< ^,,/hn.^
TMI-: AHOV1-: ST \l) I) I'KKSONAI. I' \ K T U r I, \ K S .\ K I", IK I )■'. !< > TIIH HHST OI-- MV KNOW 1,1; DC)-: WD in-.l.Ii:!'
'In f'limant
\}JL^/\yOUL U^JLoJLo
f\(1.1
res.s
VQ
OCh^\
V
D\' K AT ins y^ }'ears
(SIGNED ) J........si-....'fcA.xfe
Uoxa ^^ TQOH (A<l.lress)Ul>Y^^^ -
Hospitals,
[cilAL IN
/)<7ys Hours
M.D.
0 ')\:'^^-l^'^■
SPECIAL INFORMATION only lor
or Recent Residents, and persons dying away from home
Institutions, Transients,
s va.-....w.
Former or Usual Residence
When was disease contracted, If not at place of death ?
•\ . How long at .
..U.A- Place of Death? v
. Days
i).\'rr. ot i?rKi.\i. or ki;mo\ai,
I'l \CK OK HIKI.U. OK KI-;M<)\ Al.
^-^
'i-
be stnted EXACTLY. PHYSICIANS should
N. B._r.very ite.n of Information .houhl be cnrefully supplied. AGE should %-'^'%^^!>^'^^;, ,n>or m tio^' for p.r- Htate CAUSE OF DEATH in ph.in terms, thnt it may be properly classified. The Spec.ol Information tor p son« dyin4 away from home should be given in every instance.
hi'j^'ir
i
i
I
ill!
I
ill;* I
II 1,1
^.
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
-,,,1.1 Mf II, ;.!lh I' \''> I
t t"^^'X^^> USi !'<'<,
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
llei^istct'cd J\''(),
1351
huh- Fili-d, Oj^-jtA/^^JUov \ V)()'\
XcM-A^ dui/VM^ Deputy Hccllh CfHoer
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of Beatb
( H. S. StanCtar^ ) PLACE OF DEATH: — County ofO/Oy^v \)A>a/YVCUlCC. City ofO.CUTV 0 Axxyrvo^.^ C t
Ne.
X^'^VtYv^lOAA^ St.;
(\r OCATH OCCURS Awiv FROM U S U A L '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 pR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. /
FULL NAME
-Dist.; bet.
xct;
it;
ro
-and
^i.\"
DATH OF HIK I II
PERSONAL AND STATISTICAL PARTICULARS
! COI.ok
L
<xxx
r .-,,
MoiHll)
(Day)
tVfiii
\«-.K
CXX^t 3>0 y.,n>
Mt'ulli;
/h:
STVr.T.K. MARK !i;i)
uipowKDnR i)!voK(i:r) n
iWritc in >.i>cinl <l»-<ii'n.'iti<)ii t .J(
^ Q-V\A.O/
liiW IMI'I.AOH n\ r. A
Statt-nr CNnuitry) V
SAMR OP
I ATm-.k
lUKTinM. \iH oi- lAilll-.K (State or Coimtry)
MAII)I:n NAMI,
lUUTHPr.ArR
'•I MOTinCK
' Si,tt< m CDutitrv^
Rfsiiifit in San /'i ii in isf'n
MEDICAL CERTIFICATE OF DEATH
DATlv 1)1 DI'ATH /O
„ IA^vOl 3)0 ipoH
(MoiitlO A (Day) (Year)
I Ill'kl-r.V CI:RTI1"V, That r attende.l deceased from
.- ..J 'v 190 ■ to
that T last saw h
ahvc oil
lip -T90
and that de.i'Ji occurred, on the date stated above, .it H 60 L\. M. The CArSl<: Ol- l)I':ATn was as follows:
Ovv^rwvc o \.<X'V\A.AX'Ov^J V)\X'^aUx>vnXva
GiM^^LCA/i fri Owoi 4 Quax
DIKATION }'a7rs Mouths I^ays J lours
CONTR nU TORY \J L<;> tI'VC^A^
DTRATION Vrars
(Signed) \M\jr\\XJ>^
Mo ill /is
Davs
(^
/>V
a.
//ours M.D.
dOuUt Special information only for Hospitdls, Instiluttons, Transients,
.IxU) 3^\ ic)0^ (Address) \^\Xr^\V<A \JM
_. ^CIAl INFORMATION onlv for Ho
or Recent Residents, and persons dying .iway from liomc.
[ufions,
) V<7; >■
M.uilhs
/Ki
Tin'. \iu)\-i<: ST xit:!) j'i-rson m. j-xk in n. \ks aki; TRri-; to iiii-:
1U:ST (H- MV KNOW 1,1. !)(,1-: AND lU-.Ml'.F
(infn,,„,-,nt UJ trw/a \JY\yCry\ycx
f \(1(1
Former or + k a a iv
Usual Residence ^ AJWiA\^
Wfien was disease contracted, If not at place of deatli ?
Uxi
Wm lonq at Place of Death ?
Oavs
4
InA,
I'l \C1-: Ol- lURIAI. OR KKMOVAI. rNDKRTAKKR UJ -A^OA^^ OaA-.^^^
DA'CKo!" Hi KIAI, or RJ-:M<>VAI
A
T 90*^1
C Address
c:^t
N. B.— F.very Item of in9orm„tion should be cnrcfull.v supplied. AGE should be stated RXACTLY P^^^'^''];^,^, f «"'^ state CAUSE OF DEATH \n plain terms, that it may be properly classified. The Special Information Vor pT- sons dyin^ away from home should be given in every instance. •
■B
1
i
•-1
if
^1: ir
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
«
IJoanl ..f Iltaltlr- »•■ No. n *'^- ar[-^, lUt I' Co
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
■r
•t
l)((fr /v7^^^/,. O J^^Jbu-^W^
100 \
Begistered J^o.
135S
\Mv(
Deputy Health Officer
1, ' ■[> P' I-..
DEPARTMENT OF PUBLIC HEALTH-City and County of San Francisco
Certificate of ©catb
J? (o"^
0^
4 V A \
PLACE OF DEATH: — County ofO/<XoA "vaa-vCx^LA:^ City ofOxX'YL' 0 A-<X/> v^^i-4. c. c
No
.Ot.
)Ch<L
IxJ.
Ojj
St;
- Dist.; bet.
OCCURS Awiv FROM USUAL R E S I DE N C E Gl VE FACTS CALLED FOR UNDER "SPECIAL I N FO R H OCCURRtD IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREE
and
;IAL INFORMATION" N T AND NUMBER. J
FULL NAME
)\.<xn'\j^'\.<x
si:\
PERSONAL AND STATISTICAL PARTICULARS
j COI.oK \
voJlx
^
MEDICAL CERTIFICATE OF DEATH
DATE or ni'.ATH
DA ri-: ( )i iiiR 111
AC. H
I Month)
/.^H5
(Day)
(Vf.-.r)
O \ );■„,■
Mnuths
r>a vs
siN(,i.i-:. MAKi<ii:n
Wlix "W i:i> Ok DIVt >K( MI) 'Wiitt ill -social di'.ij.Miat ion)
lUkTIIJM.Al'l-: (Statt or roimtrvl
.'L'.^cLcrvA.^ocL_
■hJL-
xWt
<Montft)
(Day
(Year)
.1 HRRF<:nV CI'IRTIFV, That I attended (Uuvascd frmu
a
to 6jc^A± 1.
-CMX- 10 190S
tliat I last saw h X\' alive on UjL
^^
dL
NAM1-: 01 FATII i:k
lUkTHI'I.ACK <)l" I A II IKK (Stat( or C(HUitrv)
maii)i:n namk
01 MO'I'IlKk
Miki-niM.Ai-i-:
01 Mnrm-.K (State or rom\tJ v)
\jX^C\^w^^JL JVcOJv'w^
'^O. .-b 1 190 'i
and that death orcnrrcd, <>ii tlie ilate stated above, at 5 3> 0 \k.-^\. The CAISI-: ()!• Di-ATH was as follows: LLaJUtUL/^-SwAXX -r^rULA-CA-n./'vvXl. 0^1^JiA.<a:ll..^v...
nrRATION )V<7/;e Mouths Days Hours CONTRIIU'TORV ciJ A^^^JLm-AJWl..
diration ( Signed )
)'cars
Mo}itJis
OuiU.^, ^^kvd
Days
( u
Kf'uifd 111 Will /'i iiiii iMi> lAO
\.dfX
loo'l (
Address) OIT . MfUxhXJA'fe (Vvl'. :.l
s Insnti
Hours M.D.
Special Information only for Hospitals, Insmuflons, Transients, or Recent Residents, and persons dying away from tiome.
Former or <^ '^ \ f r\4
Usual Residence (^ '^ \AXX.\/Xj UX
) I ii >
^f,„lth^
/'.
Wlien was disease contracted, a n. If not at place of death ? <> <^
How lonq at ^ /v
Place of Death ? O 0
Days
rm: ahox-i-: st \'n:i) i-KkSDNAi, p \ urn ri, \ks aki" tkik to in i:
MIvST Ol- MV KN<)\VIj;i)<'.K AND lu: I.I l".!'
(Address ^^ V^JLcUVOj CJA
IM.Afl-; <)l' ItlRIAI, OK K1:Mo\AI. j DATl'.of Hikiai, oi KI'.MOXAI.
f.NDKRTAKKR ^-^^ ^ WvvAX^ ^^ L<i
(Address 1k>1 \l VVui.^A,^r-yv Ot:
'^- B. F.very item of informsition «houM be cnrefully supplied. AGB should be stated EXACTLY. PHYSICIANS should
stnte CAUSE OF DEATH in pluin terms, thnt It mjiy be properly classified. The "Special Information" for p«r- «ons dyln^ away from home should be jt'ven in every instance.
B¥
*.<i
H
'•lillM'':'::!
I ■ •I'l
m
u
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
jtoMwi of iii-.iitii- I No. 1^ '^•^'»J^'^ n&i* Co
I )((((' hailed , O X>UjLAyvrJ!>-t>v
X V^O'i
Registered J\'*o,
1353
JL«yv-u Deputy Health Officer
DEPARTMENT OFPUBLIC HEALTH=City and County of San Francisco
Cevtificate of Bcatb
( tl. S. StauDarD )
PLACE OF DEATH: — County of
rNo. 1 0 VjV^-sJlA.' v.V\^
OJ\A,^\J
St.; Dist.; bet.
City of 0/<X'>v IXoxU^lvMC V'Oj
and
(IF DtATH OCCUnS AWAY FROM USUAL IF DCATH OCCURRED IN A HOSPITAL
RESIDENCE civt FACTS called for UNDER "special INFORMATIO
OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER.
N.)
FULL NAME
lx<x\.lju 0 , 'vu
Kb\.KrYv
PERSONAL AND STATISTICAL PARTICULARS
DAT!-: (»l- IlIKIll
MEDICAL CERTIFICATE OF DEATH
datf; 1)1- i>i:ath r\
Moiitll>
11
(Day)
vifoH
(Year)
AOR
S'^
5 V(/;
I i M^nilhs Vv D
A/1.
SI\(-,1,J<:. MARUIKIV WIDtiWKI) OK I)!\(>ki*Kn t Wi iti- in >^ixMal (k sivn.itioii)
^
lUK rn iM.ACj-:
i St.itf or (.■oiiiitry'
\AMi-; <)i »athi;r
lUKiniM, ATK OI- I AT I IKK
•St;itf or *.'<)>ujtrv)
maii)i:n NAM)-:
OF .MoTIIlvK
niKTIIlM.ACK
<ii- m()thi.:r
(Statr or Coiiiitrv>
(Moiitli) A
(Day)
(Year)
1 IIHRi:nV C1:RT1I-V, That J attended (lecca.sea from
lLvo 11
to LwvO. 'h\ itpH
CL
'6\
that I last .saw h l , , . ahve on VXCvX^l ^> ^ 190'
and that death occurred, on the date stated above, at I ^- 10 Ai M. Thi' CAISK OF DIvATII was as follows:
ivtwyxj
'\X
/cL
Dl' RAT ION )V^/-.? ^ A/0/////S ^0 A/j.? Hours CON^TRIIU'TORV vW\XX-Cr>'> X v^. <V>X<L
^\^
Hours
DTRATION -^ Years b Mout/is ^ t. A?v.?
(SIGNED) J, J v<nAy\\..cur>^ M.D.
XK\k
no
CU PAT ION pO J
f\fMt/rif III Siifi /'ill II, I III O I )V(;/.v
dx\x.t
I
T()0
(A.ldress) H 0 b
d.CvCtxK; 01
SPECIAL Information only for Hospitals, Institutions, Transients, or Recent Residents, and persons dying away from tiome.
Days
1A-^////>
n,!\.
Tin-: A IK )VK STATIC) PKKSONAI, 1' \ K'lirr !,A RS A K K TRTK TO THIC HKST Ol- MV KNo\VI,i:dc. K .WD in-lMKF
(Infoniiatit
Former or '\ ^'^t^ ^/jfn^K k ~\\ "*^ '""*' *^ '^ /^
Usual Residence^ ^'^'^'^^'^^^^^^^^ ^ Plafe of Death? <^o
Wfjen was disease contracted, }\ ^ ^ ^ ( ^ k
If not at place of death ? ^a/>v vJ/vavv^A^^o v.<VA.
I'l.ACK OI- lU'RIAI. OR RKMOVAL
N n f; R T A K K K vJ oXx'VN^ VI )\<X>LA^-rc\;
(Addre.ss ISXH. a^^^KJwXcrW
DATK of HiKiAi. or KKMoVAI. UJiy^vt 5) T90'\
.'t
N. B.— Rvepy Item of information should be
state CAUSE OF DEATH in plain term
sons dyin& away from home should be given in every instance.
carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should •ms, that it may be properly classified. The "Special Information" for p«r-
m
n
II
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
II,,;,, 1 f li.alth » No. is'*-^w^jHS:1'Co REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
. I
III 'I
'1'
y- .1.
/)(i/r Fi/c'/ ,OjL\pXjL^^Ji^\, X lOOH
Registerecl J^'^o.
1354
x'-u
V. 7- >— - ;
3l5.n mincer
DEPARTMENT OF PUBLIC HEALTH^City and County of San Francisco
I
If
Cevtificatc of H)eatb
PLACE OF DEATH; — County of ^ J/CX^T- 0 A.<x^v^cc4/Ct City ofvJ/CL/vu 0 /uo^-^^ca^xmlo No. 5^'?^ \JcK<lt St.; ^ Dlst.; bet. M I^^O^^nA; and J -acJLc\.
