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BURIAL PERMIT NO.
FUNERAL SERVICE RECORD
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(Last)
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PLACE OF DEATH
COUNTY:
STATE:
(Middle)
(Name of Deceased)
OF DECEASED: IF INSTITUTION,
USUAL RESIDENCE RESIDENCE BEFORE ADMISSION:
COUNTYy/ dL,, /
NO. ///
STATE: /
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A l 'o F/ ov/, f
CITY OR TOWN; LENGTH OF STAY
IF OUTSIDE CORPORATE (in this place)
LIMITS, RITS R E "RURAL"'
,RIERuR, 1_____/_________________
FULL NAME OF LENGTH OF STAY
HOSPITAL OR INSTITUTION;
IF NOT EITHER, GIVE ADDRESS: // o i 4 r S
DATE OF (Mo h) (Day) (Year) (Hour
DEATH 6R -
SEX COLOR OR RACE MARRIED O NEVER MARRIED
/ l ?4#- / `1- E ] WIDOWED O DIVORCED (Specify)
DATE OF BIRTH AGE Months Days Hours Min.
USUAL OCCUPATION KIND OF BUSIN S OR INDUSTRY
. 1 ,,t A5 7" C- c /,7 I,, -;?
B'THPLACE (State or Foreign Country) CITIZEN OF WHAT COUNTRY?
0 rr0 Is //<.rr! I 2ATCNR
FATHER'S "
MOTHER'S MAIDEN NAME .
,94P 11t^ A1,16 Z f&A ->4
WAS DEL-ASED R U. S. ARE RCs
PRTATLe F1O NATION
INFORMANT
Address Relationship
CAUSE OF DEATH
AUTOPSY YES O NO r
PHYSICIAN
Address
CITY: RESIDENCE INSIDE
CITY 1 CITY LIMITS?
C A. YES.b NO E
STREET ADDRESS; RESIDENCE ON FARM?
IF RURAL GIVE EXACT LOCATION: C f' r Ct J YES D NO.q
Relationship Survivors
7//4
____ 0y/A-e 0AL e/o; ; -
0/ 0. ,,l ,
"____ ICZ g- "' I ~, -
_____-- C\ ^' '< .y4' ^ w~ ^
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4 ZLet-i u "s e--, (24
CHURCH AFFILIAO ION -- '*r
pd CLERGYMAN
Address
FUNERAL PLACE
IF CHURCH DID BODY LIE IN STATF
YES [ NO E]O
DATE 7-- 7= TimeA 0
PLACE OF BURIAL Cremation or RePoval
Cemetery
Location
County
DATE
- 7 19
VISITING HOURS
FRATERNAL AFFILIATIONS
SERVICE -YES ---- NO [
State
CEMETERY LOT NO. Owner of Lot
Section Grave No. o
BEARERS
IMTFIPMATInNAL ASSOCIATION OF MORTICIANS
MUSIC YES O NO E
SINGERS
FUNERAL DIRECTED BY LICENSE NO.
EMBALMER'S LICENSE NO.
REMARKS:
_ I _I__ ~~ ~~___1 _1
I_ I_ _
I JJ ........
_/n o a/ J a s r v ^#.b/ .
a9 4i/V7 a~ver ~^.. W A9. i. CIA
~---~
State~
>f-t~
(.
t
Apt
',
DESCRIPTION OF CASKET AND OUTSIDE ENCLOSURE
NO.
Purchase Date Size Our Number Interior No.
Mfr. Mfrs. No. Material Material
Casket Cost Blanket Cost Cover Finish Color
Kind of Vault Type of Vault Finish Cost
SALES RECORD STATEMENT MAILED LEDGER LETTER SENT
(1) SERVICES, including casket
All Facilities and Equipment ..........
Personal and Staff Service .......
Professional Service ... .... .. .
Visitors Register .... .......
Acknowledgement Cards ........ ....
Funeral Sedan ..... ...... .............
Casket Coach .............
Outside Enclosure ......... .........
C clothing ................ .......
(2) ITEMS involving Cash Advances
Sales Tax ......... .. ........
Additional Autos .....
Cemetery Charges ................
Clergym an ........ .. .....
Telegram s ...............
Long Distance Telephone Calls .. ....
Transportation .......... ... .....
Flow ers . .. .. ..
Obituary Notices ..... .... .. ..
(3) ITEMS ORDERED LATER
Certified Copies ....... ... ...
CARRYING CHARGE
T erm s ............................ ....
. . . ..a. . . . . . .
Total (1).
Estate: Yes Q N o Q O ther:.......................................
Executor or Administrator .........................
Address .................................. ... ....
A tto rn ey. . . . . . . . . .. ... . . . .
Address
A. .
DATE
DEBITS
CREDITS BALANCE
_3 4Af I
-1 C 92,12
* -~J- I~ -
Total (2)
Total (3)
GRAND TOTAL
i . .
I--~--I;.. -. c-----sl r---r I----_
*(1) SERVICES, including Casket
All Facilities and Equipment
Personal and Staff Service
Professional Services
Visitors' Register *
Acknowledgment Cards
Funeral Sedan
Casket Coach
Outside Enclosure ....------------. .
Clothing -----------------
...............................---
..................................
Total (1) L/7
*(2) ITEMS INVOLVING CASH ADVANCES
To Permit Us To Render A Better Service
We Have Advanced The Money On These
For Your Convenience.
Sales Tax ....... ----------
Additidhal-Autos --------------
Cemetery Charges -,..------- ~ a
Clergyman ------------------
Telegrams------------------
Long Distance Telephone Calls.--
Transportation---------------
Flowers --------------------
Obituary Notices .------------
.............................----.
..................................
..................................
Total (2) '
*(3) ITEMS ORDERED LATER
Certified Copies ---------------
..................................
..................................
..................................
.............................. ----
Total (3)
Grand Total
ORIGINAL
FUNERAL PURCHASE AGREEMENT
A. L. Cunningham, L.F.D. J. C. Cunningham, L.F.D.
PHONES: 622-7886 622-4251
524 BROADWAY, OCALA, FLORIDA
7- 3
Name of deceased MI 3 ?1A 5/.I ---D asaIAe(
Deceased is oA4 r- P of person arr
(Give relationship)
19Ai -
Age4V-
anging services
* (1) Services, including merchandise ........ $
*(2-) Items Involving Cash Advances ...... $ 41F -
Total (1 & 2) $ClS- O
*(3) Items ordered later .................. .$
Both parties agree any items ordered later
.,hall become a part of this agreement and
shall be inserted therein.
We agree to furnish all services, and I, or we, accept and approve the above
merchandise, indicated above.
SSignature of Purchaser
Address
City State
By /
Signature of Co-signer with Purchaser
Signature of Co-signer with Purchaser
Signature of Co-signer with Purchaser
Signature of Co-signer with Purchaser
Street City and State
Street City and State
Street City and State
Street City and State
1
L(
State
City
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