It is sewn with the same pattern on each side. So, i cut the designs from bone colored muslin fabric. Cut two of each element. Then use elmers glue or fabric glue to glue the skull where you want it on one side. With that done, hold the flag up against a window with the skull on the back side so that you can see exactly where to place the skull on the other side. You want them to match up exactly on both sides. Glue the second skull in place directly over the skull on the back side of the flag.

With the skulls glued in place, zigzag stitch from one side to catch both skulls. This is why the must match up exactly.

Oh, i sewed the eyes and nose on the skulls before gluing to the black flag background.

The other elements are then added in the same way.