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Lot No,
B?oek Na
Name
Rcs 000 ArIt, Paid, S
CertiAcaw No. Page
R,Yt,rdtd Book
Date sold Date
-rransferred to -
` Block No.
Name
Resideneo
Certificate
Date Sold
Transfern
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PLACR Or NuTH PUCE: OF DZA it bez Loior CAUSE OF DEATH t""T Permit
-. - yran Mouth, Days year Mouth nay No. Pit Na. Grave Fee Name of Undertaker, Coroner
-. .. year Month Day Block Lot or Physician Nearest Relative or Friend
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REMARKS
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