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Death Certificate Sample
STATE BOARD OF HEALTH
Bureau of Vital Statistics
No.
I, yfitrec ybereh od ,scitsitatS latiV fo rartsigeR etatS ,
the following to be a true and correct copy of the CERTIFICATE OF DEATH of
on file in THE BUREAU OF VITAL STATISTICS.
Registration District No. File No.
Primary Registration District No. Registered No.
(No. St. Ward)
FULL NAME
(If death occurred in
a Hospital or Institution,
give its NAME instead of
street and number.)
(If death occurs away from
USUAL RESIDENCE
give facts called for under
“Spcial Information.”)
PLACE OF DEATH
County of
Voting Precinct No.
Incorporated Town
City
IN TESTIMONY WHEREOF, I have hereunto subscribed my name and
caused the official seal to be affixed at
this day of
in the year of our Lord one thousand nine hundred and
State Registrar.
IF LESS than
1 day hrs.
or min
PERSONAL AND STATISTICAL PARTICULARS MEDICAL CERTIFICATE OF DEATH
PARENTS
3. SEX 4. COLOR OR RACE
6. DATE OF BIRTH
1
(Month) (Day) (Year)
16. DATE OF DEATH
19
(Month) (Day) (Year)
17.
I HEREBY CERTIFY That I attended deceased
from , 19 to , 19
that I last saw h alive on , 19
and that death occurred on the date stated above at
m. THE CAUSE OF DEATH was as follows:
(Duration) yrs. mos. ds.
Contributory
(Secondary)
(Duration) yrs. mos. ds.
(Signed) , M. D.
, 19 (Address)
7. AGE
yrs. mos. ds.
8. OCCUPATION
(a) Trade, profession or
particular kind of work
(b) General nature of industry,
business or establishment in which
employed (or employer)
9. BIRTHPLACE
(State or country)
14. THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
(Address)
10. NAME OF
FATHER
Filed 19
Registrar.
11. BIRTHPLACE
OF FATHER
(State or country)
12. MAIDEN NAME
OF MOTHER
13. BIRTHPLACE
OF MOTHER
(State or country)
5. Single
Married
Widowed
or Divorced
sesuaC tneloiV morf shtaed ni ,ro ,htaeD gnisuaC esaesiD eht etatS*
ro ladiciuS ,latnediccA rehtehw )2( dna ;yrujnI fo snaeM )1( etats
H omicida l .
ro stneisnarT ,snoitutitsnI ,slatipsoH roF( ECNEDISER FO HTGNEL .81
Recent Residents)
At place In the
of death yrs. mos. ds. State yrs. mos. ds.
Where was disease contracted
If not at place of death
Former or
usual residence
19. PLACE OF BURIAL OR REMOVAL DATE OF BURIAL
20. UNDERTAKER ADDRESS
COMMONWEALTH OF MASSACHUSETTS
BOSTON, MASSACHUSETTS
81772
Edgar Firth
Allan Halsey
Essex
Arkham
34
2876877-B
1266
81772
St. Mary's Hospital
Allan Graham Halsey
Male
White
Married
August 14
05
July 12
837
68
1
2
Physician
Medicine
Pennsylvania
George Everett Halsey
Penna.
Edith Graham
Missouri
08/12
25
08/14
05
im
August 14
05
2:43 p
Enteric Fever
with pulmonary complications
due to Typhus infection
3
Exhaustion
advanced age
14
Edward Moore
05
Arkham, Mass.
Arkham, Mass.
Christchurch Cemetery
Aug 17
Gunnar Bachlund
Arkham
Herbert West
Arkham
8/20
05
Perkins
Boston
26th
September
twenty-seven.
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