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Black No. / Lot No. :2 /
Name
Residence
0
Certificate No. 7 x Arat. Paid, $ % ��—
Date Sold G� r� /e r /;: Deed Rrcorded Book /
Trans1erred to Date
No. o: NAMP. or, DECEDENT
Interment
Page �7 S
I.ot No.
Block No.Name c-
Residence U.: Lt"•Lit< - ___•c.�Lr�d' ..
Amt. Paid,
Certificate NO- -
Date Sold �L'/ / 9 0/7 Died Recorded Book
Date
Transfierycd to -
PLACE OF BIRTH PLACE OF DEATH
AGE
Year, Months Da"
Sex Color
DATE OF DEATH
Yoe Month Day
Block N / Lot No. 3
Residence C_-/� -. = C f t . �--CAPv--
page Certificate No.. �/ 3 c5 Amt. Paid, $,� S� d
Date Sold // 2/ 1,9 D Deed Recorded Book /
Transferred to_ __-- -- _ Date
CAUSE OF DEATH
a
DATE OF INTERMENT PLACE OF INTERMENT
Ynr Month Day 1110* Lot
Block N I.ot No. >!
Name r�J /�%%
Residence
3. O
Certificate No. / y p Amt. Paid, $
Page / •s - Date Sold T 1 t to /!" / } 4 y Deed Recorded Book / Page
Transfc ed to Date
Grave Permit No. Grave Fee
No.
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Name of Undertaker, Coroner
or Physician Nearest Relative or Friend
REMARKS
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