(ir DE*TH OCCURS *w*v FROM USUAL RESIDENCE give facts called for under "special information ■■ "S I IF death occurred in a hospital or institution give its name instead of street and number. J J
e
FULL NAME VVA^axx. b.
PERSONAL AND STATISTICAL PARTICULARS
DAii: t)j nikrii
L
Ct)I.nR
X'
aJL^
1 Month iT
A'-.K
Hi
) III I
(D;iy)
M,-vth^
(Vear)
medical certificate of death datp: of dkath
(Day)
x\\k
i Month)
(Year I
I HHRi:nV eivRTIFV, That J atteink'd .Icceased from
\R
An.
*^iN«.I,l" MARK 1 1: 1)
\vii)«»\vi-:i) Ok i);\< tKr]-:i)
•Writt ill «>fial «1< sit^iiatjon)
ink rmM.AOK
tSt.'iti « ir '."oiiiit !>■
I liSfi
VAMI ni F ATM Ik
nik iHi'i.xrF:
OF FAIMFk
' State or I'oiintiv
M \ II > »•: N N A M I-:
OF MoTUKk
HlkTirPI.ArK
<»F MoTHFk
' Stiite or (.oiititrx 1
. VCL/>V' IS lyo'i to
tliat I last saw h rfl^--' alive on
It/) H 190 "i
and that death occurred, '^>" the date stated above, at l^v A) M. The CAl'SF-: OT DIvATII \va^ as follows:
DURATION )'cars ^ Months fhiys Hours CON T R I P. r T ( ) R V ^.XX.^y^lA.<'T^w-<^>~vA.^CU LiAJL^.AJ
fKCUPATlON
A'
DTRATION I }'e(7rs Mont ha Pays I /ours
Signed) > AxXAOL^yvcLoi^k M.D.
vj ^^ifc at
'Xii'vAT ^ r()o'
(.\ddass) 10 5.^
Special information «"'> for Hospitals, Institutions, Transients, or Recent Residents, and persons dying anay from fiome.
/'(M
THl". AHOVK ST\ IFI) I'KkSOXAI. I'A kTron.A k S A k !•: Tkt'H To Till-: liF.Sr OI MV KNo\VIj:i)r,H AND WVAAV.V
(IiifoMiiant (AD CUVVOtt) J . ybAxJL<L^rv-v
Former or Usual Residence
Wfien was disease contracted. If not at place of deatfi?
HoM lonq at Place of Deatli ?
Davs
DATliot HruiAF. or kFIMoVAI,
I'l.ACI-: OF lUklAI, Ok kKMo\ \1,
(St 0Lv^
T90 1
^-*iUii.
N. B..
-Every item o? inform«f.on 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 p.r-
Bons dyin£ away from home should be feiven in every instance.
if
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
,1.,:m.1 -f H-altli- )'Sn i ^ "&-?,'^^^J IU«t I' Co
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
/)((/(' FiJedj
X
100\
Be^istered J\'*o.
1355
OFP
r"
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of H)eatb
( la. S. Stan^arD ) PLACE OF DEATH: — County ofOo-^^ 0;vo^a.<:AAoc City of 0/Cl^>^ ^ KXKy>^\y^iA^
.^Ou li) Cm\lrnJi J V CH(tKstA^"!. . Dist.; bet.
and
r DEATH OCCURS AWAY FROM USUAL RIE 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
J\Mjy\/J<Js
/\.'a_
I> \TK OF HIK III
UOJ'vCtx
iMondil
lb
(Day
(Year)
MEDICAL CERTIFICATE OF DEATH
DA'IK <H" DKATH Jl
cUkfc
(Month)
Ai.K
H3>
)'rii i
\ M,,ul/is V*
Da vs
SIM.1,1:. MAKUIi:i). \VII)(>\VH!» OR IHVoKCKn
'Wiit'iti «Kial <l(sij.'ji;iti'>ii )
TUK TirPI.ACK
'Stiitc or Country t
Hik riiri.ACK
01 lAIMKK (Stair or Conntrv)
M\ri»):N NAMl" III MoTllKR
J'.Ik rnlM.ACK <»J- MoTIII'.k 'St;it<- MI Coiilltl V
OCCrpATlON Qryp
VXa^ul^
^^^w\X; cL^X/^^Vv^b^
I IQO \
(Day) (Year)
I III':ki;HV ClvRTIFY, Tliiit I MttendcMl deceased from
LWo ^,0 190'i to pjJ^ .1 up\
that I last saw h <.'•.. alive on O^-^^jt: I 190 H and. that death occurred, on the date stated above, at b A,C) y M. The CArSK Ol- DICATII was as follows:
•vJt . J\DJUx>\.t \X'y\/o>J^yo^\y^i^o^
1)1 RATION Years
CONTRIHl'TORV
Mouths
Pa vs
Hours
\kj\yt^\XJ^
Dl'R ATION Years Moiifhs Pays
OL-
Hours
(SIGNED) VJ,
y"yxx.^AxL«.\.
M.D.
Add riss) CJxX^r^ J/vO-/w V<X^^-
SPECIAL INFORMATION ""'y '"r Hospitals, Inslitutions, Transients, or Recent Residents, and persons dyiny away from home.
^yv^X^^'cJ^^
Rfsidrd in Siin /'i niii nruX) * )'/'iiis
1 III, A IK) VI'. ST\Ij: I) I'KkSONAI. I* \ k I" I ' ' C I, \ k s Aki; Ikl l'! TO Till-
in-:sr «)i-^\ kndw i,i:i)«".i'; am» h):mi;i'
'Q^
f Iiif'Jini;mt
KXK^y^Jfi^ oU jeJ(rvJ-^vx^
(A<M
rcss
0
(U
Former or Isual Residence
When was disease contracted, if not at place of death?
Days
IM.ACi: Ol' lUKIAI, OR kKM<)\AI.
i)A'i:i;«»i MiKiAc. or ri-:mo\ai. Q)jLjfX 3. 190H
!\. B."
„.!„„ .h„ul.l h. crefuMy »uppM.d. AOK »h„,,..l be -.a.cJ F.XACTLY PHYSICUN8 »h„„M *TH in plain tern,,, that it ma, be properly cla..i«led. The Special Informnt.on for p.r-
-Kvery item of inforin •tate CAUSE OF DEATH «on« dyinft awoy ?rom home nhould be feiven in every inHtBOce.
'*«^..
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
HoaKl ..f Hf.iltlt »• No. \^ -^^muZiyUftcV t
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
X ifJO'i
Deputy Health Officer
lie£f6'fere(l JVo,
1356
DEPARTMENT Of PUBLIC HEALTH=City and County of San Francisco
Certificate of Beatb
( XX, S. Stan^arC* )
Hi — County ofCjO^/Tu OyV<X/YVCX^Cc Gty of U/CLAV OAXX,
PLACE OF DEATH
No
.^01
O^'TKJ \1 KXAu^
''Vhi.'
St.; % Dist.;bct.
(ir DEATH OCCURS AWAY FROM USUAL R E S I D E NC E Gl VC FACTS CALLED FOR U N DE iVl "s PEC lAL INFORMATION" \ IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OFtlsTREET AND NUMBER. J
FULL NAME
'^•■^v q^
PERSONAL AND STATISTICAL PARTICULARS
COI.OR
and
<L.sLUL m.. J aA^.O)
,'<i^tr>^.
KATK (M- HIKIII
I
\JJl
tMoiith)
.t
A « •. K
no
) rn t .V
^IN«.M-:. MARKIKl). \\II)»)\\};i) OK niVoKCKD ■Writriii social •Ksivrnatimi)
Mik rnri.AOK
Stati or Coiintrv)
|
(Day) C> Mouths . |
t |
(Vt-ar) |
|
clvvuJL. |
MEDICAL CERTIFICATE OF DEATH
DATK C)I' DKATH
(Month
1.
(Day)
190 \
(Year)
vc^-<a
I ni':RI<:i}V CICRTIFY, That J attended (leccascd from
sJ^^^o^ \\o 190S to ...dJ^xfc .1 190 H
that I last saw h --» a-' alive on O-X/^xAj I Kp '\
and that death occnrred, oti the date stated above, at iO SO J M. The CAISH OF Dl-ATII was as follows:
Urvv'CnxAw/t:, \J )^vij:^cl^x.^.,<cL^
)/C<rLLcxA^<:^>
NAMI-: <»l I- AT I IKK
niRTmM.ACK
n|- l-AinKR
' St:it( or (.'oiiiitrvi
maii)i:n' NAM1-;
<)I- MOTHKR
r.IR'rHPKACR OI- MoTllHR (Statf or Cotnitrv)
OCCUPATION
DTRATION
)'ears S' Mont /is
CONTRIIU'TORV ATtCr^^JL
Da Ys
Hours
DTRATION
VaAo
Years
Months Pars
>v\-
Honrs M.D.
'\JL^ cLCLy>'>X^^\]G
vui-
(SIGNED )
OX.^:\t 1^ T()o' \ (Address) \ 3lOO UxX/vvh\jU^ Uw
Special Information only for Hospitals, institutions, Transients, or Recent Residents, and persons dying away from tiome.
) 'ill I
yfniifiis
/hn .
THK AHOVK ST\'n;n PKKSONAI, I' A K 1" U' T I.A R S A K 1-: PKri-: To I'm-: HHSr OI- MV KNo\\I,i;i)C. K AM) lilCMi;!-
\<Mrfss D 0 I \J /<X/y\j
I) /<X/^r\; xVuLn^ LI
,A/V-t
Former or
Usual Residence
When Has disease contracted, If not at place of death ?
Hew lonq at
Place of Death? Oavs
PI,ACK OF BTRIAU OR RKMOVAI, i DATit of IliKiAr. or RHMOVAI.
(^.(9.©.<) -ilt'>^voJU-vH I o^i^ '^ '90S
r.NDl-RTAKKR V I • U AX>^ ^^ V^O
I Aihirt'HH .i51 ^ o >L^f./tI^jtv. y±
N. B. Rvepy Item off information •houlil 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 given in every instance.
I
Hij 'I
'\im. i
mM
^k
«^^_
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
II.,., 1,1 of II. :i!Hi • 1" N'o 1^ t^-i;^^?^ Uft I' (V,
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
\wA,-V>^
,^^ Deputy Health Officer
Bc^istered Js'^o,
1357
Dale FiJvil ,
DEPARTMENT ot PUBLIC nEALTH=City and County of San Francisco
Ccvtiticate of Beatb
( H. S. Stan^ar^ )
r\
"I
PLACE OF DEATH: — County of U/CL-^ J . V<X/r\^cui>c^ City of UCX/>\; 0 A/a.wCAAye,c
No.
dAjLrUi UUCkIvOL
.<Xy^
St.
Dist.; bet.
and
(IF DtATH OCCURS AwAv FROM USUAL R E S I D E NC E Gl VE FACTS CALLED FOR UNDER "SPECIAL INFORMATION" \ IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. /
FULL NAME OAXdxwcA JXxX/^^vt^
PERSONAL AND STATISTICAL PARTICULARS
i)\ri-: <M-' lUK III A
MEDICAL CERTIFICATE OF DEATH
DATK OI' DIvX'IMI
(Day)
'l
I go
(Year)
\C.K
(Day)
(■Year)
) Vl/J v
Mntlth^ O
An.v
SINC I.1-: MARUIKI) WIDdW i:i) OK DIVoRtl-:!)
! Write in '.iiciri! (Itsi^'iiatinii )
lUK IIU'I.M'I-: ' St.'itc <»r Coniitrv^
(Month) jf I HlvRIvHV ClvRTlI'V, That [ atteiKk-d (leccased from
n f o.,
and that (Uath occurred, on the date stated al)()ve, at 1 3.-H.ii V M. The CAl'SIv ()!■ DI^ATII was as follows:
11 190H t(
tliat I last saw h '- » >' alive on
190 H 190 i
\ I /Vo-Ay'ru^\AAAX
vxr->x
niKinpj.AOK
0|- .1 ATHHk
(Statf or Countrv)
MAIDKN NAM1-; Ol" M«)Tin:K
I'.IRTIH'KAC K 01- MnTHKK (Slittc or Country)
<H\ri'All«)N
/\f'yiilr.! ill Sill! /> 1! i/i :u'i'
I) I 'RAT ION }'ears 1 Months 'XS Days Hours CONTRIBUTOR V
DTRATION
)\un'S
\X \j<xjy\}
( Signed )MjJL<ww^
Liu^a V. i«)o'i (AddrrSK)U\JUlAJU^ (lbo-<lUs.\
SPECh
M<)}iths Days Hours
X<vM/>vj M.D.
Special information only for Hospitals, Institutions, Transients, or Recent Residents, and persons dying away from tiome.
Former or Isual Residence
;"\IWJrun.(
Days
TH i: -XMOVK STATl-:n PKRSONAI, PA RTICl' I.ARS A R »•: TRrH TO THK
p.HsT oi- Mv KNOW 1, 1:1 )(•.!•: AND Hi:i,n;F
(InfoinKint \|}VUi ^ \- \) /CuX
( \<l(lrcss
rj<j\j
When was disease contracted, If not at place of death?
PI,ACK OF BURIAI, OR RKMOVAI,
I A I, or RKMOVAI, 3^ I90M
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 dying away from home should be feiven in every instance.
I
'/
il' 'I
Hiiti.
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
I!(>:n<I ..f Ilcjiltli !•■ Xo. i^ **^^^«> H8: I* Co
])(( f r Filoil, d JL|^jbL/>>xisJUv a 19 0\
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
Registered JYo,
1358
v^ dJL'\>
Deputy Hc*^ 5^'- Officer
DEPARTMENT OFPUBLIC HEALTH=City and County of San Francisco
Certificate of H)eatb
( xy. S. Stan{>at^ )
A % A ^
PLACE OF DEATH: — County of ^lO^'W) ^AXX/YV^^A^ccCity of Q^O^^v O^^XWlCaacc
rNoJUlo OAyCAXX/YrULTd^ SU X T>{sXAhcxA.OUs.l^\: and Tl LoA CPrx.
f ir DEATH OCCURS *W*V FROM USUAL R E S I D E N C E Gl VE FACTS CALLED FOR UlioER "SPECIAL INFORMATION - \ V IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEA^ OF STREET AND NUMBER. )
FULL NAME hjl±r^o^\)\jj^^j.
