444 / 1028
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Inquest No.
,Received Notice
V.
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_
,
19_3'/,
Name
.
.
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.
A. M.
P. M.
R
eside
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ce
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-
-
- - - -
- -
-
-
...-
-
- - - -
- -
-
- -
-
Age
Years
_
/
0
Months
Nativity
�"""'-tW:'!\.
How long in County?_
Occupation
_ _
_L_
_
_
_
-Days
Father's Name
Mother's Name
_ _ _ _ _ ____
Estate
��
Next Friend
-
Place of Death
�-
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7.
Date of Death
et?'nd--1n
11)1')1
Body Found
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£
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/1(,
_f
Inq
Nar
Res
Wh
Nat
Mar
Fat
Est
Pla
Bo
Place of Accident
•
Pla
Nature Injuries
•
Na
Cause of Death
I
Ca
Post Mortem
-- --
Po
� ---
- -·---
Names of
Jurymen
-
•
. ·
N
Names of Witnesses
-
N
Undertaker
N
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7"L>?1>
Fees Paid
I
lJt
UNKNOWN
61
Height
Weight
Hair
Eyes
•
H
No�e
.\
.
Chin
Neck
Teeth
I
N
·\
..,,
Mustache
Beard
B
Scars, Marks;
Deformities,
Etc.,
S
Clothing
,
C
Contents of Pockets, Etc.,
-
•
C
Remarks:
•
t
-
- -
--- -
-
-
--
- - -
VE RDICT:
_________________
_
Signed
Coroner.