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J.359
Date. .....Eebr.uar.Y....1........
CHECK EACH ITEM AS COMPLETED
FUNERAL RECORD OF No.........................._ ._ _
Yearly No.... " .............
.;!;1...............
Casket .....................................................'" Outside cJ~tt;e~ault........ (.~~:).......... .. ............ Embalming Body .................................... · · · ······· . . 1 Pr ofessional Service ............................... . Hair Dresser.............................................. Suit or Dress ........................................... . Shirt, Collar, Tie ...................................... Shoes $......................Hose $.................... ..
Name. ......................Au:tna ...M.UJ'J'j,.~J...:R9..1?1?j,n~" ................................................Sex...f..El.II§.J,.El......... Address.............................. ~~.'!;.e.r.~.....MJ.1?.!'!.Q.\!:;r-*............................................................................................. County.... J!~J'r.y....................... ToWD. hip ......." ....~~E.:!F...................Phone No ........................................... .. Where Born............ T.t'.o~ .....M1.s..EI.Q.v..r.1...............:....................................Race .......
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'N.P.-J..1;.El.........................
Date of Birtl1..... 0.c.:t.o.ber.... 21....~S9.5................ Age................... (Years )
6.3...............(Months) ,........................................ .. (Days)
How Long Resident in Community.....................................................__ ....... _____............ _............................. _...... _........ . d. mar'" ... ··d owed ....................... D'Ivorce d...................... Ch'ld · I e........................Marne... S mg ...*......o" ."1'/1 I .......................... .. Husband, Wife or
Underclothes ············································ 1 Door Spray ................................................ Gloves ~.................... Chairs $.................. .. Fl' P l ' owers 0/.................. a InS ................. .. Cremation '''''''''''''''''''''''''''''''''''''''''''''''''' N ewspa per Notices ........""'"'''''''' ...... ".. . 1
t t L Robb ins Child oL ..............................ey.e.*.~L............,,, ...................................... "'"'''''''''''''''''''''''''''''''' Ex t Mi ri T .
,..
Address ............. " ........ " .. ".. ,,_ ...........................................~....§'.;r.-1............~.!,!g.~............................................. ............ Closes t Relative... J4r.J!.., ....M.+'J.g.r.~..9:.. J!Q.!,g.gg.~........ .Address.. ...... ..... ........................... .......... ................
Father's Name..........K.1.IlL.H1t!;.!;.9..n........................... _.. ".:r.::-Bn~lace... ".... """"""""""".".""."" ..... "".""""
............ , Telephone and Telegraph ...................... ..
Mother's Maide n e.......... $ .lIIanoY....Emm.allnfl.......5tll'JuMa~.El."......................................................... 6' ,n I to r y. __ .....t •• __•• ••••••••••••••• ••••. •• ••.. ••••••••.••.••• ••. Cause 0 f Death... . .... .. . .. _~ .... _..............Contr'b 1 U '" b 1 1Q h 9 ' 7• l ___ ______ F.~Ql~.i~l
~:ii: :r~~ee:~.::::::::~:::::::::::::::::::::::::::::::::::
~_._ __ _ _I~~a~:::::::::::::::::::::::::::::::::::::1 '_··"-""---1 .------------------------""--. ----"" ------. _____ . _______ --___________ _
-------1 --.-""".--.---,,------.-------.------""--------,,-----.---,,--------< Total Amount..................................j
Remains to be shipped- see reverse f or details.
Intermenta~ _____.__._.__"". ____.._~Ui:~g~Xl~~s!n___ ~:r.~~~p.y.:~t"'e~~:~~~~ ___ ~~~J~~_~!'.E~_1.~~~~~'._~.~!. ____!M~o. Lot No ............................................. Section No...............•............................ Grave No .............................................. . Ramarks __ _._____ ___________________ log ___ ffiO_ld. __,~_._l::b._._CQ_PP_~.r:!;_QnJ!___
4_4.3-___
__""_.___..
Jl/l?r..9..!1;';JL _____._.________ .
_____ __ ________________ .___R9._§_~_t_P..n. ___ F.r.~_!:lQl:l___g!.:_e.p._~ ____~_Il:~~!._~()E_ ._. ___ ._____.____ .. ___________ .__.. ______ _
_________________________________________________M
