Audubon Republican. [volume] (Audubon, Iowa) 1894-1925, 1917-01-25


marrier, widowed or divorced.
co Date of birth. including the
year, month and day.
| Cd Age, in years. months and
days. If less than one day, the hours
or minutes.
| (8) Occupation. The occupation
to be reported of any person male or
female, who had any remunerative
employment, with the statement OF
(a) trade, profession or particular
kind of work; (b) general nature OF
industry, business or establishment in
which employed Cor employer).
(9) Birthplace; at least state OF
foreign country if known.
| (1O) Name of father.
| G1) Birthplace of father; at
least state or foreign country, If
known.
(12) Maiden name of mother.
I (13) Birthplace of mother. at
least state or foreign countryif known
! (14) Signature and address OF in
formant.
(15) Official signature of regis
trar, with the date when certificate
was filed, and registered number.
! (16) Date of death, year, month
and day.
40 Certification as to medical
attendance on decedent, fact and
time of death, time last seen alive
and the cause of death, with contrib
utory secondary cause of compli-
cation, IL any, and duration of each
and whether attributed to dangerous
or insanitary conditions of employ
ment; signature and address of ply
stefan or official making the medical
certificate.
(18) Length of residence (for in
mates of hospitals and other institu-
lions; transients or recent residents
at place of death and in the state
| together with the place where disease
was contracted, il not at place OF
death. and former or usual residence
G9) Place of burial or removal ;
date of burial.
coo Signature and address of
undertaken or person acting as such
The personal and statistical partic-
ulars Utems / to 13) shall be authen-
| ticated by the signature of the infor-
mant, who may be any competent per-
son acquainted with the facts.
The statement of facts relating to
the disposition of the body shall be
signed by the undertaken or person
acting as such.
The medical certificate shall be
made and signed by the physician, il
any, last in attendance on the deceas-
ed, who shall specify the time in at
tendance, the time he last saw the de-
ceased alive and the hour of the day
at which death occurred. And he
shall further state the cause of death,
so as to show the course of disease
or sequence of cause resulting in the
death, giving first the name of the
disease causing death (primary cause
and the contributory secondary
cause, II any, and the duration of
each. Indefinite and unsatisfactory
terms, denoting only symptoms of dis
ease or conditions resulting from dis
ease, will not be held sufficient for
the issuance of burial or removal
permit; and any certificate contain
ing only such terms, as defined by the
state registrar, shall be returned to
the physician or person making the
medical certificate for correction and
more definite statement. Causes of
death which may be the result of eth
err disease or violence shall be care
fully defined; and If from violence,
the means of injury shall be stated,
and whether (probably) accidental,
suicidal, or homicidal. And for
deaths in hospitals. institutions, or of
Inon-residents the physician shall sup