81443-180368-0634

State File Number: 340

County: Salt Lake

Child's First Name: Henry

Child's Middle Name 1: Charles

Child's Middle Name 2:

Child's Middle Name 3:

Child's Surname: Jensen

Child's Suffix:

Sex: Male

Month of Birth (Number): 02

Day of Birth: 02

Year of Birth: 1912

Father's First Name: Anton

Father's Middle Name 1: Peter

Father's Middle Name 2:

Father's Surname: Jensen

Father's Title or Suffix:

Mother's First Name: Alma

Mother's Middle Name 1:

Mother's Middle Name 2:

Mother's Maiden Name: Malstrom

Is there an Amendment?: No