VITAL - Death certificate: Ethel Samuelson; Salt Lake co., Utah

submitted by W. David Samuelsen (dsam at sampubco dot com)
***********************************************************************
Copyright.  All rights reserved.
http://www.usgwarchives.net/copyright.htm

http://www.usgwarchives.net/ut/wifiles.htm
***********************************************************************

Certificate of Death
State File No.: 662
Registrar's No: 542
Place of Death
County: Salt Lake
City or Town: Salt Lake
Length of Stay: 
Full Name of Hospital or Institution: 

Usual Residence
length of residence:
State: Utah
County: Salt Lake
City or Town: Salt Lake
Street Address: 475 West 6th South

Name of Deceased: Ethel Samuelson
Date of Death (spell out full month): April 22, 1913
Sex: Female
Color or Race: white
Married, Never Married, Widowed, Divorced: single
Date of Birth (spell out full month): April 22, 1913
Age: 4 hours
Usual Occupation: 
Kind of Business or Industry: 

Birthplace: Salt Lake City
Citizen of What Country?: 
Length in USA if of foreign birth: 

Father's Name, place of birth: Charles Samuelson, Salt Lake
Mother's Maiden Name, place of birth: Ethel Rose, Salt Lake
Husband's or Wife's Name: 

Was Deceased in US. Armed Forces?: 
Social Security No.: 

Cause of Death: atelastasis
Disease of Condition: 
Interval between onset and death: 
Antecedent causes: prematurity
Interval between onset and death: 
Autopsy: 
Date of Operation: 
Major findings of Operation: 

Accident, Suicide or Homicide: 
Place of Injury: 
City: 
Time of Injury: 
Injury Occured: 
How did Injury Occur?: 

Certify Dates & Time: April 22nd 1913 to April 22, 1913, 1 a.m.
Signature: C. L. Sandberg, M.D.
Address: Mercantile Bldg
Date Signed: April 23, 1913

Burial, Cremation, Removal: Burial
Date: April 24, 1913
Name of Cemetery or Crematory: City
Location: Salt Lake City
Funeral Director's Signature & Address: Allcotts, Salt Lake

Informant & Address: Charles Samuelson 
Date Rec'd by Local Reg.: April 24, 1913
Registrar's Signature: Samuel E. Paul, M.D.

Comments: (Use for listing of correct information by submitter)