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F'o�` the Yeas` 19 <br /> NAMES AND BIRTHPLACES OF PARENTS OF DECEASED <br /> DISEASE OR CAUSE OF DEATH I RESIDENCE DATE OF <br /> (Give full name of father and maiden name of mother) 2 PLACE OF DEATH <br /> Birthplace (Primary and immediate cause) 3 PLACE OF BURIAL RECORD <br /> i <br /> I s <br /> 1I <br /> r, <br /> p— <br /> ' n <br /> t <br />