426 / 1028
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P. �I
White-Colored-Male-Female. Age
Years
---
MonJ:h§ -��
Nativity �
How long in County?
__ _
Married-Single-1l,,idow-Widower.
Occupation
_
____
__
_
_
______
___
___
Father's Name_____,___________
Mother's
Name
__
_
_
_
__
_ __
___
Estate
_ __________ ___
_
Next Friend
____ _____ _ _ _
Place of Deat1i____ __ _______
Date of Death
__
_____
_ __
_
Body Found
_
_
___
_
_
__
_____ _
_
_____
_
_
_
_ ___
_
Place of Accident
___ _ _ _____ _ ___________________
Nature Injuries
_______ ____ ____________
_
Cause of Death
Post Mortem
&i�
er
��
--
-
-
---- --------------
Names of Jurymen
____
______ _
_
_
____
__ _ _ _
_
____
_
__
_
Names of Witnesses_______ __-:- ------------------------
L
underta�er
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r1£;=-;�
Fees Paid
DESCRIPTION WHEN UNKNOWN
Height
Weight
Hair
Eyes_
Nose
Chin
Neck
Teeth
Beard
Mustache
Scars,
Marks,
Deformities,
Etc.,
Clothing
��===-- -
-
---
- -
----
-
- - -
-
-
--- -===
=�
Contents of Pockets, Etc.,
Remarks:________ _ _ __ _ _ ____ _ _ __ ___________ -'-
VERDICT:
./
__ _
-�
..
-
.,.
Signed
_ _ _ _
__
_
_
_
_____
_
_
Coroner.
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