i

•"i^«4i^

ir^

^

t. .. .f.

EGIN

«3H^

■WP

[

s

V

■"flplll

m IIP ■ ^M wi

w ocr*OR,n

■^^^p«viHVfl|9fP^ar>W7»^~

'

/.

^

^ FIB a AifUO ^

Liber.

Of

P.

Ei)>K)>m4j:)i)f^'j \nx

My...:.

t X i^ T/WV'

*^ 4

• • '.I

I

i

WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD

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

Dfffr Filrfl,

1

190 "i

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

Registei*ed J\^o.

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco

Certificate of Beatb

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

^No.

"lis \\J<A)e^ (

St.;

1

of 3

^

Dist«;bct.O/VXVYL^H.AAyv\j and

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

FULL NAME

PERSONAL AND STATISTICAL PARTICULARS

I COl.oR

DATl", <»!• HI k Til

L

\

C

'iji

r%A

i

"O^KAj.

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

(Month)

(Day)

(Year)

Month)

A OR

%h

) I'it I

(Day)

Mnufhs

(Year)

Da 1

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

lUKTHPI.ACK (State or Country)

I in-RIvRV CivRTIFV, That I attendcMl deceased from

I9O to IQO

that I last saw h -r—— aHve on 190 '

atid that death occurred, on the date stated above, at ...•.ft...'.

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

NAM!-: Of-

U) Jlti^) ^\o^i

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

MAIDHN NAMK «)l" MOTMKK

UIRTniM.AOH n|- MoTlIKR

(State or Country)

OCCl'l'ATION

m

UXv^'\Jl

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

!*.\A

Di; RAT ION Years

CONTRIIU'TORY

Mouths

Days

Hour,

1)1' RAT ION Years

Mouths

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

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

LfrV(rv\Ji\>^ V

Days Hours

\JiA. M.D.

<i.*^

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

0-A^A^AJl>vv7^VL

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

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

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

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

Former or Usual Residence

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

How long at Place of Death ?

Days

ri.ACK OF niRIAI, OR RKMOVAI,

DATJ^of IVKiAr. or RliMOVAU I I90H

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

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

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

rMLT RFCORD

WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD

REFER TO BACK OP CERTIFICATE FOR INSTRUCTIONS

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

Date Filed,.

290H

Registered J\^o,

4£

\

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

DEPARTMENT OF PURIC HEALTH=City and County of San Francisco

Cevttftcate of H)eatb

( XX. S, StanDarD ) PLACE OF DEATH: — County of Ocv^v 0 ^cwt.cv^^;u)Citv of C3/a/>v 0

'CVTv 0 A^CVvuCv^'Cr^City of ^ 'CX/>v 0 X<V/yv<.v/Q^c^

(No.

I 3 I 0 "iiryAX^.' St.; 3. Dist.;bct* LXcLo and UJ^UU

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

L^ >

FULL NAME

(^

i\^rv:YVC3uA

\jAjL:

SKX

JPERSONAL AND STATISTICAL PARTICULARS

I COI.OR

DATK OF lURTH

(Montlil

13 IDny)

/.l5.^

(Vear)

AOK

lie

J V'<7 )

Months

\x

Days

MEDICAL CERTIFICATE OF DEATH DATK OF DKATH

30

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

Month)

(Year)

I90H

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

^

\| f VcLVvvJL<L'

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

inKTMPl.AOH (Statf or Coiiiitt v)

NAMF OF FATHKR

HIRTHrUArK Ol- I ATMKR (State or Country)

MAIDHN XAMK Ol- MOTFIKR

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

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

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

DURATION

) ears

Months

Days Hours

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

DURATION Years

^-.i

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

(Signed)

uwuu-t» Isb

Mouths Days Hours

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

""'^:t r-^-

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

Former or Usual Residence

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

How long at Place of Death ?

Days

\

fArldrc.s.s

Si 0

\^tr>vt^ otj

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

(Add

less

^ 1 C^V.\^t«Ai

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

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

.MAi^E-M-r RECORD

WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD

REFER TO BACK OP CERTIFICATE FOR INSTRUCTIONS

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

Date Filed,.

^/LA^Lu

190^

Be^istered JVo.

XArvuui \jL^^.. Deputy Health Officer

Vi

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco

Certificate of H)eatb

( in. S. Stan^ar^ )

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

1^

^No.

Id 1 5 ih o.^

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

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

a^

FULL NAME

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

^A^X^.O.

PERSONAL AND STATISTICAL PARTICULARS

DATK OF HIRTH Q^

COI,OR

kildc

ij.

(Month)

n r.'^A.^.

<Day) (Vear)

MEDICAL CERTIFICATE OF DEATH

DATE OF DKA'l

'\JU

(Month)

AC K

.-I JV'(j>,'.

MnulfiS

13

Da \.

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

(Write in social (Ifsi^'iiiitioii)

niRTHPKACE (State or Cotuitry)

VAMK Ol" FATIIICR

BIRTH PI,ACK OF FATHER (Statf or Country)

3.0...

(Day)

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

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

( (\//

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

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

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

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

•<^CL<Uv>-va ;4X\/c^<iv>^'\»^\.\,\X?'

DURATION -^ Years - Months i^ Days- Hours

^

MAIDFtN NAME OF MOTHER

KIRTHPI.ACE OF MOTHER (State or Country)

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

CONTRIRUTOR\^

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

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

( SIGNED ) Lo^>^J!^«xi J O-'ui

Hours

OCCUPATION

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

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

O^^X^V M.D.

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

itals, Institutions.'^rj

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

Former or Usual Residence

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

ffow long at Place of Death ?

insients.

Days

(Informant

(A<Mrcss

2

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

(Address

LoAXcvr V

a^ 1' a..

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

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

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

MT AECORD

'St lil

?

WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD

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

Date Filed,

I

.^O-Aaa^

190^ Registered JV^o. .

Deputy Health OffS^'^r

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco

Certificate of S)eatb

( "CI. S. StanOarD )

PLACE OF DEATH: — County of

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

tXW\^; City of

■^'VVAA:

' LoX'

Dist«; bet. and

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

)

FULL NAME

X^:

■^ULaa

SKX

PERSONAL AND STATISTICAL PARTICULARS

) COI.OR N

QU^L

<\)A\a1j^.

DATE OF JURTH

(Month)

3

(Day)

rlX'h.

(Year)

AGK

1\

) V(i I .

X M,

>H//>S

0.5

Da rs

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

HIRTHPl.ACK

(State or Coinitry)

NAMH <>J' FATHKR

lURTHPKACK 0|- 1 ATUKR (Stalf or Country)

MAIDKN NAME OK MOTHER

lURTIIPI.ACE Ol" MOTHER (State or Country)

OCCUPATION

%\4

r

MEDICAL CERTIFICATE OF DEATH

DATE OF DEATH

(Day)

(Year)

I HHRHBY CHRTIFY, That I attended deceased from

190 to 190

that T last saw h alive on 190

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

.V:^vx.

■ rsi. The CAlSfv OF. DIvATlI was as f

DLRATION I'ears Months Days

CONTRIBUTORY

Hours

DURATION JLear.

( Signed )..UL).. J

1 190 H (Address).

Afonths

Davs Hours

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

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

Former or Usual Residence

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

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

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

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

(Informant

( \<l(lress

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

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

o

I) indertakf:r

1904

(Address

OL^Vvu

lm:

IN. B.

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

MT RECORD

M

i«

r

•

WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

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

lOO"^

Registered J^o.

Date Filed, H4.\JLu, 1

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco

5

Deputy Hepfth Officer

Cevtiftcate of H)catb

( Ta. S. StanDarD )

J? on J?

(^

^o.

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

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

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

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

it V^i^L %

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

J&-^.

FULL NAME

OJ^J

PERSONAL AND STATISTICAL PARTICULARS

SKX

(TluL

COI.OR

\X}MjXx

MEDICAL CERTIFICATE OF DEATH

DATK OF IJIRTH

ACIR

I Month)

(Day)

(Vear)

1 b )ra,s

Months

*~^ Days

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

HIRTHPI.ACK

(State f>r Comitrv^

NAMF OF FATHKR

HIRTHPI.ACK OF FATHKR

(State or Country)

MAIDKN NAMK OF MOTHKR

lUKTIIPI.ACK OI< MOTMKR (State or Country)

OCCUPATION

Rfsidfd in Siiti Fi mil iu-ii

LUX<J^^

I.

(Year)

DATE OF DKATH

onth)(j (Day)

I HKRliHV CivRTlFV, That I attended deceased from

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

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

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

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

OU CW

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

.V-i5.

ears

Months "Days ^ I /ours

CONTRIIU'TORY

DURATION Years Mouths Days Hours

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

d>WAjttxNj at

SPECIAL INFORI

(Address) 5 3> "i

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

I Mnnlh^

Ihi^

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

( ^'!(lrcss

U AXcVt^jL (AjO-^^V-

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

former or Usual Residence

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

VbtOV

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

UNDKRTAKKR

(Address

N. B.-

-Fvepy Item o? informntion should be CBPe?ully nupplied. AGE should be stated EXACTLY. PHYSICIANS should state CAUSE OF DEATH in plain terms, that It may be properly classified. The "Special Information'* for p«p. sons dying away from home should be given in every instance.

WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD

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

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

i

II :?!

Date Filed,

lOO'i

Registered J^o.

6

cL/0"-\AA^

P^PM^y Health Officer

Mi

DEPARTMENT OF PUBLIC HEALTH^City and County of San Francisco

Certificate of H)eatb

( "Cl. S. StanDarO )

(No.

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

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

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

FULL NAME

tou'

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

PERSONAL AND STATISTICAL PARTICULARS

SKX Q^ DATK OF UIRTH

TVUxJ(jL>

coi.o

\XjJrvdju

AOK

0)\cw

(MontH)

(Day)

(Year)

)'i'at .

MoHtfis

Davs

MEDICAL CERTIFICATE OF DEATH

DATE OF DKAT

1

(Day)

(Year)

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

MIRTH PL AC K (Statf or Country)

d^C^n^j^AJ^

NAMK OI" FATHHR

hirtmpkacf:

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

MAIDKN VAMr,

01 • motiif:r

lUK'ririM.ACK

OF Mrj'rHKR (State or Country)

OCCUPATION

Rfsiiird in Stnt Fi iitu isrit

at J * (^ ^

I HEREBY CERTIFY, That I attended deceased from

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

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

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

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

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

oxau

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

n.. A-VV^r>vOvoi

A.\kA

^■^oo^

U-t^A>

) ra I A

Davs

/fours

DURATION ^Ycars ^Months

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

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

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

(Informant

(A (Mr CSS

Former or - ^ , «

Usual Residence 35 vVcv^^

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

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

?

Diys

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

y RIAL Of rf:movai,

I 190V

UNDlikTAKFIR

(AcMrt'ss

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

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

«.«a^riav RECORD

WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD

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

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

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

l^trVLA^ Ijl^^ Officer

DEPARTMENT OF PUBLK HEALTH=City and County of San Francisco

r^

PLACE OF DEATH : — County

Certificate of 2)eatb

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

«?

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

(No.

351 , 3.0...il

A* St: ID Dist

>ist:bct. LILmw\C^"

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

C) CL/^luORx-l ^

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

b-

FULL NAME

«,

.^CVA.'

.AjUL'^

PERSONAL AND STATISTICAL PARTICULARS

SKX

J-tWvOAJL

COI.OR

\X)kdx

DATK OF IlIKTH

(9*fc

I Month)

(Day)

(Vear)

MEDICAL CERTIFICATE OF DEATH

DATE OF DF:ATH

1

(Day)

(Year)

ac;r

as

)■/•<;; .

I

Motifhs

Pa 1 .

SIN(;i,F.. MARKIKD.

wino\vF:i) OR nivoRTF:!)

(W'litrin social (Usij/^natioii)

HIKTHIM.AOK (Statf or Cotuitrx')

n'amf: of

FATMKK

I IIIvRHBY CKRTir'Y, That I aJtendcMl deceased from

" ■" .>kvlL i

190 S

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

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

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

'VO

niRTMFM.ACE Ol- FATHKR (Stale or Country)

MXIDKN NAMK Ol' MOTHKR

HTRTIIPLArF. OF MoTnF:k (Slate or Country)

-J '"rvCTYWOL^ J CrtjtM.

7

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

DURATION C

OCCrPATlON

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

DURATION Vtars Mouths

(Signed) vj-.A?, 'J

cxk'^

Pavs

/fonts

SP

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

'OA^Tvw-rw' M.D.

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

t

/).M.

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

(Infotinant

(Address ..

35 T* 3»ot!v ^t

Former or Usual Residence

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

How long at Place of Death ?

Days

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

^ I90H

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

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

*£ b b \)^^

(Address

IN. B.-

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

AUCORD^

WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD

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

REFER TO BACK OP CERTIFICATE FOR INSTRUCTIONS

<::':; '; » ■;

i!

Iff

Date Filed, ^<uXcl 1

J( d L

190^ Registered JSTo.

Deputy Health Oflflcer

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco

Certificate of 5)eatb

( xa. S. StanOarD )

(^

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

(No.

ai

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

and

%

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

r4:\/VWCV,c1W. )

FULL NAME

,CL\x^^."»'xn/;'Lr\A^.

t.

PERSONAL AND STATISTICAL PARTICULARS

SKX

^JL

COI,OR

DATK OF lURTH

?

] ]

MEDICAL CERTIFICATE OF DEATH

DATE OF DKATJ

^■.\j:^-\JU

(Month)

(Day)

(Year)

I Mouth)

(Day)

(Year)

AOR

cuu-tnvX'

It.

) I'd I >

Months

Dii 1 .s

.tl !«'

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

niRTFfPI,ACK

(State or Coiintrj')

NAMF, <)!•■ FATIIKR

BIRTHPLACE OF lATHKR (State «)r Country)

AX

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

MAIDEN NAME OI- MOTHER

T

I HRRRBY CKRTIFY, That I attendetl deceased from

-^ to

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

that I last saw h -^ alive on '■ 190

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

. \Jfv

V.^JrwAAA^

rVQv^t.

SJnrs,^'^,

\^^-<k.A^\

DURATION Years CONTRIHl'TORY

41

wJi,*\4

3 /on //is

Days

Hours

^t^CJ-Vy.n V'

niRTH PLACE OF MOTHER (State or Country)

OCCUPATION

o'^^UlIxx^^.A^

DURATION years Months Days Hours

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

(Signed)

iqo

(Address)

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

.lA';////«

/)./).

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

(Informant

^ Address

Former or Usual Residence

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

How long at

Place of Death? Days

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

UNDERTAKER

^^ CvtaLvA^k;.

(Add less

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

^JstL..

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

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

aJS-Ml

['fTy^Vl-

In

It

^i'.

It

■ (

!

I

WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD

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

Date Filed,

iLj^ 4 igO'i Registered JSTo, 9

Ltrwu) Ixoh.^ Deputy hfeafth omccr

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco

Certificate of Beatb

( la. S. StanOate )

-P

<^

(No.

PLACE OF DEATH: — County of C) .O^w ^ Ko^/w^iiKi/t^CHy of O xXav 0 A..O-^w-t:,v«,/C^

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

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

.^i

FULL NAME

PERSONAL AND STATISTICAL PARTICULARS

""" *?

JtT>^

oJsJj

COI,OR

UJ.rujtx-

DATK OF HIRTII r|\ Q

/..lli.

(Month)

AC.K

3.x.

) V'(/ t s

(Day)

Minilhs

(Year)

X's

Da )v

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

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

niRTHPI.AOK

(State or Country)

XAMK OF FATHKR

HIRTMTM.AOK Ol- lATHKR (State or Country)

MAIDFtN NAMK OF .\tOTFIF;R

L^(nA.v^t(

MEDICAL CERTIFICATE OF DEATH

..3j.O...

(Day)

(Year)

I IIRRRBY CKRTIFY, That I attended deceased from

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

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

and that death occurred, on the date stated above, at r? . A 0 M ^I. The CATSlv OF 1)I<:ATII was as follows:

<\^

Days " Hours

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

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

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

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

KIR TIIPT.ACK OF MOTHHR (State or Country)

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

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

(Inf<)rniant

f \(U1ress

4 as XuM ^t

N. B.-

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

(SIGNED) Lii JvJC!

M.D.

\ IQO^ (.Address)

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

Former or Isual Residence

How long at Place of Deatli ?

Days

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

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

INDHRTAKKR

DATICof IMkiai, or RF:M0VAL

u a..

190H

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

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

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

fw

WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD

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

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

.f '»

i

^

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

XiiwvLj Deputy Health Officer

t

>Oa.aa.a

DEPARTMENT OF PUBLIC HEALTIl=City and County of San Francisco

Certificate of H)eatb

( ia. S. StanOarD ) : — County of C)

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

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

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

t^ 'qJ^ )

FULL NAME

PERSONAL AND STATISTICAL PARTICULARS

SKX

CP

0-C^vvv/OuLiL

COI.OR

U)Jvct

DA'I'H Ol" HIKTU

AC.K

<M<inth)

} ca > s

\

(Day)

Mouths

(Year)

Dii \s

SINr.I.K. MARKIKD.

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

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

crrvr

HIR rUPI.ACK

(Statf or Conntry>

NAMK OF KATHKR

(lb crrvrLo^Lvc' jI) . J

BIRTUPT^ACK OF I ATHKR (State or Country)

^C^'^

MAIOKN XAMF OF MOTHHR

niRTHPLACR OF MOTHKR (State or Country)

OCCUPATION ^j;,^.^^i

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

M.oith-^

Da \s

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

(In forma

(Address

MEDICAL CERTIFICATE OF DEATH

DATE OF DEATH

(Month)

.3>.0...

(Day)

(Year)

I HEREBY CERTIFY, That I attentkMl deceased from

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

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

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

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

DURATION

Years Months d\\ Days Hours

DURATION Years Months Days Hours

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

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

> FECIAL INFORMATION only for Hospitdls, Institutions. Transients, or Recent Residents, and persons dying away from home.

