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Rec ��tice
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A
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P. M.
Nam
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Re
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idence
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White
CoJm:ed
�Female. � �ge
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lf
Years
�hs
___
Days
How long in County?
_ _ _
l
lla11icd
Occupation_
·
_ ___ _ _____________
Mother's :Name
_ _ _ _ _ ________
Estate
:Next Friend
_ _ _ _ � - - ---
Place of Death=.J.
�
L
f
Date of Death
O
cd:
�
Jr
/f.:/
O
I I
Accident
_ ___________________ __________ _ _
Injuries
__
_
_
_
_ _
_
_ _ _
__ __ _
_
_
_
______
_ __
_
P�Mortem
���
�
�
�
·
����
Names of Jurymen
__ _ __ ___________ _ ___ _ ______
_
Names of
Witnesses
_ _________________________________
Undertaker
2n�
d
t
hA{
�
�
Fees
D
P:.00 WHEN UNKNOWN
Paid.
_ _ _ __
_
Height
Nose
Beard
Weight_ _____
Hair_ __ _ _ _
Eyes·
--- - �-
Chin_ _ _ __ _
:Neck.
_ _ _ _
Teeth
_____
_
Mustache
_
_
_
_
_ _ _ _ _
__
_ ___
_ _
Scars, �arks, De�rmities, Et�,- ---- - ------ --- -- -- ----
Clothing
---
-
-
Contents of Pockets, Etc.,
_______________ _ _ _ __ _ _ _ ____
_
Remarks:___________________________ __________
VE RDICT:
___
-
-
-
---
--- -
-
-
- -
-
·
-
-
- - - -
---
- -
-
-
-
-
---'--
y
Signed
Coroner.