1986 Ed.]
Births and Deaths Registration
[CAP. 174
21
(M.D. 854.)
Counterfoil for the use of the Medical Attendant, who should in all cases fill it up.
Name of Deceased
FORM 18
BIRTHS AND DEATHS REGISTRATION ORDINANCE
(Chapter 174)
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
(s. 20(a).]
No. of corresponding entry in register book of deaths to be inserted here by the registrar.
Age
Last seen
I HEREBY CERTIFY that I attended
during the last illness; that such person's age was stated to be
Died on
Deceased's nationality
Deceased's profession
that I last saw h...
that
of
on the...
died
to the best of my knowledge and belief the cause of h...
An anaesthetic, namely
before the death of
administered before the death of...
day of
19..
on the
day
19..
at
and that, to the best of
death was as hereunder written.
was administered...
(or, if such was the case: No anaesthetic was)
* 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 before death the anaesthetic was administered.
Deceased's address
CAUSE OF DEATH
I. Disease or condition directly leading to death.
(a)
due to (or as a consequence of)
(a)
due to (or as a consequence of)
(b)
due to (or as a consequence of)
(c)
Other significant conditions
Signed
Date
Approximate interval between onset and death
Antecedent causes
Morbid conditions, if any (b) giving rise to the above
cause, stating the underlying condition last.
II. Other significant conditions contributing to the death, but not related to the disease or condition causing it.
due to (or as a consequence of)
(c)
This does not mean the mode of dying e.g., heart failure, asthenia, etc.
It means the disease, injury, or complication which caused death.
Deceased's nationality
profession
address
place of death
(The Informant should read the notice on the back of this form.)
Dated, the
Signature
day of
19...
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. Fine of $1,000 or 6 months' imprisonment for neglect of informant to deliver this certificate to the registrar or a district 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 a district registrar.
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