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Lot No. S
NO
Block
-Jot No.
Name
Block No.
Residence
Amt. Paid, $
Name
Certificate No,
Deed Recorded Book
Residence
Amt, Paid, $
Date Sold
Date
Certificate No.
Page
Recorded Book
Transferred to
Date Sold
Deed
Date
Transferred to
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PLACE OF Hill"No. of
NAME OF DECEDENT
Interment
V Lot No. 'Y 16
y Block No.
Nye
Residence
Amt. Paid, $
Certificate No.
Deed Recorded Book
pkt ` Date Sold
Date
Transferred to
s
0
Page
Block No.
Lot No.
Name
Residence
Certificate No.
Amt. Paid,;
Date Sold
Deed Recorded Book Page
Transferred to
Date
- - - - _ ACE _ - - DATE OF DEATH c - IENT PLACE OF INTERMENT Gears Permit Green Name of Undertaker, Groner, Nearest Relative or Friend
— Se: Color -'—' CAUSE OF DEATH t DATE OF INTERS Na. No. Fos or Physician
PLACE OF DEATH Years Months Days
Year Month Day year Month Day Block Lot
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