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Date
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PLACE OF BIRTH
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PLACE OF DEATH
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DATE OF DEATH
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Grave Permit No. Grave Fee
No.
Block No..V
Name
Residence
Certificate No.
Date Sold
Transferred to
Name of Undertaker, Coroner
or Physician
Lot No.
Amt. Paid, $
Deed Recorded Bonk
Date
Nearest Relative or Friend
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REMARKS
2,63
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