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B!erk No.
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Date FOA Date
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No. cf NAMD or DECEDENT
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Lot No. �41
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Name
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t pesidenee
Amt. Paid, S [
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Residence
Certificate No•
Drcl Recorded Look
Certificate No.
Amt. Paid, $
Certificate No. o.
Date Sold
Date
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Dote Sold
Deed Recorded Book Page
Date Sold
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pw,CA of DEA'1H
PLACB OF BtArtt
DATE of DEATH
ArS te-- Sea Color
Year Mouth Day
Yea" Montt, Dal'
e
A.
DATE OF INTERMENT PLACE OF INTERMENT
Gave Name of Undertaker, Coroner
CAUSE OF DEATH " —� Stock tot No permit No. Grave Fee or Physician Nearest Relative or Friend
Year Month nay
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