The
Third
Joint
Certification for Resident's Death Cancellation D0017700
The
Fourth
Joint
Certification for Resident's Death Cancellation D0017700
Deceased’s Name
XX
Deceased’s Name: XX
Gender
Male
Gender
Male
Chronological Age
63 years old
Nationality
Han
Age
63 years old
Occupation
General Manager
ID Card No.
2102021947102022XX
ID Card No.
2102021947102022XX
Residential Address
No.14 Gangjingyuan Residential Quarter, Zhongshan District, Dalian, Liaoning Province
Residential Address
No.14 Gangjingyuan Residential Quarter, Zhongshan District, Dalian, Liaoning Province
Date of Death
12 Sep. 2011
Date of Birth
20 Oct. 1947
Causes of Death
gastrointestinal bleeding and hemorrhagic shock
Date of Death
12 Sep. 2011
Place of Death
MICU
Causes of Death
gastrointestinal bleeding and hemorrhagic shock
Family Member’s Name and Contact Information
Xiaohong Gu
Place of Death
MICU, The Affiliated Zhongshan Hospital of Dalian University
Family Member’s Name and Contact Information
Xiaohong Gu
Doctor’s Signature
Lidan Wang
Doctor’s Signature
Lidan Wang
Medical Unit’s Seal
Medical Certification for Dalian Resident's Death, The Affiliated Zhongshan Hospital of Dalian University
Medical Unit’s Seal
Medical Certification for Dalian Resident's Death, The Affiliated Zhongshan Hospital of Dalian University
Date
Police Station’s Seal
Police Station’s Seal
Date
Date of Completion: 12 Sep. 2011
Date of Completion: 12 Sep. 2011
① This certification shall become invalid without the medical unit’s seal.
② This joint shall be kept by the household registration office.
③ The family member shall keep the copy.
① Please cancel the household registration before cremation.
② This certification shall become invalid without the doctor’s seal, the hospital’s seal or the police station’s seal.
③ This certification shall be registered and kept by the Funeral Parlor.
④ The family member shall keep the copy.
