

...if(rutntt Qlnuut y Qlnrnurr�s ®ffirr...
�/-�-
L�/'
, ,
)
19...4..q
__
A. M.
P. M.
---- -���-Years
___ _
Months
LL
Days
·-d-�-�w-Widower.
Occupation (./(0<�)
l>,
<&
cth.-
..._,;;f__
¢d
(l({?/S
Undertaker+
Mother's Name
________ ___
_
Next Friend
___
��----- - --
Date of Death
&�_,.
�-I ,
I
9
,�Q
l'
�
,,
'1:tiMAC�
__
,,L
•
:itJ,-
d
ce
Abo,._
7V\
{.
d
�
lt1
�6
Fees Paid
____
_
DESCRIPTION WHEN UNKNOWN
Weight
_______
Chin
_ ______
Hair
____ __
_
Eyes
Neck
Teeth.
_ _____
Mustache
_________________
�arks, De�rmities, Etc.,
_ _ __________ _ __ _ ___________
_
Contents of Pockets, Etc.
,
---
- -
- ---
-
--
-
- -
-- - -
-
------
--
Signed
Coroner.
•;