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Date
No. cI NAME (IF DECILDEST
Interment
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Page
Lot No. ro
Block NO- 4 S'
Name
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Certificate No-
i Date Sold Adw-41� ;�r_ _/,9//Av_Deed _Recorded Book
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Block NO -Ilk Lot No. 7
Name Block No. Lot No.
Residence Name
,,age Certificate No. Aint. Paid, Residence
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Certificate No.
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Date Sold
V - Transferred- to Date IfXj Deed Recorded Book Page
Transferred to Date
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DATE OF DEATH • DATE OF INTERMENT PLACE OF INTERMENT
PLACE OF B:RTII PLACE OF DEATH Sex Color CAUSE OF DEATH G.... it No.
Yon waths Days Year Month Day No. permGrave Fee Name of Undertaker, Coroner
Yw Mouth Day Block Lot or Physician Nearest Relative or Friend REMARKS
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