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Page: of 259
LY tor Me ReCOrd Of, Funeral.
192 3_ No. FAS _ Date (Oet/ WA 1972
. Name of the Deceased.. Lereavain, Ade 2th 441 2tt{ae
ee Charye to
Order Given by ..
a
Feces
S. 2A . tow secured Price of Casket or Coffin. . . . $ 35
Date of Funeral eH L lo Z GIS 1 Metallic Lining see ee oe
‘* Outside Box
Place of Death “Grave Vault ee ee a
~— Funeral Services at Bore. “Burial Robe . . . . . La .
oo a ; Time of Funeral Services Voie Z 4 0 La we “‘ ~ Burial Slippers and Hose
— Clergyman ee a Engraving Plate . . . . . . — —
id)
satbaennecrssa. assassin — nv Embalming Body C3317, Fluid) nee, (aa =
sveenesetenes ses ene Certifying Physician Li, fi. Lacey ¢-7— Washing and Dressing. . . . seamHis Residence Shaving
a . Number of Burial Certificate_, Keeping Body on Ice a
cectnssesenseee eens on Cause of Death, Disinfe ecting Rooms rvccteeeentate . oeeeneennneee
A Use of Catafalque and Drapery . . en
Date of Death L ty LLL. ‘* Folding Chairs Loe el
Cooapadton oft aw Pesonant _— ‘* Candelabrum
a Bae Aged. LO Years, ZL. artis 2D Daye Gloves 7 es se 6 o we me hae
<s Va) Body to be shipped to Hb i Gunaves, oo 7 .
ZT B. —— . Sixeand style of Casket or Copin.0.—D___\ Hear
K_A Wagon Deliveries <A An,
“to : Manufactured by OC Ce Death Notices in.....Newspapers » . . }. _
Fn Metallic Lining (Names of Newspapers) es
; Flowers 6 6 ww i ctf oe =
Ussside. Bax: Outlay forLot. . . . «© « «
Number of Handles Opening Grave . a . en ce _
dL. _ Interment a Cemetery. . Lining Grave . cen
es ie _ Lot or Grave No. &_ Section No. Shipping Charges, prep aid cond nanan
Removal Charges ee
a ~ 5s Cremation Charges . Lo
al 7 2. q
~ 3
nn . en — 5. ,
3. 7 7 . 50 6. . Total Footing of Bt. . . . . gl27 .
4.7. sD “ olgan a J By Amount Paid in Advance ; en
, Designate all Graves in Lot with Numbers (1, 2, 8, 4, ete.). and mark
a _ Space for this Putiead with cross re 7“ ene mer : Balance sian oe emery
Designate place for M: it with a small (g). .
7 0) _ Use space to the: right ot Diese for the names af thiaes burted in Lot. . Entered into Ledger, page......or below. . _. .
. a CV 0. To Funeral Charges. Total, $ 2 Va 60 By Cash $
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