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BUSINESSINDUSTRY

By Barry Gray,2014-07-29 03:17
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BUSINESSINDUSTRY

    TAIWAN R.O.C. STANDARD

    CERTIFICATE OF DEATH

Registration No.( dept. use only )

    TO BE FILLED OUT BY ISSUER

     1. DECEDENT’S NAME (First, Middle, Last) 2. SEX 3. IDENTIFICATION NUMBER

     Male Female

    4. REGISTERED PERMANENT RESIDENCE (Street and number, city, town, country)

     5a. DATE OF BIRTH (Month, Day, Year) 5b. TIME OF BIRTH (For death within one week after birth)

     AM Hour Minutes

     PM

     6a. DATE OF DEATH (Month, Day, Year) 6b. TIME OF DEATH

     AM Hour Minutes

     PM

     7a. LOCATION OF DEATH 7b. PLACE OF DEATH

     (Street and number, city, town, country) Hospital Clinic Midwifery Center

     Own Residence Others

    8. MANNER OF DEATH

     Death from Illness or Natural Death Accident Suicide Homicide Could not be Determined

     9a. KIND OF BUSINESS/INDUSTRY 9b. DECEDENT’S USUAL OCCUPATION

     10. MARITAL STATUS

     Never Married Married Divorced Widowed Unknown

     11. CAUSE OF DEATH (Enter the diseases, injuries, or complications that caused the death. Approximate

    Do not enter the mode dying, such as heart failure or respiratory arrest.) Interval between

     PART I. Onset and Death

    IMMEDIATE CAUSE (Final

    disease or condition resulting

    in death ) a.

     DUE TO (OR AS A CONSEQUENCE OF) :

    Sequentially list conditions,

    if any, leading to immediate b.

    cause. Enter UNDERLYING DUE TO (OR AS A CONSEQUENCE OF) :

    CAUSE (Disease or injury

    that initiated events resulting c.

    in death ) LAST

     PART II. Other significant conditions contributing to death but not resulting in the underlying cause given in Part I.

THIS IS TO CERTIFY THAT THE ABOVE STATEMENT IS TRUE.

     Name and License Number of Certifying Physician:

     Name and Practice License Number of Hospital (Clinic):

     Address of Hospital (Clinic): No. 325, Sec. 2, Cheng-Kung Road, Neihu 114, Taipei, Taiwan R.O.C.

Date Signed (Month, Day, Year) :

    INSTRUCTIONS 1. This certificate shall be filled out after death by physician of hospital (clinic)

    or administrative and judicial official attending autopsy.

    2. For either administrative or judicial official attending autopsy, items 11 and 12

    shall be certified by the person attending autopsy and his/her institution.

    3. Each item shall be filled out and information in all items shall be in agreement.

    4. Instruction for selected items:

    Item 5b. TIME OF BIRTH

    Enter the exact time that death occurred if under 1 week.

    Item 9a. KIND OF BUSINESS/INDUSTRY

    Enter the kind of business or industry to which the occupation

    listed in item 9b was related, such as fishing, financing, public

    agency and national defense, or retail trade.

    Item 9b. DECEDENT’S USUAL OCCUPATION

    Enter the recent occupation of the decedent, such as director and

    chief executive, computer programmer, teacher, ocean fishery

    worker, plasterer, or cook.

    Item 11 CAUSE OF DEATH

    In Part I, the immediate cause of death is reported on line (a).

    Antecedent conditions, if nay, that gave rise to the cause are reported

    on lines (b) and (c). Not entering is necessary on lines (b) and (c) if

    the immediate cause of death on line (a) describes completely the

    sequence of events. Only one cause should be entered on a line.

    Additional lines may be added if necessary. Provide the best

    estimate of the interval between the onset of each condition and

    death. Do not leave the space for the interval blank; if unknown, so

    specify.

    In Part II, enter other important diseases or conditions that

    contributed to death but did not result in the underlying cause of

    death given in Part I.

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