Form No. 25

MOORHAVEN HOSPITAL, IVYBRIDGE, SOUTH DEVON.

NOTICE OF DEATH

 

35 hereby give you jtiutitiz that ....... i31s:_te::1e.:ierber_i2.eX4‘s?9.

____  patient received into

this mental hospital on the .......... ..Eigh‘.kh ........ ..day of. ..Haxe§;.;....19§6..
died therein on the ......... Jiinth ......... .. day of  .... .19 56.

(Signed) ...............  .......... ..
Acting Clerk of the Hospital.
DATED the .... ..9tn ............ ..day of...“ ____________________ March, ....................... ..19..56.

 

STATEMENT RESPECTING THE ABOVE NAMED PATIENT

Name .........................  ....  .......................................................................................................... 4.
Sex and age "316.-l.€.?.g ....................................  .......... ..years. Married, single, or widowed..l£aII'i8d....(_Di'!IOr03d)
Profession or occupation ........... ..53ed,3m8.n. ................................................................................  .......................................... ..
Usual residence (postal address) before ad-
mission. (If the patient has been transferred ........... ..2,...Ha.3‘h111g,a._S7h1?ea?h., ................................................... ..
from another Institution, the place of ., , ,
residence before admission to the first '
Institution should be given.) . . . . . . """"""""""""""  """""""""""""""""""""""""""""""""" "

CAUSE OF DEATH

Approximate interval

I I between onset
and death
Disease or condition directly (a)...C.a.rdia.c...F.ailure. ...............................................................  ............... ..

leading to death* . due to (or as a consequence of)
Antecedent causes. Morbid (b) ................................................................................................. ..
conditions, if any, giving
rise to the above cause due to (or as -a consequence of)
stating the underlying
condition last. (c) ................................................................................................. ..

II II

Other significant conditions

contributing to the death,

but not related to the

disease or condition
causing it.

* This does not mean the mode of dying, such as, e.g., heart failure, asphyxia, asthenia, etc., it means the disease, injury,
or comhlicafinn whirh minced rirz-:11-In -=‘-‘-'


 

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fou_n‘t=1 subsequently on body of deceased,or a

stafen}_ent*that t'he_1€e were none

 

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