642
THE HONG KONG GOVERNMENT GAZETTE, AUGUST 10, 1934.
[The informant
should read the No- tice on the back of this form.]
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.
such person's age was stated 19 that he died*
; and that, to the best of my
I HEREBY CERTIFY that I attended
to be
on the
; that I last saw h day of
in the
19
during the last illness; that day of
at
>
>
death was as hereunder written. was administered t
before the death of
No. of correspond- ing entry in register book of deaths to be inserted here by the Registrar.
Duration of disease in
Years. Months.
Days.
Hours. I
knowledge and belief, the cause of h
An anaesthetic, namely,
(or, if such was the case: No anaesthetic
*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 bere how long before death the anaesthetic was adminis- tered.
The duration of each form of disease or symptom is reckoned from its commencement until death occurs.
Primary
Secondary
was administered before the death of
Cause of death.
day of
19
Signaturee
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 $200 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 a registrar.
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