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Block No.
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y Residence (�
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Lot No. /
Amt. Paid, $ 2
R�fiote No"
C 5'/ <0�-- - Deed Recorded Book
pate colas Date
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0
- - - - - -- - - ME DATE of DEATH
PLACE or ffir<rl PLACE of DSATH Sex Color CAUSE of DEATH t DATE of INTERMENT � OF INTERMENT
Years Mantas DaYs Ycar Month Day Block Lot
Yvr Month Day
Page
Grave Permit No. Grave Fee
No.
Block No. 3 X
Name
Residence
Certificate No
Date Sold
Transferrer to
Name of Undertaker, Coroner
or Physician
Lot No. -1 0
Amt. Paid, $
Deed Recorded Book
Date
Nearest Relative or Friend
Page
REXARRS
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