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LOCALITY OF
RECORD S
SAN FRANCISCO COUNTY
S AN FRANCISCO CALIFORNIA
HEALTH DEPT
M I CROP I LMED
FOR
THE GENEALOGICAL SOCIETY
OF SALT LAKE C A L I FORM I A
C I TY
UTAH
j^
DATE
APRIL
1
1975
PH OTOGRAP HER
CAMERA
NO ^'=;
MAX JOHNSON
RED J
I
RECORD
CERTIFICATES
VOLUME 2031
Y EAR
1904
)U
» I
♦ ..
X
'•)-.*Aj:v>^v'-,
P^i
EGIN
4 I
I
f
• •
I
..^•••••'
.^. » " • "
^ FEB8 i«0>^ ^
i»l.^f..waA. pew*' -•-•'*'•
fl/ P.
iiber H'
El)M()NI)(i()l)(^!lArX,
) I, OUDtrt
By-"
DEPury.
I
i
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
.,1 II^;.!lh I- N.^. !. •ft.'^^^^tr 155:1' Co
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
Dale Filed ,
hj \
100\
Be mistered J\^o,
3a3i
1
vcoo
Deputy Health Officer
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
No. IHS
Certificate of IDeatb
{ *a. S. 5tan^ar^ ) PLACE OF DEATH: — County ofO/CLY^ J-^^O, ixo.^ci Qty ofCj-O-AT^ 0/vxx.-\-^C.^<i. Cc
/ ir DtATH OCCURS ^WAV FROM USUAL R E S I D E N C E G I V E FACTS CAILED F V IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NA_M E I
FULL NAME
St.; ^ Dist.; bet. G A^^ vcJ l.Ui and ' I
-OR UNDER "SPECII^L INFORMATION ■ \ NSTEAD OF STREET iAND NUMBER. /
^ n } u
A
li A I ], ^ U lilK III
PERSONAL AND STATISTICAL PARTICULARS
Cf^
U. mil
11
(D.'iv^
/?
A' . I-
/',M
•^iM ,!,i- M \u\< n:i>
u'l In t\\ ]■ I » » iK It ;\< ii-T i: t)
iiiK rnri. st^-"
(Stat. I.; '■ .mill
A 111 Ik y I
p.iK I'll I'l.ArK <»i I \ rin-k
a. , "
\a
M MI»KN N \M 1 m- Moilll-.K -^
cLttrwcfuX'
JUX
Jn
Jus-A.
I'.iR iiiri, \t*i: t>i %T<»riii.K
-•• 1 1 .11 t". Ill Hi I \'
I M I I TA 1 ION .
(v..
^'
);-,i
Ar,,,'//'
/hi
Tin: M'.n\ I' ^ r ATi:n fi-KsoN m, rxKriiti, \ks ah )•; tkik m rm- in%sTi>i 'IN KN<iui,!,i)",i'; AM) i;i'i,n,i-
MEDICAL CERTIFICATE OF DEATH
DA Tl.; nl- DMA'CH J)
U-t^UZt. 1^ /Qn\
(Mofithi 'I>;iv) (N"f,ii)
1 HlvRIUJV CIvRTll'V, That I alk-iuU-.l .U-iH-ascd from CLl^q iS iqo , to a-dAl XH upH
4 f
> I ' f
Up
tlial I last saw li '. - alive on
and that dt-ath orciirrcMl, on tlicdalA- --t.iti'il alnivi', a
M. Tlu- C.VrSi: <)1- I)i;.\TII was as folh.ws:
Dik \ rioN
) 1 </; >
CoNTkllU'lN >RN"
Mouths
Diivs Hours
S ...i^'_'^ I
3-1^
»...,., }'(t/rs Qt Jf(>>///is
NED)C,3). ^^^xtU^ ,o l f AiMrc-ss) Ss'X'ivJ
1)1 RAT ION fSlG
/hivs
Hours M.D.
0^'.A>-»i^U.; ^t
Special information «nlv for Hospitals, Institutions, Transients, or Re»ent Residents, and persons dsinq awdy from home.
Former or Usual Residence
Wlien was disease contracted, If not at place of death ?
HoH long at Place of DeatI) ?
Oa\s
'i,Aci': oi- nrKiAi. or kkmdvai
DATK (.1 Hi I'i \i .)! KKMOVAl,
I N I ) J : K T A K !•; K VJ ^\XX>\} ^U. LL A '. ^
T90'*
IN. B. Hvery Item of inf.,rm,tion should b.- cnfcfully Hupp!'. mI. AHr. hHouIcI be stated HWCTLY. PHYSICIANS Hhould
Htate CAlJSli OF DLA TH In plain tcrmn, that It may be properly classified. The "Sputial Information" for p«P- «nns dyinft away from home should be d;iven in every Instance.
WRITE PLAINLY WITH UNFADING INK
;|. :,Mh
^i, l!^;:!' Co
THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
Dufr' Fi/rfi, y^tc^v I
IfWi
Bniisfered J\^o.
203^
o'i
V^ Deputy Health Officer
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
N
Certificate of IDeath
( 11. 5. StanDarD ) PLACE OF DEATH: — County ofHo.^ si JU>jy\/:AA.C^ City of H Om; ^ KOjYs^^^l o Ul5 LlaA.1 St.; X Dist.;bet. ^ I tO-^tr^ and ^ <X^^
/ .F DtATH 0CCURS AWAY FROM USUAL RESIDENCE GIVE FACTS CALLED FOR UNDER "SPECIAL INFORMATION" \ (^ V IF DEAtJh occurred in a hospital OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / J
FULL NAME
lid
a^
PERSONAL AND STATISTICAL PARTICULARS
- I , X
(.<
UA 1 1-: < M lUKTIl A ^
\ < }•:
bl
M.uit
)
Davi
0s. M.,>i!li^ C\. J^
/>,!'.
U i ! M i\\ 11 1 t >R 1 'IX'i )Ri- 1 I)
\\i !!( i ti *' irial lit -i^'li.il ion)
^!.,i.. I li I '• 111 nt! \
1 A 111 l.R
luk rHi'iAiK ni- I \iiii:r
^ t I t ■ • •'. t " \ ! 1 1 t * ■>
M \iiu;n n ami; ()]■ .Mt»riii;K
lUR rmM.AC!-: (ii M(rriii''.R
i ^ia!i , u (.'ounlry
d
e 1 In
Aw VCU J -t\AXV)
y^^
/\'r:-;-ff'' •" Sil>r /
11 H-. AH')\'l", STA TI-: D PKR-^nXAI. I'A R Tl i " r 1 . A R S AR l*. I" K T l-l T* »
iu>riii MN' RNnwi.i.Dt'. J-; ANi> i'.i;i,ii;i
III 1-;
!liifiii inaist
lis [AjXxl 6fc
^V>Xs
X'l.h I'-s
MEDICAL CERTIFICATE OF DEATH
DATK Ol- Dl.ATH I'
(M.mtli)
(Dav)
I go
(Vt-ar)
I III'IRIU'.V C 1:RTI1'\', riial^I attoiukMl (Ucrascd fnun
axkfc
Q
1 1 1 '^ , 1 nai 1 aiU'iuuMi ii
that T la'^t ^a\v h
190 alive <Mi
JJLi ..\j
it)0 H
in<l that diath iHHurred, on t he ilatt. ^ta!t.<l almxr. at llob
AISI-; ORDi: A
^ • M. Thr CAISI'! OU, DI.A III \vt- a- tuUows:
K^^VX^fr^ VCLA V 1
Dl'R ATION \ Years ^ Mouths CONTkllU'TORV
Day
Hon
/ s
DTK AT ION (SIGNED)
^
)'t'ars ^ J/oi///is /^avs Hours
*^K. d^i M.D.
Special Information «nl> for Hospitals, Institufions, Transients, or Recent Residents, and persons d^ini a^dv from home.
Former or Usual Residence
Wlien was disease fontrarted. If not at plareof deatfi ?
How lonq at Place of Deatti ?
Ddvs
l'I,ACI'; 01* lURlM, <)R K!.Mii\\I,
m €.Lv>^t
>\rU.'i; I'a HiAi, <M Rl'MOXM,
I NDI R lAK i;K
(Address
W^lX I TQO'
IS. B. F.very item of infopmiition should bsr carefully supplied. AGB should ha stnted RX4CTLY. PHYSICIAiNS should
state CAUSI: Ol' DLATH in plain terms, thnt it may be properly clussified. The "Special Information" for p«ir- Rons dyin^ owny from home should he given in every instance.
'?SjS
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
'111 1 Vo :^ ti-'^>S.i: lUtP C,
l)((h' nfefl.MizkA.-
n)(r
JRo^istcred .A^o.
0
L
Deputy Health Officer
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of IDeatb
( 11. S. StanDarD )
PLACE OF DEATH: — County of
\
%
CXJ.
City of
e^\)
OJ
No.
St.;
Dist.; bet.
and
/ IF nrATH OCCURS AWAV FROM USUAL R E S I D E N C E G I V r FACTS CALLED FOR UNDER SPEC i IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREE
F + n '^
lAL INFORMATION" ^ T AND NUMBER. /
FULL NAME
SKX
PERSONAL AND STATISTICAL PARTICULARS
I'l il,i >K
\)\oL
\
DAI'i: I >1- iilKI'll
\< .!•:
I7i<
1%
!l)av)
)■(■(;» t
^
M'liHi
X
/
VI
ar
I hi 1
>^I\< 1 I' MA K K II- n
wi I )i iw i- n ( iK I) :\'( )i',t' 1' I)
^ S\'i it: 1 n -SK i.il '1< -li' naliiiil'
luK rm'i. \oi-'.
>t:ili ii! I "i iiml ! \
NAM J <M } \in IK
TUK riiri, \t'i-: oi I' \ rii I'k
\! XIDIN XAMJ-:
(•1 MornHR
lUR rniM.An-;
(Ii Mu'nil'.K
(UHT I'A liOX
<f\^^'XKOj
A'
V,;;,' /■; ii Ihf.u'd
IV (II 5
yr,>iif//s
ih.
Tin- M'.ox'i'. STA'i'i':n i'I'-r^onai, r NKfirn.AKs ar}-: ikri-: in;s 1' ni- Mv K.N'< •\vi,i;i)(',i<: and in;i,!i:K
i"< I I'll 1'
f liifDinirmt
^ (5? (1
'YY^^XLK.^xXj
fA(1.1rf«<«4
J AJtn^^A.^'W WO-X
MEDICAL CERTIFICATE OF DEATH
I) ATI', (M- Dl'ATH J?
Ox^aI:' 'h^ I go'
(Moirth) 'I)av> (V<-:ir)
I IIERlUiV Cl'iRTlF'V, Tlial I aU(.'iiiK<l 'lt.Hias(«l from
— — — ————up -to — ""190 "
that I last saw h - — alive nti — — —— up
and that ikalh ncnirred, on tlie <lati- stated almvr, at M. Tlu- CAISI'Ol" DI'.ATll was a^ follows:
IH" RAT ION }V,/;s-
CONTRIIU'TORV
I )r RATION ^ Ytars
Montin
na\
Hours
.^fonths
Pav
(SIGNED)
'\
f-f
/t.
.i
«i^
Hours M.D.
19.
oH (
Address) OXAnA?vO--^^ \jOM
Special INFORVIATION f>nly for Hospitals, Institutions, Transients, or Recent Residents, and persons dyini| away from home.
Former or Usual Residence
Wlien was disease contracted, If not at place of deafli ?
flow lonq at Place of Death
Oavs
lil.ACH (»1' lUKIAI, OK KI'.MoVAI
in "
DAXI". of I'.IHIA
I, 01 K1-:N!( i\ A1
rSDKKTAKl-K Uk/O^ V US An^Ui-y^^^ .
T90H
(Addresf
rS. B. Rvery item of mformntion should be cnre?ully supplied. AGB should be stated KX4CTLY. PHYSICIANS should
state CAUSE OF DEATH in plHin terms, that it may be properly classified. The "Special Information" for per- sons dyin£ away from home should be ftiven In every instance.
WRITE PLAINLY WITH UNFADING INK —
;ii-. I
No :- t'-r^arS^: liS: 1' I
IXile Filed , U^Clt^r^MJ
K^ \
10 a
THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
2034
Broi,sfef'cd J\^o.
DEPART
puty Health Officer
DEATH: — County of^^a
Lie HEALTH=City and County of San Francisco
Certificate of IDeatb
( 11. 5. StanDarC> )
'Tu ' J V
City of U CX>^ J,\.CL vxxn.
No. ^ ^ X^-^
4-
St.;
Dist.; bet.
and
FULL NAME
.kXxxaJs
\JLcL
v^roKcet
■rt
4
■ 1. X
PERSONAL AND STATISTICAL PARTICULARS
fl.
i»A 11. «>i ink ill
\ " . !•;
! 1
Muiithi
D.iv)
5 ■--.,■
n
14
an
Jh!\
<!\<,1 }■' MAR ]<!)■'. I)
W\ \n >\\Ki» < >K I) ;\i i!--! i; I)
I W- il! in ■•- ' U -iL- iiatmn )
Hli
■St.
,^
1
L
MEDICAL CERTIFICATE OF DEATH
DATK <»i Dl.A'lH 0
(Moiitli)
(Vcar)
. Day!
I Ill':Ri:iiV CI'.RTII'^V, Thiit r altt. ii-U-il .krr.i^cil fniiii
190 to — — — jfp
that T last saw h — alive on icp ^
and that (k-atll iHHurreil, dii the date -taU-.l ahove. a*; - ~^~ M. The CATSI-; OI' DI-.A'PIl wi- .i- follows:
^jj^^,.^^
N V \I 1 < 1! I A!'1!1;k
I'.iKfii I'l, An-:
()!•■ 1 Alili: K ' Stat I- 'ir I'tiluitlN
MMDKN NAMl Ol" MuTIUtR
UTR'niPLAeK
i>I NKiTlll'lK I Slati ..I t'oiuUl
hCLc^r
lo, a.^L
r
^
.\f,i,ll/lS
Ptn.
Tin" \!'a>vi*. sr\'n:i> phrsonai, i-akiutlaks ar>-: TRii': r< > rm
Hl-.sr ni- MV KNoWl.l I)!',)-; AND lUCUllCF
(It
Adilrfs*
%
H^^ IX ibcrWv><vN^ dt
i
^l.v.OyVU.. ■. -
DT RAT ION )V<//-.s- Moiiihs
CONTR lI'd'ToRV
Pay
//.
'//; \
DTRATION
)V«;-
Pars
(SIGNED ).L^&A\-^V . /xJb LO- iiJUx>XcL noU-h'V^ j^oH (Ad.lress) Wurv\.iA,^ ^. ^ >
M.D.
cuycfc ^0
SPECIAL INFORMATION only fur Hospitals, InslittMi^iis, Transients, or Recent Residents, and persons dvinj anav from home.
Former or nn r 'i F, ' Hov» lonq at , »
Usual Residence M^5 la Jt'&AA.vaK ' piare of Death? C <^ (\.:.. D»vs
When was disease contracted. If not at place of death?
PI.ACK Ol" HTRIAI. OK Rl'.MdVAl,
I)A'n:..t" Hrui.xi. <»r RHMOVAI, U'tLfc 3^ 190H
(Address IQl'?^ "^i C^Ldjl^^ D^Ojtx LLv^.
IS. B. Rvery Item of information should he cnrefully supplied. AGE should be stated EXACTLY. PHYSICIANS should
state CAUSE OF DEATH In plain terms, that It may be properly classified. The "Special Information" for p«r- nf>ns dyinft away from home should be £iven In every instance.
|s)RM 31
^n
ss.
m
m
1-4
M
15 O
I M
K H
Sq O
za
o
I— I
Eh O
H OQ
o o
>
lU CO
o:
STATE OF CALIFORNIA Local Registered No. .<'.yv.^.
3D(^p^rtlnetlt of ^lublic Henltfi
VITAL STATISTICS
Af flDAVITS rOR CORRECTION Or A RECORD
City or Town of.
W^»
.. of.
^ r-
ll'V
22 ' ' -thj^ ^en
(Name of Affiant) Calituriiia, bein^ tirst duly sworn, deposes and says that she is
-^ *-
J-
A.l.:rt.i<i
Coiint\ ot
Julius ...Fxad Brockwoldt " [X^f^l '"
(If relate 1. spi ■ • • It. r-— 'f frynd or gUipr>vIs<'. so &['i^ql^
the City I'i
on the.
. .V*j*.
;iN stated in a rertifieate of
wi
th flu I.ucaj Kegi-tiar loi the City of .
. f September 19 04
day or a ^^
I filed In- Porter . anjd :l;i..t.:.
/ death ) ■ (Givu name of I'hysitian or Midwife for Birth — Undertaker for Death*)
County of ■ ■ " N FF A N.GlHCiX California
r-irtifl^j
19.
04
on the ^.s. w day of
That the following tarts set forth in said certihratc are not correctly stated therein, to wit;
Pull name of decadent
w,.
:f father
li, • ;,tHai>' upon her own knowledge ^tate^ the true facts to be, and the changes necessary to make the record correct
T^nHl name of decedent- Julius .Fr^HiBockwoMt
Name of father- Jacob H. Eocfewoidt __
are. as follows;
T
y u
h.
U.
O
( Affiant) ^^
( Address)^.C.4:...lr.¥ InjL?: ..S t
Subscribed and sworn to before me t\ih...^..y^^^ day of
»-• I
u
SiAir or C M.n oRS! \ CfMintv of
N.it.nv Public in and for the Coun^4flf.*^....ft ..'..>....SS%* <Wjalifornu
^ZZao
( .Name of Alll.iiii )
he
s Aiiait.'.-
Calif.. rnla. being first duly sworn, depos.s and says_that^ has kriowledgey,^ the facts hereinbefore alleged and that the said tacts as stated therein are true.
(AlTiant)
(Addres|). ^.x2. C^G Subscribed and swuii, to before me this.v^.../. day of^^^
I , . ^ ...l- , 1 93 j[;^,,rv Public in and for the County of Sr^te of California
•F.,r ,,,11,. tin,; ,,i ;i inuiia^f rntincsifp. in raic lii'itnnrrs where n.-.',.^<ai y, llic word ■justiri-," It... miy i... i,n..; J spclully t'.v way of suhstitullon througlmut this blank.
•were married." "marriage," and "minister." "priest." "judge" or
! : I:
Two
INSTRUCTIONS
iTr
inncipal artida\ir
.( ,; H'
<H1J\- Ji
niii a,
wi^ write plainly u,;,.- black ink.'^'' '''" '"' '''' ^'''"'^ '■■-'■'" M.nat
1^ ith
•*• N'o clmnu'. can .e made in a cert,T,,„. ,
maU changes that will l.-avc In,,,,,, ..,,, /^' ^; '"'"'-'•''■ ''"■ ■'■"c • > :^ :r. ■ ,K, :,, ,,,
' ]( rU ■ ■ , in,., ,n the ccrtilicat,. '
' ■ It the onjrinal certfficite to be
• '-al Reg.trar. on the <;„h of each month '■"^■""""'- ' 'n«inal cer.i.ica,,- .
ppr
ilea:-
Othe-
f'j acre-
.I'd \vi:; affidavit "rwardcc
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
REFEH TO BACK OF CERTIFICATE FOR INSTRUCTIONS
/)((
tv F}h'il}ui&A>\Kj
U)0\
Fie^htcred >N*o,
'^\^*.
i /
Ow^VA^-
Deputy Health Officer
DEPARTMENT OF PUBLIC HEALTlI=City and County of San Francisco
PLACE OF DEATH:
n
No. I'XSc.
Certificate of Beatb
( 11. S. Stan^al•^ ) County ofCjCO^Yx; J /vcL-^^-e.^.^t^City of '^ -^^^"^ -J Axx^-^cv.^c^
St.; 3. Dist.; bet. ^ J^sA^ and A.<XX.Ka_,-> ^ )
/ IF DEATH OCCURS AWAY FROM USUAL R E S I D E N C E G I V E FACTS CALLED FOR U Ad E R "SPECIAL I N FO R M AT I O N ' ' \ V. IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIWE ITS NAME INSTEA* OF STREET AND NUMBER. J
FULL NAME >0^^^J^
H C
PERSONAL AND STATISTICAL PARTICULARS
■IS A (.Ol.OR
I
j:x)
^l,+
- TV<_^^,
n \ ii: < »i I'.iK Til
f^
M..nth>
\i
n
I>av
Moilln
M%
'X'^:
\ car
/>,
-. I \ ( 1 1 • M \ !< !< ! K I )
\\ \ I M I A I-. I » < iK 1 >;\i III ! I)
I Wi !!( Ill >-. H 1.1 1 (li -11' !ial ii in )
luimiri, \cv.
Slatt lit i". iiint I %
I \ rii ! K
• ii I \ rmtk
^' • ' • I It It ,11 nt ! \
M \ ini: N X AMI-:
isiH'cuiM, \rj-: (If. M(.rni:K
I vta'' ' il i'l iitilll \' I
J AxLcrvAj- MIxut
1
(1 \
1/
)i'C !
MEDICAL CERTIFICATE OF DEATH
uAi'i-; « u Di: Ai'n
axivt
igo \
Mental' I Day) (Year)
m-Rl'lJV tl.RTIl'V, That I atteii«U-.l .KcrMsc.l fn.m
tli.-it I last saw h-iA; alive on C'_L.^^xt: ^\ n>o
and th.it death tKH'urrcd, dii the datt.' stated ahove, at J iX M. The CAI'SIv (>!• DI.ATU was ■a< foll-.wsj
C O N T k 1 1 U "1" « • k \' O/CU A \.CXVv-VA^ cLsJtt. J <>t \
Dik A'l'ION ^ Yt-ars CONTkllU'TokV
i()0 r.Xddre^s) 13^^ uLl
Mini I /is , /^h\:jl Iloh
I Xk AT I ON' )'rv?;,v Months IH />./rA //iv/; n
(Signed) ^X A. rC.u ^^0 .. j.\ ' M.D.
Special information only for Hospitals, Insfifufions, Transients, or Recent Residents, and persons dying away fron home.
A'C df'' III V,i;, /■
M. nil,
I I.! S
rm: \novH st \tki) pkkson m. par i iiilaks ark Tkii; to tiik
lU.S'!' nl MV KN«»\\I,J in ,}•, \N!) P.l" IJI'.F
(^
f Fn f >• inaiit
'^wAa.x:^
r
.s 1^5^
^iU.^^^v <jt
Former or Usual Residence
When was disease fontrarted, If not at place of deatti ?
How lonq at Place of Deatli ?
Days
DATi; o! P.iRiAf, c)i Rj;Mi)VAI.
i;i,ACK OI" lURIAr, f)k kp:m<)\a!,
r M ) p; K i- A K V. k MX/V>vX^ i ll O-C^^-vX; ^v K,K
N. B. Every Item of inJofmntlm should b.- cnrcfully ftupplied. AGE fifiould be stated EXACTLY. PHYSICIANS should
state CAUSE OF DEATH in plain terms, that it may be properly classified. The "Sjiecial Information" for p»r- s'lns dyin£ away from home should be A'lven in every instance.
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
,f !!■ 111! !i F No. 1^ ^■^?^;"- li^l' ^''
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
llcdistcred jYo.
i^036
HU^jLA^ dUL\KM Deputy Health OfTicer
DEPARTMENT 6f PUBLIC HEALTH==City and County of San Francisco
PLACE OF DEATH: — County
Certificate of Beatb
( 11. S. !^'tan^arD )
\ ^ . A ^
oiQ/Ouy\j vj .^vxX'^^ocAl^cc City of O.ccav 0.*
/v a, vv
No. \'^TH
r\
(^
St.; 0 Dist.; bet. 0 KAJ^
^^rrv^cAJl
and 'J
Li^c \
)
/ ir DEATH OCCURS AWAY FROM USUAL R E S I D E N C E G 1 V E FACTS CALLED !^0 R UNDER "SPECIAL I N r O R M AT I O N ' ' \ V IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. J
FULL NAME ^Ivvyv
W
^.^Y^
Ibx^rvcLuui c
• J". \
PERSONAL AND STATISTICAL PARTICULARS
N
DA n. < II lilRlII
\i. K
IM.mtlit
• 1 >il s- I
^1
/>,n
\\ \\ - ' . . •:i! .!« -it' ii-il imi )
BiK in ri. Xi'K
'->t.i' ' • ■ -iii \-
.vxoo<L
k
X \M 1 ( M 1 \llil.K
HIK 111 I'l. \iH < )! I \ ni I'.R
NI it" I i! i( lUIl! I %
M M1>1 N NAM 1-:
(ti M<triii:k
I'.ik rnrLAi'i*,
<•! %!<>riii-:R
■^I.l! Pi !'• .11 lltl \
OkV
\ f
?