SKX
PERSONAL AND STATISTICAL PARTICULARS
Xrr\
DATK OF HIK rn
A<.K
\
lAIoiitli)
lb
(Day)
fVear)
MEDICAL CERTIFICATE OF DEATH DATE OK DKATH
Ixkfc I
(Month)
(Day)
790 M
(Year)
V ^ Ytiits Jv U<in//is 1.5
/)ii 1 .s
SINt.I.K. MAKKIKI). WIDoWKn OR DIVOKCKD (W'ritf in sotial <1» si^fiiatinii)
HIKTHI'I.ACK (State <ir Country)
0^
<xw.kxxL
I HHRICBY CERTIFY, That I atteiided (leccased from
'^^ 190H to (Xu^ 5>.i igo H
that I last saw h -^*> ' alive on Lmw*-<5 'iX j^q '^^
aii(l that death occurred, on the date stated above, at iQ.-'bO vIm. The CAlSn: UK DI'ATII was as follows:
.^Xk Hl
<x
NAMF OF FATUHR
lURTHPI.ACK ()»■• l-ATHFR 'Statf or C(»untrv)
MAIDKN NAMK OF MoTUFR
hirtmpi.acf:
Ol- M<)TnF:R (State or Coiiiitryl
i
OCCrPATION (Tpw? Q
()\d (y\A>i.XA.A>vLc Rf^idrd III S(iii /'i ii III i>,-i> \^j Fr//; ^
DIRATION Vc^'s Mofii/is ^ Days Hours CONTR IIJUTORY \JrsJ>.J^ry\^uZ L^cudu^^
rXRATlON
( Signed )
Vears
Months Pays
V^X.'-VYX)
QX^ 1 yqoH (Address) ^^H ^K^Xkxr^, Ut
f/out's M.D.
SPECIAL INFORMATION only for Hospitals, Insfitutions, Transients or Recent Residents, and persons dying away from tiome.
lA-;////'
lhi\.
Former or Isual Residence
When was disease contracted, If not at place of deatli ?
Hew lonq at Place of Death ?
Days
TMl'; AHOVK ST\Ti:i) I'FRSONAI, P A R T II" C I.A RS A K I" TRIF Ti > TIH' HF:ST Ol- MV KNOWIJ-DCK AM) I!I:i,II;f
^'b\\V' ^T "^'U'^^' ^^^ RKMOVAI, I DATkof IJt RIAL or RKMOVAI,
rXDlCRTAKF
N. B. Every item of informHtion •hould be cnrefully supplied. AGE should be stated EXACTLY. PHYSICIANS should state CAUSE OF DEATH in pl»in terms, that it may be properly classified. The "Special Information" for osr- «on« dyini away from home should be iiiven in every instance.
'.••' I
,.■ /;
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
lto.it.1 of H.allh I" Vo. !!; "fr'Fiiap.S^ jj&P Co
I )((!(' AV/^v/, dx^^JjL^mlvOvj X /'>^H
dJL/\>M
Registered J\'*o,
1359
n
ricer
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of Beatb
( Xl. S. StanC>ar^ )
PLACE OF DEATH: — County of 0 Cla^ 0 A/Oo^vC/waCij City of 0/Cla^ OAxXa^i^v<lco
No.
J Cr ^'>\X
St.;
-Dist.; bctr
-and-
/ \r DEAfH OCCURS AWAY FROM USUAL R C 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. )
FULL NAME
K).<X/yY\jYy\i.
PERSONAL AND STATISTICAL PARTICULARS
DAIl-: ni HIKril A
M\t\r VX /.?>1H.
Moiitlj) (Day) (Vtar)
A(.K
MEDICAL CERTIFICATE OF DEATH
DATK OF I)1:ATH
(Month
1 igo\
(Day) (Year)
^A )'tins \ Months ^
Davi.
SFN(.I,K. MAKklKD UII)<)\Vi:i> OK DIXoRilU) ' W) itf ill '^ixial <U-'<ivniatiuii)
HFRTFIIM.ACK
(State or Oouiitrv^
^a^/cLmaj^
CLA-/OaJw
FATin.R
HlRTHIM.ArK Ol J-ATHKK iStatf or Coniitrv!
MAIDKN XAMK oi MOTHKK
MIKTHI'UAt K Ol- MOTHKK (Statf or Countrv"!
^toAAj
I HICRI'HV CIvRTim-, That I atteiidcl deroascd from til at T last saw h
P9©- to ^ A\^
X^ alive on 3-^^
?
^ 190 H
and that (kath occurred, on the date stated above, at \ \ U^. M. The CAl'SK OF DIvATH was as follows:
sj YyNJ2A/<wOa'V.0''v^A/^
X^JpJu ^U'6-^iX^»\J
DTRATIOX ^ Years Months X\ Days Hours CONTR I nUTOR Y Qjl^>A.^JLuL^
^OJ\y'
?
DURATION (SIG
Years
Mont/is
Pays
X}r\)^ \ Tcjo'i (Address) TS'l OAAytLiAj OA
Hours M.D.
Special Information only for Hospitals, InsfUutions, Transients, or Recent Residents, and persons dying dway from fiome.
oi'Cri'ATlON
f\f^iiffif III Siin /'i mil i I'ii V, O )'iiii<:
\r,>iitlis *- Ihivs
VWV. AHOVK srAll-.l) I'KKSONAI, I'A K TH" T I,A KS A k l'. I'KIK To J"HH
jii':sT 01 MS KNOW i.):n<'. K AND in:i,ii:i*
Former or Lsual Residence
Wfien was disease contracted. If not at place of deatfi ?
HoH long at Place of Oeatfi ?
Days
J^I.ACH 01 .HIKIAI. OK RKMo\U, I D ATI-: ol HnnAl. .)r KI-:moV\I
(Address
JIH 0"5',a^.x;Jli±
rNDi:RTAKKK
(Address .
N. R. Kvery Item of InformHtion should be ciirefully supplied. AGE should be stated iiXACTLY. PHYSICIANS should
state CAUSE OF DEATH In plsiin terms, that it may be properly classified. The "Special Information** for per- sons dyin^ away from home should be ti^iven in every instance.
,•»
m
1
m
%
\
il' 'I
llr :;';'!'
i;' Hi)'.
•1
i
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
Hn!.t-.l..r iic.-iUh- >-No. yK-^^^^wS^vCn REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
l)((h' Fi/rd.A.JL
.CJ-VL^C>5
X.
IfWi
HegLstered J\^o.
1360
Deputy Health Officer
DEPARTMENT ffF PUBLIC HEALTH=City and County of San Francisco
Certificate of Beatb
( tl. S. Standard )
(^
PLACE OF DEATH; — County ofO.CLw JX<X/>"vcA^^(.City of 0/CXyVu j .h.xX/^vv/ciA.ci c ^
^Pic^^A.<.t"yxa!
U AAta. Qj cu'>x<xt^\.i.^<.-\^ V St.;
(ir DEATH OCCURS *WAV FROM USUAL ir DCATH OCCURRED IN A HOSPITAL
Dist.; bet.
and
RESIDENCE Give FACTS CALLED TOR UNDER "SPECIAL INFORMATION OR INSTITUTION GIVE ITS NAME I
FOR UNDER SPECIAL INFORMATION" "\ NSTCAD OF STREET AND NUMBER. /
FULL NAME
±-
.vvA-'Lco
SKN Q^
PERSONAL AND STATISTICAL PARTICULARS
I COI.OR
Ja-\aXjl
MEDICAL CERTIFICATE OF DEATH
DATE OF DK
DAIl-: <)| lUK III
\\^r^
"Month)
Ar.K
U
) I'it t .<
H
'1
(Day)
Monl/is
.,1.H.X
(Year)
•:ath P
a
(Month)
I
(Day)
(Year)
x\
/hi VA
STVC.I.K. MAKHIKI). WIDOWK!) OK I) IVOR (• HI) •Wtittiii s(Ki.'il (hsijj^iiatioii )
lUK rHPI.At'K
'Stall- nr Country^
NAMK ni FATIIKK
lUKTllI'I.Ai'K <»( 1 API IKK iStatr ur Comitrv)
MAII>j:n NAM1-: <)!• MOTIIKK
niK'nii'LAi'i-; <»!■ M(>'rni:i<
(Statf or (."0111111%
OCCri'ATlONCAP
I HKREBY CHRTIFY, That I attended deceased from
Laa/^ ...H 190 H to 3jL.\:vte: I igo H
that I last saw h a.'^ alive on CjJLyxAj [ igo ^\
and that death occurre«l, on the <late stated ahove, at IV- iO Q: M. The CATS I') ()!• 1)1-; AT 1 1 was as follows:
A
^Oy^hw't^tjrvvwa.
k^
*\y7v:W'.
I
I>r RATION CONTRIHUTO
} 't^ars V. Mouths
Days
IAa^^^Ow^v^i
(y'L>^^AJLA.^/-^JM.
J
L
Kfsidfd ill Siin /'i (UN iscii
) Vit I s
.1 A »;////,-
/ ',1 1
RY .Q.A^^^-<C|^v^:,^ Qj:>w:<^.:?:^k
l^^AJub\M\/\\jCL U|>JAXxjL\^<rw
DURATION }r(irs Mouths X Days
(SIGNED) Lt. 0. dJx<X>./dLvJll
JJ^xt Ov iQoH (A.hlress)M^/OAMytl) VJj.
Special Information only for Hospitals, institutions, rranslents, or Recent Residents, and persons dying away from home.
Former or ^i
Usual Residence vJ AXVWO
LoX
Hew lonq at
Place of Deatfi? Days
When was disease contracted, If not at place of death?
THl", AMOVK STATi;i) I'KKSONAI. PAK'IHT I.AKS AKF. TKrF TO TIIF
i5f:st 01-" MY KNo\vi,i;i)c.F AND iii-:mi:f
(Infoinianl
'X^-vw
(!!?
\
JvO. VD /txonXK;
r\<Mioss OXX^i-^rv^
KjdJo
JM.ACK OI- lURIAr, OR RKMoVAI. I DATF of Mi KIAL or KKMOVAI,
^ K^J^^r\A>..\joX I 0-M^' /^ T90H
UNDICRTAKKR
(Address .. 1*^^ 5 I UJ.A-J(^1y^t, SrWrr^.
/CXXVOu^V 'V*v V-C
N. B. F.very item of information should be cnrefuily «upplied. 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.
irn
i|..:lH<l
►^•^..1!
li
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
^__ REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
lionnl of Jlcnitli • I-" Nf>. K ^'V^'Sgi.:?^ u^\> c<
Keglstcvecl ^^o.
1361
Ihtfr Filed, aJL^xXjL^>>U.M^ X lOO^i
d.Jtr\^^^,Aj^ Xt\vM Deputy Health Officer
DEPARTMENT OF PUBLIC HEALTH==City and County of San Francisco
Certificate of Beatb
( H. S. StanOarD j
/^
PLACE OF DEATH: — County of
<Xa)-V\.<x.^
City of Uc^
No.
(IF DEATH OCCURS IF DEATH OCCU
St.;
'Dist.;bct.
and-
s AWAY FROM USUAL R E S I D E N C E G I V E facts called for under "special informatio
RRED IN A hospital OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER.
N.)
FULL NAME
C\A.<c. Cl '>A.' KJX.
PERSONAL AND STATISTICAL PARTICULARS
DATi-; oi iiiurn
Woiith)
KJX
MEDICAL CERTIFICATE OF DEATH I>ATK OF DKATH /O
(Montli) rt (Day) (Year)
(I):iv)
(Year)
A ( . }•:
I IIHRI{BY CI'IRTIFV, That I attended (leccased from
to
ID ),iiis
yfouifi^
\x
Pavs
STNC.I.K. MAKRIHI). WFDnWHI) OK DIVOKrKD
iWiitfiii «)rial dr^iij-Miatioii )
lURTHIM.AOK 'Statf or Country^
a^A^^-'CtVaAa,'
-190 to ■ 190
that I last saw h ~ alive on : — 190
and that death occnrred, on the <late state«l above, at
^r. The CAl'SIv OF DMATII was as follows:
XXA^
XANfi: 01
FA TJIl-.k
RFkTMIM.ACK ni- I ATHHK (Stat( or C'oimtrv)
MA III}-: N' NAMl-:
lUK rm»i,A("H or M(n-m-:K
Stall- or Coiiiitry)
OCdTATlON
Dr RAT ION Years
CONTRIIU'TORV
Months
Days
HoKts
DURATION
(SIGNED) .. OJUV'
)\'ars ^ font /is
Days
>GVVA,U
\jOf<)^ 1 190 'i (Address)
Hours M.D.
SPECIAL INFORMATION only for Hospitals, Institutions, Transients, or Recent Residents, and persons dying anay from tiome.
^^^ How lonq at Mi Plare of Deatli? Days
Former or Usual Residence
^
^ KKJiAjj</ry\/>rsJL
Resided in Sun Fi nni i^en " )'r<n
y/nntln
IhlV.
Wfien was disease contracted. If not at place of deatli ?
rni". AUovF. sTA'ri-:i) pkrsoxai. i>ak ikti. \ks \ki: trik to tmh
IU-;ST <)l' MY KN()\Vl,i:i)<".H AND JUIIJF.H
(Iiifoi niaiit
b , vj . X^"
V-v^v-O
f \<l.lrcss
(^LlxXi^aJXol vXX-V
ri.^CK OI" r.l^RIAL OR KKMOVAI, I DA'^'i;.)!" MlKiAi, or RKMOVAI,
^t X
i9o'\
Ad.ircss S.XH \nV UJjLAA,txA). cjt
N. 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 given in every instance.
( 1
i ' fi
XM^
h' ' fl
i' I. 't
Li:«i'
^«'l
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
l!.,:n.l of II. ■■tlth I- No. 1^ t^t^]^ ns,v c, REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
Ihf/r /vV^v/, dxipjLi/>T>is^ X WO'i
O^^^^WaA
Registered J\^o,
1362
Deputy He c<!;, 7 Officer
DEPARTMENT ()F PUBLIC HEALTH=City and County of San Francisco
Certificate of Beatb
( tl. S. Stan6atCi )
%
^ ^
PLACE OF DEATH: — County ofO CX/w JA/Ct/>xc^^ccCity of Q/CUvu 0 A.CL/vxc-Mi.e^
^N©.
C>^a
^vJs<^)(j
Dist.; bet.
and
IF DEATH OCCURS AWAY FROM USUAL P E S I D E N C E G I V E FACT IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE I
TS CALLED FOR UNDER "SPECIAL INFORMATION" \ TS NAME INSTEAD OF STREET AND NUMBER. /
)
FULL NAME
SKX
DATH <)1- lUR in
PERSONAL AND STATISTICAL PARTICULARS
I COI.OR
MX/rrOA;
/CLuj-<i.^trv\;
<n V
y
Month)
AC.K
\ U )V./;.' 6
(I)av)
.^/of////s
11
i.
r Is L .
