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Page: of 159
136 f
RECORD OF FUNERAL
ig (Total Number) aaa (x es a Dases 4.+ Lod Ls 19.An.-3 ‘otal Number year! umber
Name of Deceased Ysa Liha ee ad AAA add.. VW. ‘toh, 2 f. i , {
(What Race) (Where Born)
é
Wite---Widow
*
ccm Domaeeoree t
Order Given by
Charge aan» oh rath.. GanattesSeosaceatesmnnnenses Price of Casket or Coffin ; $ JL&0 oe
Address Ni oer eeeneneesecccnneneeccnnnennnnmananannnnaa eg ee “ — Metallic Lining -..------------------1-a
How Secured a es ac nenbseaenlS ce eoaba edits crestbeesnnneeai one ace eaatatd Bok Aes eget . yalog.
Date of Funeral.. pts (4. Ww.. st (State kind)
“ Grave Vault ro . ee oe
Residence MVAu een. ae m (State kind)
Place. of Death-.-:v---™ cr EL Se cee 4 can ae 7x -. ‘ urial Sli atid FAO SO ec saccsee soem eevee . . eee etn entree ae
Funeral Services att Palen cited. CQeeren tate U4. 4 Engraving Plate or ‘
Time of Funeral Service...-.-at ae Qo MWA nee Embalming Body (with
Clergyman -..-.Tus toe brmacend US WAR hae cnneessenenennnnencenne Washing and Dressing.. ff
Certifying Physician ... ie imencaate Gell seebewsnds Shaving
His Residence Se Cos Disinfecting Rooms jn ae ea a
Number of Burial Certificate,.-.-. Use of Cotesalque and Drapery. eee ies oa
Cause of Death.. aie deh. fas ‘ ayaa Tens
an
vihary condary andelabrum and Candles....--c---cescseesenstett . fenneneeenen. Aton
Date of Death Ait. Slee NAS Cou Chi Sp
¥
PO Suernesenrencecccncnnesennes [fe Qy.-\9--&
Occupation of the Dectased tad. Aer ttrtod Door Crape $ Canopy $ Stee . (Naam lela Poel See
Single or Married.. (A...Religion.Caetere be.’. Hearse hab.) 2.2.
‘eth /§ 43
Carriages to Cemetery . Soccesccvcevnncnsersscee . focsevceneen. meen
Date of Birt Automobiles to Cemetery.1-@ $... . Pe es mee . Pee Yt NO-OAged acer 40 seas Years, -.---.------+--2-+0° Months, ....-.--.------Days. . Wagon Deliveries
Name of Father.. rT AAd..Oe) ert Cty Re ee
ea OFICES iN.--.---<n-e2<-0
His Birthplace Sh errno!
Name of Mother. CL Ah sacs a (Names of Newspapers)
Ey (Maiden nga) Pile Gas isc espa a escent ere msneowetgued ent se econ cennes[fnetecssetants reer
Her Birthplace echo \Pecte : Outlay for Lot
Body to be shipped to i Opening Grave or Vault
kG sae = be S08 ll Lining Grave
Size and Style of Casket or Coffin.“ at eae _ CS Sep Sea Evergreen
bar enaene Sertt L Tent or Awning Charges
Manufactured &y GS. re ae ee ee hai ie, 7 ;
: ippin ATGES, PLEPAid -.-n.aenvecceneeeceenmsceesescenees . foseesten . eee
Interment at Cal Ccthre ( 4.) ‘ ..Cemetery nde . Charges “ {ee ee ae
Lot or Grave No...----::-essse Section No...--.-ssessesesesserte Cremation Charges
1 Porters: $.------+0-c-0s-c-e--v+0-Fs Personal Services
yn a a ". Music
oe ay 3 . Church Charges
\ 4
6.
b4 .
—
: Total Footing of Bill $
Diagram of Lot or Vault $ es $ . Ad.. Ja
Designate all Graves in Lot with Numbers (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 square (C) DS Es oy aan area ee Poona . Braye Bead Ween
Use space to the right of Diagram for the names of those
buried in Lot. Entered into Ledger, page.-.-----------------+or below'. . . .
To Funeral Charges.....Total, ler wile hl ceo eee enced By Cash ¢$