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Page: of 213
RECORD OF FUNERAL
6A Total No Yearly No Date of Entry.. OT s/% ¥
Name of Deceased... LLG aX. LK, LE
O Married Single Oj Widowed O Divorced Nanaia, Tywiecine (What
Residence oe OS id CAS. an! ST, Ces (hp or. of Age of Husband or Wife (if living)
Charge to._és5. Luarce keocTork
Address.. 5. + a Ceaser STS G .
Order given by L7CS.. FR MA La ales.
(or Ye
How Secured ye Lon” ag
If Veteran e of We Papi eg te
Occupation* Ls je is LROLS. a er
urity Num
Employer and Adlneds Gor < ke Sau ;
Date of mig tyr: De LG 6 rs G.' dd #
(Day) (Yr.) ES tia
Date of Birth/ya/C..o39 /SIF Age XO 3. 2 ~f(Mo.) (Day) cP (Yrs.) ant ) (Days)
Name of Father.. Z(/7._... Ce Ok
His Birthplace !
Maiden Name of Mother_/’Z 4 re PLE We ASTER ne
Her Birthplace Ln beke: ALL f 7
Date af Raper a oe. a ae chord,
Cause of Death 7é CLO SLL ey ALLY ae 4A
Contributory Causes Bey Ze Ce hebeal,
ascudar. lcciden Tr
Certifying Physician é J. (AY. daed. (hsb
His Address. Vewa.ol 4. COL. i
Motor
Ship
Size of a
beta,
(4 PZ) Aap 6) Color afd mae ome ee gil
wl fe7“en Lz
Lot No.
Grave No.
Manufactured by
Cemetery t
Crematory —
Section No.
Block No.
Owner
Diagram of Lot or Vault
Misc.
(hs #20 HP Sikyer (ere
Complete Funeral (except outlays).. a
Casket Pail as
Burial Vault or Box ConenT. KAMER.
(State Kind)
Embalming Body
(Name of Embalmer)
Barber, $.......... Hair Dressing, $000.00.
Dressing Body, $....... Underwear, $1.00..
Suit or Dress
(State Kind and Color)
Slippers, $.0.2..--.-----is (6S: A A ne EA eB
Folding Chairs, $.0.0.0... Tarpaulin, $1000.. .
Candelabrum, $....... Candles, $1000.20.. heen
Door Spray, $..202.--2--0.-.-.--. Gloves, $0.0.. kis
Funeral Car, $......... Ambulance, $..00.0... ies
Limousines to Cemetery OS.28 Sere H
Extra Limousines ER aes ae Ls
Autos to R. R. Station CE aT ea . ..
Getting Remains from..
Taking Remains to.. ci occ c.c-scseoccseececctecteoeeceeneanes
Trip to Coroner’s Inquest
Delivering Box to
,. Deliver Flowers to
Removal Charges
Procuring Burial Permit.. wu.
(State Number and District)
../.Certif. Copies of Death Cettimeates NO..
(State Physician’s or Coroner’s)
Pall Bearer Service, $..... Use of Chapel, $..... i
Gross Total for Sales Tax $. . ..
. Outlay for Lot
Cremation
Flowers, $...... Palms, $...... Matting, $..... . _..
Rental of Tent, $.... of Temporary Vault, $..... . _..
Opening of Grave or Tomb.. CASA) Gel..
Lining Grave, $...... Lowering Device, $....... . ...
Outlay for Shipping rare? oo le es
Clergymen, ¥@..Singers, $....Organist, $5..
ue t Tickets, $...... pis Service, $....... . _..Telegr., Phone, Cable or Radio Charges...... . _..
Cash Advanced
7eOut of town Funeral Director’s Charges 20
Personal Service 2 ed
eon tt line Death Notices in Papers Lees
(Names ‘of Newspapers) _ “i
Sales Tax..
Total Footing of Bill $ . <
Less
$. . —_—
Balance $]]..--.
Entered into Ledger, page...... or below