Death ID:                    

Certificate Location:        
Certificate Number:          

Death Location:              
Death Address:               
Death Date:                  
Informant:                   

Decedent Name:               
Immigrant ID:                
Sex:                         
Marital Status:              
Age (Birth Date):            
Occupation:                  
Home Address:                
Birth Place:                 
Residence Years:             

Spouse Name:                 
Immigrant ID:                

Father Name:                 
Immigrant ID:                
Birth Place:                 

Mother Name:                 
Immigrant ID:                
Birth Place:                 

Burial Place:                

Death Cause:
                             bullet wound chest, jaw & abdomen / internal hemorrhage / homicide

Comments:
                             

Exhibits: