Translated from Russian:

Death Record No. 282, Lodz, Evangelical Parish, of Sw. Trojcy, of a stillborn female infant, delivered on the 16th June 1903, death reported on the 17th June 1903, daughter of Rudolf Ziegler, a clothier, 31 years old, and of his wife, Berta, born Reich. Death reported by Rudolf Ziegler, father of the deceased, and Reinhold Maslich, a weaver, 24 years old. Signatures of Rudolf Cigler (written in Russian), and Reinhold Maslich.