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P. M.

Days

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101

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Inquest

No.

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_ __ Days

Next Friend

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Place of Death

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Date of Death

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Hocly Found

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Place of

Accident

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�ature Injuries

_ __

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_____________________________

_

Names of Jurymen

__________ _ _ _ _______ _

_ _ _ ___ _ __

:-.,mes of Witnesses

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Fees

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aid

Height

____ _ _

Nose_ _ _ ___

Beard

DESCRIPTION WHEN UNKNOWN

Weight

___ _ _ _

Chin

_

_ _ _

_

_

Hair

_____ _

_

Eyes

_ ___ _

Neck

Teeth.

_ ____

_

Mustache

__________________

Sea�,

Marks, Defurmities, Etc.,

___________ ______ _ __ _ _______

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contents of Pockets, Etc., ��

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Remarks

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VERDICT

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Signed

__ _ _ ____ _

__ _ _ _

Coroner.