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01
Inquest No
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Rec :! ved Notic
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Residence
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eubriWiJ.-Male�e.
Age
Years
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Months
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Days
Nativity
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How long in Co
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nty?
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Occupation
____ ________
_ _____
Mother's Name
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Estate
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Next Friend
Place of Death�
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Date of DeatL-F j
ft,
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Body Found
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Place of Accident
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Nature Injuries
_______ _ _ ____________________ __
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Cause of Death
l)nd
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Post Mortem
_ ______ _ ____
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Names of Jurymen
_ _
_
---
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Names of Witnesses___________________________________
Undertaker
�of
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Fees Paid.
_ _____
_
Height
_ _____
Nose_ ______
DESCRIPTION WHEN UNKNOWN
Weight.
_____ _
Chin
_______
Hair
___
_
Neck
_ _ _
Eyes
Teeth
------
Beard
_ ___________ _ _ _
Mustache
________ ________
_
Scars, Marks, Deformities, Etc.,
________________
_____:____ ____ __
_
Clothing---------- ---------
C,
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Contents of Pockets, Etc.,
_________ _ _
Remarks:
_____________________________ _ _____
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Signed
:W
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Coroner.