Death ID:                    

Certificate Location:        
Certificate Number:          

Death Location:              
Death Address:               
Death Date:                  
Informant:                   

Name of Decedent:            
Immigrant ID:                LGSC-09MAR1909-3-13-0022 CHGO-05DEC1911-3-17-0019 
Sex:                         
Marital Status:              
Age (Birth Date):            
Occupation:                  
Home Address:                
Birth Place:                 
Residence Years:             

Name of Spouse:              
Immigrant ID:                PHIL-21SEP1912-3-C4-0002 

Name of Father:              
Immigrant ID:                
Birth Place:                 

Name of Mother:              
Immigrant ID:                
Birth Place:                 

Burial Place:                

Death Cause:
                             hypertensive heart disease, uremia (enlarged heart, chr[onic] nephritis)

Comments:
                             wife's age: 45 years