HomeMy WebLinkAboutCemyBk2-pg35Block No. Lot No. /
Name
Residence
Certificate No. Amt. Paid, $
Dale Sold Deed Recorded Book
Transferred to Date
CiliDM leliTiif. V.1Di{16. IDiMD CICH- - -
No. of NAME OF DECEDENT
laterment
I
Page
Block No. '
Flame
Residence
Certificate NO -
Date Sold
Transferred to
Lot No.
V Block No. b
Na(ae
Amt. Paid, $ Residence
Deed Recorded Book Certificate No•
Date Pam '► Date Sold
I Transferred to
Lot No. / 1
Amt. Paid, $
Deed Recorded Book
Date
Page
Block No. 6 Lot No. / 1-3
Name
Residence
Certificate No. Amt. Paid, $
Date Sold Deed Recorded Book Pa;;c
Transferred to Date
-- - DATE OF DEATH RSIENT PLACE OF INTERMENT Grore Permit Grove Name of Undertaker, Coroner, i Nearest RelnOra or Friend
AGE Sol Color CAUSE OF DEATH DATE OF INTE No. No. Fee or Physician
-
PLACE OF DEATH Year Month Dal car Month Day Block Lot
PLACE OF BIRTH Yeara Months Dare 1 Y_
s 5 J�G cuX.o.w
j
,5'r l3 Cts�t .f.1 � rl��.a.eou GCik�e-�tret G�-�•'�-� .
�2- _
�7 0
r
o�J �O� 'CJ IR � ✓ tJC �d' ,
71
113,
Iasi
3�0 �W V
/-i
(gam-?
l�
66
I13�k i
15�s'
l 9a5t5' �
l U
6 6
I I I zr/r �
z
n�
I (6Q. aG
(q�Q�
n\!
/6%G
y+P
Imo.
l/oXQ W/
REMARKS
..-_-._...r-
\ �.