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A. M.
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Residence . -(�
White-Colored-Male-Female. Age
�ati\"ity
S:..3
Years
_ _ _
Months
Days
How long in County?
_______
_
Married-Single-Widow-Widower.
Occupation
__
_
_ _ _ _
_ _
_
_
_
_
_
_
_
__
Father's Name
Mother's Name
_______________
_
Estate
Next Friend
_ __
--.-
_ _ _ ______
_
Place of Death
St,
F;J,,.,,,
/._,g
Date of Death
¥·
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7, .j!:?.
Body Found
_____�
(/
� --
--
-
-
-
-
-
-
-
-
- - --
-
--
--
-
-
-
- -
-
-
-
Place
of Accident
�
('(
fi
1
(l
L'
(}-1/L
r-
.Nature Injuries
____ _ __
Cause of Death
Post
Mortem
i�J\L
n
b
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·
--;---
.
-----
Names of Jurymen_ __________________ _ _ _ __�------
>James of Witnesses
_
_
_ _ _ _
_
_
_
_
_
_
_
_
_
_
_
_
_
_
___
_ _____
_
_
_
_
_
_
Undertaker
·
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r/
1
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·
Fees Paid
_______
.
-)
DESCRIPTION WHEN UNKNOWN
Height
Weight.
______
_
Hair
__ ___
Eyes
_ _____
Nose ________
Chin
___ ___
_
Neck
____ __
Teeth
______
_
Beard
Mustache
________ _________
Sea�, Marks, Defurmities, Etc.,
_______________________________
_
Clothing
--
-
---
-
-
-
Contents of Pockets, Etc.,
__ _
Remarks:
___
_
_
_ _
Signed
Coroner.