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No. of PLACE OF BIRTH
xAnte of necenexr
Interment
Block NO -
Nome
Residence
Certificate No.
Date Sold
Transferred to
Lot No. K Q
Amt. Paid, $
Deed Recorded Book
Date
4
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17 eo
Block No.
Naze
Residence
Certificate No•
Date Sold
Transferred to
Lot No. 7
Block No.
Lot No.
Name
Residence
Amt. Paid, $
Certificate No,
If l
Amt. Paid, $
Deed Recorded Book Page
Date Sold
Deed Recorded Book Page
Date
Transferred to
Date
DATE OF DEATH
AGE - - -
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