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i III' <br /> Form R-323. 2m-2-59-M805 <br /> t4 - <br /> (USE TWO LINES WHERE NECESSARY,ALL NAMES TO BE GIVEN IN FULL.) <br /> FULL 'NAME OF DECEASED Condition AGE DISEASE OR CAUSE OF DEATH <br /> DATE OF 1 Whether sin <br /> NUMBER i (Ii a married or divorced woman or a widow,give also SEX COLOR gie,married, (Primary and immediate cause.) <br /> } # DEATH mai;en nasi•and name of husband) widowed,or years Months Days <br /> divorced <br /> I <br /> till <br /> f '✓K/ <br /> 3 <br /> -71 <br /> 01 � ,, <br /> ` <br /> u�cv <br /> �i A <br /> UV <br /> 73 <br /> t �� 1 <br /> 1 <br /> e6e eu& *4*., <br /> �C <br /> ,fit. ,19GG <br /> ' ' <br /> „i <br /> �y 1 <br /> J <br /> , <br /> ..------..----,. <br /> 51 I <br /> FI <br /> �i <br /> ,' 1555555 <br /> C. <br />