515 / 1028
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White-Colored-Male-Female. Age
Years
.
Months
Days
Nati\'ity
_______________ _ _ __
How long in County?
___ _ _ __
Father's Name
�
Mother's
Name
- ,,....
V"'-"'- ...... �
-
• -·
-
,__
,___ ·,-
.•,-----
Marcied
-
Single
�
Wi � . . Occupation
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Estate
Next Friend
_______________
Place of Death_____�---------
Date of Death
·
·-. .•
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.
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Body Found
\J;l,.,.....,�
!'lace of Accident
Nature Injuries
Cause of Death
(p���
�A
........
.
Post Mortem
· ·
l,
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cxJ
Names of Jurymen
_
_
__
_
____
_
_ _
_ _
_
__
__
_
_
_
...__
__________
Names of Witnesses
_
_____
_
_
____
_ ___
_____
_
__
_
_______
____
U
ndertaker
_
-
L
.,_
,
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6-CC
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--'
�=c___:__
_
______
Fees Paid.
______ _
_
DESCRIPTION WHEN UNKNOWN
Height
·weight
Hair
Eyes
Nose
Chin
Neck
Teeth
Beard
___
Mustache
Scars, Marks,
Deformities,
Etc.,
Clothing_:__
_ ___
-=
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-
=-- -
---
-
----
--
-
-
-==
==
=--
=
===
=
=
=
=
==--
---
Contents of Pockets, Etc.,
_
_
_____
_
_
___
_
_______________
_
__
Remarks"fL �� �bffi,O
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I
VE RDICT:
__ --- ----------------
Signed
Coroner.
"