A
0
( »i I ', 1' \l li >N
h'riisri! ill Still I'l i; III ntii O T. t/if/»
1/..,///
/',/i
Till ^ i'.< »\ !■• s r \i"i:i> i'KR>^< »N \i, !■ \Hrn*ci. XH'^ ARi: TRri-: to rii i%
P,l>r »>! MV KN< lUIJ'.IX.l-; AN!) iu.i,ii;i-
MEDICAL CERTIFICATE OF DEATH
DAI'H ni Di; \TH >^
'J
1
D.iv
I !II:R l-;i'.\' f i: k'll 1*V. That I aUcntU'il <kHHasc<l I'mm
a
IqO H
1»/1 \ to
tliat 1 la-^t -,i\v ll alive nti .\..y.-A. 's . t<)0
ami that <lt ath iHHUirt'il, «>ii tlu- datr >>tatiMl ahnvc, at UJt>^ ' M. Tlu- tWrSl-: <)1 DI". A Til was a'^ follows:
LaJvxLv^O^i:^ J W -<^v\^-£.^^
Vf
Jy^
) '( \i I
Dik \ri()N
Motifhs
IIo
lit s
<i^'\^X4XA^
/',
i\\
I In HI s
DrkA'l'lON )'ca)s < .]f,y>i//i.s
(Signed) i /\^ix^^^^ OS ^..<r>x.,L4>'-^^. ' ' .^t v^^ M . D .
a-t^vt %C) ic,nM fA.l.lnss") 9.U DC- Lcxj
Special Information »nH for Hospitals, Insfitulions, Trdnslpnts, or Recfnt Residents, dnd persons dyinij .may from home.
Former or Usual Residence
When was disease contrafted, If not at place of death ?
How lonq at Plar e of Death ?
Days
I'l.ACK «>1- lUKIAI, OR KI-:M(>\ \I.
a
INDIRTAK 1"K
DAi'Fof Mi RiAi, or RHMoVAI,
T90
Ci,
fA.l.!
^51 oLtU/x. Vi
M. B. livery item oV inlf.iriniition should be cnrefully HuppHecl. AOB shoiihl be HtJited fiXACTl.Y. PHYSICIANS Hbould
«tntc CMISr. or DIIATH in plnln terms, that it mny be properly classified. The "Special Information" for par- son* dyin{^ away from home Nhould be (^iven in every instance*
WRITE PLAINLY WITH UNFADING INK
I)
fffr /^y/rfI,V^z)i<Ah^>\j I
/.96>H
THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
2037
J^eo'/\s/r/'rd A'^o.
VMwO
.K^ Deputy Health Officer
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Ccititicatc of ©catb
( tl. 5. 5tan^ar^
PLACE OF DEATH : — County ofO<X'>\; O-VO;
Citv of ^XX^ru g /V>cx.^^ec4 c <
. > i ry\JL<X>v Cj/0^^»^' \i^.A.>-^ -v-^< ■ No. 1 5 D ^J (VV^Uc ^.. ' ' St.; t) Dist.; bet. and
/ ir DEATH OCCURS AWAV FROM USUAL R E S I D E N C E G I V E FACTS CALLED FOR UNDER "SPECIAL INFORMATION ' ^ V IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. /
FULL NAME
V/"Y>^vjJb (J^XX/y^JiKj
PERSONAL AND STATISTICAL PARTICULARS
l> A i i 111 ii; i<
,XX^
Ul.(.._l
a
M. Iith'
(I)av
\< .i-;
On '
--IN" 1.1 ■ MAKKll'Ii
\\ I 1 H i\\ 1- !) I iK IM\ « >Rr 1-: I)
Wi iti 111 -.iH'ia; (U -it/is.iliiiui
^ ;.»,/// '
> < ar
/>,
lUUrni'I, \r]'
\ \ M )■ < »r
1 \ 111 1,R
, ; 1 1 : K-
M MDK""^ NAMi: or Ml I 11 1 KH
niRTin»I,\i I,
<}]• M<»'i'm:i<
' --tnt' 1 I '. Ill lit r\
I ). r r 1' A TM >N
U CXa-v O.Kcx
<"^ I. s^ f"^
1)
(\
<Xc*^^
1 1
4
L
-C'U y >
^r^j^/yy^JUuuhj
t
h'ttntfit III ^i!" /'i ilui i^fi) rA, 5'
5
^r,,„ii,^
Ihi
iM xHovi-' ^ r xrii) I'l'iRsoNAi, I'AH lu 11. \Ks xHi-. TR! J' To rni-:
lU'.'^T ni" MN KN< »\^■M'.I)«■.1^ AND FU", I, n'. I'
(Iiifoniirmt
T>
MEDICAL CERTIFICATE OF DEATH
ATi: OF DKATII _y
Dav' I Vt-ai <
I M.mtli* I Ili:U!':n\ (I'.kTIIV, That I atUMiiUil ilt( i-ri-^i-d frnni
— — — — — -— I^ to — — ——————— Itp
that I last saw h - alive on ~ — -~ iw"
and that dt-ath ncrurred, on tlu' dati- stati-il aliovi-, at —
V M. Tlu' C\\rSI'; Ol' I)i:.\TiI was a- follows:
I )r RATION )V<7r,v
CONTUlDlTokV
DTRATION ViiU
M OH I /is
/hi]
I /on I
^/o)li/l.s
/hiv
NED ) LyurrUA^O.vfc.Uj. dulLcxAoA
/ /I'N > s
M.D.
(SIG
OxUj: so r»)oH (Addn-ss)V^ra^rraA^ , . .
Special information only for Hospitals, InsmiH^ns Trdnsipnh, or Recent Residents, and persons dvini awav froni home.
Former or Usual Residence
When was disease contracted, If not at place of death?
HoH tonq at Plare of Dedth ?
Days
ri,At'H Ol" p.iRF.xi, <>R ri:mo\ai.
r.NDi.H'iAK i:r
/€L/>'
'vL'WJlAj
fX.Mnss laOH OT
F)AI"K..f 111 KiAi. i.r K1:Mi>\'\I,
©^ X 190H
wV-nL^ U^ V"\w
IM. B. Rvepy Item of mformiition should be cnrefiilly supplied. A(JI. shoiil.l ha stateil EXACTLY. PHYSICIANS should
state CAUSE OF DI:ATH In pinin termM, that it may be properly classified. The "Special Information" for per- sons dytnft away from home should be ftiven in every Instance.
WRITE PLAINLY WITH UNFADING INK
,1 .,r n. :i!
\ Vu 1^ t-X ^:-^^ lift I' C
Dff/c Filr>l, \L'/C.t<rlHL>v
I
V)(n
THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
]i('o'/\s/ef'ed jYo,
Deputy Health Officer
DEPARTMENT ()F PUBLIC HEALTH=City and County of San Francisco
PLACE OF DEATH : — County of *^ i<X-.v 0 ."va NoiV.! VJ Lt aLO-v' ' St.; Dist.;bet.
Certificate of "0eatb
( "U. S. StanC»arC> )
Jl ^ A ^
> vJ.Mx ^ ^ City of 0/Cuy-u JXXX.^^^<^ e c
and
/ ,r DEATH OCCURS AWAY FROM USUAL R E S I D E N C E G I V E FACTS CALLED FOR UNDER SPECIAL INFORMATION' \ \ IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. J
FULL NAMEO'^^^^^
.vv\.>
PERSONAL AND STATISTICAL PARTICULARS
t'oi.oK \ , A
I » A ! 1(11 lU K i II
'l<
M.iiii h i
.S^H
\t .1.;
T
m\<. l.l" M \K1< I 1!) W I ;!< -11 , : lb -ii^natioti)
luirni IM. \' 1
-?
tit )V4
SL I )
MEDICAL CERTIFICATE OF DEATH
DATK <)l- DHA TH /A
(Ml null I
I)av> iViai
I 11 i;i>J I{i'.V Ci; kTI 1"\', That T atU'!i'U-«l iltMH'.isctl ffimi up to ' — ~~
tliat I last saw h
alivi- on
'Icp
*^ >va
N XMl- 111 I- A III IK
111 I \ : III- K
M X ! Ill- N N \Mi: III Ml I'i i I I K
Mil' • II ri, \i' I-; »i MMiiii: K
-!,it. -H 1 .iU!ltI\
}Ooj\X<nj<r \c
I V I \.
TTU ^>^C\
0
ami that death oinnirretl, on the dntv stated al>o\«,', at ~ M. The CMS!': Oh" DI-.ATIi wa- a^ follows:
I )!■ RATION )t(ns Miuith
Pav
IIou)
c oNiuimroRV
)'iar
:u>>>it/is
/hjv
//on,
I )re I lA I i< 'N U
l\r tjr-! I II Sill/ / I i' III i^i'i)
C4t\/A
) I ill .
V/.M/Z/r?
/),/!
!! I \ r.i i\ 1 s r \ ri i» im-k^on \ i, rAK'ricri.AKS ak i: ik r j-' I'l » rii i-
lUslo: MS K M i\\ lj;iH -K AM) Hl-iUHK
Ca"LcLL<X; >1rW\'
<Xj W'Y\r\'y^^M > V
Xi'.iIk
3l\MCi
"ti\» 0% \i)/CMOLa.vuJL vod.
Dr RATION
( Signed ) UrXCTrA^^ '.^d^Au. cixLou% M.D.
//C!t I T()nH f Address) WH.<rrXjt^^ UI|a.<^..
iT!
Special information onH for Hospltdls. Institufibn^. [r.insipnfs,
or Recent Residents, and persons (f)iiij .iwd> from home.
former or lO 5 5 P J How lonq at
Usual Residence ^ OJfiJLCij'w/dj VXJjU PJare of Deatli ?
U
Wfien was disease contracted. If not at place of deatli?
Days
IM.AC)-; (U* m RIAI, OR K|.;MnVAI,
i>\n*..r niRivt, m ki;M(i\Ai,
r M 1 1 i< r A i; i : k NrCL/VVVXG -J 'v^c^A.^^
N. B.-
-livery item of informntlon shouhl be ciirufully 8upr»Iie<l. AGE shf»uld be stated EXACTLY. PIIYSICIAINS should •tutc CAliSi: Ol- DIATH in plnin teriim, thiit it msi> »»e properly clussifled. The "Siiecinl Informntlon" for p«r- Kons djln^ uwuy from homu Hhotild he given in every instance.
«m-
IU:iUh I- Vi,
WRITE PLAINLY WITH UNFADING INK
'ii; HSil' Cn
l)((h' ri/rr/,Vctj:r^-l\j
llWi
THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
2039
Jlro/s/r/'ed A7a
Deputy Hcallh Officer
DEPARTMENT OF PUBLIC HEALTH==City and County of San Francisco
Ccvtificate of IDcatb
"U. S. GtanDavC j
0 Q^ A ^
PLACE OF DEATH: — County of CJy<X^v J V<X ^ \ <- 1.^ ^ City of ^ cun^ JAa
^ A '" '
N©
m
tuLl)
\ I
HJ>\AACt
St
Dtst.; bet.
and
(
IF DEATH OCCURSUWAY FROM USUAL R E S I D E N C E G I V E FACTS CALLED FOR UNDER "SPECIAL INFORMATIO ,F DEATH OCCURRED ,N A HOSP.TAL OR .NST.TUT.ON GIVE ITS NAME .NSTEAD OF STREET AND N L, M B E R .
N)
FULL NAME
xXXAJO^yy^
c
til.
1
PERSONAL AND STATISTICAL PARTICULARS
1) \ir. I >1 !,!i; I'll Y
M. Mill '
5
i i \
A t . !•;
^h
^ I
M.n:lh
An >
-^I^< l.l- M \ K l< 111'
W 1 1 n i\'i I ' 1 > < >K I 1 ' \i f '. I'D
' \\; it, '11 -11.;: .li -• na' i. .'1 I
lUK'llll'l, M"
ol^^uuL
C<r
--U
\Ml ■»; \ 111 IK
iUKIIi li. \* K
<)i i\rm; K
M\;i)i:x NAMi:
or Mo'l'lIKH
( u- M«>riii-:R
I --, 1 , 1 1 1 lit i ■ 1 1 u n 1 1
n\Tr\iii»N r^
u
.-n
L
-I
CCrLA^O^^v
r-^
\
I \„v
V A
I < ,1
■ a>t
5
.^f..,Hh'
I hi 1
I'll I- MUiN'I-* ST \ ll-It fl-HSi i\ \I. I' UrrfiT!, \KS AR I" TK!'!'" TO I'll I-; Hi:sl' <)l- MS K N« lU !,1.|M , 1-; AM) I'. 1 . 1, 1 1: 1-
( 111 fii' 'nanl
x.i.iK-s \X'X s^X^CkXXjO^^ry.As'^f^O^ C)X
TOO s
(Vtar)
MEDICAL CERTIFICATE OF DEATH
DATJ-; Ml- Dl'.A'I'H jJ
Oxkl
(MoiiflO l> in'
I ni<:iU-;HV CI':k ril'\', That I alU-iuk-.l .UHv.Kf.l from
a^Wt It !./.'■ to d^^xt ^ T<)oH
that I hist saw h -• < . anvc oil O-X^vV ,1. ', y<p
ami that (k-ath (ucurroil, on thi> <hitt.' statc-il ahoxL-, at «• 3v M. Till- CAISI-; <>h' I)l{\ril \va^ a^ follows:
1).- RAT ION CoNTkllU'TOkV
)V(7;s M on ills
Hav
Hi
out <
1) r U A T I () N (SIG
t'iirs
NED) LU. vJ
Months I />.7r
//ours M.D.
U/Ot I looH (Ad.lrc-ss) lllO g^CctUA. J. I
Special Information on'y for iiospiidis, institutions, Transients,
or Rt'itnt Residents, anJ persons d)inij away from fiomc.
Former or
Dsudl Residence'*.^
I y I I ^\ How lonq at
MAXCtCcL >^<-CKacL Jl»idrc ol Dcatli ?
Wlien was disease contracted, II not at place of deatli ?
i
Days
iM.ACi-; Ol' niRiAi, OK ri;m(»\ai.
I)\Ti:-i!' I'.t HiAr, or Rl':Mti\Al,
TQO '
fAildicss
HHb Yrv
A.^4. C<^-V\
IS. B. Kvepy item c.t' inforiniition should he Ciirctully supplied. AdT. K^iould be stated EXACTLY. PHYSICIANS should
state CAlISr OP DLATII in plain terms, thnt it mny he properly classified. The "Special Information" for per- sons dyln^ away from home should be feiven in every instance.
lir-
WRITE PLAINLY WITH UNFADING INK
\{. .' :i'. I ^<
'i;^ I'nSll' c,
Dff/r ri/r(/,h.<^)uX<>\j
■^
Dep
ino'i
k% f^ffi
THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
:040
J^po^isfr/'prJ .A^o.
t3i
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
PLACE OF DEATH: — County of^O/^v yi K<X
Ccvtificatc of IDcatb
,, ^ ^
y]K<X , ^ City of O^Xj-ysj Jxo-^vC , ..
N
J (rlA/fvw
„ 2) 1 % - I aI St.; 2» Dist.; bet. J OXA^r'yyX' and "Vl^ CUv-v^A^m- ^
FULL NAME oL O-AvoO) 0
PERSONAL AND STATISTICAL PARTICULARS
1 < tl,» >K \
^yudx
i> \ ii' < •! r.
CxJyj
0 IvCtx
M,
3^
: >;t\')
1/, »/'//.
3L"i
S ( ; 1 !
/^,/l
-,!X. I.IV MAR I- 11 :i W I 1 11 '\ ! I 1 1 iR I I ' . i in
Wiit
niK ' II I'l, \i 1'
-1 • . ■ ' ■ mi N
I l\<X\.>vOL<L
VXXVuCa^
MEDICAL CERTIFICATE OF DEATH
1).\ 11-, < '! I»l. v III J)
M.,nllfi 'I>:iv> (Vt-ari
I ill'Rl'lSV Ci'R'ril'N'. Tlial 1 attrinK-il <lr(Hasf,l itoin
)x^ a.0
AMI (H
\ i li I.K
lURI'lii'I, \i I-,
''' iiiiiiin %
M \I1>1%\ N \M i: Ml Miiiin K
lUR riiiM AC1-; 111 M<»rni-: H
( >. 1 r I' \'
,o\A C
I I
J.uJL(a./\m
Krsidf.l I'l S,nl I
l',! I
K.) \runfln '. ( /'.'
Till MioVK sr\-n-I. i'FK-oN M, l'XI<ri<Tl,\KS ARK TKlH Tn THK
i5i-:>r ni- MS isNi iu i,i:i)( ,)■, AM) lu'.i.ii.i-
( lllfii; m;ml
^t
A I IqOt to aJCyVAj OU I()0
that T last ^aw ir alivron O^^ ■ s-' -^ l.p
ail. I that (k'.ith . .(•cu rred, ..ii thf <lati- stati-«l ah.ivr, at " M. The CAl SI-; (»1" DI'.ATIl was as follows:
I )r RAT ION
)'i:ars
Moulhs
CONTRIIHTOR
^V vlAAXX>-\.<Jt -if
Pax
Hour
-o
I )r RATION ^ ,^''''^'^'^
(SIGNED)
/^//
^'s
li
H
M.D.
■ \
* t
SPECIAL Information nnly tor Hospitdls, institutions. Transient* or Rfcent Residents, and persons dyin;) away froii home.
Former or Usual Residence
When was disease contracted, If not at place of death ?
How lonq at Plareof Death?
Days
ri.^CH oi- lURiAi, «iR ki;M(»\Ai,
^^^<^^
,1
'CX
K i:m»»\ \i,
Pi. B.-
«t»t/cAUSE OF DEATH in pl,.!n terms, that it mny be properly class.t.eU. The Spe.lai Information *or pT mnn9 dyinft away from home should be 6<ven in every instance.
i
t
Li
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
/)(//(' riicii , yA^LdjJuv> V
ino\
lla^Lstered -jVo,
*>
041
dUL/v-u Dep
/~. e*T -* ^ .J
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
PLACE OF DEATH: — County of ^ ^Xnt^ ■J Ax^ '♦fo. VLlU^ W^ V^tu. ill: H. Wv' . '\. \ St.;
Ccvtificate of Bcatb
( tl. S. StanDarD )
^ ^ ^ ^ City of 0/O<.^'\j 0 A.<X>\.Cla.,
■^
H)
Dist.; bet.
and
)
I w -i^.. iiciiAl or e; I nF NCE r.lUE FACTS CALLED FOR UNDER SPECIAL INFORMATION \
( '^ r/rCATH"o3c"u%r.r.;*rHo's^p"T'AL o"r fN^.'.TJV^o'^O^V.'^.Tl NAME INSTCAO OF STREET AND NUMBER. )
FULL NAME
av^
PERSONAL AND STATISTICAL PARTICULARS
n \ ri: < »r hik i ii
Vlv^
V
.vxt;
"I,
ID
1 ',,1 '//
/',/i
^ ' \i 11 M \ K K I 1 Wn'.
lUKTH J'l, VC!"
*-; • . ■ 'i uinU
N \ M i ( M J- A 111 l.K
A
^ ^ cjbv^cJi
x<xci<.
iMK 111 ri, \t'i\
( »I i \ I 11 !• K
M \ h>i:n n wn: (»i Miiriii-.K
lUK I'll i'l, AC I" iH MnTlIl-.k
oi cri' A rio.x
1-
c1
o
Oa^^<x>^ ' vc
.hJLLcc yvcL
MEDICAL CERTIFICATE OF DEATH
DATH «»l I)i;Aill \
\!. Mtll)
iKivt
(Year^
4
I III-;kin'.N' CI'.kTll-N, That ! atttMiik-(l (Iccasc.l Innu
I I I % IS I . I > 1 V 1 , IN J 1 1 • ,
\ , 1 . f
T()OM
that 1 la-t vaw h .' alivi-on "" ! ^"^ ^'- ^'>«
ami that dentil omirred, <>ii tlu' datr -talfd above, at I-IO ;M. The CArSI{ Ol' I)I:A'I'II was a< follow
III I
)\vs :
-k^CrVMXV
DIRATION )'ruis
eoNTKiiurokV
DTRA'I'K >N -. )V'/'
Hours
MiUitJi
Pav
NED^ 0 'a. Ob-OXfc
rsiG
M.D.
1% H, (' % N only lor flospitdls, Insli
SPECIAL INFORMATIO..
or Recent Residents, ami persons dvin-i dv^.iv fro;ii liome.
litutions, Transients,
J",,/
^^..,lt^n
/hi
Till- \Hnvi.- ^rxTii) rHK>-i)\ \i, r\K ruri SK-- \ki riuH to phi- liisrm MS KNOW i.i:n<;i'; wn i;i:i,ii;i-
; Info- nianl
( \<Mr'
U^
rt
D 0-^vaX<X.I'
l-hA^llAi
Former or Usual Residence
When was disease contracted, If not at place of death ?
How long at Place of Death ?
Days
ri.ACH Ol- lURIAI. (>K RKMoVAI.
i)\'iT:.)t lui-tiAt, (.1 k1';m(>\ai.
TOO'
■J , ,, [^ i *cp «hniilil be Rtnted F.WCTLY. PHYSICIANS should
IN. IS.— Every Item of inif.,r„.Uion «h„uhl b. cnrefully «"PP'- • „^,^f;X7laBsmei? The ^Special Information" for p,r- •tote CAUSE OF DEATH in pliiln terms, thnt it miiy be properly ^.lassiticu. lions tlyinft oway from home hHouIcI be given in every instance.
i
I
WRITE PLAINLY WITH UNFADING INK
(^
Dfffr hlli'd ,^"6
iXxsaMA;
in()\
THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
llroisteird ^'o^ 2042
£crv^l^vvu Deputy Health Officer
DEPARTMENT OF PUBLIC HEALTH-City and County of San Francisco
Certificate of IDeatb
^
^
^
PLACE OF DEATH:-County of^^<X- ^ Xc..x^..< Gty of ^^^^ 0/.C^-v.^u.
St.;
Dist.; bet
and
f4€>. ^'^^ *^WCrVC^VLU ''^ '^'^ ' "^"^ "h' „,^=?i^^lrF r,«r t^crrcArtED roR under 'special intormation' \
\
FULL NAME
tCVv
Mluv
>^i:\
PERSONAL AND STATISTICAL PARTICULARS
i < 1 1 .1 • K \
(V
1 I •
IOlU
lLi.a..
M%
\'
,1 .}-.
-:Nt ,1.1
at
\ 1 .1!
n,t
(Vt-arS
UiK I'M'" ^'-^
NAM I 'M »• \ ri I 1 K
HiK rnri. \rH Ml r \ rin-K
■Slut. ' i nil
Ml MMllll-K
i;m.' rni'l, MK Ml N' I I '■ 1 1 K H
■ - • : . 1 (.'.illlitl %
ri' A timn
A',
MEDICAL CERTIFICATE OF DEATH
DATH OF DKAIH j . ^
1 lll{Ki:i'.V C!;RTII"V, That I .iUcii.UmI .UHnavcl fmin
: ; -t >*'\ ,.^nH t.) C)-^t^ ^^ T(,n K
tliat I l;i-t ^:iw h -. -Hvr Mil ^^ i '- ' ^ ^'P '
;,„.l th^.t drath ..rrurn-a, <n, llu- -Intr stated alH.ve. at IC H5 M Tin- C \r<l' Ol" Dl-A rn wa^ a^ follnsss:
j^:
0 A.vy^.^v.c •^<^-
I
■\/,.j,f/n
/>,!
