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i <br /> Form&-323. 2m-2-59-924805 <br /> (USE TWO LINES WHERE NECESSARY,ALL NAMES TO BE GIVEN IN FULL) <br /> FULL \AME OF DECEASED Condition AGE DISEASE OR CAUSE OF DEATH <br /> DATE OF 1 ; Whether sia- <br /> NUMBER i (If a married or divorced woman or a widow,give also SEX COLOR er,married. (Primary,and immediate cause.) <br /> DEATH maiden name and name of husband) widowed,or Y ears Months Days <br /> } divorced <br /> ! <br /> _ 2ST <br /> ! - — <br /> G-4v- <br /> 4 <br /> y <br /> 4_ '3 <br /> e� <br /> t � <br /> n <br /> a <br /> ti <br /> 5 <br /> f <br /> _ t <br /> 1 r ! <br /> t, <br /> �551 <br /> r� <br /> 1 <br /> Q <br /> t, <br />