Former or Usual Residence

How long at

Place of Death? Days

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

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

g I90S

UNDERTAKER

(Address

%1 ^

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

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

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

ACCOBS.

.1

il' I

.^r^

»«

i:

k^

WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD

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

REFER TO BACK OP CERTIFICATE FOR INSTRUCTIONS

Dafe FiJed,

I 190^ Registered J^o,

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco

Certificate of 2)eatb

( TO. S. StaneatO )

J? ?!>

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

fNo.

^H

tl

\Ji^>XJCVM

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

AJk.

ifJu^.^'TNxJv^tXAJj

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

FULL NAME

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

SK.x

PERSONAL AND STATISTICAL PARTICULARS

COI^OR,

JJUy^xoJjL

■U)Jv.u.

n.\TI-: ol- ItlKTM

(Month)

(Day)

rial.

(Year)

A<-.K

I \ )Vins

Monllis

Da vs

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

niRTIUM.AOK (State or CoutUry)

NAMK Ol" HATin-.R

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

MAIDKN NAMK Ol- MOTIIKR

MEDICAL CERTIFICATE OF DEATH

DATE OF DKATH

30.....

(Day)

190 H

(Year)

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

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

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

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

\X^^Jih-\oX 0^

DURATION

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

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

DURATION Years Mouths Days Hours

(SIGI

1URTHPI,ACK

01* MoTMHR (State or Country)

OCCUPATION <W

V Q p.

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

Ar,>,i//is

/hj^

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

(Itiformaiit

(Addres.H

SH

I

k. 1.3.0.

NED ) .ly... .X 0 AX^^jL^h/Vvv^vOv M.D.

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

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

Former or Usual Residence

How lonq at

Place of Oeatli? Days

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

IM.ACK OK niRIAI. OR RKMOVAI,

DATKof HrKiAL or RKMOVAI,

JV). vj. C)vcUVv%.U

1131 OOwxL^^v.. it

INDliRTAKKR

(.Xddress

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

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

i'ilil

Si

•SI

(

<1

>r!'

'

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

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

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

Deputy Health Offlcor

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco

Cettificate of H)eatb

( in. S. StanDar& )

of O <cx^w 0

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

(No*

I la

tLiL

St

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

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

FULL NAME

PERSONAL AND STATISTICAL PARTICULARS

SHX (T^

OX/Vnu<xJuL

COLOR

UjJvvtx

DATK <)I- lURTll

Mfloxoru

(Month)

as-

(Day)

(Year)

AC.K

J 'ra t s

M.inlhs

Pa 1 .

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

niKTm'i.ACK

(Slate or Country)

NAMH OF FATMKR

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

MAIDHN NAMK

<)|- M«vrnKR

lURTHPLACK OF MoTlIKK (Slate or Country)

ilCCTTATION

(K(

Rf}ii(ifif in Snti / nun isro

) til I s

/>,n

(Infoiniant

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

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

1 \ X (k'^fU "dt

(.\(Ulress

MEDICAL CERTIFICATE OF DEATH

DATE OF DKATH

y\JL

Month)

3.C

(Day)

I90H

(Year)

I HRRKBY ClvRTIFY, That I attended tleccased from

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

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

and that death occurred, on the date stated above, at V- I 0 (P M. The CArSFv OI' Dl^ATII was as follows:

r.VO.VV.

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

a.

DURATION

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

Years Mouths Days Hours

M.D.

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

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

Former or Usual Residence

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

How long at

Place of Death? Days

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

I 190S

(mx oi.'v^

INDKRTAKFK

(AiMteHH .

C^CV-CV.TN^A

;>vto at

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

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

Si I

M

WRITE PLAINLY WITH UNFADING INK —

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

Date Filed,

THIS IS A PERMANENT RECORD

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONt

190'\

Begistered J^'^o,

,^v,cvc»

\ju^^ Deputy Health Officer

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco

Certificate of H)eatb

( "Cl. S. StanOarO )

(No.

PLACE OF DEATH: — County of

S ^

aiio

crvYx.

St.; 5 Dist.;bet.

itL

and

qt

I

ru

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

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

FULL NAME

Q

PERSONAL AND STATISTICAL PARTICULARS

"•^^

d L^vaxAX

COI.OR. »

DATK OF lUKTH

Month)

ACK

an

) V'c » .<

(Day)

M.nillis

(Year)

Da vs

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

niKTmM.A('K

(Stalf or Country)

NAMK <>1 FATHKR

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

CV-^v

ck.

v^ 0 oJL

MAIDKN XAMK

Ol MoTin:R

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

fo 0

^vr

oCCrPATION

%^

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

.yf.>iilhs

I hi 1 >

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

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

(Informant

(AtlilresK

3?)S

MEDICAL CERTIFICATE OF DEATH DATE OF DKATH

onth)

3d.

(Day)

(Year)

I HEREBY CIvRTIFV, That I attended deceased from

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

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

and that death occurred, on the date stated above, at O 3 0 U M. The CAl'SH OF DKATII was as follows:

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

DURATION ^ Years ^ Mouths '^ Days ^ Hours

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

CONTRIIUrrORV

DURATION Years

(SIGNED)

Mouths

Pavs

Hours

(Address) 13»0 b J(

-L4.^^>v. o'l

M.D.

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

former or Usual Residence

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

How long at

Place of Death? Days

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

(Ad<lrcss

N. B."

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

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

•iII.y!! ir 111'

M 11

ijii'

7

no.'i

WRITE PLAINLY WITH UNFADING INK

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

THIS IS A PERMANENT RECORD

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

Dafc Filed,

Eegistered JVo.

»• — ^

-^ .m,- •» j^i~ f^ ^**f .^ ^ ^*

DEPARTMENT^PuIlIC HEALTH=City and County of San Francisco

Certificate of Beatb

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

No. ^\H

(IF DCATH OCCUBlp AWAY F IF DEATH OcdijRRED I

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

FULL NAME

si-:x

DATK OI- lURTH

COI.OR

PERSONAL AND STATISTICAL PARTICULARS

lol^t.

M<)iilh>

(Day)

(Year)

AC.K

,3s

) 'ra I s

Months

Da vs

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

Ql

MEDICAL CERTIFICATE OF DEATH

DATE OF DKATH

Lu.v^JL 3wB /poH

(Month) (Day) (Year)

Til R RUBY CKRTIFY, That I attended deceased from

190 -^- to 190.— r-..

that I last saw h - — -alive on '9°

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

\CUV\.^^CL

HIRTHPI.ACK

(St:itc or Country''

NAMl-: OI" lATmCR

niRTHPI.ACK 0|- I- ATI IKK

(Statf or Country)

MAinKN NAMK <)1- MOTIIHR

vfr-v.''-^

cLo

cnx^Vcv

U dJUXK

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

I

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

.)CCUPATION (^ >vwx^->^-«.V

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

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

(Informant

(Address

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

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

W-^wA..^

wcLt

DURATION }'ears

CONTRIIJUTORV

Months

Days Hours

duration (Signed)

)\\irs

^Tn}lths

f

»

Days Hours

\<Lr. M.D.

yArO^^o iQo

SPECIAL INF

(^

^ (Address) VfrVcn\X\^

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

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

Former or (Vi « w 0 D, ""^ '""' ** I U .

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

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

?

^

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

>'^V

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

(Ad«lre«*s

1 in I QfYluLA^vrn jM

Jc/\>

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

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

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

;'l

*

lluanl of Hc:.lth-KNo. l^

WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

JaE?i)n&PCo

I)(f/r Filed, VaXu, 1

y

loo'i

Deputy Health Officer

Begixtercd JVo.

.i.Q

DEPARTMENT OF PUBLIC liEALTH=City and County of San Francisco

Certificate of S)eatb

( Vi. S. Stan6atO )

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

'No.

aSb lj>LU-cU

St.; X ^ctoist.; bet. w 0 a,\.'

and UXClH^M

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

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

FULL NAME

<jb

SK.\

DATi-: or HiK rn

PERSONAL AND STATISTICAL PARTICULARS

I COI.

.OR \

'dl

Kjih

\

(Year)

AOK

?1

) ■»•»; » >

A/.)fiffis

JDavs

MEDICAL CERTIFICATE OF DEATH DATE OF DKATH

(Day)

(Year)

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

^-— r 190 to 190

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

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

HIKTHIM.AOK (State or Country)

N'AMK OF FATHKK

niKTHPI.Al'H

0|- l-ATHKK

I State or rounlry)

MAIDKN NAMK OF MOTIIKR

[LyyJkjy

.^

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

I was as fol

— Months Days Hours

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

.v^r^kiVOw"

l)rR.\TI()N Years

CONTRIBUTORY •— ^

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

HIKTHPUACK Ol MOTHKR (State or Country)

OCCUPATION

Kfyidfd ill Sdii I'l niKisri)

)'iiji

-^ }r.<lllll:

Pit

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

(Inforniant

rxddress

kL>\X> g^ligoS (Address)

LfrVcrvvJtN^A UJLlLuiLi.

oPECIAL INFORMATION only for Hospitals, InstituliW^ Transients, or^Rccent Residents, and persons dying away from liome.

Former or Usual Residence

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

How long at Place of Death ?

Days

PI.ACK OF lUKFM. OK KKMoVAI,

UNPHRTAKKR

(Address

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

lb oJuliul V U

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

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

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

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

WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD

IVjard of Health— K No. n

H&P Co

REFER TO BACK OP CERTIFICATE FOR INSTRUCTIONS

loo'i

Dafc Filed, Y""""^^ ^

dvcrvw^ Xjl-^^ Deputy Health Offlccr

Registered JVo,

*! r»

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco

Certificate of Death

( H. 5. StanOarD )

i 0?

PLACE OF DEATH

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

%

ti

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

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

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

t

FULL NAME

lLJtvl^ w... (iw^

SKX

PERSONAL AND STATISTICAL PARTICULARS

COI.OR

DA TH <>l" lUK 111

Ia.) AwXju

\c.v.

(Month)

,. *- )■/•</;>

0.%

(Day)

Mi»iths

(Year)

3

Pa v:

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

HIR rUPKAOK (StaU- or Conntry)

NAMK OF FATHKR

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

MAIDKN NAMK Ol- MOTHKR

MEDICAL CERTIFICATE OF DEATH

DATK OF DKATH^

(Year)

1 HliRKBY ClvRTIFV, That I attended deceased from

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

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

DURATION Years

CONTRIHUTORY

Months Days

Hours

La^V-<X'

Lev

-W(A.V

PTKTIIPLACR

<M<" mothf:r

(state or Country)

r

nOClPATION

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

)'i'ii I .

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

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

(Informant

(AtMiess

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

DURATION )'i'ars Afont/is Days Hours

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

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

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

Former or Sr'Tn'*.., n

Usual Residence P'^^e «' Dfatli? Days

When was disease contracted,

If not at place of death ?

PI.iiCF: OF' BTRIAI. OR RHMOVAI,

DA'Pli of lifRiAi- or RKMOVAI, 51 I90H

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

^

t' A APF oVionlil he Rtnted EXACTLY. PHYSICIANS should

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

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

III!

■ t

<ii

li

s)

:!

. -1

Jloa

rdof nt«lth-FNo. n

WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD

RCrCR TO BACK OF CCRTIPICATC FOR INSTRUCTIONS

HM'C)

Date Filed,

1^

7^0^ Registered JVo,

Deputy Health Oflflcer

DEPARTMENT OF PiJBLIC HEALTH=City and County of San Francisco

Certificate of Beatb

( "CI. S. Stan^arD )

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

(No,

mty

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

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

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

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

(y>w

^ ^A.A.'* )

FULL NAME

n^-x^^KAx}

SKX

PERSONAL AND STATISTICAL PARTICULARS

COl.OR ,

mJi.

u>

DATK OJ- lURTH

AC.H

CllxK-d

at /SHH.,

(Day) (Year)

(pO

] 'i\i I

.UoMtJii

Pa vs

MEDICAL CERTIFICATE OF DEATH

DATK OV DKATll

(Month)

3.^

(Day)

(Year)

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

190 "~~

190 ■~~~

that I hist saw h

190 - alive on

to

sivr.i.K, MAKHn:i>

WinnWKD OK DIVOKCKI) (WrJttiii social (UsivrnalJnn)

tStiilr or Couiilry)

JATHllR

niRTJU'LACK 01 lATHKR (Sliitf or Country)

MAIDKN NAMK oj. M()Tni':R

niK'ruri.AOK

«)l" MOTHKR (State or Country^

OCCl'PATION

S)

f ! A.

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

nr RATION Years

CONTKIIU'TORV

Mouths

Days

Hours

Pars

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

Moiilh^

Pay.

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

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

:infonnant LAAX^Lo ^''^- 3 /»-wt.)(v

1 lb (B

(Adclrt-ss

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

DTRATION Years Mouths J 'ays Hours

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

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

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

Usual Residence Place of Death ?

Wfien was disease contracted,

If not at place of deatli ?

.. Days

ri,ACH OF lURIAI. OR Rl-MoVAI

DATl". of HCRIAI. or RKMOVAI,

^wIm. ^ 1 90S

vnJkrtakhr hA^^^^ ^^ ^t£ \WU C,

....S.M.'l.S. m1\n^^' — -^^

(Address .

^ufr'y^.

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

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

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

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

•; hi

WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

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

i'

Dale Filed ,

190H

i Li. Deputy Heaitn Officer

Registered J\^o,

18

n

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco

H

PLACE OF DEATH: — County of

Certificate of H)eatb

( "U. 5. StanC>arD )

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

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

St.;

Dist.; bet.

and

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

VJ OaaJL 8o>vlLL

FULL NAME

PERSONAL AND STATISTICAL PARTICULARS

COl.nK

...ttllS

r
SKX		(hi	c<xu
n.\Ti:	Ol-	lUKlll		7 Month)
A (.I-:

1

« ]

ta

) 'fVJ » .V

(Dav)

M,»illi^

{\vi\r)

Pit r.v

MEDICAL CERTIFICATE OF DEATH

DATK (>!• DHATIl

(Month)

1%

(Day)

(Year)

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

-" •': icp *"

-; 190 - -

•I()0

to .-:—.

that I last saw h alive on ■^—

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

HIKTIU'UAOK

(State or Country'

NAM I" Ol" JATHl'.R

niRTmM.ACK

Ol- iwrnHK

(State or Coimtry)

M \II)1-:N NAMK <)»•• MOTMKR

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

Aj^i.

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

dU cL<)

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

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

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

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

Mouths

Days

Hants

Years Months

/)avs

DURATION

(SIGNED) lU.d. J^Y^

//ours M.D.

'VOl'iOiooH (Addi

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

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

\fnlltliy

/hn.

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

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

(Address

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

How long at

Place of Death? Days

Former or Usual Residence

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

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

,„„.... (J* i>UO-A

~ -^^^tW^!^

^v

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

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

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

state CAUSE OF DEATH in pi

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

I

i 11 '

\i

IP ■- I'll 11

n

(Kinl of llf.ilth

Dafe Filed ,

WRITE PLAINLY WITH UNFADING INK-THIS IS A PERMANENT RECORD

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

Registered J^o,

I

IDO^

v-vi Deputy Health OfTlr*»r

Jkr,.%J...

DEPARTMENT OF PUBLit HEALTH=City and County of San Francisco

Certificate of 2)eatb

( "CI. S. StanOarD )

(^

PLACE OF DEATH: — County of ^^Oj-^

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

11.^ and aa^cl )

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

(

FULL NAME

Q.KOsJUb

''■"m

DATi; OF lUKTH

M,V.

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

JX/^mcXxXX'

COLOR

(Moifih)

y\)

) 'lUt » «

10

(Day)

M. nit lis

(Vear)

EPICAL CERTIFICATE OF DEATH

DATE OF DKAT

(Month)

3 0

(Day)

I go \

(Year)

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

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

ao

Days

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

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

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

NAMK Ol- FA rill'.R

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

MAn)i:N namf:

OF MOTin:R

iiiKpmM.ACF:

OF MOTnF:R (State or Country)

r !

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

.10 190 H

above, at ^

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

) J CJuM^'

OCCUPATION

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

0

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

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

(Signed) uXC)

'J,

/)<n

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

(A.Mrrss

1\ ^ \

U\ c)t)

Special information only for Hospitals, Institutions, Transients

or Recent Residents, ano persons dylnq away from home.

c „, How long at

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

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

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

Days

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

\CF" OF lU KlAi. i»K iM

DATKof .in-RiAl. or RKMOVAI,

aJLh. .1 190H

lNnF:RTAKF:R

(Address

H Hie. ^v<i^^^

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

N. B. Every Item of Inform

•tate CAUSE OF DEATH _ :„.»«„ce

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

.

Mil, , t

Inrrl

WRITE PLAINLY WITH UNFADING INK-THIS IS A PERMANENT RECORD

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

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

LrvL iL^v- Deputy Health Officer

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco

1

Certificate of Death

{ Ta. S. Stan&atO )

<7r>

<(V

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

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

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

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

SKX

PERSONAL AND STATISTICAL PARTICULARS

COl.DR

^^wL

DATK «)I r.lKTII

a<;k

<l,lUr_

Motilh)

(Day)

r ILL..

(Vear)

MEDICAL CERTIFICATE OF DEATH

DATE OF DKATH

..s^Y^JU ^-0

(Month) (»ay>

T90H

(Year)

il

) V«7 > A

Mmiths

W

Day:

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

niKTm'UAOK

(Statf or Cntuitry)

FATHKR

HlRTHPl.AOK or lATHKR (State or Country)

MAIDKN NAMK Ol- MOTMKR

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

■y^ .1 190 H to ^WV-O. a..fe 190.4

190 H

51

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

lURTHlM.ACK OF MOTHKR (State or Country)

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

Lw^>^Jv'«■-<iA/> -^ ....dU^v.'v'. V

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

/hiVS

Hours

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

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

DURATION Years ,irou//is

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

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

Usual Residence

When was disease contracted.

