579 / 1028
P. M
Days
...if(rutou <trouui y <trorourr
'!l
®ffirr...
.
====
�
101
====
�
:
���!Et�
�
Jo
__
�
1
9
_
j}
,
_
A
�
_
P
,M.
Reside11ce '\\.\� ().,.\1A.�
White-Colored-Male-Female.
Age
·
�
�
"
j
J.-/:"4
Years
Months
Days
Nativity
_
______
_ __
_
_
_
_
_
_
_
_
_
How long in County?
_ _____
_
Marri
e
d
-
Single
-
Widow
-
Widower.
Occupation
__
_
_
_
__
___
_
_
_ _____
__
_
Father's Name
Mother's Name
_
__
_
_
___
_
__
_
_
___
Estate
Friend
_____ _ _ _______
_
Place of Death
t,>'
t"
.
"'""
:{
V-,,J=
l.
"'v
�
Fv::v
'
Body Found
______ _
+
�
--+-
-
-
--
----------
- - -
-
- -
-
-
---
Place of Accident
_
_
___ _
_
_
_
_ __
_ _
_
_______
_________
_
Nature In j uries
!
Cause of Death�A.�,
Uc,.:t
�
(}QA�)
.,.-,
Post
�lortem
__
'
_
_
_
_
_
_ __
_
_
__
_
_
_ ___
_
Names of J urymen
_
_
__
_
_ _ _
_
___
_
_
__
_
___
__
__
_ _
______
_
�ames of Witnesses
_
__
_
_
_ _
_
___
_
__
_
_ ____ _ _
_
___
_
_____
_
t:ndertaker
r
/'r
bJ'::tlu.}i
,
Q}-
..Jl..v.d
/4'ees Paid
_ ____
DESCRIPTION WHEN UNKNOWN
Height
Weight
Hair
Nose
Chin
Neck
Beard
Mustache
Scars. :\brks, Deformities ,
Etc.,
- - ----
Clothing-
----
-
-
-
-
Contents of Pockets, Etc.,
__
Remarks:
VF.IWIC'T:
Signed
_________ __
_
- -
Eyes
� -
Teeth
- - -� C oroner.