VITAL - Death certificate: infant Samuelsen; 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.: 376
Registrar's No: 542
1. Place of Death
a. County: Salt Lake
b. City or Town: Salt Lake
c. Length of Stay: 
d. Full Name of Hospital or Institution: 
2. Usual Residence
length of residence: 
a. State: 
b. County: Salt Lake
c. City or Town: Salt Lake City
d. Street Address: 527 So. 7th East
3. Name of Deceased: infant Samuelson
4. Date of Death (spell out full month): February 6, 1920
5. Sex: Female
6. Color or Race: white
7. Married, Never Married, Widowed, Divorced: single
8. Date of Birth (spell out full month): February 6, 1920
9. Age: 0
10a. Usual Occupation: 
10b. Kind of Business or Industry: 
11. Birthplace: Salt Lake City, Utah
12. Citizen of What Country?: 
13. Father's Name, place of birth: Charles Samuelson, Salt Lake City
14. Mother's Maiden Name, place of birth: Ethel Rose, Salt Lake City
14b. Husband's or Wife's Name: 
15. Was Deceased in US. Armed Forces?: 
16. Social Security No.: 
17. Informant and Address: Elizabeth A. Rose, 527 So. 7th East
18. Cause of Death: premature birth
I. Disease of Condition: 
Interval between onset and death: 
II. Antecedent causes: 
Interval between onset and death: 
19a. Date of Operation: 
19. Major findings of Operation: 
20. Autopsy?: 
21a. Accident, Suicide or Homicide: 
21b. Place of Injury: 
21c. City: 
21d. Time of Injury: 
21e. Injury Occured: 
21f. How did Injury Occur?: 
22. Certify Dates & Time: Feb 6, 1920 to Feb 6, 1920, 5:00 am
23a. Signature: H. Z. Lund, M.D.
23b. Address: Salt Lake City
23c. Date Signed: Feb. 6, 1920
24a. Burial, Cremation, Removal: Burial
24b. Date: Feb. 7, 1920
24c. Name of Cemetery or Crematory: City Cemetery
24d. Location: Salt Lake City
Date Rec'd by Local Reg.: Q-327
Registrar's Signature: Wed Christopherson
25. Funeral Director's Signature & Address: S. M. Taylor & Co., Salt Lake City

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