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Death Location:              
Death Address:               
Death Date:                  
Informant:                   

Name of Decedent:            
Immigrant ID:                
Sex:                         
Marital Status:              
Age (Birth Date):            
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Residence Years:             

Name of Spouse:              
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Name of Father:              
Immigrant ID:                LLRN-07MAY1904-3-T-0015 
Birth Place:                 

Name of Mother:              
Immigrant ID:                LGSC-13JUN1904-3-B-0001 
Birth Place:                 

Burial Place:                

Death Cause:
                             internal hemmorhage (contributory: etopic)

Comments:
                             birth date: 15-Jul [year blank]