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Lot No. �i
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Lot No. _" I Name
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a� soft No. �. ^� Page { 1 �' (J Date
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NAWL of DE=EKT PLACE OF b:r.Til
PLACE OF DEATH
Atts
Sex
Vora MaatM Dart
Color
DATE or DEATH
Year Month Day
Block No.. Lot No.
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Residence n
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CAUSE OF DEATH DATE OF INTERMENT PLACE OF INTERMENT
Year Month Day Block Lot
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Block No. > Lot No, J'G
Nome
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Residence IX/ -�� jX1.
Certificate No. f Q Amt. Paid, $ O (70
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Transferred to Date
Grave Permit No. Grave Fee Name of Undertaker, Coroner
No. or physician Nearest Relative or Friend
REMARKS
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