T,lv\lM,VHSTAT!Un.KR.oNX, 1.AKM.M_;,XR-XKKlM<rKro THH
ni'-r Ml MY KNOW i,i,i>''. 1-: am> i.i-i.ii-t'
DrUATIi »N
SIGNED
dxMX
Mouth.
Pay
KJ
AL INFORMATION only for #nspitrtls
VU.%m4
//ours M.D.
= 4
or RctenI Residents, and persons (l)in<| away fron home.
Instilutlons, Transients,
former or s *> f -
Usual Residence ^ ^ ^
When was disease contracted, If not at place of death ?
Lliv
Hov^ lonq at Place of Death ?
Day
(Infii- inant
XUlrt'^
\.
l'I,ACK 0\- lilKLM. (»K RKM«>\ AI,
datUj')*' hthiai I.I ki;m<'\ai.
' <3 ' ~^ ZTaGB ehould be «t«ted RXACTLY. PHYSICIANS should
„. B.— F.very item of information •hould b. cnretuHy f"PP«'=^- ^^ ,y ,,«,emed. The "Special Information" for p.r- state CAUSE OP DEATH in plain terms, that -t may »»e proper y nnnn dying away from homo should be given .n every Instance.
!l' Mil '.^ Ni
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
2043
JUtIm-*
.^rx.^ 1^' Deputy Health Officer
Jlrf'is/i'j'rd J\''o.
DEPARTMENT Of PUBLIC HEALTH^City and County of San Francisco
Certificate of IDeatb
■a. S. 5tanC>arC>
J? (\,
-^ ^
PLACE OF DEATH:-County of ^ a/>^ J ^vcc^*^^* City oid<^ JA.a..vc.^....
No.
's'> ^
St.;
T
Dist.;bet. C^AJ
JLcvL^^^^ and Ax->vl^
t^
( ^ --^^i^^Jr^v. -J^i^^t :^v^f^^-i-^}^^i^^ ,;^^-: s^^EEi-No^-eEr ■ )
FULL NAME
PERSONAL AND STATISTICAL PARTICULARS
lO.kd.
Mi.lltll !
'i);
)V,-
1/
■, ; \, 1 r M \ k K 111) \\ 11,1 I iK l)'^■l ''■ 11'
\\ I n ' 1:1! 11 -.iL' n.,; ■
.^
1UK'"n 'M. N" 1
I A I II IK
lUK 111 ri, \ri-: (»i 1 \ ni 1: K
-,• ■ ' r, .nut! \
(ii Mi»rm:K
HIR'nilM, \< 1:
<>r N^iiini". K
-^ M etc
MEDICAL CERTIFICATE OF DEATH
DATl-; 01 niA TH li \
I III'IRI'IIV CI-:rTII'V, Tliat 1 aiu-n.Ua .kcca^cl from '^jLM. Vi upH to ^/cit: I 190 H
that I last ^;uv h ■* alive on ^ C w igO ^
an.l that death nccunvd, -ui tlu- .late stated ahnve. :-t 4 >T. The CAl'SI' Ol" nilATH %va< as loUn%vs :
V
\
Cx^oiiyw
A>Vt'
t I
DT RAT ION
)■ -/v
.l/o.'i/Zis /^tns 10 //<j///.s-
» >.-
. 1 "^
v
■T
4" ''^
coNTRir.rroRV
I)rR\ri<>N )V</r.v .Vi>>,'f/is
X.
fhivs
SIGNED)
:|
'>'>x^-^
flours
M.D.
l<»n
^t f Address) l\ H b JLtAAJ^C^kt "
SPECIAL INFORMATION only tor Hospitals, Institutions, Transients, or Rcient Residents, and persons dying away from home.
r,'
I
1/,
.■„:^ 1
l>.'^
)K CI I'A Tit tN
Tiir xnovr-TXTini-KR.nvM.rxKTirrKXKSAKKTKrH T<> thh
lU-sT 01 MV KN«>\Vl,l-.lH'.l-; AND lU.lJl.H
(I
\iMrp«s
5X0 ' ^i
^ d
*
Former or Usual Residence
When was disease contracted, If not at place of deatli ?
How lonq at Plare of Death ?
. Oavs
rLACi". »H- in KiAi, OR ri:m<>\ AI,
^
I
DA I
I.MAI 1.1 k1';m<)\ \i.
let ^
rSD.RTAKKR ^C^CcL^ WxLt^l<^k4M
IQOH
;a.i.1!. -
, TT TTf. ^sould be stated RXACTLY. PHVSICIAIN8 should
IS. B.— Every item o? inWmation should be ca.eH.lly f "PJ* "^;'- „ ' ;H>classmed. The •'Special Information" for p.r- •tate CAUSE OF DEATH in plain terms, that .t may >^ P^"'^^*^ '
state V#^kUi5i, Kjr i#i---i 1 .. •■■ t - ■ . l«ot-»ice
sons dylnft away from home should be given in every Instance
• a of HiiUh 1- N
WRITE PLAINLY WITH UNFADING INK-THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
2044
-t"^*'^..n^iT
H Officer
Be 'Mistered J\'*o.
\ \ ^ Deput. -^
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of ©eatb
PLACE OF DEATH: — County of^ '<XmJO,^.<XA ^ity oi
No.
4 (1^ l' ^ 14
St; -~ Dist;bet.
and
( '^ --^^^c^uR^v -°"ti^^t -?^?^^^ .;^ .^s p. ,
..S.DENCE O.VE .ACTS CAL.XO ^^^ER ^ ^ CC • AL^ N ^R M ATK, . •■ )
K Y\
FULL NAME
XCX'
CL*
\
PERSONAL AND STATISTICAL PARTICULARS
1 1 \ i 1* til r, IK in
■>iat
Ihis
MEDICAL CERTIFICATE OF DEATH
DA XV. <>1' DKAIH JJ
iDav'
I (JO .
,Vc,U '
1 iii':ki-:r.v ci-rth-v, Thai.i auiMuK-.i .Urriisni
lolll
1 1 )1T
H'l' rni'i. \i'H
that I last saw ll ■' alivi- mi a„.l tl.at <ivalh ..rcurrrd, .ui tlu- -1 at. .tat.-.l aln.vc, at M. Tlu- CAT SI-; Ul" DI'ATI! was as follows:
flav^o^-cL
I
I- \ 11! l.K
!'IK rni'i.ArK «»i 1 ArilKK
-,' i< I III I'l i\5 nt t N
M MI UN N \Mi: Ol MKini-.H
HiH rI^'f,A^]^ (>i \;<>rin".K
! vt:itt oI riilUllI %
CONTKinrToRV
Months
DiU
'S
/lours
UJL^..<:^ ^
OkxX^ . -^
( HIT J'A'I'KtN
^5
DTRATinN (SIGNED)
n,jv<
IJouys M.D.
■ .i - I V
..t r^
I()n
SPECIAL INFORMATION «nly for Hospitals Institutions. Transients, or Recent Residents, and persons dving m^s froii fiome.
K,-:Afd ill V,(>' /
■I' /...I t
)'i a ' »
M,,„!ln
I
Of)
11
I 1 Ti I . . ' t n ; I n t
\<l<lr("^H
J^J^
31
Former or y
Isnal Residence i
V^tien Has disease rontraded, It not at pla( e ot death ?
As fi J How lonq at
VirUUv^ at Place of Deatli
Oavs
(IccL
/CL.-»-x^O.; ^ ^
nAl'lii; r.nuA!. Ill Ri:M<t\AI,
i ' 1
I'l \il-- nl- lUKIAI, OK H1;M«»VAI
TQO
■ 1 ' ■ ,. , .pp ^H,.,,tl be «tate,I F.XACTLY. PHYSICIANS should
!S. B._F.ver.v Item of Information should b. cnrofully f"n»> '^ " ^^ ;^,y '.^^^iried. The "Special Information" for p.r- «t«ti. CAUSE OF DEATH in pinin terms, thnt it mji> nc p
if
WRITE PLAINLY WITH UNFADING INK
THIS IS A PERMANENT RECORD
REFER TO BACK OF r.FRTIFICATE FOR INSTRUCTIONS
10()\
DEPARTMENT OF PUBLIC HEALTH
Mes^fsfcrrd JS^o.
204
City and County of San Francisco
-^ v'^vCl
PLACE OF DEATH: — County ofOa^OA^O.
No "i QCL^^ IWUvv.- St.: Dist.;bet.
(
Gcvtificate of IDcatb
\ ^
< City of ^'^'^'^ O.h^cc^vcc^
^c
\
L^O
' '^?^^v^:^:^ — ^^^ ^^ii^^^^-^^-^^^^ :^^i: s^^-^^-r=
and J'^>-
TION" \ ER. /
)
m^
iQ\' /D
FULL NAME \my^
'lvcn'>xo.<^
\ : \ V
^_X. i\
i> \ 1 1: ' '!
PERSONAL AND STATISTICAL PARTICULARSv
mr^i. ^^--'
5.
'i; I
-.ivi I r ^'
Ji I l_ : 1 I l-I % '
N \ M 1 II 1 x lis l.R
I'.iK rui'i, A<1%
M N I I>1".X NAM 1-, (»| MnTHl.H
iUR Tiiri, \ri-: ni Miriin: K
oiHTl'A'rinN
1 1
MEDICAL CERTIFICATE OF DEATH
DATl-: i>l I'LATll -^ . I
I IIKRKHV CI^RTIl V, Tliat r.Ur.i U-.l .Uhh a.c.l fnm, Vt\<t \^ iqoH to OJjJp^t ^Ci T.)oH
tliat 1 la^t -aw h • aliN^ -mi t- -*- ) >
^,,,.1 that .U-alli nrrurre.l, nn tin- .late slatcl above, at H LU M. Tlu- C VI SK OF DKA'ill Nsas a- follow^:
1 1 ■ ^n
DIRXTION y"^rs Moulin ^ Pays
Hours
nr RAT ION y^'%^
(SIGNED) I
.][, tilths
/hw
f fours
M.D.
V.,'i' /
(. /VM
lU'.^r »)1- My KNONSl.l'.IX-''. AM) l.!.I.'l •
\
f Infii: matit
\juyvaji
o-a
.\AjJyw
fA,i.iT.-% CJ/CWw
axx/>^ IX^W^^rv^^
J i.:)l
SPECIAL INFORMATION only for Hospitals, Institutions. Transients,
or Recent Residents, and persons dyini av^rtv from liome.
Former or Usual Residence
Wlien was disease contracted. It not at place of deatfi ?
HoH lonq at Place of Deatfi ?
Days
I'l ACH OI' lUKIAI, <iK Ki:M"V \
1 S-
rNDl'.HT.
1^ X
.cv>^'
TQO'^I
1
(T>
— " ' "^ ; T"! TTr Hho.ld he «t»te.l r.XACTLY. PHYSICIANS should
^. B._Bve.. U.„, oV ......nntlon «Hcn.r.. H--^^^;^ ^^ ^^ pt L.. c.„«eWled. The "Speda. lnfo..„«t1..„" fo. p.r-
.1 ^ .-*i!«i iW- ni-\TH in pltun terms, tnni n ■•■"^
«nn, dyS„4 oway from home should he ^nen ni every
m
^
1
r.....r. .MK THIS IS A PERMANENT RECORD ^Wm WRITE PLAINLY WITH UNFADING INK — THIS 15 M rt
"^"'^^ ..c.p TO BACK OP ^..^...r^Tr rOR .NSTRUCT.ONS
,! ,.t" III :i'tli 1 ^"'
,-^^*^'%i.i\f<vc„
REFER TO BACI
Be <^i stored J\''o.
046
l)((le /v7^>r/,L)ctM>?-A, I -^'"^^^"^
"Lxr^^-^ Ijl^xhj Deputy Health Officer
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Ccvtificate of Bcatb
( XX. S. GtanDarD )
PLACE OF DEATH: — County ofOcL^-vAJ
v} . VOLA'vX^^ACt) City of C )/CV>v 0 X O.
St,; \ Dist.; bet.
No. Cs6bv V,<X/>A; M WC-X^' " ^.cilill RESIDENCE GIVE FACTS CALLED ►i
- ,. DtATH OCCURS ^^^'^ ^ , ;« ° "^^ ,^3^,V,'^,i: J,^ f^! ST^.^UT.ON O.Vt .TS NAME .N
and vJ.>ULt'V\
C^IlED rOR UNDER ^SPECIAL .NroRMAT.J>N'. "J
u<:)
(
IF DEATH OCCURRED II
FULL NAME
si:x
PERSONAL AND STATISTICAL PARTICULARS
v.*»»I,(iR
STEAD Of14tREET AND NUMBE
A^ \jcrvw^>vi\
I '
j_
I) All". <»» r.IKTH
xr. 1-:
I Mi.tUhi
I Dav
/%5H
oL' y.ai^
lA
Vtarl
I hi ) V
\vii»< '\\ in OK !)!V.)Kri-:n
iWi ;t> ni -'"1.11 '1< -luMKt;.)!!'
lUR rniM.Aoi-:
f st:it<- >! i.'.i-;nli V
NAM J <•! 1 A'l li KK
lUR rin'UAri-:
nl lAPintK
M Ml U.N' NAMl-
oi' MDrni-.K
lUK rm'i.Aci*.
n! \!t lill l-'.K (St. a. 'ii CdUtilry
f^
aur UaJ^^o-
MEDICAL CERTIFICATE OF DEATH ^
DATH «)l DEATH J ^ .
I lll-KlU'.V CI-RTIFV, That LatteiuUMl .Ucca^cMl from Clu.q ... 190S to ijtj^^C icpH
that 1 last ^axv h ^'^ alive on t.^)^ ^' Kp'i
an.l that .U-ath oocurrcl, on the date statr-l above, at 1 1^0 OL M. The CAISI- OF l)l-:ATn was as follows:
^^(^
t
XlU^j
1)1' RAT ION )V<7/-.v ^ .Uofi/Zis
/)</r.v
//oil PS
<^\p
VVC^-Q^^^S t
t
Mt^tiths
ni'KATloN I '^^ Vi'ors
Pavs
'rw\i
(SIGNED) ^ ^- ^ a
Hours M.D.
.trVc^s.'Lv.O.A vcx
(Kcri'A rii>N
•u
n ,
i' n
)V,.'.
M,nifJn
/).n.
ruV v,M.vrSTXTriM-KK<..NXl,PAHiU-,I,AKSAKKTRrH TO THK ' HKSt'». MV KNoWU-noH AND nHl.lKl-
(Iiif.Minant
< \Uill
SPECIAL INFORMATION only for Hospildls, Institutions, Transients, or Reient Residents, and persons dying away from home.
Former or Usual Residence
When was disease contracted, If not at place of death ?
How lonq at Place of Death ?
. . Days
ri.ACI-: Ol- IHKI.AL OR RHMo\AI,
(Aaar.ss, bll U'CC^x. M\.U1.^ llx>
DAI To! I'.i RIAL or R1-;MoV\I,
O'ctr I 190H
I
.. , .,,F «Uould he stated RXACTLY. PHYSICIANS should SN. B.— Every item o? Infort^Btion should he cn.cfuny -PP^-^; p^perly classified. The -Special lnfor.„Htio„" for pT- state CAUSE OF DEATH in plain terms, that it may ne pr»p*;r , «on, dyinft away from home should be given in every instance.
'4fi£*-J«.c^,
i I
.It" 11: ,::!]
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
"" . lu-vl eu REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
\. ■
lie i:! isle red JS^o.
Ajl/v-u Deputy Health Officer
DEPARTMENT h PUBLIC HEALTH=City and County of San Francisco
\
No.
Certificate of Beatb
( 11. 5. i?tanJ>arD ) PLACE OF DEATH: — County oi^CK/y^ Oxcu-^vcv.; ^ C^\^J nf U<x.-rx^ J
City of *^' O^^rv vJ /UO-'W/C u^
D-'Tr^xtrWalL'Ku:'Cj/a',\Lwa\u.' .St.;
Dist.; bet.
and
(ir iJeath occurs away from USUAL R ES I DENCE give facts called for under "special information" "X IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. /
FULL NAME
'L>A.^^\JU
PERSONAL AND STATISTICAL PARTICULARS
iX
iMl.Ok
u^
4
i> \ri: III i;iR rii
A< . }■;
\J
I
^\
1
3.1
M.iih
I tar)
Ih
^IXt.I.l-: MAKKIl'K
U • ;;' Ml - . -ii' ' • .til, Hi
'UK T!!!'!. \(*1-:
i \'iH i:r
lURTIir!. \«K
<ii- I \ rn Ik
• '■ 111 nt \\
111 Ml tTII hi^;
niui'iii'i, \ci% ill- ^;l•^^l•■. K
< !il' I I' \'l' It iN
v] oX,K.\^^
"VA;
(11
^ AJUL a.' X ^ ^
^
MEDICAL CERTIFICATE OF DEATH
DATK nl- 1)I:aTII
i Ml. nth)
I
igo \
fl)ay) (Year)
I ill-: k i:i'.V Cl'KTIl'^V, That I atlcii<UMl .Ktxasccl from \^k ^.L um'i t.. APct 1
I(p
1 90 "i that I last saw li . ahvc on ^^-^\yX; ^b ^^p '
and that death ocrurred, mi the datf -^tatt'd ahovc, at "i •A M. The CArSF*: ()!• DI'ATII was as follows:
Jj A^Crvw-^4x,A^X ■
DC RATION
}\ar
in
t oNTkim Tory >
Hours
v^vXO„ ..
1)1 RATION
(Signed )
i\^\:
TQO
Address) b^b QxCtt.' S
Hours M.D.
AV ,/.;'
'^fnith^
I hi
1 in. AH()\J" STAT I'!) I'KKsoNAi. i'\K ri<Tl, \RS AKI" rKri' in THK
m;sT ni Mv KNi >wi,i:i)c,}.; AND rn:i,i);i-
In!
Special Information only for Hospitals, institutions, rranslents, or Recent Residents, and persons dyinq anay from fiome.
y r- o 1' I ! ' How lonq at
Former or Usual Residence
Plate of Death :
Days
When was disease contracted, If not at place of death ?
I'l.ACH <»|- lUKlAI. «iR R|.:M«i\AI
nATi-; -it I'.i RiA
I ill Ri:M(t\ Al,
•Nni:RTAKi.:R OvO. 0 OAv'i'^H/ ^''«C Lt
A<l(!ii
N. B.-
-Kvery item «V informatiofi «»houid b.- ciirefiilly supplie<l. ACJfi should be Htntecl EXACTLY. PHYSICIANS Hbotild state CAUSE OF DEATH in pliiin terms, that it may be properly classified. The "Special Information'* for p»p- Rons dyinft away from home should be j^iven in every Instance.
m^^
't »
II
^KR. '
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
l;.>at<l
:;;th r X(,
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
/)((/(' Filed ,
^ctxrv>-xAj
100\
lie ii isle red jYo.
2048
Deput '■ - - - Officer
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of IDeatb
( "U. 5. StanDarC* )
PLACE OF DEATH : — County o{yjiCur\j -)ao
%
^, ^ r^
" V " ■ City of VJ i0^y\j 0 AXX^-^ X.C oci. c ' ( Na oL 0 ^ -^ 1 I . ' . ', St.; S" Dist.; bet. ^ W CrUKXXxl and 0 Crl^Lryrw
(IF DEATH OCCURS AWAY FROM USUAL R E S I D E N C E G I W E FACTS CALLED FOR UNDER "SPECIAL INFORMATION" \ IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. /
FULL NAME «W>VU4 \yx\/>\JvO.\cL (j/Orvy>\A.<lt
PERSONAL AND STATISTICAL PARTICULARS
roi.oR \ 5
I 1 , \ ;/
I'- ll >:iv)
^
9. M '2
A( ,1.;
b! .■.,,,
i/,.,//A>
\ ( ari
/),;
SIM 1.1" M \U U II' I »
U I i I. >\\K1» OK li!\ I "Kv 1 I)
* I"
I
I VuXhJ
N \ M I . .'
I A 111 IK
lUR III IM. ACK m 1 \|in-:R
■--l ;it I III < '( i\! !lt ! %■
oi- Mol'llJ.K
iMRi'mM.Aii':
' '^t:lti )1 i'ltUIitl \
h^uixL
:1 Q^
-: f
MEDICAL CERTIFICATE OF DEATH
DATIC OF DKATH
6x{^'
1
SO
(I)av)
/go
I Ill'.kl'l'.V CI'.R'ril'V, Tliat I j^tciiiU-d (IcHcasc.l frniii
dx|^
10 npH to OJL^^t; ^0 T()0
that I last saw h A/'Wx alive on QJL^^^' OC up .
and that (Uath niMnirreil, on the date <tatL'<l aliove, at O-oO LA., M.^ Tin- CVrSIC 1)1' DI'ATII was as iollnws:
DC RATION
U jJ\jy^Xy(Xyyxx,i
Hiri'A rioN J( 0
)V<?;-.s^ .I/o/jZ/js H /.)<?r5 Hours
CON T R n u "r () R \' LlAXAr^-/oJC &. j^^-^^^axJuo^c^, .
DTRATION Yrars Jfouf/is X\ /hns IIouis
NED)|.^.Q7lCLC.U^J-
i<)oH (Addnss) "il^ LxL-du -^
(SIG
M.D.
\
SPECIAL INFORMATION only for Hospitals, InstituNons, Transifnts, or Recent Residents, and persons dyinij away frou home.
v,/// /■/
M.nifin
/),n
iii). \i'.(»\-i': s rsii!) i'j''RS' >NAi, PAR rirn.ARS aki-; Tur j: r< > mcsr oi- y\\ know i.i.ix.i. wd r,i:!,n:i''
0 i^ 9
[it
I j:
(Inf
Former or Usual Residence
When was disease contracted, If not at place of death ?
Itow lonq at Place of Death ?
. Days
I'l.ACl-; Ol lURIAI, OR RKMtA'Ai
x)ULt
DXIT,"! J'ti roAi, .11 RlCMuVAI,
T90
Ct'.
INDl-RTAKKR UU. ^ . VJ JLLfi.^
fA.l.lross 11^ \iy\, (JJUUA-liA; Ut
N. B. Rvcpy item of infopiiintion should be cnr-efully supplied. AGB should be Htnted F.X4CTLY. PHYSICIANS should
state CAIISI: OI' DM ATI! In pinin terms, thnt it mny be properly classified. The "Special Information" for per- sons dyinji away from home should be feiven in every instance.
I
1 1
♦I
Bonn! . f lie ,1 Itli r Vi) I -
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
.^-^r^^oc.,., REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
-r. !U<s:l- (',,
Megisfei^pd .jYo,
'^049
L,^^!., i:>eputy Health Officer
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
f4©.
PLACE OF DEATH: — County of ja-yx
4-
Ccvtificate of Bcatb
' . City of ■J'Cf~'^' ^''^-'C*^'*^
J 0
^'\y\jy\JXQ <Xr\\xXxx^ St.;- Dist.;bet. and
/ ir dVath occurs away from USUAL R E S I DE NCE give facts called for under special information" "\
V inOEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. /
FULL NAME
0
.fyxmAj UynX'
Xo-r
PERSONAL AND STATISTICAL PARTICULARS
'A
h
■< !l < iR
I n
Li,
fX^
C, CI
M..nt'
> tar
Ai.
1 1' M \k k ii:ii
A I !> ( »K \> '.
■ 1.1 -M -.ll .l.-K
lUK in I'l. si'j".
