NAME ADDRESS

In Memory of
_______________________________________________________________ _____________________________ ___________________________
Name of Deceased
_____________________________ ___________________________
_______________________________________________________________
Date and Place of Birth _____________________________ ___________________________

_______________________________________________________________ _____________________________ ___________________________

Date and Place of Death
_____________________________ ___________________________
_______________________________________________________________
Year Month Day ____________________________ ___________________________

_______________________________________________________________ ____________________________ ___________________________

Age at Time of Death
____________________________ ___________________________
_______________________________________________________________
Residence of Deceased ____________________________ ___________________________

_______________________________________________________________ ____________________________ ___________________________

Name of Surviving Spouse or Relative
____________________________ ___________________________
_______________________________________________________________
Date and Place of Interment ____________________________ ___________________________

_______________________________________________________________ ____________________________ ___________________________

Name of Cemetery
____________________________ ___________________________
_______________________________________________________________
Block No. Section No. Lot No. Grave No.