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Information of deceased person: 

First Name:
Middle name, Initial:

Last Name:

Additional Last Name:
(Optional)
Religion: (Optional)
Sex : 
Male   Female
Times of Marriage: None,    1,     2,   3,     More
Age of First Marriage:
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Last name Of  1st. Spouse:
(Optional)
Last Name by Marriage:
( If any)
Occupation:

Other Occupation:
(Optional)
Date of Birth:
City of Birth:

State of Birth:

Country of Birth:

   ______________________

Cause of Death:
Date of Death:

Place of Death:
i.e.: Home, Hospital, etc.
City of Death:

State:

Country:
Place of Burial:

City of Burial:

State:

Country:

            ______________________

Your Information:

First Name:
Middle Name, Initial:

Last Name:

Relationship with Deceased Person:

City Of Residence:

State:

Country:

Email Address:

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