1)
'X >"vo,C
(
X \M1 Ml
I \ I'll IK
M \im:\ NAM I
(i! Miirill'K
ii!R rni'f, \ri-:
111 MmTIIKH
< uori'Ai'ii i.N
A
MEDICAL CERTIFICATE OF DEATH
iiAi 1-; I >i 1)i;a ill
c\
^ct
^M(.!lt1l>
Uav
(N'rrii
I II1;In1':I!V C'i:K'ril'\', That I att. n.lr.l lUcrasc.l fn>ni
uoH
U)0
I i l( )
6ct I
that T last saw h - alive nii * * ' up
ami that lUalh ocru rred, mi tlu- ilatr state-il aliovi", at 0 M. Tlu- CAISK Ol' Dl Ai'll xva-. as follows:
Q
H
^
1
W^xr
I
V, V
ktrKnA^^^Cr >v
'0
K^O. ^vo
-4 ,-.
/,/•■,/ /^' V,f„ /
yhnilln
Ihn
rni: aishvk stai'i: r> pkksiixai, v xhtuti, vk^ .\ki ikii; in in i-
JU'lSTiH'.MV K Nt »\\ 1.1 III, !•; WIi i;i ill-
flufotiiiniit vJ-X-vCXvX*
\,!,i,-,... RM"i oxa-vu
%
I )r RAT I ON Via I
CoNTkllUTORV
Dr RAT ION Ycafs
' a
J/o>///is
Da 1' ?
//
OH) V
(Signed )
Mouths
Ck
Par
A.hlri-ss) 111 '^io.n.^jl
//ours
M.D.
Special information omy (or HospifiiK, InstikiUons, Transients, or Recent Residents, and persons dyini awav from tiome.
Former or Lisiidl Residence
When Hds disease contracted, It not at place of deatit ?
HoH Jonq at Plare of Deatfi?
Oavs
Pi.ACi-: <»i I'.tRiAi, OR ki:m<«\\i,
I < , ,
UATi: >.; n
190 ,
Imiaa^o »\j
IS. B. Rvery item of informntlon shnuhr b.- cnrefully Hupplitil. AGF. should be stated EXACTLY. PHYSICIANS should
state CAUSE OF DEATH in plain terms, that it may be properly classified. The * Special Information" tor per- sons dyini away from homu should be Jiiven in every instance.
h. -Nl^;*^-
WRiTE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
l>...ar.i t n :, th I N .. *^Y^~. v,:^\-(., REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
,(rv'-.'-o i^-' vu Deputy Heairh Officer
Itegistered vVo.
2050
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Gcrtificate of IDcatb
I 11. 5. 5tnn^ar^ )
^
PLACE OF DEATH: — County of
^'
1 U ^' JV '
h
City of ^ CX^^'
4
No.
nd J ^ ^^ ^^ ' '
^ ' St.; S Dist.;bet. OlDcru>a\xi
/ IF DtATH OCCURS AWAV TROM USUAL RESIDENCE GIVr FACTS CALIED FOR UNDER "SPECIAL INFORMATION ' \ V IF DCATH OCCURRED IN A HOSPITAL OR INSTITUTION dlVE ITS NAME INSTEAD OF STREET AND NUMBER. /
.^ N
FULL NAME
0
0
<X\.Kjj dj . U C^ A C
I
PERSONAL AND STATISTICAL PARTICULARS
1. \
Jl
J
r « i! i;!K rii '^
J)V
M..iith' h
D ^ y
/>,n
W I 1 >( 'W 1- I » I iK ! > 'X't >!• r i: 1)
BIK III PI, Xi'J'
iStnti i.T I ■. Hint • \
ci
Cuw
vi
s
<X
N \ M I 1)1- 1 \ I II IK
nil: I'll PL \>K
> i: I \ III i-:h
■ ■ r (.'i It! Ill I \
MEDICAL CERTIFICATE OF DEATH
ii A ri-. I >i i»i; A Til
N't Ml
M..iUli) D.iV
I lIh:Ui;r>\' l i; KTU-'N', That I att<--n'k-<l ilnx-asiMl li..iii
.. ; - 1 \i ^..„ lyo'i t«» Cvclu I I(;0*1
tlial I last "-aw h ■■' ■ ali\c nn w i^u Ti,o
and tliat lUath m mirred, on tin- dati- ^tatru alxtVf, at O. I U ...'. M. TIk' CAl SI-; Ol' I)i;.\rn was as foUnws:
1)1 RAT ION
}'itir
Miniths
Pax
I lout
CoN'Ikll'.I roRV
MAI i»i;n X w! 1 OF \!(>riij:i
^ VI A
f L(xr
^ 1 /
lUK ruiM. Ml-; • •I Mii'rm'.K
I HAll-A riON
A'
s,;,/ /
)'
1,
/ hJ \
III 1-, AI'.OX'K ^^TATl-'.T* l'KR<()V \1. 1' \R lirr I, \RS A HI-, rkl}-:
> Till
I AT, KN'iiW
1 lllf..Mli;|!lt Sj ,\^<X^
rxd,h,.s ass a ^ S Ub lW,
nr RATION (SIG
lV(^rs-
NED ) VL- <^. Uj.U
X
p V- «»^ 1^ I
I^ax
/fours M.D.
I I/O
SPECIAL Information only '<»'■ Hospildls, institutions, Transients, or Recent Residents, and persons dyinq <iway fro-n home.
Former or Usual Residence
When was disease (ontracted. If not n\ plare o( death ?
How long at Place of Death ?
Davs
>.\ i L I)!" I'.iHiAl^ II' kl',Mtt\'AI, X TQOS
PI \CH oi- mkiAi. OK ki;m(i\ \i,
w J P
r N I ) 1 •; K T A K i: K U /CX ^-AA.^x-tA.' "-J^ -N^^^o
IS. B. fivcrv item of informntion «hm.UI be cnrefuliy .supplied. AGR should he stated EXACTLY. PHYSICIANS should
state CAUSK OF DEATH in phiin terms, that it may be properly classllfled. The * Special liOormation *or per- sons dyln^ flwny from home should be (iiven in every instance.
t
,( II. ;i'th i V
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
i',.-v i- I
/),f/r riJcd , U/elcrA>4J
.Hi I
lOO'i
Rrof'.sf ('/'(' f/ jYo.
O
o;>i
KJS <Xu^
'\ V-i
rv
^
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Ccvtiticate of S)catb
! X\. 5. 5tnn^.u^ )
PLACE OF DEATH: — County
ofQ/CX^ 0 AXXavC^UlCC City of CJcu-yv ^ >^<^
N«
0 '\k^.)^\.\: ' St.; Dist;bet. ^3.CuH.^\< and cUwi.C'
/ IF DEATH OCCURS AWAY FROM USUAL R E S I D E N C E G 1 V E FACTS CALLED FOR UNDER "SPECIAL INFORMATION' V IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER.
A
A
FULL NAME
il
L
r
^V-w »
PERSONAL AND STATISTICAL PARTICULARS
A
1
■« >i < Ik
n
It \ IH t
Kill
C
u
:!;i\-
\". I-
to
M \ 1 ■ ! . n ■ 1 )
Ul I X t\\ 1 I > I ' \\ I Itt 111 -
[ f 1' i
X \ M 1 It 1 \ I 11 ! I<
M \ , I iix NAM i;
iUK ri! 1*1, \r I' 111 \:< t rii IK
- : ' ! i Milt I \
\
A
elv
:(T^
^U
V\ >^ 0 XC
Id
r^
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t ll. I ', 1
"■""'(Lt.
A,<A.
V
THi' \nr»vr. SIX II. I) i'i-'Ks(»\ \i, r AK ri'i !,Ak> \in: I'kn: to tiik H!--^r<».^^ M\" K Nt i\\ i.t i>' . I-: WD in;i,n: I-
unit V ^ C\ \ \ C^. '^ kJ A^K^KXj^Ka ,..
i 1 11 1. .> m
I 1
MEDICAL CERTIFICATE OF DEATH
1) \ri' ' l! Ill'ATII i: \
%
Miiiilh
/ 0<^
V.,.i1
I II P: 1< l.l'A' r i; k'l'I l"\', riinl I ntU-mUd dc-ciasr.l fn'iii
i*^ 4 : I
, ' i i.,(i 'i to V ^\: . i(p \
that 1 last saw h ali\f on w -. - ^ iqo
.iiul llial lUalll nciairrcMl, on tlu- ilale -tatnl above, at ' .\[. Tlu- C'Al SI', Ol' |)i; \rn was as fnllf.ws:
nik \ lit >N )V</;a H
CON Tkiiu rokv
Moiitlv
Ihiv
llou
rs
l)\'\< \rn)S
}'t'iirs
M^Nl/lS
/hiv
I
Signed )
i.U-4l^'
1 1 it lit s
M.D.
'N,-
KiO
Aa.in-.s) 5 IH \|)la4.frt
I \
Special information "iH for Hospitals, InsliliifiiHis, Transients, or Rctrnt Rfsiilrnts, and person'* rtvin) awav fron liome.
Former or Usual Resident e
When was disease fonfrarted, If not at place ot death ?
How lonq at Plare of Death ?
Oavs
IM ACl-: <)1' lUklAI, <'1C R1:M(i\\I,
) \'i'i' ..:' i;: Hi \i -1 !•: i;Mf t\ ai.
■ N I ) i: R T A K iv R H u 0 ccdLdU^>v M u ^.M. aKtt^
IQO
fAd.lti
^^as^
1
N. B._,:v..,v U..,n ,„■ ln!,..„„..l„n ,h„ul.. h. .„ne»..Uy supplied. ACE .h„„l.l b, H.a.edl fiX*CTLV PHYSrClANS ,h„„M HtHtc CMISI- OH nriATH in plnip term,, tha. It p.,.y he properly .lo,»lfl»d. The Specnl ln!or,n,.t,..n »ur p.r- Bt)n« dyint owny from home Bhoiild he ftiven in every inntsnce.
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
J )(!((' Filed . U.cl.^iMA^ 1
V,)()\
Bcillsieviul J^o,
'Wvf • ^'•'•m
M
j^^K^KA -iJ->M Deputy Health CfHcer
DEPARTMENT OF PUBLIC HEALTH =City and County of San Francisco
PLACE OF DEATH: — County of
Certificate of IDeatb
11. ili. t?tanDav^ )
City of C' <X,^^ J /v
^r\j vj . wp
C\
A
■^
TS[o I [^iX X.^a - , — ' , St.; i Dist.;bet. JCr^C--.. • ' . and OA.v'
• iP DtA- • '.AV FHOM USUAL RESIDENCE GIVE FACTS CAtLED I^OH UNDER ' ' <^ P E C 1 ft L INFORMATION ■ \
V IF DEATH OrruRRED IN * HOSPITAL OR I^JSTlTUTtON GIVE ITS NAME INSTEAD OF STREET AND NUMBER. /
^ .1) r 1, ..
FULL NAME 'X^cUv\.Cn U, Ix \ . .
PERSONAL AND STATISTICAL PARTICULARS
\ -\
ll,. ^
X
A
a^v
4
r^J: a
Ht »\ 1- SI" \ r
I'l-' U ' t >X \ I. r \ I: I
\K-, \K]: iKi 1 I "• I'll I-:
If 1,1 1,11
1 11 1| I 111, ml 1
JUs
wv-v.
cL Lc
. IIH <
\^ocM5^^iv Ot
MEDICAL CERTIFICATE OF DEATH
> \r >■ I M 111 \ ill V
■ • iI);iV
i\'.
I II1;KI.I1\' t ! Kill-N', rii;!' ■ "m.lctl <k'f<a-^fil Ipuii
ibiil I l;i-1 -.iw
1
i! ' ' till
^^Ji\rX ^H
y^
\
;v'
itioH
li;0 H
111 i lli.r '
d M.
1i I Ki'll I K-'il. I '11 1 ill t':l'
!;<• C \1 >-l: < >1 l>I- A'
• tat I'll :iiiii\t.-
\\
|( )!li i\\
M K A ri< >N
I I >N 1 K
(>i<\ '-J
// /
Mi^nths
iKix
1 A ^ 1
(Signed ) U. > ^^ '
M.D.
■J^ '^D
.,nH ^ (
gp^^l^j_ ify^FORfVIATION on'^ ''ir Hfispihils. InslittillonN. Tninsienls, or Kt'irnt Ri'sidfnis, .mil pfrsons (Uin'i rt\*.iv from \wm.
Former or Isudl RpsHli'nif
When was discisr <ontr.i(f('d, If not al pldifol dpdil).'
Him Imiq .it Pld< (• ol f)i .illi .'
Od^s
PI, \»"i: < •! IM 1^ 1 \!. ' \ Ni)l- K I'AKHK
\l.
M \'i'
- I< 1M<>\- \I,
N. II.-
' 7T ,. ., AfiF «h.» .1.1 be Btnteil HX^CTLY. PHYSICIANS bIiouIcI
-!;vcr.v item o»' inform,.t!on .houl.l h. cnre»»lly «u,»,.I.e I. ^^J' '^^ " ^^'J;", t^,,^ ••Sp.d,.! ln?ornn.f.on" for per-
HtuU- C \lISf ; OF Di: ATH In pli.m tcrmn, that !t mny be p^opcrI> U..sh,»,ccI. I
«of». tlyinft Hwny from homu nhoultl be ftiven In every inntance.
c o
M
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
Ai REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
Dnh- Fi/rf/ ,\J zXy(AT<Aj 1
VJr)\
Iic^ish'fcd J\'*o,
a053
1
^
c
Deputy
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Gcvtificatc of "5)catb
PLACE OF DEATH: — County of ^^^
City of
^
No.
A
/%
(
u
St.;
Dist.; bet.
and
^•y rROM USUAL RESIDENCE give facts called por unocr " special information \
r^DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME I N STCAB OF STRCCT AND NUMBER. J
f D E A T
FULL NAME
^ : \.KMJ
PERSONAL AND STATISTICAL PARTICULARS
I li.i )K
^ t \ K '' n ! t
\
N S M 1 III
I XTiil K
t! %■>
M 1 ■ ! \ 1 1 ■
. I ni 1 K
ir A rii 1
n
rin^ % !!mn*h s'r \ r K n iT K - 1 >N M. r \ K i ! 'I t \
l;| - r I n MN is Ni >\\ 1. I 1 »' . 1'^ \ \ 1 > Hi ; I.l 1 . 1-
^-^ULu XJUv\^wtrv^ 'V*^ K-
\ 1< 1 IK
V V
I i; I'n rn !•
MEDICAL CERTIFICATE OF DEATH
\ ri
M.,r
/(JO :
! lIl^KKIiV Ci:Rril'\, Til. It [ atU!itk-.l tUHxa<^LMl fmiu
— l^p to " Tip
th.it I la->l -Mw h ~~ alivv on " Kp
ail.l tliat ik-alh orrurri'd, on t he <laU- '-tatt.-il ahovr, at - M 'riu- CAl^K Oh IM: AIM \va< a^ folh>\vs:
u
s^ ^aX^N'n- >'"''^CX.
CON ruiiir i'Hkv
'/IS
/hi
I! u,
DTK ATI ON
-->
'li
/hn
SIGNED ) JV. ^
>VO->
//ruj s
M.D.
JtnX^
,^X
\i)ry%
Special information »«'> t'»r HosplhiM, institutions, rransients. or Rcient Rfsiilenfs, ,inil persons dsin'j .i\*.t\ fro;n liome.
Formfr or Usual Rfsidrnre
When wns discasp contrartcd. If not at plare of deatt) ?
How lonq at Place of Oeatti ?
Dav*
iM \ri
I ) \ I
r /A) , ,
1, r
I QO
Ad.h.-s bH'b I a /.A. .
L
^^""^^ .. , -^c I, ,..1,1 Ko Bfnteil HX\C Tl.Y. PHYSICIANS should
,. „._nvery 1.1 n, oV inf ,.n,i.,1on should b. carefully supplied. ^^^;;^'^ ^^.:*^'^^J:>:\^,,.u.l Information" for pT- «t«tc CVUSI or DIATH \n pl»1n terms, that .t mny be properly Uass.t..U. IS dyin^ inviiy from home should be given m every instnncc.
nnn\
c G
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
! \..
!;\.r r.:
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
n^fjH.
M
DEPARTMENT OF PUBLIC HEALTH
Jtf'(f/\s/('r('(/ 'jVfh
City and County of San Francisco
Ccvtificatc of IDcatb
■A
Q
%'
PLACE OF DEATH: — County of '' ^ City of CJ.<x-y-v 0.V.O
IVo -I ' St.; i Dist.;bet. l^U^ and l^t(
/ IF DtftTH OCCURS AWAY rROI* USUAL RESIDENCE GiVE FACTS CALLED FOR UNDER 'SPECIAL INFORMATION' \ V IF DEATH OCCiiRRjn in A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. J
FULL NAME
.c
LcLa; LoJ
kJYXJL '^^ t '^K. j^-'
PERSONAL AND STATISTICAL PARTICULARS
■^
X^
~> I
• \ i r
I;
\i I
r >t \ R u ! r ! I
I \ I I 1 1 K
II r
111 M' . . ;, I K
' r II 1 K
•■ i' I r \!i( iN
A'
A
rv>x
\ >s
'w^. U
(\
\
Ll^v^^'^^.
u\lL^.l.
L>VQ
■^
in-:"-^T « ii M \ ; iM .1-: \ M> Hri.ii:!-
I". !•> i'
I II !• I- inriiit
(
H
MEDICAL CERTIFICATE OF DEATH
It
I IIKRHBV Clk riFY, That I it
1 1 1
. il I rum
'/
that I ]avt V ,w h
alive nil
iii' I'l-
;inil I !i;it lU ilh I H-iMi rrt'd, < n t lu- i
\T
latr >>tat(.'(l al>n\"f. at
Thi.- C \I SI" Ol' Di; A'I'I L was .m folldws
A
DlkArHiN )V<//
t'(»N'rRIHl luRV
i/,.//-^
/h
I] •^
1 lom <
I M K A r 1 < ) N I SIGNED )
Months
Par
l<)0
\
//itlll s
M.D.
h n 1 . A
SPECIAL INFORMATION ""'^ '"r Hi)S(iil.ils, Insfitufions, or Recent Residents, anJ persons (hir.) .ih.iv tmn tiome.
former or Usiidl Residence
Wlien Hds dise.isp ronfrarted. If not at place of deatli ?
ffow lonq at Pl,i( e ol Dcith ?
'ransiriits,
Days
PI. \i I I 11 I'.IKI AI. I iK M l.M< '^ '^'.
U
' ^
\
r^ «
1) x'n i' I'
Is I
AKiVAI. TC)0
m
INDKKrAKHH
"""""""""■■"^ TTT n ,1 A(iF should be stnte.I RXACTLY. PHYSICIAINS Khould
B.—Hvery it. m o^' i„form,.t1on nhonl.! I.. c.reVuMy supplied. ^'^1'^^''':"'^^^^^ Th, "SpccU.! Infor.nHtion" tfor p.r-
stnte CAlJSi: OP DII A TH in plain term., thnt it may be properly Uoss.t.cd. I
son, dyina away ffom home Hhould he ftivcn in every instfince.
&■-
^•
i~
c
G
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
•
REFER TO BACK OP CERTIFICATE FOR INSTRUCTIONS
i
l)nh FHp'I , \Ji^
V. X
ll)0\
Jici^isl ci-vd v\Vy.
2055
XoA V , Deputy Hesith Officer
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Gcvtificatc of Bcatb
11. i?. !^'tnn^al•C^
'V I
m
PLACE OF DEATH: — County of
City (A^^O^-rxj ^KO
N
().
xl
and
, v^ ^ ,■ ' , St.: 1 Dist.;bet. "^ OJ\h.y <. ' , and •■ ■'
/ ,» otATM ,, r ■ AWAY rROM USUAL RESIDENCE GIVE FACTS called for under '^--cial information \
I ,r DEATH /, MRtD IN A HOSPITAL OR INST TUTION GIVE ITS NAME INSTEAD OF STREET AND NUWBER. J
\ 'y
FULL NAME
\ /
.U\.L.V
PERSONAL AND STATISTICAL PARTICULARS
A.
o /
L
L A.'^ -
^^ik_- -^
\W\ iii
niRTIl v\. \i H
fit ! \ rin K
nA ;i
(^
' i I i I iv
L^
A, U-O
\ I I« 'N f l)
d^L
m
^ /
L
^.-^
^^
dL
Tin N I'.i »\'!.: V r \ r 1" I > ri-' i< SI t\ \
i;i:-.r»»iM\ K Ni .\\ 1. t.j " ■ ' ' ^^ ' ' '•'
j I !, \K-. AKK rKi I' ■'■<» ■l■^"■■
fi
1,1,-. 1 » il M N
OCYSJ
I \<\.
^1. <^X^,^vvX^'
MEDICAL CERTIFICATE OF DEATH
DA ri-: i
;>i: \ iH
! );l v>
/Or)
1 II!{RI'I'.N' t"i;Rril-N, Thai I atU-ii-kil .k'» i a>^e<l IniHi
tn
^■4
II,'
A
•hat I li^i ^iw h .. alivf di! '• ■
ami that df I'li < .(a-urrc<l. lui tlu- daU- -^taU-.l alxivi-, al O ' M, TIh- CAISI' or |)i: ATI! was as foll<i\vs:
111 RATION ' )■"?/ (.ONTRllU i'* >I^V
J/(-;.'//V.c
/ ></ ]
//,///
[Ir.
1)1 RATH >N
(SIGNED )
)'.'<ir
Mruth^
K.
K I
/>(i\< tk \ I Ilia s M.D.
I < lO
Aildrt-ss)
HftH
SPECIAL INFORMATION «nb '"^ Hospitdh, InsfitufiinN Iransienfs, or Rercnt Residents, and persons dvinq <m.iv from home.
Former or Usual Residence
When was disease fontrarled, If not at plareof death?
How lonq at Plaf e of Death ?
. Davs
I'l.ACH OF lUKI \!, <»R Kl-MiiX AI,
i
1 1 ^
ni,.;rtaki.k Uw'>^.CtiU^. I^^cUUv^
^A^t
^ , u ,,,,. ....fullv Huppn -.1. AGF. HhruMcl he «tnte.l l.X ACTLY. I 1I>S!UANS should
IN. B. !.vcr.v Item otf ir.formi.t -on Hhoi.I.I b. ...fcVuHy f"t*'»"' „^„.,crlv cluW.tficd. The "SpccM.I lnform,.ti-,n" lor p«r-
«t«tc CAllSI. or DI \TH 5.1 pli.ln Icrms. that .t mny he propcrl> .Ium.
son, clyinft owoy from home should he Aivcn In every instance.
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WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
Ml) IS.
:'.v\
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
Ddfr Fih'ii , \j <;^u)<t~U\j 1
iy)()\
Ih'i^ish'fcd J\^().
2056
.<^ v,^\^
Deputy
V^ i » I *_» ^. f
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Ccvtificatc of iDcatb
PLACE OF DEATH: — County of^<Xi\ ovccvvcc^ec City ofO^X^v
n\
'Sxo
No.
f
I
St.: 1 '^ Dist.;bet. " ^ ' '■^'^ ^ and cLrv^v''
USUAL RESIDENCE GIVE facts called for under
/ IF DtflTM orCURS AWAY FROM USUAL R E. Sj I U t Wt^ t G I V C FACri, i-BUi^tu ► ■-■ r. u f'. u c r, V IF DtATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF S
S='ECIAL INFORMATION" \ JTREET AND NUMBER. /
I
fO
FULL NAME
H
^CX...
PERSONAL AND STATISTICAL PARTICULARS
»iii.i>k ^ ^ ft
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M A R k :
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ou
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MEDICAL CERTIFICATE OF DEATH
! Ill : 1 \Tii
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IcjO
aiiM' I'll ' i 'v*'
■cil 111) 1 1u- ilatt statt.Ml ahtni-, at S>
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DTK AT ION
C<)N TKinrTORV
Dl'R A'PioN
y'tdj s
.3^
Moiii/rs H
/>ii\
Hours
(SIGNED ) dU . U. ViJ
Pays
)<x. c.^^
I lotn s
M.D.
