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Block No.
Name
Residence
Certificate No.
Date Sold
Transferred to
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Lot No. j I
Amt. Paid, $
Deed Recorded Rook
Date
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PLACE OF BlaTll
No. of
NAMF. OF DECEDENT
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Page
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Nam°
Residence Amt. Paid, $ Residence
Amt. Paid, $
Certificate No. Deed Recorded Book Certificate No. Deed Recorded Book
Date Sold Date P$tt r pate Sold
Data
Transferred to Transferred to
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AGE DATE OF DEATH - Grove Permit
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PLACE of DEATH Year Month Day ![onth Day Block Lot
Ton" Months Days Year
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Block No.
Lot No.
Name
Residence
Certificate No.
Amt, Paid, $
Date Sold
Deed Recorded Book Page
Transferred to
Date
Grove Name of Undertaker. Coroner, Nearest Relative or Priead.
Pee or Physician
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