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:              
Immigrant ID:                

Name of Father:              
Immigrant ID:                
Birth Place:                 

Name of Mother:              
Immigrant ID:                LSVO-13JUN1908-3-12-0008 
Birth Place:                 

Burial Place:                

Death Cause:
                             automobile accident

Comments:
                             address of informant [father]: 1749 College Ave., E. St. Louis, IL