To be returned to the Registrar of the Town in which the death occurred
within the week of the first month after death.

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:

Headstone of Silas Lounsberry and wife Ann Jennette Brown.

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© 2002 Photos contributed and owned by by Geraldine Ryerson K. Geri is seeking contact with others researching the BROWN, FINCH, YOUNG and LOUNSBURY families of Fairfield Co., CT. Thank you, Geri!