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Name
Residence � .,,,._ ,
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_A. M.
P.M.
W-b:ite-: Colored-M:ti,e-Female. Age
l'ems
7
Months
D�ys
Nativity
�
How long in County?
__ .
Namel>ctfl� �
�-Sing
l
e u.� owe�on
Father's Name��·Mother's
Estate
_
_
_
________
_
__
_
__
Next Friend
___ _____ ____
_
Place of Death_ _________ _ _
Date of Death
_ __________
_
Body Found
_ _______ ____ ______________
_
Place of Accident
_______ _____ _ _ _ _
Nature Injuries
'
- -----
-
- - - -
-
---
-
--
--
-
-
-
--
�
-
Cause of Death
Post Mortem
A��ffi,
Oc.4
cr� �
i&-��
Names of Jurymen
_
____
_
_
_
_
_
_
__
_____
_
_
_
_
_
_
_
_
_
_
_____
_
__
N
am�s
of Witnesses________ _ ____________ _ ___ ________
L2�
Underta�
Height
______
_
Nose________
Fees Paid
_
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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