Death ID:                    

Certificate Location:        
Certificate Number:          

Death Location:              
Death Address:               
Death Date:                  
Informant:                   

Name of Decedent:            
Immigrant ID:                LCHM-17DEC1895-3--0209 
Sex:                         
Marital Status:              
Age (Birth Date):            
Occupation:                  
Home Address:                
Birth Place:                 
Residence Years:             



Name of Spouse:              
Immigrant ID:                PRET-28OCT1905-3-B-0002 

Name of Father:              
Immigrant ID:                
Birth Place:                 

Name of Mother:              
Immigrant ID:                
Birth Place:                 

Burial Place:                

Death Cause:
                             acute gastritis (contributory: dilatation of heart)

Comments:
                             [marital status is incorrect, should be married]