I certify from the best information which I can obtain that:
1.Name in full: Ann Jennette Lounsberry [Small "Lounsbery" written above]
Maiden name, if a married woman or widow ____________________________
2. Place of Death, - Greenwich, Ct.
No. _______________________________ Street
(unreadable) ______________________________
3. Date of Death, - August 1st, 1883
4. Age, - 73 Years, ____--______ Months, _______--_______Days.
5. Sex, Color and race 4, - Female, White, American
6. Single, married or widow, - Widow of
If a wife or widow, of whom, - Silas Lounsberry
7. Birthplace: New Canaan State, - Conn.
8. Residence at time of death, - Greenwich, Ct.
9. Occupation, - ________--______________
10. Name of Father,- Samuel Brown
11. Name of Mother,- Abigail
12. Birthplace of Father,- Town_____________________ Town or County ________
13. Birthplace of Mother,- " ________________________ " ____________________
14. Duration of illness, - 2 weeks
15. Disease or cause of death, -Dysentary
16. Signature of attending Physician or other persons making this report, - IL [?] Mead for MB, undertaker.
Dated at, - Greenwich, Ct. this 2 day of ________ __________ 18
4 If other than white-- {A.} African {M.} Mulatto {I.} Indian. If other Race, specify what:
