DEATH CERTIFICATE: infant Jackson; Beaver co., Utah

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State Board of Health File No.: 29
Stamped File No.: 0400031

Place of Death
County of: Beaver
City, Town or Village: Beaver
Street and No.: 
If in Hospital or Institution, give name: 

Full name of Deceased: infant Jackson
Former or Usual Residence: 
Sex: male
Color: white
Date of Birth: 5 Sep 1904
Age: stillborn
Single, Married, Widowed, Divorced: 
Birthplace: Utah
Name of Father, Birthplace: Joseph Jackson, 
Maiden Name of Mother, Birthplace: Zelpha Neilsen

Occupation: 
Informant: H. B. Nieber
Address: Beaver

Place of Burial: Beaver City
Date of Burial: 5 Sep 1904
Undertaker: Jos. Ash
Address: Beaver City

Medical Certificate of Death
Date of Death: 5 Sep 1904
Time: 1 pm
Chief cause: stillborn
Where contracted: 
Duration: 
Contributory if any: 
Where contracted: 
Duration: 
Signed Doctor: I. E. Huffman, M.D.
Date: 5 Sep 1904
Address: Beaver City