SPECIAL INFORMATION ""b f«r Hospitals, Institutions, Transients, or Rrrcnt Residents, dnd persons d^inq .may from home.
Former or *^"** '""^ **
Usual Residence Place of Death ? n,.vs
When was disease contracted,
If not at place of death ? __«
I ; 1 ■ in A I -
t' ^t
i'l ACK or lUKiAi, (iR ri:m< •\ M,
i:M" >\ ai,
TQO'
Atldl f'i'^
• I, I 1 h. ..r.fullv ,.n.„ii.<l. AOB »l.....l.l h« «t«t.H EXACTLY. PHY.SICIANS should
N. B. fivery item oH* ln^:»rin;it
HtntL CAUSE OF DEA . .
sons dylnft oway from home should be fe.ven .n every instance.
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REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
;th 1- V
♦ »
/}(//(' Filed , \iy /^lijyiy^K: ^
!f)n\
Bcslisfcred J\^o.
2057
^trv.c^v/i
\>^ Dep
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Gcvttficate of ©eatb
A
11. 5. StanDarC^
City of Ucw^YV 0 AXX
^
PLACE OF DEATH; — County ofv a^^ ^
0 mo
*io ^^ Xh/ry\XXrY\) UUMi -' St.:" Dist.;bet, and
/ -r OrftTH OCCUMS AWAi FROM USUAL R E S I D E N C E G 1 V C FACTS CALLED FOR UNDER SPECIAL INFORMATION ( ir DEATH OCCURRtD IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER.
> \^^-. ' ^-
)
FULL NAME
OuAaX^ .
PERSONAL AND STATISTICAL PARTICULARS
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' St
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ufK rm'i, M'K 'ii %!!iriii:H
•ill r \ri« IN
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rin" \r.< i\'i* ^r \'ri:i>
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! WD ni;i,ij:t-
*Kri-: TO Tin-:
(In f'i- tii'tut
MEDICAL CERTIFICATE OF DEATH
\ ri; < >i in: \ TH J/
Muihh)
I ili;i^ i:r,V C1{RT1FV, That LLcCQ -^ iuo'3> to
t 'iO i.,oH
that I last ^a\v h '■•-' alive on ._■-,.'. I90 1
:in,| that .Icalll -.(MMirrcl. <>ii tin- date -^tatcil ahovf. at H H.
^
M 'rile CXi'^'!'" ('L^Dl.ATII was as follouv;
H^ 0 ^' .
YX-O
, i "S
A^A^WvXr^
4
nr RAT ION )'(;;
coNTRir.r'roi
Moulin
/><7)s 1 1 Oil y
n 1 K A T I < ) N (SIGNED )
I. ■
liirs
jrnuf//.<i
IhiV
'i'
I lours M.D.
X.l.lres.) U-4A/VV^0,A^ ftp CH^M. J„O.J
SPECIAL INFORMATION <»"') *''r H ispitais Institutions. Transients, or Recent Residents, and persons dying away from liome.
■ IxXA/UAvt
Death
Ddvs
When was disease contracted, If not at place of death ?
U,tl,
I'L \CV < n IMiyAI, (»K KKMi |\ M-
U l-Mt >\ AI,
INDllK TAKlsK
-^
Addit ss
IN. B.-
'*!
' TT .^p should be stated RX4CTLY. PHYSICIANS should
-Every item of information should h.- cn.otuU.v suppi.e ^J^Z^^^A, The ^Special Information" for p.r-
state CAUSE OF DIZATH in pli.in termn, thot .t m»y be properly Uass.t.ea.
sons dyinji away from home should be feiven in every instance.
s:
wwntpg-
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WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
,,! !l. .ilih 1- "-
luv r <•
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
Dah' /'^ifr(/ ,\^ zk^>-^K' X
lt)0\
JiCiiisfet'cfl v\7>.
2058
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Ccvtiticatc of Bcatb
PLACE OF DEATH: — County ofwCtiv
Tr\
^
City of '.OAA^ v].va.iv^
V
(\,
a
No.
f -,
^ ,. St.; -^ Dist.;bet.M t wO ^-' and^nU4.4-
/ ;r OtATH OCCUPS AWAY FROM USUAL R E S I D E N C E G . V £ FACTS CALLED FOR UNDER '■•"'" ^ <^ '* "-j;^ ''^.^^f^^ '° "' ) ( .FDtATH OCCURRED .N A HOSPITAL 0« INSTITUTION GIVE ITS NAME ,N3TEA0 Or STREET AND NUMBER. J
4 r-
FULL NAME
^l [La^u
4 I ' ^^'-
PERSONAL AND STATISTICAL PARTICULARS
St 1 ! . t > K
t °% *
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ill NfOTIllR
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Tnr MinxH htatkii im-k-hx m. pah nrt :. xk-. akh ikts: t- • ini
l;i-^r<.i MS lsN<»\\ I.l J>< .H \"^I» J^l- '••'
(Illf ,; ni;iiit
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\ %
MEDICAL CERTIFICATE OF DEATH
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ii.is-
! I!!:K!;1!N' t i:k'ri I'N', Tliat. l attc-ii.Uil «UHr;i-.cil frnni
il,,,t I ! . I; .ilixt nil Cn^l. -"wUviL^ a.cv
an.! that thalh ■.<. arrvMl, .ui tin- 'late -tati'.l ;,1h.vi', at ^ M. Tilt- (' \l ^l^ Ol- I)! \TII wa-. a- t"f)!l<nvs:
-!(
CONTKIIUTOKV ^
Months
Pays
1 1 1)11) <
1 1
Ur RATION'
(Signed) J C
Mo)iths
Pays
M.D.
V.Vl\,
Special information ""I^ ''••' Ho^PiMs Inslitutions. Trdnsients, or Recent Residents, and persons dvifii) dw.iy from Ijonie.
Former or tsudi Residence
When was disease contracted. If not at place of death ?
HoH lonq at f'Idce of Death ?
Dd>s
J. I \oi' ni- IHRI AI, ou ri;m«ivai r.NI.l.KTAKKR VwO.^^C'wU- ^^ O
i»A ri; ..; Hi v.\ w <•• k!:m<>nai.
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H's^ <k.H. w
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"-* — i— ^ ,. , TTp „H„i,u| be sti.UMi liX4GTLY. PHYSICIANS stiould
N. B.— r.vcry ftc,„ o* i^V^,rm„t!on shoul.l be cnrcfuHy -r>»> '^ ;. Z]^^ f;;^ dosslfled. Th. -Speclol Information" for pT- Htiitc CMJSF. OF DEATH In plnJn terms, that it m«> >- '* ""^'^ ^ «nn, dylnft nwoy from home should be gUen In «very .n.tnnce.
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REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
1 N.
I'-.-v !■
Jifo/sfr/ if/ .jYo,
2059
Deputy Health Officer
DEPARTMENT ot PUBLIC HEALTH==Clty and County of San Francisco
Gcvtiticate of IDcatb
^0
PLACE OF DEATH: — County of ^^arv
J ^
\ n
< ^' City of d/Ow>\. J ;uOl > V c.cA
Ml
?4i
,j^tv l.^«^ku ob(v4>v-^"^ ^^
St.:
Dist.;bet.
and
/ , - orATH OC-URS AlWAV FROM USUAL RESIDENCE Give F«CTS called rOR under "special INroRMATION' ^ ( ,r DEATH OCCURRED IN ThOSP-TAL OR INSTITUTION GIVE ITS NAME INSTEAD or .T«CT AND NUMBER. J
FULL NAME
\.(1Xm
)(rr\xSJ
u
PERSONAL AND STATISTICAL PARTICULARS
LL', '.
(\
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a^'
b
N \M 1 Ml
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if ^
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< »1- MmTIIHK So il
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(T)' W\' >N PTn '
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r.AKS AKK TRVK Tn nil-
(Iiif(.nn:i!it i '
CQ^ J C^^-^
.U.I.... 3H50 ^ inl!.^ "t
MEDICAL CERTIFICATE OF DEATH
DAlli ill- I>i; \ IH
Ni'.lit
!!:ivl
1 II I:In I". I'.V CI'.KTIIV, That T atlLMitUd ilf.r;i«>.<l Inuii
that I last -aw h . ahvc on t</'
atiil that lUalh occurred, <»ii the <hitv -tateil alu.ve, at H \\ . The CAl'Sh; (>!■ hl'.ATII \va>- a- fn!l,.uv:
Co ■ ■
a>.
1)1 RAT ION
I 0
) N r R I r. r T <> R N' LxX^^-C^'TL^Cr^^ vO^M^\>^-<i/
//(!///'?
A C
DIRATION (SIGNED ^
IcX.
Vrars
Mn*llll>
Pays
T«in
f AiMress) '
M.D.
>. <, A
SPECIAL INFORMATION only for Hospitals, Institutions, Transients, or Recent Residents, and persons d> in] av^ay from liome.
'^X.C > V V.
Former or ^
Usual Residence J
Wlien was disease contracted, If not at place of death ?
How long at Pldce of Deaff??
Oavs
i-i.ACi-; OF nrKiAi, « ik •; iM' 'V \i,
X ['K of ncuiAr, or Rl'Mn\\I, % Tqo'
at
(Ada,... iHlli ^^\.^-^^^'s\.
!N. B.-
-"- ... AnB should be stated HX VCTLY. PHYSICIANS should
-livery Item of informnf.on should be ^nreVully f"nP •;^^- ^.operly classified. The "Special Information" for pT-
«tate CMJSF: OF Dl:ATH in plinn terms, that it m.«> be pr< p y
;in. dylnil oway from home should be felven In every .nstnnce.
c
G
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WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
1, 1 V.
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
mm
'\, Depuc h O^ -
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate ot IDeath
"Cl. S. '-•tanJ.irC
PLACE OF DEATH: — County of
■X
"\
n
City of ^^CU^rv '» \0
^i.
No.
^
A
Aaaj
and Al C
(
St.; ^ Dist.; bet. M I U^^QAm^A;
^.. orrun- -^Wfty FROM USUAL RESIDENCE give facts called for under "special .NrORMATIOM' "\ .,,.M nr-uRRED .N A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBCR. J
'■^'^ A C' ^
n
FULL NAME ^ h^o^
PERSONAL AND STATISTICAL PARTICULARS
rs ;
u
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(\r '^
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t-
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ml
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I \. !.;!.-■
i ()\l,l^.v1 ^^
MEDICAL CERTIFICATE OF DEATH
I! XlK < >l l>i; Alii
4
I IIKki;n\ I IKlll-N. That r :ith!i.U-.l .Ilh t ,i<e<l I'r.
nil
tliat i last saw h ali\t "Ui ''
and thi* ilraili (iri-urrr.!, i.ii tlu- <latt- vtatr.l aliove. at M *riK- C \l SI-; <»1* hi:. \ I'll was a^ foll.nss:
, J r^
ri . "
„^A
/-S - - r^
CnNTKIlUTnRV vWu>-
Mo^iths
r-v
/>^7r
i_, VA.-
Hcii^
Signed ) Lo^^toa^
Ho Ills
M.D.
SPECIAL INFORMATION wN *»r Hospitals, InNliftilionv. rr.insifnts, or Recent Residenis, and persons dvinq dwri% frfiT, hnmp.
Former or IKii.il Residence
Wlien was disrasr i nntrarted, If not at plare of deatti ?
Htm lonq at Place of Deatti ?
n.iv^
PI.A01-: >tL' r-i K 1 \i, < >K K i
c^LoJuu^:
\
DA ri
_Q^.
-s'
i:m<>vai,
'4 TOO ',
,. , >nF s'v>uld be stated I.XACTLY. PHYSICIANS should N. B.— Hvcry Item of Inform .tlon should be cn.etully f"Pr> -d ;^;J;^,^^,^^^.,f.,d. The ^Special Information" for pT- •tau. CAUSE OF DLATH In pli.m terms, that .t may he P^''P^'"y "n. dylnii away from home should be felvcn in every mstance.
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REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
«« ■**»*^
uKl- c<,
{\
\_'
Ifff/
Deputy Health Officer
Ju'iji sfcrcd JVi),
2061
DEPARTMENT OF PUBLIC HEALTH-City and County of San Francisco
Certificate of iDcatb
1 1
PLACE OF DEATH: — County of C
No. oL L v^*^Lu. ^
(IF DCATH OCqunS AWfiir FROM I, ir DEATH dcCURRLD IN A HO
O.
4
V - 1 City of O
St.;
Dist.; bet.HllU^C
O
vXOAXand
\
i n n ' .
USUAL RE S I DENCE GIVE facts called por under special information \ \
SPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. J U
FULL NAME ^ Lclt\
V I
PERSONAL AND STATISTICAL PARTICULARS
fi i ' '1.' 1^
\ I VI
/''^
>^
L
5
H
rk, -
A
r^
il W I wS.
^ IVct
MEDICAL CERTIFICATE OF DEATH
I
K.iv
/ f>( '
lint I 1 tiii| I h ■
i,,.j'v to • ^' "^t) I r.ioH
' y h alivi- nil W " V l.,n" .
h ' Hiurri-tl, on till ilatc statril ahoM-, at -
M. Tlu- t \
i<\ Dl \TII \\;.
1)1 UAl'loN )V</r
C( iNTklin I'f >KV
A/o>ii/t
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Q-vcvcec
I'l \> }■
' . ^i ' 1 1 1 ( 1
;• K I II IM, \i-
» ri- \ ! h IN
V
l
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I HI' '>
1.!
\< i\\ 1.1 "i' <
I Pt.R^oN \I. I'XRTh I I. \H'^ NNi; TKrH k' I i\\ I.KIii.K \ A
"-?
Cj (^V <x^<i^
\.l.ll.-.v
)^K/VVw<b'V"^-^'LjL CoJL'
Dl l< A in »N SIGNED
J/-
'///I
LC
M.D.
! I in
f AiMn--'-) HOX
a.A_0 1 W i
Special information »"'> '"f Hnspildls, InNfitufions, Transients, or Recent Residents, m\ iirisims dvini -i^''^ '"'" '"•"""•
Former or Usual Residence
When was disease (ontratted, II not rif plare of death ?
How lonq at i'ld« r of Dcitf) ?
Days
rxnKk
aki;h Lo^OU-aX
^l
I QO
>
^
Aa.h.s^
k^ \j<xjy\j
•WNL-
N,
H._,..,,, Item nV into.m.f.on should b" cnretully MuppI.e I. '^"':;,7' '^' ^^^^^ t,,^. -SucciHl Intormr.tion" for p,r-
HtiiU CM SI OP DliATII in plain terms, that it may be properly .l»s«.t.ed. IS <lyina i.vvay from home should be given in every inHtnnce.
noni
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i^wmwip
|
■ 1 ■;' |
1 |
|
i |
|
|
i |
; |
|
i |
|
|
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|
|
1 ] |
|
|
1 |
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
"v -. ! r . REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
% Deputy Health Officer
Jfr<j/s/rrr(J A^o,
2062
M
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of IDeatb
cap
4
PLACE OF DEATH: — County oi
City ofClXX
• , 'I
No. V
.ouC
StU
Dist.; bet.
1 r ! r A T H f I
r i) ( A T H
»./,*v rHOiV' USUAL RtlSIDENCE GivF F'lrT*; «- a
(?RED IN AHOSPlTSL OR INSTITUTION C, IVE 1^ NA^/l
and
FT FOR UNDER _ _ i A L INFORMATION" \
A I NSTFAD Of STREET AND NUMBER. /
A
^
tl
FULL NAME
/U-c'
PERSONAL AND STATISTICAL PARTICULARS
h
LCUU.
X
^.
>
'V
b
1 M \k
1 ' >
1 !)
A
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in
1 1
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111 I \H()Vi' ^ r \'! rti vvM
HK--^ r ni MS I. Ni p\\ !,1
\ R< \ w K iH I 1-: I ' » I 'I •
^
MEDICAL CERTIFICATE OF DEATH
;i; 'i_-IliU'il (It ( < I
iN .a; -I'll t II Mil
I (111
lie
;il|i I Ilia'
hi R A TM »N i;(t\Ti; iiirToRV
III R \ rh 1^
\ 1 --. 1 { ( » !
Ml- (latt
lu: \ r
c &=
•i| a I )( iVf a'
a^ fnll.iu^
M^h
t
'UC'
/>./rs
Ihuys
•r^\
IhlVS
Signed • L^X-cmJ^v J ^u5.Uj JjlJUMx^
l^ in
M.D.
SPECIAL INFORMATION •►n!\ Jir Hospi or Recent Residents, and pfisoiis dsin'i .mnv from lioftip.
als, InsfituTiohs,
tnrmer or s f ^,. . 'm' ,
I'sual Rfsidiriip ^
When w,is disp,)sr ( ontr,ufed, |[ not at plare of deatti ?
tfrm IniKi <if PIhi c lit flcifti ?
[idH'^icnts.
n,)vs
•1 \CJ- » Il V.\ V 1 \I, "
\X:
1 QO
I NI)IJ< I \l- 1 i;
\-Mi' s"
'^5ivy>v
SCSI-'
N. B.
, TT ;^pp Hhm.ia l»c stnte.l HX^CTLY. PliVSICIAN>i Mhotild
r> item oif inf..rmut loii shoul.l «'^ oi.-u>ull> svippli^u. • • . .. , y,,^. -SiKciH' liiformit i.ii" tor p-r-
U- CMISi: or DI ATH in pl»in terms, that It mnv he properly .Iuhs.UcU.
"fivt-r:
• tote w ,»,.,.- -,. - . . . »„„,.„
mnnm dyinft nwny iVom h«,mu should he ftivcn u, overy .n«t«nce.
c
G
t;«:
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
t 1
](ri>isfr,'(ul JS^O.
mm
Deputy Health Officer
DEPARTMENT OF PUBLIC HEALTH-City and County of San Francisco
K^*U^
Ccvtificatc of IDcatb
■a. 5. t?tnn^ar^
PLACE OF DEATH:— County of av
s
CU^CC City ofw
N<,. ^\Xc\,^^ LcrWW'
St.:
Dist.; bet.
and
^ ( ir DEATH OTu^, & A' » V TROM USUAL RESIDrNCE GIVE FACTS CALtED ^OR UNDER "SPfCIAL INEORMATION \ 1 V ir DEATH OCC4jRRID IN A HOSPITAL OR IN' ' ' _, n O N GIVE ITS NAME INSTEAD O? STREET AND NUMBEH^ /
FULL NAME
--^
■4-
PERSONAL AND STATISTICAL PARTICULARS
^\
n
^ u I
^
n !>
4 1 lavvct-<l
0
K
(n^^^xU ^^^
OA^cLo
MEDICAL CERTIFICATE OF DEATH
li
r
lllMl I 1;
ail'!
^\\ 1
I I ill
r 11
N , ,'I 1
:-t. ll t 1' III!
I(,0 H
1 UO i
M. Tlif C X
■ ' ' ' : ■ id a hi >\'«.', at il l>i: ATM wa-^ a- fo!]^ u-
//.
M 1
%•' nil iJ<
IM, \r>
.1
0
I
I<.N(^'
ni>i
u! MV K Ni iW I.llttU-; \M» i;i l.:i :
ri » I'll I-
\>M'
mi'wvxsj
^
vvxs-.4x^
/>
n'v
O
//I'l/rs
M.D.
\.
SPECIAL INFORMATION ""l^ J'lr Hrispitals, Institutions Iranvirnt or Recent Residents, and persons dvin) ,ih.iv fnvii linmr.
.U^
Former or Usual Residence
When was disease confrafted. If not at plare of death ?
How lonq at Plare ol firaft) ?
I)avs
I'l \v'K or Hi U ! \i. < >i^
\ 1
Xlv. ^v^Yvcv.
ti i\ \i,
I qo
rNlU- K I'AKl- '<
(Ad.lr.sv oU'
^'J
I 'T I ' 1
'~*'"'~'"'"""~~""'~~"-~'"— """'"■ Tm IlTd \nF. shouia be stntecl KXACTLY. PHY.SICI ANH «houlcl
N. B. !;vepy Item ol" inV* >rmBtion should b." ciirctully siippii<-«i. ' L.^^ii?!^.! The "Suecial biforiii:itHHt' lor p«p-
«t«te CAllSr or DEATH !n plain tcrmn. tb„t 5t m»y he properly .lHH..t.ecl.
son. dylna nway from home should be j^iven in every instance.
s
9
■f
c
(
r
■•pa*'
^
i
« ,
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
RErER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
Hiiai ' if III Mil IN.p 1' '5--v:'3r|;^5 liS: I' r.i
^
/)/(/(' F//('f/, L/cL(rlK.^s 5>
HJfn Eeg/sfr/rd A'o, 20G4
d^\^ov_xs Xvwu Deputy Health Officer
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Cevtificate of IDeatb
( XX. S. StanDarD ) PLACE OF DEATH: — County ofU-O/^W J K<Xm/lA>U^ City of C)xXa\; O \.a tvC^UK^ No. li 51 0 (ruMrnPy\: St4 4 Dist.; bet. 1 kJX) and ^
(IF Dt»TM OCCURS aWAY FROM USUAL RESIDENCE GIVE FACTS CALLED FOR UNDER "SPECIAL INFORMATION" \ IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. /
FULL NAME
>!.\
!i \ ri: 1 ii i. IK III
PERSONAL AND STATISTICAL PARTICULARS
^
4-
M. nth
.t
MEDICAL CERTIFICATE OF DEATH
KATI-, (•!• Dl'. \Tn
\
i nav
Ac.H
1/
/'.n
^IN«. !,l MAKHII-.I*
\\ \\n (Win I >R I»l\( iRi 11)
Wilt' ; !i -I II ' ' ' - : s.' ii.it ii ill '
■^t -• 1 I >; < '. iuntr\'
^
L>xa
t
■1
I- ATI! i:k
i; IK rii I'l, \i}', »>i I \ rin-K
ist.i!, I.: (oiinttx
%! \II»1"N- NAM I ni- MnlHl R
lUR llllM.Al'l-:
Ml M(»rin.;R
' St.'itr or (.'(Mint 1 \
' l\c Vq aiv i^ \x >T > \ a r
^
IL'tt
(Month)
3
'l>avi
(Year)
I IIl':ki:r.V C1;RTIFV, That I att<.Mi<k<| ilcnased from V^X-l^t aO iQoH to ^'tt; ?>
i(p*( T90 1
that I last saw h OYi alive on C 'ZXj 'h
and that death occurred, on the date stated altove, at \
U. :M. The CAI'SH Ol" DliATII was as follows:
nr RAT ION )'iU7rs
CoNTRIiU'Tol
A f Of ///is 3. /)(iys
11 out
\\ LLojCLl Uj \>0-"A,c4vvXtA
^i\\A^U^vl
t\^vlLa
\i<>jysJXKK^OJ
\
C/AJ^Lc-^-vd-
ot'CII'A TIDN
Kf'^niffi in Sail /'> ,i h, i ^r-t
)', ,1
.1/.
..*////' 2,
/',n
Till' \HoVH STAT1',I> I'KR-^nNAl, 1' AR PliT I.A KS AKI-: TKIK T* > 11 IK Hl>r Ol- MV KNOW I.l.Ix.K ANDiilLn'!
(Infotiiiant
^HWq
\
niRATION
(SIGNED)
]'tars Atou//is 1 0 A/vs'
J ^>
Iloui <> M.D.
^/tfc ^ i<,o^ (Addrews) lUH 0 Q^<Ur>Vu ot
icyt^
Special information only for Hospitals, Institutions, Transients, or Recent Residents, and persons dying away from liome.
former or Usual Residence
When was disease contracted, If not at place of death ?
How ionq at Place ol Death ?
Days
1M,\CH<>I HlRrAl, OR RKMoXAI,
i)ATi-;.)f lUHiAt. <»r rj-;movai.
Udarcss . 1 OS' 1. A} I'U^AUt^X .J.
N. B.— F.very item of inWmi.tlon should be cnrefully supplied. AGE should be stated EXACTLY PHYSICIAIN8 should state CAUSE OF DEATH in plain terms, that it may be properly classified. The S|>ecial Information for p«r- 8on« dyin^ away from home should be feiven in every instance.
i
I I
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
•th f V.
