Medical Certificate of Death in Beijing
The Beijing Municipal Health Bureau
Made by 2003
Province Beijing City, Haidian District (county) Street(town) The police station No.0020981
MMedical Certificate of Death in Beijing
Made by 2003 No. xxx
The name of the deceased: Xxxx Gender: Female The forth copy: Retained by the Household Registration
Chronological Age: xxx Ethnic: Han
ID No. xxxx
Permanent Residence Address Haidian, Beijing
The cause of death Colon cancer, liver cirrhosis
Name of contact families and address: Xxxx
No. ,Xxxx，Zhongguancun
Date of Death: 2004-12-31
Signature of Physician: Signature Hukou police:
Seal of medical institute
Seal of the Household Registration
Seal: General Hospital of Beijing xxx Region
Dept. of Clinic.
The name of the deceased: Xxxx Gender:
1. Male 2. √ Female Ethnic : Han Main occupations and trades: Researcher ID No.xxxx Hukou address:
Beijing, Haidian The third copy: Collected by Household Registration dept, and regularly submit to the health sector.
Current address:No. Xxxx，Zhongguancun, Haidian district, Beijing Marriage: 1. Unmarried 2. √Married 3.Widowed 4.Divorced 0 Unknown
Education: 1. Illiterate or semi-literate 2. Primary schools 3. Middle schools 4. √ University 0. Unknown
Place of death: 1. √Hospital wards 2. Emergency room 3. Home or en route to the hospital 4. Nonlocal or other 0. Unknown
Date of birth: xxx Date of death:
xxx Chronological Age: xxx
The deceased employer: Chinese Academy of Agricultural Sciences Name of contact families: Xxxx Family residence or place of work: No. ,Xxxx，Zhongguancun Haidian district, Beijing。
The main fatal disease diagnosis（Please fill in the name of the disease, instead of completing the symptoms and signs) The approximate time of onset to death
4 days
I.(a)The disease or condition directly cause the death: Late stage of colon cancer
(b) The disease or condition cause (a)
(c) The disease or condition cause (b)
II. Diagnosis of other diseases (Promote the deaths, but other important circumstances unrelated to the cause of death)
The highest unit which diagnose the above diseases of the deceased: 1. Provincial (municipal) Hospital 2. Regional (municipal) Hospital 3. The county (district) hospitals 4. Town Hospital 5. Rural doctor 6. Not visit a doctor 0. Others or unknown
The highest basis which diagnose the above diseases of the deceased: 1. Autopsy 2. Pathology, 3. √ Surgery, 4.Clinical + physic- chemical, 5.Clinical, 6.After death concluded 0.Unknown
Inpatient No. 563948 Physician: Seal of the Unit: Submission date: 2004-12-31
(The following prepared by the statisticians) The fundamental cause of death____________ICD code_______ Statistical classification No_________
External causes of injury and poison:_______ E code:________ Statistical classification No_________
Seal: General Hospital of Beijing xxx Region
Clinical Service
Investigation Record
The deceased's medical history and symptoms:
The patients had Cholecystectomy in 1989, she was found in decompensated liver cirrhosis, 4 days before admission, Abdominal Pain, stopped defecating, diagnosed with Intestinal Obstruction, she was found colon cancer during surgery , Ascending colon expansion in the preceding paragraph, Liver Cirrhosis, Nodules.
Respondents name: Xxxx Relationship with the deceased: Couple, Contact address or place of work: No.12,Xxxx，Zhongguancun, Haidian district, Telephone: xxx
The cause of death: Late stage of colon cancer, Liver cirrhosis Investigator name: Survey date: 2004-12-31
Notes on Completing
1. Main occupations and trades: Fill in the profession and mainly engaged in work at the same time as possible, such as workers, farmers, cadres, students, soldiers, service industries and so on. You can also fill detail jobs, such as turner, fitter, textile workers.
2. Hukou address: Address should be registered according to Household Resistor, including the specific code of residency.
3. Chronological Age: According to one full year of life. A baby can be done by completing the actual survival of the month, day and hour.
4. Lethal disease diagnosis can be divided into two main parts to report. In part I (a), fill out the final diagnosis of the diseases that cause death or clinical signs of injury or poison, such as Pulmonary heart disease, cerebral hemorrhage, skull fractures(Do not fill in respiratory and circulatory failure and so on): in (b), Fill out the diseases and conditions which can cause (a) , such as Emphysema, High blood pressure, external causes of injury and poison(Bike collided with a car, suicide and so on); in (c), fill out the disease or condition which cause (b) , such as Chronic Bronchitis. In Part II filling in other diseases or conditions with nothing to do with Part I, but contributed to the death.
5. The highest diagnosis unit of diseases: Generally refers to the final diagnosis unit of the main diseases before he died, You can also fill out the highest level units which diagnose the disease reported in in Part I (a) .such as Provincial (municipal) hospitals or the hospital including equal to or above the provincial level. Others according to the principle.
Seal: General Hospital of Beijing xxxx Region
Clinical Service |
