1913 public laws – Ch.109 Sec.7

That the certificate of death shall contain the following items, which are hereby declared necessary for the legal, social and sanitary purposes subserved by registration records: | -1 Place of death, including state, county, township, or town, village or city. If in a city; the ward, street and house number; if in a hospital or other institution, the name of the same to be given instead of the street and house number., If in an industrial camp, the name of the camp to be given. -2 Full name of decedent. If an unnamed child, the surname preceded by Unnamed. -3 Sex. -4 Color or raceas white, black, mulatto (or other negro descent), Indian, Chinese, Japanese, or other. -5 Conjugal conditionas single, married, widowed, or divorced. -6 Educational attainmentsas illiterate, able to read and write, common school education or equivalent, high school education or equivalent, college education or equivalent. If the de ceased is less than fifteen years of age the educational attainments of the mother, if living, or of the father, if living, or of the guardian in the order named, shall be given. -7 Date of birth, including the year, month and day. -8 Age, in years, months and days. If less than one day, the hours or minutes. If exact information is unobtainable, give approximate age. -9 Occupation. The occupation to be reported of any person ‘ who had any remunerative employment, stating (a) trade, profession or particular kind of work; (b) general nature of industry, business or establishment in which employed (or employer). -10 Birthplace; at least state or foreign country, if known. | -11 Name of father. ! -12 Birthplace of father; at least state or foreign country, if] known. -18 Maiden name of mother. J -14 Birthplace of mother; at least state or foreign country, if! known. / Pub.13 -15 Signature and address of informant. -16 Official signature of registrar, with the date when certificate was filed, and registered number. -17 Date of deathyear, month and day. -18 Certification as to medical attendance on decedent, fact and time of death, time last seen alive, and the cause of death, with contributory secondary cause or complication, if any, and duration of each, and whether attributed to dangerous or insanitary conditions of employment; signature, date of signature, and address of physician or official making the medical certificate. -19 Length of residence (for inmates of hospitals and other institutions; transients or recent residents) at place of death and in the State, together with the place where disease was contracted, if not at place of death, and former or usual residence. -20 Place of burial or removal; date of burial. -21 Signature and address of undertaker or person acting as such. The personal and statistical.particulars (items one to thirteen) shall be authenticated by the signature of the informant, who may be any competent person acquainted with the facts. The statement of facts relating to the disposition of the body shall be signed by the undertaker or person acting as such. The medical certificate shall be made and signed by the physician, if any, who last treated the deceased for the disease or injury which caused death, and such physician shall specify the time in attendance, the time he last saw the deceased 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 causes resulting in the death, giving first the name of the disease causing death (primary cause), and the contributory (secondary) cause, if any, and the duration of each. Indefinite and unsatisfactory terms, denoting only symptoms of disease or conditions resulting from disease, will not be held sufficient for the issuance of a burial or removal permit; and any certificate containing any such indefinite or unsatsfactory 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 either disease or violence, shall be carefully defined; and, if from violence, the means of injury shall be stated, and whether (probably) accidental, suicidal, or homicidal. And in deaths in hospitals, institutions, or of nonresidents, the physician shall supply the information required under this head (item eighteen), if he is able to do so, and may state where, in his opinion, the disease was contracted.