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ite-�d-M*-Female.
Age
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How long in County?
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Occupation
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Mother's Name
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Next Friend
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Date of Death
_____________
Place of Accident
___ _ _
_____
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Nature Injuries
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Cause of Death
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Post Mortem
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Names of Jurymen___ _ _ _
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Names of Witnesses___ __________________ _ ____________
Undertaker
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Fees Paid
______ _
_
Height
Nose
Beard
DESCRIPTION WHEN UNKNOWN
Weight
_ _ ___
Chin___ ____
Hair
___ ___
_
Eyes ,
______
_
Neck
Teeth
___ __
_
Mustache
_ ______________ _
Scars, �arks, De�rmities, Etc·,---------��- - - -- - ------------
Clothing
_
____
_
_
_____
___
_
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____ _ __
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_ ________
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Contents of Pockets, Etc.,
_
_
_ _______
Remarks:
____
_
_ ___
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___ _
_
_
_ _ _ _
_ ____ _
_
___
_
_
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VE RDICT:
______ _ ________ _ ___________________
_
Signed
Coroner.