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Block No.
Name
Residence
Certificate No.
Date Sold
Transferred to
6 7 Lot No.
Amt. Paid, $
Deed Recorded Book
Date
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No. of PLACE OF BIRTH
NAME OF DECEDENT
Interment
Page
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Lot No. 16
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Lot No. 7
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Name
Name
Name
Residence
Residence
Amt. Paid, $
Residence
Amt. Paid, $
Certificate No.
No,
Certificate No.
Amt. Paid, $
Deed Recorded Book
Certificate
Pate "
Deed Recorded Book Page
Date Sold
Deed Recorded Boolc Page
Date Sold
Sold
Transferred to
Date
Date
Transferred to
Date
Transferred to
Date
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PLACE OF INTERMENT Grove Permit
AGE DATE OF DEATH DATE OF INTERhENT
Sex Color CAUSE OF DEATH No. No.
— Year Month Day
PLACE OF DEATH Year Month Day Block Lot
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