Death ID:                    

Certificate Location:        
Certificate Number:          

Death Location:              
Death Date:                  
Informant:                   

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

Name of Spouse:              
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Name of Father:              
Immigrant ID:                LSVO-27JUN1903-3-G-0017 
Birth Place:                 

Name of Mother:              
Immigrant ID:                CHGO-23NOV1910-3-18-0030 
Birth Place:                 

Burial Place:                

Death Cause:
                             burns to body general, fell in boiler of hot water, accidental

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