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Place of Accident
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Nature Injuries
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Names of Jurymen
_________________ ___ _ _ _ _
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Names of Witnesses___ __ _ _ ________ _
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Undertaker_ _ __________________ _ _
Fees Paid
____ _ _
_
DESCRIPTION WHEN UNKNOWN
Height
Weight
Hair_
Eyes
Nose
Chin
Neck
Teeth
Beard
Mustache_
Scars, Marks,
Deformities,
Etc.,
Clothing
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Contents of Pockets, Etc.,
_ __ __________ _ _ _ _ _ _ ____ ___
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Remarks:
_ _ _________________ _ ______________
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VERDICT:
___ _ ________
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_ _ _ _ __ _ _ _ _ ___
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Signed
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Coroner.