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Block No. Z
Lot No. 2 %
Name
Residence
Certificate No.
Amt, Paid, $
Date Sold
U_:d Recorder] Book
Transferred to
Date
I. -- - .. �._ ,..... <........ >........w.....--was. -- - - - No. of NAME OF DECEDENT
Interment
4! f
Page
Block No.
Name
Residence
Certificate No.
Date Sold
Transferred to
PLACE OF BIRTH PLACE OF DEATH
AGE
Sex Color
Years Months Days
Lot No. 3 e
Amt. Paid, $
Dccd Recorded Book Page
Date
DATE OF DEATH
YeM Mouth Dar
0
Block No. 1
Name
Residence
t Certificate No.
Date Sold
F r Transferred to
A
t
1
CACSF. OF DEATII
DATE OF
Year Mouth Dar
Lot No. 3 /
Block No.
Lot No.
Name
Residence
Anit. I nid, $
Certificate No.
Amt. Paid, S
D. ed Recorded Book Page
Date Sold
Deed Recorded Book
Date
Transferred to
Date
-tfti. Jl At D y -cow . kA 3 0.31. 3 2.
PLACE OF INTERMENT
Grave Permit No.
Block Let No.
Grave Fee Name of Undertaker, Coroner Nearest Relative or Friend
or Physician
39
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