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==
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101
==
Inquest No.
Received Not
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CJ
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19
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P. M.
Name
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Age
Years
____
Months
---
Days
Nativity___________ ____ _ ____
How long in County?
______
_
Married-Single-Widow-Widower.
Occupation
______________________
Father's Name__________ ___
Mother's Nallle
__
_______
__
_____
Estate
Next Friend
_______�------ - -
Place of Death
Date of Death_
_
______
_ _
Body Found
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Place of Accident
Nature Injuries
__�-
--
-
-
-
-
- - -
- - -
- --
-
-
-
-
-
-
-
-
-
-
-- -
Cause of Death
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Post Mortem
__
_
___
_
_
_
_
__
_
__ _
_
_______
_
_
_
_
_
__
_
___
_
"'(
Names of Jurynien
_
___
__
_______________
_
_
__
_
_
_
______
Names of Witnesses_
_
_
_
_
_
_____ _ _
__
_
_
___
_ _________
_
_
_
_
rg
Undertaker
b
�
?
Fees Paid
________
DESCRIPTION WHEN UNKNOWN
Height
Weight
Hair
Eyes
Nose
__
Chin
Neck
Teeth
Beard
--
Mustache
Scars, Marks,
Deformities,
Etc.,
Clothing
--
---
-
--- ---- --
- --
-
..LL
N
?t)e,
Contents of Pockets, Etc.,
..2 - 7 �
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Remarks:
__
_
_
_
_
_
_
_
_
_
_
_
__
_
_
____
_
___
_
_____
___
_
__
___
V!<:RI>ICT:
._-----,
Signed
Coroner.