Death ID:                    

Certificate Location:        
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Death Location:              
Death Address:               
Death Date:                  
Informant:                   

Name of Decedent:            
Immigrant ID:                OCNA-22DEC1911-2-2-0019 
Sex:                         
Marital Status:              
Age (Birth Date):            
Occupation:                  
Home Address:                
Birth Place:                 
Residence Years:             

Name of Spouse:              
Immigrant ID:                OCNA-22DEC1911-2-2-0020 

Name of Father:              
Immigrant ID:                
Birth Place:                 

Name of Mother:              
Immigrant ID:                
Birth Place:                 

Burial Place:                

Death Cause:
                             cerebral hemorrhage due to old age

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