If not at place of death ?

^ I

a»o

(Informant LU -'^^^VVOu ^^

AA.^W

(A<lclress

PI \CK OK BIRIAI. OR RHMOVAI,

^0 "

D.vriCof niKiAi- or rk;moyai«

.':\ :_i90l_

rNDHRTAKKR

(Address

U)

i<k.

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

.. , APF should be stated EXACTLY. PHYSICIANS should

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

Ifl

y\ •

WRITE PLAINLY WITH UNFADING INK-THiS IS A PERMANENT RECORD

I'jo'i

BEFER TO B*CK OF CERTIFICATE FOR INSTRUCTIONS ^

21

Registered JSTo,

Dale Filc'l, V™!' ^

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

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco

(Xettificate of Death

( "d. S. StanDar^ )

(^

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

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

FULL NAME

ornxx^

PERSONAL AND STATISTICAL PARTICULARS

MEDICAL CERTIFICATE OF DEATH

si:\

^oL

COI.oR

^\^}Ji

DATK oi r.iK rii

^! M

7

(Month)

7

A(.K

S4

) V*(T ; >

(Day)

Motitfn

(Year)

DA'lE OF DEATH

MonthT)

I

(Day)

(Year^

Pars

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

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

lUKTUl'LAi'K (State or Co»intr5'^

NAMK Ol F

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

.A^CU

AMK Ol- /^

ATHKR f i;

^L).

niKTMIM.AOK I ^^

Ol- I \rnKR [7)

(State or Country) I 1/

V(X>v

t

maii)i:n name

Ol' MOTHKR

II

lURTHPT.ACK oj- MoTHKR (Statf or Conntry)

Qa,cttcu ^"^

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

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

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

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

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

nrRATION f^ Years ^ Months ^ Days - Hours

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

(SIGNED) ^)\-

M.D.

a looM (Address) 1X0 T d-^

\,ttt»v a.i

Rfsufrif in S(in I'unuisro

a^v.n>

;;///

1

/)<n.

rm-: ap

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

(I

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

^ 0 4 i Mow long at u n

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

Usual Residence 1 * ^ -^ n

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

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

l'I,ACK OF lURIAU OR RHMOX AI.

OlOLAJL/"VVV'

.3..ICV 0 '^"TaNVLli ..-^.t

iress

<5»V

DAj"K<if HtKlAi- or RKMOVAI,

3. 190H

INDHRTAKKR

(AcUlress

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

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

N. B. Kvery item oV' information

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

son. dyinft away from home nhould be ftiven in every

» I'

ll

%

WRITE PLAINLY WITH UNFADING INK-THIS IS A PERMANENT RECORD

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

Xa.{. cl.

i^Ol

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

Date Filed, J i"

Vtr^w^ IviAh^Y Deputy Health Officer

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco

«i>

Certificate oi 2)eatb

( "a. S. StauDarD )

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

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

FULL NAME

vLcdt^vck !S.cv>^kL

PERSONAL AND STATISTICAL PARTICULARS

DATH OF HIRTH (^ A

0 ^(r

COI.Oli

iMonlli*

.\<".K

31

) V'rt > .«

3.

(Day)

■^l Moul/is

(Year)

MEDICAL CERTIFICATE OF DEATH DATE OF DEATH

u

I

(Day)

igoH

(Year)

xs

Davs

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

lUKTHPI.ACK

'Statf or C'miitry^

NAMF <>J FATHER

niR rniM.AOE

<H- I AIHl'.R iStaU- or C<»uiitry)

MAIItKN NAME OI MOTHER

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

I IIICRICBY CHRTIFV, That nLttended deceased from

^yyJL '^ 0 190S to ■^■'^ ^ ^90 H

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

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

i^ . ft f) ^ w '' ■

DURATION - Years - Months \Days ^ Hours

LrVrL

CONTRIBUTORY DURATION

(Signed)

Years

ai-^

Mouths Pays Hours

lvUryv<\^<i^ M.D.

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

«)CCri'ATION -^ I)

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

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

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

(InformatU

SPECIAL INPUniviMi \\ji^ "•• ■.

or Recent Residents, and persons dying away from home.

Former or Usual Residence

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

How long at

Place ot Deatli? Ns

l-EACE OJ- lURI.M. OK REMOVAL

I)\TEof HruiAi. or REMoVAE

^ (n\'V>v-tBvi ,

N. B.

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

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

di

i

;l|

WRITE PLAINLY WITH UNFADING INK-THIS IS A PERMANENT RECORD

^^.^^^ ,rrrp TO BACK OF CERTIFICATE FOR INSTRUCTIONS

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

1.1!

a. i'-^o^

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

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco

23

,^^^-^v^'*

Ccvtificate of Bcatb

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

•J J

No.

aiH

0 0 .

c*. R ni'«:f»l5ch <V<X>CVVA»^vU>J and

CavC/tvOAv

^

cv>>)

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

FULL NAME

SHX

PERSONAL AND STATISTICAL PARTICULAR

i COI.oR

4

katk of 111 Kin

LL'.VVAjtx

(:ll..nth»

AC.H

4*^ ..„.. ^

IS

( Day)

ytnulhs

rl^S

(Year)

MEDICAL CERTIFICATE OF DEATH DATE OF DEATH

(Month)

(Day)

(Year)

1-^

Aj v.

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

W IDnWF.D OK DIVOKiF.n

Wntfin •^<H-i:il «l«--ij.'tiation)

niRTffPI.ACR

Stiiti- or C-mtitrv

namf: oi- FATin:R

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

maii)f:n namf:

Ol MoTIIF.K

HIKTHPT.ACK

OF mothkk

(State or Country)

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

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

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

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

nr RATION I i JV^r.v CUNTRinrTORY

Months Days

-VaTV-^-.

Hours

7 I I ! iqoH (Address) Hb

'^^.li^i

iik^t

OCCTTATION (VVA , 0 X-

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

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

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

(Infoini.'int

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

Former or Usual Residence

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

How long at

Place of Death? M^

FI.ACF: 01 lU KIAI. OK KHMOVAI.

(Adare.. 3^i.H\ ^Kv^V^^ «

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

Jl^mm , FXACTLY PHYSICIANS should

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

|1 :

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

V 1

n

ll,,anl..f H.aHli- »■

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

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

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

" ' — 24

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

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

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

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco

Certificate of Beatb

( "U. 5. StauDarO )

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

No.

\%%'\ - l^

-Cvv'

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

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

)

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

V IF DEATH OCCURRED IN A HOSPITAL

FULL NAME

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

sex

PERSONAL AND STATISTICAL PARTICULARS

I COI.OR \

^oL

llVfvvtL

1 1 \ IK or niKTu

tM(iiith>

u

(Day)

/

IHI,

\<,K

.T5

)■/(// >

^

.\/.iii//i<

Xt

(Ycsir)

Pay.

MEDICAL CERTIFICATE OF DEATH DATE OF DKATH

(Day>

,\ Month),'!

(Ycar>

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

iWtit'in "iorial fl<sH'"ati«>ii)

%^>

niRTfiPT.ArK iStatt. oi t. ouiitryi

i\Tin-.R

Sj^\>c6juy^J

U^vk

AV^-vvrvv

^. a \xOLVV<rvv

niK rnri.AOK

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

MXllM^N NAMK «H- MOTJIKR

.1

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

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

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

x^aL. <^-^

/;a.v^ 1^0 UPS

/)<7V.?

,^-V'

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

/l.M

OCCUPATION •-•►•'

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

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

(Infoimaiit

-W^

X) Ot^vwC^^rvc'

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

CONTRim-TURY d>vtjlA<^

DIRATION X Years JN^'/^-^

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

V.L.X u>o4 --— .Irvc^^vt^cl

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

.. Days

Hours M.D.

a

Former or Usual Residence

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

How lonq at Place of Death?

(Address

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

4t

1-1 ACK or lURIAK «'K KKMoVAl

UNDKRTAKKR

(Address

DATl*. of lURlAl, or RKMOVAI.

3^. ig?!

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

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

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

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

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

■% ..

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

I)(ffr FiJrdf

i

WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD

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

\i' n

t-w

I

Kju

'i

cs.

WO'i

BeSisteved Xo.

24

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

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco

Ccvtiffcate of 2)eatb

( *a. 5. StanC>arD )

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

No.

lax^ - R Ov

ti

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

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

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

FULL NAME

j^irrtov 0 H.

'a/>\Aj^

L4.C \>.

SEX

PERSONAL AND STATISTICAL PARTICULARS

I COI.OR

^\ctU

DATK t)!- lUkTU

Motith^

III'

II (Day!

VctjL

(Vear)

AtlK

i'.'^

J • •< #

S

M.iuihs

//<f 1

( WrUe te iKici«l de»txOatton)

lUK THPI.AOK

SAMf. nf FATHKR

HIRTHPLACH OF FATHKR

• State or Cotjiitry^

MAIDKN NAMK OF MOTHKR

BTRTfflM.ArH "f VoTHKk

or Coentrj-

OCCIPATION ..

'V ./^ '

!f 1 .11 - f,'

I , ;>

1/ ,.'A

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

informant

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

XVlf"**

J\%\^ ' \^

L

MEDICAL CERTIFICATE OF DEATH

DATK OF I) i:\Tn

(Day)

^IfMonthl'T

(Year)

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

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

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

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

1)1 RATION 'x Vear^ Months Pays

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

Months

DTRATION '•^ i ^"rr%

f)av^

Signed

f>%J-

Hours

M.D.

'

S r>d'lr.

VCCrtt r <t<^-a

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

formff or tsu.»l RfsMrnff

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

Now loni] <4f Ware •! D<at* ?

Bays

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

]frVt U Xv\Mjt

irNl>KKTAKKK

'Aflclre**

r>AT}

^M

r

or REMOVAI,

PHYHICIANS nhould

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

.'

V. i

f

> t

lii

WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD

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

K

0)

190H

Megisterecl JVo,

Date Filed,

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

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco

24

Certificate of 2)eatb

•Q. S. Stan^arO )

No.

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

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

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

EATH OCCURRED IN A HOSPITAL OH INSTITUTION GIVE ITS NAME I

FULL NAME

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

-y —

icsa.v.

m:\

PERSONAL AND STATISTICAL PARTICULARS

I COl.iiR

^\oh

i.ATK ov i;n<Tn

iMnllth*^

id;

U

(Day)

VctjL

(Year)

Ar,K

-5-5

) < ■;,

S

M.>»it/is

Xt

Dij vs

•^iN*.!,!-: M\KKn:n.

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

HlKTmM.M'K ' StiUf or Country^

^

vh^wtcL

(S ^v^JtcLt'Wj

I- ATUl-.R

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

maiih:n namk nl- mothkr

U^vk

AVCrV^ryv

^ a\^uJLA-&Av

nTRTTIPT.ArV,

<>»■ M()rm:R

(Statf or Country^

4 A

>V.^'V^rW

nCdPATlON •. •► —

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

lht\.

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

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

nTifdintaiit

-VA^

^

(X-AVV-^

(\<U1

rcHs

./ni'-"\ - R

i

MEDICAL CERTIFICATE OF DEATH DATE OF DKATH

%1.

(Month)

\ -Z

1

(Day)

(Year)

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

.WvyX I 190 S to . |Y^-•^ ^'^ ^

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

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

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

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

DIR ATION % Years Months -^ Days

CONTRIRl'TORV U>uQAa^

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

DURATION X Vfars Months

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

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

Hours

Days

/fours M.D.

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

Former or Usual Residence

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

How long at Place of Death ?

Days

IM \Clv OI- HI RIAL (»K K1:M*>\AI.

DATHof lURlAl- or Ri;MnVAI.

% 190I

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

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

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

•I-

I'

i-;

WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD

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

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

IC'i

,^il<'

I

pii/r Filed ,

DEPARTMENT OF

X

100 1

Registered J\''o.

25

De|ju'.i' Heafth Officer

UBLIC HEALTH=City and County of San Francisco

Ccvtificate of Beatb

( "a. S. Stan^arD )

"^

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

rfO.

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

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

and

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

")

FULL NAME

i

CL ^-^.WsJL

'-CW-^A^^^

r

-i.\

PERSONAL AND STATISTICAL PARTICULARS

QXcL

|t\ IK OF lUKTM

7

t Month)

1

A<-.K

cd>t 5J)

y^ats

1

{ Day)

M.tntln

\

(Year)

An.s

\vii)i»\vi:i) OR nivoRi'Ko

I Write in M>cial fli«<iKnatii)n)

lUK TMPI.ACK

St.itr or ('oniitrv'

» ATMl.R

d"AxLcXAvrL

niRTHPUACK

<)|- lATMKR

I Stat f or romilry I

MAIDKN NAMK <>1 MOTHKR

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

}

cL

/L(X ^

nccrPATioN ^

MEDICAL CERTIFICATE OF DEATH DATE OF DKATIl

Month) jT

1

(Day)

(Year)

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

\

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

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

1

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

Mouths

Days

//our.

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

(Signed)

//ours M.D.

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

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

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

/)<M

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

(Informant UjA>\;An\. "cLcL^vV-Ct-V -mV ob • (Xdflress Vvtu "^^^ ^ (I 0 C^-Mv

Former or .

Usual Residence I

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

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

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

Days

PI.ACKJ^)!- HIKIAI.OK KKM<»VAI,

,Ad,i,e« l(,lJirVv«A,vm.

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

'V Cc

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

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

N. B. Every Item

state CAUSn Uh UtA Itl in p

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

iii

VK

WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD

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

lf)OH

Registered J^o,

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

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco

26

Certificate of S)eatb

( "U. S. Stan^arD )

PLACE OF DEATH: — County

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

0^

No,

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

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

FULL NAME

Llv-tlv

\^vV

m;\

PERSONAL AND STATISTICAL PARTICULARS

COl/JR,

QlwL

loivcU

i)\'n-: <n- lURTii

A(*.H

a a

Yea*i

10

10

(Day)

Mnil/i^

(Vt-nr)

C7%^^

Da vs

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

O^^xqUj

UK rm'i.ArK, n ne^

Stiiti or ('Dtiiiti V' -A hM

<^ 1

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

Cat

NX Ml- •»! » A ^ /-^

HIKTIIIM.ACK

<»»•■ f-ATin:R

'Stati- or Country)

MAIDKN NAMK <H' MoTUKK

lURTin'I.ACK <U M()Tin«:R

Vhn^o.^vc^

cyv\M^v

ClMii^a^rJv!

\xan^XAHA<'

"■•■"■■•■ (nwi^^Uc^ii

<>cc

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

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

(1^ (?

'Iiifi.tmant ^/r

VOl^

(i^

^ V'Mrrss

mi

TlUt 4.

a

MEDICAL CERTIFICATE OF DEATH

DATI-; nl- DKATH

M(»n(h

1 (Day)

I go i

(Year)

HiAAvt 'X'S 1904

tliMt I last saw h -A^^WValive on

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

■ to .^Vr:^.V^ 3.^ 190 'i

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

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

Dr RAT ION Years

CONTRIIU'TORY

Months

Days

/louts

DTRATION Years .Vof/f/is f^ays

Hours

(SIGNED)

M.D.

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

:*

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

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

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

rNDURTAKKR ^ ^^^^ > . t) 0

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

-9s^

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

N. B.— — Rvery Item of information

state CAUSE OF DEATH In p

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

M il

•r-4

WRITE PLAINLY WITH UNFADING INK

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

X

7f)0H

/)((/(' tailed y

DEPARTMENT OF PUBLIC HEALTH

THIS IS A PERMANENT RECORD

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

27

Registered JVo,

'HX

City and County of San Francisco

Certificate of 2)eatb

( 13. S. StanOatP i

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

/

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

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

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

FULL NAME

VtOLvixJc-..

,.Qli ii ,0.

vci-wrT^.'

PERSONAL AND STATISTICAL PARTICULARS

SKX

COI..)R

JU

!> \ IK nl- MIRTH

\C.K

Vl i\av<vr

I V.uithi

m

)

» (/ 1

5

(Day)

MnHlll!

(War)

"X H /><"

MEDICAL CERTIFICATE OF DEATH

^s^^yJL. %.^\

(Month) ''>:'>■)

IQO J (Year)

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

inKTmM..\OK

^tatf or Country!

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

i

lURTIiri.AiK

It! » \iui:r

' st;tti or <.'oiintry)

III MOTIIKR

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

OCCri'ATION

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

.|vv lAX 1 190 '•( to ^^.'^^ .l-'l

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

I90H

190 H

(? "

rvtrv.vt^ll.-vvtv^

CL. , Ccv kcuLo^UA

Dlk \TI()N ■ Years CONTRIIU'TORV

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

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

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

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

1-

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

7 / »

^f.uilh'

/hn

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

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

r 1 1 !•:

^\<Mrcs^

Formfr or Isua! Residence

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

How lonq at Place ol Death ?

Days

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

^ -icu Cat

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

V-w.

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

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

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

it III

t-

;

■ 11^'

Heard. .f H.nUli

ill

OS.'

loo'i

Registered J\^o,

WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD

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

, '"^^ .. .. , 28

l)(fli' Filed ,

dc(rvcA^ oOtoru^ Deputy Health Officer

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

Certificate of 2)eatb

( -a. S. Stan^arD )

4 ^ ^ '^

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

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

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

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

'^ 1 M

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

FULL NAME

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

SKX

PERSONAL AND STATISTICAL PARTICULARS

I COI.nR,

t

DATK <•! niKTM

It-

\x) AxOjl

ID

(Day)

(Vear)

\<".K

i1 >•-./»'

^ M.tNthii

IM

A/ 1 .

