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NAMES AND BIRTHPLACES OF PARENTS OF DECEASED <br /> DISEASE OR CAUSE OF DEATH I RESIDENCE DATE OF <br /> 2 PLACE OF DEATH <br /> (Give full naive of father and maiden name of mother) Birthplace (Primary and immediate cause) 3 PLACE OF BURIAL RECORD i <br /> jbma <br /> JIM <br /> A aft . I--. I <br /> U�z Wp. <br /> r _ <br /> la _ <br /> II <br /> t <br /> is <br /> 1 <br /> I <br /> I <br /> ,f <br /> I <br /> M 1 <br /> L-4 <br /> {l <br />