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Name
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Certificate No. 217 Amt. Paid,
Date Sold C,f/" c11 3 / % o Sr Deed Recorded Book
Transferred to Date /
AGE
PLACE, of BiBTH PLACE: OF DEATit Sex Color
Ycva Month$ Days
DATE OF DEATn
Year Month Day
Block No. Lot No.
Name
Residence
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Transferred to Date
CAUSE OF Dennc
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DATE OF INTERMENT PLACE OF INTERMENT
Grave Permit No. Grave Fee
Lot
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Year Month Day stock
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Certificate No.
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Transferred to Date
Name of Undertaker, Coroner or Physician Ncatea Relative or Friend
REMARYS
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