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Page: of 213
RECORD OF FUNERAL
21) nea RO Yearly No.. 76 Date of Entry. 2/d/ eye mole
me of Deceased. A The hk..» S Te phe nbs UhiLe
O Married O Single Widowed O Divorced cirlesad ait Petes (What Race)
‘idencel47,. lO). E D1 RL sl (ie S iL or. of t T gs of Husband or Wife (if living).
7 best
re A ALLs lag SE, Lue dale Complete Funeral (except outlays) . nes LZ7y . . CompleteFuneral (except outlays).
Iress Le Le a Oe, ik
b 7 Casket , eo.
er given by /Ue WA Sie ae Dip Ka th Burial Vault or Box. Eres eee ee
L (or informant) F tate Kin
v Secured Sp A Pot 5 lide ane Embalming Body. Name of Baba
‘etetan, Name of Wars 8 eh a ete see ie ee $ ~~
upation yy WA C. LZ SS72 22.2 ASIF Suit or Dress mee bigest , wey Bp
ve (Social Security Number) h (State Kind and Color)
dloyer and Address.. 7 oe eee nannies oo Slippers, $.. Safes ithe ty Hose, $.. Se . eens BEE
e of Death UY 3-4 bd Z GGL wae LYVS FE ce Chairs, $__.. Tarpaulin, $d ne
(Mo.) (Day) (eS (Hour) andelabrum, $. Candles, $d
2 of Birth QU.. SE ge Ld. oti fs. Door Spray, $.. Gloves, $0 We .
Mg) (Day). (¥r.) rs.) (Mos) (Days) . aneral Car, $s_ ss . Ambulance, $0000 . .
Q /S ’ ?
1e of Father. erg 29 eas hee Lea hen: > eae eee Limousines to Cemetery eS 2 atl GS ee tu aman” Ii
Birthplace.. 2 Ca lucky ree Sa Extra Limousines. Gene) Ny ae
Autos to R. R. Station.. ee Woe eam . e tng
den Name of Mother.. (/2/& ee ee Getting Remains from.
Birthplace. U, DK. Heck . Taking Remains to
: of Paneeniiee. i So es Hi Ne m,. Itip to Coroner’s Inquest.
(Date) Day of Week) (Hour) Delivering Box to Antennae nnn awe nnn ee enn boned . ieee
ices at. Qeecen wad SR Abi ee hn clleght tel tne a deliver Flowerstol. 0 =) ope eon
. Rettoval ‘Charges 0
scam eee maser ea (padeete) ON ee Procuring Burial Permit.. rao Number aad Bacco
: tate Number an istrict
‘lon of the a a aaa eter . Certif. Copies of Death Certificates } . i ee
7) (State sician’s or roner’s)
‘place AY. Cn luck, EOE ne eel MeE Nh a Pall Bearer Service, $... Use of Chapel, $ "
: Gross Total for Sales Tax. $]]..
ted in the State ek Chie TAS at (iioathsy . Outlay for Lot
: Of Death.. VE.u/ eeeren ail: can a Cremation {
s of Meath eee gents Zelinn).. Flowers, $00. Palms, $...... Matting, $ soccenene
C /tnemiyer.Blais . phe cope ee Rental of Tent, $..._of Temporary Vault, $.... . _ a
ibutory aise,” GasZe dad L6STinlirk. Opening of Grave or Tomb a
leeV ini & ~-Beal, Aeeaiicc Aegagg-ining Grave, 8.... Lowering Device, §
(o , _ . Outlay for Shipping Charges od
ars f , eg . ,
‘ying Physician.. “ Sa ‘2 a {uiteled. “Ud Drereymen, A Singers, $...Organist, $.... . _ a
; or Corgéfe
i d L Aero3
ddress CVn VA p: Lif _ he Niotot t Tickets, $... plane Service, $
R fat ‘ Telegr., Phone, Cable or Radio Charges
NeIpS me ae wy SPC iiaa IN Sic iet gat Cash Advanced
f Casket : 6 ew Ai fat ee Out of town Funeral Director’s Charges
State Color afdjNumber) ;
factured by ae) poner BS PLC innate ee
ety S&S Wis 7, &. Uf DIMDREVEY . line Death Notices in.. Papers
EO No. ee ae (Names of Newspapers) 07770 errrreercsaseeeceeceeseeelfeocennaneeee
Gtaye Nocti Gs eo a Oa Naan a cee
Section No. al 2 2a Se easeTotal Footing of Bill $I. Ld.6.1-S
a . Block No.. } . ae ee eel Z. $
Balance $
; Owner..
Magram of Lot or Vault ee’ Entered into Ledger, page.. or below.
ae eric) eee to! umn y Mice