(Vtai)
Days
MEDICAL CERTIFICATE OF DEATH
DATE OF DKATH
slM.I.K. MAKkn:i). UIDOWKI) OK I)I\(»K('i:r)
'Wiitfiii ^<H-i.'il il«si</nati<)ii)
lUKTHIM.ACK
(Statf or Coiiiitrv)
1 rLojv.\.'Oui
(Month) K
31
(Day)
(Year)
I HEREBY CERTIFY, That I attended deceased from
sXxA^CL \ I90M to LLlv^ 2)1 IQOH
tliat I last saw h -^^''^ alive on \Aaw«w<3 ?>0 up H
and that death occurred, on the date stated above, at i LL M. The CAl'SI^ OF DI'ATII was as follows:
^\ol^-
/y^^j
\AMi-: oi-
I- ATii i;k
lUKTIIIM.AOK n|- I ATHHK
(State or Ooniitrv)
MAII)1:N' namk 01- MOTHKR
lUKTni'LAc 1-:
<)1- MOTIIKK (State or Conntrv)
DF RAT ION
Years
0
Hours
ION J 0 p
Kfsidfd in Sa)i /'i (ni</>r<) 31 C )Vim> " . !/-</////>
Mouths ^ Days CONTRIUFTORY JvOw^'XA^ii. /O^v.^^.
DFRATION )'iUirs Mouths Days
(SIGNED )..Uj. M. y^AA/v/vvlAXX.^^ M.p.
'^\ TQOH (Address) 1 1 ^ b W^ UJLl'uJa.Nj O^.
/fours
SPECIAL INFORMATION only for Hospitals, Institutions. Trdnsienls, or Recent Residents, and persons dying away from home.
Usual Residence 'C^ll aIxxX^^h Ot^ Place of Death ? S i\AA... Days
Former or
Till', AHOVK. S TAI'i:!) PKKSONAI, PA KIR- T l.A K S AKl-, TKrH TO r\\\\
nicsT t)i-" M v^jsNowij: !)(.>: AN i> hi:mi;i'"
When was disease contracted, y l ^ ^
/)„,> I If not at place of death ? OXH^^aA) .o^^^XVv^
(Informant
(X.Mrcss
PI.ACK OK BCKIAL OK KI:MoVAI, I DATi; of Hikiak or KKMOVAI,
Ukxx\XjU Jo
.V
(AiMrt-ss
N. B. Bvery Item of information should be carefully Kupplied. AGE should be stated EXACTLY. PHYSICIANS should
state CAUSE OF DEATH in plain terms, that it may be properly classified. The "Special Information" for psr- sons dyinil away from home should be ft'^cn in every instance.
! !
II"
i II
.n
I t
!'■
,1 I
Mi
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
Unanluf H.MiHi !•• Vo. i> ^^^^]U^]>Cn REFER TO BACK OF CERTI FICATE FOR INSTRUCTIONS
/)((
/r Fi/r(/,^
X l^O'i
Deputy Health Officer
Registered J\^o,
1363
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of 2)eatb
( TH. S. StanOarO )
PLACE OF DEATH: — County ofvJa/\x 0;v<X>vCA^/c;ACity of vJ /Curv J A.<\^^^t>,ocic,c
^
/No. U-LV>>XO^^ (ib(H4w^XX.l St.;
-Dist«; bet.
and
(IF DEATH OCCURS AWAy! FROM USUAL RESIDENCE GIVE FACTS CALLED FOR UNDER "SPECIAL INFORMATION" "X IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. /
FULL NAME
o^XxJij
SKX
DATK <)!• I'.IKTU
PERSONAL AND STATISTICAL PARTICULARS
j COI.OR
A"^
Otx
i^t
M..nth)
Dav)
(Year)
A<". K
^0 ,v<M. 10
Months
r'\
Pa r.v
WHxtWKI) OK DIVOKC'KO
'Write ill •>.«i;il (U si<'n;itinii )
lUKTnPI.AOK I St.itf or Comitrv)
NAMK OI-
I- ATI I i;k
niKTUfl.AC'K <>l lATMHK (Statf or Country)
MAII)1':N' NAMK OF MOTHHK
lUK rniM.ArK
Oh MOTHHK
(Slati- or Country)
MEDiCAL CERTIFICATE OF DEATH DATE OF DE:ATH J?
d.xi\i. 1 7poH
(MonthO (Day) (Year)
IIIF^REBV ClvRTIFY, That J atteiidtd .Iccoased from
1% 190M to ax^:. 3L 190 H
that I last saw h A. . . ^ alive on <:j.JiJ^<X:.. SL igo i
and that death occurred, on the date stated above, at ol 3» 0 ^*^ M. The CArSli OK 1)1-:AT1I was as follows:
C^rvvtjLslXv>%'<xA U X-<tV'\A.Ayt)A.<A.^cnv^
DURATION Years Months X Days
CONTRIIU'TORV LL-C^S-aA^ AJJ
Hours
"vwv<v.<>
DURATION (SIGNED)
XhjpSi 'X TQO'l
Years
Mouths 1 Days
■Ka-^yv^
(Address) \) V\JywJX/\>^
SPECIAL INFORMATION only for Hospitals, Institutions, Transients, or Recent Residents, and persons dying away from home.
DCCl rATR)N -^
Resided in San I'l airi isrd I )'riiis
.\f.>>ifh>
/'.M
Wa/^^^u- 3
Former or | u c:
Isual Residence VO vo _
Wfien was disease contractiw, If not at place of deatfi?
■ H»w lonq at
X: Place of Death? Ht
Days
TWr, AIIOVK ST \ ri: I) I'KKSONAI, I'AKTHMI.AKS AKH TKrK TO THH
ni-:sT OI- MY kno\\"m;i)c. K AM) Hi:i,n-;i-"
(Iiifotinaiit
\
(It) O-'^^'ovX'oJ^
f \(Mrc»is
I'l.ACE OF BUKIAI, OR REMOVAI,
DATE of Ht KiAi. or REMOVAL
OjJ^ ^
UNDERTAKER ^ ykjUK^i->Cr^ oU-Oe..^UK^
I90H
^Aildrtss
N. B. Kvery Item of inPormHtion should be carefully suppiieti. 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 feiven in every instance.
«
,f-l,'
I
'! ' ft
i
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
l(,,n<l -f n.altl. 1- Vo 1^ •g^^Sr^^"''^''^'" REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
Dff/r FiJrd,^
l^X^^
X
vM Deputy Hv
lOO'i
h Officer
I'iCglsfei'ed J\'*o.
1364
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Ccvtificate of S)catb
( XX. S. Sta^^ar^ )
^ % J (Up
PLACE OF DEATH: — County of C'O^^Aj 0 /vCl-> vcv^cc City of 0/CUvo J /vxd^^x/c^a^C-C 'No. SIH JaXI^a^VX St.; ^ Dist.;betNlll ltlU4.LN..' and 0 U^lt<rv\;
(ir DEATH OCCURS AWAY FROM USUAL RESIDENCE GIVE FACTS CALLED FOR UNDER SPECIAL INFORMATION" "\ IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. /
FULL NAME
^\^'
0<J^^<X/Y>'\j
1X>\
<.i;\
I) ATI-; •)» HiK 1 n
.\(.K
PERSONAL AND STATISTICAL PARTICULARS
COI.OR
VL
■Xjl
I Mouth*
t
a.5
(Day>
,%%k:
(Year)
MEDICAL CERTIFICATE OF DEATH KATE OF DKATH J)
dxlvt
MoiitlO
(Day)
(Year)
H^
)V,/;,
iO
M.ititlis
b
Da v.<
'^IN'.I.K. MAkKIi:!), WIDoWKP OK IHVoKCKI)
'Wiitt in "XH-iril flt<iv^ii:iti<nO
HIK rni'i.ACK
i Sl.itc or C'liintrv
NAMH OF I ATHICR
MIKTIIF'I.ACK Ol- I ATMKK
' State r,r Cximtry
MAIDKN NAM).
HIK rm'j.ACK
<»!■ MoTlll'.K (State i»r (,''niiitr\ I
^ ^ ()
I HERKRV C1-:RT1FV, That I attended deceased from
VIA-OLu O IgO^ to LLlA^CL '^'^ IcK) H
! I '^ (T
that I last saw h ;- ^ > ■ alive on vAa,a«o X*^ up ^
and that death occurred, on the date stated above, at ll-oO
J^ M. The CArSl{ Ol- DI-ATH was as follows:
"1-
c)
<X/>n^ vj /vOcO^^-^^Xt *OC'
(^
y
<XA
y0.y>V'
I) r RATION CONTRinrTORV
)'tujrs Mo}iths o Days Hours
^'Wnul
DERATION Years ^roulhs Days
(Signed) LOrryo; UJ/oJll) JXJiAA;
OJ^\f^ X 190H (A.ldress) IQwDO U.<Vvun\jU/L vLvol
Hours M.D.
Special Information only for Hospitals, InstituHons, Transients, or Recent Resi(Jents, and persons dying away from home.
OCCri'ATION ['^p 0
Kf-idfd III S.iv ria>in>r,> \K) )V-.;;. 10 M.»,ths ^ Pm^
THK AHovK sr\ri:i) hkksoxai. i>\k ihti.aks aki-: tkik tu rm-: HKsT Ol- Mv KNt)\\ij:i)<Ali AND Hi:i.n:K
(InfoMiiant
(W."5
CXddrcss
Former or L'sual Residence
When was disease contracted. If not at place of death ?
How long at Place of Death ?
Days
PLACK Ol" KIKIAI, OK KKMOVAI, I l)A'ti:.)f }{t KIAI. or RKMOVAI, (Address 1.^ \j<3U->^ \j\jUji ^V\^^
!N. B. F.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 per- sons dyin^ away from home should be given in every instance.
•I
);ii
I'
I
I I . il
1
i
> i
I
■3; *
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
"""•' "^ n..-tlth t-Vo. 1^ T^-^^^HS:l'Cn REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
VJO\
Registered J\^o,
1365
l)((te Filed ,
DEPARTMENT Of PUBLIC HEALTH=City and County of San Francisco
Deputy Health Officer
PLACE OF DEATH: — County
(ir DEATH OCCURS A\A/AV FROM USUAL R IF DEATH OCCURRED IN A HOSPITAL Ol
Certificate of H)eatb
( tl. S. Stan&at^ )
St.
Dist.; bet.
and
ESIDENCEGIVE FACTS CALLED FOR UNDER "SPECIA R IhLSTITUTION GIVE ITS NAME INSTEAD OF STREET
■f^'
FULL NAME ^)
hJX,yx£JL%.
iL INFORMATION" N AND NUMBER. /
va
.\.<i.
PERSONAL AND STATISTICAL PARTICULARS SKX (Yr\ ft I COLOR
0 X'Vv^.
oJui
nATi-; 01 HI Kill
\<.K
MEDICAL CERTIFICATE OF DEATH DATE OF DKATH 9
DxUt X
(Montli)
(Day)
190^
(Year)
iMoiUh)
Hb
J' (/>
H
3.0
(Day)
Months
r % b H .
(Vt-ar)
/)<n.v
S[N(-.I,K MAKHIi;i). WIDOW KD OK DIXOKIKD
• Wiitfiii sKcial drsii'iiatioii)
|
niK riii'i. |
AOK |
|
1 stall' f)r C" |
ounti >•' |
|
NAMH 01 |
|
|
fatmi:k |
|
|
HIKTHl'I, |
\('K |
|
OI- I ATIIKR |
|
|
(Statf or C |
oil 11 try' |
I HHR1{HV CIvRTirV, That I attendod deceased from
l5 innM to _VA,A,A,^ ^.l IgoH
190
that I last saw h-AAj alive on
and that death occurred, on the date stated above, at \
'^\
190
I
M. The CATSi^ OF DlvATlI was as follows:
nr RATION
<xx.cL
e.
MAIDKN NAMl". OF MOTHKK
lURTM PLACE Ol- MOTHKK
• Stall- or Comitrv)
orcrPATION
Jb^rv>\AlJLA^CLAaAXL
y't'ars J\ Months Days
CONTR IIU'TOR V \|y\JLXLL^^vix^,v l. J J\A./0:^
Hours
L
n
^
Ct'v_.'
DTRATIOX
(SIGNED )
Years
Bx.
^^i:. 1
^Tont/is
TC)0 A
(Address) 59^0
I
Days Hours
M.D.
-o^
SPECIAL INFORMATION only for Hospitals, institutions, Transients, or Recent Residents, and persons dying away from fiome.
A^V^CVo
Resided III Sun /'i itiit isri)
] III I
^/,'n//r
/'<; 1.
Till-: ABOVE s rA'n:n pfrsonal i'aktum'i.aks akh tkif to iiii-; iif:st Ol' Mv KNo\\i,i:i)c.K AM) in-:Mi-:F
Former or Z\
Usual Residence vJ /Oav \t>-^^
When was disease contracted,^ If not at place of death ?
V^^ ^oX,
How lonq at Place of Death ?
Days
anfonnant \J Y\\A vAj \J, J
f X.Mress
O/O-'Vv
I'LACE OF niKIALOR REMOVAL j DATE of lit rial or REMOVAL C)<5uw V^ Col I ^^^'^' ^
6x^ «> _i90't
rNDi:RTAKFK VX00JH5'\a<>wvxx; lX'YvcijL\XxxJkv\va
(Address ^ H <i^ Q ^r^^^L ^t ^
r©
I
vc
IN. B. Bvery Item of information should be carefully Kupplied. AGE should be stated EXACTLY. PHYSICIANS should
state CAUSE OF DEATH in plain terms, that it may be properly classified. The "Special Information" for per- sons dyin^ away from home should be given in every instance.
m ■ft
i
I
11
If
/^U'fl^
WRITE PLAINLY WITH UIMFADIIMG INK — THIS IS A PERMANENT RECORD
REFER TO BACK OP CERTIFICATE FOR INSTRUCTIONS
I!. ..ml nf II( I nil I" Xo. !!; ■*^^^^>H.*tl' Co
Ihf/r Filed, ^
cL^-\>^A^
190\
Begisterecl J\^o,
1366
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of H)eatb
( vt. s. stall^at^ )
PLACE OF DEATH: — County olO^O^yx: 0/vco^^ou!,a.Oty ofO'O^"^ 0 /vcx--»-v'CA.<t c^
No. 1 IH
ckA^lu LL'V-, St.; 1 D;st.;bet.J-
(ir OtATH.fecCURS *W*V FROM USUAL RESIDENCE GIVE facts called for under "special INFORMATION" \ h
IF OEAnH occurred IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / \j
Dist;bet.J^O^wkAA/rb and U MAXVV
FULL NAME
'TVYVUL
XJki
PERSONAL AND STATISTICAL PARTICULARS
COI.< )k
I) ATI". <>l- itlK TH
MEDICAL CERTIFICATE OF DEATH DATE OF DEATH
(Month)
(Day) (Year)
AC. K
alt
I Montli)
^ )Vi/>-
(Day)
(Vear)
MntiShs
fhn.
