591 / 1028
P. M.
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County?
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Occupation
______ _ _ _ _ _ _______
_
Father's
Name
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Mother's
Name__ _ _ ____ _ _ __
_
Estate
Next Friend
'
-- - -
·
----- - ----
Place of Death_____________
Date of Death
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Body
Found
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Place of Accident
_
_
__
_
_
_ _
_____
_ _
___
_ _ _ _
___
_ _ _ _ __
Nature Injuries
_________________ ____ _ _ _ ____ _ _ _
I' 1,
Cause
�f
Death
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nd r
-
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Lr
�
--
-
-
- -
-
-
Post Mortem
_
__
_ _
_
_ _ _
___
_
_
_
_ _
_
_
_
__
_
_ __ _
�ames of Juryn1en
_ _ _ _
_
_ _
_
_
_____
___ _
_
_
.
_____ _____
>James of Witnesses____________ ________ _ ____________
lludertak�r �
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4
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Fees Paid
_ _ ___
_
DESCRIPTION WHEN UNKNOWN
Height
- -
Weight
Hair
Eyes
Nose
Chin
Neck
Teeth
Beard
Mustache
Scars, Marks,
Deformities,
Etc.,
Clothing
--
- -
--
---
--- ------:
Contents of Pockets, Etc.,
__ _
--
Remarks:
___ _ __ _ __
_
VE RDICT:
__
_
_
_ _
_
_
_
_ _
_
_
_ _
__
Signed
Coroner.