DEATH CERTIFICATE: Willie Jones; Beaver co., Utah

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State Board of Health File No.: 23
Stamped File No.: 0400024

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

Full name of Deceased: Willie Jones
Former or Usual Residence: Frisco
Sex: male
Color: white
Date of Birth: 15 Feb 1892
Age: 12y 5m 20d
Single, Married, Widowed, Divorced: single
Birthplace: Frisco
Name of Father, Birthplace: John E. Jones, Wales
Maiden Name of Mother, Birthplace: Margaret Williams (adopted name Walters), Wales

Occupation: 
Informant: John E. JOnes
Address: Frisco

Place of Burial: Beaver
Date of Burial: 5 Aug 1904
Undertaker: none
Address: 

Medical Certificate of Death
Date of Death: 4 Aug 1904
Time: 11 am
Chief cause: diphtheria
Where contracted: Frisco
Duration: 2 days
Contributory if any: none
Where contracted: 
Duration: 
Signed Doctor: F. H. Lay, M.D.
Date: 4 Aug 1904
Address: Frisco