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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 /> t � w <br /> Ph <br /> 00 <br /> ftA <br /> i <br /> f <br /> � AM AV 1-54f <br /> - -- <br /> t <br /> I <br />