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Father's Name
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Place of Accident______ _
Nature Injuries
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Cause of
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Post Mortem
_ ______ _ _ _ _
Names of Jurymen______ __________ _
_ _ __
_ __ _ ___
Names of Witnesses_ _ _ _ _ _________________ _____
Undertaker
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Fees Paid
____ _ _
DESCRIPTION WHEN UNKNOWN
Height
_ _ _ __
_
Weight
_ __ _ _
Hair
______
_
Eyes
_
__
Nose_______
Chin_ _ _
____
Neck
____ __
Teeth
___ _ _
Beard_ ________ __ _
___
Mustache
______
---:-- - - --- -
Scars,
Marks,
Deformities,
Etc·,
- -- - ,,-------- ·
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Clothing ___ __ ___ _
Contents of Pockets,
Etc.,
___
_
Remarks:____________ _ _ ____ _________._____
V E RDICT:
__ _ ___________________ _
....
Signed
_
___________
__ _
___Coroner.