Death ID:                    

Certificate Location:        
Certificate Number:          

Death Location:              
Death Date:                  
Informant:                   

  

Name of Decedent:            
Immigrant ID:                LAQT-06APR1904-3-SS-0003 
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:                LAQT-06APR1904-3-SS-0001 
Birth Place:                 

Burial Place:                

Death Cause:
                             cerebral hemorrhage due to arteriosclerosis (other: diabetes mellitus)

Comments: