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Place of Accident
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Nature Injuries
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Cause of Death
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Names of Jurymen
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Names of Witnesses
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Undertakej"""�-
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Fees Paid
____
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DESCRIPTION WHEN
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Height
Weight
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Eyes
Nose
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Neck
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Teeth
Beard
Mustache
Scars,
Marks,
Deformities,
Etc.,
Clothing
_
_____
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Contents of Pockets, Etc.,
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Remarks:
_
____ _ _
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_____
VE RDICT:
______ _ _ _________ __________
Signed
_ __ _ _
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Coroner.