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Lot No.
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AGE DATE OF DEATH
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3 Lot No.
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Date Sold
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DATE OF INTERMENT PLACE OF INTERMENT Grave
No. Permit No. Grave Fee
Year Month OaY Block Lot
Black No, 3 3
Name
Residence
Certificate No.
Date Sold
Transferred to
Name of Undertaker, Coroner
or Physician
l.ot 1o. / Z-
Amt. Paid, ;
D,ed Recorded Book
Date
Page
Nearest Relative or Friend REMARKS
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