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(USE TWO LINES WHERE NECESSARY. ALL NAMES TO BE GIVEN IN FULL.) <br /> Condition• <br /> FULL NAME OF DECEASED. AGE. <br /> DATE OF ! 1 iWhether sin- DISEASE OR CAUSE OF DEATH. <br /> NUMBER ? (If a married or divorced woman or a widow,give also SEX COLOR. igle,married, <br /> DEATH. Y <br /> or widowed (Primar and immediate cause.) <br /> maiden name and name of husband.) a ears. Months. Days. <br /> divorced. <br /> 1117 <br /> e 7Z <br /> Zt <br /> ! f <br /> 4 <br /> s <br /> a � <br /> f a <br /> x <br /> z.. <br /> T_ <br /> a: <br /> M. <br />_ i f • <br /> i i w <br />