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.