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Days
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How long in County?
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Father's Name
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ate of Death
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Place of Accident
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___
___
_
_____
_
__
ature Injuries
______
ames of Jurymen
_
__
__
___________
_
_
__
_
______
_
____
ames of Witnesses_______________________________
Undertaker
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ees
Paid
_______
_
DESCRIPTION WHEN UNKNOWN
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Height
Weight_______
Hair
______
_
Eyes
___
Nose_
Chin________
Neck
_______
Teeth
_____
_
Beard
__
_
___
_
__
_
_
_
_
_
Mustache_
_
_
_
_
_
_____
_
_
_
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cars, Marks, De�rmit ies, Et�,---------------------------
Clothing
-
-
--
-
-
---
-
----
----
-
-
-
-
-
-----------
Contents of Pockets, Etc·,
-
-
-
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--
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-
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-
-
-
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------
-
-
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---
---
- ------------
Remarks:
_
___
_
____________________
_
__
__
__
_
_
_
_
VE RDICT:
____________________________
_
s
Signed.
____________________
Coroner.