MEDICAL CERTIFICATE OF DEATH^ DATE OF DKATM

slNi.l.K MAKKIl'l)

u ii)«i\\ j:i> ok i)!v«tKri:i)

Writ*- in ^'Hial <le«iv:tjatiun)

HIRTinM.AOK

stMt«- or Country'

im

i'l

»1

N \M1, ()t I ATMLR

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

• »l MOTIIKR

r.iR'rmM.ACH

t»l- MoTllKR 'State »)r Country)

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

<^ A^Lcv^vcL

A-v^frvcnv

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

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

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

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

"a

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

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

II outs

I lour

M.D.

nrRATION years Mouths Pays

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

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

CCNA^CL

\!n„th'

n,t\.

OCCrPATlON <»-•►•-

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

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

(Iiiformaiit N rVVA>5 <7VWV

JLvlxvkvcLc

U.l.l

ross

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

Former or Usual Residence

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

How lonq at Place of Deatfi ?

Days

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

DAIi; of IJiKIAi. or RHMoVAl.

TQOH

rNIH-.K'lAKl.K

(AtMreS!*....

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

• I

h

ii

tii

l:i

•|i

, li

", J

i

HiiaT

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

lOOH

Registered JSi'^o,

WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

„ _.. S9

Dale Filed ,

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

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco

Certificate of Beatb

( "a. S. Gtan^ar^ )

PLACE OF DEATH: — County of

<\^

City of

CcJUAt^O^X' L<XV.'

r

No.

St

Dist.; bctr

■ and

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

FULL NAME

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

m;x

(JUa-L

PERSONAL AND STATISTICAL PARTICULARS

COI.OR r^

l\ iM<»nth>

AC.K

n .

«»flr*

(Day)

.MfOilhs

(Year)

IL

) Da

».\

MEDICAL CERTIFICATE OF DEATH

DATK <)I- DKATH

(Day)

190 A

(Year)

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

: "" 190 "

— — — 190

190. ~— "~to

til at I last saw h • ^alive on —

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

U IIHIWHI) OK DIVKKiKI)

■Write in MK-inl iksijf nation)

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

N'AMK OF 1 AT 111: R

HlRTHIM.ArH or l-AIHl-.R

'State or (."oiuitry)

\t\II)i:N NAM1-; «»1 MOTHKR

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

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

I

v.^.

v^vvAvrcA.^^

(^

# ()

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

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

rhir.

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

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

(Informant

f \<MresH

DIRATION )'t'<irs CONTRinrTORV

Months

Days

I louts

nr RATION

Years

Months /^<n'.?

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

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

Hours

M.D.

rj

SPECIAL INFORMATIO

or Retenl Residents, and persons dying away from liome.

/TJ , How long at (

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

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

Former or Isual Residence

^ only for Hospitals, InsHtulions, Transients,

.. Days

?

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

DATKof IMRIAI. or R1:M0YAI,

\lwvu Ij L99H_

<..a,„c„ L5J-.H d.Uc4<-., r^*

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

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

N. B.—— KverylKem of

state CAUSE OF DEATH in p , i„„t«nce

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

Y

%

:l:

8

I -I

\

, I ■'■

■ I, ■'»

f 1

'•* .a^f^.' '■ !j!!!tL!

WRITE PLAINLY WITH UNFADING INK-THIS IS A PERMANENT RECORD

I

S^^-vv^v*

V

100'\

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

lie^lstci'cd J^'^o.

30

Deputy Health Officer

DEPARTMENT OF PUBLIC HEALTIi=City and County of San Francisco

Ccvtificate of IDcatb

( •Q. S. StanC»arC> )

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

No.

S-'?'^ Lev,

IF DEATH OCCIF

St.; ^ Dist;bet. I

% ti

and 1^

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

tlv Ou

)

FULL NAME

.O.AA.A.a

,l\/\vcu- . dwX'

SK\

personal and statistical particulars

vTX^>volUw

COI.oR

U).

kttx

MEDICAL CERTIFICATE OF DEATH DATE OF UKATH

DAIi: «»l- J'.IK I M

\(.H

a^

(Dayl

(Year)

siNc.i.K MARK n:n.

WinoWKD OR DlVoRrKI)

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

S

M.nilhs

v\

(MoiUlO

I (Day)

IQO H (Year)

Davi

^Vv^rUOAX

niRTnpi.ACK

I state or Cotiiitry^

I \ini".R

((^ '^

?s

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

MIRTMri.\<*K

t>i I Arni:R

iStatf or Country)

MMDl-.N NAMl*. ()!•■ MOTHI'.K

BIRTinM.Al'K oi' M(»TnHK

(Slate or «,'(>\it\try)

h

llDA^Ur^J^tiv

I HKRKRY CKRTIFV, That I atUMuleil .leocascd from

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

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

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

(%Xxr<i C<rLuiA.>> •■

DTR.XTION )Vrt;-.? CONTRII5UTORV

Mouths I'>ays Hours

(irCfl ATTON

Rrshtrtf iti Stift /'i iiih /yrn

0 XvA"v^CV>v^{^

JV<r;'5

.}rotiths

Pavs

./ .»///! /'..,.. Hours

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

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

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

M.D.

)'rii>

I 1 A, ;////> 7^ 1 /''■'

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

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

„„r,„ , ^XV'-r^O-A^ %XvUvtk

Former or Usual Residence

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

How long at Place of Death ?

Days

n \CK OV niRlAL OR RKMOVAI.

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

,X % TQOji

l^Vvtu -^

I NDKRTAKKR

(.Address

( \ddress

IN. B.-

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

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

I

1 .

vinw^ ,'»->■

m

l0

WRITE PLAINLY WITH UNFADING INK-THIS IS A PERMANENT RECORD

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

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

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

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco

Ccvtificate of Death

( XX. S. StanOacS )

1^

PLACE OF DEATH: — County of

J? ^

^

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

Plo.

.e

I S ..V

Dist.; bet.

and

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

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

(

IF DEATH OCCURRED II

FULL NAME

:\9.(rru

AJO..

si:x

PERSONAL AND STATISTICAL PARTICULARS

COI.oR

DA IK *H- lUK III

/ (Nfoiitht

15 /..US--

(Day.) (Vear)

ACK

3^

JV<;» A

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

lUKTMPI.AOK 'Statf or Counlry^

SAMK Ol-

I- atiii:r

inRTHlM.Av'K

<)» iArin:K

(Slate or C<Hnitry)

MAIIU'.N NAMH ni- MOTllHR

luu ruruACK

(»F MOTHKR

(Slate or Coiintry)

^ .M.,tilhs \.\

Oft (]

n

MEDICAL CERTIFICATE OF DEATH DATE OF DP:aTH

Davs

Lrvrv

I HKREBY CKRTIFV, That I attended deceased from

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

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

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

DFRATION ^ Years CONTRIBUTORY

.C Months ^- I)ays

I)i:ration

Years

Jfonf/is

Davs

Hours M.D.

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

sUciiL INFORMATION^ tor Hospitals. Institutions, Transients

CiJh

00

11

CrPATION 1^,^;^

nlltll'

n,n

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

(Iiif()t«n;int

\Ay\^

(Address .

or

ReTeni Residents, and persons dying away from home.

J '?p How lonq at

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

Usual Residence ■^'^'^ ^^ ^ ^^^

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

.. Days

f

ri,ACK OK nVRlM. OK RHM««VAI,

DATi: nf HfKiAl. or RKMOVAI,

V[l\atcc C

0_-

Vvvu 3 T90H

r

INDHRTAKKR

(Address

A/TUV

A^VW

,..iB EUm ''^^^

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

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

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

IN. B. Kvery Item of inform

state CAUSE OF DO.- . . Instance.

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

••riiKi*"»a >av 1 "

WRITE PLAINLY WITH UNFADING INK-THIS IS A PERMANENT RECORD

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

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

32

Registered J\^o.

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco

Certificate of Death

( ■a. S. iataiiCatS )

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

A

No.

)

FULL NAME

SKX

PERSONAL AND STATISTICAL PARTICULARS

QtxcL.

C

'Vv^aX^^

DATi-: <>i- lUK in

i Mouth >

( 1 ).M y)

/^SS

(Year)

MEDICAL CERTIFICATE OF DEATH DATE OF DICATH

(Month)

.3..^

(Day)

(Year)

I UKRRBY CHRTIFV, That I attctKled deceased from

to 190— "■

— - "" IC)0

A(*K

'^b

)'/'.f I

M.mth-

Da v.

that I last saw h -

190""" — alive on

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

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

lATHl-.K

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

lURTTTPT.ArK

01 1 Ariii'.u

(St;it<- or Country)

MMDKN NAMK Ml- MOTIIKK

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

;o

Ukx/'

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

nr RAT ION

CONTRIIil'TORV

Years

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

Months Days

Hour

DIRATION

Years

M'onihs

Pays

//('//; V

WOw

JoUpw<

'VUL

(X>

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

V^VVOs.

OCCl

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

yrmitii-

n,n.

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

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

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

(Address ...

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

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

OJk,

Former or Usual Residence

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

Hnw Innq at |»l,i( e ol Death ?

Days

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

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

1»\ ri';ol UiKlAr, or Kl-.MOVAI,

it

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

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

mv>

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

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

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

I)((/e Filed,

^v,v,Lu A.

1V0\

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

Re mistered JVo.

«1S

DEPARTNENT OF PUBLIC HEALTH-City and County of San Francisco

CcrtiHcatc of ©eatb

( tl. 3. StanDarO )

PLACE OF DEATH: — County ot u^rv

- )

FULL NAME

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

SKX

i)\ri: t)i lURTu

PERSONAL AND STATISTICAL PARTICULARS

COI.OK ,

" rViEDICAL CERTIFICATE OF DEATH

DATE OF DKATH

(Day)

(Year)

a^t HVV'^^Ul'

MonOit

(Day)

\<.K

4>S )v.M>

Mouths

(Year)

/)(/V.V

SlNC.l.lv MAKKIKD

\Vn)t»\Vi:i) OK DIVoKlKI) rt

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

lUKTinM.AOK

I Mali- or Covintry '

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

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

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

lUR'nnM.Aci-:

oi- MOTHKK (State or Country)

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

.; ——..190 to ^^

that 1 last saw h •- »live on '^ '"^

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

Jrvrnfv.

DIRATION y^'ars CoNTRll'.rTORV

Mouths Am Hours

Pays

I.IRATION years ^Tonlhs

( SIGNED ).C*^«^^' ■* .

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

//ours M.D.

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

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

Months

/),n^

TMH

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

Usudl Residence I 'V.-VVW.

(Informant

(JU <Ctq n.n \.

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

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

If not at place of death ?

,., XCEOI- HIRIAI. OK KEMnVAl.

Days

,uv^'

,,Ml.:n! hIuiai. or REMOVAL

l%c.ac..vVt

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

IN. B.

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

i I

Ni'^.^'--r:«>ff»^^»'^'

i

f

H

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

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

j /I J (I

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

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco

Certificate oi Beatb

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

rftn

PLACE OF DEATH: — County ofUCLW

Ltii"^"^ wv^'

1c

FULL NAME

Ox'vI'v.vaAx

^nx^

PERSONAL AND STATISTICAL PARTICULARS

DATK <>l- lUKllI

U).ivU

I Day)

(Yeur^

MEDICAL CERTIFICATE OF DEATH DATK OH I)P:aTU

(Mdtltlj

1 ..

(Day)

(Year

'A

\(.K

ai

) 't\i I

\

M.itilhs

n

Dn \s

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

^TNX 'X\ 190 H to .^.f^ » ^90 -^

T90 '

i ' - D. JO

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

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

I A Tin: R

lUKTHlM.ACK 01 lATJlKK

'St:itc or Cotinlry)

M VIDKN NAMK «tl MOTHKR

V^Ow

en

^<X>V-

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

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

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

. . .y . . >cJi>«-^«-^*-'"^-^-

\.^-

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

Mouihs Days

I lours

a

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

OCCVI'ATIO

lor lilospitdls, Institutions, Iransients,

or

/)(M

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

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

iiPFc lAL INFORMATION only

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

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

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

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

Vl.ACK «)1- m-RIAI. «> KKMOVAI,

^ Days

]

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

(^ . a r^ u^ W I h V (Ad.lross 0»^ ^

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

•on. dying oway from home should be fti

1^

ih

!i

W':. \

WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD

REFER TO BACK OP CERTIFICATE FOR INSTRUCTIONS

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

t

(

l90'^

Me^Lsferecl Jfo.

35

ChWVW^

AsJUv

^i Deputy Health Officer * ^^ t^

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco

Certificate of Beatb

( XX, S. StanDar^ )

r?r>

<?Ji>

^>.

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

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

Dist.;bet.

and

FULL NAME

Q)\

<XCL C5L'

Ni:\

PERSONAL AND STATISTICAL PARTICULARS

.Month) •I>ny^ ^^^^""^

M

EDICAL CERTIFICATE OF DEATH

ttVVvCUA^OL-a

\«.K

UV OV> )V«Mv

....i

(Day)

(War)

C^

SJN(.1.1-., MARKIK!>

W n)«»\Vi;i) «»K T)!VnKrKI>

Wiittiii vtH-ial iU->»iv''ia»i'>ii)

Miitifhs

An

'4 ■«

Stiitf or Country) \ l\ .

0

NAMK OF

I AT in: K

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

n jwv

->vOw'

MMDl.V NAMK ol- MoTllKR

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

OCCrPATlON

-%.

DATE OF DKATH^ ^

\x\Xjji.

I (Moji^i)

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

W'>Vt X'?». I90H to . W TcpS

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

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

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

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

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

CONTRIBUTORY S <A.w^-C^

\.^i

(Signed)

J/ont/is P(iy<

Hours M.D.

DURATION >Var^ -.

C..i)Jli.i- ..

cIal INFOR

i i MATIO

IM onh for Hospitals, Institutions, Transients,

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

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

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

(IiifotmatJt

0 M l\v. V CV>AXV

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

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

Former or ^ f\{ 'i

Usual Residence <?k U D «>

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

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

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

rNI)i:KTAKKR

(Address

C.li.VUX^NtN

. FX4CTLY PHYSICIANS should

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

I

>

I ' i

I ♦

;

! il

i!

II <

IJ

Si

i ■,.:il ii'j

IS

ii 'il

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

WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD

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

X

lorn

lies^Lstered A^o.

36

pff/r Fih'd y Nk^JLu

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

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco

Ccttificate of IDcatb

( n. S. StanDarD )

4

J? ^ :4; '^

No.

PLACE OF DEATH: — County of ^ Cc^aj

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

and

IP f) I

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

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

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

FULL NAME

Q^Wvu flT^vt^lxJll.

SEX

n\'i J. oi- lUKiii

PERSONAL AND STATISTICAL PARTICULARS

COI.OR

OjItaxolUI

lOlvU

\r,K

JV**^^*

I

(Diiyt

!/.<»//// «

(V<ai

MEDICAL CERTIFICATE OF DEATH

DATP: of DKATIt

I

(Day)

(Year)

/»,n

\VIIM>\VKI» <»K DIVOUrKP

Wjit'iii viM-inl (IrsivMiatioii)

<^ ^^\.aL^

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

N \ Ml ■ n I'

lAi II i:r

lUkTHlM. \CK

(ti- i-.\rni:K

• state or Country')

M.MOKN NAMK <il MOTMKR

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

nrrrpATioN

(>v.

iVwLM

(MotithJ

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

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

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

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

■ rJiJi. ,.^^..vx^

DIRATION ^.. Vrars ' MontlH ^

CONTkllU'TORY

Days

J lours

^ Ltb

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

Pays

//ours

(SIGNED)

M.D.

^SIaL information onMor Hospitdls, Institutions, Ifdnsients.

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

^ );-,j,, •- MiHiths.

/'.M

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

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

(Inrmnrint

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

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

Usual Residence

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

Days

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

rNDKRTAKKR

(Addri-ss.

DATIC ol HiuiAi, 'II K1:MoVAI,

1 Vi>VvM-wr>v ''

.: 3 ^ s i^^cHtk^ ■■->. ^^:^^ri^

[l , EXACTLY PHYSICIANS should

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

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

I

II

ilti

il

} )

WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD

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

Co

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

IV

tc

L

7.9(9 S

Begisterecl J\'*o,

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

37

Certificate of 2)eatb

PLACE OF DEATH: — County of

r) /t-N^

D^x.<r>i V ct'

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

No.-

St.;'

Dlst.;bet.

and

"1

( ir Dt*TM OCCUBS AWAY TPOM USUAL R E S I D E N C E G I V E FACTS CALLED FOR UNDER "SPECIAL INFORMATION" ^ V. IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. /

m

FULL NAME

\[^^^k MiVm.

C..^u£r.v.v:.

si:\

PERSONAL AND STATISTICAL PARTICULARS

COI.oR

^HcvU

UlLt

ItAIi: •»!• IUKTII

Q <Motith>

15 (Day)

(Vcar)

\<-.H

L'VA^^ •^A^ -d,'>->-^'^\v.*-vA,*^V'

Mouths

Do YS

W inoWKlJ nK IHVoKCKn

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

M i\awoLcL

BlRT»n'I,AOK (State or Comiti v^

N\M1- (H 1" ATIIHR

V^V<

lUKTni'i.ArK

<>1- lATHKR '^tale or Country)

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

I'-iK'nnM.ArK

<>»• Mt.TMI-.k fstate or roiii!trv>

Dcrt'PATION

MEDICAL CERTIFICATE OF DEATH

DATK Ol- I)1:aTM,

k

(J

(Month)

aa

(Day)

(Year)

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

190 to IQO

that I last saw h ■• alive on I90

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

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

LC t^c^^^cC»-'vv Ct

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

A 3

'<X/>'vCv

DCRATION )'tars CONTRIIU'TORV

Months Days

I lours

DrRATIOX Years Mouths Days Hour

NED) 0 '^Jj V\) -JL'i^n V iX civ wq LncYu' . M . D .

(SIG

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

"^ - d<v (ivMta- Cn

1 'lit I

yfniiih^ •• . f^m-:

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

'iTlf.

