694
THE HONG KONG GOVERNMENT GAZETTE, AUGUST 24, 1934.
to be
on the
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.
I HEREBY CERTIFY that I attended
}
that I last saw h
day of
knowledge and belief, the cause of h
in the
was
during the last illness; that such person's age was stated day of that he died*
at
J
19 death was as hereunder written. administered t
An anaesthetic, namely, (or, if such was the case: No anaesthetic was administered before the death of
* 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 anaesthetic 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.
19
; and that, to the best of my
before the death of
).
Duration of disease in
Years. Months.
Days.
Hours.
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
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 registrar.
an
assistant
*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
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