Age(s) now/at death

Medical problem(s)‎

Mother ‎ ☐ Y ☐ N

Father ‎☐ Y ☐ N

Sister(s)‎ ‎☐ Y ☐ N

Brother(s)‎ ‎ ☐ Y ☐ N

Daughter(s)‎ ‎☐ Y ☐ N

Son(s)‎ ‎☐ Y ☐ N