Death ID:                    

Certificate Location:        
Certificate Number:          

Death Location:              
Death Address:               
Death Date:                  
Informant:                   

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

Name of Spouse:              
Immigrant ID:                

Name of Father:              
Immigrant ID:                OLMP-11APR1912-3-C33-0012 
Birth Place:                 

Name of Mother:              
Immigrant ID:                ASIA-10OCT1922-3-7-0029 
Birth Place:                 

Burial Place:                

Death Cause:
                             broncho pneu[monia], septic peritonitis (contributory: malnutrition)

Comments: