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Name ZZ`
Anit. Paid, $ 7 3 o
Ca::ilicate No. 6 p
Date Sold (G/tir / O G D;ca Recorded Book /
Transferred to Date
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Intermcnt NAMEoF' DecEDENr
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Residence
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Certificate No.
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Transferred to Date
PLACE OF BIRTH PLACE OF DEATH
AGE
Yam Months Days
Sex Color
DATE OF DEATH
Year Month Day
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Pa$e / Certificate No�.3—� Amt. Paid,
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CAUSE OF DEATH DATE OF INTERMENT PLACE OF INTERMENT
Grave Permit No. Grave Fee
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