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Block No.
Name
Residence
Certitical.c No.
Date Sold
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Lot No.
Block No,
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Lot No. AML Paid, $
Residence
Decd Recorded Book page
Certiftcato
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pDW Sold Date
Amt. Paid, ItPAPI Transferred to
D-;ed Rceorded Book
Date
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Oeruficato Plo.
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Lot No.
Block No.
Lot No.
Name
Amt, Paid, $ Rcaidenee
Certificate No. Amt. Paid, S
Deed Recorded Book paw
Date Date Sold Deaf Recorded Book Page.
Transferred to Date
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PLACE OF INTERMNT
sfENT Name of Undertaker, Coroner
DATE OF DEATH DATE OF INTER Greve Permit No. Grave Fee Neatest Relative or Friend
_ --- AGE CACSE or DEATH No, or Php'ician
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Year Month Day Year bfoaaf MY
- ' -- - PLACE OF DEATH Ycan rtomC' Dar'
No. of PLACE OF ISIBTH
NAME OF DECEDE7:T
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