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b� Ao6 t� DATE OF DEATH —__-- - - - DATE OF INTAA>IENT FaAcE OF INTERMENT GIav!--------
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CAns6 of DEA P�[mGrave it No. GFName of Undertaker, Coroner
Years Nonths Mrs Year Month D Tf[ t No.
Day ! Yam, Month Day Block Lot or Phpsicim Nearest Rehire or Friend
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