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Block No. 1
Name
Residence
Certificate No•
Date Sold
Transferred to
lqt No, � /
Amt. Paid, $
Deed Recorded Book
Date
Page
n r Lot No. [ 2—
Block No• �3
Namo
Residence Amt. Paid, $
Certificate No' Deed Recorded Book
Date Sold
Date
Transferred to
Lot No.
ill No
Homo
Re ideate Amt. Paid, $
Cert'ficsteN°' Deed Recorded Book
P Date Sold Date
Vansferred to
Block No.
Name Lot No.
Residence
Certificate No.
Page Amt. Paid, $
Data Sold
Deed Recorded Book Page
Transferred to
Date
"— - -- -- - AGE DATE OF DEATH
Sea Color DEt DATE OP INTERaifiNT PLACE OF INTEEbiENT'' Cnra Permit Cnn Name of or Pby lcl Ceromr,
-- Year 2tonth Day CAUSE Op H No. No. Fn Nearest Relative or Friend
maul. u.uvu='u"jO1t- - PLACE OF DEATH Yson 3fonthsDoPe IIloek Lot or Phralehm BP.HA883
' PLACE OF BIRTa ita Dlonth D4
Na of NAME OF DECEDENT
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