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Age
c5�
Years
____
Months
P. M.
Days
h � t ��� Male-Fem&k.
at1v1ty �
How long in County?
____ _ _
_
er:-' .
arried-�e-�w-\\Jaidoow::r.
Occupation
Jo../.-<
�
Mother's l\lame
_ _
_
_ __
_ ___
�state
�
Place of Death�0&'«
J,/;;iJi
Next Friend.
_ _ _ _ _ ____ _ _ _
Date of Death
A�
2
L,
/'iJO
Body Fonnd ,,
1,�
1
,,
1 ,
(L� ,,
'
ames of Jurymen
_
_
___
__
_
_
__ _
_
_____
_
_
_ _
_
_
__
__
_
_
_____ _
'ames of Witnesses
_ _ ________ _ ________________________
_
Undertaker
__
_
_
__
_
_____
_ _
� - ------
Fees Paid
__ _
_
DESCRIPTION WHEN UNKNOWN
Height
Weight
_ _ _ _
_
Hair
_ _ ____
Eyes_
ose
Chin
___ _ _ __
Neck
___ _ _
_
Teeth
_____
_
Beard
Mustache
_
_
_
_
_
_
_
___ ___
_
_
_
____
can,
Marks, De�rmities, Etc.,
__
_
_
_
_ _ _
_
___
_
__ _ _
___
_
____
______
- ----
Clothi
n
g
--
---
-
-
--
--
-
-
- -
-
--
- -
-
Contents of Pockets, Etc.,
_
__
__ __ __ _ _ __
__ _ _
_ _
_
_
_
_ __
_
_
Remarks:
_
_______
_
_
_
____
_
_
_
____
_
_
_
_
_
___ _ __
_
_
_
___
VERDICT:
Signed
Coroner.