REGISTRATION OF DEATHS

NEILLSVILLE CLARK CO., VOL 1, 1870-1879

(pg. 4)

1. Full name of deceased: Moh, Selma Rosalia
2. Color: White
3. Sex: Female
4. Age: Two years, 1 month & 16 days
5. Name of the father of deceased: Christian Moh
6. Name of the mother of deceased: Amelia Moh
7. Occupation:
8. Place of Birth: Town of Grant, Clark Co., Wis.
9. Name of wife of deceased:
10. Name of husband of deceased:
11. Date of birth and date of death: 1871 - 1873
12. Cause of death: Cholrea Infantum
13. Name of the place,
town or township, and county,
in which the person died: Grant, Clark Co., Wis.
14. Name and location of burial ground
in which interred: Zion Cemetery
15. Name of person returning certificate: Christian Moh
16. Residence of such person: Grant, Clark Co., Wis.
17. Date of certificate:

Transcribed by Janet.