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S NAME (First, Middle, Last) DECEDENT 2. DATE OF BIRTH (Month, Day, Year) 5. NAME AT BIRTH OR OTHER NAME USED FOR PERSONAL BUSINESS (include AKA s if any) 6a. AGE - Last Birthday 7a. LOCATION OF DEATH (Enter place officially pronounced dead in 7a, 7b, 7c) HOSPITAL OR OTHER INSTITUTION - Name (if not in either, give street and number and zip code) 6b. UNDER 1 YEAR MONTHS DAYS 7b. CITY, VILLAGE, OR TOWNSHIP OF DEATH 8c. LOCALITY (check the box that describes the location) 8b. COUNTY CI.

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