

21�
Inquest
Name
Residence
...if(eutnn <nn:unty <nnrnnrr�s ®ffirr..
:
�
,
_
,
19�
__
A. M.
P. M.
Father's Name_____ _ _______ Mother's Name
_
-+-
-1--
-
---
-
---
-
-
Estate
______ __-----==-----� �
_,__------r-----,.--
Next Friend
·
---
7""'1
�
- - - --
-
-
-
-
Place of
Death---(�-1---J---'.---�-�==-Jti::7--I-:_:____
Date of Death
____,i
__.
�
"""'�
/"--_
/
_
7_._
_
-
_
r==--.J,__j--"-
-
3
_7J
__
Body Found
�
Place of Accident
____________ ______________ _ ____
Nature Injuries
______ ______________________ _ __
Cause of Death
fu
r
CU
Post Mortem
__
_
__
_
_ _ _
_ _ _
_
__
___ _
_
Names of Jurymen
______ _ ________ __ ___
_______ _
_
Names of Witnesses_________ _______________________
Undertaker
C,£�
Fees
Paid
�ESCRIPTION
WHEN
UNKNOWN
Height
Weight
Hair
Eyes
Nose
Chin
Neck
Teeth
Beard
Mustache
Scars,
Marks,
Deformities,
Etc.,
Clothing
____________
_
Contents of Pockets, Etc.,
______ __ __________________
_
Remarks:______________
____________________
VE RDICT:___________________
Signed
_
_
__
__
_
_______
____ _
_
_
-Coroner.