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Name
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Date o Date gold
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AGE DATE OF DHATB
PLACE OF DEATH S72 C0107 CAUSE OF DEATH 1 DAB INTERMENT PLACE OF INTERMENT Grave
Permit No. Grave Fee Name o: Undertaker, Coroner
Wan M.Whs Days Year Month NO.
Day Block Lot or Physician Nearest Relative or Friend REMARKS
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