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
^
J)ff/(' Fi/f'f/, L,I^tcri.^^' ^
If^O'i
Be<^isfere(l JS^o.
2065
<^v
DEPARTMENT OF PUBLIC HEALTH-=City and County of San Francisco
Cevtificate of Bcatb
PLACE OF DEATH: — County ofJa-^v 0 Vavvcc^co City of Oa^ 0 ;v<X>\ c uix^o jVfo 1 Ul V a CU St.: 5^ Dlst.;bet. X\.-)\A.> and 3.3^.<i
/ \r DEATH OCCURS Aw»y rpoM USUAL R E S I DE NCE give facts called por under "special information \
V IF DEATH OCCURRtD IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. /
FULL NAME ^.V^ a ^v
Ka4X
PERSONAL AND STATISTICAL PARTICULARS
>
n
iR \
U^
1 1 I'^du
:^ /^■ L—
/tS5
\ t ! :
^H
]■ M \H l< I»
1 \
LI
Lr^^
V • ^ V Ca.
IlIHTIII'I.Ai 1 (St;it«' or t'om I
X \ M 1 I »!
1 \ III 1 K
lUK 1 II ri, \r )
M ^ I 1 il N N XM I »>! Mi»SHi;i<
lURI'lII'I. Nri*. <•!■ MMfMHR
' St.ii' 1 >i i'l Hintt \^
V>X'
.0
u ^^^
vav.A>iAX'r\)
. 5
1 , .7i
M. uth>
iHcrr A ri<»N
■\-\\r M'.<(\-i* ST \ri n iM'-!<'^nNAi, tar ricn, \k^ ari-, rRii-: r<> 1,1 --r ui MS KNDW i.i'.ix'.i'; AM' ini,ii;i'
/'.M
(Iiir<i!iii;iiit
^Qx^
JC\XX^
\.l<ll.ss
A
H,'h\ UA.CVOLA^^-fi-">^
X<5
MEDICAL CERTIFICATE OF DEATH
DA ri-; ' >i iii;aiii i \
l^'ct
(M iiitlii Davl (V.:ii>
I Ill'lKlir.V C1;RTI I'\', That I .ittrinUd «K(r.isc»l fnnn
that 1 la-t ^aw \\ -^S) ahvf on *^ ^ ' lyoH
and that lU-atli .HCiiirt'<l, on thi- <lati -tateil almvv. at H
i^^lj M. Thr cwi'si-; or hh; \rii ua^ as rnii.-ws:
V
DrkAI'loN O )'t'ins i( )NrR I lUTORV
< ^ '
MiDiihs
Par
Hour
DT RAT ION (SIGNED )
)'( ay$
M,>)it/is
I
/Vfr>'Vu<X^
^1 ^
/hivs
I Ivios M.D.
l(>n
H
A.hlrLss) SIH UXX,LLvV^.a.'^"'
Special information on'y for Hospildls institutions, Transients, or Recent Residents, and persons dyinij .m,iy fro:n home.
Former or Usual Residence
When Has disease contracted, II not at place of death ?
How lonq at Place ol Death ?
D,<\>
» WW (i! Hi RIAL i>i R I Nil i\AI,
IQOH
ij^ H
.. 1 4nP =^r„,l,^ ha stilted RXACTLY. PHYSICIANS Hhould ,f 1nfo.n,.,ion should b. cnrcfully Hupph.d. ^^J' f " '^i'^,,^! /'^ ,nf<.i.nuf.un" for pT-
; OF DliATH in plnJii terms, thnt it m»y be properly cluH»i^i..il. int. , .»c
IN. B. Bvery item nV
• tnte CAlISn _ . . ^_„^^
lions dyinft iiway ?rom home Hhould be fe.ven m every instance.
^WJW_JJPUP1
mfmmmmmm
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
:,<,) iif Hi :i!ll! I
No ; ^ -f*^^^ IS.t I' O
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
Dftfc F//r(/, L -[rlcrAMAj 3
jorn
Jfeo^i.sferrd J\^o.
20G6
\
^
cLtv V- -.VI Deputy Health Officer
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Ccvtificatc of E)catb
( XX. S, SranDarD i PLACE OF DEATH: — County of a^^ A/X nxCUXM) City ofU>a^A; J ^X>Ct/VLCA,A/CMi
No. 3.HD
4-
-v<X^^q\fc^x St.; i Dlst.;bet. ^txXWULtm. and^KLLO^y^k )
/ IF Dt«TH OCeflWS •WAV FROM USUAL RESIDENCE GIVE FACTS CALLED FOR UNDER "SPECIAL INFORMATION" \| \ IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. Aj
FULL NAME >ta-^-v ■■ V.lci^C\d
-•l.\
PERSONAL AND STATISTICAL PARTICULARS
1 N
HICL^..
IL'vJii
MEDICAL CERTIFICATE OF DEATH
DATl-: I >I I>I. Al'H
1
Let
!»A*I i; Ml HIK in
lU
4CS
\i .]•'
*^ IN '1.1 MAKKH 1>
WllM t'A »• It < »H Iix . r. 11)
U ! It. Ill -... !.i' ill -iy n.it i.'iO
H
L^ va^^
HIK rnri. \t"i'.
iSt;i!i 1 i! 1 '. uiil' \
N \M 1 t »1 I ■ ! in K
lUK riii'i, \»*i.: Ill 1 A rii!:k
■->t I ' • lit (ill"!
<»1 MolllJ K
lui' I 111'!, \ii:
't| Moflil K ->taSi .! t'liuiit I \
vtVv>\ Ll^u^cl ' \ \ ^' A
iVtatl
(Month) n.tvi
1 in.RIJ'A' C IlkTII'V, That I atftn.U.l 'IcfLiiscd fn>ni \t m 190 i tn U'ct^ 3. icpH
\
A
tlial I last saw h -^^n alivt- on V. tAi X up M
iin! that (k-atll iHi-iirrt'iI, (»ii thf datr statiil ah<ivr, at ^ U M. 'I'hi- C Arsl-; (M* l)i;.\ Til was as follow^:
LIcmJIx L^vbjVO ^^OU/^i
coNrkiiuroRV
A/o////ts \ Days //o.ns
DIRATION }'fars
(SIGNED) ;>UU>
^
Mouths
/hiv
UU^y\ uw
/
<»i'r\i' \ rioN
fsf'itifi! Ill Siiii /'ill II. ' ' ) 1.1 1
rm- .\H()\ i-: sr \ ii ii i-kksun \i. j'\k ih n. \i'> aki; tki » r< > rii>-;
llI'lS'l'tM MN K N< i\\ !,) IX'. !•. AN|) lU I.II'.I
1 M,.iitl
' lufotiiirint
10 ^1\; H. CcxXK^
\.l.!i
1%
d^<XaA^oA^^
c^t
C)<ib "X ii|o\ f.\.l.ln-ss)'t>0"l IXVO-Ah/
A
.0^
Hours
M.D.
Special information mIv tor Hospitals, Institutions, Franslents, or Recent Residents, and persons dying anay from home.
former or L'sual Residence
When was disease rontracted, II not at place of death ?
HoH lonq at Place of Death ?
Days
I'LAt,"!.: <>l- I'.l HIM, i»K Kl.MiiNAF,
INDJ.KTAKKK
DA TK lit lUHiAi. or H i;Nti i\AI,
V.' €fc 3 T90H
\(l<!i<>;s
in I
A
l\
ft >.
■\
rV
, .. 1- I AHF Khould be stated EXACTLY. PHYSICIANS should
tS. B._Kvery Item o^' Infor.nntion should b. carefully -ppl.ed ^J^^^^^lll^^^^^^ ..Sp,,j„, ^formation" W pT-
Btotc CAIJSK OF DEATH in pluln term*, that it mi.y be properly Uassmea. son. tlylnft aw«y from home should be given in every Instance.
f !
t
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
!I. :!i); 1
l'.."vl' 0
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
l)(il(' Filed ,
V,
4
,\. 'h
l'.in\
]l('i>i,\lrri'il jYo.
2067
Deputy Health Officer
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
PLACE OF DEATH: — County of
Gcvtificatc of Bcatb
itv ofO<X>X. J.*\_n^ > ^ ^ ! <}
City
0
U
No, N-^^<-
^. *w >
. >K
St.;
DE
STI
Dist.; bet.
and
\ / ir DEATH OCCURS *W«Y F R O P>$ USUAL R E S I D E N C E G I V E FftCTS CAllED ion UNDER "special INFORMATION ' ' \
' V If DfATH OCauRRtD IN A HOSPITAL OR INSTITUTION GlVf ITS NAME AO OF STREET AND NUMBER. /
FULL NAME
,1
"^JXXXxh
\ I
A
PERSONAL AND STATISTICAL PARTICULARS
if H / '
\' I
: : S M \ K !. I ! t i
i\ I I H i\\ 1 1 i ( I K
I ' I
I II
ItlH I'll 1'L \"J-; I i! 1 \ in I R
M \II>HN N\MI
<ti m<>thi;k
lUK 111 I'l, \<K
>'i MMi'iirK
I'll' \ riuN
MEDICAL CERTIFICATE OF DEATH
i» \ ri-;
r\
1 llKkl-l!\' r 1:1nT1 I'N', Tliat I attituUil «kH-iavi-.l fnuii
tllal 1 la--t ^,ii\ li * ' ' ali\«/ nil
^
r
TikT
aii'l that iltatli > h ruiri-il. <>:' 'he dati- •-tatril alioVf. at ' M. Till- (■ \i>>l-' <»1" l>i;A'i"ll \sa- a- foUnws:
<?^y
V r 1 ,
iS\ XaxX Qv
v^.
1)1 RATH iN
I < (NTH 1 lU '!<ikV
) i iN
.)/i>////lS
/I
1 lom
\
/
/
S,;,, /■
\
\
'\ T ST NTH I) I'KR-,. >X \l, l'\KT|i'ri, NR-^ \KK THI l- I' » I
111 M\' ix\< >\\ !,i;i i< . i: \ n: > hi i.ii'f
III-:
In T'l-iiinnl
y ^1 ,
, I
I ) I K A '1 I <> N (SIGNED )
^%
Motilh.
fhiv
^
M.D.
!<,'>
Special information nnly for Hospitals, Institutions. Transients, or Reient Residents, dnrt persons dvini m,\) from liome.
Formfr or ^ , i
Usual Residence ^
When Has disease rontrai ted, If not at piai e of dealfi ?
How lonq at flare of DeatI) ?
f
Dh\^
I'l \cv or in RI \i, i>i< 1^ i
Ml
I) \
k i-;Mif\ \i, TQO'
I ni)i;ktaki:k
m
VL
Addi <ss ob li- ■ i * ' ^ > ^'
^ 7\, ,. , AHF should be stnte.l n>:4GTLY. PHYSICIANS nhould
N. B. Every item oV inV'<.rm.ition »hmil(l he cnreVully supplied. a . ,„^^\i\^A The '*.Snecia! InformatM.n" for p»r-
«tHte CAlJSi: or DI:ATII in plnln terms, thnt it m»y he properly wlus«.*.eU.
son* dyinft owny from home should be given in every instnnce.
c
G
r
h
H
m
w^
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
De
IfJO'i
u •^ .«v^
Me^isfercd J\^o.
2068
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of Beatb
"a. S. StanDtirD
(^
No.VC
PLACE OF DEATH: — County ofOCc^^ J/uOL-rxoUt^o Gty ofCj<X^^ J\<X >
v<"<.^ <" (
(
St.;
Dist.; bet. and
.„ -i - ---- ■• ■ ..».». ■^.-^ FACTS CALLED FOR UNDER "SPrriAL INrnRuaTin
.r DtATH AJCCURRED IN A HOSP.TAL OR INST.TUT.ON GIVE ITS NAME INSTEAD " STR EeJ AN D NUMBER
ir DEATH OCd^RS AWAY TROM USUAL RESIDENCE G.VE rACTS CALLED TOR UNDER 'SPECAL .NTORMAT-ON
FULL NAME
)
fWxA UriLL
-1 \
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
n '
• \ n ( »! i;!R rn
\<-i':
a
H^
M
\
.111! hi '
b
:):iv)
DATK ()!• I
)i;ATfI ^
ux-
%
•Dav) IViar
\r.>i'/n
x\
/>.,v
"^I^ ' ] (■ MARK F }•■.!) \\ i IH i\\ I 1 . ( iK IMVt )!••> }:n \\ I 1 1 ' ;n Alicia! i !t'-»i"!iat ii ill )
1 HKRHBV CHRTIFV. Thai J alien. led .Ic-rcasc-.l fm,,
^JLivl
that I last saw h •• alive on d^CVvt t< I
OX^-t
Ti)0 H.
lUKfm'I ^ ■! ^
N \ M 1 ill I \ I II I K
HIHTHIM, Ai'i: Of' FATHFk
M \ II>1:n NAMl
'ii m«)Th1';k
luk riM'i.Ari.; <»r Mnrmic
iSiatf or (.Nuinli \
oi'crpATiox ^
n f
-CdcOu^^v
III
aiid that death ..ceurrcl, mi the date vtate<l al.ove, at IQ.'^O ) n *^" ^"■^' "^'v-S'^' nHATII ^^as ;,. follows:
\.\.^<A>
^J-^aX/w
K.<. > \_iX
U Uc , .^
DlkATlON )•,•,/;
C'oNTk iniTORV
Mouths
Ihn
I lOH) S
i)rk.\Tir>N SIG
nav.<;
<ryv^rucr\)
Yeats ^ M.^)iths NED) 10. b. C^ >X.Lo,. ,
1Xy\A ^H Tool (Address) L\Xa->%Xl4a. ^We
Hours M.D.
Special information onlv for Hospitals, InsmuHons, Transients or Recent Residents, mi persons dyim] aw,iv froii home.
) , ,;
M.niih^
\-\\v. WMwv. sT\-n:i> i-kksonai, i-ak irt-rt. \ks ari- tki j.- -lo i-in-
in'sTolYOJV KXdWi.l.Dr.H AM) IUI,[i;i-'
iifv.inatu OA/CL/>xJk Uw- Cj<:Jx/\'>Axta
Former or Usual Residence
When was disease confrarted. If not at place of death ?
How lonq at Place of Death ?
Oavs
(III!
\'lilrr>-.s
VA-^^>VV4U■\ <i
I'LACH ()I- lUKIAF, Ok RI-tMiiX \I, I n a Tl
Ha^'W
tN"i)i:RrAKi':K *
^: .1 Ri;Nf()VAI, T9ON
^- **• Rvery Item o»' Infcrmiitlon should be carefully supplied. AGB should be stnted liXACTI.Y. PHYSICIAINS should
state CAUSE OF DIIATH In plain tcrais. that it may bs; properly classified. The "Special Information" for per- sons dying away from home should be feiven in every instance.
n
f^l^
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
_««____^«___ REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
/)(f/r Filed
J DO
Ii0^isfer(ul vA7>.
2069
-^
X ^ \
Deputy Health Oflficer
DEPARTMENT OF PUBLIC HEALTB-City and Countj of San Francisco
Certificate of Beatb
tl. S. Stnn^arD
(^
PLACE OF DEATH: — County of Cl/CX^x- J a
.a.
^ ^
ly,
0
V City ofv^'/<X/7XJ 0 AXt
A
No.
r^i.
(
St.j ^ Dist.;bet. LcL4.t^..
'^'^^M ^T.j I L^ist.;bet. v^CLnlA.A,c and i^"
" f/nrl.!.^^'"' ""^"^ '^''^'^ USUAL RESIDENCE GIVE TACTS CALLED FOR UNDER 'SPECAL INTORMATION ' \ IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. J
FULL NAME
/w
PERSONAL AND STATISTICAL PARTICULARS
V
> \ n < 1 !
i)
ri ii ( Ik
MEDICAL CERTIFICATE OF DEATH
;ik ill
/loH
Month
Dav
/(JO
i \'t ill
M.nth
D.iv
S*i-ar)
lURTHI'!, \C]:
10
f HJ{RP;i>,V t'i;RTII-V. That I attiiKU-.l .let > ,s< .1 f nm
If)
Jj A. cL^
UJ
V \ ^T I ill
r \ in I R
lUk III i:. \r |.; < H I \ III IK
St.il I lit I'l in 111
M Mill- N V \M 1 Ul- Mori! Ik
lUR nil'!, \i i; •I \'ii||(ll<
■-■1 ti . .! ('i 111 lit I \
KxXo
*^^ » 190 i to . ly^d:. [
that T last < iw h -v' alive on ^ zX: I
ami that <k'ath nrcurrc'<l, on tin- daU stated alin\r, at M. 'llu CAl>^H Ol" DKATII was a^ follows
190 i
\iLhJLAj\^<xX.
V
I
9
c'oNTRinr'idi
I
Months
< N' N / IaAaxOu Oyyv^AA,JSr^v\.oJL'\x,'C
'//; V
n
1)1 'RAT [OX Yrars
( Signed ) dubo ^1 1
Monf/is
Ihn
'S
i -4
/^
Too
X^UT>X^CV>\.
.%
flours M.D.
i:
< M ,•! I' Aiinx
h'f'^iilfii III Still I I ,; II
Special INFORIVIATION only for Hospitals, Institutions, Fransifnts, or Recent Residents, and person** dvins) hwh) Iron home.
)■,,,'
v. /////«
Tin* MU)\-i' ^ r \ii;i) !'».R--nv \i, k \ k Ifr I I, \ k s A k V. TKl). T" • rili: HKsT «)! M)»:^js X( »\\ ij'iii ,!•; AM) Hr!,n:r
'W
Former or Usual Residence
When was disease contracted, If not at place of death ?
tloH long at Place of Death ?
Days
rjL.\CK ni' nrRiAi, OR ri.:mm\\i.
f 1 1) fo- inaiil
J A4D»-^rJk L<rvuwvo
\.Mi
\V\
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\J\J^>-^iJ^
DAT!' -: n
Ni>i;kTAKi:kM il 0 <XxdLdL«/YV Hrw ^4U _,
xi ..I ki:Mi)\ \i,
•^ T 90 ' I
N. B. livery item oif informnlion should be ciiroifully »upplied. AGB shfuiltl be stntetl HXACTLY. PHYSICIANS nhould
state CAlISi: or DliATH in plnin terms, that it miiy be propi^fb wlaBsified. The "Spcciiif Information" for per- sons dying away from home nhoiild be fe'ven in every inHtnnce*
^
^
9-
» .
^
!i 1
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
- REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
:f<\' r
Dulr Filr.l. ilctfrW.
liei^i.sli'ii'il J\'().
2070
.^ V A <.
Deputy Health Officer
DEPARTJIENT OF PUBLIC HEALTH=City and County of San Francfsco
Ccttificatc of E)catb
PLACE OF DEATH: — County of o^^^ vj .^.cu-*^ec4X: o City of Cj,cc^ No. I2)b Oa/>^ St.; 4 Dist.; bet. M rUAXL\.^r>% and Jb C^^^HXHA )
r .r orATH occuBs AWAY FROM USUAL RESIDENCE GIVE tacts called por under -special information \ V IF death occurred in a hospital or institution give its name instead of street and number )
Vcu >
I
FULL NAME
Cs
XooX^OL'
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
liAI'l-; I )1- DI- \ 1 H
Ll
I) \ I1-; 1
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(Vt'Mr)
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i/nutiiin
I lIHR!;nV CHKTll V. Thit 1 atiLii.k-.l .ItHvascMl fnm, ^ - I go t<; — — — -
thai I last saw h
alivi' on
i<>o
TtjO
ati.l that .hath occurred, on tlu- .late staled aliovc-, at " M. ThfC.\rSl{<)I [)1{\TI1 Nvas^as tullnws:
3r
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iNED )L
SIGI
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IL'/CAi ^ i(,n H f \, hirers) UrVfrVuiU) L ' '
flours
M.D,
SPECIAL INFORMATION »«!> for Hospitals, InstituHons, Irdnsienis, or Recent Residents, and persons dviny awav from home.
,'(■ /
\r.,,ij,^
l>,i\
Till' \i'.« i\i' s r vn i> !'».• R-,(»\ \ i_ !• \H run \Ks xki; pri-h tc i iFii-: lij.srtii M \- KNt >\\ i,i,i». ,!•; AM) iU':i,ii:!-
Former or llsudi Residence
When was disease rontrarfed. If not ^{ place of death ?
HoH lonq at Place of Death ?
Oa>s
ri. \K'\', <i|- IM K I \I, ( >K H |.>!i i\ \
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IN. IS. Bvery item oi' informiitlon whoulcl he cni<iifiiii>^ HupplK-il. ACT. shuilcl be «tntcil f.XACTLY. PHYSICIANS sliuuld
etnte CAUSF OP Dl A TH in phiin li-rms, thnt it irmy he properly claBRifiefl, The "Spcv'ml Informntian" for p»r- «on« flying away from hoinu sluuilti he ftiven in every inntHiice.
♦ .
Ili 1
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
,.__,.,^___. REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
* *• ^*»'v
H^J' C
1
'C.t^yvMA;
trvoui
Dep
n)()^
Er(j/,s/r/'rfl A^o.
207i
cer
DEP4RTNENT 6F PUBLIC HEALTH=Ci> and County of San Francisco
Certificate of IDcatb
^
^T^
PLACE OF DEATH: — County ofOc
o
City oiO/(X,y-\j v .\ cx >
^-M f;
i- ^ V.t '^^ ->\.Lu, V. . ;. , ) V . \ ■ . St.; ^ -- Dist.; bet. ^ and
/ >F DfATH OCCUfIs AW4Y FROM USUAL R E S I D E N C E G I V E rACTS CALLED TOR UNDER SPECIAL INFORMATION ' ' \ V If DtATM OC^RRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER /
^n If P
FULL NAMEUj.L.Lico.>>A., Uuo --
PERSONAL AND STATISTICAL PARTICULARS
h It III Ik N
Iv
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\(
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MEDICAL CERTIFICATE OF DEATH
DAi'K Ml- Di-: \i n ij'
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I III-;RI:i;\- n,RTll-V, Thai I atltn.k-a (UHcascl fn.m U;nS to 0^\X X'S up S
that I la-t saw h .. alive nn ^. . >.'\, i«p'',
and that «kafh <KHiirre<l, «iii the «lati- >>tritr.l alxivf, at 10. IS M. Tlu- C^ArSI- ni- I)i;.\ril wa- a. folh.uv;
aiiu
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y
Dlk A riON },,/;s
CONl'Kil'.r'IOKN-
nr RATION ),,/;v
Mouths 3lH Ihns Hours
Mofiths
fhivs
Signed ) u
.0
t Ml I' 1' \ r i> ».\
OA^vl
^w OJwwLu,
i
J U^|\.S %, \j Iqo'
AiMress)
IIoui s
M.D.
-Uwa^'
SPECIAL INFORMATION onl> for Hospitals, Inslitutions, rransients, or Recent Residents, and persons dvinq dw,»y from home.
Kfsuied
ni .Siiu i i iiii
^I.nfhs
/■
'I'll I' \i'.n\!-' s r \ T) i> iM''R->(>x \i. !• \k rill I \R-, \Hi; I'krr: r« » i'lii-; Hi>i«>i us KN« »\\ i.i;ih;i-: and iu;i,n;i-
f 111 r, 1' mniit
Former or Usual Residence
Wlien was disease confrarted, If not at place of deatli ?
How lonq at Place of Death ?
Drfvs
L/Ui/vv'
A-, J
q,.\C}f. in- l!tRI\I, (ik ki;Mn\Ai,
DATI-; ,,! h
\\ .1 k i;m« (\ \ I,
IQO ;
N. B. livery Item of inforrriHtlon should be cnrclrully supplied. AGB should he stated RXACTLY. PHYSICIANS should
state CAUSE OF DEATH In pliiln terms, thnt it mny hs pr(»perly classified. The "Special lnforinntion" f»r p«r- Ron« dyln^ away from home should be given in every instance.
f
!!■ !h IV
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
_^-^__-________ REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
0
Ddlr Filed , iL ' oLcr{>JU\) 3 VJO\
Deputy Health Officer
Registered JVo,
2072
1 "^
DEPARTMENT OF PUBLIC HEALTH-City and County of San Francisco
Certificate of IDcatb
11. 5. 5tnnDai*C> )
v(
-? w
PLACE OF DEATH: — County of Qa^v J \o ,
St.; Dist.; bet.
