240 / 1028
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Inquest No. ':
<J Received Notice i
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Name
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Residence-----t:x-
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A. M.
P. M.
White-�d-Male-�e.
Age
Years
Months
____
Days
____________________
How long in Co �� X?
-
Occupation
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-
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-
-
Father's Name
_____________
Mother's
N£Jne
______
_
Estate
______
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Next Friend
Place of Death
-ft� ��
(Jo it
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Date of Death
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--'9
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Place of Accident
_______________
_
Nature Injuries
_
___
_
_
__
_
_____
_
Cause of De
a
th
_
¢
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----
-
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Post Mortem
_________________
_
Names of Jurymen
____
_
_____
_____
_
Names of Witnesses �
Jtr.w.124
"".Cnrc,�.
Undertaker
___________________
_
Fees Paid
____
_
DESCRIPTION WHEN UNKNOWN
Height
_______
\V'eight
_______
Hair
__
Eyes
____
_
Nose.
________
Chin________
Neck
____
Teeth
_____
Beard
_________________
Mustache
_
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--
------
----
-
-
Scars, Marks, Deformities, Etc·,
-
-------
--
---,,-
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---
-----
--
-
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---
-------
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Clothing
-
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----
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------
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______________
R
emarks=
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----
-
-----
--
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----
-----
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--
-
-
VE RDICT:
_____________________________
_
Signed
____________________
Coroner.