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,
_ _
A. M.
P. M
White-�d-�e-Female. Age
Years
_ __
Months
Nativity
How long in County?
__
Married-Single-Widow-Widower.
Occupation
___ ___
_
Days
Father's Name_ ____________
Mother's Name
_______� -
-
--
Estate
_ _ ______________
_
Next Friend
____
-----J'-1--
-
-
-
---
--
Date of Death
tncl:
2-
,./f--S
l
Place of Death_________ _____
Body Found
__
_
____
_
_
_
_
_ __
_ __
_
_
__
_
_
___
_
Place of Accident
_
__
_
_____
_ __
_
__
_
__
_
__ __
_
_ _
Nature Injuries
_ _ _ __________
Names of Jurymen
_
_ _
_
_
_ _ _ _
_ _ ____
_
__
_
_______
_
_
_
_
Names of Witnesses_________________ _ _ _ ______________
Undertaker
�
trJ�
Fees Paid.
____
_
DESCRIPTION WHEN UNKNOWN
Height
_______
Weight.
______
_
Hair
_______
_
Nose____ _ __
Chin______ _
Neck
.
___
Eyes.
_ _
Teeth
_
Beard______ _____ _____
Mustache
________________
_
Scars, Marks; Deformities, Etc.,
_____ _ _ _
_
_
__
_
_
_
_
_:____________
_
Clothing----------------
Contents of Pockets, Etc.,
__ ________
_
Remarks:
___________________________________
�
VE RDICT:
__
_
_
__
_
___
_
__
_ _
_
_
_
_
_
___
_
__
Signed
Coroner.
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