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Block No.
Name
Lot No. -
Block No. t, l Residence
Name ! Certifirnte No.
Residence I Date Sold
An;t, Paid, 8 page -----
Certificate No. Book Transferred t°._-=
Dr.cS Recorded —
Dntc Sold Date --
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Lot No. 6-1 — 5-
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Lat No. 53 - 55q
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Block No. SS
Int No. 55-- S
Same
Name
Amt. Paid, $
-
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No,
Amt. Paid, $
Residence
Dced Recorded Book
PageDate
Certificattc
Deed Recorded Book
Certificate No.
Amt. Paid, $
Sold
Page
Date Sold
Date 1
to
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Deed Recorded Bnok Page
Transferred
Transferred to
Date
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OF INTERMENT PLACE OF INTERMENT Grave
DATE OF DEATH D�'t'E Permit No.
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No. of NAME OF DECEDENT puo r or BIRTH Yw, Manths Days
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Grave Fee Name of Undertaker, Coroner Nearest Relative or Friend REMARKS
or Physician
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