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Name
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Cv ttfio.tta• No.
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Lot No. I
Amt. paid, $
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Date
Page
Lot No.
Block No. J
Name
Residence - -- ---
Amt. Paid, $
Certificate No.
Deed Recorded Book
Date Sold Date
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AGE
1.� PLACE of DEATH Sex Color
NAXE of DECEDENT 14nrx OF BIRTH
In: r: r:rrt Yeah MootN boys
DATE of DEATH
Year Mouth Day
Page -
CAUSE OF DEATH
Block No._ .� ' , - / Lot No.
Name.
Residence Q t
Certificate No. Z/ ` y _Amt. paid, $ 2 2 5�a
Date Sold 1)_e� /� G, ✓ -Deed Recorded Book Page
Transferred to Date
DATE OF INTERMENT PLACR OF INTERMENT
Grave Permit No. Grave Pee
Year Month Day Block Lot No.
Block No. 5 " 3
Name I of N56 �!
Residence c
Certificate No. Z d o Date SOtdcAmt. Paid, $ �1s
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Deed Recorded Book
Transferred to
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Page f 4
Name of Undertaker, Carona
or-Rbysiuun Nearest Relative or Friend REMARKS
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