Death ID:                    

Certificate Location:        
Certificate Number:          

Death Location:              
Death Address:               
Death Date:                  
Informant:                   

Name of Decedent:            
Immigrant ID:                LBRT-17FEB1908-3-4-0017 
Sex:                         
Marital Status:              
Age (Birth Date):            
Occupation:                  
Home Address:                
Birth Place:                 
Residence Years:             



Name of Spouse:              
Immigrant ID:                LLRN-16DEC1907-3-21-0016 

Name of Father:              
Immigrant ID:                LBRT-17FEB1908-3-4-0014 
Birth Place:                 

Name of Mother:              
Immigrant ID:                
Birth Place:                 

Burial Place:                

Death Cause:
                             puerperal sepsis (contributory: dystacea of fetus)

Comments: