VITALS - Death Certificate of:  Johanna W. Pettersen; Smithville, Millard co., Utah

Transcribed by Stephen D. Robison (kinseeker @ hotmail.com)
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LDS Film # 2230661, State of Utah, Death Certificates, Millard County:
Certificate Number: 0400641
Death place: Smithville
Name: Johanna W. Pettersen
Usual residence: Smithville
How long resident:

PERSONAL AND STATISTICAL PARTICULARS
Sex: Whtie
Color:
Birth date: November 12 1904
Age: 78 y 8 m 4 d
Marital status: Widow
Birth place: Sweden
Father:
Father's birth place: Sweden
Mother:
Mother's birth place: Sweden
Occupation:
Informant:
Informant's address:
Burial place: Garrison
Burial date: Nov 13th
Undertaker: Robert Smith
Undertaker's address: Garrison Utah
Filed:
Registrar:

MEDICAL CERTIFICATE OF DEATH
Death date: Nov 12 1904
Cause: Old Age
Where contracted:
Duration:
Contributory:
Where contracted:
Duration:
Doctor:
Dated:

Permission is hereby granted to bury/ship the body of the person above described
Health Officer: George Bishop
Address: Smithville
Date: Nov 12 1904