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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:                
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Residence Years:             

Name of Spouse:              
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Name of Father:              
Immigrant ID:                CHGO-24JUN1913-3-11-0020 
Birth Place:                 



Name of Mother:              
Immigrant ID:                MAUR-23OCT1920-3-16-0015 
Birth Place:                 

Burial Place:                

Death Cause:
                             shock following operation for intestinal obstruction

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