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Certificate No.
Date Sold
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Amt. Paid, $
Deed Recorded Book
Date
PLACE OF BB;TH
Page
of Lot No. /
Block NO-
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Residence Amt. Paid, $
Certificate No. Deed Recorded Book
Date Sold Date
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PLACE OF DEATH
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Year Atonth Day
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Certificate No.
k' Date Sold
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Amt. Paid, $
Deed Recorded Book
Date
Page
Block No.
Name
Residence
Certificate No.
Date Sold
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Lot No
Amt. Paid, $
Deed Recorded Book
Date
Page
PLACE OF INTERMENT Grave Permit
CAUSE OF DEATU DATE OF INTERHRNT No. No. Pee or bnGrove Name et or Pkvakm. Gtoeer,
idea Neeesl Rotative or Priced AR EEHBE
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