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Collection: Original Records > Grass Valley Orphan Asylum
Record of Orphans Half-orphans and Abandoned Children (1900-1914 & 1929) (243 pages)
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Page: of 243
CL DEATH CALIFORNIA STATE BOARD OF HEALTH
County of i
BUREAU OF VITAL STATISTICS
plain
Town of s an viet ORIGINAL CERTIFICATE OF DEATH State Index No.
City of i peniist-pd — Local Registered No. a 7.
hs Ward If death occurred in a Hospital or Institution,
No wa HO AE 28 i Prertes give its NAME instead of street and number.]
[If death om USUAL / / Sep Le
RES E ive facts called for
AS aie, FULL NAME: \/Lootteg LOTUTE“E iA at eetl,
PERSONAL AND STATISTICAL san if MEDICAL CERTIFICATE OF DEATH
Length of Residence Date of Death
At Place of Death years, _months CM: 2G a ¥ fe 19 If ,
Moth
Day Year
Ceilificel 7 f(S . In California iforia__ 7 Feathads iinet A __months 5 I HEREBY CERTIFY that I attended deceased from
= i U4 “tf wil Oprat C4 19/1 ;
~ 7 5 Color-or f >
: << Nats Race F Me ape ha alive on ap t ‘Dg 3 19/7,
Date of Birth 1 and that death occurred on the date stated above at eye mere
Pres Fs israictdeat The CAUSE OF DEATH was as follows:
Month A Year
zs, Se ee SZ
I years, ad months, G. days Lf fkecd Si eA Ueid
; Single, Married, Widow-d or Divorced? ‘ (duration) days
oe dies oon ws tips nae ee Contributory ifuit
Birthplace nee 2 (dyraty _. days
~. :
jeeawete: Vallee. sha. eee Signed V ig wag 7 kA MD:
. e lf 19 We Address Clateurit, Cin d:
\-Batd
Age
deg. omS 4 A
MARGIN RESERVED FOR BINDING
WRITE PLAINLY WITH UNFADING INK—THIS IS A PERMANENT RECORD : y,
AGE should be given EXACTLY. PHYSICIANS should state CAUSE OF DEATH in
The “Special Information’’ for persons dying away from home should be given in every instance.
/
Occupation
Dean SPECIAL INFORMATION ONLY FOR HOSPITALS, INSTITUTIONS, TRANSIENTS OR REGENTS RESIDENTS.
.
Name of Father
Z£0 iy ala eteoct parame siest 9% Former or usual How long at paige?
residence__ place of death
Birthplace of Father Za: Where was disease contracted,
i ?
C7, Abs if not at place of death?
of
ee
Cee
4
Maiden Name of Mother 7 Place of burial or removal Date of Burial
a1 Gur g Ur PORT Se
Birthplace of Mother if “i entaker y, f Address
a Seatche omntay } O fabok {4b lis ttn
The above stated Personal Particulars are true to the best of my knowledge
and belief. FILED
gc fe< a Geteeckf S & os Subregister > FILEDA e on ee
Address Pee vtattl, Gat. T/A
ae
N. B.—Every item of information should be carefully supplied.
terms, that it may be properly classified.
Registrar oy Deputy
cette ce presage ROA AN AON ORR AA te NR a th a st
epurt; .