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Block No.
Name
Residence Amt. paid, $
Certificate No. Deed Recorded Book
Date Sold Date
Transferred to
Page
Block No'
Name
Residence
Certificate No.
Date Sold
Transferred to
Lot No. 2,
Amt. Paid, $
Deed Recorded Book
Date
__ ---�---�` _-- -- - DATE OF DEATH
- AGE CAUSE OF DEA28
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nnae r•.nne. a„wm lo,«e,m, - PLACE OF DEATD Year Month Day
Na of sAxe OF necnnrrr
PLACE OF DIRT" Year. )lonths Dare
Interment
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Lot No. f 7
Block No.
Name
Residence Amt. Paid, $
Certificate No.
Deed Recorded Book
DaCe Sold Date
Transferred to
Page
Block No, C
Name
Residence
Certificate No.
Date Sold
Transferred to
Lot No.
Amt. Paid, $
Deed Recorded Book
Date
Page
MENT E OF INTERMENT Grave Permit Gnse Name of Undertaker, Coroner,
DATE OF INTER PLACE No. No. Fee or Phpielan Nrarert RelttAe or Friend REMARKS
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