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Block NO.
Lot No. Name
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Ara. Paid, 3 Date Sold
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Lot No.
Amt. Paid. $
Deed Recorded Book Page
_— Date
Stock So.
Santo
i Residence
iCertificate No.
Date Sold
Transferred to
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Lot No.
Block No.
Name
Amt. Paid, $ Residence
Deed Recorded Book Page Certificate No.
Date Date Sold
Transferred to
Int No.
Amt. Paid, $
Deed Recorded Book Page
Date ..
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Aog DATE OF DEATH -------
OF INTERMENT PLACH OF INTERMENT -------- ---
:,,t NAarn o� UtaoErrr Sea Or F3a.ru PLACE OF DEATH Sex Color CAOSE of DEAT$ �� �� GNaos.e Permit No. Grave Fee
Name of Undertaker, Coroner
Yean D{catl•J Days Year Mouth Day
ypr Month Day Block Lot or Physician
Neatest Relative or Friend
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