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Page: of 213
120
Total No
RECORD OF FUNERAL
Yearly No ) 80
Name of Deceased LAr! L£¢ ) LER MER
1
A’
Date of Entry Gye eA J.
Wh Ze
O Married ws Single
Residence LIL AA 'S 6
0 Widowed O Divorced
Lasf:
pee 74
Charge to A tual vo VA} eu
ne
Address Ale U4 o, Ana
Lay (beac auch Order given by le uw. 6:
or info:
How Secured SD. 4 pAlE
If Veteran, Name of War
—
Occupation d yal Lle€ BR.
Employer and Address é% BUN Ly. “OL = wi
fie: Lord Date of anh aay '
(Mo.) (Day) (Yr.) (Hour)
Date of Bi el. st. /810.Age 74. “4. Dd
(Yr,) (Yrs.) . (Mos.) (Days)
CCRAL CR
(Day)
Name of Father nae Ar
His Birthplace Und we
Maiden Name of Mother GwW/ 2
Her Birthplace Lnritl,
LV ABYCR
7
Date of Funeral Zoey ‘Cant FO ae Lt Lad Xr.
(Day,of Wee (Hour) (Date)
Services at.. 5 receen/ «larg C1421
Clergyman Y ey 2 TR Ce
Religion of the Deceased
Nees
(Address)
Birthplace Meu.. Teese a 5
Resided in the State._...
(or U.S.
Place of Death Likes
72
‘ity or County) ears) (Months)
"Ps AGA) Os:
Cause of Death Jeu, uZe (beedeak “Les. Et
Contributory Causes Cea nd L118 Mee L2as. SME
Certifying Physician a 7, KA. Soh cel 14)
(or Co:
His Address (AUP -ASES MPL (C4
ceetiad t Remains to 4
Ship
Size of Casket Cc G YY) We
> (S
Manufactured by aS Ze
y) lor and miper) aie Be a
cattle A FIR nah ET a
Diagram of Lot or Vault
Misc.
Lot No. L2LK/ _/
Grave No.
Section No
Block No.
Owner.
° (What Race)
OHusband [Wife Widow t
or. of Age of Husband or Wife (if living)..
Complete Funeral (except outlays) $
Casket. 1LD.6.
Burial Vault or Box
(State Kind)
Embalming Body
(Name of Embalmer)
Barber; $2.. Hair Dressing, $
Dressing Body, $....... Underwear, $ Wad LQ
Suit or Dress
(State Kind and Color)
Slippers; $00 Hose, $
Folding Chairs, $........ Tarpaulin, $
Candelabrum, $......_. Candles, $
Door Spray, $....--.-.--... Gloves, $
Funeral Car, $.0.2.0.-.-..0:. Ambulance, $
Limousines to Cemetery @ $
Extra Limousines @ $
Autos to R. R. Station @$
Getting Remains from
Taking Remains to
Trip to Coroner’s Inquest
Delivering Box to
Deliver Flowers to.
Removal Charges
Procuring Burial Permit
State Number and District)
Sirol Certif. Copies of Death n Certificates No.. oe. Maer ney
Pall Bearer Service, $..... elise of Chapel, . . fSteeaae
Gross Total for Sales Tax $
Outlevitor or te i ee at .
Cremation
Flowers, $ Palms, $ Matting, $_.}. 0.
Rental of Tent, $.... of Ree SE eee tema . REA i oa
‘Opening of Grave or Tomb Letiabe St
Lining Grave, $...... Lowering Device, $....... . _..
Outlay for Shipping Charges ae
Clergymen, $..... Singers, $.... Organist, $.... ) 0..
Railroad { Aeroor Motor { Tickets, $...... plane Service, $....... ..020..
Telegr., Phone, Cable or Radio Charges
Cash Advanced
Out of town Funeral Director’s Charges
Personal Service
Bisa line Death Notices in Papers
(Names of Newspapers)
Sales Tax
4
Total Footing of Bill
SK O22.
Less.
$
Balance $
Entered into Ledger, page...... or below.
Misc