475 / 1028
P. M.
Days
..JKentnn- Qinunty Qinrnner's ®ffire...
====
�
101
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Inquest No.
Received Notice
JH�
2--.j-
, 19___}___J_,
__
A. M.
__
P, M.
Name
Residence
White-C�-Male-�le.
Age �
tS-
Years
____Months
Days
Nativity
How l ong in County?
___ ___
Married-Single-Widow-Widower.
Occupation
_ _ _______________
_
Father's Name
Mother's Name
_ _ _ ____ _____
Estate
:;j)
n
Next Friend
Place of Death
ci(Vf}
f1
. �
Body Found
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,
Place of Accident
___
_ _
_ _
_
_
_
_ ___
_
_
____
_ _
________
_
_
_
�ature Injuries
___ __
_
Cause of Death
__ _ _ _ _
Post Mortem
_____ _____
_
Names of Jurymen
__
_
_
_____
___
_
___
_
_
___
_
_ _
__________
_
Names of Witnesses______ _ _ ____ ______________________
lJndertaker
��
A�
v .... - -"
--,
Fees Paid.
____ ___
_
DESCRIPTION WHEN UNKNOWN
Height
Weight
Hair
Eyes
_______
Nose
Chin
Neck
_ _ __ _
Teeth
_____
_
Beard
Mustache
Scars, Marks,
Deformities,
Etc.,
Clothing
--
--
--
-
--
-
-
Contents of Pockets, Etc.,
___ __ _ _
Remarks:
_
_ _
____
_
_
VERDICT:
_
_ __
_
_ __
_
_
__
_
_
__
_
Signed
Coroner.