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Sex and
Condition.
Name and Surname of Parente.
' If a married Female, the name of
Husband.
Name and Surname.
Set and A. Occupation. . Date of Death.
Condd ition. Yrs.: Moeo,. Dye.'
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When
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Occupation. . " Date of Deat}t.
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Place of Birth.
Name and Surname of Parent'.
If a married Female the name of
Husband.
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Name and Surname.
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Name and Surname of Parents.
If a married Feuwle, the name of
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Condition.
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"lace Cl interment. nfaeato or Gnaw of Death. Place of Eh h.
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Naata ani Surname. s Data d1 Death.
Begiricred. Condition. Yra: i Mow I Dr wonpaliv 1. I
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Place of Birth.
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Name and t3nraadac. sax•attd, aux.' . �Dstd Maxi.
--- . . .. Condition. Yt�, Mos.j DIL L •-, Oc a of iat+rrm at. ; . Dtae ee i I _ s rn Cartes of Death.
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Name and Surname.
Condition, '=' ' Sox, and A01�' • _ . Yrs.
�.< D9r.; � A�►DGbf Death.
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I Of :tftclment. -Mews ar Cause of DiAth. Place of Steil. Il a And 8arname of Parents (-
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Name and Fee 1 a theof Pa
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CL -/GC eve-- (JV�ls.-ovrs:ri
(eee-d/ery.
Name and Burnanse. conditieon; .. iyrs. Mos. I
i iDp;, ' Ocotspattop. Date cf Death.: ! Placer of Interment.
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Registrar.
. 'Manse or, Cate of Death. Puce, oi`�firtb. Nine and Burnam of Parents.. ; If a married Female, the name of
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Name and Surname of Parents.
iosaee Dt Carne of Death. Place M`Birth. i If a married. Female the name of
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Condition: ' _
Yra.. ]�aa tea. data:At Death' Ptaca of Tntelmea i�aasa a� Cause of � �Naute a Surname of Parents.
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Name and Saruame.
[lea and
Condition:
Date of Death. 1
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Place of Birth. of par t'.
If a married Fenmaleame the namene of
Husband.
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Name and Surname of Parente.
• If a married Female, the name of
Husband.
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Nuno and Surname.
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. Place of Interment.
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Registrar.
Name and Surname of Parente.
Place of Birth. If a married Female the name of
- _ .-. Husband
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