Spirit of the age. [volume] (Woodstock, Vt.) 1845-1913, 1904-12-31

Date of birth
Month";. Day.. Year, 100
Age
..........Years ..........Mos. ..........Days
Occupation
Uf none, SO stats)
Birthplace
Estate or country
Name of husband or wife. II married
Name OF father
Birthplace Of father
Estate or country
Maiden name of mother
Birthplace Of mother
Estate or country
The above stated personal particulars are
true to the best Of my knowledge and
belief.
Informant.
Address.
Place Of burial.
Date OF burial. ........
Undertaken. ............
(To be filled by person issuing
burial permip
Medical Certificate at Death.
Date Of death
Month .Day.......Y Year, 19o....
hereby certify that I attended de-
ceased from...... $780,, to...... $780,, that
I last saw h.. alive on..... .19O. and
that death occurred on the date stated
above, at......M.
To the best of my knowledge and belief
the cause of death was as follows:
CAUSE OF DEATH.
(See instructions on back.)
Chlel. ......................
Contributing.
............ ............ ........ ..............
............ ............ ."".... ...............
''.''''.'''' ........''.. ....... ............
DURATION. Observation-Disclosures.
Where contracted. ..............
signed. DECENTRALIZATION,
bate...'.. ...................
Address. Observation-Disclosures.
Filed. .......190 ,..............
Health Oficer.
The physician filling out the above men
toned certificate of death shall, within
thirty-six hours after death, deliver the
same to the family of the deceased, if
any, or to the undertaken or person who |
has charge OF the body, which certificate |
shall be filed as provided in section S of |
this act, and certificate of permission |
for burial, entombment. or removal OBJ
tained by tho person who has charge OF
the body, before such dead body shall be |
buried, entombed or removed from the
town or city. When such certificate of
death is filed with the health officer,
deputy health officer, or other person as
herein provided. such officer or person
shall Immediately issue a certificate of
permission for BURIAL entombment, or
removal Of the dead body under legal
restrictions and safeguards.
Whenever person dies without medi-
cal attendance, the head Of the household
where such death occurs, or the next of
kin, shall Immediately notify the health
officer, II there be one, otherwise a men,
Der of the local board of health where
such death occurred, who SHALL after
proper investigation. and IL deemed
necessary by him after an autopsy to de-
termins the cause Of death, issue a GER
tificate OF death.
Whenever q dead body Is brought into
this state for burial or entombment from
any state or territory or Dominion of
Canada, the health ofiicer or clerk OF
the town or city where 1t Is desired to
bury or entomb such body shall issue a
certificate Of permission for burial or
entombment upon receiving a certified
copy OF the death certificate or the re-
moval or transit permit accompanying
such body. issued under the laws of the
state. territory, or Dominion Of Canada,
where the person died.
All certificates of death and all removal
and transit permits filed with the health
officer, deputy health officer, or other
person, in accordance with the proyi-
sions Of this act, shall be returned to
the town or city clerk during the first
week of each month next following the q
month in which they are received
Any physician failing to furnish GER
tifcate Of death within thirty-six hours 4
after the death Of any human being, Civ.
Ing a true and faithful statement of tbe
FIRST receiving certificate of death or
cause Of such death. and all the other
facts provided for in the blank form for !
death certificates. mentioned in this act,
SO far as these facts are obtainable, shall
be fined not less than ten dollars to the
use Of the town or city where such death
occurs. 4,
Any health otpcer, deputy health ~,,asr
Or other person who issues certificate a
If permission for the burial entombment r
Or removal of any dead body, without 7
irst receiving a certificate OF death or a
removal or transit permit as herein pro. t.