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VERIFIED TRANSCRIPT OF DEATH fiO11fi1 N0.1~1 wr+...« u. tlow co. wou~ww.. w r usa
A Verified Transcript from the Register of Deaths
. 495166
Name of Deceased -
Date of Death ~ -!~~:~la-Register No. /D?
t~Aor+t) (Dayf (Ysu
Place of Death -
/ ~
Usual Residence _
length of Stay in Town, City or Village- SD_~
Sex
Single _ - Married -~------Widowed Divorced
Age :Years Months ~ - Days
Social Securiy No. ' .
War Veteran (if yes, what war) -
Occupation
i
Birthplace
Citizen of What Country Lf~ -
Father's Name_ -
Mother's Maiden Name
Cause of Death Interval Between
A ~ land Death
I
t
B.
3
c
C.
Medical Attendance or other Attendant /
y.
Undertaker L
_ - • ~•y.
Place of Butlar ' .
I hereby ;oferptltf.~etteatr~ttat this is a true tr ript om tl~e Reg' ter of Deaths kept
in tM_'
County ot_~ - -State of New York
OaLgd at ~ ~ the day of • 19
-
r .r/.....,. .
_ ~ ~ f t •~1) GISTH/1R OF VITAL STATISTICS
495166
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