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taths xvqfStfrd M tht N <br /> (USE TWO LINES WHERE NECESSARY. ALL NAMES TO BE GIVEN IN FULL.) <br /> Condition. <br /> FULL NAME OF DECEASED. AGE. <br /> DATE OF Whethersiu-' i DISEASE OR CAUSE OF DEATH. <br /> NUMBER i (If a married or divorced woman or a widow,give also SEX. COLOR. j gie mnrried,I <br /> DEATH. widowed or ! (Primary and immediate cause. <br /> maiden name and name of husband.) j Years. Months. Days. <br /> divorced. 1 _ <br /> 79 <br /> i <br /> � <br /> � I <br /> I. <br /> i <br /> f <br />• � � � f I <br /> I � I <br /> e <br /> I <br /> f <br /> 1 i <br /> �7 <br /> r <br /> 1 <br /> e � � <br /> i <br /> I <br /> I E 41 I i <br /> I I I <br /> �f 3 ,P <br /> i I t I I <br /> 7 <br />