City ofOo^"v JAXXy>xt.ML<: '
Nt>. I lXcv "^ UrU/Yxl^^
and
(1, ^»., .^^.oi.*^ i^*,i« *IX1U
IF DCATM OCCU*S AWAY FROM USUAL R E S I D E N C E G 1 V t FACTS CALLCD FOR UNDER SPECrAL INFORMATION ' ' 'X IF DEATH OCCURRED IN A HOSPITAL OH INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. J
FULL NAME
PERSONAL AND STATISTICAL PARTICULARS
XX..r-
^
i;x
\t \ , \
Qic^L
i < li.i >k
u.
k IH
MEDICAL CERTIFICATE OF DEATH
i>A T1-: oh i»i: \ IH
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So
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' ^!a!i I •! I'liu lit 1 \
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^I HKKl'IiN' (l-RrirV, riiat J attriuk-.l .kHHasc.l fmin
that I last saw h . alj\rnii O ^ 'i^"^' ^- * up >
and that death ' n^cii rrril, <hi thi- date stated ah«i\i-. at ^ ■ M. 'Jhe CM sK nl' |)i;\ril wa- a^ foII..s\s:
DCRA ri(>.\
)'tiirs
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Dr RATION ( SIG
Ycuys
Months
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V^Aj tiO KjoH
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/?<n.T
0
I lours
M.D.
'VV\A-^ V^ VA.AJC
Special information only for Hospitals, Insfilutions, rransients, or Recent Residents, and persons dving away from home.
r^ r»
Rf>iilfii IH Sii II I'lOHii'iii
M..,.'h'
J hi I -
Former or 1'su.il Residence
When was disease contracted, If not at place of death?
How lonq at Place of Death ?
Days
III I AHovK sr \ !'i:i) !'KK'-'>\ \i, !■ xK'rim, \Ks \H j; iHrj-: 'r<> thh
HI-,sr(H-MS KNt i\\ i.i;ii(,l-; AN!) lUl.Ii:!
f I !i fir ni/inl
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d.lnss 2>bTX' iq tl
,%. ji. fivepy item of informntion shoulil b.- cnre'tully siippUcil. AHR should be stated f.XACTLY. PHYSICIANS Hhould
state CAlIsr OF DKATH in pliiin terms, that it may be properly clasHified. The "Special Information" for per- son* dyin^ away from home shoiilil be given in every instance.
V
» i
f I
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
/)a/r rih'il , h^tAylh^ ^
lUO'i
Jfr'(f/\s/(>/-rfl JYo,
2073
Deputy Health Officer
DEPARTMEM OF PUBLIC HEALTn=Ci> and County of San Francisco
Certificate of IDcatI?
1 11. 5. *5rnn^ar^ i PLACE OF DEATH: — County ol Cl ^\ VC City ofO<Xov 0 Vn i
. (Hi 4 n h ^ m :
No. ill \| ft.<mXatV>viN.u. lb>i St.; 1 Dist.;bet. O-XUriLCV.:; ;. andCtl
/ ir DtATM AccuRs «w«v t-ROM USUAL RESIDENCE GIVE facts called for under special information \
V, IF DEAT^ OeCUR«CO ^ A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. /
^ ^
FULL NAME
v-^.Lx.'>\o..
sHN (
• \ 11 ( li
PERSONAL AND STATISTICAL PARTICULARS
V I > I , I 1 1-:
g < , > , o
- \_'L
ox^fc
1^
>,i\
R01
MEDICAL CERTIFICATE OF DEATH
DA TK < ir !>i: \ rii n \
( Mnilth ) I I »;i s
•^I^.< , :.l* %f AR k II l>
BIKIfl I'l. \il*
'•^htf- .' '■ .mit'\
; k
-D
. I ni-:Ri;i;V niRTlI-V, That I attcn.U-.l ,hrr,i-~.<l In.m
tliat I la'-t '-aw h alivi- on ^-^-.^J- ' T<p H
aii<l that flcatli < h-cu rre.], cii the dati- stated ahnvc-, at '\ ' >r.^Thi- CAISI-; (»1- I)i:.\Tll was as follows:
I \ 111 i;r
lUR in I'!, \i K
or I \ I II IK
'^.Llti i It I'l ilMit
M \ 1 PIX N \M1
I >i Mt I'l" 1 1 1- k
Hik ni iM, \ri:
» ir V.i ill I KK (st.ii. ,t v'.iimti
HiM 1' \ IK )X
U 4i
I )r RAT ION }'riirs Mo>ilh^ fhiys
I lout V
DC RATION )V^/r.v
(Signed)
Months
/hi]
IIou
;v
^J
M.D.
\
€u
Cc > V V Ao. \v e ui ^ c
n»n
f A.hlnsv) Hb5
ft>\LaAi U^
SPECIAL INFORMATION only loi ll.is|Mfrtls, InstifulM, Trdnsienls, or Recent Residents, and persons dyimj dw.iv from home.
Kr^idfil lit Situ /;,■',>;•
M.nifln
i>ii\-
Hi" \i',()\'i-: ^ r \T!'i» i'l- k--nx \i, I'AK'ri'.r !, \k'' \hi; rkti-: ii » r
HKsT «»!■ MS KN« »U 1,1.;|)<;H AX!) i!!;i.ii;i-
cLOUmj^\X^v^'^L
{ I n !i i: iiinnt
. ^
N,Mn.. 1^1 M rUnxla ^^ . > ^^^K-U L
:T1
Former or Usual Residence
When was disease confrarted, II not at place of death?
HoH lonq a{ Place of Death ?
Days
I'l.ACH OI* lURIAI, Ok RKM<1\ \!, | DATKo! Hiimai .,: RrNtn\-\i
0^
IS. B. Rvery Item of infornifitlon shoulfl be Ciirefully supplied. AGB shoultl be stnteil F.XACTLY. PHYSICIAIN.S should
•tote CAUSE OF DLATH in plniii terms, that it may be properly classified. The "Special Information" for per- sons dyinft owny from home shouhl be feiven in every instance.
I ' j
I. .,'!)
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
' ^^ ••■■-^^ - '■■■ ' ' ' REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
I
"^ Officer
Ii.eijli,sh're(l J\^o,
^074
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of IDeatb
PLACE OF DEATH: — County of' a . , City of CJxx-w V\ o .. No, ^3jy\XKXkM L^»XJl^J:^,^ , wCu Ol Ov ^t4 ' V u • Dist.; bet. — and
(IF DEATH OCCURS A\Ay FROM USUAL RESIDENCE give facts called for under "special INFORMATION'- \ IF DEATH OCCURR^ IN A HOsjpiTAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. /
FULL NAME
\j
k, y\A
- \
I» A
PERSONAL AND STATISTICAL PARTICULARS
HlK I
, ^V'
MEDICAL CERTIFICATE OF DEATH
DA ri-; I >i- Di.A'in
0
^to!lt^l
I);iv
(N\;il
l);iv
\< .!■;
1C3 '
/>„
i: ril PL \."l'
I fli:ki;i;\' CI;rTI1-\'. That I attLMi.k-.l .leci-ascd from
— : up to ~ —;■■■- . — -
that T last s;i\v li -~ — alivr on
■~ Kp — Up
and that death occurred, on the dati' stated above, at — ^ M. The CAISI-. OI- I)1;ATII wa- a- tuUous:
X\M)- It)
I Sin I K
HIK in I'l, \' V
Ml- I \ III ! ■
M X :i»i:n; v \m j
111 Mill HI k
HIK 111 ri,Ai'|.: Ml Mirnil-H
< Ki' I ■ rxi it iN
I) I k A T I ( ) N
CON TR IIU rokV
) 'I'iir
Mont ha
/hiy
I Ion I N
Is f ' .if if HI V.?)' f'l it II
M-iiilli^
t) IS
DlkATloN
( Signed >
^t 3^ iQoH
9?>
}r,niths
L^A.'<n^jl?v 0. \Jj U). dLtLoc-i.^
^ax^
fliiHI S
M.D.
(
(A(Mress) V<fUrv^JLN,^
m
Special information only for Hospitdls Instifuflolf^V Transients, or Recent Residents, and persons dvinq away from Ijome.
Tin' \Hn\' ic ST \Ti'i> I'KKSMX XI, I' \k II. ri, \Rs aki; Tk iu;sT of MS- KNM\vij;i>< .I-: x\i> I'.ii.ii;!-
i: r< > THI-:
Unf.itininl
Former or Usual Residence
Wlien was disease rontrarfed, If not at place of death?
How lonq at Place of Deatli ?
Days
I'l.ACK <>I- ni'RIAI, OR RlSruSAI \ ^S ft A
I>ATK .if n
Hi 4
I 1 \ ■
C^
kl'.MoSAI. TQOH
Si1(lu-s
N. B. Hvery Item of InformntloTi should hi cnrcfully .supplied. AGE should be stated KX4CTLY. PHYSICIANS should
atntc CAUSE OF Di:ATH in plain terms, that it may he properly cfassiitied. The "Special Information" for pri- sons dyinft away from home should be felven in every instance.
M
I r
ipi
^.\
m
all
I. : :t'. I \
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
. REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
I' c
■S
7.9/9 4
Jlc^i sf rii>(l JSfo,
2075
DEPARTMENT OF PUBLIC HEALTJWity and County of San Francisco
Certificate of IDeatb
I 11. S. StnnDai'D ; PLACE OF DEATH: — County of 0 -CU^w J ^\XX^'vc\A/Co City of Oo^-yv 0.^.<X>\^AULCo
Dist.; bet.
U%A/yu\^^>^'>^<x^\AlA^UA vv v^t.; Dist.; bet. and
f ir DC*TH OCCURS Ayw4\y from ^SUAL R E S I DE NCE gi we facts called for under special information
V IF DEATH OCCURReQ IN A HOtPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER
)
FULL NAME
^^Ow^AJU
\)X\/y\j
iXx.
PERSONAL AND STATISTICAL PARTICULARS
u
r
4
•<<i,i »k ^
r-
MEDICAL CERTIFICATE OF DEATH
DA ri-; I >i PI. A in 0
'&
i N'tat )
\ I . 1
l^
ok
r>a
M \RKIKI'
HIK rtU'l \.'l
NAM! «il FA 11! ! K
lUH lli I'l. \. }% 11' i \ I HI K
-t.it. I ,t rtmiu ! V
MXIIH^V NAM!-:
Ill M<>i"ni;R
iiM- ni I'l, \r!-; •>i %ti ii'iiKk
••^1,1! I I i'liimt 1 \
' >'-A ri>A riuN
^0^
^ I m{Ri;i5\ ri.;kTlI-V, That I ittcipK-d ,KH,,i.r.l from
c
i,pH ti. pJOfi 'X%
that I last saw h vy-'j-v alivu on
^
^i.^xt XL
and til
■I' lUau
1 iiccurrcd, nii tlu- date '^tatl•d almvi.- at
4- M. Thu CArSK Oi- |j|;.\TH wa^ a^ follous
K^<XSjk.K.£X. c
DCR.MION )'i'ui.
CONTRIIU TORY
Mont /is
/hjys o Hours
DIR.XTIOX
)\'ars
^f<>>it/l^
NED)\!Tl. d WUx>lAi
/?rn'C
(SIG
'VC\. ',. *,
Ilout s M.D.
.Xddn-^s) S.S0O
^A^'U.
A%> '■,//',/ /;/ V,;m /'; ,M/.
M.,„ll,^ K_ o /)„,
Special Information only for Hospitals. Insntufions, Transients, or Recent Residents, and persons dying av»,iv from fiome.
Former or I'sual Residence
Wlicn was disease contracted, If not at place of death?
ftoH long at Place of Death ?
PdVS
Tin' AH<)\'K '-r \ ri i» i'Kh^i »x \i, i- \k riiTi. \ks \r i: ih i !■■ I'o I'li i- iiHsr ui MN' Is x< i\\i,i:!MU-: .\m> in:i,!!;i'
fA.Mnss is 0 0 0 x,\XA'ru:r\X 3a
;i,A<.'i': 1)1 iitkiAi, OR i<i;m<>\ \
XV>\AX.M ^ X','.
! ) \ !■
c ^ ^
\\ .1 RKMmXAI, IQO't
rNi)i:KiAKi:R J^^-^JLaXli ^^
(Address ^ SblX' .H i
IS. B. Rvery item «»>' i ii form iit ion shoulil be carefully supplied. ACB should be statetl l.\ \CTLY. PHYSICIANS should
•tote C AlJSr or nriA TH in plain terms, that it may be properly classified. The "Special Information" for p«r- Anns dyin^ away from homo should be ||iven in every instance.
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
,,.__^ I^E'^ER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
s- ■^. H\ 1' (■
10 OH,
Deputy Health Officer
JlegLsteird JVo.
;2076
,d La.
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of Seatb
< in. 5. i?tanCnr^ )
i "^ i Of?) ■
PLACE OF DEATH: — County of OO/n^ 0 .\XX/YVCX^C0 City of w/CU^v J ;u<X.'>^ o <^ <- <
« _j'
No, W VUUWU^' :L L ^ ^ C ^ • St.; Dist.; bet. - - -^nd
/ IF OtATH OCCURS AW«Y FROM U S U A L ' R E S I D E N C E GIVE FACTS CALLED FOR UNDER "SPECIAL INFORMATION ' \ V IF DEATH OCCURRED IN A HOSPITAL )0R INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. )
k
I \
FULL NAME
-I
d-
"^I'X
PERSONAL AND STATISTICAL PARTICULARS
Wu
> i i ( I !
(
MEDICAL CERTIFICATE OF DEATH
!) A ri; 1 !)• ni; Ai'n -A
V.zl
fMoiitlil
I I):IV
\« . i:
■^ I ^ ' 11 ■> ' ^ '■ ' ■ F K ! '
\\\u 111 ri. \r)
'^\
K >
L!
a,
I lll{Ui:};V Ci:f<TIFY, Thai. I .ittcn.kMl (U'cia^cd frnm
tliat I la<t saw !i.?». >i\ a!i\{. on
-t,
IC)0
T<P
)vr, at D
ami that ckath nrrurrcd, nn the dati- stated ah« ^- M. The CAT SI-; ()!• Di; API! was as foIlf)wsr
LwvCo
AJ,^-kxxs4uui, IDi-
N \M I ( I!
1 All! IK
nil- riii'i.ACH "I I \ niKk
--t.tr III r.,iinti
<n MOTH J. K
lUR'nil'I^ACH
«ti Miiriii:R
I Sl;it< u! t'ount I \
• »t V IP \ IK i\
Axxr l^^t
Uv
Cr'>\.q
Dlk.XTlO.N CONTRIIUTORV
Mi^uiln
\ /hns
d-3
I lours
^ \
1f.>f////s
fhjv
\
/^fi,!r,
f'l itH,
'^XOL
r> I )v,,/
DTK AT ION
rSlGNED) ll) to. ^U tvU
^' '^ ■'' fA.i.iivss) s^imoxt
fliuirs
M.D.
[i)0
<■
SPECIAL Information nnn for Hospltds, institutions, Transients, or Recent Residents, and persons dying away from home.
Former or Usual Residence
M.nithf
/)./!
Ill" \i'.M\'i-: '^r \ri-i) I'KRsnx \ 1. r NKTii'ti xk'^ xki jk! i: ro thi-; iu:>i' lu MS K N*i iw i,i;iH .M and iu;i,n;i-
K 1 1! fii; ina til
.u
When was disease contracted, If not at place of death?
\Vl ^5 1^ S HoHlonqat
f H LUaMIxXXiULC UOJu Place of Death ?
i UxJu
Oavs
i'i,Ai-i; ()i- lURiAi, OR ki:mo\ai,
A
^
OL/>'>u
\jOa
1
X^ Jt
IS. B. Bvery item of inV'.>rmnt!on should be carefully supplied. ACJE shi.uld be stated RX4CTLY. PHYSICIANS fihould
Btate CAlJSn OF DEATH in pliiin terms, thnt it msiy be prf>peply classified. The "Special Information" for pri- sons dying «wny from home should be ftiven in every instance.
I i
"J
I
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
- REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
" -•■ !;^i' V-
4* -P
^
^-vcv
M
Deputy H
h Officer
liegLsfercd JS^o.
(4
DEPARTMENT Of PUBLIC HEALTH-City and County of San Francisco
Certificate of Scatb
PLACE OF DEATH: — County of a rv J Xn , „< -_ Qty ofUcv^v J Axx-^'X.c c --
No.
I I
I s
F,
^
n
St.; 3 Dist.;bet. Hi I v and 'K 0
ruRS AW*V TROM USUAL R E S I D E N C E G I V E FACTS CALLED POR UNDER SPECIAL INFORMATION OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER.
)
FULL NAME
( J
A
Xaj^
KKJ^AAj^T^^KX)
PERSONAl AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
n ATI-; < »i !)!. \ 111
A
D.is-i
IV. al
X' K
I II!:Ri;n\- tlirni-V. riiul I alten.UMl .Uirascl fn.m
t
i',<
»K nivjii
A
i
V ■' t
Xj^
A
tl1.1l 1 la^t saw It .»-' aliNf on
aii.l thai (It .ilh » k curriil, .»n tlic dali' ^tati-d alxn-f, at l '5 0 I
M. TIk- CAISH Ol' m:Aril was as rollnw^:
Ml I »l III IK
nik ni !'i, \( K < »r ] \ ni HK
^' • • ' ( 111 n! I
M \ I1»HN NA^1 1 <>S MOTHHK
Hik III !M, \i i:
il Mii:ill-K "■i.iti 1 a t'liuiit 1 N
I >v*'(p \r;< r
0
(
u
K^
>
k
DIR ATION C<'NTRir,rT
DIR.XTIO.N ( SIGNED )
Pax
II,
tifrs
},,i
IS
n\.
M,i>!lJlS
1)0 »^
/>,
/ I s
//i^N I s
M.D.
HK'
(A.l.ln-ss) it I'l iL^O.
SPECIAL Information onI> for HospiJah, institutions, Iransients, or Recent Residents, and persons d)in) away from home.
rm-; auovk sTAii't) im-ksonai, tak iiiii, \hs .\ki-: tki. j-. r< > lu-sroi MS K xi )\\i,i;i)('.H A\i> i;i;i,ri:i''
!•:
Former or Usual Residence
Wfien was disease contracted. If not at place of deatfi?..
ftoH lonq at Place of neatf? ?
Days
fin fiiriiiattt
'XA.^^aX^^
<X/"v^
> L, . V '
\.M
)A I'l'. ,)!' I'.rHiAr,
I'l, ACi; ol- HfRiAi, OK ki-;movai.
I ni»i-:k rAKJ':RVyyVCUi. «t' V Ja^ ,v .
I
KHMiJX AI, TQO';
IV. B. F.very item oi inf(»rmation should be cnrefully supplied. AGR should be stated HXACTLY. PHYSICIAINS Hhould
stntc C.AlJSr OP DHATH in pliiin terms, thnt it miiy be properly classified. The "Special Information" It'or p«r- fions ds'infe away from home shouhl be 6,iven in every instance.
«
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
t 11, ,:ili I \., .- ':■- '^ ~.^ i;^,!' r.,
Ihilr Filv,l. PctXov S
REFER TO BACK OP CERTIFICATE FOR INSTRUCTIONS
^mmfmrnfammnmin
I !) 0 H
0 ^
Jlr o' /,<:/(> /-r (I jYo,
J^o?8
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Gcvtificatc of IDcath
No.
PLACE OF DEATH: — County of
AtV ofC)
\<X/Vc^^«.>ax^t) City of-'<Vvu O/UX-vxCv^^r ^
4
Dist.; bet.
and
; - ^- • 1 -vw-w, j^iiju, ucu ^ ana
/ IF DFATH OCCUBSlAW«V FRO|| USUAL « E S I D E N C E G I V E FACTS CALLED FOR UNDER "SPECIAL INFORMATION ' ' \ V IF DEATH OCCUl^RED IN A>lf<OSPITAL OH INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER /
FULL NA[V!E^<XAAKxX^\j
-^
v ^
-l.X
PERSONAL AND STATISTICAL PARTICULARS
;
V
I' \ I 1 ' il HIK 111
\< .H
WlUnw ! 1 1 Ilk : I \ I i
I: \
N \ M ! t 1 1
r \ I'm H
MEDICAL CERTIFICATE OF DEATH
DATK Dj- I)i:.\ I'll \
L*
r<}n
IV. ai!
t
/',/!,
•Ml Hit 111 I):t\i
I IIKkKBV CI;RTIFV, Thai I atU inU-.i .UH.asci fn.m
I ( )' )
that I last saw li alivt- on
ailil that (kalh mHurrfil, mi f hr A.\\v ^-tatid ahiivi- at
It/)
f\
lUK ill PI, \V
• »• 1 \ in IK
M X IDI'N" N \M 111 MMlinK
nils I'll IM. AC IC <»i Miiilll'R
■ ■*! it 1 -A I '( mill \\
M. The CAI SK (»1' DlXlil was as follows : .K-X^t^K^ix^^tL Orv^jLevN^-oslb lix-^-L^vVLJ%xt'a^
i-v L;
\ -<^-
Di k \ rioN c<>.\TRinrT()k\
Dlk ATION
M,>uths
/hn
I lout \
Yra
r<
M nths
/hivs
( »iA' r r A III »N
/■
,^
MwO^Lu.
f SIG
NED )Ur\^xJl^ J Al^.U) dULL<X/vudL
//(>urs
M.D.
X
( A . 1 ( 1 r.ss ) L.tr\..crvUlM
t:
SPECIAL INFORMATION only for Hospitals, InstitufioWs^ transients, or Recent Residents, and persons dying away fron tiome.
Former or Usual Residence
aa
<A.XX,A,^
4 t
HoH lonq at Place of Oeatti ?
1/, -,'//-
Pnv
Tin-; \Ho\i-: sr \ri- r» 1'i-;rs»»\ai. i- \h !"hm"i,ars a ri; rRiK to I'li i; lusi'oi' .M\' K N< >\\ i.r.ix .1-; AM) in;i.n:i-
(Inf.Hm.nU M lUyC^VJUL WOw^A^-rxLlX^ '^
Davs
When was disease contracted^ If not at place of death ?
nxil^.tf Hi M!Ar. Ill HKMOVAI. ^ ^ ^^ TOO H
I'LAOK OI- nrRIAF, OR RHMOVAI
I N I ) i; R T A K 1.; R U ^OJJj-YVjb \ I J^^"^ ' ^ * > ^ ^
^. B. F.very item ni liiformBtion should be carefully supplied. AGB should be stnted F.XACTLY. PIIYSiCIAINS should
stutc CAUSE OF DEATH in plnin terms, that it mny be properly classilfied. The "Special Information" for p«r- finns dyin£ away from home should be <iiven in every instance.
|
I |
y |
||
|
■uli |
|||
|
^i:U |
|||
|
1 |
'■*^^M |
||
|
} |
|||
|
i |
|||
|
f i |
1 |
1 |
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
'!.('!!. 'Ill I N ,
\'.S.V I
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
Dn/r /'V/r./, L.el(rUc\; Z
U)(n
M^cc<i
Begisfered JVo.
20?9
\Kj Deputy Health Officer
DEPARTMENT OF PUBLIC HEALTH-Cit)- and County of San Francisco
Certificate of IDcatb
( 11. £. 5t^n^nr^
r>f«.
PLACE OF DEATH: — County ofd/OAv J Axxoo^cvAci City of CjOla^ o Axx^^vcc<s r« < U>Vt\XU.^%CM. UwCVdl-M^^l Dist.;bet.
