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Place of Accident
_ _ _
___
___ _
_
_
Nature In j uries
_
_
__
_
_
_ _
_ _
___ _
Cause of Death
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Post Mortem
___ _ _ ______ _ _ _
_
Names of J urymen_
_
__
___
_
__
_
_
____
Names of Witnesses_ _
_
_ _ _
__
_
_
_______ _____:
______
_
UNKNOWN
Height
______
_
Weight.
_ _ _ _ _
Hair
___
_
E yes_
Nose
C
hin___ _ _ _ _
Neck
_
__
Teeth
__ __
Beard
__
__
_
_
_
_
_
___
_
_
_ _
Mustache
_
___
__
__
___
__
__
_
_
Scars, Marks, Deformities, E tc.,
__
_
_ _
_
_ _ _ __
_
_ _
_
_
___
___
Clothing______ _______ _ _ __ _
C
ontents of Pockets, E tc.,
____ _ _ _
Remarks:______ _ _ _ _______ _ _ _ __ _______
____
VE RDICT:
____ ________ _ _ _
.
Signed
_ _ ___
_
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