Medical Certification for Resident's Death D0017700
The family member shall keep the copy.
Residential Address: No.14 Gangjingyuan Residential Quarter, Zhongshan District, Dalian, LiaoningProvince
In case of pre-hospital death and unknown death cause, please complete
Investigation Record
Deceased’s Name:
Min Gu
Gender: Male
Nationality: Han
Main Occupation and Job Type: General Manager of Dalian Guofeng Airline Travel Service Co., Ltd.
ID Card No.: 210202194710202215
Current Residential Address: 2-8-1 No.14 Gangjingyuan Residential Quarter, Zhongshan District,Dalian, LiaoningProvince
The deceased’s medical history, signs and symptoms during his lifetime:
Autopsy: Yes No
Marital Status: Married
Education Level: JuniorSchool
Work Unit during His Lifetime: Dalian Guofeng Airline Travel Service Co., Ltd.
Date of Birth: 20 Oct. 1947
Date of Death: 12 Sep. 2011
Chronological Age: 63 years old
Place of Death: Ward of a Hospital
Available Family Member’s Name and Phone: Xiaohong Gu 13322266726
Family Member’s Residential Address or Work Unit: Dalian Guofeng Airline Travel Service Co., Ltd.
Diagnosis of Main Fatal Diseases (please fill in the specific disease names, but do not fill in the signs and symptoms)
I. (a): The direct death-causing diseases or statuses: primary liver cancer, gastrointestinal bleeding and hemorrhagic shock
(b): The (a)-causing diseases or statuses: Decompensated liver cirrhosis after hepatitis, primary liver cancer after intervention
(c): The (b)-causing diseases or statuses: Massive upper gastrointestinal bleeding, hemorrhagic shock and severe anemia
II. Diagnosis of other diseases (other important statuses promoting death but being unrelated to the induction of death)
Approximate time interval from onset to death: One year
Relationship between the Investigated (immediate family member) and the Deceased
The Investigated’s ID Card No.:
Contact Address:
Contact Phone (required):
The Supreme Diagnosis Unit for the Deceased’s Above Diseases during His Lifetime: Provincial-levelHospital
The above information is true! The Investigated’s Signature:
The Supreme Diagnosis Basis for the Deceased’s Above Diseases during His Lifetime: Pathology
Verbal autopsy:
Hospital Admission Number: 1011883 Report Section: MICU Doctor’s Signature: Lidan Wang Report Unit (handwriting): MICU Unit’s Seal: Medical Certification for Dalian Resident's Death, The Affiliated Zhongshan Hospital of Dalian University
The Investigator’s Signature:
Remark Date of Completion: 12 Sep. 2011
Date of Investigation:
