555 / 1028
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Inquest No.
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Name
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Residence
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Whirc-Gol,m:d-Male-J'emole. l1 ge .
I,
7
Years
@�onths
0-Days
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How long in County? �
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Occupation
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Father's
Name
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Mother's Name
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ac>y
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Estate
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Next Friend
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Plal·c of Death
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ef:'..
Date of Death
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Rody Found
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Place of Accident
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Xaturc Injuries
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Cause
of Death_J ���
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Post �1ortem
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_
Names of Jurymen___ __ _
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:O:ames of Witnesses
_
_
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_
_
_
_ _ _ __ ___
__
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___
_
_______
Fees Paid
_________
Undertaker
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DESCRIPTION WHEN
UNKNOWN
Hei"ht
b
Weight
Hair
__
Nose
Chin
Neck
Beard
-
Mustache
Scars, Marks,
Deformities,
Etc.,
Clothing
------
Contents of Pockets, Etc.,
_ _
_
Remarks:
VERDICT:
--------- - --
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.
-
-
Eyes
Teeth
Signed
Coroner.