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

submitted by W. David Samuelsen (dsam at sampubco dot com)
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Certificate of Death
State File No.: 
Registrar's No: 
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: General Hospital
2. Usual Residence
Length of Residence: 17 years
a. State: 
b. County: 
c. City or Town: 
d. Street Address: 
3. Name of Deceased: Jean Annie Samuelson
4. Date of Death (spell out full month): August 17, 1935
5. Sex: F
6. Color or Race: white
7. Married, Never Married, Widowed, Divorced: single
8. Date of Birth (spell out full month): July 18, 1918
9. Age: 17 years 29 days
10a. Usual Occupation: none
10b. Kind of Business or Industry: 
11. Birthplace: Idaho Falls, Idaho
12. Citizen of What Country?: 
13. Father's Name, place of birth: Charles Samuelson, Utah
14. Mother's Maiden Name, place of birth: Ethel Rose, unknown
14b. Husband's or Wife's Name: 
15. Was Deceased in US. Armed Forces?: 
16. Social Security No.: 
17. Informant and Address: Charles Samuelson, Twin Falls, Idaho
18. Cause of Death: 
I. Disease of Condition: purulent pansinusity, meningitis, cavervous sinus
thrombosis
Interval between onset and death: 5 days
II. Antecedent causes: quinzy
Interval between onset and death: 7 days
19a. Date of Operation: 
19. Major findings of Operation: 
20. Autopsy?: yes
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: Aug 15, 1935 to Aug 17, 1935, 3:15 PM
23a. Signature: T. A. Clawson Jr.
23b. Address: Salt Lake City, UT
23c. Date Signed: Aug 19, 1935
24a. Burial, Cremation, Removal
24b. Date: Aug 21, 1935
24c. Name of Cemetery or Crematory: City Cemetery
24d. Location: Salt Lake City
Date Rec'd by Local Reg.: Aug 20
Registrar's Signature: Sol G. Kahn
25. Funeral Director's Signature & Address: Deseret Mortuary, Salt Lake City

Comments: (Use for listing of correct information by submitter)
mother, Ethel Rachel Rose, born Salt Lake City, Utah