K<X.
and
/ ir DtATH occurs/Way rRoii USUAL rIESIDENCE give facts called for under "special information- \
\ if DfATH OCCURRED IN A S|<OSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. )
FULL NAME
I tax.c4va >v':^.
PERSONAL AND STATISTICAL PARTICULARS
^ r< »l.< iR \
<X.U
rf
MEDICAL CERTIFICATE OF DEATH
i> \ ri-; < M- !)i;a III 0
i» \ ri; ( ii i;iK 1 11
/^i'i
I>:i%-
Jjj/vt
M..:iUri
'! , ,
/ (JO ' I
\' . I,
/',
: I i>
WIIHIWI
I Wt itf ill
lU!; ;•!! ri \ 1
1 lll';ki:!;V CI':RTII-N', Thai I attLMi.U-.l ,k.,-,.asc,| frniii
I (/) t< ) 1 iff)
that I hist saw h —
alive oil
Icp
and that (h ith ( icciirrtMl, mi *J\v <la*( sfati-d aliovc at
M^. Thf CArS)-: OI* hl-.ATII was as fo]|,,ws:
CH-<L<; > ' ,\.o
VJ-\,MKX>U. vDi\A^Ay»%C)
I '
VAMl (.1
f- ^ 111 I i<
ni k I' 1 1 1'l, \i' J^
< tl 1 A 111 I- H
^1 .' ■ ;
M \ • •
N \ M 1 ,
!)!' RATION
CoN'I'KIinToRV
} 'rtir
Moutfn
Da
rv
lloi
Its
>: '.:■ 1 i II i.k
iUKriii-i,A> i: <M M<iiin:R
I >t*it< 1 ,1 ii milt I
< »< I ! !' \ r Ii i\
1)1 'RAT ION )',iirs
(Signed ) Lox^crvw^^
6x>
%
'iriuu/is
/hiY
3-H rqoH rA.i.lriss) UA-'
XLUx >
, A
M.D.
0-yUA>6
SPECIAL INFORMATION onlv li»r Hospif,ils, InstifiKians, franslfnfs. or Rctfnt Residents, and persons dyiti) dwdv frnm home.
f\f Itlfii III S'i'tf /'iiniilu'ii
V.>ii//n
Ih
'I'll H ^isovH s'l'M"!-;!) i'Kksov \i. 1' \ K lu r I xksaki; ik; i; r<> riii:
liu
Former or Usudl Residence
When was disease contrarted, If not at plar e of death ?
HoH lonq at Pld« e of Drafh ?
Days
I'l An-: oi lu kiAi. (IR ki:M(.\Ai, I \)W^.,,\ i'.' I \i. Ml ri:m(.\ai.
I !l fill iii:i til
\j:f\Ary\jJ\M
\,l,|n.ss --
^
NDHRTAKI'K J\JLaJLX<-JL H. UC <X C^O, ^V
I
M. B. Jivcry item of inforination shouicl be cnrefuMy supplied. M\T. should be stntetl F.XACTLY. PHYSICIANS nhould
«tiitc CAllSr or ni ATH in plnln terms, that It mny i»c pr«»r>'-'»'ly clonsifled. The "Special Informiition" for per- son* tij inji nwtiy from home Hhoiild be ftiven in every instance.
i
n<.:n,
I h I
i:K r ( ,,
/J(^/r /'VAv/, ^^
1
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
w
bx.K^y-^
u Deputy
h Officer
DEPARTMENT OF PUBLIC HEALTH-Cify and County of San Francisco
Cevtificatc of ©catb
I XI. S. 5tan^ar^ )
4 ^ ^ ^
PLACE OF DEATH: — County of C\a>X' 0 Va,ixci4CoCity of O/Ct^YV ^KKX/yxcuic^
No.<
1U\' 'Lacaivt '^Ji...Vci St.; H
Dist.; bet.
and
( IF DEATH occJbs away FROM USUAL RESIDENCE give facts *called for under 'special information \
\ IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER J
FULL NAME
lai!
VC\.LlXi
i
v.v.
'<dL
(\\
oxju
PERSONAL AND STATISTICAL PARTICULARS
It \ i 1. « li
1
a'
11
\\^
n \
Dav
3.C)
L
MEDICAL CERTIFICATE OF DEATH
DATi-: . ii m; \ III _ , ^
iNfotith) I)av> (V.ai
I ni;Ri;i5\' CI:RT11-\-, riiat r att.n.k.I .kc^a^d fn.m
that I la-t saw h X>U alive on iL ctT ^1^
upH
■^i \ i; i- 1 1 [1
ri
x )
in '.' I'n ;■! n .■ k
I \ I'll t K
iuk r H iM, MI.; ')' 1 xriii'K
M A N>!:X V \Ml-
or M<>rin;K
lUKIFI I'I,AC1%
'>! M<.rHi.;i<
o.tirA 1 KIN
Ix
(X^\. J .Vet ^ VCMLCMi
1^tk>\,
<X\
kUi
ami that <li'ath occurred, on the ilatr stated above, at b ^ M.. The (*.\ISI{ OF m;.\ri! was as follows:
Mlcur J (^-wovA^ ^ d.
^
Dr RAT ION* )V.;;s- 3, J/,>„///s L Days
to N T R I n l" T <) R N- A. . .„ N ^ \Xr7vtXv^,v<i a. AVCL;
DC RATION (^SlGNED )
//o
ID S
(1)
)'iiirs
i(»o H
\)
(A<l.lress) '^1 Vj CKtA)4,il 8t
SPECIAL INFORMATION only for Hospitals, Insmutions, Translrnls. or Recent Residents, and persons dyinq dwdy fron fiome.
/\ri.lr,i : ii s,,)> I'l ,!ir
'\^
t
) \/-^„'//-
H
/).
(hi fi)* niiiiit
Tin: \Hn\}' ^r \rj'i) i'kkson \i, pxk rn'ri, \hs aki; TKri-; I'u iii i: ni:sr oi M\ K \(>\\ij.;i)<,K a\i> iu:i,ii:t'
Former or Usual Residence
When was disease ronfrarled, If not at place of death ?
HoH lonq at Plare of Death ?
Davs
IM.ACH OI- in R[ \I, (IK
U^
\i\)\Ji:L^-
K i:n'i >\ ai.
l)\ri.ii.' Ht KrAi, (ir KKM«»\AI,
iqoH
rxDi-KTAKi-R LolVXOU" ^^ L^xoXMi,ni
(Address '^, .U/CLO^ y\iA4
IN. B. F.very Item of information should be cni-efully supplied. AGR should be stated EXACTLY. PHYSICIANS should
stntc CAUSE OP DEATH in plnin terms, that it may be properly classified. The "Special InforniHtion" for per- sons dyin£ away from home should he ^iven in avery Instance.
«
}•„.:, u] ,.( !i, ,11), I V
WRITE PLAINLY WITH UNFADING INK-THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
t.£^.^^
^»:r?^;!!&l'Oo
ySXi 6
190H
Jieo'lstcred A''o.
20H i
DEPARTMENT OF PUBLIC HEALTH-=Ci> and County of San Francisco
Ceitiffcatc of Seatb
( tl. S. Stan^arD )
Am J) Q^
PLACE OF DEATH: — County of'"^CL-.v OK^^xcu^Oiy of Oxx^ J^UC^^vCc^ec
No.
a ^ D. L CU :.. L ^ V C A X St; I 0 Dist; bet. a 1 ^<i and 1?,aA
( " .■^/•;\°'^^^''^ *^»^ -"o« USUAL RESIDENCE GIVE facts called for^nder "special information N
V IF death OCCURRtD IN A HOSP.TAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STR EET AN D NUMBER )
FULL NAME '\'C^^^^JL^
L
PERSONAL AND STATISTICAL PARTICULARS
-•IX A * I COLOR
€U\XA>LL
I'Ai}-: ( ii luk I II
w.
rX>
dLsL
M..iithi
A<,K
5i
I>;iv
1/ '»/'^>
( Vear)
/OOH
/ hn.
*^IN<.IJ- MAK1<II !•
U MX >\\ l-;l» OR l»;\ I t'-M |.|,
lUkPHPI, \C}-.
^I.lti I IT I (1)1 lit t\
\ \M 1 ( U 1- A Til l.k
MIR rillM, \CV.
f»i. I \ri!|.;K
I stall ur I'liiint 1 \
mahh:n' namk
<>1 MoTIIKR
nTRTiipr.Aci-:
I Stat! i II I'ouiit I \
MEDICAL CERTIFICATE OF DEATH
DATK OF DICATH , A
(Motitli) ,i,;,y) ,Vrart
- 1 II1';RI{BV C1':RTII'V, That J atten-ld decease.! fnuii I 190H to U/ct; I np1
that I last saw h A/A^ alive on U-^vt ^^ j^ ^
an<l that death occurred, on the dale ^ta(c<l above, at Si
yj M. The CUSI- ()!• DIvATH was as follows:
.KKJ-
Dr RAT ION 3 Years L .Voui/is Days Horns
CONTRIiUTORV LL\.aX^-c^lL ALcr . ^^J.AM)^vUi
DIRATION
">
)'rars
'^fouths Days
iytfc 3 ic)oM (Address) 153)0UUild*
(Signed) V'^J'cclx.a
Hours
M.D.
oiiTPAIK
Special Information only for Hospitals, Insmullons, Transients, or Recent Residents, and persons d>ing away from home.
rm: \movk stai"if) i-kksonai. p\u iui i. \ks aki: ikih to tiii-;
III-;ST ol' ,MV K NOW i.iix.H AM) lu;i<I i; I'
Former or ' K . y - J , . 1 V How ionq aX ,. ^,, *a Usual Residence iP-'UU AKJt<UAX LoJU. Place of Death? ^^ ..
When was disease contracted, If not at place of death ?
Oiys
I'l.ACK Ol- IITKIAF, (»K KHMoVAI, I DATK ..f Hihiai, or KHMoVAI,
n
fill fonna tit V-.A./^./OU
(A-Mr«-.s
(Xaj^ C
V
I- DIKIA
f Address . .31 "^ U J /ZkKhXlX 3i
I90H
INDICKTAKK
N. B. Kvepy item of inform«t!on should be cnre?ully supplied. AGE should be stated EXACTLY. PHYSICIANS should
state CAUSE OF DEATH in pinin terms, thiit it mny be properly classified. The "Special Information" for per- sons dylnit away from home should be 4iven in every instance.
t
WRITE PLAINLY WITH UNFADING INK —
n.-.M^i of !i, :iiii, !■ No is t-^^*^,, i:«ti'0<,
4^ -p
THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
.\J 3
100\
Registered jYo,
2m2
^^■/VA^A^l.^
«l
DEPARTMENT OF PUBLIC HEALTH-City and County of San Francisco
Ccitiftcatc of Scatb
( XX, S. Stan^arD j
PLACE OF DEATH:— County of^ct^^ "^ \ 0L^vc^4/:cGty of ^cl^ 5x<x
^ V C K. C^ -co
No. bOT
0 ^
-V
oU^vr>Vu St; 3. Dist.; bct]aXlJ<5\/>v\X]u and d CUXXXAVLlAiKs
f .r nl'' °*=^"''^ •^•^ ^"O*- USUAL RESIDENCE GIVE facts called rOR UN^ER ■'SPECAL .NroRMAT,ON^\ ^
V IF DEATH OCCURRED IN A HOSP.TAL OR INSTITUTION GIVE ITS NAME INSTEA^OF STR EET AN D NUMBER )
FULL NAME
^U^^-y^^Oj
mLcl/H
<X/rLcu)
--1 \
PERSONAL AND STATISTICAL PARTICULARS
a
i» \ ri'. <i! i;iK in
X < . »■:
•M..iithi
1
(l)av)
i
MEDICAL CERTIFICATE OF DEATH DATK OF DEATH //A
I
Ik
rgn
(Month) (Day) (Veat
5o )-,.■;
yr,„ii)is
3
i
Vc:u
Ihn-
\^.K.
I HI:RI':HV C1.;RTIFV, That I attciKkMl <krca.sed fn.m
H t.. €\/^ I
^^.Q i \(p'
^
up\
i
» I
Ul It. !!!
lUkTiUM, xrj-:
(Stati iir t'liiiiitrx
\ \\!l' Ml I A III I'k
lUK rillM, At K
< ti- I N I'll Ik (Hlat« .IT r, MHiti %
M\!I>J;N NAM!-:
<>i .M()Tiii.;k
liikTni'F.Ari-; '»! Mi>'nn:K
I stall III I'ouiit I V
.it :..ll)
.>w
<i
A
>cv. va ■>\j
I
?
that I last saw li-t.>>A alive on U/ot I icjo H LO
atid that ikalh <irciirre<l, on thi- liaU- state*! above, at S ' Uw :M. Tile CAISI-: Of- I)i;.\TII was as follows-
i
DTK AT ION 4 )'t'ars Miuiihs
C { ) \ 'J' R I lU 'T ( ) k \' ' 4\. ^.\
Days
Hi
ours
cT^
I ) r R A T I ( > x
)\'ars
V-v
.'Sfi^fiths
Days
■\
Rfsidrii ill San I iiiiiii-iit ^ ),,! i ■■ ^ '^Jinitli^
( Signed ) LI. ^-^ L uxU.
Ij/./ctj I ic)oH fA.hlress) iDDH L)Umj^ 5tj
>tifufWns7
Special information onlv for Hospitals. InstitufMns, Transients.
or Recent Residents, and persons dviny dH.j> from liome.
I hi I
Till.; AHOVI-: sr \ I'Kf) I»KKS(1NA1, I'AKTKI I.AkS AKi: I'KI !•: TO THJ-:
HKST ()!• Mv KN<)\vi,];i)c.i-; AM) ni:i,ii:t.
(Infotmaiit
^.-1.^
Former or Usual Residence
Wlien was disease contracted, If not i\ place of dcatli ?
How lonq h\ Place of Oeatli ?
Days
IM^ACK OI- niKIAI, (»K RHMoVAI, J DATI-of Hi hiai, ..r KI-;M(nAI,
X.l.hcs^ Ho^X si^ A.VkX/Cnv'VAj i.Jt
/D
T90*<
N. B. Kvery item of information should b- carefully supplied. AGR should be stated EXACTLY. PHYSICIANS should
state CAUSE OF DEATH in plain terms, that it may be properly classified. The "Special Information" ior par- Hons dyin^ awny from home should be given in every instance.
t»
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
Board (if II ■ > \ '-' zf '-. Ik's; 1' Co
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
Re^j/sfcrcfl jYo,
2083
<vvcA N ' I Deputy Health Officer
DEPARTMENT OF PUBLIC llEALTH=City and Connty of San Francisco
Ccitificatc of JDeatb
PLACE OF DEATH: — County ofUCL/Tu J^-XX/^VCUl.CCiCity of 0<X^V J .^^XX ■»VC-Ci''
No. 'liH?5 >l/lc''v.v,'cL'^.. St.: b Dist.;bet. I'^'v.'^. and V\ U
r IF DtATM OCCURS AWAY FROM USUAL R E S I D E N C E G I W t FACTS CALLED FOR UNDER SPECIAL INFORMATION' \ \ IF DtATM OCCURRED IN A HOSPITAL OH INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. )
FULL NAME ^6^Kxyy
\)
n v
t
uavu
-(;\
i>.\
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
tTlol.
kill
fU(
.0^
Month)
\( . I-
^1
1>,I\ I
1/ ,,'1:
\ . .1! i
DA'Pl-. nl Dl'AIIl
I'ct
1
Dav)
/on I
(Viat)
-9
w riH i\\ I' I » Ilk 1 1 ^ I u ■ •
lUK nil! ^>- ) "'^tit' . .1 1 . ,11111 ■ \
)w
OJxM^o
^4
4X/v>v<x.i
A k
iMoiitll)
I i!i-:Ri:r.\- ri;kTii\-, That i.ittcu<k..i .u«t:isi-,i f,,,iii
that I last '^aw h *>> >- . .alivf on nL C\^ X lip '\
iikI that (k-ath occurred, on the >\n\v <tatii| aliovc. at >. ^-^ M. The CAISI' i)V !)i; ATll wa^ as follows;
N \M1 ( II
I- \ ill i;k
p.iK rii i'i. \( i<:
MM i<i;n' N \M I
Ml MoTHHK
niK ruri, Ai'K
ill MtiillHR
' -' :' I -l (■( III lit! \
I >i>- IT ATIDN
nri-i\ri<)X )•,,,;. Mouths Pays
Jh)i
lis
COXTRIHrT
..\jQy-^-v\, <.
\xxk'
DURATION )\'ars
(Signed) v
Hottts
V I<)0
J/iif/Z/is /hirs
^X^UMXt M.D.
SPECIAL Information onh for Hospitals, Insntytlons, rransienls, or Recent Residents, dnd persons dyinq nvtay from tiome.
'^ ^ v'-vv.XK-
f\/''ii!f'i! ! II ^.;>> f ) ii III nro 1 .>
U..„//n
Former or Usual Residence
Wfien was diseasp rontrarfed, If not at plare of deatti ?
How lonq at PIdf e of Deatti ?
Days
'I'n I". \!!(»\'i" ^1" \ riu I'KRsoN" M, r\K TTii t \Rs SRI rKfj.; iU';sT <)i MN isN« iv\ i,i;i»< , J-: and lu.i.n.i
(Inf-.n,.aiit Uj Ow^K- Jl^cLcL ' fUxhJV
1) rm-;
I'l.AOK <il- IHKIAI, OR KK>tn\\i,
Qllt
^ltLAN4±
IiXri'i.f I5i PiAi iir RHMuX'Al,
T90H
r.Nur.R iaki:r Ow ■ -J 0-Ca^V\,A^
^\(l<lr< ss I I 2)1
A^'^X
Pi. B. Every item of iiiformation should be carefully Hupplieci. AGE should be stated f.X4CTLY. PHYSICIANS should
state CAUSE OF DEATH in plain terms, that it may be properly classified. The "Special Information" for per- sons dyin^ away from home should he ^iven in every instance.
I »
%
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
ll.alt!
"^. !1^1T„
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
I)(f/r Fihul ,
.0^-oU)
\
3 V)0\
Deputy Health Officer
ll('!di'^tci'('<l JVo,
2084
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Ccvtiticatc of IDcatb
I in. 5. StnnDarD i
4
ni
PLACE OF DEATH: — County ofvJ/aj>%' O A.<Xi-^cu<i.e(N City of 0 CL^v JA.o ,
i[
li^
^Na.VxT^l;uxiJ L>>\X;U5uUvvCH L C^^^^UulaA Dist.;bct*
and
/ IF DEATH OCCURS aAjAV FROM liS U A L R E S j D E N C E G I V E FACTS CALLED FOR UNDER "SPECIAL INFORMATION" N \ IF DEATH OC'-'RI^Vd IN A HOaPITAL OR INSTITUTION GIVE ITS NAME INSTFAD OF STREET AND NUMBER. /
FULL NAME
t 1 fvil
UuV^
- 1 \
1 1 \ I r ' 1 1
PERSONAL AND STATISTICAL PARTICULARS
i 1
/
I M-.tlthl ll:i\ '
MEDICAL CERTIFICATE OF DEATH
iiA ri-; (ii- Di: \ rii ,
W I I 1. .w . I 1 ,
ii!K I'ni'i, \.' I-;
^\,S\I I ,• I . 11 III
X \ ^t i III
I \ ill i;r
!UK r II I'l, \' 1
< •: I \ III IK
■^t l! I I il 1 I Ml II
(ti MM'nii R
' ^! it 1 1 i! ('(Hint I \
I »t ( rp A'liox \
Cjv
V
^
i ^tl.|l'lil • . Kav)
I Ill-:ki:i!\- CI:RTII'V. That F atteu.U-.l .InHa^d fruiii
that I last s,i\s h alivt- <»ii -- jip
and thatdtath < xi ii t rt-il, cni thf <lntc statc-d ahovi', at M. Th.- C \I -:• i>\ l»i':.\TII was as foll-.ws:
i r. *. N. '
A
{\
DIUATION }Vuis
CONTRIIUTOKV
DIRATION ^ ),,/rH
Mouths
Pa
J'V
I /oil Is
W
<X\M
I
(r
(SIG
( NED ) \J^
m
Mrulhs
/hus
\trA\jUv
%v
dL
Hours M.D.
'-1 0 k 1 '^■
U)n
\d<lri-ss) MrX^vuL^U Cn^
Special Information onb tor HnspiiaK insfitutfeiis, TMnsifnts,
or Recent Residents, and persons dyini] dWciy from tiome.
k,
/ ; t II, I ,-,l TS -) )'l'll I
M.Hltln
Ihn
Tlir \Ht )\! -^1 \ I 1 n l'KR-< >XAI, 1' AKTFtTl, XR-, ARK TR t*l" '!"' » TIIH
)!i->^rni M, KNi »\\ i,i;i».;i.; AND hkijki-
( f n f()' ill
mt 0 yK^^
\J
X.Mrc.s ^XS \t
Former or Isutil Residence
When was disease confrarted, If nut at place of death ?
HoH lonq at Plare of Dcalli ?
Days
I'l.ACJ" <)I- r.IR I \I, (»R RI"M()VAT, | UNll ' Ili|.'i\t
i:m<>v Ai,
I QO ' 1
INDl-.l
Ad.lit s.
^A>4. w«
IS. B. livery item of informntlon shoulfl He cnrefully Huppllecl. AGE nhoultl be stated RX4CTLY. PHYSICIANS should
• tnte CAIJSI: OF DEATH in plain terinM, that it may he properly classified. The "Specinl lnformati<m" for ptr- nnns dyinifc away from home should be ^iven in every instance.
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
,._,_,..,^.,________ REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
J)(ff(' Filed
0
Registered J^^o.
3085
l<rU^\. a 7/y^H
Deputy Hoafth Officer
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of 2)eatb
I tl. S. Staiiear6 ) PLACE OF DEATH; — County of d\ 0 \a^\/CAulcoCity ofO<X>\; XVa>XCU^oo
No. -t \1 iWu^ liVviKciaA) St.,
(IF DtATA OCCURS *WAir FROM USUAL IF DciTH OCCUKRCO IN A HOSPITAL
RESIDENCE GIVE fa
OR INSTITUTION GIVE
Dist.; bet.
and
FULL NAME
4
CTS CALLED FOR UNDER "SPECIAL INFORMATION • \ ITS NAME INSTEAD OF STREET AND NUMBER. /
PERSONAL AND STATISTICAL PARTICULARS
Wrf\j
l
'\
yy\XUJ>^
• \.\ y
Ha
v(»I,uK
:> \ ! I < >! luk in
c w.t.
N!o!it)i '
M.V.
Dav)
M •uth
(Year)
/hns
MEDICAL CERTIFICATE OF DEATH
DATK <)1- DI.ATH \
Day) (Vt-ar)
^IN'l.l" MAkRIi;!)
\\ [III t\\ i'i» OK i>:\i iKi i:n
' Sfnti or CiMifitry
K
I- \ III l.R
nik III I'l. \v"K ni- I AiHHk ' StMli- or c'diinti ^
MAIIU-N NAM1-; ni Ml en IKK
lUk I'llIM.MI':
ni M<»rm-:k
( '^tatr or I'onnt 1 v
ccL^u-vcL
(
iMoiith) I Hl'KI'UV Cl-RTII'V. That ] attcn.k.l .kacMstMl from
U \t aa 190H to t ot 3) u)oH
tliat I last saw h A-^T^ alive on WxA X up H
and that death occurrcjl, on the date stated above, at 1 LI -.M. The CAISI^: OF DI-ATIf ^va^ as follows:
^'^'^^\yJ\JLAAA^^^>^ \Xx^<,yyJL
Dr RAT ION
)'t'ars
Mouths
L
A.
0 (
r>
Day
/lours
r
c:^
CONTRimTORV C ..|^»iMxtl.frVA. .^.^^<tatx.ot^>^x^ I
DIRATION
} 'cats
Mouths
/)av.
Hon
rs