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Lot No.
Block No. a
Name
Residence
Certificate No.
Amt. Paid, $
Deed Recorded Book
Date Sold
Transferred to
Date
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No. of PLACE OF BIRTH
NAME of DECEDENT
Interment
Page
Lot No.
Block No.
Name
Residence
Amt. Paid, $
Certificate No.
Deed Recorded Book
Date Sold
Date
Transferred to
Pace
6
Lot No.
Block No.
Name
Bcstdence
AmL Paid, $
Certificate No
Deed Recorded Book
Date Sold
Date
Transferred to
b
Page
Block No. C�
Name
Residence
Certificate No.
Date Sold
Transferred to
Lot No. /. S K
Amt. Paid, $
Deed Recorded Book
Date
- -- AGE DATE OF DEATH DATE OF iNTERhfENT PLACE OF INTERMENT Cnre Permit Gore Name of Undertaker, Conner, � N<anet Relaaw or Pslend �
GE Set Color CAUSE OF DEATH Na No, Pee or Physician
PLACE OF DEATH Year Month DR), IIlock Lot
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