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i <br /> 1. RESIDENCE OCCUPATION CC `.. <br /> 2, PLACE OF DEATH 21.O <br /> . CC SERVICE i PLACE OF BIRTH NAMES AND BIRTHPLACES OF PARENTS OF DECEASED <br /> 3, PLACE OF BURIAL DATE OF <br /> ' RECORD <br /> (Circ full name of fatter and maiden sameBirtbol— <br /> of motter.) <br /> __. <br /> - - -- I <br /> -• 1 <br /> y <br /> - <br /> „ -ham -- ---------- ._ <br /> . . .. . ...... <br /> r <br /> • <br /> t <br /> I <br /> 4 ` <br />