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Page: of 213
KNROUVURYD UP FUINLT RAL
iD No Yoo cuadacknpebaaarasseasacinn G 4)
ee No.
ame of Deceased Sa AIM ECS 3 Cre. Ke tf
1 Married O Single 0 Widowed O Divorced
Res idence. u Ld.. Cp TACRIME Lett. ©.
arge to... BL! Ape Ly. Llaglut.aey
Fires: 3.2 =: ati CHeatl)
eho ll ; rir given by.... m7: = fe
Tow Secured.....------342.47. 20S
Veteran, Name of Wie
ec cupation Ue, Oda. aoe
sa. ii a
Employer and Address 2K U/. “ae Poth nnd Lok fy
te of Death. Mav. BD.. L4GA “Qep A 14
_ (Day. (Hour)
sich £29 ALD Nee. \ Cited: Biter =".
5 0. Mos. (Da: 3
Name of Father, yy Wicd LE, PEEL m=)
is Birthplace Ll . Ae.
faiden Name of Mother Ul, a Kv
ler Birthplace L Ne LE K
te SENG 2: Ae ree et Se coe M
Beds (Date) (Day of Week) (Hour)
BIES AotW a e ee lahky
‘ , an
a f th D d (Beare) tate Number and District)
— or tne Veceased.._._.. ; Certif. Copies of Death Certificates No.
(State Physician’s or Coroner’s)
th nplace cll Lad, LALLA : Pall Bearer Service, $..... Use Of Chapel, $
ided i in the State iL aap) Gross Total for Sales Tax $
(or a ity or County) ~ (Years) (Months) Outlay for Lot
Ice : of Death. CoS AT ees a EO, eel Cremation
€ of Death hye Caan Ln Lawch. fh pR lowers, 8. Palms, $..... Matting, $
tory Causes. CLERLIS. Lele A 1k.
. ae ae
Remains to.. Sag aA.. i ‘s VIVA
of ECasket
ufa actured by.
(State Color and Number)
. Taking Remains to
‘. Delivering Box to
. Outlay for Shipping Charges
Date of Entry Mev ey, 196 ~
Be Se ie AON . li), 4 t Le (=e
(What Race)
(Husband [Wife [Widow
(I of Age of Husband or Wife (if living).. Years
eae Funeral (except outlays). . a
Pasket
i :
rial Vault or Box
Embalming Body act Bid Bi tiie. 2d . oO.
Barber, Sie Hair Dressing, $
Dressing Body, $....... Underwear, $
Suit or Dress
(State Kind and Color)
CM Slippers, $ Hose, $
Folding Chairs, $...00... Tarpaulin, $
Candelabrum, $......... Candles, $
Door Spray, $........-..-Gloves, $
Funeral Car, $......-... Ambulance, $
Limousines to Cemetery @ $
Extra Limousines .@ $
Autos to R. R. Station @$
Getting Remains from
Trip to Coroner’s Inquest
Deliver Flowers to
Removal Charges
Procuring Burial Permit
Rental of Tent, $.... of Temporary Vault, $
Opening of Grave or Tomb
Lining Grave, $...... Lowering Device, $
Clergymen, $..... Singers, $.... Organist, $
Rail ‘ Aero;
eo Mee t Tickets, $...... ane Service, $
Telegr., Phone, Cable or Radio Charges
Cash Advanced
Out of town Funeral Director’s Charges
Personal Service
tLaple eM) <4 (bon ar K GRA.. Beas line Death Notices in Papers
Lot No. tes (Names of Newspapers)
rave NO ce ee
section Noite cies oe Sales Tax
Total Footing of Bill $]. ..S 0.) OQ.
Block No. Less g
Owner : Balance $
Entered into Ledger, page...... or below.
"
.. Misc.