I IIHKI'RV CIvRTIFV, That I attended deceased from
190 to 190
that I last saw h alive on ~~~~~ ~ 190
>i\c.i,K. MAKkn:n.
WIDOWKD OK niVoKvHD
iWritf in soriril 'IcsiiMiatioii)
niK IIU'I.ACH ' Stilt t or Country)
AXL^A.A>^^
FATH I.K
hikthjm.acf:
<)|- I AlHICk (Statf or (."onntT \-^
MAII)I-:n NAMF OF .MOTMFK
niKTHPI,ACK <)l" MoTlIHK
(Stall- or Coiititrvi
and that death occurred, on tlie date stated afjove, at ~ M. The CATS]': Ol' I)1':ATII was as follows
r^
n./0-<tA^ 01^ dL.^^AM'Sj
Di; RATION )'t'ars
CO.NTRIIU TORY
Months
Days
Hours
nrRATION Years Months Days
NED ) UrVCrvjlA; 0. Mb. U). iiXo^vc^. (Address) LC)^UrVyJiAA
(SIG
I()0
Hours M.D.
occri'ATioN (7r\p
Rf.'-idfd in Sail /'lain ism ^' 310 )'-•</; >' *" ^h>iitli< " /',; i >
0-V-AA.JUw*-^V^
SPECIAL INFORMATION only for Hospitdls, Instilutlons, Transients, or Recent Residents, and persons dying away from fiome.
rui: \iu)VF. sTAii:i) pkksonai, I'XKiicri.AKS akf tkck to thf: ni:sr <)i' m\ kxowi.iux; f and iu;i.n:i"
(Infoiniant
%.%
\'l(1ro«s
\LxtdLu o-t
Former or Usual Residence
Wlien was disease contracted, If not at place of death?
Hew long at
Place of Death? Days
D
HrKiAi. or RF:M0V'AI^
I'LACF: Ol" n'KIAI. OK KKMoVAI.
INDl-RTAKFK MfCX/VVvJi/O Vf fV O^^/WyW ^^<*- V^ (Addirss 3LIH Od./cU^ Q'k.
I9OH
IN. B. Kvery item of inforinntion should be cnrefuily 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 dyin£ away from home should be ^iven in every instance.
ft ' r
■'^
f
M iii
jITl"
^
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
l>.,an]Mf Hc-r.Uli I- Vo. \^ *^^^i\fkv C<y REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
I)a/r Filed, d
X ^190^
Deputy Health Offln<*^
Registei'ed •A^o.
1367
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
•■?
Certificate of H)eatb
( "U. S. StanOar& )
PLACE OF DEATH: — County ofO/CX^^; J ^uCLa v aAACX^^ City ofO^C\/W J AxXy'>A^Cv4.^1 Wo* 11^^ k 0 LcrOV\icr^'A : St.; 1 Dist.; bet* U/CL^Ca1\. i;i and ytx^^^^Atr'vv
(IF DEATH OCCURS AWAY FROM USUAL R E S I D E N C E Gl VE FACTS CALLED FOR U N DE R] "S PEC I AL I N FOR M ATI|( • N " "\ IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OC/STREET AND NUMBER. /
FULL NAME
SKX
DATH OJ- HI KIM
PERSONAL AND STATISTICAL PARTICULARS
j COI.OR/
i
iMoiith)
^155
(Year)
4
MEDICAL CERTIFICATE OF DEATH
DATE OF DKATH
(Day)
(Year)
AC.K
\\ }V,/;« b M.»,l/is V?.
n,j
SINCI.K. MAKKIKD. WIDOWKD OK DIVoKiKD iWtitcin s(K-i;»l dcKii'iiiitioii)
lUK ruI'UAOK (St.'tti- (»r Countrv*
NAMK <)I I" A r I \ 1-; K
niK'rm'i.ACK
()!• lATHKR (Statf or Cotintrv)
MAIDKN NAMK <)!• MOTHKK
HIRTHPr.ACK OK MOTHKK (Statf or Country)
(Month) ,1 I HF':RI':HV CIvRTIFV, That r attcndcMl .letcascd from
■•■■■ "■" 190 to- ' 190 — ~.
that I last saw h alive on 190 ~
and that death occurred, on the date state<l above, at - -:.. .-..■.:..:... - M. The
r::— M. The CAl'Siv C)I- I) I! ATI! was as follows:
...•tft .V<\<N^\.<i(X.:^. (fo .Wr^X^J^V^^'vu
1?'
'}
i
^^
D I" RATION Years
CONTRIUrTORV
Mouths
Days
flouts
nr RAT ION
)'cars
/>VCX
OOCri'ATION 9 0
Rfsiiifd i>i Son /'lain/yro 1 0 )'>,ns i \f,>nth.< I ^ J >a \
(Signed)...s]aj^
« oU^%
Afout/is
QjL^t I u)o'\ (Address) k) 0 b J -^LA^ttxAi . UJ
!J
C
a^
SPECIAL INFORMATION only for Hospitals, Institutions, Transients, or Recent Residents, and persons dying away from home.
THK ABOVE STATi:r) PKRSONAI, I'A RTKM' I.AKS A K !•: TKIK To Till-: HEST OF MV KNOWI.KnC.E AND HIvMlvF
Former or Usual Residence
Wlien was disease contracted, If not at place of death?
How long at
Place of Death? Days
(Itifoinianl CXA^w^TWO ^ CrtT fx O/
('
\<l(lrc.ss 10b
ot.
ri„\CK OI' lU'RIAI. OR KKMOVAI, J DATE of BfRiAf- or RF:moVAI,
rNDl-:KTAKER (>A^v^>(r\>-A- vJ CTtT^ Cjcv^-wq
(A(l<lress. iDb
IN. 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 dyin£ away from home should be ftiven in every instance.
mwiiinii
I
ll ll#
f .{6
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
i;,.:iniof ilcMltli- FNo. ■ . "^ggg^ H^IM',, REFER TO BACK OP CERTIFICATE FOR INSTRUCTIONS
Dfffr /07f>r/, 6Jo\^Xx/vvJU^; X 2D0\
Begl.stei'ed J\'*o,
1368
Os,Ar\j^-K^
Deputy Health OfTlcef
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of 2)eatb
( Ta. S. Stan^arD )
PLACE OF DEATH: — County ofQ<X/>^jtcu UuuvCu
City of
Ne.
tojtx
J (>-<t-
i^A^VoJu
CcJ.
(IF DtATH 0( IF DtATH
St.;
Dist; bet.
and
ccuWs Aw*v FROM USUAL RESIDENCE GIVE facts called for under "special information • "X
OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. /
%
FULL NAME
^
L^
<VV^:^X^.'
PERSONAL AND STATISTICAL PARTICULARS
I COI.OR
DATI-: <)l- I'.IKTM
iMoiitlil
A < ; K
(D.tv)
M'ulhs
4hs
fVear)
MEDICAL CERTIFICATE OF DEATH DATK OF DKATH 0
OjLkt I
(Month)
Day)
(Year)
Ditvs
^IN<.1,K MARKIKI).
wiix »\\ i;i) OK i)i\"nKrKi) 'Write in social (K -^ivnation)
|
lUK rUPI.AOK |
|
' state or Country) |
|
NX Mi; oi |
|
lATIUiR |
|
HIKTJIFM.ArH |
|
oi" 1 AIMKR |
|
(State or Country) |
|
NTAIDKN NAMK |
|
OI MOTHKR |
|
lUK'rHPr.ACK |
|
<>1" MoTIlKR |
|
(State or Country) |
X/ywyw/x>^^
HI<:RI:HV Ci;RTn'V, That I attendod deceased from
QwC 190?. to OjOfC^. I iQoH
tliat riast saw h -Ji-^' alive on C)-iJ|^Jb I 190 "^^'^
and that death occurred, on the date stated above, at l*L H.5 V M. The CATSIC UV J)IvATII was as follows:
Llt\jJLr\xxX dtoJi/YVAw^rVvivcJt^v-e.
J\JUo~\Jr\/<.<i
AA/ucj^fejU ci..
DURATION }'i'afs MmiiJn Days
CONTRIIU'TORV vl
nJ. /<x'voJLouaA-^
DURATION Years Motit/is Pays
>je4^ X TQOH (Address)
Hours
(Signed)
Flours M.D.
SPECIAL INFORMATION only for Hospitals, Institutions, Transients, or Recent Residents, and persons dying away from home.
OCCri'ATION (JU? A
(7b (>VAw^cuL^Aj-^-jy2-
Rfsidfd i)i Sav f'l am ism
) 'id I .
Months
f>,n.
Former or Usual Residence
Wfien was disease contracted, If not at place of deatfi?
Hew long at
Place of Deatli? Days
Tin: AMOVK STATl-:i) I'KRSONAI, T \ K lIC C I,A KS A R 1 ! TKir: T« > Tm-
iJHsT OI-' Mv kn'o\vm:i)<;h and in:Mi:F
(Informant Cr>NXu AJL/W^^rvXxX- i>JL'WWA>t.
f Address ."T
PI.ACK of HIRIAI, or RKMoVAI. I DA'IXj; of Miuiai. or REMOVAL
INDKRTAKKR OV) . \J . ^ JXjU\j(UL^r^
1 90 "I
(Address
of information should be cnrefully supplied. AGB should be stated EXACTLY. PHYSICIANS should E OF DEATH in plain terms, that it may be properly classified. The "Special Information" for p»r-
IN. B.—— Every item
state CAUSE ^. , . . .
sons dyin^ away from home should be given in every instance.
< >
f
i
t
.f
I
It
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
!!..,ti.l i.f n< .tltlr I* Vn ; - t^*'S^^^-. iu<v 1M\)
Dfffr FiJrd, r
i ^ 1
Re^lstei'ed J^'^o,
1369
■I
'i,''i
If ^
':.: lOO'i
Deputy Health Officer
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of Beatb
( XX. S. Stall&at^ ) ^PLACE OF DEATH: — County of O/CX/^aj ZKo - ^.utcxGty of 0<X>\; v) A.<X/vv.ca_a.cc No. vCtu, VL^TLC^vt
Ut
u i/UCK/|%A..L<X-' St.;
-Dist.; bet.-
and
f IF DtATH OCCURS 4**^ FROM I) S U A L R E S I D E N C E G I V E FACTS CALLED FOR UNDER "SPECIAL INFORMATION
lAL INFORMATION" \ DEATH GCCUN^IED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. - /
FULL NAME J.aX'u^ok LUu.a'v„ ,
PERSONAL AND STATISTICAL PARTICULARS ^'J.X A . . i COI.UR
lX<xL
MEDICAL CERTIFICATE OF DEATH
DATE OK DKATII
I) \Ti: (>i itiK rn
A< .!•:
5
M..titlii
) V(/; >
(I);iv)
Ck'car)
ckki
(Month)
1 (Day)
(Year)
I HRRHBV Cl-iRTIFY, That I attended (Icccascl from
S«L\A. C
I90
■\
to a^.^xt'. \.
\
190 H
190
Mttulhs JhjV:
^IN'.I.i:. MAKUll-;i).
U nxiNVHI) OK DIVOKCHr) Q
■W'litfiii ^cH'ial <h sij.'natioii ) —X
lUkTHlM.ACK I Statf or foiiiitrv*
a.
that r last saw h • ahvc on
and that death occnrred, on the date stated above, at 5- "iC ;^..; ' :M. The rArSl-; Ol" I)I:aTFI was as follows:
•!i.
NAMl. OI
i'.\Tin:K
mkiiu'i, \»'H
<'l lAPIIIvK
' Statr or (."onutix'
MAIIU'lN NAMl-; (»1- MOTHHK
lilRTlIPLAOK
OI' M()Thi-:k
(Slate or Couiitrv)
H<D^A'>"uU
V-v^QAa\
DIRATION H )'c'ars Mouths Days
CONTK I lU'TORV ...cU..O-VsJ[>Xl...i^^^ ■ .
//on
rs
CX/>^X^
(jLl-. . . L{rUjt\j
.VL-LO^'Wyi^-
[)r RATION
,y^}'i'ais Mouths H /^avs 15 //ours
'1 0 I V \v
T^L 1,^.1
M.D.
(Signed )
ax\\t i igoH (Address) Ut.| ^'-C
Special Information only for Hbspitals, institutions, Transients, or Recent Residents, and persons dyina away from fiome.
M|\t
nCCri'ATION
V.
o
'y^f.^idfif ill Still I'l iiiit isro 1 t )'riiis
\ ^^ioft^<UkjUY>
M,„itli^
n,i\.
THic Auoxi-: sr vv\:\) pkksonai, r ak iuclars aki: TKr}-: to thh iti-;sr OI- Mv knowm:i)c.k and hi-;mi:i'
(Iiifonu.tnt
■l^
^JUt\.AXJL mX/cc"Lc
Former or ' " ^ „ , 'S q. ' ' ' How long at Usual Residence ^AAX:t«T^^4.M >Xfa4*>M piare of Death?
Wfien was disease contracted,
If not at place of deatfi?
• Days
y.ACE OK Hl-RIAI, OK RKMOVAI, I DATI-: of Hikiai. or KICMOVAl,
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 f^iven in every instance.
■! i
i
I:
I ^f
11 I
!' Ilk
1^:1
lli
i 1 !!
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
RgFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
/^/'//r AV/fv/,.. Ox^^tj^ JfJO^
Kes^l^slet'ed J\'*o.
1370
a
Deputy Health Officer
DEPARTMENT OFPUBLIC HEALTH-City and County of San Francisco
No.
PLACE OF DEATH: — County of ■a^^'vT\o -,
Certificate of H)eatb
( "CI. S. StauOarD )
•> (^ 1
T J/
dt)
St.;
Dist.; bet.
