Record of Orphans Half-orphans and Abandoned Children (1900-1914 & 1929) (243 pages)

California State Board of Health 1 PLACE OF DEATH BUREAU OF VITAL STATISTICS State Index No.__COUNTY OF SHASTA STANDARD CERTIFICATE OF DEATH Local Registered No. of TOWN OF ; (If death occurred in . OR é : a hospital or institution, CITY OF. = : Eetrercae ; Se cae give its NAME instead of street and number, and fill out No. 18.) PHYSICIANS statement PERSONAL AND STATISTICAL PARTICULARS): whee ooh coo CERTIFICATE OF DEATH Exact 3 SEX . 4 Coror or Race 5 ONGE oS oe WIDOWED, WYr Cant SO eS i se 191 PE é Lz A OR DIVORCED burt arc WRI‘! E the word 6 DATE oF BiRTH Day Year classified. See instructions on back of certificate. ~ x If Less than lidays 2 hre. __min? The CAUSE OF DEATH ® was as follows: 8 OccuPATION bal Later tulvaed (a) Trade, profession or particular kind of work and that death occurred, on the date stated above, aver MM. AGE should be stated EXACTLY, ‘b) General nature of industry, business, or establishment in which employed (or employer) 9 BirtHPLAce State or Country Soa 10 Name or FATHER Mu fount _ Contributory 11 BirtTHeLAce Secoudary oF FATHER ee State or Country AA. Bee 2 s 2A Fay 12 MaipeEN Name SIGNED prey a 11-2. Ca 13 BirntTHPLACE OF MoTHER Va “oe * State the DIsaSE CAUSING DEATH, or, in deaths from VIOLENT State or Country oo CAUSES state 1 MEANS OF INJURY; and 2 whether ACCIDENTAL, SUICIDAL, HOMICIDAL. D FOR BINDING RVE Duration SI ~ “4 MARGIN RE PARENTS important. 13a LENGTH OF RESIDENCE P 15 SPECIAL INFORMATION ONLY FOR HOSPITALS, INSTITUTIONS, At Place of Death y ¥------------months TRANSIENTS OR RECENT RESIDENTS is very Former or How long at eS j ‘ ' S 14 The above is true Kes best of my knowledge Usgel. -Besidence.-:--. .-~. : ; ance cs CERES) eee : FGA 7 Where was disease contracted, Informant . __: ’ F if not at piace of death? In California_____ae, months 0 r Q Q W Fs ' Z W Z < z r3 W a ¢ 2 0 I < Z Q Z 0 < Le Z 2 I E 3 Ds di Z e < J a W E C4 3 Address . : Be Lot eet a eel! 19 PLAceE oF BURIAL OR REMOVAL . DATE OF BURIAL 15 Snbregistrar. 0 Aopress hould state CAUSE OF DEATH in plain terms, that it may b> properly OCCUPATION & N. B.—Every item of information should be carefully supplied. Filed

California State Board of Health 1 PLACE OF DEATH BUREAU OF VITAL STATISTICS State Index No.__COUNTY OF SHASTA STANDARD CERTIFICATE OF DEATH Local Registered No. of TOWN OF ; (If death occurred in . OR é : a hospital or institution, CITY OF. = : Eetrercae ; Se cae give its NAME instead of street and number, and fill out No. 18.) PHYSICIANS statement PERSONAL AND STATISTICAL PARTICULARS): whee ooh coo CERTIFICATE OF DEATH Exact 3 SEX . 4 Coror or Race 5 ONGE oS oe WIDOWED, WYr Cant SO eS i se 191 PE é Lz A OR DIVORCED burt arc WRI‘! E the word 6 DATE oF BiRTH Day Year classified. See instructions on back of certificate. ~ x If Less than lidays 2 hre. __min? The CAUSE OF DEATH ® was as follows: 8 OccuPATION bal Later tulvaed (a) Trade, profession or particular kind of work and that death occurred, on the date stated above, aver MM. AGE should be stated EXACTLY, ‘b) General nature of industry, business, or establishment in which employed (or employer) 9 BirtHPLAce State or Country Soa 10 Name or FATHER Mu fount _ Contributory 11 BirtTHeLAce Secoudary oF FATHER ee State or Country AA. Bee 2 s 2A Fay 12 MaipeEN Name SIGNED prey a 11-2. Ca 13 BirntTHPLACE OF MoTHER Va “oe * State the DIsaSE CAUSING DEATH, or, in deaths from VIOLENT State or Country oo CAUSES state 1 MEANS OF INJURY; and 2 whether ACCIDENTAL, SUICIDAL, HOMICIDAL. D FOR BINDING RVE Duration SI ~ “4 MARGIN RE PARENTS important.

13a LENGTH OF RESIDENCE P 15 SPECIAL INFORMATION ONLY FOR HOSPITALS, INSTITUTIONS, At Place of Death y ¥------------months TRANSIENTS OR RECENT RESIDENTS is very Former or How long at eS j ‘ ' S 14 The above is true Kes best of my knowledge Usgel. -Besidence.-:--. .-~. : ; ance cs CERES) eee : FGA 7 Where was disease contracted, Informant . __: ’ F if not at piace of death? In California_____ae, months 0 r Q Q W Fs ' Z W Z < z r3 W a ¢ 2 0 I < Z Q Z 0 < Le Z 2 I E 3 Ds di Z e < J a W E C4 3 Address . : Be Lot eet a eel! 19 PLAceE oF BURIAL OR REMOVAL . DATE OF BURIAL 15 Snbregistrar. 0 Aopress hould state CAUSE OF DEATH in plain terms, that it may b> properly OCCUPATION & N. B.—Every item of information should be carefully supplied. Filed