- 527 -
FORM NO. 19.
Medical certificate of cause of death,
(s. 20 (1).)
THE BIRTHS AND DEATHS REGISTRATION ORDINANCE, 1934.
MEDICAL CERTIFICATE OF THE CAUSE OF DEATH.
To be given by the medical attendant to the person whose duty it is to give it, with information of the death, to a registrar and TO NO OTHER PERSON.
; that I last saw h day of knowledge and belief, the cause of h
during the last illness; ; that such person's age was stated day of
An anaesthetic, namely, (or, if such was the case: No anaesthetic was administered before the death of
19
that he died*
; and that, to the best of my
I HEREBY CERTIFY that I attended
to be
in the
on the
at
>
>
19 death was as hereunder written. was administered t
before the death of
).
Duration of disease in
Years. Months.
Days.
Ilours. ‡
* Should the medical attendant not feel justified in taking upon himself the responsibility of certi- fying the fact of death, he may here insert the words “as I am inform-
ed".
Insert here how long before death the anesthetic was adminis- tered.
The duration of each form of disease or symptom is reckoned from its commencement until death occurs.
Primary
Secondary
Cause of death.
No. of correspond- ing entry in register book of deaths to be inserted here by the Registrar.
[The informant should read the No- tice on the back of this form.]
day of
19
Signaturee
Registered qualification Residence
un assistant
N.B. This certificate is intended solely for the use of the registrar, to whom it should be delivered by the person giving information to him of the parti culars required by law death. to be registered concerning the Penalty of $200 for neglect of informant to deliver this certificate to the Registrar or registrar. *The Registrar of Births and Deaths cautions all persons against accepting or using this certificate for any purpose whatever except that of delivering it to a registrar.
Dated the