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Days
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Nativity
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How long in County?
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Occupation
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Father's Name �"� ��
Mother's Name Gaeiena�.q -���
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Next Friend
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Place of Death \�'\
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Date of Death
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Body Found_____,_,\
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Place of Accident
_____ __
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Nature Injuries
______
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Cause of Death
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Post Mortem
____ _ _ ___
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Names of
Jurymen
__
_
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______
__
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Names of Witnesses_______ _ ___________ _________
Undertaker
Fees Paid
_____ _
OESCR.IPTION WHEN UNKNOWN
Height
Weight
Hair
__
-
-
-
Eyes
Nose
Chin
Neck
_
Teeth
Beard
Mustache
Scars,
Marks,
Deformities,
Etc.,
Clothing ______ ______
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----
--
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Contents of Pockets, Etc.,
__ _
Remarks:
_____ ______ _________� - - - -----
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VE RDICT:
__
_
____
__
_
__
_
_________
_
_____
\
Signed
____ ______ ______ _
Coroner.