224 / 1028
218
t.
�
���t
}
...
l(rntnn Qlnunty arnrnnrr'n ®ffirr...
.
j
(!ff�
-=
�
101
-
I,<,\':
Inquest No.
Received Notice
f
_ _
,
19
__
A. M.
P.-M
l
N
a
me �
�DAA-CJ./lA..-eAW
_
Residen�
nLJ\
�
IL.
f}
.__
-
__,,,.___
__ ________ _ _ ____
_
Wl>it,e
��
I'@Haale.
Age
dti
/\tl4,/
Years -C/,f:!-Months
____
Days
N
at
iv
it
y
How lo
n
g in County?
___
Mani@d-Single- ;w iSN
:: :
Vli T * :
r.
Occup
ation
�
Father's N
a
me
l)J,/1
�
(t(t
,£
7L,
4,tk
Mother's N
a
me
_
__:::::..A
IJ,&,�
�
A-
-
�
'....ll,,�:::::::::�
.
Esta
t
e
___________
�__,___ _ _ _
Nex
t
Frie
n
d
_ _ _ _ _
i+---------
Pl
a
ce of
Death
----='-j__..
�A
,,__
l
__._
7�of�n
"-'-
.y+--+-\
bi�_,,_,____
D
a
te of De
a
th
________ _ _ _
Body Found_______
___,
O
'------·- - - -
-----
-
- ---
-
-
-
Pl
a
ce of Accident__
---'):LL-
--1
1---
....
SJLQ__�
_
__,.-=-...,_�-
=----=--"CJ./J"'---'---
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.