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Inquest No.
Received Notice
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19
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A. M.
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Age
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/\tl4,/
Years -C/,f:!-Months
____
Days
N
at
iv
it
y
How lo
n
g in County?
___
Mani@d-Single- ;w iSN
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Occup
ation
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Father's N
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Mother's N
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me
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Esta
t
e
___________
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Nex
t
Frie
n
d
_ _ _ _ _
i+---------
Pl
a
ce of
Death
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bi�_,,_,____
D
a
te of De
a
th
________ _ _ _
Body Found_______
___,
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'------·- - - -
-----
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-
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Pl
a
ce of Accident__
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N
at
ure Injuries
_ ___
___ _
_
_
_
_
_
__
_
_
_ ___ _ _ _
C
a
use of De
at
h
Post Mortem
N
a
mes of Jurymen
_
_ _
___
_
_
_
_
_
__
_
____ _
___ _
____
__
L...__
N
a
mes of Witnesses_____________________ __________
Under
t
Fees P
a
id
___ _
DESCRIPTION WHEN UNKNOWN
Heigh
t
Weigh
t
Ha
i
r
Eyes
Nose
Chin
Neck
_ __
Tee
t
h
Be
a
rd
Mus
ta
che
Sc
a
rs,
M
a
rks,
Deformi
t
ies,
E
t
c.,
Clo
t
hing____________ __ _ ____ __ _____________
Contents of Pocke
t
s, E
t
c.,
__ _
.........
Rem
a
rks:__________________________ __________
VE RDICT:
___ _____ _ _ __ ___ ___
--'-- - - -
-
Signed
- -- ---- - -�--- ---Coroner.