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Page: of 159
aS —<emaeaEaES
RECORD OF FUNERAL
Date py S
No No hort J 19.2.2
(Total Number) cowl Number)
Name of Deceased.recsssscss-} aac.. Al. w Loads ee ES
¢
(What Race) (Where Born)
in heh, =. Order Given by
Charge to \ can XC NAD MA er heanchrere
g , a PRY: Price of Casket or Coffin $. . _A50) 0.0.
Address S Vc ete vee. AeA 3 “ Metallic Lining
How <apenred ; “Outside Box acl L012
Date of Funeral ed br uf i re
(State kind) wo Be
“Grave Vault
Residence Dhecscitre clea.. Sayer. WAM Et ; (State kind)
Place of Death ey sepa PES = sine sn a
: urial Slippers and Hose
Funeral Services ea ee i) es @ tes E : PP .
ye ngraving Plate
Tipe of Funeral’ Bemyiee f. sy acs fis wy Embalming Body (with Fluid) . . __.d.4-. 0.0.
Clergyman feaat: Washing and: Dressings. 202 eee eee
Certifying Physician CA, VER settee val 2b Shaving
His Residence ce bry bre Abs Disinfecting Rooms
Number of Burial Certificate Use of Coraisieise and Drapery.
Cause of Death.. 1 eet BEM nnn : peor ce aie Pr sac eg ea oa "4 ai r
eeimary Recuaae ry, andelabrum an andles. ad.
Date of Death eS 14.2 uM. Gloves $ ‘Ae, wee Crape $ eee Se eens SR pag . tude 0S eh 2.0.
Occupation of the Deceased Year. Door Crape $.. ..-Canopy §. iets
Single or Married. Vhadda..».Religion.. Catbe.: on, Hearse 1.45..) 0.0..
17 1K 39 Carriages to Cemetery. @ $ a8
Date of Birth a . Automobiles to Cemetery.3.@ $.e.ci. eee aa? a 0.4..
Aged &.2..Years, / Months, ...4,3.....Days. . Wagon Deliveries
Name of Father....220-1.. Macactrwalyad City Calls (Coaches)
lire Death Notices in........ Newspapers.
His Birthplace = 44
Name of Mother mv us <etninee of Me wanapers:
(Maiden Name) Flowers
Her Birthplace Ac a Outlay for Lot
Body to be shipped to Opening Grave or Vault Z 0.0
Lining Grave Z 2.
Size and Pb eS, of Casket or Coffin.. is. cen ones te Evergreen i
ee 5 cR-= set Tent or Awning Charges
Manufaé red by Vault Rental ;
C Shipping Charges, prepaid
Interment at emetery . Removal pS I I A
Lot-or Grave Now.. Section No......-ssscnscsconsieee Cremation Charges
4 Porters, $5.04. cclseiedee Watchers §.
m4 Personal Services
oo v J ge a A ten ESE. mise ee Se ee . See Ra UU
3 b 3 Church Charges deel fnethes
4
5 gen ——
6 Total Footing of Bill $. .22./.15 0
Diagram of Lot or Vault if
Designate all Graves in Lot with aumibars (1, 2, 3, 4, etc.), By Amount Paid in Advance
and mark space for this Funeral with a cross (+
Designate place for Monument with a small sae (CQ) Balance
Use space to the right of Diagram for the names of those
buried in Lot. Entered into Ledger, page. or below
ae To Funéral Charges.....Total, $ . By Cash $
ee
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