'inrnit

i t > V

(Ad.l

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

Former or

Usual Residence

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

HoH long at

Place of Death? Days

i'l^ACH <»1- lUKIAI, (iK KKM"\ AI

I)\I"1' •>! IltRiAl. or K1-:M«>\AI,

190M

rNni'.KTAKKK

'Adilic^^

N. B.-

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

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

ft. 1

» I

11

ih

,r -f

•>• rf

:l

WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

l)(ffc Fi/r(L

nJOH

Registered Ao.

;38

•f^.

r^T

■f%ff>ft.

er

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco

Ccvtificate of IDcatb

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

No.

St.:

Dist.; bet.-

and

/ ir ot*TM OCCURS Avw*Y FROM USUAL RESIDENCE give facts called for under "special information •■ "\ V if death occurred in a hospital or institution give its NAME instead of street and number. J

FULL NAME

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

PERSONAL AND STATISTICAL PARTICULARS

\y\VK of IlIKTH

COI,t>K

bJuL^

/ 6bl

(Mr.nth)

XC.V.

^%

] V</ »

wrnowKn OR niv«»K(Kf>

'Write in sfirial (l»"*iviintiiti)

HIKTIU'I.ACK < Stair or Country^

(D«y)	(Vear)
Months ... TT..	Aj.v.v
kKUlA^ ...-

N.XMK oi FATHKK

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

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

<>1 MoTIIKR

BIRTHPT.ACR

<>l- MMTIIKK ISIalt «ji (uiuitrvt

'• y \ \' \ iiuN

f^ffuffd in Siiti /'i ii III /'■fit

MEDICAL CERTIFICATE OF DEATH

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

(Day)

'i

/go

(Year)

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

" — llyO ■— " to ' Kp

;ilivf Oil ~ •

that 1 last saw h

ItjO

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

4ltUU' t^Li

1)1 RATION Vtdrs CONTRIHI'TORV

Months

Days

Hour a

DTRATION

)'ears

Mouths

Pays

Hours

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

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

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

.\^\ iqoH.. (

.^f<»if/> <

lhi\

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

(Inf.

i'liirnU

A.XJL

'Address

(1^

»^\.^6VT>-

\j Oxn.^1 -x

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

[::;:*«« «-«'»"'" »'»^

Wfien was disease rontrafted,

If not at pla*e of deatli ?

I'l,

,0

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

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

t t \ r\4GTl Y PHYSIGIAINS Khould

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

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

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

I

I

f - I i

»<

h

t

!> I'm'

(:.•

*P

WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD

,.,„.,> . '

If, iitii I' ^'f) 1 =

: nf<.\' r.)

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

/!((/(' riled , NluXu 5

i^(9S

liegislcrcd Xo.

39

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

Ccvtificatc of Beatb

1 "U, 5. StanDarD )

4

PLACE OF DEATH: — County of '^ A^^:V.UJv..0.a^tAA<«*City of Oclav

vCrC>l "• '..

No. OM JaaAJ.

(ir DC*TH occurs I IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE

St.* ^ Dist.;betil<^^t

and

1) JLA;-uuxcL2.^Ji )

• w.Y FROM USUAL RESIDENCE GIVE FACTS CALLED FOR UNDER "SPECIAL INFORMATION' \ AWAY FROM US,UAL «tl, , JS N A M E I N ST E A D O F STR E ET A N O N U M B E R . J

FULL NAME

LcL.^:>:\-M»^"n-«L V' '

'XAjJ^Ji^-^

kk..

HKX

I>\TK (IF lUkTH

COLOR

PERSONAL AND STATISTICAU PARTICULARS

I

3o /,B,a

(Day) (Vearl

ACR

10

I^Vtfrj

10

Mamths

na%s

Hfsni,K. MARK ten. \vri)«)\vKi) OR nivoRrKi)

(Write ill .social de.siKiiulioii)

BIRTH PLACH < State or CowntryV

NAMK nv FATHER

k.'UjLu^

MEDICAL CERTIFICATE OF DEATH

DATE OF DEATH

I

(D«y>

ipo \

(Year)

I HFRHP.V Cl'RTIFY, That I attended deceased from

|vvtu^ 190 ^ to .^1^vL^.....i iqpH •

that T last saw h ^v^vvvaUve on Hvs-Ujl. 1 190 H

^ U C) an(i that <kath occurred, 011 the- date stated above, at v?- T v

..(P... M. The CAl'SIv OV DI-ATIl was as follows:

t/v^^^^^^^^-^^---^*^^

^^.1

\^\Axy^^-

nTRTTTn.ACK n|. I ATHHR

(StHtCOT COMtttir)

NfA!l»KN N\M1-: <>l- MuTIlKK

nTRTHPf.ACR

n|- MdTHKR (Slate Mf (■(>\iiiti\

II

rm \iio\ |-. sr \ n i> i-kkson \i, w\k ruri.ARs xki: ikii-: to Tin-:

IlKST OI- MV KNOW I.KIX.K AND HIU.IICK

nilfti;iu;nit

(.% i dress

IDIW

^Km..

I)rRATK)N ■ )Vrt;-.? CONTRMU'TOKV

OU^.Ur^^'^f..

Months

Days ^^-Hours

Dl-RATION i Years Months .^ Pays --Hours

^.Jul,^ .uvJv. vdi M . D.

fA.l.lrcss) 14\^\)0->v^Ki4^ll-

(SIGNED)

T()0 *

SPECIAL INFORMATION onlv tor Hospitdls, Institutions, Transients, or Recent Residents, and persons dying av^ay from liome.

_ How lonq at

Former or pjace of Deatli ? Days

Usual Residence

When Has disease contracted.

If not at place of deatli ? ' ""^"^"' "'

n.ACH OF HIRIAU OR KF:M0\ Al

6

DAfHo! HiKiAi- <jr KF:M(»\AI,

190 I

UNDKRTAKKR

f \iMifss

I rXACTLY. PHYSICIANS should

N. B. r.very Item of ln?nrm«t5on should be cnrey'ully supplied. AGK **''""'*' *^,."*" %,,; ••Special InformHtion" for p«P-

«t«te CAUSE OF DLATH In pli.in terms, that it may be properly classi^uU. sons dyinft away from home should rte feivcn in every instance.

i

» 5

11

*>

linlllit

WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD

^'f^r^r^wKVio REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

,,f II. Mini- »■ V'> i*- ^'K'^.

J)nf<' Filed ,

tu 3, lOO'i lieglstered ^'o. 40

/I

-Lev-., Deputy Health Officer

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco

Certificate of S)eatb

( XX, S. StanDarD j

PLACE OF DEATH: — County oP' Ct^v T \a'>vCA^ m City of C'a^ ^T.'vaTLCUlcc

/ ir orATH occurs avm»v r»

V' St.; — — Dist.;t5Ct.

RESIDENCE GIVE FACTS CALLED FO

and

(ir OEATH OCCU*S AVMAV fnOM USVAU HtaiUtrn-E. Qivt rw^ia .--luii^ ir DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME I

FOR UII©tl» "•PECIAL INFORMATION- N NSTEAD OF STREET AND NUMBER. /

FULL NAME^

uLiU^ L}j^y\/r\^trZjt.\^^-

%9.X

PERSONAL AND STATISTICAL PARTICULARS

lATR OF BIRTH

Vo.Ltt.

v^^-^^-^*M:v^. /

■ Monlh* (Iter) (Vear)

\<'.V.

oJA 3,5?

)■»■(/»

Affmtki

Day:

W IIMJWKI) OR DIVOKCKO < Write in mciiU desiKnaiioti)

r.lK lHIM,\OK Slide nr I'uuntry)

FATHKR

HIRTHPl.ArH <>I" lATHHR 'State or Countr^

MAIDKN NAMl OF MOTHKK

l>

■v>i:L

niRTlll'LACK 'H- MnrilKR (Statf or lOuntrvl

'""■'■ "■'"''^Ivv^t ^

WWCc

f\fiifrff in San Franrhm

t^

);-,i>

* V-..////t

Pars

Tin-: \H0VK ST ATKI) I'KRSnNAl. P \ R 111" f I, \ KS AKl". I'RI K To IHI-; HKST Ol'- MY KNOW I.I.IX.K AM) iu:i.n:i"

Unf. .-TiiMtit

i\i\A

KNOWI.I.IX.K A

'1 04 Tyia,<L.ir>v3t

MEDICAL CERTIFICATE OF DEATH

DATE OF DEATH.

(Month)

(Day) (Year)

1 IlKRlUiV C1':RTIFV, That I attended (IcccastHl from

■' ■ 190 to 190 —

- 190

that I last saw h -r— alive on and that <leath occnrred, on the date stated al)Ove, at M T he C \ r S I*: ( ) 1- I > \-J^ 'r 1 1 ^^■•^^ «^ ^^^ 1* >^^^ •

O.-'S'^SrS^^^^i.d-J^ ---■

I )r RATION Years

CONTRIIU'TORV

Months

Days Noiirs

Days

nr RAT ION Vi^rrs J^'"'^^'%

Vv>v4.30 TQOH r Address) LnaiVaA-^ U|f.C^.

(Signed)

I louts M.D.

T

fepECIAL INFORMATION only lor Hospitals. Institutions, Transients, or Recent Residents, and persons dying av^ay froxi f»on)e.

Ml?..

Former or Lisual Residence

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

^s

I

]')..\CK Ol lU KIAl, OK KKMOVAI, rNDKKTAKKK U olcwU-

DATKoiJ. niRiAL or RKMoVAl,

VC

(Address

15 W Ht^t^ktevu ','

N. IS.

-Hvery Item o? informntJon should be ciirefully Hupplie.l. AHK «'^""'*'^°. •tnte CAUSK Of- DP; AT Ron» dying awny from home should be given in every instance.

stHte.l EXACTLY. PHYSICIANS should

ion should bL- cnr«»'ully supplied. A«.r. sn.n nu .^ •'Sneclol informntion" ?or p«r-

•H in pinin terms, that it mny be properly class.tieU.

If

I !

^1

1»

1*

iU

II

11

*il

i 'i

^

WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD

i'„,.,i.i .>f n

r.i)l»l- l-No !«. "fr^l^^M&J'Oo

!)((!(' Filed ,

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

,Vvlu 3 ^^^^ Registered ^'o, 41

cLtrv^\^^ dUL/v^wi Deputy Health Officer

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco

Certificate of 2)eatb

( tl. S. Staii&at£> )

(TO

A

^

JP inn -^ en

PLACE OF DEATH: — County of '^- 0L/>^ Xh^<X>vcv^C.lCity of ^-O^/^v Lv<x--vvc.ui^'S^

-O-A-vxvLu G'b 0-A.K\^La.lSt.; '"* — Dist.;bct. • •• and

/ IF DEATH OCCUnS,>WAY FROM USUAL R E S I D E < C E G I V E FACTS CALLED FOR UNDER "SPECIAL INFORMATION ' N V, IF DEATH OCCUHJRED IN A HOSPITAL OR INST .UTION GIVE ITS NAME INSTEAD OF STREET AND NUM3ER. /

(Pfc. LCtu^vi C

FULL NAME

Xa^w^ .^,C

''llX

?

PERSONAL AND STATISTICAL PARTICULARS

COl.OR

^J

n.\ IK OF lUKlH

{• 'Month)/

\l

\x\.

u.

ac /I'll...

(Day) (Year)

\r.K

Xl

M.mlh-

"^IM.I,!-:, MAKUIKI). UIDOWKI) OR DlVoKCKn UVritf ill s(K-i;i1 iUHij,»ii;(tiuii)

lURTHPT.ACK i Stittf or Oonnlrv

WMK Ol- !• X'lHKR

1

IC

Pars

CV\^v>-\Jt^>^/tiJL '"'XMrlv^vv.

1u>.v

MEDICAL CERTIFICATE OF DEATH

DATK OF Dl'.ATll^^

.\jyyJL S..(ii.

(Month)

(Day)

(Year)

I HI':RrCr.Y CIvRTII-V, That I atteiKk-d (leceaseil from

OX^

<X^.Xb..

X¥ iQoH

to ...Ua,:

yyJL, 33.Ci.

190

that I last saw h f^'tA^ alive on k^-VA-^. 3ii 190 '1

atiil that death occurred, on the date stateil above, at 60O U M. The CAl'SIC OF DIvATlI was as follows:

rVAw^-'V^ y-wLwv{r\.\.o^L.uo

nTRTHl'l.AiK

oi- I A 11 if: R

(State or Country)

mmi)i:n' namf; 01 .motiif;r

hirtiipi.acf: oi- MoTin:R

'Slate or Countrv)

Ivci

CL\^cL

\/^c^clc\)

f)

d

Hi

DTK ATION ) 'cars Months Days Hours

CONTRIIU'TORV

Years 3font/is

DIRATION

(SIGNED) ^ ^ ^ %Au 1 iqo4 . (Address) utM^i U..%»^.ki.

/hiv^ /fours

M.D.

^^^j^Lcw^^^-db^

oOCrPATlON

Rfsidrd ill Sail I'l atuisra o )'i'<ji.<i

Ar.'iif'/s

/),n.

rm-: aijon'f stati-i) pkrsonai. far tuti, ars arf; trif, to tiii-

HHST OI- MV KNO\VUKD<*.K AND HF:MF:F

Address LCLu ^^ ^ )bc»-:^kl

'h

SPECIAL INFORMATION only for H or Recent ResWents, and persons dying away froni home

(Kpitals,

institutions, Transients,

Usual Residence O 5 1 ^1 HA^

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

trwv

How long at n h

Place of Death? O...J. Days

VI \CK OF nrRIAI. OR RKMOVAI, I DATJ: of m kiai. or RKMOVAI,

rXcMiess

L^H'^ '^-^ <vtt.

!N. B._Rvery Item oV informntJon «hou1.l I,. cnrofuMy supplied. AdB should be stntcd EXACTLY ^"Y^'^*'^?;*'. f ^"'*' «tate CAIJSL OF DnATII In pl..ln terms, that it m»y be properly classified. The Special Inlormat.on for p.r- sons dyin^ away from home should be ftlven In every Instance.

f M I

1

1,:

fj

'li

'I

li

IN

'H,

■i

I

If

m

.'•

11^;

H'^^^

luL

WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD

li.MvlMf ilr.Uh I No i^ *?^^)HS:PCo REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

/)((/(' Filed y

100 H,

Registered J\'*o.

42

<^^wv^ x^^L Deputy Hearth OfHcer

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco

Certificate of S)eatb

( Xl. S. Stan^ar^ )

PLACE OF DEATH: — County of ^ tX>v' v'/Va ^\c\ALC City of Olvl' 1 N^^X^x/t^uiac

'Tlo,

.t^>

(HL.

V^.

La,L

St.;

Dist«;bet4 and

/ IF DEATH OCCURS Awi*Y FROM USUAL RESIDENCE GIVE FACTS CALLED FOR UNDER "SPECIAL INFORMATION ■ \ V IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. /

FULL NAME

_ PERSONAL AND STATISTICAL PARTICULARS

■^y^j.. Jj\j,Os.:y\AJU\\^.

<!f)\c.u

DATK OF HIRTH

ll).LtL

i\,^'^yJL '^l / '£ iXi...

I Month) (Day) (Year)

MEDICAL CERTIFICATE OF DEATH

DATK OI- DKATH

1,

(MontflT)

A(iR

^H

IVrt»jr

Mi»ii/is

\t

Da vs

^INC.I.K. MAKklKI) WIDOWKI) OR niVORrKI) (Write in social clesi}fnati(Mi)

4

T'.IRTMF'LACK (State or Countrv)

XAM1>: OF FATHKR

inUTHlM.ACE

<M I-ATHKR 'I

'State or Country)

il]

Ok

(Day) (Year)

I 1N{RI;HV C1;RTIFV, That I attended deceas^Trmu

:y>^.X^. 190*^ to .XW.VtIUa^.I 190 S

that T last saw h'Ar'^-\vaHve on 4v\<<L'Li, i jqo S

and that death occurred, on the date stated above, at 3 ...>.L M. The CArSiC OF I)F:ATII Nvas as follows: wf \/V^-VWV^. . /^^\\,lr1J■r^L.CL^.r0L\..L^«^

n

r\

<XA\^i>v

L

MAn)F:N XAMK 01- MOTIIKR

.If-

RTRTIIPI.ACK <>l" MnTHF:R (State ur Countrv)

aL

-Vcv't

?

kjLK.^^

ut^A^vV\-

DURATION U^;^Afi^R^WtW\^/?Vr^

contriiu'Torv Uv!utrv-u^^\

Days

Hours

X^X'>VL<XA-'k

or RATION

(Signed)

T()0

^i^ayh^^-^f^tlis nays

Lv. Aj. L'V'v./V.L4^^r>v

'; (Address) Ot \,K.^UjU /S.ft^fV

Hours M.D.

orcrpATioN r»> y

ffrsidfd il, V- . J-,,ji,.i\,-,> !Sh )

'X/y\'>r\\.OJ\,'

I'd I

U, :>,///<

/hn.

UhSl OF M\ KNO\VM:D(.f: and HKUnCF

Special Information only for Hospitals, Insmutlors, Transients or Recent Residents, and persons dying away fro-n home. '

Former or *> ft ^ ( Vl f

Isual Residence ivX^I UaU^yivO,

HoM lonq at Place of Death ?

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

Days

fiiif.

'M)irint

(fv '<X^vv<i..C<rv^'

Vj LaX/o>vtx

ri.ACK OF lit RIAL OR RKNfoVAI. I DATF! of Hi hiai. or RFMoV\I

(Address

hvery item o1? information should be carefully Hupplled. AGE should be stated EXACTLY. PHYSfCIAINS should state CAIJSF OF DEATH in plain terms, that it may be properly classified. The "Special Information" for per- son* dyinft away from home should be ftiven in every instance.

I

I

V

I'

!

» ' ■'*

li

nn

WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD

arc! of llenlth-P No. i^ t-f^^^ H&P Co REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

T)ff/r FiJed, ^

<X-<rwU3 SJU:

100\

Registered JVo.

