391 / 1028
r.
...if(rntnn a.tnunty a.tnrnnrr�a ®ffirr...
==
=
�
101
=
==
: :: st �e .
ce iv �� ot�� ,
1
9�
_ _
A.M.
__
P.M.
Re
s
iden�
�-� � ���
-
�--�
--����-
-- ---------
Days
·
•
Whit � �Gnl"5f'1- Mal � ,Ce � . Age
rff'/.
Years
.
Months
Days
Nat1v1ty
>!lr_�
�o
�
How long m County?
_
___ _ _
c::::--
Married-Siugl�-�w YvVidowet.
Occupation
o
Z
�r:v.J
�
Father's Name
� )n
�
{ft
'1Y::h>�
c.l(
Mother's Name
G
L..,.
·
{).,,_,,'h.u-....l
Estate
Next Friend
___
----,()___
___ _ ___
_
Place of Death
Q,,
rF:;?J
J,�J&.}I
Date of Death
Jk.
l
If
:Jo
- ,f:
�
Body Found
� � U
f+d' �
Place of Accident
Nature Injnries
_____
_
_
_
_
_
_
__
_
_ _
__
_
_____ ___
__
_
__ _
_
_
Cause of Death
c""-��:)
c!t
u;::,::;:
+
n
(
Uf
e e,I�)
.
Post Mortem
.
Jr.�-
/{
Names of Jurymen
_ _ _ _
_
__
__
_
_ _
__
_
_ ___
_
__
_
_ ___
_
__
_
Names of Witnesses
___ _
___
_
___
_
_
__
__
_ _
__
_ _
_
__ _ __
____
Undertaker_______ __________ ______
Fees Paid
________
_
Height
Nose
_
- - ---
DESCRIPTION WHEN UNKNOWN
Weight
_ ____
_
Chin________
Hair
______ _
Eyes
_______
Neck
Teeth
______
_
Beard
Mustache
__
_
_
_
__
___
_
_
_
_____
Sea�, Marks, Defur1nities, Etc.,
_ __________________ __________
_
Clothing
---
-
-
-
- -
-
-
-
--
-
-
- -- -
Conten� of Pockets, Etc.,
_
__
_
_
_
___
_
_ _ __
_
_
__
__
____
_
___
__
_
Remarks:________________ ___ _ ___ _ _____
------
VE RDICT:
_______ _ _ _______ ____________________
_
c!itt_
Signed
Coroner.