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224

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�101

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Inquest No.

Received Notice

-

__

, 19_�, _

A

. M.

P. M.

Name��

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�o�·

- -

Residence � o �- a

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�pt

.

(fL�

'-�=4-

�,

.,.__

___

White-�-Male..-Female. Age

_

-

-

ears

Months

Nativity��

How long in County?_

___

Days

Married-Si,,;:le-Widow-w;,i,,.,.er.

Occupation

}t4

Father's Name

Mother's Name

_

_ _

_

_

_

__

_

_

_

_

Estate

_______-y,�---th-;-----.--- - -

Next Friend

____

,--

_ _______

_

Place of Death��

.___

t:J��_?;_.���il�-'-

M.._____

Date of Death

J-

�, ,

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l)

.....__

__

Body Found__--ff-

-

-

-

·

-��-

--

-

---- -

--

------4

4

Place of Accident

___ _

_

_

_

_

_

_

_

__

Nature Injuries

_ ___ _ _

_

Cause of Death_��

-��·��

4

=#-

- -

Post Mortem

_ ___

_

___

__

Names of Jurymen

_____________

_

Names of Witnesses______ _ __ ___________ _________

Undertaker¥

\-\-\,L]c£.......�-

Fees·Paid

__

OESdk.lPTION 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.