City of ^ ' <Xaa^ K)A.O^■^ - ,
and
/ 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 \ \ IF DEATH OCCURHtD IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. )
\
FULL NAME
OiuT\JdLA
f
PERSONAL AND STATISTICAL PARTICULARS
SKX A . I Coi.oK
^w.<
DATl-; i)|- lUR III
A • , }•;
Li
/go \
(Ve.'ir)
Moiitlil
15 r,v,«
iD.'iy)
M.mth,
IVfiir)
Da 1 >
NiNt.i.i:. MAKi<ii:i)
W'lix >\\i;ii OK i)i\()ki-i-:i)
'Wiitfiti Hoii.il (I( ><irii.itiiiii)
I'.IK rill'I.Ai'K
I St:itf or (.■(Jiiiiti \ '
IxXAA^UUiw
NAMl- (>I
1 A'llI \\<
niRTm'i.ACK <>i I Arm:K
' St.it>- or C()\iiili v)
"MAIDllX NAM1-;
liiK'rm'i.AOK «)i- M()Tni-:K
(Statf or C(juntrv)
MEDICAL CERTIFICATE OF DEATH DATK OF DIvATH 0
fM-'iitli) (Hay)
1 lIl'Kl-r.V CI;RTII-V, TIimI J attcn.kMl .IcrcascMl from
.uL\,UOL 1 I90'! to i^JL^-Jb. I Igo'l
til at I last saw li ■ alive on CjJL.<^t up
and that death occiirreil, on the date stated ahove, at O vi ^r The CArSl<: Ol- DIvATH was as follows:
^ct
nCRATIOX
,0/^
Years \ Months C ( ) N 'J* R I li U TOR V \^OJ\.Aa^<X.<;l .... LL XO^ i-L:>:
/hivs Hours
y\JJLh.
n
I) r RAT ION
^
Years
Mouths
.l4^t 'I iQoS (Ad.lress) ISa^'l
Davs
Hon
rs
( SIGNED ) 'ilrlv^'V 2^0.0 r«
d
■1.
x%\k.^^
^V^AA
M.D.
OCCUPATION (Op p^
AV
sided ill Sou I'l tuii I'u'd ■ \j )'rins ,lA»;////.>
n,i v.<
rill", AHOVK ST ATI-: I) I'KRSOXAL I'A K T U" f I, A RS ARl! IRll': To UHST 0|- MV KNOWI.HDC.K AM) Hlilji:!"
Till-:
(liifonuimt
O
J)7l Qylo.-dk
(Address
SPECIAL INFORMATION only lor llospitdh. Inslitutions, Transients, or Recent Residents, and persons dying away from home.
Former or 9. ^ u i I w j- -f Mow lonq at
Usual Residence ^v A wXi>-^iA.4^ piare of Death? ^ Days
When was disease contracted. If not at place of death ?
DAil-lot' MruiAi, or KKMOVAI^
< P
'OjJ^
(Address H b.l Vl b.\^slA.<rvV Ul
N. B. F.very item of informntion should be cnrefuMy 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«r- sons dyin^ away from home should be fitiven in every instance*
1
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
__^ REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
f.o.ii.l ..f Hcnltli I" Vn i'- ^^^^^USiV ('.,
290 "i
BegLstered J\^o.
1371
r^ /^ ^^ ; I V . I
DEPARTMENT k PUBLIC HEALTH=CHy and Counfy of San Francisco
'ler
Certificate of H)eatb
PLACE OF DEATH: — County ofOcx-w vJ.\a->veuiC(. City of O Ct^^- O.VCL>vc\.^
(^
'No. niH ' ^il
St.
Q
iM Dist; bet.
FACTS CALLE OR INSTITUTION GIVE ITS NAME INSTEAD Ol
and
(ir DEATH OCCURS AWAY FROM USUAL RESIDENCE GIVE FACTS CALLED FOR UNDER "SPECIAL INFORMATION" \ IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. /
FULL NAME
J-xdlN-^. ^.d_,. w
^.^^^<>.: .
\
PERSONAL AND STATISTICAL PARTICULARS
^'■^^ '^-^
!>.\TK (>l liiK 111
a-LJi
COI.OR \
ll-(^.r
QfU:
M..nth)
MEDICAL CERTIFICATE OF DEATH DATK OF DKATH ^
:>].
rgn \
(Montrf) (Day) (Ytar)
\«.j<;
11
) ,-,n
9
^\ ( / •Dav)
M-niths
<Year)
If
/'<n
wnx lU i:i> OK i)i\t iKrMi)
Wiitf ill ^()ci;i] <lfsiji^iiatioii)
MiK rm'i.AOK
St.itt or ••'■•iintrv)
1 flawvxdi^
I irrvFM'HV CivRTrrV, That r attcii.lcM <lc(va^c(l from
Lm^Cl "■^■■'. u>o . to QxloiA. 2> up H
that I last saw li ■ alive on v.^JL-^Ajt. ':'. k^ .
and that death occurred, on the date stated above, at O U. M. The CArSI'] Ol- DlC.XTIf was as follows:
NA\T1-; (M-
I- A'nii:K
RTKTHI'I.ArH Ol" lATHHK (Statf or Cotitilrv^
MAIDHX NAMl. Ol- MOTIIKK
BTRTHPI.ACH OF MOTIIKK
'Stall- or Coimtrv^
Vi'VA.
^
f>
\
DIR.VTION )'t\irs
C()NTkII5UT()RV
}'i\irs
Moiith<;
Da j'.v
Months
Days
0
l%hJj<j(X ■ ) \A^ '
DTRATIOX
( SIGNED ) LL lb I U.^ vla^Xc. , .IlKA-'^ Tc,n'i (A<ldress) ?Ca (H, C^i
//o/ifS
Hours M.D.
SPECIAL INFORMATION only for Hospitals, Insfifutlons, Transifnts, or Recent Residents, and persons dyiny dwdy from home.
OCCUPATION QfU) i)
R^siilfil III Sit 11 /'i i!H( isrr) \ 5 '(■■(/ /A
.^fnllfh.<
/h:^
Former or Usual Residence
Wlien was disease contracted, If not at place of death?
Now lonq at Place of Death ?
Days
Tin-: AHo\-i-: st vn- d i-kksonm, i'\k ricri. aks aki-: rkri-: to tin-; iii-:sT oi-' MY i:no\\i,i-;i)<".h and hi-:i,ii;f
(In foiinriut
ri.ACH OI- lURIAI, OK ki-;mo\ai<
%
Ov^-<i^.
DAriiof niKiAi, or kf:mo\-ai.
r\(Mu-ss
ixia- '^ .tlv U..- I
rNDl-;KTAKF:R
(Ad
OXJvt i: T90''.
.Irt-ss nil V) l\ois^V.{rr^...&.
[N. B. Hvery item of informotJon should b;; cnrefully supplied. AGE should be stated EXACTLY. PHYSICIAINS should
state CAUSE OF DEATH in plnin terms, that it may be properly classified. The "Special Information" for p«r- Rons dyin^ away from home shoulil be feiven in every instance.
i
i'
;,(• ' '\
1
i
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
i; .;ii.l >,f H. Midi- !• No. i", t-rfar;.^) \iScV Co
REFER TO BACK OP CERTIFICATE FOR INSTRUCTIONS
/e96>H
liec^Lsteretl J\^o.
137S
1 :il .' \
• Mi , 1
I •*
/>^//f' /vAv/, 0)X^^^-Uy^v[^^^;x; ,-
DEPARTMENT OF PUBLIC HEALTB-City and County of San Francisco
Ceitificate of H)eatb
( 'a. S. StanC>arC> t
(.M
PLACE OF DEATH: — County of J<X-.v
V,
V ("1
^ ■ City of ■^ '
No. '-^HH ^^.^l^:' SU " Dist.;bet. V)a..C'^_<:.a and'^lix
(IF DCATH OCCURS AWAY FROM USUAL RESIDENCE GIVE FACTS CALLED FOR UNDER "SPECIAL INFORMATION" N IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. )
iV
FULL NAME
., \ o
i,
PERSONAL AND STATISTICAL PARTICULARS
0 A ^ ^ ^
I>.\ ri". ()!■ lUKTII
\<.H
J ■/•(/;.
a
,0
(Ditv)
.^/,^^rf/^\
MEDICAL CERTIFICATE OF DEATH
I).\TK Ol" i)i;ath
|
I |
.a.,(^..4.. (Year) |
|
.M |
Days |
"-IN". I.i:. MAKKIi:!)
\vii)i iui:i) (»K i)i\nKri:r)
\\iit' ill siH-ial (lfsivn.it i'lii)
1 lllvRI'FJV CI':RTII'V, Tlial I atteii.led Icivascd from
L.L^i^<:^. ' 190 to Cl^vt' .X i()o'\
that I last saw h • alive on CJ-^iLJ^ ..\ ^ xtp
and tliat dcatli occurred, on the date •stated above, at 0
•?
jr. Tlie CATS I'! Ol" DIvATII was as follows
I i.
lUKTUPr.AOK ' Statt- or Coniiti v^
NAMI-: (»J-
»"ATni;K
M1KT!!PI.A«'K 01 l-ATHHK (State or CoiMitry)
DCRATION
Years
MoNths
•••"••f"
Pays
Hours
CONTRIIUTORV
J,-.
h
r» \ I
MMDl.N N.XMl.; A 01 MOTHKK ]/
.1^
Years Mouths Days
0 '^
1)1' RATION
, N E D ) LU..'Tr\. V V C <kjK >-wa:k:vu
IMU'l-HIM.AllC 'Stat<' or lN)Uiitr\)
0-*-^c4X^iv|'VL/%'va' ^J) a^<i<ftUi
jL<xi
(SlGI
A 1
'...'..i.i...
;...Tr\.
I<)0
(.Ad.lress) !HM Lla.., '
Hours M.D.
SPECIAL Information onlv for Hospitals, InsfUutions, Transients, or Recent Residents, and persons dying away from liome.
t
orClI'A'lION
R\'\r(lril in Siin i'l <: III nri)
);■,!,
a
M.'iilhy
\ I
n<!\:
Former or I Isual Residence'
1 1 How lonq af a OXAa' \. > pidre of Oeatli ? Days
When was disease contracted, If not at place of deatli?
llaAcA-:
<X' L<?.'
iin; AHoxH sr \'n:i) pkusonai, pak rnri.AKS aki-; i^KiK ro
Hi:sT OI' MY KNn\VIj:i)('.H AM) lil'.I.Il'.K (Iiifonnaiit 0 JLVVji-2-. V V I A^^ oL .A./<jA\X'\XXVA.'
fA.ldre.ss A*^ HH.
Tin-;
'vt ."^l.
ri^VCK Ol" HIKIAI, OK KI;M(>VAI, j DA'IKuf Hiklai. ..r Kl-'MoVVI
T9O
(All.
N. B. Every Item of information should be carefully Huppliecl. A(1F. should be stated EXACTLY. PHYSICIANS should
stnte CAUSE OF DEATH in plnin terms, thnt it may be properly classified. The "Special Information" for per- sons dyin|^ away from home should be given in every instance.
If 1 1
I
I
^tl
I
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
M,.,„i..n...Hh- rNo...l^>r^..H^l-0. REFER TO BACK OP CERTIFICATE FOR INSTRUCTIONS
f M
n)o\
liCi^istei'ed J\^(),
1373
\>-U
eiii
h ' h
DEPARTMENT OF PUBLIC HEALTH-City and County of San Francisco
Ccitificatc of Scatb
t' '
A cap
PLACE OF DEATH: — County of ' <X'^^J 0 xo ■
n
No.
\%
.'^
City of
J AxtX
St.; -■*> Dist.;bet. ^i ' ^UAt^>x and
(ir DEATH OCCURS AWftY Fft'PM USUAL R E S I D E N C E G I VE FACTS CALLED TOR UNDER "SPECIAL INFORMATION ■ ' \ IF DEATH OCCURRED I N^^k, H O S PITA L OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. /
FULL NAME '- ■ .vaa.^ Ltc4."ta.i- ! v...."
\ ( , . A
( • n
PERSONAL AND STATISTICAL PARTICULARS
■-I.N r>r\ I r< >i .( iK ^
i> \ii. « •!• Ml kin
^c.v.
iMontli I
*^ ).-,n
^tN'< . I,l\ \! \K U Ii:i)
Wllx iWl.Ii OK I)I\ iiKi i;i)
l\Vrit< ill v<x<tal dfsijfiiation)
o.^
(I):iv)
M.nilhs
I I
MEDICAL CERTIFICATE OF DEATH
DA TJ-: <)l- I) I', \ Til V
(Montrf;
VX^
Dav)
(Year)
Da \$
K K, cC
' St.-iti I u < iiiiiit I \ .
' J
^ ^ ' I "^j
CrVAw^
a. viVxxUw
J m{Ri:ii\' Ci;RTiI<V, That I^attcndcl <lcccasc(l from
wLlA^O^ i .. I(p'i to . O-L.iAX 1 KjO ' .
that I last saw h alive on - VJ-^ixtj \*.p
and that death occurred, on the date stated ahove, at 0. o 0 U_M. The CAISI- OI" DI-ATIf was as follows:
-rVN.x^r'W/Ow'
n
\A\u-: (»i
F
A MM (»1- ,xA
ATHKK ^ , j^f
HIk rMIM.AC'K <»!• l-ATMHK 'St.ifi- f)! c"<)uutrv)
M\I1H:\ NAMi: <»I Mori IKK
I?Ik'l'HIM,ACH OI MoTHHk (Statf or ("omitrv
OCCr I'ATluN
I )r RATION Years Months 4 Days Hours
CONTRIIU'TORV \^^^4M^<X.^\»d.. '„! ■...-.
^^U^ 1'>X (X ■> X^ OL MiL^ K,(X
DURATION
Years
Mouths
(SIGNED) ^' X VCCLU4 J O. 'X.
Days
a
A
—L
190
^ .7) .
(Address) iC^H ^Us^ ^y
Hours M.D.
SPECIAL Information only tor Hospitals. Insfifuhons, Transients, or Recent Residents, dnd persons d)in:| dwdy from tiome.
f\r>iifiif III Sim /'t (I III i^iii 1 '. J'lf;
M.'nth-
f',i\
ill f
III i: XimVH ST ATI", I) l'HK>^0\ \I, I' \K lUri.AkS AK 1. IKli:
HHST OI- MY KX()\vi,i;i)c. i<: AM) in;i. n:K
To Tin-
Former or L'sual Residence
When Has disease contracted, If not at place of deatfi ?
How lonq at Place of Deatfi ?
Days
(Iiifi);in:itit
rvdcln-^s
ri<ACK OI- HiuiAi, OR ki;mo\ai.
rNi)i-:kTAKi-;k
DATJ^Iof IJiKiAl, or kl-;Mo\AI,
N. B. Hvery item of itiforiiirttion should be cnrefuify supplied. AGK should be stated EXACTLY. PHYSICIANS should
stnte CAUSE OF DEATH in pinin terms, thnt it nuiy be properly classified. The "Special Information" for per- sons dyin^ away from homo should be given in e\ery instance.
