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Amt. Paid, $
Certificate No.
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Date Soldj/yi.Q. J /
Date
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AGE
PLACE OF BIRTH PLACE OF DEATH Sex Color
Ynrr MomM Days
DATE OF DEATH
Year Month Day
Block No. Z Lot No. i /
Name
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2 & Amt. Paid, $ /p \ °
Date Sold i°�( „vt-e�n. 3 Y !/ t)ccd Recorded Book /
Transferred to _ - Date
CAUSE OF DEATH
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DATE OF INTERMENT PLACE OF INTERMENT
Year Mowh Day Block Let
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Certificate No. �Y Amt. Paid, $ /10 TT
Page i/ Date Sold Gnu Deed recorded Bonk /
Transferred to Date
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