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:              
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Name of Father:              
Immigrant ID:                EDAM-28JUL1884-3--0108 
Birth Place:                 

Name of Mother:              
Immigrant ID:                CEPH-11NOV1884-3--0249 
Birth Place:                 

Burial Place:                

Death Cause:
                             shock due to pancytopenia, pre-leukemic state

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