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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: fracture dislocation of left shoulder / septicemia & secondary hemorrhage (this man fell from electric car at corner of Pekin St. & Douglas Ave. & sustaining injuries to left shoulder)Comments: