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Block N°• ✓ J
Name
Residenco
Ccrtifiaatc No'
pate Sold
Page
Transferred to
PLACE. Or DEATll
AGc
Years Mvc:s Days
Sex Color
Lot No. �-
Amt. Paid, $
Iced Recorded Book
Date
Lot No.
l ge. - /4
y fi ;dears Amt. Paid, $ /O
f�ificite N°' %/ 3 Deed Recorded Book / paw
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Date s — Date
(,Fred to_ TlOe
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DATE OF DEATH
IDATA or INTMIENT PLACE OF INTERMENT Grave Permit No. Grave Fee
Year Month gay CAUSE OF �� Yeu uoath Day stock Lot No.
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Block No. y'
Name LOt No.
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Residence
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Certificate No.
Date Sowd Amt. Paid, $,$
Transferred to D(','l Recorded Book / Page ,f S
Date
Name of Undertaker, Coroner
or Physleian Nearest Relative or Friend
V o S- Lo �r�c 2 ",v C" e
60
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REMARKS
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