CAP. 174]
Births and Deaths Registration.
(M.D. 854)
use
Counterfoil for the use of the Medical Attendant, who should in all cases fill it up.
FORM 19.
BIRTHS AND DEATHS REGISTRATION ORDINANCE.
(Chapter 174 of the Revised Edition).
MEDICAL CERTIFICATE OF
THE CAUSE OF DEATH
To be given by the medical attendant to the person whose duty it is to give information of the death, to a registrar and to no other person.
[s. 20 (a).]
No. of corresponding entry in register book of deaths to be inserted here by the registrar.
Name of Deceased
Age
Last seen
I HEREBY CERTIFY that I attended
during the last illness; that such person's age was stated to be that I last saw him on the................ that....
of....
died* on the................ 19.........; at
day of...
my knowledge and belief the cause of his death was as hereunder written. An anaesthetic, namely
case:
Died on
At
Deceased's
...before the death of
19......... on the
...day and that, to the best of death was as hereunder was administered†.
(or, if such was the
No anaesthetic was administered before the death of
Should the medical attendant not feel justified in taking upon himself the responsibility of certifying the fact of death, he may here insert the words "as I am informed."
† Insert here how long before death the anaesthetic was administered.
CAUSE OF DEATH
Approximate interval
between onset and death.
Deceased's nationality
Deceased's profession
Deceased's address
CAUSE OF DEATH
(a)
due to (or as a consequence of)
I. Disease or condition (a)
directly leading to death.‡
Antecedent causes Morbid conditions, if (b) any giving rise to the above stating the underlying condition last. (c)
cause,
II. Other significant conditions contributing to the death, but not related to the disease
or condition causing
due to (or as a consequence of)
due to (or as a consequence of)
This does not mean the mode of dying e.g., heart failure, asthenia, etc. It means the disease, injury, or complication which caused death.
(The Informant should read the notice on the back of this form.)
(b)
due to (or as a consequence of)
(c)
Other significant conditions
Deceased's nationality
profession address
Dated, the ...Signature
day of...
Signed
Date
place of death
Registered qualification Residence
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 particulars required by law to be registered concerning the death. Penalty of $1000 or 6 months imprisonment for neglect of informant to deliver this certificate to the registrar or an assistant 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 himself or an assistant registrar.
334
[OVER]