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Page: of 213
80 KREUVURYD UF PFUIND NAL
Total No. ceeeeeeenq Yearly No... . eae) ae Date of Entry Fe VA 5S” 19.¢€
Name of Deceased. A/imi Laced.. tf. LURE AM Klhile
0 Married O Single JZ Widowed D Divorced Z (What Race)
> > 5 OJHusband [Wife DWidow
Residence.2/7 aaa b Sy) mtn \& (ye Che. SZ. E. L ‘ or. of t Age of Husband or Wife (if living) Years
Charge t. YAS.. M0 hal i. ¥ b. bes Be Eves 1( tins
omplete Funeral (except outlays
Address.. 4" 0.... Becchustdl Da Caklesabper, : 00
Order given by... Motifreed,.L.. 4 ades.. Burial Vault or Box.. mCAlL.. 4/NCR Le
(or informant) (State Kind)
How Secured ye 4. AML. Esibaleaing ct : (Name ofEmbalmer) {. Ss
+ -_ rs ». Barber, $.........--Hair Dressings Siac Ns cascocts. neds
t ,N f W : Z
af yeteras es a ie Dressing Body, $....... Underwear, $
Occupation CUSCIUTF €. = UIE On Dyrese:e ert nt Mee gene eet eg el nk 8 had 2
(Social Security Number) r (State Kind and Color)
Employer and Address Slippers, $ EI GGe Ou ane eS ay ere as
Daisve Death ee ikea.. Liste.. Folding Chairs, $....... Parpaulin, Gn anna. feansnnnnencnnn. pone
(Mo.) (Day), (rd. our) Candelabrum, $.........OC cfe . . A Seo eee . Seem oe
Date of whe gees ba Z age x “hla = hide] DOOE Sprays $n Aires Bue
s y. C¥rs (Yrs. (Mos. (Days)
re ,) Funeral Car, $..0.0..-.-. Ambulance, $.......... . _..-... .-.
Name of Father. 2420 LBL. pea Mh beep Cedestty are et Limousines to Cemetery. GN cle Sela ee ae
His Birthplace wh O.bl b9,.. Extra Limousines Se ke eo te et de
4 Autos to R. R. Station CCN SIU OMNI tne . ROG a4 [ea
Maiden Name of Mother Aace. uae Lima nl. Getting Remains from.. . .
Her Birthplace [Lu Cd User. BT aking ReMmaitis tOu tne he ol de ew Laas eee do
Date of Funeral. FEL, 5” bay 1.300 by,. PtP to Coroner's Inquest. -neeeeneeeeeneeeeeensssee. fneeeeenneeee fone
ay 7) fa Weel (Hour) Deehiveritig Bom tan cs cate fence ater
Services at H, 2 ite E KA AER Delivem Blowers toc) dee Le i Ne os DS
a Sli sRemovalChareese amici) Pir ee ry oe ON
Clergyman Wa.slithal ae ee Procuring Burial Permit nee [nl
er < tate Number and Distric’
Religion of the Dec pone eons Certif. Copies of Death Certificates Noo Es
rt + (State Physician’s or Coroner’s
Birthplace ‘© AL iL. Pall Bearer Service, $..... Use of Chapel, $ ‘ ee:
Resided in the Sinks OS” Gross, Total for Sales' Tax ee SH
(or U.S. or City or County) ears) (Months) Outlay ROC Nba ee tet cet eet Wek Wig en hg oe ae . . Cet Lg
Place of Death Denlés.. L000.. (Lb on bee aL (Cy eves e940 (os Mee TMLee Ue, oe Oe sera ie Beacon Orage . aed oe
Cause of DeanMMemaLyLit..Aaltming-Leeartatth? lowers, §....-. Palms, $.....Matting, $.) nee)
; HX. : LE, Rental of Tent, $.... of Temporary Vault, $....]) 0020)..
Contributory Causes Se pls€...£7 hip ees tt Opening of Grave or Tomb.. C/ess Ve Ot
Aa2Zek. o8.Clp.0lee Fle! . Awa Fe. easce. Lining Grave, $.. ages Lowering Device, $
ee : D) Outlay for Shipping harvest U2 eer ok che We, mee oe a
Certifying Physician [email protected]_. Frthg elL.. Clergymen, $/0 Singers, $.... Organist, $4./% ee
Hid Adages oe eee ee he or Motor ¢ Tickets, $.... tans Service, $...[. ... .Motor } porai x Telegr., Phone, Cable or Radio Charges. Lf
: emains to
vance Ship t U if Gash Advanced..« 2) Bue te ln ieee,
Size of Casket 823% “ASs Blue SdedJ¢rJ_. Out of town Funeral Director’s Charges....-----.--. . --------2----. -----v £Siate Coloyand Num Beyegrial Seng ICC. ao ca ap des pea tne . f nsec .
Manufactured by. Cats S C Fal SFCZ. Welz. S460). LIRR S =
Cemetery 1 MM ascalce line Death Notices in P
ah Pe a a a a arco nn) PT apers
: Lot No oF. Chagall.
f Ni a .
ere PAM LAUER
Grave No
Section No Sales Tax
Total Footing of Bill $
Block No Veen 8
jagram j Owner
Balance $
see gt eye
Entered into Ledger, Page ce! or below.
Misc.
Misc