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For the Year 19 f � <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 /> it <br /> --------------- <br /> I <br /> i <br /> I -- <br /> i <br /> G1 <br /> Az�z <br /> - i <br /> 01 <br /> _ 1 <br /> C� - <br /> 2 <br /> . 2 <br /> 10 <br />