M-
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
I" '"1 "'■ MeaUh >•• N.). i^ •g"«;:Htr'^ '<^>' ^''> REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
' II
I)(f/r /v/^v/,(3jlAaXx>^aX-Uv'
<j<js
10 a
Registered jYo,
1374
Deputy Health Officer
DEPARTMENT riF PUBLIC HEALTH=City and County of San Francisco
Certificate of Beatb
( "U. S. StauDar^ ) PLACE OF DEATH: — County of 0,Ou->X' 0 A^O/VVC^ACC City oi^Ojy\j 0/vxX/>a.<iaxlc.o No. \ M ?^ ' - ^1 1 V. . .. ' St.; ' Dist.; bet.VJl.aA.A \,c A. d.^ and H H
(IF OtATM OCCURS AWAY FROM USUAL R E S I D E N C E C I V E FACTS CALLED FOR UNDER "SPECIAL INFORMATION" \ IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. /
FULL NAME
%i\
PERSONAL AND STATISTICAL PARTICULARS
SI
I'ATl-: (H H1K)"U
COI.OR >^
I
UJruJji
MEDICAL CERTIFICATE OF DEATH
DATE OF DKATH
i\
M(.iitll)
Af. I-:
?.
J 'tUl I
t,
I r3.£l
(Day) (Year)
Mntitlis Davs
r
(
iikl.
Mont'h)
I
I
(Day)
(Year)
^IXt.I.I' M \RRIi:i) \\ Ilx iWi:i» ( tK DIVi iKtl-;!) Write in social <1« >«ivMi.iti<iii)
I I
t|
State <)r ' "i iimt ry
NAM I- i»l- KATHi;k
HIRTHI'l.ACK <>l l-ATUKK
•State (ir Cojiiitry)
MAIDKN NAMK
<n- Moi'UHK
niRrHJM.Ac'H
<•! MoTHKR (State or Country)
LcJLu,
I irp:Rr':RV Cr-RTrFV, That I MttciKled .Icrcascd from
LA.\A,:C\. I 190 \ to vArr\rfS,^, .6.1 190*1
that I last saw h XHj. alive Oil v vV^vn ' jip
and that <k'ath Droit rrcti, on the date stated above, at *^ J\I. Th^ CAISI*: Ol- DIvATH was as follows:
Ct\jLAJ^^a.V n[ /\x>a,v.-».vol\.1'..
I '
DT RATION }'fars Mouths /\iys CONTRIIJUTORV Lv:>\A.>^^:^.•..
Hours
occri'ATiox
Rfshlrd in Sav /'lan.isr,) ^ )%\}i< L Mmithf
Dl' RATION (3IGNED)
Years
Jfont/is
Davs
TC)0
Hours
(Address)
{-
Special information only for Hospitals, Institutions, Transients, or Recent Residents, and persons dying away from home.
Former or Usual Residence
How lonq at
Place of Death? Days
Hav:
\'\\V AUOVH ST\ TI-I) I'KRSONM, I' \ K I" U' f I. A R S ARl'! TRIK T« > THH J5KST OV MY KN()\VI.i:i)C.K AND HllI.II-F
HSb - S liv LU-4 O
When was disease contracted, If not at place of death?
ri.ACK Ol' lURIAI. OR ri;m(>v.\i. INDICRTAKH
ajLcJL.
I).\'l 1; of I'.iKiAi. or RKM()\-.\I,
Jx['vt' H 190 H
(.\<l<lrcss
.:RUOL)U.^\.tjL JTl^N^-^^Aj VU
(Address 15 IH Ov^oklLfr^A; U.I..
N. B. Kvery Item of informHtion 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 given in every instance.
I
". 7
mil
? n
'i
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
I! ;,t.l of lh;ilth - !•■ N'f). !^ '*-5'.'!ir'?tii M.vtl' C,
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
Ro^istered JVo,
1375
X^Crv^v. ^ L Deputy Health Officer
DEPARTfflENT OF PUBLIC HEALTH-City and County of San Francisco
Certificate of H)catb
1 "U. 5. StauDarO ) PLACE OF DEATH: — County ofOa^yv 0 VCL^xcu.'et City of'^A.-^v 'No. C ^ C^..^.. ^ ^ L ... ' - St.; Dist.; bet. — — and
\j
/UCC^XCA.
vi '■ :. ;.,
(If DEATH OCCURS AWAY FROM USUAL R E S I D E N C E G I VE FACTS CALLED FOR UNDER "SPECIAL I N FO R M ATIO N *• "\ IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. /
FULL NAME
0
:^
;i
CyXxQj
' '• A.
°i-
PERSONAL AND STATISTICAL PARTICULARS
; c(»i,<ik ,
I>Ari-; nl IIIKTII
ACK
UJ^aA^
MEDICAL CERTIFICATE OF DEATH
DATK (>i< i)i;\rii
LL
Month) V
n
(Day)
,^5-5
^ » Ym*s
M.nilhs
\\
( Vear)
n,i\s
CMoii/li)
(Day)
I go
(Year)
^iN'.i.K. m\ki<ii:d
\V II)<)\yi;D OK DI\'< >Kii;[) 'Wiiti in social dcsi^niMt ion)
'voixL
MiKTni'i, VO-:
' state or ("on nt i \ <
N.XMl-; oi-- lATMKK
niKTun.ACH
O!' l-ATm-K (Statr- or c'onntrv)
M MI>i:n N'AMl-:
<•!• .M()'rm;K
lUKlIIlM, Xt'K
(»i' Mnrni-;K
(Slate or Country)
occri'.\Ti»)x \^
I HFCKIvnV Ci:kTI!'N', Tliat I attcii.k-.l «k-ccasc(l from
.rrrrr- ii/) to ■• Kp
thai I last saw li alive on ~ — k^
ati<l that <lfatli occurred, on tlie <latc statctl ahovc, at M. The CAISI': OI- 1)1-; ATI I was as follows:
L<c^^w<t)r:Q■.-:L^..e....y^>^^ ..y.CHw^.t r.v...v...^...,..q
l*.»^*»-»»*»»^M«#»-» •■••••••■
■■>
^
\JS
DURATION Years CONTKIIUTORV
Months
Days
Hours
(1
DURATION
) 'cars ^ Months
Days
Hon
rs
( SIGNED )..L:^\C. • J 4^ LL. Axla > ..r^., M.D.
Special Information only for Hospitals, Insfitutlok Transients,
'CSA.\
V
I
Rrsiiffd in Sijtr Fiain/s/'i) ■' )<'i7;
1A'»///>
/>,!
or Recent Residents, and persons dying av^ay from fiome
Former or Usual Residence
How long at Plare of Death ?
Days
Tin-: MtOXK STATl-.D I'KKSONAI, J'A K T If l' I,.\ KS A K i: TK t" J-: To TlU' UHST OJ-" MV KNoWl.l-nC.l-; AND i!i:mi:i'"
( Iiifoiniant
.1 ^J
(\<l<lress
IHH5
When was disease contracted, If not at place of death ?
}'I,ACK OF UrHIAI, OK RllMoNAI, j DAT^JCot JUkiai. or R1:MoVAI.
Q}ii_'Luv^a I ^^1^ H 190
r.VDi:KTAKKR
(Address ll.^.'l.
V^A,!i.«\\
\f
N. B. Kvery item of informntion should be carelrully supplied. AGE should be stated EXACTLY. PHYSICIAINS should
stntc CAUSE OF DEATH in plain terms, that it may be properly classified. The "Special Information" for par- sons dyin^ away from home should be ^iven in every instance.
>
k
U<4x,\ ,,f Hffiltl) »■ No. !^ ^'^^^^^: lu^l' (\,
I ,
! I
f
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
h^f/r /•V7f>./, Bx^Wv^J>.^ ? IfJO'i Registered ^'o, 1376
h' ■ (i
or
.^^KXA cLcwu Deputy ' '
DEPARTMENT Of PUBLIC HEALTH=City and County of San Francisco
I \
' tt:.;ir!iiim»!: I
Certificate of IDeatb
i "a. 55. 5tnnc>nrC> }
No,
PLACE OF DEATH: — County of
J.
\,a/-vA.'C^4ct City of Oo.
Q^
W
VO
1 M ^
InIJA A.^. . St.; Dist.;bet.
(IF Di<ATH OCCURS *W«V FROM USUAL RESIDENCE GIVE FACTS CALLED FOR UNDE »t/DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD O
l^
and
R "special INFORMATION" *\ F STREET AND NUMBER. /
FULL N A M E ^ A. ) v o. , .Ia. o
-'^ v..
PERSONAL AND STATISTICAL PARTICULARS
C<iH)K >^
MA 1-^
I) A IJ- . .1 I!IK I'M
ACK
UuJvcU
MEDICAL CERTIFICATE OF DEATH DATK OF m:\ 111
(I)av)
/HCH
k cur*
r\
xi\x
(Monthl
ts
'Day)
(Year*
) 'ra I A
M.niHn
U
Pa vs
^I\<". 1,1".. MAKRIl-:!)
\\ II»< >\Vi:i) OK DIVoKi i:i)
{Write in six-ial desijrnation)
|
lUKTMl'I.ArK |
|
^! lie or (."oiUlttA' |
|
NAMi: <»l |
|
FATin.K |
|
HIkTMFM.AOK |
|
0(- l-ATHKK |
|
'State or fonntry) |
|
MAIDKN XAMK |
|
<n- MoTHKR |
O/CX^TV O AXX/YVC -^ C^C
rHHRI-nV CP:RTIFV, That I aUen.k-<l (Icrcase.l from
Uv\.\X\ 'A. 190 H to 'pJU-'^-s^ Kp
that I last saw h X-\.' alive on C'^r^AA '..-.. j(jo
and that death o(u-iirrf(l, nii the date state<l above, at ^r. The CATSI-; OI' Dl-ATII was as follows:
Dr RATION Years \ Months i '' Hays CONTR I m'TOR V L^AA.i'^A^^ftr..■..,^.
Hours
v^.
lUK'iui'r.ArH
•»|- Mo'l'Ul'.K 'St;il> 1 .1 Cotiiitrv)
A
\J
^sy
^
I) I' RATION Years Mouths Pays
(SIGNED ) . LUl>0A''^^^^ "d^OucAXuJLvVL
lxi(\t 1 T90H (Addrc>;s) l';iO ^K.'.Vll-A<. 0.0
Hours M.D.
SPECIAL INFORMATION only for Hospitals, InslituHons, Transients,
or Recent Residents, and persons dying away fro.Ti tiome.
OCCri'.XTlON „^
!V-,;;
M.,»Hn
/h,\
Former or Usual Residence
When was disease contracted, If not at place of death ?
How lonq iA Place of Death ?
Days
\
VWV. AU()\K STAri'I) CKKSONAI, I'.\ K I" FT T I,A K.-. .VKl". I^KIK I'D III V. UKST OK M\Y^N<)\VIJ:I)<". K AND JIIUJKF
^Infoiin.'iiit
(.\fMrcs.s
lAxWcti > . ■
.^^
IM.ACK Ul" IJlklAI. OK kl,Mo\.U, I DArj;.)! Hikiai. or KlMoXM
A . J < ,
•ni)i:ktaki;k JaxUIu VL uVOLOitX.
(At
N. B. Every item of infarmation should be cnrefully supplied. AGB should be stuted EXACTLY. PHYSICIANS nhould
stnte C.AlJSn OF DEATH in pliiin terms, that it may be properly claHnified. The "Special InformHtion" for p»r- Rons dyin^ away from home should be ^iven in «\'9ry instance.
' II
!■*
.ill
i\
1 1
M
p
Iti't
! 1
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
|!...,m1 ..f Hiiitth - |- No i< "fr't^^ifi^ii IJ&I' Co
!)((/(' Filed ^
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
^
VJO^
lle^istevcd J\'*o,
1377
v-u
DEPARTMENT OF PUBLIC HEALTH-Cify and County of San Francisco
Certificate of Death
SI Q^ i
%
PLACE OF DEATH: — County oij<X^r\j vj/>^ct-^vcc^ix;f<:ity ofO/<Vvu J A.CL/>Ay^^4^ c t.
No. HS2) OcrlxU/>^ U.oX^ lli-i St.; \ Dist.;bct. OUXX.Alv>v andVirLK
(IF DEATH OCCURS AW*V FROM USUAL RESIDENCE GIVE FACTS CALLED FOR UNDER "SPECIAL INFORMATION • \ IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER /
^ , is
FULL NAME
m;x
'9
PERSONAL AND STATISTICAL PARTICULARS
1
i»Aii-: <»i' liiKiii
KV.V.
\\ y.uus 0
(IX-iv)
Moiif/n
(Vcar)
MEDICAL CERTIFICATE OF DEATH
DATH ()!• 1)1:AT1I
MontH]
X.
)
i
(Day) (Year)
a'^
Pa Ys
^INt.I,!':. MARK IK I) U'l|)<)\\i:i) OK DIVoki }•:!) 'Wiitcin --.H-ia! (It'siv'iiatiuii)
niF<TmM,AOK
i State (11 Coniitrv-^
XAMK OI- JAI IlKK
Hik rniM.Aii-:
OI" lATIIKR iStatf or Cimiitrv)
MAII)}:n NAMl-: OI MoTUHK
itikTm'r.Acj':
OI- MoTIII-.K (Statf t)r iDiiiitrv^
^
cL'
X.tXtrXAr
r ill'KI-BV Cl'iRTIFV, That I attended deceased from
LLlv..O Ik icp'i to ..).x|x.l' 190':
that I last saw h •-<- ahve on '3 , i 190 •
and that death occurred, on the date stated ahove, at 10. 0 S^ IV ^r. The CArSF-: (>!• I) MAT II was as follows: \y0..ry\,^v:JJ\> cry . cL<wv,'>vci. AX>vci^ S J6.*\^:..o.-y'^'
(J XV^^'VOL/V^Ci
nr RATION Years Man //is * Davs
CONTRinrTORV \j\^"
/louts
">\X.
\>i
DURATION
(SIGNED).. .LU /v>^ \X) a. ti JXX^^
90
)'cars Mouths Pays Hours
nnno \AJ <X.\.\^ JOtn,^; M.D.
Address) * 'U I l.O. ».. 1 JLA. ). i.L ' :..
(.
oiHTi'ATlON
Special Information only for Hospitals, institutions, Transients, or Recent Residents, and persons dying awdv from fiome.
fso/drd ill San /'i iiPii isro
)'rii > .
A/<»////y
n,n
v\{V. AHovH sTA'n;n i-kksonai, p.xk rirri..\KS akic ikik to tiN'; HHST OI^MN' KNo\\1,i;I)(;H AM) ni-:i,ii%K
Former or Usual Residence
When was disease contracted, If not at place of death?
