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228

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Residence____L_.!O�����:�-

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White-Colored-1\k+e-Female. Age

Years

Months

Days

Nativity

(1£4

h

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a)

How long m County?

_

_ _

MarrierJ-S+ttgle-Wi � w-Wif™r·

Occupation

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Father's Name

Jtfn-i

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0 Mothds Name {2��-

Estate

Next Friend

____ ____

------

Place of Death

flJ.e(

Date of Death

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cfi.

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9

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0

Body Found

t1.NC£

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Place of Accident______ _

Nature Injuries

_

_ _ _

_

_

_

__

_ ___

_

__

_ _

_ __ __

_ _ __

·

Cause of

D

ea

th

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Post Mortem

_ ______ _ _ _ _

Names of Jurymen______ __________ _

_ _ __

_ __ _ ___

Names of Witnesses_ _ _ _ _ _________________ _____

Undertaker

/ff:::

{;�

J:

Fees Paid

____ _ _

DESCRIPTION WHEN UNKNOWN

Height

_ _ _ __

_

Weight

_ __ _ _

Hair

______

_

Eyes

_

__

Nose_______

Chin_ _ _

____

Neck

____ __

Teeth

___ _ _

Beard_ ________ __ _

___

Mustache

______

---:-- - - --- -

Scars,

Marks,

Deformities,

Etc·,

- -- - ,,-------- ·

------ - - ----

Clothing ___ __ ___ _

Contents of Pockets,

Etc.,

___

_

Remarks:____________ _ _ ____ _________._____

V E RDICT:

__ _ ___________________ _

....

Signed

_

___________

__ _

___Coroner.