A Verified Transcript form the Register of Deaths
"FOR GENEALOGICAL PURPOSES ONLY"
A Verified Transcript from the Register of Deaths
Date of Death.....
Place of Death ..
Name of Deceased.
... ......... Registered No..
... ............ .................................................................
Age, .............
Sex..................
Years, .............. .........Months,
. Color or Race...... ... .......
. .Days
Single, Married, Widowed or Divorced................
Full Name of Husband or Wife.............
Date of BirtlJ...............
Birthplace. ......
Citizen of what Country.... ................................... ......................................
::r~::g }r::.e s. ;f~~r~i~. .... ..... ...... ....... ............. ....... ... ........... B.... B....... ....... ........
Occupation............... ..... .... ....... S. S. No......
Father's Name ............. ..... ............................. ...... .................
Mother's Maiden Name.
If Veteran, Name of War ....... ........................................................................
C~::~f } ~::::atecause.. ....... .............. ... ..... ..... ...... ..... .... BB. ....... ....
Time Dr. in Attendance} .................... ......................... .................... .............
till Death ...... .... ........ ....... .......... ......... .... .................. ........ .....
Medical Attendant or other Attestant ............................................................
Place of Burial
Undertaker
I Hereby Solemnly Attest, That this is a true Transcript from the Public
Register of Deaths as kept in the
Coonty of ."
Dated at .
the.
.., State of New York
. day of
., N. Y.
. 19
(Signed)
Official Title