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Years
Months
Days
Nativity
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Marrie<l-Sing1e-Widow-Widower.
Occupation
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Father's Name
-------- - -----
Mother's Name
_
_
_ _ _ __
__
_
___
Estate
Next Friend
_________�-----
Place of Death________ ______
Date of Death
_______ _____
_
Bocly Found
___
____
_
_ _ _ _
_ _ __
_
_ __
____
_
__
_ .
____
!'lace of
Accident
_____
_
_
_
_
_
__
__
_
____ ___
_
_
_
_
_ _
____
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:-.:ature Injuries
_______ _ _ _______ _ _____ _ _ _ _ _ _ _ _ __
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es of Jurymen
_____ _ _ _____ _ ___ _ ___ ________
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Names of \Vitnesses
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DESCRIPTION WHEN UNKNOWN
Height
Weight
Hair
Nose
Chin
.
Neck
Beard
M
_
ustache
Scars, Marks,
Deformities,
Etc.,
Clothing
Paid
_______
_
Eyes
Teeth
Contents of Pockets, Etc.,
_ _ ___ _________ ____________
_
Signed
Coroner.