517 / 1028
P. M.
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Name
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Residence
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White-Colored-Male-F�e.
Age
2
7
Years
S-Months
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Nativity
How long in County?
________
��-Single-\\liQ�vr \I/idower.
Occupation
_____________________
Father's Name
Mother's Name
_
_
_______
_
___
__
Estate
Place of Death
Body Found
Next Friend.
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Place of Accident�
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Nature Injuries
____
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Cau,:-of Death ��,,(, .
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Post Mortem
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Names of Jurymen �
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Names of Witnesses____________________________________ _
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Undertaker
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C)Fees Paid
_ ______
Height
Nose
Beard
Scars,
DESCRIPTION WHEN UNKNOWN
Weight_______
Hair
____ ___
Eyes
_ __
_
Chin _ _____
Neck
_ _ ___
Teeth
______
Mustache
__________________
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De for mities, Etc . ,
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Marks,
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Clothing
Contents of Pockets , Etc. ,
________________________ ______
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Remarks:
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Signed
Coroner.