Appendix E: Public Hospitals Act Form

• Author: Richard D. Schneider
• Pages: 630-630

630 ANNOTATED ONTARIO MENTAL HEALTH STATUTES

630

Appendix E: Public Hospitals Act Form

FORM 1

CER TIFIC ATE OF D EATH

Public Hospitals Act

Name of Patient

Date and Hour of Death

CAUSE OF DEATH

Approximate Interval

Between Onset and

Death

I

IMMEDIATE CAUSE—State the disease, injury or

complication that caused death, not the mode of dying,

such as heart failure, asphyxia, asthenia, etc. (a)

due to

MORBID CONDITIONS, if any, giving rise to

immediate cause (state in order backwards from

immediate cause). (b)

due to

(c)

II

OTHER MORBID CONDITIONS (if important)

contributing to death but not causally related to

immediate cause.

Signature of Attending

Physician

Date Signed

R.R.O. 1990, Reg. 965, Form 1.

Forms 2, 3 Revoked: O. Reg. 761/93, s. 14.