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Th c ertificate Full Name of Deceased: First Name___________________ Place of Residence: Address: City______________ Middle_________________ Last___________________ State____________ Zip Code______________ Length of time living in this area ______ Moved from ________ Religion _____________ Member Y/N Attended Y/N Non-member Y/N Church / Synagogue __________________ Clubs, Organizations, Other Information __________________________________ Send memorial contributions to ___________________.
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