DEATH CERTIFICATE

死亡證明書 DEATH CERTIFICATE 死亡證字 號之 Shi-Wan-Chen-Tze No 醫療單位代號 Health Unit code 證明書開具單位填寫 To be filled out by the issuing organization (I) 姓名 Name (II)性別 Gender: 男 M 女 F (III)身份證字號 ID No.: (IV)地址 Address (VI)死亡時間 Time of death (VII)死亡地點 Place of death (VIII)死亡類別 Category of death (V)生日 Birth date 以上事實確實無訛特此證明 This is to certify that the deceased named above has been duly 診斷或證明者 身份代表 diagnosed with the particular causes given above. Diagnosed or certified by 醫師姓名及證書字號 Name and license code of the diagnosing doctor:: Approx. time from the disease till death (IX)死亡者職業 工作類型、職位 Type of job, position Occupation of the Deceased (X)死亡者婚姻狀況  未婚 Unmarried 已婚 Married  離婚 Divorced The deceased’s marital  寡婦 Widowed/鰥夫 Widowered  不詳 Unknown status (XI)死因：盡量不要填寫症狀或死亡當時的身體狀況如：身體衰弱、心臟衰弱 原死因註碼 Causes of death： Do not remark symptoms or physical conditions upon death, Death cause e.g., feeble condition, weak heart.. code 1. 直接致死的疾病或傷害 Disease or injury directly resulting in the death: 發 病 A. 至 死 先行原因 (若有引起上述死因之疾病或傷害) 亡 Precedent causes: Disease or injury resulting in the above, if any) 之 概 B. (A 的原因 Cause of A) 略 時 C. (B 的原因 Cause of B) 間 2. 其他對於死亡有影響之疾病或身體狀況 Other disease or physical conditions having an impact upon the death. 醫院  診所 Hospital Clinic  因病而死 意外 或自然死亡 Accident Disease or natural causes  上班地點 Workplace   自殺 Suicide 自家 Own home  被殺 Homicide 其他 Others  不詳 Unknown 醫院：行政院國軍退除役官兵輔導委員會玉里榮民醫院 Hospital: Yuli Veterans Hospital, VAC , Executive Yuan. 醫院代號 Hospital code: 064503001 院長 Superintendent: 地址：981 花蓮縣玉里鎮新興街91號 Address：No.91, Sinsing St., Yuli Township, Hualien County 981, Taiwan (R.O.C.) 日期 Date: 填 表 人 蓋 章 Prepared by 附註：死因將來如發現錯誤，惟錯誤係在當時難以避免情況下發生時，斷醫者不負法律上責任。 Remarks: In case of an error in the cause leading to the death, the error took place in the inevitable situation for which the diagnosing doctor assumes no legal responsibility.