How long at
Place of Death? Days
flufonjiaiit
.kAa
(Address
ri.AClC OKIUKIAI, OR RKMoVAI. j DATIvof ItiKiAr, or KKMOVM UNDKRTAKKR 0 19 . J . Cj -V<
^)j^^\h) ''"^U
(Address
I WVAUl,A.^r>V..C.II.
N. B. Kvery item of itiformHtJon should be cnrefully supplied. AGfi should be stated EXACTLY. PHYSICIANS should
state CAUSE OF DEATH in plnin terms, that it may be properly classified. The '^Special Information" for per- sons dyin^ away from home should be f^iven in every instance.
I !{
r. i
J^jh^^^A -Kf
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
11,.:,'. 1 ..f Id ;itt!l !•■ V')- !-
■^Sf^!!!!;^, n.«t
■m.,-^^
V Cr)
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
Registered J\^o.
1378
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
"I"-;
il'i
I 111
t ■
Cevtificate of 2)cath
( *a. S. StanDar^ ) PLACE OF DEATH: — County of ^^'^ ~>\ ^ K(yjy -\A^': City of OxXav ^ Kcui\..r^.<i.'i<.
N«.
-w
l'
C (lb CSai\\aXo i. __ __.,
(IF Dr»TH OCc6bS *W«Y 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. /
St.;
Dist.; bet.
and
-)
FULL NAME
€L'y\X
x:
PERSONAL AND STATISTICAL PARTICULARS
I COI.OR ^
i> \ 1 1-: < >j niKTii
1-^.
(Day)
?
MEDICAL CERTIFICATE OF DEATH
DATK OF DKATH Jj)
axkJt:,
(Monthf
0
t ..<... .
(Day)
(Year)
A«',K
A V 5V,/;.«
\l,»,lli^
IC)
(Year)
/)./
MNt.l.I". M\KKIi;i». WIDoUKI) OK I)I\()R(HI)
'M'titciii '-ocial <U-siv'nalii)ii)
liiK rm'UAOK
'Statf or Cotiutrv)
1 HRRRBY CKRTIFY, That I attended deceased from
••••■■ I9O — to -rrrrr:. icjQ — —
that I last saw h alive on 190 — — -
XAMI-: Ol'
1 \iin;K
t'.IK IIU'I.ArK Ol" lAIHKK (Stall itr (.'oinitrv)
MAinilN XAMI
niRTHIM,ACK <>»• MOTIIKR (Stat<- ur C(iunlr\
OCCrpATlON
and that death occurred, on the date stated above, at „ :vr. The CATSlv OF ]>I':AT1I was as follows
LJL^^JQ3-^^<xJL JoX':v'%:-^Cr\^
Dl'RATrON Years MoJiihs Days Hours
CONTRIBUTORY OXk-vv^Jk Jlmjl Xjti<LArYYsA?u^r'>JL....S^k.
L'LL<^>/vv\ji.<i,.<x,. ..LxxL-
ZA/v.?
I ) r R A T I ( ) X ) \\i rs ^y^^'^^o n ths
(SIGNED) Ltr^.tr^\x^; J / J6 . U3 . ivjj^^
Ox|-\:i. X TQo'i (Address) L(r\.fr^\jl\>^ V 4 1 \
Special information only for Hospitals, Instituflohs, Transients, or Recent Residents, and persons dying away from home.
Former or Q '^ '7 ^Jv k^ ♦. J vi '*"** '""A ^^ Usual Residence v) >- V ^W CrVA^uaa. ./t. piarc of Deatfi?
Hours M.D.
Days
Rfsidrd ill Sun /'niin isfo 0,*5; )Vvr;.v
Moulin
Day
Tin-: A no vK ST A 'n: I) i'kksonai, iwr riori,\Rs ari; trih to i'iik nivST oi- Mv KNo\\i,i:nc. H and wvaav.v
(liifoiiiiant
^A.,AJ^.xx^^L/C^^'■
Wfien was disease contracted, If not at place of deatfi?
rr.A^K OI- niRIAI, or RH.MoVAI, I DATJ-:.)!" Hiriai. or KKMOVAI.
%.^. d-Uv. ^^-l!; "
UNDKKTAKKR
fA<l<lri-ss lA/i."!.
vM^v^orvx
..^ :
N. B. Every item of information should be CHPefully 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«rj sons dyin]^ away from home should be (^iven in every instance.
'iv' '■'*■•
M
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
|
,: ■ 11, i!il', 1 N'o I> ■?"*!^J^i' Hftl' C |
o |
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS |
|
|
Dfffc Filed , OjLVvtl/v A /■ |
^v.XMA' ?5 |
100^ |
Registered J\'o, 1379 |
|
\ 1 |
Deputy |
Health OfYlcer 1 |
|
|
DEPARTMENT Of |
^ PUBLIC HEALTH^ |
=City and County of San Francisco |
Certificate of IDeatb
( "U. 5. Stanc>arc> ) PLACE OF DEATH: — County of ' ' ' City of
No.-
St.;
■Dist.; bet.
-and
(ir DtATH OCCURS AiWAY TROM USUAL RESIDENCE GIVt 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
PERSONAL AND STATISTICAL PARTICULARS J N OOj . I COI.MR
\>Vl'K or HIKTU
V
4-
m
1 ■ . Ht^.
c> z" .
ri-.u
M'»|it}i I
1
(I);iv)
.IS I
(\'vnr
MEDICAL CERTIFICATE OF DEATH
DAT}-: OF I > HATH U
-....\J.-.«4w/kX'Vj
(Month)' (Day)
(Year)
AC.K
J -„•
i M-»itfis CSO /hi\s
^IN'.I.I" M.\kKIl-:i).
w ii)« »\yi;i) < >K nr\< tkcj;i)
Uiitiiii sotial ilrsii'iKilimi)
HIRTm'I.Xt'H < Statr or C'lmit J \'
1 n ^, N * C '-^
^.i *
I HlvRI-HV CIvRTII'V, That I attended deceased from
190 to i90~~~:.
that I last saw h "^^ alive on ~~~- ~" iqo
and that death occurred, on the dale stated above, at
M. The CAlSlv Ol- DI'ATIl was as follows: WCXrVA./?:!^:/
CXAA Cl CL/fV^ VnLa_ tLi
tL
NAM): Ol-
I A rMi:K
''•IKTIII'I.MK Ol- l-ATIIKK
'•^t.ttf <,i I'oiintry)
MAIDI-.N NAMK OF MoTHlvK
liik'nnM.ACF: "I M(>tiif:r
'State or Countrv)
OCCll'ATION
Dl' RAT ION }'tars
CONTRIRUTORY
Months
Days
I Jours
DURATION Years Afont/is
(SIGNED) U.Jsh a (y<i.tj2A;
lAjfc" 1 iqoH (Address)
Days
Hours M.D.
/t)
U.
SPECIAL INFORMATION only for Hospltdls, Insfitutions, Transients, or Recent Residents, and persons dying away from liome.
AV-i,,'./c\7 /;/ Situ i'l ani i^ro
) 'ill I
M.'uHi^
Ih
iJii-; A MOV f: ST A 'n:n p» ksonai, fauititlaks aki; TRrH to thh jJi:sT Ol- M); kno\vij-;i)c.f: and Mi-:i.iF;i-
Former or Usual Residence
Wfien was disease contracted, If not af place of death?
How long at
Place of Death? Days
(ii
r\'l.lr(
La.\^-
xxU^^ ^ -^y
,^
vACf: oi- iukjai^ok kkmovai.
Ui/*pJvJAA> d-0-'
-W
DA'lLFof MiKiAl- or klvMOX'AI,
FNDICKTAKKK UCoAjk ^t vfc OVL^Ja.
N. B. Every Item o? informntion should be carefully supplied. AGIi fihoiild be «tote<l EXACTLY. PHYSICIANS nhould
state CAUSE OF DEATH in plain terms, that it may be properly clasnified. The "Special Information" for par- sons dyin^ away from home should be feiven in every instance.
Ii
,1.'
.'1
i
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATg FOR INSTRUCTIONS
l)((f(' FiJe'l ,'Qji}^dU.^^-.ylh^
100'
Registered JVo,
1380
<KA^ cU.\M^ Deputy Health OfTicer
DEPARTMENT OF PUBLIC HEALTII=City and County of San Francisco
Ccvtiftcatc of 2)eath
( Ta. S. Stan£>at? )
^
PLACE OF DEATH: — County of C)<Xo^ Oxa wcui.'Cc^City of d/Cc^^. 0,h„<X/>xcU,e'.
/ 1 )
\
A^d.i\Af.V
and
%A
( " .°/!i',".,°"^''""^ *"*'' '"°" "SUAL RESIDENCE Give r.CTS c.LLtD roR UNOtn •sprciAL inporm.tion-- N
V .r Ot.TH OCCUR. £D ,N . „OSPIT.L OR ,»STm.T.ON CIVt ITS NAME INSTE.D OF STRtCT .NO NUMBER )
FULL NAME vIlJ^Aj it JLY\.,-n.,u. ajLa.
i
PERSONAL AND STATISTICAL PARTICULARS
si;\
'la.L
COl.OR
DAIi; «t| IHRTH
\ < ; 1-:
'i^i:^s!^J.«iL
IDriv)
M,,„tl,.
r iJ.' .
(Year)
Pa 1 ,^
MEDICAL CERTIFICATE OF DEATH DATK OK DIUTH Jj ~~~
(MontH)
(Day)
I go .
(Year)
SIN<.I,I". M.\KKIi:i) \\nM»\yj:i) OK I)t\"< (RtKi) • U'liit in soriiil <l«>i>.Mi;it ioii)
lUklMI I'l, MM-:
iSt;ttf <.t <".(iiiitrv)
. f LaV\A.eci^
J JIRRKBY CF-RTIFV, That I attended deceased from
'-^-^ I'-i up'i to . Q ji^vt X 190 H
that I last saw hi.. alive on 3 JL^rxi f^ ^^^ '
and that death occurred, on the date stated above, at ^ H5" I UVm. The CArSl<: 01- DKATir was as follows:
y^^XAy
.\^^^:t>^^S
N'AMi: 01 FA IHlvR
lUK lill'l.ArK
Of" i-ArmtK
iStat*' or Coiiiitrv)
MAinivN NAM}.-
niK'nii'i,.\ci-: •>!• M()Tin<;K
(stale nr Coiiiiti\ »
F) I- RAT ION Vrars Mouths \^^Days J Jours
CONTRIBUTORY kA.CL.'^
.^...
DURATION . Years
(SIG
Jfont/r
NED)....l,k/tKi lb. C)J
'x-0„
^^<W^^ I /ours
M.D.
1 •.■^ )V,//.
^^ '^I^ [Address) Xn on LaLL\.v^A,.a "^>.
?^^9'^'- INFORMATION only for Hospitals, InstitutLs TransienK or Recent Residents, and persons dying away from home. """^"""n^. irans.ents.
Rr\i(1riJ nt S,ni I'l ,;;/,
Mnlllln
IhlV.
Former or Usual Residence
Wfien was disease contracted, If not at place of death ?
How lonq nK Place of Death ?
Days
Ilhsl 01 :vi\ K.\()\VI.i;i)C.H AM) lUCMHK
(II
I'^CK ()..■ .UKMAI, OR KKMUVAI. I OATl- o! n.H.A,. orRHMOVAI." C\^^ I "^-^i^ '' T90H.
^Ad.lress 1 lllAJ. )l^5L^,A^:vv..a^^
N. K.-
>
I
m>
|i
If
I *! #
WRITE PLAINLY WITH UIMFADIIMG INK — THIS IS A PERMANENT RECORD
___^ REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
.;!i,l .,f II, ,1 1 til -I" Vn. !«; t-«^»!!'^-, !U<t 1> Co
i
JL:
:1
,3 7.9 ^M
Deputy Health Officer
liegisleved J^fo.
1381
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Ccvtiffcate of Bcath
( U. S. Stan^arO )
J?
^
X
(^
PLACE OF DEATH: — County oiOcxrwi ' .'X<XAVCAi' City of O/cwu 3 Axx^vttv^ t^. ,
No.
*t)
\\x^ m^<X-KkoX
St
Dist.; bet.
"-and
/ ir ot*TH OCCURS A^«AY FROM 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. )
FULL NAME
crillAjJb- XqXx,
SKX
PERSONAL AND STATISTICAL PARTICULARS
coi.ok
DAT1-: <>l- KIKIll , \ ^
MEDICAL CERTIFICATE OF DEATH
DATE OK DK
.vn. J
(Montlj)
1
(Day)
IQO .
(Year)
Mujith*
AHK
I I Vmti. \
(Day)
Mntiths
X
/.ti.^.J.
(Year)
/><n.
^ IN'. I.I-: MXKKii:!)
u !!)« »\\ i-:i) «»k i)!\< >KCi;r)
'\\'riti id sotiai <l<>.>i}.'ii:it imi I
IlIkTHI'I.AC'K ^t;itf or I'lniuti \*
llW
\J\^JL<k^
\AM1-- ()|
faihi;k
HIRTllI'l.AiH 0|.- lATHKK (Sttitt Dr Couiitrv)
JcX/T^vOw-yv-
MAIDKN NAMF OF MorHHK
I'.iK'rniM.AcH
OI- MOTHKK (Slatf (ir Counlrv)
I HHRHBY CI'RTIFY, That I attended deceased from
^^^^^^-^^ l*^ 190'A to ..DjL^.I % i()o H
that r last saw h •>- > )\ aHve on f 3. JL:|-vl, 'X up
and that «leath occurred, on the date t^tated ahcive. at 1^ " M. The CArSlv OF DI-ATH was as follows:
-A^^.
DURATION Years Mouths % Days ^^...Hours
COXTRIHUTORY "^ <^<-^il>^.AA^^.
\^^JjLh^O ■ o
Years Mo fit /is 5vC) Days Hours
DURATION
(Signed)
m
r
IX|\1) :X TQo'v (Ad.lrc-ss)
L^-V»Jl
"Cn-ATION J) . Q
),„l >
M.'„th^
n,i
Special information only for Hospitals, litl(itutlons. Transients or Recent Residents, and oersons dying away from home
M.D.
f;"Tn"^ S^^^ ^^t f J n Hovv long at
Isual Residence v)UU VJ^v\XX.'>\CL \A\v piare of Oeatfj?
Tin: AMOVH STATi:i) I'KK«-;«)NA1, PA K i' IC T I. A R S \K1- TRIK T< > TUF