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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 /> 2 PLACE OF DEATH <br /> (Give full mune of father and maiden name of mother) Birthplace (Primary and immediate cause) 3 PLACE OF BURIAL RECORD <br /> /o- /7- ZC:- <br /> �lv <br /> ,OTS o-Lo�(�CiCi9C.�- '1Z� <br /> / "Z -Z <br /> a� enc <br /> 1z -,-7- <br /> / �� <br />