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�101
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Inquest No.
Received Notice
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, 19_�, _
A
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P. M.
Name��
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Residence � o �- a
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White-�-Male..-Female. Age
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ears
Months
Nativity��
How long in County?_
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Days
Married-Si,,;:le-Widow-w;,i,,.,.er.
Occupation
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Father's Name
Mother's Name
_
_ _
_
_
_
__
_
_
_
_
Estate
_______-y,�---th-;-----.--- - -
Next Friend
____
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_ _______
_
Place of Death��
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Date of Death
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Body Found__--ff-
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Place of Accident
___ _
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Nature Injuries
_ ___ _ _
_
Cause of Death_��
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Post Mortem
_ ___
_
___
__
Names of Jurymen
_____________
_
Names of Witnesses______ _ __ ___________ _________
Undertaker¥
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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.