43

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco

Wo

Certificate of 2)eatb

( "U. S. Stan^arD )

SI n -? .

PLACE OF DEATH: — County of ^^<X^^ vj AX^^\^:^4aCity ofO^X^nu O.VCL >xca^c<c

(IF DEATH OCCURS IF DEATH OCCUI

St.; Dist.; bet.

and

IS AWAVH FROM USUAL R E S I D E NC E G I VE facts CAtLED FOR UNDER "SPECIAL INFORMATION" \ IRRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. /

FULL NAME

CtN-

U^

,,..

PERSONAL AND STATISTICAL PARTICULARS

COI,OR

"'"__ "WJ^

jMjJJl^

MEDICAL CERTIFICATE OF DEATH DATK Ol' I) HAT 11/

DATK or lURTM

(Month)

(Day)

(Year)

\t'. K

b 0 JV,7;..

M->n//is

Pa t .

VilNC.I.K. MARKIKI). W IDONVKI) <>R niVOKCKD Wiitoiii s()ri;il (ksivrtialioii)

HIKTUVLACR (State or Countrv^

NAMK (1F »"ATin:R

lURTHPl.ACK <)l" I-ATHKR 'Stale «)r Country')

^w j^^Wtru^nAj-

0 \

.)^u^W

f (Moiyfi)

X...

i) (Day) (Year)

I HI':R1':BV CI':rTIFV, That r attended deceased from

.W-rUL X^ 190S to |v\Xu, a iqoH

that I last saw h «*-^v>>.alivc on ^lAArVUL %. ^'PI

and that death occurred, on the date stated above, at \i) ■^ 0 ff M. The CAl'SIv ()I« DI-ATII was as follows:

'^w^«^CX^.y.O'^jLA-A^A-VA,^;:\:XA^a^

DIRATION ^ Yeats ^ Months S' Days " Hours

coNTRiuuTORY Lm::,>.aJLl . ^o\.:^^^ I

u

MAinKN NAMK *)I- MOTHKR

)nRrnpi.ACK

Ol- MOTHKR (State or Country)

•«

occT.P.vnoN (Xt^-Uv^ ^X,

f\rs/ifrif III S,ni I'l ,i ih :sii> X • )'riiis

.y/,',if/is

Pax.

DURATION •" Years ^ Months 3 Days

(Signed)

" Hours M.D.

(^

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

Former or Usual Residence

30lDl)alx.

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

How long at AVCV.CL Place of Death ? 3 Days

Tin: AllOVK STATi:i) I'KRSONAI. I'A RT ICT l.ARS ARi; TRUE TO TU H HHST OK MY KNOWM.DC.H AM) MIIMICF

(Infonnnnt

'-^'T^'

(X.l.l

ress . O

^

l)\'IM;<)f Hi KiAi. or RIvMoVAI,

S' T90H

ri.ACK OI- HIRIAI, OR RKMcWAI,

INDHRTAKKR

(Atlchess

/O

•^^ •*• E-.ery Item of infnrmntion should hi cnrefully Huppfied. AGE should be stated EXACTLY. PHYSICIANS should

state CAUSE OF DEATH In plain terms, that it may be properly classified. The "Special Information" for per- sons dyln^ away from home should be H^iven in ^\^ry instance.

m%^

' t

I "

i \

) M'

)

{

'

fl

WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD

Borinl of Health~F No. is -^'tS^ »^»' ^o REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

Eegistered JSfo.

Duli' Filed, WU, A l'^)0'\

0 d X^ ()

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco

Certificate of 2)eatb

( "a. S. Stan^ar^ )

i ^ \ ^

PLACE OF DEATH: — County of '^'/CLax' 0 A^o^-tl coa.^o City of ^'<W\.) vt\xX'>-L/e^4 c <.

44

'No. Uf-U.

.1

\L^O.A)

St.; Dist.; bet.

and

(IF DCAT IF DE

H OCCURS AWAV EATH OCCURRED

FROM USUAL RESIDENCE GIVE FACTS called for under "special INFORMATION" \ IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. /

FULL NAME

^))Wl'

fVOU

"\^A^CU^V

VtK'KV. OF' lUJtTM

PERSONAL AND STATISTICAL PARTICULARS

COI,()R

15

(Day)

(Year)

Af.K

O y lilts e>V

Months

IS

/></r.s

SINN'.I.K. M,\KUli;i). \\II)t»\\I-:n OK IMVoRrKI) fWriti' ill s<Hi;il (lfsi>.'iiati<)ii)

HIRTm'I..\CK (State or Conntrv)

NX Ml-: oi.-

lATHKR

c

MEDICAL CERTIFICATE OF DEATH DATE OF DKATH

X

(Day)

T90%

(Year)

<^

I,HBRI':BY CI«:RTIFV, That r attended deceased from

IS? 190 A to \>r\XAj^ 3i.

that I last saw h -^^^v alive on >kv.U.v X

190 4

190 S and that death occurred, on the date stated above, at 3. 3 Ci ll. M. The CAl'SH Ol'^ DIvATII was as follows:

^

HIRTHPT.ACR or KATHHK 'St.itc or Co\iiitry)

MAIDKN NAMK OK MoTm;R

niR'nn'i.ACK <»»•• MoTm':K

• Siatf or Coiuitrv)

V/V'^PV^ VOl/^aj

DIR.VTION " Years " Mouths H Days - Hours CONTRIIU'TORY X.Kr>r^^CUU\^^^X^^

(fc-UXA-t; "ijL4j.^..>r>x

DrR.ATION '^ Years X Mouths \^nays Hours

(SIGNED) ..wXc3L^^v^J^JL 0 Ct>v ^^.wa^vJVI.D.

WL^ 1 iQo'l (Addrrss) U^vOUiNX^ 'rO.^!^\<X

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

.W<X_

OCCUPATION

Krsidrii ill Sail I'l aiu i>ri) ,-J )\\u

q

Mnlllh^

Dax.

rnj-: Aiun'K st\ti:i) i'hrson m, PARricn.ARs akh trik to thk

HHST Ol- MY KNO\Vl,l-;i)(',H AND lU'.IJllK (Itifonn.Tiit •CvJL^ A^ CVXA^"

f \.l.Ii

iHl^

A

former or a u n <3 ( K k . .. J ""^ '""« ^* (n></v '^.

Usual Residence «*! 1^ VU ^'fr<>-cl.^A^<Xu pijff of Oeath? />j^.V!. toys

When was disease contracted, T 0 0 j

If not at place of death ?

-NJL-v-i^

^ ^^vd.cvi

i;X,ACK OI- lURIAI, OR R1:M0VAI, I DATK of ncHiAl. or REMOVAL

^ ' ' V^M ^ 190S

kxJUA'

<^*.<CVW\-'

UNDHRTAKKR

(.\(l(lrcss

YV^^A-O ^

Qi. o^vxw.Hl Co

N. B. Every Item of Information should he cnrefully supplied. AGE should bo stated EXACTLY. PHYSICIANS should

state CAUSE OF DEATH In plain terms, that it may be properly classified. The "Special Information" for psr- Rons dyin^ away from home should be ftiven in 9\^Ty instance*

m

I

+1:

t

f

H

W

i

!(

WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD

, „ „,, , v<, ..-^'■S-^.IKS.l.Co REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

45

D/ffr Filed, "iW

i

%

VJOH

Registered J^o.

Deputy Health Officer

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco

Certificate of Beatb

( H. S. StanOar^ ) C'OL'^nj o,N.<x >xcc^ a<: City of C3<X^V' O^vaTvcui/CL

PLACE OF DEATH : — County of

I

Mo 3)^?^ -^ II tlv St.;^ Dist.; bet. V <X.ii/>x^v^ and A.Uu.hA.cH-^ )

^^^* c^ "-- i.eiiAi DceinrNrr nvr facts called for under "special information" ^

( '^ rF"DrAT°H"o^c"u%rcVirrHo"s"prAt o"r": ^n^JV^O^N^O./ETTl NAME INSTEAD OF STREET AND NUMBER. )

FULL NAME

Lii^kx>v' \I ILcLu.

PERSONAL AND STATISTICAL PARTICULARS

DATK t)l- HIRTH

L

COI.OR

vX^^VvCLl

AGK

Month)

,.q

(Day)

tlVx..

(Year)

(i)0

J 't'O » v

D

M .1,1 1 In

3*.X ■^"•

\s

SIN(".1,K. MAKKIKIV WIDOWHI) t)R DIVORCK!) (Write in social desijftiation)

Statt or Country^ / H .^1

NAM1-: iW FATHKR

HIRTHPI.ACK Ol- l-ATHKR 'State or Coti

WVt^TVV

MAIDKN NAMK Ol- MOTHKR

;try) \ n

LtLv l^]

1

\hjiK,^-^QL,K^

niRTHPr.ACR OF MOTHKR 'Stale or Country)

k

OCCT'PATION

.O-^Xtu vJXh^\vuX'>vu

sidnl in Siui /-Ktrnist'o \i ]rais

.}/,>ii//i?

/hi v.

■nil'. AHovK srA'n:i) pkr^onai, tar tutkars ari*. trik lo rni-;

HKST OF MY KN<>\VIj:i)C.K AM) lUUJKF

flnfiiniant

(Adilress

MEDICAL CERTIFICATE OF DEATH DATE OF DKATH

Month)

th)T

H

(Day)

(Year)

I HKRICBY CliRTIFV, That I attemled deceased from

^XcuuL lk> 190 H to 4"-^^ 190H

that I last saw li ^"^ alive on T" ™:l^ ' ^'^ "^

and that death occurre<l, on the date stated above, at Ij -oO

Q. M. The CArSIC Ol- 1)1:AT11 was as follows:

voLh^xJcyuoJL UUv^ivLc-vu- (>c/ca^vs-juL wvt I

.(?...^M..., .&i^. ..|v\l.vi. .1 At IhLaH.'/^^^v^^^ UjLcdjLiL

fc,.. aoiXt<i.'ttryv^. ih^AxX. \Ti(')N ** }'t'ars '•^Mofiihs Days 1 b Hours

^/yXXA^ij^^\jL^.

CONTkllU TORY

Hours

DTRATION - Years ^ Months *" Days

r Signed) J J jL4 vL<LA,<iJt^ \..'^ M.D.

,4 (Address) \X\ 0 ^"^^cttx^- J

M^

f

iqo

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

Former or Usual Residence

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

How long at Place of Death?

Days

ri,ACK OF niRIAI. OR RKMOVAI. j DATlCof lii KtA(. or RKMOVKI.

I90H

a

if

M. B.-

-F.

8

ivery lUn. „« -.nW.nB.lon .h„uld be cnrcSuMy ».,pplie.l. AGK »h„uld I.. „....d F.X*CTLY PHYSICIANS ,ho„ld tote CAUSE OF DEATH in plain term., that it m..y be properly cl...i«ie<l. The 8,».c,nl l..,„r„. n for per-

son* dylnft away from home should be ftiven in every instance.

Wit

[,:

a-

m
V	' ♦
iPPW	rf
fp.	t
1	M
	!
	\\
	i
	'H
	'■ ♦
*	s
t	(
%	■;-
i :.,	t.Ji

' I

1 1

:L

^

WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

lOO'i

nal.mul, --• - '•"- Registered J^o. 46

i

d^trvv^U) '^^-^^-^^^ Deputy He.Tlfh Off?--*r * /^ r* •

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco

Cevtiticate of IDeatb

( H. S. StanDarD )

No.

PLACE OF DEATH:-County ofC^O^ ^KO^^^x^^^^ City of ^^'O^r^ v] A^.v^<. I l^ %&U\vlnl' St.;— Dist.;bct. ■ and "^

!. \^^ UVW v-l V.VV, ..v .,^,,^, orcsmrNCEGivE facts callcd for under "special information-

( " r/o;':TH"c".*r;,"r»o,^p"'.t "f»"?u" "".'"S name ,»st..o or .....r .»» »u„s.,.

CO

^\

FULL NAME

n

9ii

trtr'.uc

SHX

PERSONAL AND STATISTICAL PARTICULARS

COI,()R >^

%..

DAIK OI-" niKTH

„S

(Month)

1 0 / "s."!;'..

(Duy) (Year)

A CI-

U

} ra I A

M.>},ths

X\

Pn\.

WIDoWl.n OK niVOKOKI) (Writr in sofial dtsiKnatioii)

O >L^

auOVjL

MEDICAL CERTIFICATE OF DEATH DATE OV DKATH

m.uLu.

/] (Montwf (I^ay^

rTlT:Kl';HV CIvRTIFV, That I attended dcceastMl fruiii

(Ycrir)

190

to

that I hist saw h-.-r:^ alive on

and that death occurred, on the date stated al.ove, at M. y\\<^ CAISI-: OI- DIvATII was as fo lows

190

190

niRTTTPT.ACK

(Statr or Country)

NAMi; OI" lATHKR

niKTnPt.AOK OI" lATMKK (State or Country)

MAII)1-:n NAMK ol- MOTHHK

\JL

lURTMPI.ACK

OI- MoTHKR (SiaU- or Country)

_ Cy .cv^Aj J . VOL'Av'C.^A-^c^

OCCrPATION -\ 4 , X

h'r.-iifeJ ill Siui I-,,!!!, nro ! ■ )>'?'> . M.'>ith> t

/)<M

THK AHOVK STATJ- 1) PHRSONAl. PAKTICII.ARS A K l*. TRrK T«> Tl ' H

m:sT OI- MY KNOW 1,1: IX .K AND in:i.n:F

Otn

(ll

N,i.„..s iMk; (^ <X^v<:.k.iL'^ ''^t

4

COvd; (A;T U.-^.tv-UsJ

DC RATION }V<i/'J Mouths Pays f fours

CONTR I m'TOR V .9..fciLV)uC<k lv\i. jJu^lAA.t.^. ..^^

DURATION Ytars Mouths

;iGNED ) ..L^V^^raA) 0 a3^ lU. AjlLow-^v

(S

f')ays Hours

cL M.D.

ydu .1 TQo'i (Address) Lcr\tn\X\^ Uij'.':^..

Special information «nly for Hospitals, institutions, Transients, or Recent Residents, and persons dying away from liome.

Former or »^ ^

Isual Residence i v

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

,.b..,d.a.>vc.fvi.

1

^

VLt

IM^ACK OF liTRIAU OK K1;MovAI,

'i..\en yiv ru rvi-n. >'

^1^ n Art

4

HoH tonq at Place of Death ?

..5:.M;'

Itoys

UNDFRTAKKR

(Adtlri'ss

1)A'1'L;i>! niKiAi, or RICMoVAI.

. I^^-Ul-^ T904

cdltul ^^vc' C

N. B._Bvery Item of ln?orm«tlon nhouhl be cnrefully Kupplled. A^^' «;°!;'''^;;;"f j^*"''ti!I'''^8^^^^^ In'Jo^Jl'tTon- Vr^'p.r- stDte CAUSE OF DEATH In plain terms, that It may be properly Ja8«.tled. ope

sons dylnft owoy from home Hhould be ftWen in every instance.

■0

'?JF

7'

m

WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD

,,f ll.allh 1" V«i 1'

-*.t!r»r5LjD nfav

c<,

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

47

Registered JS^'o.

,uU,'l-Vr<J, XJ^ Z 1^0^

dLt^^^ c^o^Mj Deputy Health Officer

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco

Ccttificate of 2)eatb

( tl. S. Stan^arC» )

^

PLACE OF DEATH: — County

of ^CU>^'O.VCV^v<M,^cCCIty of ^* ^>^ ^^ Vcv>vC.^C^

( '^ r/rrlT°H^o^:u%roVN"rHi's"pVT*.t o"r'?:?t^^^t^o^n'^ci;e7tS name instcao o. street and nu.ber.

)

FULL NAME

CUV'

at

tx \

^'■'" n

PERSONAL AND STATISTICAL PARTICULARS

COT.OR \

VJ

DATH «)i' lUK rn

J JirY\^JoJil^

aJjL-

\c.K

/,l.1.L...

(Year)

%%.

)■<•<;» >

o!^ Mimffis I.

Davs

'^IN'.I.K. MARKIi:!).

w inowKi) OR i)iv»>Kri>;i)

I Write in social <Usij):"ati<iii)

lUKTHPl.AOK (State or Country^

<X^\.UL

^cL^-

LAxavcv>vc^>

1 ATin;R

HIRTHIM.ACK ni- I ATMKR 'St;itf or v"(ninti y)

MAIHKN NAMK <») MOTHKR

X^Oj^aJZ.

MEDICAL CERTIFICATE OF DEATH DATE OF I) HATH ^ '

vJiu I ^90^ ■

(Moulin (Way) (Vear)

rrrHREBV CKRTfFV, That I attendtMl deceased from

T90

to

tliat I last saw h alive on

and thai death occurred, on the date stated above, at" M. The CAl'SIC C)l'' DlvATII was as follows

190

.C).fr^W\r.V«.^>w<:^JL.

Dr RAT I ON Vrars 7A;;////\

CONTKIIU'TORV

Davs

Hours

niKTMIM.ACK <»1- MoTHKR (State or Country^

e if

\jy\

OCCIPATION

Kf sided in Situ Fi 1I ih isri>

0

<^vxx/'\rv

0 O-VvAJUA.A-M^^-fe, 0

ruj-, AUovK sT\ri:i) wk.rson au i'akiuti.ars ari-; irtk r») rni-.

IIKST Ol- MY KN«)WI.i:i:>(".K AND nHMi:K

n n f. It ma tit \JJ .^AAt'

vo^-v-w

(Address

H 1 IJOlct.v^^, '^-^

nrRATIoX Vrars Afotiihs Days

(SIGNED)

X iQoS (Address)

I lours M.D.

\\ \\

gppQ|/\|_ Information ftnl> for Hospitals, institutions, Transients, or Recent Residents, and persons dying away from tiome.

