1893-1894 - The University of North Carolina at Chapel Hill

56 NORTH CAROLINA BOARD OF HEALTH.
justice of the peace, to a fine of not less than S."5 nor more than $25, or
imprisonment for not more than ten days, at the discretion of the convicting
justice, besides costs, which he may inflict in addition if he see fit.
BIRTH CERTIFICATE.
N. C, ISO-
Date of Birth
Name of Child, if named
Name of Father
Name of Mother
Residence, No Street Ward
Color Sex ^
Condition of Child
Attending Physician or Midwife
'»
CERTIFICATE OF DEATH AND APPLICATION FOR BURIAL
OR TRANSIT PERMIT.
To the* of N. C:
Date of Death
Full Name of Deceased!
Sex, Male or Female
Age Years Months Days.
Color
Married, Single, Widow' or Widower
Occupation
Birthplace
Place of Death, No. , Street, Ward.
Cause of Death
Duration of Last Sickness
Place of Burial -_ ^
Date of Burial I M. D.,
Medical Attendant.
f Undertaker
\ Place of Business
f
j %
Personally appeared before me on this the day of 189--
and made oath that the above statement
in regard to the death of
is true.
,J. P.
*This certificate must be returned to the official selected for the purpose—Town Clerk,
Chief of Police or some other— for Burial Permit.
tif still-born, give names of parents on this line.
jlu case there was no medical attendant, this certificate may be signed by the Health
Officer, after careful inquirj' as to the facts required to be noted. Or it ma3' be signed
on oath before a Justice of the Peace by the householder in whose house the death
occurred, or by the next friend of the deceased who was present. Where there was an
attending physician no other signature than his should be accepted.
Note.—The apparent amount of " red tape" in this certificate in the matter of requiring
the householder or next friend to make oath before a Justice of the Peace is rendered
necessary by the fact that death certificates are often used in the courts as evidence,
and the disposition of large sums of money may depend upon their accuracy and
reliability.