test Your Name Your Email Name of diseased Date of Passing Time of Passing Location of Passing (City/Borough/Township) Country of Passing Age Race Sex Was death due to an infectious or contagious disease? YES/NO YesNo If Yes, please explain Pacemaker? YesNo Radioactive Implant? YesNo Prosthesis? YesNo Silicone Implant? YesNo Any other life-sustaining device? YesNo Δ