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White-�d-Male-----=Pemale. Age
_____
-----CP:'V-"""'---
____
Months
___ _
Days
Nativity
How long in County?
____ _
Married-Single-Widow-Widower.
Occupation
______
� -- ---
________
_
Father's Name______________
Mother's Name
_
_
_ _
_
_
___ _
_
_
_
_
_
Estate
Next Friend
Place of Death �
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Date of Death�
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Body Found
___
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_____
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Place of Accident
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Nature Injuries
_____________________________ _
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Cause of Death
_
_____
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_ ___
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____ _ ___
_
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_
_
_
_
Post Mortem
_______ __________
_
Names of Jurymen
_____ _
___:__
_
___
__
__
___
Names of Witnesses____________________ _ ___________
Undertaker__J\/a/f
£&.n
(ud'.,<< (:),
Fees Paid.
__ __
Height.
_______
Nose________
DESCRIPTION WHEN UNKNOWN
Weight.
_______
Chin____ ___
Hair
___
Eyes.
___
Neck
_
_
_
_
Teeth
_____
Beard________________�
Mustache
__________________
Scars, Marks, Deformities, Etc.,
_________________________ ____
Clothing------------ - ----
Contents of Pockets, Etc.,
___ ___ __ _ ___________ ______
_
Remarks:______________________________________
VE RDICT:
_________________ _
Signed
Coroner.
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