Former or Usual Residence

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

HS UJ .Kvt^xJlM ^ ^' Pla^f of Death ? 3» 5"

(toys

ILACK OH BIRIAU OR KliMOVAI,

iiiu I l^lOSAiU)llCtvw,fAt

DA'CH of. Hi RIAL or RKM«^VAI.

tvu^ X 190*^

INDKRTAKKR

'Adiln'sv

CWcVA-s-jiA'

n^i>-c

I acq Q^\v^4.vtAv ^M.

IN. B. F.very Item of h,?ormnt1on should be cnrefully suppI.eH. A(,b «^^' ''' J^^,.^*" The "Soecial InformHtion" ?or p.r-

state CAlISt OF DEATH in plain term*, that it may he properly claHH.V.cd. The Spc.al «ons dying away from home Hhould be given in every instance.

t

!!

1

i

"^

% .

)l»

i I

i

WRITE PLAINLY WITH UNFADING INK —

,,,,,, ,1 .,f Ik:.U1i I- No ". ■^'Z^-^S^'^ScVCo

VJO\

THIS IS A PERMANENT RECORD

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

Ee^is'tered JVo. ^v^

l)((fr Filed ,

d<w.(rvvvo ' dUL'^Mo^ Deputy ■Health- ,

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco

ficer

Cevtificate of 2)eatb

( "a. S. StanDarO )

A ^

No.

■^

PLACE OF DEATH: — County of

\ % ox V vxh St4 H Dist.; beJi^^^^VtV^ and^^ ^a^^^v.^ ' ■- )

FULL NAME

.cr>x.OL.L

PERSONAL AND STATISTICAL PARTICULARS

sicx

(?0

I

\X/y^^\xs^

DATK OF I5IRIH

COI.OR

\

UiUv^jU

(Month)

i (Day)

./.ao..H

(Year)

AC.K

^Vo^.*

(

MnHt/lS

1

/^rt v.v

SINCI.K. MARRTKD, W

MEDICAL CERTIFICATE OF DEATH

DATE OI' DKATH

1

-%

(Day)

IQO

(Year)

VIDnXVKI) OK DIVORi'Kn (\ A

Wiitf in siK-ial <ksiKnati<in) "A U

niKTiiri.ACK

.Mate or Covintiy^

\\M1', OI J-ATllllR

lUaiu...vW'2)o.aU

0 (^ . 0

A^ L crV\'VC<x-

.Vi.-'M.'iTHHR'"" n M^^^^On

T'.lRTHn.ArH OI" lArilKR (State or Country)

MAIDKN NAMK

r.IKTHPI.AC^: ol- MoTlIHR (Stati- or Country)

.LoJla^v

CyV'^ v/- ^.

I IllCKlUiV CIvRTIFV, That I at^tendcd deceased from

.w%^.....a.s....i90.H to jv 1^*^ ^- '90S

that I last saw h-^i^ alive on H.VA.Lu, X 190 1

and that death occurred, on the date stated above, at ^ ^^ ijt„ M. The CArSH OI- DIvATII was as follows:

y.,^:1r^JLvw'"^<^^.<C^^^-vC^^^

DURATION CONTRIBUTORY

Years Months Days

.m'Vr.Cr^v.C-r^X.tJL.*^.

Hours

DURATION

)'i'ars Mouths

Days Hours

(Signed) v. Virl- J-v^^-'VvW^avcx.'-vv^v' M.D.

JprciAL INFORMATION only for Hospitals, Institutions, Transients,

or

Recent Residents, and persons dying away from fjome.

OCCrPATlON

Resided in Sou /'iiiiiiisfo

]-e,ns 4 .U,.»//;- \ /'<"

Tin: AHOVK STATl-.l) I'KRsONM. CA K T UM' I.ARS ARK TRlK TO TtlK BKST OF MV KNO\VI,Ki»«".F: AND IU'.I.1F:F

(informant Ll) TW^ • \- M^fV ^' r^^^cdJ^

^\(l<lrcss

Former or Usual Residence

When Has dise-ise contracted. If not at place of death?

How long at Place of Death?

Days

ri.A^K OF lURIAI. OR KKMoVAI rNDF:RTAKF:R

(Adtlress

of information nhoulcl be c.refully supplied. -^^'^ "^""'''Jj^.j^j^'^Th^^'^SpTc^^^^ Information" fo^r pT- F OF DEATH in plain terms, that it may »>e properly dassiHcd. He op

N. B,— — Rvery item

state CAUSE OF DEATH in p

sons dyinft away from home should be ftiven In every instance

i'iii

n

J?

m.

I I

WRITE PLAINLY WITH UNFADING INK —

llnai.l ''f H

^._,,,j,,„,.So, ..T^^^Hftl'Co

/)((/r Filed y

100^

THIS IS A PERMANENT RECORD

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

49

Registered J\^o.

DEPARTMENT OFfUBLIC HEALTH=City and County of San Francisco

Ccvtificatc of 2)eatb

( "a. S. StanDarD ) PLACE OF DEATH: — County " "^ -^. T ^ n ...^. ^^cruv nf O

'7^

No.

unty ofCJO/^rv J A^a^vCUtMCity of "<5^^ J-'v^X-Tv-C.vi, ct S.'VO Mcr\cd.O_ St.; -5^ Dist.!bet. 3.J and

«« lieilAI RESIDENCE GIVE FACTS'CALLED FOR UNDER "special INFORMATION" \ ( " °,"o»TH"oCCU%'-"V,"rH"s^P?T*' O^T^Sn^u" « C.e ,TS NAME ,.ST..O O. ST-..T .HD ~U« = t,. >»

FU LL NAME nOTU J^xJj lO JlLa-^.. ^ IT Jlu>.^

SKX

PERSONAL AND STATISTICAL PARTICULARS

DAl'l-: nl- lURTH

,1,1

(Dtiy)

r%hl

(Year)

A ( . K

>Va».v

1

Moiilhi .

l^

Pa v.v

^IN«'.1<K. MARHIKD.

U IDOWK.D OK I)I\'«)RCKI>

iWriteiti social fk-sivrnati<in)

lUKTHIM.AOH ^Sliitt or Cowntry)

MEDICAL CERTIFICATE OF DEATH DATE OI' DKATll

() (Montli^

1

(Day)

(Year)

NAMlr OF FATHKR

a

X

<XV>vv.O

V ^X l^m..

r.lKTMl'I,ACK Ol- 1-ATHKR (State or Country)

<X/^vcL

maii)i;n namh

lUKTHPI.ACK «M- MOTIIKR (Statf or Country)

''WW

I HI'RI-'BV CI<:RTIFY, That I attetulcd deceased from

tliat I last saw h ..:^v»dive on .."^vU^ Ov 190 .

and that death occurred, on the date stated ahove, at 4-30 (P. M. The CAl'SK OI' DICATII was as follows:

,.V<^>:\.^^^^►:^«v•'^v^>^^■

DL RATION •" )'cars ^ Months " Days ^ Hours

y Ji^^v^*v^^vcA-^-.*^^

Years Afont/is ^ Days I/ours

V \jL' ^1.V^'^^.:^x V' M.D.

Address) 0?

duration (Signed)

v^lLy a ic)oH

(Address)^-)^^C^a^^.t''\C W^^^^- ^^ '-^

Special information only for hospitals, institutions, Translfnts, or Recent Residents, and persons dying away from home.

/',M

OCCUPATION

Rrsidfil in San /'i uni iMo ^^^^^^^^^^^^^_^^^^^^

rm: AllOVKSTATKI) PKKSoNAI, I'AKI-UMI.ARS ARHTKri' T< > TUJ- hV.ST OI- MY KNn\VI,»".IK'.K AND iu:i.n.l'

1 )V,M> ^ M.'iilh^

KT

(lufuMuant

iA crr\' -ij^^

( \(l<h'ess

WO

30 *Xo

'^Jo

"\.\^cL

^

^

former or Isual Residence

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

How lonq at Plare of Death ?

Days

IM.ACKOl" lUKIAl, OR K1;M'»VAI,

U1

Ki v^.^-<A;

DATJ^t'f Hi KiAi, ot kllMnVAI,

190*1

'^-VA,Lu. •!

(.Address

I Hi Q0l.v<lAwrrs.....t;5.'

« <, >v

^ r\l It 1 ACF Hhoulcl be stntetl EXACTLY. PHYSICIANS should

N. B. livery Item o? in?orm«tlon should he cnre?ully supplied. ^^'^^ '^^Y'' " ,.^ ^he ''Special InformHtion" for p.r-

state CAUSE OF DEATH In plain terms, that it may be properly classified. he »,

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

Hi

' \]

»,^'

yn

}i..:i

;,1 ,.f !Ir:l)tll 1

I

t

n

WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD

..„,.*r^„U^HC„ BEFtR TO BACK OF CERTIFICATe FOR INSTRUCTIONS

Reiiisterecl •A'o. OU

atcFih;!, UL 3. ^^^H

DEPARTMENT Of PUBLIC HEALTH=City and County of San Francisco

Certificate of Beatb

( xa. S. StanDar^ )

J ^

PLACE OF DEATH: — County of

(No

ti

0

11 u..

lL

FULL NAME y, jl^^vux^U ILl J

SKX

^

VJ

PERSONAL AND STATISTICAL PARTICULARS

COI^OR

jc

DATl-: OI- lUKTU

M iVcuvt^vv

(Month)

ACK

m

) Vvj > >

(Day)

Mntifhs

,%Kl

(Year)

3LC

Da I .V

^INT.I.R. MARKTF.n.

wiDowHi) OK niv<iKri:i)

iWritcJti social <ksiv:iiiiti<ni)

MEDICAL CERTIFICATE OF DEATH DATK OF DEATH

(' (Month)

ac

(Day)

7poH

(Year)

niKTnrKAOK

(Slate or Conntry)

NAMl-: «>F,^ I ATHKK , ^

•ATHKK .^ t

niRTHlM,A« K OI" lAlllKK (Statf or Conntry)

M\ini:\ NAMi

Ol- MDTIIKK

C^.V<LL<Xn^u:L

HIKI'Ul'I.Ai'K <M- MOT I IKK (State or I'onntry)

OCCrPATlON

I UXVu

Rfsiiifif in Sail /'i attcist-o IS )'>,}< s

Months

/),n:

IHl \n()VHSTATl-n PKRSONAM'ARTIcri.ARS AKi: TRIK TO TIIH Hi:sT Ol- MY KNOWl.HDCK AND Hl^Llh^

(Informant

IC V%l1

1 HRRI":HV ClvRTlFV, That I attended deceased from

.W^v^^. 1 190H to W^^^ ^^ ^90 H

tliatl last saw hXK; alive on |wv-»<>JL IH 190 '<

and that death occurred, on the date stated above, at 1 .(x....M. The CATSK OF DIvATlI was as follows:

'JJiJ/\.riX^\:£,...\^K^\^\x.^riL\^^.

DURATION Vears ^ Mouths Days

CONTRIIU'TORY A.

dt ration (Signed)

Years

Mo)ilhs

Days

htrvv^v (A-.cx-cx/tx. i

QfU,

Hours

v.^

Hours M.D.

FECIAL INFORMATION only for Hospitals, institutions, Transients, or^Rcccnt Residents, and persons dying away from home.

Former or Usual Residence

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

How long at Place of Death?

.. Days

^ \(1(lre«s

IH^

LVVO-Yv.'

.,a.

\^4.

ri,ACE Ol' lURIAI, OR KHMOVAI

dktw, Cvft-^^

DATJCof III KIAI- or KKMoVAI,

,vvJUf A 190H

; 1

INDKRTAKKR

(Address

■'k

W. U' L^^VVCtrV V Lt

Ibl

OYv

V^A^\.^<n\

-i

N. B.— F.very Item of 1n?ormik1on should be cnrefully supplied. ^*^^ ^^^/^'^^'j^j^'^'Th^^^ lnform..tlon" fo"r p.r-

«tatc CAUSE OF DEATH in plnin terms, that it may be properly dassitica. sons dyinft away from home Hhoiild be ftiven in every instance.

•in

llij

I

,,„„,,, ,,f n..,.,nh~ F No. IS ■i^^^mvc>>

WRITE PLAINLY WITH UNFADING INK-THIS IS A PERMANENT RECORD

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

Dale Filed,

-?

190'i

3

cL^rvAA^ djLri-u Deputy Health Oflflrjer ,

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco

Certificate of "©eatb

( TH. S. StanDarD )

Jl

im

nCt'VX' JX^-YVCA^A-

No.

PLACE OF DEATH:— County of<"^CU>v J.>UX^^Z^.A^aty of l^l^\lnL-wo. o St.;^ Dist.;bet. )i)W^R-i^

( " °r'r»TH"occu%*R"V,"rHos^p"*l: o" ^ st'tu"" " .. .xs NAME ,nsT„o or S-^.CCT ..O «U«=C.. J

and

■^ if

FULL NAME

SKX

PERSONAL AND STATISTICAL PARTICULARS

COLOR

^fflJj.

UJJvLiji

I»AT1-: OI- HIRTH

i)

(Month)

31

(Day)

./I.IM

(Year)

A»".K

..i.M... )■'•'">

M.ml/is

X

Pa \s

SlNC.l.K MARRITtn, WIDOWKI) OR I)IV()K< Kl)

iWritfiii social (ksU'nation)

lUKTITPT.ACK

(Slate or Country)

NAMK <)1- PATMKR

MEDICAL CERTIFICATE OF DEATH DATE OF DKATH

h

(Montri)

(Day)

IQO '. (Year)

I in<:UIvHV Ci:RTn^V, That I attciKled (leoeascd from

.^v>^j^ X^. IQO H to ...WW i 190 H.

^v^ajC X^. 190 H to •■•WtH- ^

that 1 last saw h r.V-i^x alive 011 Hvv-"LLf.. I ami that death occurred, on the date state<l above, at ..U. M. The CAI'SP: OI' DICATH was as follows:

190 \

niRTMIM.ACK

OI" i-ArnF:R

(Stale or Coimtry)

MAIDKN XAMF: OF MOTHKR

lURTHPUACE OI' MOTllKR (Slate or Country)

OCCUPATION

^•^ Oxcl^

Rrsiitfit ill Sau /•"; (///< /W''

L I. "'■

'VQa.^'V.J^'^

-^

5 V(7;

Mniilh<

f\n

TMF \HOVE STATFI) PFRSC^NAI. PARTICn.ARS ARK TRFH To TMK HF.ST OF MY KNOWMCDOF: AND lUU.lF.F

.!L>v£L^C-CL\^cL.v-.Lv^

L Days

Hours

Dr R AT I ON * Years - Mouths

eONTRIHUTORY aX.jf\lvc .(^^^tt^voI

DURATION '•^. Years I Mouths \^ Pays '^ Hours

'\ddress) H b D nII tnvl-avt Llv

, Institutions,

(Signed)

a TQOS {

M.D.

^FECIAL INFORMATION onl> for Hospitals or Recent Residents, and persons d)iny awdy from liome.

Transients,

Former or Usual Residence

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

flow long at Place of Death?

Days

(Informant

(Address

i^a

A„eA.CL

ri \cH oj- iHRiAi. OR rf;m<)V\i,

ISDERTAKER

(Address

DAli: o! IUki.m. or RF:MoVAI,

^^-tH \ 1 90S ^ H ^ 'M>V^^4A..c.(m ...it

H„„.H H. ...... ...pne-. -^•-;l- -•- -?-k:, .rrrn^vr.:'."-

IN. B. Every Item of InJormntion s

state CAUSE OF DEATH in plain terms, that It may be properly «ons dylnft away from home nhouUI be ftiven In every instance.

I V

ll'

I

I

I li

hf

I

HI

H

I (

\m

'i

nyHfli

►IK-

m

WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD

,„,.,H„-.No...^^...-Co B.PER TO BACK OF CERT.P.CATE FOR ■NSTRUCT.ON.

Italc Filed, \JU, H 100^ Registered ^^o. 52

^trUUVO

AjL'

^

.A>u Deputy Health Officer

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco

Certificate of Beatb

( "CI. S. StanDarD ) PLACE OF DEATH: — County of J ^VV1X^^^^^ City of

.>aA/Ol

No.

St.; Dist.;bct. and ;^

„ ^„„„ IICIIAI RESIDENCE GIVE FACTS CALLED FOR UNDER "SPECIAL INFORMATION" \ ( " rF"DrATH"oCCU%;rD\N''rHo''s^PrAt o"r"nSt'i?u'V'o'n OIVE ITS NAME INSTEAD OF STREET AND NUMBER. )

FULL NAME

..w.^LLc

O^^VAA.. i! •)■ OlA.^-<

n--

PERSONAL AND STATISTICAL PARTICULARS

— COI.OR

•™ (IftlaL

luJLu

DATK OF HIRTH

A(".K

(Month) (J

,3* ^ )Vrti.v A

(Day)

/ill

(Vear)

M.nilhs

Pa r.v

SINC.I.K. MARKIKM. WIDOW HI) OK DIVoRfKO (Writf in »;<K-ial (Wsiv:iiiiti<)n)

TUkTMPT.ACK Slutf or Coiintry)

NAMK OJ- FATIIKR

RIRTMPI.ACK oi lATHKR (Statf or Country)

MAIDKN NAM1% OF MOTHKR

HIRTIIPI.ACK

<»F MOTHER

f State or Country)

MEDICAL CERTIFICATE OF DEATH DATE OF DEATH

X

(Day)

I90H (Year)

I HI^.RICBV CICRTIFV, That T attended deceased from

— to

190

that I last saw li ■":—" alive on

and that death occurred, on the date stated above, at .TTrr- M. The CATSK OF ])1':ATII was as follows:

tXc/5-^^-^t^^'-•^!^A^^fcoJL ...^^^

190

190

^

■X-^

c) AJu^y^^JC'^rJ^

OCCri'ATION

Rffidrtt in StJti /'t niiiisri}

)''(i I .

