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...if(rutnu illnuut y illnrnuer's ®ffirr...

�101,

Inquest No

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P. M.

Name

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Residence

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�Colored-Male-'iu:rna]e

Age

1

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v

Years

__ _

Months

Days

Estate___________ _ ____

Next Friend

_____________

_

Place of Death_________ _____

Date of Death

_____________

Body Found_________ _ _ ____________ _ _ ____

Place of Accident

___________ ___________

.

______ __

_

Nature Injuries

_______ _

_

_

___ _ _ _____

_

______

_

__

Cause of Death �

-

�- C

Post Mortem

-

----

---

·

---

- - --

----

Names of Jurymen

___

_______

___

_ _

_

_____

_

___

______

__

Names of Witnesses_______ _ _______ __________________

Undertaker::

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y,:

v

"'CLC"'

\II

Fees Paid.

____

_

Height

______

_

Nose_-,-______

DESCRIPTION WHEN UNKNOWN

Weight.

______

_

Chin________

Hair

__

_

Neck

_ _

_

Eyes.

__

_

Teeth

____

Beard__________________

Mustache

_ _ _ _ ___________

_

Scars, Marks, Deformities, Etc.,______________________________

Clothing------------- -----:- --

Contents of Pockets, Etc.,

-- -·

----- -

----- - -

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-

Remarks: _____ _ _ __________ _____ _ _________

VE RDICT:

________ ___ _____________________ _

Signed

Coroner.

lnqu

Nam

Rcsi

Fath

Plac

Body

Plac

Nat

Caus

Po:--t

Nan

Nan

lJ nd

Hei

Nos

Bea

Sca

Clo

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