| BUREAU OF SPECIAL RELIEF Department of Relief and Rehabilitation San Francisco Relief and Red Cross Funds GEARY AND GOUGH STREETS | ||||||||||||
| San Francisco, | 190 | |||||||||||
| Name | ||||||||||||
| Address | ||||||||||||
| Dear Sirs: | ||||||||||||
| Please deliver to | ||||||||||||
| the following articles | ||||||||||||
| and charge to Bureau of Special Relief. | ||||||||||||
| Cost | Cost | |||||||||||
| Apples (dry), | Potatoes, | |||||||||||
| Beans, | Prunes, | |||||||||||
| Bread, | Rice, | |||||||||||
| Butter, | Salt, | |||||||||||
| Cocoa, | Soap, | |||||||||||
| Coffee, | Sago, | |||||||||||
| Condensed Milk, | Sugar, | |||||||||||
| Eggs, | Tea, | |||||||||||
| Flour, | Pepper, | |||||||||||
| Macaroni, | Candles, | |||||||||||
| Mush, | ||||||||||||
| Total | Total | |||||||||||
| Received above articles | ||||||||||||
| Superintendent. | ||||||||||||
| IF UNABLE TO DELIVER, NOTIFY THIS OFFICE AT ONCE | ||||||||||||
Above form as [illustration]
HOSPITAL REPORT SHEET
| SAN FRANCISCO RELIEF AND RED CROSS FUNDS INCORPORATED HOSPITAL DEPARTMENT | ||||||||||||||||||||||
| Hospital Report for week ending | 190... | |||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Name of Hospital | ||||||||||||||||||||||
| Superintendent | ||||||||||||||||||||||
| No. | Name of Patient | Age | Single | Mar- ried No. of Chil- dren | Occupa- tion | Address | Society, if any | Admitted | Diagnosis | Condition when Admitted | Discharged | Cost of Main- tenance at $2.00 per day | Remarks | |||||||||
| Be- fore | Af- ter | Be- fore | Af- ter | Day | Hour | Provis- ional when adm’t’d | Con- firmed (date of) | Pulse | Temp. | Resp. | Day | Hour | ||||||||||
| I certify that the above is correct in every detail: | ||||||||||||||||||||||
| (Signed) | ||||||||||||||||||||||
Actual size of sheet 16 x 21 inches.
Above form as [illustration]
APPLICATION FORMS FOR BUSINESS REHABILITATION
| [FORM A—GENERAL STATEMENT. FACE] | Ap. No. | ||
| APPLICATION FOR BUSINESS REHABILITATION | |||
| 1. | Full name | Age | ||||||||||
| 2. | Present residence | |||||||||||
| 3. | Residence prior to April 18, 1906 | |||||||||||
| 4. | Present occupation and place of employment | |||||||||||
| 5. | Physical condition | |||||||||||
| 6. | Nature of business to be re-established | |||||||||||
| 7. | How long in this business? | |||||||||||
| 8. | Location of business on April 18, 1906 | |||||||||||
| 9. | How long at above address? | |||||||||||
| 10. | Prior address | |||||||||||
| 11. | Has location for re-establishment of the business been secured? | |||||||||||
| 12. | If so, where, and under what conditions? | |||||||||||
| 13. | If no location has been secured, what is the outlook for a definite and permanent | |||||||||||
| location? | ||||||||||||
| 14. | Statement of losses: | Amount.Where? | Amount.Where? | |||||||
| a. | Store | f. | Houses | |||||||
| b. | Office | g. | Furniture | |||||||
| c. | Fixtures | h. | Clothing | |||||||
| d. | Stock | i. | Misc. (household) | |||||||
| e. | Misc. (business) | |||||||||
| 15. | On which of above has insurance been collected, and how much? | |||||||||