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FULL NAME
ADDRESS
TOWNSHIP/BORO/STATE COUNTY
DATE OF BIRTH PLACE OF BIRTH
SOCIAL SECURITY NUMBER
FATHER'S
NAME 		 LIVING Y-N WHERE?
MOTHER'S MAIDEN NAME LIVING Y-N
WHERE?
PRECEDED IN DEATH BY
SURVIVORS (SPOUSE, CHILDREN, BROTHERS,& SISTERS) ADDRESS (CITY, STATE)
NO OF GRANDCHILDREN
NO OF GREAT GRANDCHILDREN
NO OF GREAT GREAT GRANDCHILDREN
CHURCH MEMBER/ATTENDED
LODGES/ORGANIZATIONS
VETERAN Y-N YES  NO WHICH WAR?
BUSINESS/INDUSTRY TYPE OCCUPATION
PLACE OF EMPLOYMENT
EDUCATION (YEARS)
NOTABLE EVENTS
LENGTH OF VISITATION DESIRED
PLACE
PLACE OF FUNERAL
MINISTER
CEMETERY