" M.^iitli> 0 ^'"■

TIIK ABOVE STATED PERSONAL PARTICTLARS ARE TRIE TO THE

in%sT oi" MY knowij:d<*.e and in:i,n-.F

(Informant

f Adilre'ss

TWO

DIRATK^N Years

CONTRIBUTORY

Months

Days Hours

nu R \TION Years Months Days Hours

t) . J >:M•^A.^-A-.^rvv.....LfeV•rv^JlV M.D.

A,1dress) (Lul ^i^^Cal.

(Signed)

(•A

^PEcJaL information only for Hospitals, Instituflons, Transients, or Recent Residents, and persons dying away from Ijomc.

Former or Usual Residence

Wl»en was disease contracted, If not at place of death?

How lonq at Place of Death?

Days

PLACE Oi^IURIAI. OK Kl-MOVAI. DATE of lU KiAi. or REMOVAL

T90S

1 bl u)1a^i,'^i<^.*>a..

N. B. Every Item o* information .hould be carefully «uppl.ed. AGE •^°"'^ ^* "'"* ^^^ -Special Information" for p-r-

Btate CAUSE OF DEATH In plain term*, that it may be properly classitied. The »peci«. «on« dyinft away from homo nhould be ftiven in .very instance.

m]

(

I

, (

t'!

■pi

H .

i.^

I i

WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

nlof llrMllh |-N". l^Tf'*ii

n&pco

nw^

Registered J\'*o.

Dale Filed, '^k^'^-W H

X^yv^uva Xt^vMjL Deputy Health Officer

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco

53

Certificate of Death

( Ta. S. StanDarO )

PLACE OF DEATH: — County o

No. 15.0V LLLtXAKX^-VAyO-

(ir DCATH OCCURS AWAY FROM IF DtATH OCCURRED IN A H

St.: t Dist.;bet.

as

tl

^nd d<. sj

.rfv

USUAL RESIDENCE GIVE FACTS CALLED FOR UNDER "SPECIAL INFORMATION" "S OSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. J

FULL NAME

dL-trvvA^ U).L<Xoa,c4^^JtA!^

PERSONAL AND STATISTICAL PARTICULARS

si-;x

DATK OF lUKTU

3J.

COI/)R

U)Jv^

( Month)

II (Day)

(Year)

AC.K

.bl.

) 'ea / i

Months

3.1

Da vs

SIN'r;i.K, MARKTKn. \\II)()\V1\I) OR DIVOKC'KD (Wiitf in social di-siKHation)

lURTHPT.ACK

(Statf or Country)

NAMK OF FAT11HR

RIRTHn.AOF,

Ol- lATIlKR

f Statr or Country)

v'Xl\>4A) ^O^.uxA^/Ukjixii

V^X^^^WOwXXO.

MAIDKN NAMK <)!• .MOTHKR

Vl iLoN^o^

(^

su

J (O^wIa

niKTnpi..\CK

oi MOTHHK 'Statt* or I'ountry)

occrr.vTiON

c^i-

C 3 ^^.V^A A \^o^)

K'rsidrd In S,ni /'i itii, /•■r'n I J ),(ii.<

1A"////>

n,r 1,

TMK AnoVKST\Tl-,I) I'KRSONAM'AKTUT I, A RS ARi: TRIK TO THH HKST OF MY KN0\VI,F;I)C.K AND nFtl.IKF

'Informant

( \<l<lrrss

MEDICAL CERTIFICATE OF DEATH

DATK OF" DKATH (\ -^

^r Month )(]

.%

(Day)

(Year) I III':R1:HV JI^RTIFV, That I atteiKkMl (leccased from

igoH that I last saw h <W*^ alive on yVAAA.^ :^ 190 4 aii.l that death occurred, on the date stated above, at t- ■^0 (j M. The CAUSE OF DIvATII was as follows:

L/u^>:^A,I^,,^r^r^

•^'A-A.^CL..

DURATION "" )'ears CONTRIHUTORY

Month

s " Days Hours

Hours

DURATION Years Months Pays

^axAJr La ')iA/A-v>vt M.D.

Ic^-' Incfifiidnnc Trsnc^ailic

(Signed)

:^ i<)oS (Address)

FECIAL INFORMATION only for HospltalsVlnsfitutlons, Transir or'Recent Residents, and persons dying away from home.

Former or Isual Residence

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

How long af

Place of Death? Days

n acf: of iuriai. or ri-.movai.

,5-V^

DA'l'F^of lU KiAi, or RF:M0V.\I,

5r 1904

UNDKRTAKKR

(.Address...

N. B.-Bver. Iten, of Information «houU. be c„refu,Uv supplied. AGF. should be stated EXACTLY .^^^"^^^J^^J^^^^^. V^pr'r' stnte CAUSE OF DEATH in plain terms, that it may be properly classified. The Special Information tor pT sons dylnft away from home should be ftlven In every instance.

I ■

. in

m

I

f

s\

\ .

"/

I

WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD

„ „, „.,„„ ,.• so . ^-tl^..^ ■■<-■» REFER TO BAC^ OP CERTTICATE FOR INSTRUCTIONS

54

ii".it

100"^

Ue^istered J^o,

I )((!(' Filed, V^^/h '^

X^H^vuN doi/vM.u Deputy Health Oflflcer

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco

Certificate of S)eatb

( Ta. S. StanOarO ) inty of UJLoL/^v>"UU^xx> City of

\jK^yy\J<\j\j^^

^No.

St.; Dist.;bct. and

• •eiiAi or einPNCr r IWF FACTS CALLED FOR UNDER "SPECIAL INFORMATION" \ ( '^ rF"DrAT°H"o^CU%r;."rH "s^PrT^t o%":St'iTu"o^n"oi;eTt1 name instead of STREET AND NUMBER. )

FULL NAME

si;\

PERSONAL AND STATISTICAL PARTICULARS

COI.OR,

DATK ni* lURTII

LUv'vJ-

I Month)

lOiwbL

(Day)

(Year)

KV,V.

Oo )Vi/>> ov

Mouths

10

Pa vs

SINCLK. MARKIi:n.

W IDOW HI) OR DIVORlHI)

.(XK'^JJl/j^ -

MEDICAL CERTIFICATE OF DEATH DATE OI" DHATH

X

(Day)

(Year)

I n|.;RI<:BY ClvRTlFY, That I attended deceased from

190 to 190 '-■ '

tliat I last saw h ^^r— alive on '9°

P.IK rupi.ACK (Slatf or Codiitry^

NAMH OF IATm:R

RTRTnn.ArK

OI* l-ArHKK (State or Country)

MATDKX XAMK oi- MOTIIKR

lURTHPT.ACK OF MOTHKK ISlalf \n Country)

.c-o^uLcvvoL

a

A-

VvMP^v

."vv

(

OCCUPATION

Re.iifi'd ill Sill! I'tdihi^rn

)'i(t I .

.y ;,'>///,'

— /?,/i.

Tin-. AHOVKSTATl-.I) l•KR'^0^•A^ »' A RllCr l.A RS AR !•; fRTH TO TMH HKST OK MY KNO\VM;d<".H AND lUllJlCl"

(Informant

■^ ^' ^i^^t^tp^^t

■A.Mre.s UL^'AX.VWv>V4X W.'

and that death occurred, on the date stated above, at - M The CArSl*: Ol' DIvATH was as follows:

DTK AT ION )'t'ars CONTRIIU'TORY

Mofitfis

Days

Hours

duration (Signed)

Years

Mont /is

Days

W) T ^^.vyAvOrsj

HVV?» T.)oH (.Address) tt>\U\^vV^t ^Cyl 'T • __.. _ ^1 ^^m.m nnli' {/\r MAcnU^lr I ncf if III Iaiic Trsncta

/Jours M.D.

SPECIAL Information only *<>•■ Hospitals, institutions, Transients, or Recent Residents, dnd persons dying awdy Irom home.

Former or Usual Residence

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

HoH long at Place of Death ?

Days

I'l^ACK 01-- lURIAI. OR K1:MoVAI

DATi; of^HiKiAi. or RKMOV.\I,

.^v%fVM. 'S' T904

tNDKRTAKHR

(.■Xddrcss

%' y oa^k'v'^'^^vc

II

3.nCy>v

VAA^i^rv\

IN. B.-

E OF DEATH In plain tern... thnt It n.n> be properl, clo.»med. The Spici.l In.ormntion lor p

-Every Item

state CAUS

son* dyinft awBy from home shoiiltl be ftiven in •very instance.

it

IM

.1:

I

WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD

^_, ., „,,,„-. NO. .. .^.u^.Co RCPER TO BACK OP CERT.F.CATE FOR INSTRUCTIONS

190H

Registered J\^o.

Date Filed y

Xjr\j^^ osX^\j-\y Deputy Health Officer

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

Cevtificate of Beatb

( Tfl. S. StanDarD )

A ^ J? C^

PLACE OF DEATH: — County of (^] CC-^ ^ AXV^v^^^^City of CJo.^ JA.aA^xevA.^M)

55

'No.

'xiXA^A^^

CHi-Wvva.i

St4 — :"■" Dist; bet. - ' and

-^

/ ,F nr*TH OCCURS *»i*V FROM USUAL RESIDENCE GIVE FACTS CALLED FOR UNDER •"SPECIAL INFORMATION" \ ( Tf DEATH OCcJrrIo IN A HOSrVtAL OR INSTITUTION GIVE ITS NAME INSTEAD OP STREET AND NUMBER. J

FULL NAME .LJvuav AjLwL/\\jri^ ^.LvvJLL

/WXl-

SKX

PERSONAL AND STATISTICAL PARTICULARS

I COI.OR

DATl-: <)l- lilRTH

(Motitli)

0.%

(Day)

/ M.a

(Year)

.\(*.R

J 'i-a I .<

M

Moufhs

5

Da vs

SINCI.K. MARRIKI).

\vn)(>wi<;i) OR DivoRn.i)

iWritfiti social (lisid^ nation)

niKTnri,.-\CK

iStatf or Coutitry^

^]TI<wvv^cC

a

f\,^^^o^

NAMH OF FATin:R

WrWw dsA/OL^

BTRTHPT.ACE OF FATIIKR iStnlf or Country)

^^O^

MAinKN NAMK OF MOTHKR

HIRTHPT.ACK OF MOTHKK (Stati- or Country)

^\^. if

^jul

hL<!Uj-V\xX'

IVCWOW

OCCUPATION

AVsidt'd nt S(i)i /'i ,iih iri'

) 'nt I

U.. ;////>

/>.n

THF. \HOVH SrATF:i> T'KR^ONAl. FAR IKTI.ARS A R 1-. TRl K To TMH

iu-:sT OF MY kno\vi,f;i)<*,k AM) in:i.n;i-

(Infojnuint

(Address

MEDICAL CERTIFICATE OF DEATH DATE OF DKATH

(Mont

(Day)

(Year)

I HRRIvBY CI^RTIFV, That I attciidcfl deceased from

h-VV X^\ 190 H to . jkN^vy X 190 S

(l/ ii /i

that 1 last saw h .^^>Aalive on NLvsA^.. <^ 190 H

V (] Q

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

Cll M. The CAI'SP: OF DlvATII was as follows:

U^VA-L■'0-A.^'vL{rv-W1:^.■(^^;v.s.c::^.v.

1)1' RATION

Days

w. .X.. ..w., Vt'irrs b Months

CONTR I HUTOR Y \JJ^S,r\.^^^^^rr\...'o.^'>iy\^^^

Hours

DURATION ^ Years "" J/o>///is ^ Days (SIGNED) V ^A. "tIJLC

^ ic)0^ (.Xddress) 9 0 Cl Vl ^^^<

I /ours M.D.

PECIAL Information only for Hospitals, institutions. Transients, orUecent Residents, and persons d\ing dv^ay from home.

Former or Usual Residence

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

-^ V \) ^ -^ How long at t ,

CjL^^RUnv err Place of Deatli? 1

> Wfr.^ Days

FLACK OF HFRIAI. OR RF:MoV.\I. FNnKRTAKKR

I)ATF:of niKiAi. or RKMOVAI.

H. 190H

(Address "Li!).' 'n..tVtA^>vv4^>.v^ .1

£

^\

-f

^ .. It I *npf oV,r..ii<i Ka stHteil EXACTLY. PHYSICIANS should

ai in?orm«tlon .hould be cnrefully supplied. AC.F. should »l« «*"'*^ ^'"".r^ ' "^^^^^ Information" for p-r- E OF DEATH in phiin terms, that it mny be properly class.Hcd. The Special intormation tor p«r

IN. B.— ^Bvery item

state CAUSE

son* dyinft away from home should be Jliven in every instance.

i

M

1 1

I If

u

I

^

I',<i;i!'l "f '

])((fr Filed,

WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

56

lealth-K No .^ l^^-Wi^^ H& P Co

H

100^

Registered J^o,

.^vy^-A^/LVO cijLA>'U

Deputy Health Officer

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco

Ceitificate of Beatb

( "CI. S. StanDarD ) . . v^,wv^..w.^ SU 3) Dist.;bct. '^^^^ and H pk

• ■<>iiAi DC-einrNr r r lur FACTS CALLED FOR UNDER "SPECIAL INFORMATION" | ( '^ .V*DrAT°H"o^CU%rD\"rHo"s^PrTAt o"r ?NSX^^U^4^n"c.;e7t1 name instead O. STREET AND NUMBER. )

PLACE OF DEATH : — County

No. SH^ 0 xi VCV^V^xOj

FULL NAME

E UkuLcl (^ J

t

PERSONAL AND STATISTICAL PARTICULARS

0 jL^na cuUL

DATF. or III KIM

COI/)R

lUJvctc

(Day) (V«'ar)

AC.K

) (1/ ; ^

M,>ntlis

Pa V.

SINC.l.K. MAKKIHI).

WIUOUKI) OR DIVORil-:!) -

'Write in social <lt>.i>.rii:>ti<)ii) I'

L

UIKTin'I.AOK (Statf or Comilry^

NAMK OK FAIHKK

lUKTITPI.ArK «M" I AIMIKK istatf or I'ountry)

MAIDKN NAMK Ol- MOTHKR

lURTHPLACR Ol" MOTHKR (State or Country)

.1

^

QUvJv

o^-s^^^^^.jsjy\,iy^

\JX^ojyy^

J? (^

OCCUPATION

Rrsidrif In Sa» /'i aiK /sro

)'i(!l ^

\/,.,>f//y

n,i\.

TFIl". AIIOVK STA'ri:i) I'KR^ONAI, PARTUTI.ARS ARK TRfK TO Till-: HKST 01«* MY KNO\VI,i:i)C.K AND invMi:F

'4

(I

^\<l(lrt>ss .

VOw^v-v"<-0-

MEDICAL CERTIFICATE OF DEATH

DATK Ol- DKATH

(Month)

3

(Day)

190'i

(Year)

I. HKKKHY CIvRTIFY, That I aUeiuUMl dccoased from

3 190 S to ..^\(^^sL^ .^. IgoS

that I last saw h - ali%-c on ^' AAA-V yj^TV/W 190

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

M The CAUSn Ol' HIvATlI was as follows:

(l.>U^5rL^r>A..aX<i^ ■,V<xl*-*r>J

vj v^-LcUi

DIRATION Years

.1 -C'»^>

Mouths

CONTR IHUTORY oXlLs. JJj. ^\^^

Days Hours

duration (Signed)

3 190M

^

) 'ca rs Mo nths Days

Address) ail- Ttfv it

Hours M.D.

(

SPECIAL INFORMATION only for Hospitals, Institutions, Transients, or Recent Residents, and persons dying away from tiome.

Former or N«^ '•>"<! af

Usual Residence Place of Death? Days

Wlien was disease contracted,

if not at place of deatfj ?

DA 11:0! Ill KiAl, or KlvMOVAI,

^ 190 s

PI.ACK Ol- lURIAI. OR KKMOVAI.

ITNDICRTAKKR VtTLvtX<A. V^\V<:L^A.t<0(<JL^

(Address..

N. B.— F.ve.y item of liWon.naf.on .hou.c. be c«rc.'u.,y suppi.e... AGE should »>-i«*'^^f .i^^^^^^.^^', ,rrj,Tot» Vr'^:!." state CAUSE OF DEATH In plain term., that it may be properly classified. The Special Information »or p.r sons dyinft away from home should be ftiven in every Instance.

I

"II

'i

■tvv

i

m

P

%

WRITE PLAINLY WITH UNFADING INK —

„,„.l of H.-alth- I' No. ..-»-gEg^n&l'Co

Dfffp Filed ,

H

100^

THIS IS A PERMANENT RECORD

REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS

Registered •A^o.

\^ cUyVKU Deputy Heallh Officer

DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco

PLACE OF DE ATH : — County

Certificate of S)eatb

( xa. S^tan^arD ) of 5<xmt(V IXoA^ City of 3 <X.>^ %r^

VOuL'

Wo/

St.;—-— Dist.;bct.

and

( " r,"JcU=i^e"„%;ro\'."r-o".^r.t o%^f^?/,?>:^<^";r,;i ?.*«c r.c-rs? s;%%^Ti.';;°::=';r ■ )

FULL NAME

sj:x

PERSONAL AND STATISTICAL PARTICULARS

COI.OR

LvJ^aAX

DATK Of' HIRTH

7

?

(Day)

, Il3£>

(Year)

ACH

IS

) V(i ; 5

MoHlllS

Dii vs

SIVC.I,K. MARKlKn. WIDoWKI) OK DIVORfKO

(WriU ill Mxiiil ih-vij.Miatiou)

lUKTMl'LACK (State or Co\intry^

NAMK OF

iatiii:r

nTRTlTPT.ArK <)l FATIIKR (State or Country)

MAIDKN NAMK nl MOTHKR

lURTHPUACK (»»•■ MOTHKK (Slatr <)r Country)

yy^mA,

r ^

MEDICAL CERTIFICATE OF DEATH

DATK OK DKATH

(Month)

3.C..

(Day)

(Year)

I HIvUlUlV Cl'RTIFV, Tliitt I attended «leooasc(l from

— . to

that I last saw h

190 — - alive