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PLACE OF DEATH
AGE
Sex Color
Venn Moeths Days
DATE. OF DEATH
Year %lonth Day
Paige
CACsE of DEATH
Block No.
Name
Residence
Certificate No.
Date Sold
Transferred to
DATE OF INTERMENT PLACE Or INTERMENT
Amt. Paid, $
Treed Recorded Book
Grave Permit No. Grave Fee Name of Undertaker, Coroner
Y., Monm Day Block Lot No. or Physician Nearest Relative or Friend REMARKS
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