1. NAME OF DECEASED: Katherine De Rouchie
2. PLACE OF DEATH:
(a) New York City
(b) Manhattan
(c) Memorial Hospital
3. DATE AND HOUR OF DEATH
(a) March 18, 1976
(b) 12:30AM
4. SEX: Female
5. APPROXIMATE AGE: 66 Years
6. She was attended from January 1976 to March 18, 1976 and last seen alive at 12:30am on March 18, 1976. Signature by M. Sloan.

7. USUAL RESIDENCE
(a) Vermont
(b) Chittenden County
(c) Williston
(d) INSIDE CITY LIMITS? Yes
(e) Oak Hill Trailer Park

8. Widowed

10. DATE OF BIRTH: November 4, 1909
11. AGE at last birthday: 66 years

12: USUAL OCCUPATION:
(a) Housewife
(b) Home

14. BIRTHPLACE: Vermont
15. WHAT COUNTRY IS DECEASED A CITIZEN AT TIME OF DEATH: U.S.A.

17. NAME OF FATHER OF DECEDENT: Emery Abair
18. MAIDEN NAME OF MOTHER OF DECEDENT: Ida LaForce

19. NAME OF INFORMANT: (a) Lyle De Rouchie
19. RELATIONSHIP TO DECEASED: (b) Son
19. ADDRESS: (c) Williston, Vermont

20. NAME OF CEMETERY OR CREMATORY: (a) Mount Carmel Cemetery
20. LOCATION: (b) Charlotte, Vermont
20. DATE of Burial or Cremation: (c) March 22, 1976

21. FUNERAL DIRECTOR: (a) Metropolitan Funeral Service Inc.