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Page: of 213
SADUVIALY VL DUIN VINA
Total No Yearly No
Name of Deceased Cean i= WAVELAYE
&.
—
Date of Entry. AUK if
D Married Single D Widowed
Residence /2/ Fy ahtre Ka Ge L
OD Divorced
OHusband [Wife DWidow
(What Race)
of or.
Address wy
Complete Funeral (except outlays)
ae ek oat, eee
ra
we, Lu Lb tds tod
Poe informant)
How Secured Sad Ae
Order given by.
Casket
Age of Husband or Wife (if living)........
Burial Vault or Box..C 22 Bi. Live le
(State Kind)
Embalming Body.
If Veteran, Name of. “a. WA bod f
(Name of BARGE
Hair Dressing, $
(‘neptal lee ly SF eee Occupation
Dressing Body, $
r Suit or Dress
(Social Security Number)
Employer and Address any LA.
Date of Deaths 4oZ = LE ee
(State Kind gpa Color)
Slippers, $ Hose, $
Folding Chairs, $ Tarpaulin, $.
Li MY
( _ (Day) Hour)
Date of Birt Go? QL ix Age, Je iG PS
(Mo.)
Name of Father
Candelabrum, $ Candles, $
Door Spray, $
Funeral Car, $
(Day) ie ) Ways)
CLL i Wo VA oh LZ. 2. ss
His Birthplace pee ae 2.6) #2
Maiden Name of Mother.“X% We) Lith. aA WAS.
Limousines to Cemetery.
Extra Limousines.
@$
@$
Autos to R. R. Station @$
Her Birthplace ees fun.
Date of Funeral. £4 Ld « as
te) (Day of
Services at
Getting Remains from
grt ee Remains to
Trip to Coroner’s Inquest
aR as Box to
Deliver Flowers to.
(Hour)
é {fp C R= Ce a AUC.
Clergyman
Removal Charges ¢
(Address)
—
Religion of the Deceased
aids pee Permit
te Number and District)
eee
wertificates No
tate Physician’s or Coroner's)
Birthplace
Resided in the State
Pall Bearer Service, $ Stee of Chapel, $
Gross Total for Sales Tax
Place of Death./
Outlay for Lot
Cremation
(or U.S. Be or County) / (Years) (Months)
ce isin ; Cause of Death e eee Rist 2 LL.
Flowers, $ Palms, $ Matting, $
Rental of Tent, $ of Tem
Opening of Grave or Tomb gran peal §
és tributory Causes dec. ballags.L
Riditeah.. bE Li oe
Lining Grave, $
Certifying Physiciany, Z vg ee Cf Hasd ead
Outlay for shippiy Og Charges
(or Coroner,
His Address.. Je “wala 4 Ly
. Telegr., Phone, Cable or Radio Charges
Clergymen, $2¢.__Singers, $
Railroad
or Motor { Tickets, $
Organist, $S-9
eroplane Service, $
aeoter { Remains to
Ship
sc ue gre Color and ies iw wp a
Manufactured by
Cash Advanced
. Out of town Funeral Director’s Charges........Person ice fig 5!
Ses a ee
Size of Casket 3d. H. Dp we L “lA
PR: A wk.
Lot No
eet F hu
Cc
line Death Notices in Papers
(Names of Newspapers)
Grave No.
Section No
Sales Tax
Block No
Total Footing of Bill
Less.
Owner. Balance
Diagram of Lot or Vault
Misc
Entered into Ledger, page or below.
Misc.