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Page: of 313
7
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INN
AR
Total Number to date, 02.9. —
Funeral No. this year, .:
Seow 9 Date of Death,
Name of D
18 Lad Color + Yt Age
Place of death, “— %, Street. Ward NO e.cecccecccccossscsreeseeresnsenens
Residence,. oe ~ Sex, Single, Married,
Occupation, ... Wife of.....
Birth-place, Ce Widow of .
Name of Father,
Name of Mother,
His Birth-place, *
Her Birth-place, *
Duration,
Cause of death, } a) es bate
Cause of death, 8 dary,
Duration,...
Certifying Physician, ........h4<&&2-5&.,
Place of burial,
Section No..... Tot Ob cssscsssnscpacvessiniccare
Date of burial, eee ws LF, 3
Funeral held at House, or.
Church. ——
Put in the Diagram one mark like
this, § for every Grave in it, And mark
Diagram of this Burial with double dagger thus : .
Burial Lot. ew
~ State whether White or Black. * Insert Town and State.
— Designate site of Monument thus: .
ITEMS OF BILL. (Cross out items not furnished.)
Casket or Coffin No. .. Style, Made by..” oy. Yorave 42. \70
Length of Caskety.....0 ee Inches, Width of Casket,.........0 Inches.
_ Box, Pine, Chestnut, Oak, Cedar or Mahogany,
Robe, Shroud, or Dress No. Color, Maile iy a aicsiesesamzuissesgenyonsssssarssoncommnrers
Liming Noe.. eecccsecessseeessseeeesseeess COLL, ssesssssesssssssseenneersereeeeee thandles No, Plate No
Time of Dr Sr ssrsceas Crape on door,
Washing and laying OUty...sscssssssessemessssessssesssneseeesennnnssnsseeeersssunansnsanenseeees Shaving,
Embalming,.. Preserver and Ice, .
Hearse and.. "ees C g'
aweassrocceossneeseseiisea Carriage to call for. : Time, .
Time,.
Time,
Use of sussseeMolding Chairs, Pair of Gloves,
Personal attend Porters or Help,
Delivering Box to Cemetery Use of Pedestals or Pall,
Badges for B " Use of Candlesticks,
Inserting death Notices in Papers,
Bill to be charged t0.....scsssssesssssseeesssssessssssseseesnsssceeesessnarseessssesnssnerecssss sts
Date Bill was presented Date Bill was paid
ee Amount of Bill,
Time of Bervives,. A. M.,. wee Pe Mey. cccccecseecsseeecneees Forward from last page,
Amount forward to next page,
Copyrighted by Gao. W. Donna, 1884.