477 / 1028
P. M
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101
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19
,
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A. M.
P. M.
____
Months
____
Days
ativitY
--
--
-�---
--
------
-
--
How long in County?
____
larried-Stttgloe-�Widower.
Occupation
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Father's Name
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Mother's Name
I
--------------
E tate
___
_
___
Next Friend
_
_
____
_
_
_
______
Place of Death
_____________
_
Date of Death
_____________
Body Found
__
_
Place of Accident
1
1
ature Injuries
_
--
---
---
---
---
- -
----------------------
Cause of
Death
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,
1
Post Mortem
--
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-+L _
___
_
_
___
_
____
____
_
_
__
__
'ames of Jurymen
_
_
_
__
____
___
_
__
_
____
_
____
_____
__
'ames of Wit nesses________________________________
Undertaker
({eight
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Beard_
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Fees Paid
____
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DESCRIPTION WHEN UNKNOWN
Weight
______
_
Hair
______
_
Eyes
______
_
Chin
_______
_
Neck
______
_
Teeth
_______
Mustache
_________________
Scars, Marks, De�r1nities, Etc,
__________________________
_
Clothing
__
_
- -
---�-------------------
Content s of Pockets, Etc.,
__
_
Remarks:
__
VEJWICT:
__
Signed
__
-- ______
_
____
_
__
_
Coroner.