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Date Sold (y
Date
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AGE
PLACE OF BIkTH PLACE OF DEATH Sex Color
year; Momha Dar,
DATE OF DEATH
Year Month Day
Block No. ✓7 _ Lot No. .�
Name
Residence
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Date Sold 'ro r ;Z / i' / /) t)ced Recorded Book / Page S
Ti cd to_ Date
CAUSE OF DEATtt
DATE OF INTERMENT PLACE OF INTERMENT
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Block Lot
Grave Permit No. Grave Fee
No.
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Block No. ,j Lot No.
Name f` �A Ck r
Residence
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Certificate No. Amt. Paid, $ �\n
Date Sold (c/ / 3r / y / D Dead Recorded Book / Page f �`
Transferred to Date
Name of Undertaker, Corcner Nearest Relative or Friend
or Pbyslcian
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