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NAMES AND BIRTHPLACES OF PARENTS OF DECEASED — <br /> DISEASE OR CAUSE OF DEATH 1 RESIDENCE DATE OF <br /> 2 PLACE OF DEATH <br /> (Give full came of father and maiden name of mother) Birthplace (Primary and immediate cause) 3 PLACE OF BURIAL RECORD <br /> t <br /> .t I <br /> r <br /> i• <br /> 1 <br /> i <br /> ,f <br /> 1� <br /> t <br />