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Inquest No.
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Received No
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Name
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Residence
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�ite-Colored-Male-�e. Age
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Years
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Months
Days
NativitY---------------------,-- How long in
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_
Occupation
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Married-Single-Widow-Widower.
Father's Name
_____________
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Mot
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Name
_
Estate
________________
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Next Friend
_________
__
__
_
Place of Death______________
Date of Death
___________
_
Body Found
______
_
__
__
___
_
_____
Place of Accident
_________
_
Nature Injuries
______
_
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
_____
DESCRIPTION WHEN UNKNOWN
Height
______
_
Weight
______
_
Hair
__
Eyes
__
_
Nose________
Chin
________
Neck
__
Teeth
____
Beard
__
_
____
____
____
_
_
Mustache
______________
_
Scars, Marks; Deformities, Etc.,
_
_
______
_
__
__________
___
_
_
Clothing
_________
_____
___
_______
_
_
_
____
_
__
Contents of Pockets, Etc.,
___
_
Ren
44.
·
VER
.
If heart disease, name the particular •
Please state the p ri mar y e ause . d . tis (acute or chronic), mitral
form as, endocarditis or m y ocar i
regurgitation, etc.
Signed
_
_
_
______
_
_________
_
Coroner.
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