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...if(ruton Qlouut y Qlorourr�s ®ffirr...

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�A. M.

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P. M.

Name

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Residence

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White-C�Male-Female. Age

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Months ____Days

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Nativity

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How long in County?

______

�,<'._�-Widow-�r.

Occupation_ __

______________

Father's Name

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Mother's Name

_ _________ _

Estate

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Next Friend

Place of Death

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Date of Death

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Body Found

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Place of Accident

________________ ______ _ _ _ ___ _ __

_

Nature Injuries

__

_ _ _

_

_ __ _ _

_ _

_

__

_

_ _

_

_

_

_ _

_ _ _ _

_

_

Cause of Death

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Post Mortem

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Names of Jurymen

_________________ ___ _ _ _ _

___ ___ _ __ _

Names of Witnesses___ __ _ _ ________ _

__ __ _ _ __________

Undertaker_ _ __________________ _ _

Fees Paid

____ _ _

_

DESCRIPTION WHEN UNKNOWN

Height

Weight

Hair_

Eyes

Nose

Chin

Neck

Teeth

Beard

Mustache_

Scars, Marks,

Deformities,

Etc.,

Clothing

--

- -

-

-

-

- - -- -

-

--

Contents of Pockets, Etc.,

_ __ __________ _ _ _ _ _ _ ____ ___

_

Remarks:

_ _ _________________ _ ______________

_

VERDICT:

___ _ ________

_________ _

_ _ _ _ __ _ _ _ _ ___

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Signed

.

Coroner.