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Form&-323. 2m-2-59-924805 <br /> (USE TWO LINES WHERE NECESSARY,ALL NAMES TO BE GIVEN IN FULL.) <br /> _ -- — <br /> Condition <br /> on AGE <br /> i <br /> NUMBER DATE OF <br /> l FULL NAME OF DECEASED DISEASE OR CAUSE OF DEATH <br /> EA.Irg (If a married or divorced woman or a widow,give also SEX 1, COLOR gie,married, <br /> a maiden name and name of hnahaad.) ! widowed,or Years Months Days (Primary and immediate cause,) � <br /> divorced <br /> . / iT G:e!C � ,� /l w <br /> i – –- – <br /> f <br /> 2 <br /> 5� <br /> x <br /> r <br /> : <br /> , i ��_��_._%ice-_ __ ____ __.____/�f_._ G✓__ �— �_.,,3 _//.. _.3___ _ r�-r.��� ' <br /> t, t <br /> I <br /> ! W d <br /> ----------- <br /> V11 - <br /> i i I <br /> 1 i <br /> Y <br /> i <br /> I <br />