Death ID:                    

Certificate Location:        
Certificate Number:          

Death Location:              
Death Address:               
Death Date:                  
Informant:                   

Name of Decedent:            
Immigrant ID:                PATR-17JUL1902-0-B1-0015 CHGO-24MAY1911-3-18-0027 
Sex:                         
Marital Status:              
Age (Birth Date):            
Occupation:                  
Home Address:                
Birth Place:                 
Residence Years:             

Name of Spouse:              
Immigrant ID:                LGSC-13JUN1904-3-B-0002 

Name of Father:              
Immigrant ID:                ADRI-03OCT1907-3-C31-0009 
Birth Place:                 

Name of Mother:              
Immigrant ID:                PATR-17JUL1902-0-B1-0014 
Birth Place:                 

Burial Place:                

Death Cause:
                             acute cardiac dilatation & edema of lungs

Comments:
                             wife's age: 52 years