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36
No._'
Nanle 4
Clcarge -----------
Order given
How secured— OIG19' -`�
Date of Funeral l F
Funeral Servie at-�
Funer l Serv' /d 0---` .. .
Time of - -
Clergyman -
Certifying Plc sician -
Number of Burial Cerliftcate_-_ �
Cause of Death
Date of Death
Occupation of 1ae De eased
{
Single or Married eligion
Aged—�Y'ears, Months, Days.
Body to be shipped to
Size and Style of Casket or Coffin -
R5,0RD FUNERAL.
Manufactured by
Metallic Lining
Outside Box
Interment at —Cemetery.
Lot or=�o. -__-_Section No•
4.
s.
_..._..
llNagram of )at J
Designate all Grates )n Lot with numbers 0 2, 3, 4, etc.), and mark
apace for this Funeral with a cross (d.). Desighate place for Slonument with a small s quare (13).
Usespaco to the right of Diagram for the names of those buried in Lot.
710Fumeral Cha ges__-_--Tola!
$
RECORD OF FUNERAL.
¢� Date_(Z
Price of Casket or Coffin
Metallic Lining
Outside Box .
Grave Vault
Burial Robe
Burial Slippers and Hose
EmbalmingBody (with... . ............... ... . ... Flu
Washing and Dressing .
Shaving
Keeping Body oil Ice •
Disinfecting Rooms
Use of Catafalque and Drapery
Folding Chairs . . . . .
Candelabrum
Candles • • • •
Gloves . . . . . . . .
Crape . . . . . . . .
Number of Carriages ...._......... _.._..__.. @ $............
Hearse . • • • • • • '
Wagon Deliveries.._...........__..
_. Death Notices in...____..___._._Newspapers
-- _ - -- ----- -_- --- .._......_......_...
J1Ia7Lufaetured y_.._.__.__ — (Names of Newapapent
_ AIetallie Lining-_ _------•----- Flowers
_ Outlay for Lot • •
Outside Box ____ 1 Opening Grave
Cemetery.
I7Lterment at_ ..- _. ..._ ---�• -- Lining Grave '
Section NO "_...._._........ Shipping Charges, prepai
Lot orCt�rar�e�No._ _�__ • l
Removal Charges '
.....
- Cremation Charges
3._.............................................
4 _. _. ............... _.._.. —-.._....- ..._......
Total Footing of Bill
By Amount Paid in Advance
Total Footing of Bill I " �,`?v a. �• f
By Amount Paid in Advance (Dtagram of Lot.) Balance
Designate all Graves in Lot with numbers (10 2, 3, 4, etc.), and mark
space for this Funeral with a cross (•I•).
_: or below
Balance Designate place for Monument with a small square (13)•.............
Uso space to the rightof Diagram for the names of those buried in Lot. Entered [ntOLe get, Page
Entered into Ledger, a e..........._.....____..orbelow• I
9 p 9 I I _ _ — , _,,r t i I_ —_.—_I _. I ----- jBy Cash__ .__ —__. _ $
Price of Casket or Coffin $
il Metallic Lining
Outside Box
" Grave Vault
Burial Robe
Burial Slippers and Hose
EmbalmingBody(with ........... ........ _............... ..... Raid)
Washing and Dressing .
Shaving
Keeping Body on Ice ,
Disinfecting Rooms
Use of Catafalque andDrapety .
It Folding Chairs ,
It
Candelabrum
Candles . . • . . . . ,
Gloves
Crape .
Number of Carriages ...................
Hearse . . .
Wagon Deliveries__ ..... ,......... _r.........................................
D th N to in `'r=SaWs
ezfrspapers .
(Name)
Flowers
Outlay for Lot
Opening Grave
Lining Grave
Shipping Charges, prepaid
Removal Cbarges .
Cremation Charges .
the Deceased
Name °f
C1Large to-_
Order given ----._.
)Tou secured-•-••••
Date of
Funeral__ - --� - - -
Funeral Services at _ - _._:�
funeral Services .�.G4%1�/?f...._....
Time of I' _
Clergyman
Certifying playsieian p!/.�.O..t/ 'Sk%
Number of Burial Certificate ........... ......
Cause Of................. Deatla.z'�1.l..rr.."[�1'_..
Date of Death,-f fi --
Occupation ofehe Deceased.
// l eli•� ion
Single or .Married.(4_`
Years, ...... _ _ . Jlionths, ....�-Days.
Body to be slaipped to -- - -- -
Size and Style of Casket or Coffin
- _
coma7rey —by F, o. FE)NEMAN, St.._ .... .......... ........ __...
—
Lou7s• Arc., in
the Year 1000.