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PLACE OF llmru PtACs of DEATH
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Died Recorded Book
Page
Date
Lot No. 3
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Date Sold
Date
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DATE OF DEATTi 7- DATE OF INTERMENT rLAVE Or aras,(men'r
AGE
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Permit Na. Grave Fee
No.
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Date
Name of Undertaker, Coroner
or Physician Nearest Relative or Friend REMARKS
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