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:                FLRD-05AUG1909-3-5-0030 
Birth Place:                 



Name of Mother:              
Immigrant ID:                ZEEL-13DEC1920-3-C11-0019 
Birth Place:                 

Burial Place:                

Death Cause:
                             gastro enteritis (contributory: bronchitis - sub-acute)

Comments:
                             [birth year incorrect, should be 1923]