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____
Months
�-Colored-Male
Ft1uli.
e
.
Age
-..:S '1
Years
Nativity
r
How long in County?
_ _ _
Days
Married-Single-Widow-Widower.
Occupation
__ __
_
_
_
_
____
__
__
_
_
_
_
__
Father's Name
___________ _
_
Mother's Name
_
_
_
_
_ _
Estate
__________ _ _ ___�
Next Friend.
__
___ _ __
_
_
__
_
_
Place of Deatb
__
�
-
------ - --
-
-
Date of Death
____________
_
Body Found
____
_ _
_
_
__
_
_
__
___ _ _
_ ___
_ _
_
Place of Accident
_ _-.
___
.
-----,,--
�
Nature Injuries
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·
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----=-
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Cause of Death
Post Mortem
______ __________
_
Names of Jurymen_
_
_ ______
__
_
_
_
__
_
_
Names of Witnesses
______ ________________.,_____ _ _ ____
_
?
Undertak�
Fees Paid
__
_
DESCRIPTION WHEN UNKNOWN
Height
_______
Weight·
----�--
Hair
__
_
Eyes.
_ _
Nose.
_____
__:___
Cbin________
Neck
__
_
__
Teeth
__
_,,__
__
Beard
Mustache
_____ _________
_
Scars, Marks, Deformities, Etc.,
__
_
__
__
_
_
_
_
_
__
__
_
__
___
__
_
____
_
_
Clothing
-
--
-
----
-
--
-
--- - -
Contents of Pockets, Etc.,
___ _
___ _ __
_
Remarks:
_
__
_
____ _ _ ___
_
_ _
_
_
__
_
_
__
__
__
_
_
_
__
___
YE RDICT:
_
__
_
___
_
_
_
_
__
_
_____
___
___ �
Signed
Coroner.
In
Na
Re
Wh
Fa
Es
Pla
Bo
Pia
Na
Ca
l'o
Na
Na
lJ
I
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No
Be
Sc
Cl
Co
Re'
Vr;