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Interment
PLACE OF BIRTH
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Certificate No. /fC.2-- ._ - __ _
Date Sold /7 y f Dccd Recorded Book
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PLACE. OF DEATH
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Sex Color
DATE OF DEATH
Year Month Day
Block No. - / _. ,,_CC - _ Lot No. -7
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Page Certificate No. 76 _ Amt. Paid; $, �`�
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CAUSE OF DEATH DATE OF INTERMENT PLACE OF INTERMENT
Grave Permit No. Grave Fee
Year Month Day Block Lot No.
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