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42

,

,

�--<

...1l(rutnu <nnuut y <nnrnurr�s ®ffirr...

===

101

=

=

=

Inqu

e

st

No.

Re

�otic

e

V

Z...S-

-·,

19

_

3

.(

_

A

.

M.

..:___

P. M.

Name

;Ji

W�

R�idenc

e

I

l�

��-

-

��

���

� ��

��-Whit

e

-�

e

d-Mal

e

-�e.

A

Y

ea

rs

Months

Days

Nativity

How long in County?

__

Marri

e

d

-

�m

g

le Widow vV1

.

Occupation

_______

��

- -----

- -

Fath

e

r's Name

Moth

e

r's Nam

e

_ _

_ _____

_ _

Est

a

te

Next Friend

4

Plac

e

of D

e

ath

\

3

S1 (?

4,,r't�

Date of D

e

ath

?J--:t

J

Body Found

_________ _______

�-- --

Plac

e

of Accid

e

nt

_

Natur

e

Injuri

e

s

___ _ _ _ ______

_

�:::

e

�: rt �:

a

-

th

- - -

--

-

·

-

- -

·

_ ··

-

--

-

·

- - - --

Nam

e

s of Jurym

e

n___________

--

- -

---

--

- - -

-

·

--

------

- -

-

Names of Witn

e

sses_______________________ _____ _____

Und

e

rtak

e

r

�l��

s-o(

F

e

es Paid

_ ______

Height

______

_

Nos

e

________

DESCRIPTION WHEN

UNKNOWN

W

e

ight.______ _

Chin____ _ _

Hair

__

Ey

e

s.

___

_

N

e

ck

Teeth.

____

_

Beard_________ ________

Mustache

____ _ __________

_

Sc

a

rs,Marks, Deformiti

e

s, Etc·,

------ --

-

--

-

--

-

- ------

--

-

--

Clothing

______________ _

_

--

-

-

-

---

--

--

Contents of Pockets, Etc.,

_

_

_____

_

_ _

_ _

__

_

_

_

_

_

_

______

__

_

Remarks:

VERDICT:

Sign

e

d

Coroner.

Inqt

Nan

R

esi

1

Whi

Nat

i

i

Mar

Fat!

Est:

Pl:H:

Bod

Plac

Nat

Cau

Post

Nan

Nan

U11d

Hei

Bea

Scar

Clot

Re

VJ-:R