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A. M.

P. M.

---- -���-Years

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Months

LL

Days

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Occupation (./(0<�)

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Undertaker+

Mother's Name

________ ___

_

Next Friend

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Date of Death

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Fees Paid

____

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DESCRIPTION WHEN UNKNOWN

Weight

_______

Chin

_ ______

Hair

____ __

_

Eyes

Neck

Teeth.

_ _____

Mustache

_________________

�arks, De�rmities, Etc.,

_ _ __________ _ __ _ ___________

_

Contents of Pockets, Etc.

,

---

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- ---

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--

-

- -

-- - -

-

------

--

Signed

Coroner.

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