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Block No. 4 1 Lot No.
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Block No. 4 Lot No. ' r
Name
Residence
�^ Amt. Paid, $ /a
Certificate No.
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Date
PLACX or BIkTN PLAcr or DEATH
AGE
Vein Moeths Days
Sex Color
DATE OF DEATH
Year Month Dar
Block No.
Lot No.
Name
Residence
Certificate No.
J�- of
Amt. Paid, $ /�l
Date Sold
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Deed Recorded Book /
Transferred to
Date
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CAOsE OF BUTS DATE or INTERMENT PLACE OF INTERMENT
.� Grave Permit No. Grave Fee
A YM Month Day Wmk Id No.
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Block No. ye
Name �0V.
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Residence �Gei L_GL� G /—e'e L
Certificate No. I 'Amt. Paid,
Date Sold / •
( G ! zrL / 3, /fe?Deed Recorded Book / Page y
Transferred to Date
Name of Undertaker, Coroner or Physician Nearest Relative or Friend
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