department nf (Cnmmerre anb S.alwr 
REGISTRATION OF BIRTHS 
AND DEATHS 
DRAFTS OF LAWS AND FORMS OF 
CERTIFICATES 
BUREAU OF THE CENSUS 
S. N. D. NORTH DIRECTOR Dryartnunit nf (tfnmnwrre aiib ICabnr 
REGISTRATION OF BIRTHS 
AND DEATHS 
DRAFTS OF LAWS AND FORMS 
OF CERTIFICATES INFORMA- 
TION FOR LOCAL 
BUREAU OF THE CENSUS 
S. N. D, NORTH DIRECTOR 8-451-H. 104 
Ojiwrrnmrui llnniuty (Offirr REGISTRATION OF BIRTHS AND DEATHS 
LAWS, FORMS, AND METHODS 
INTRODUCTION 
In a pamphlet on ' ' Legislative Requirements for Registration of 
Vital Statistics," recently published by the Bureau of the Census, a 
draft of a law for the registration of deaths was given, and in another 
pamphlet on ''Practical Registration Methods," issued by the same 
bureau, a copy of the ''Standard Certificate of Death," approved by the 
American Public Health Association, was inserted. The former pam- 
phlet was sent to the governors of all states, state medical societies, 
medical journals, and individuals interested in the extension of effective 
registration upon uniform lines. 
When these pamphlets were issued it was thought best not to attempt 
to include the registration of births in the plans recommended, but the 
interest manifested in the subject and the disposition to urge legislation 
requiring registration of both births and deaths, have made it desirable 
to treat also the question of registering births, and to give a draft of a 
law for that purpose, drawn upon the same lines and based on the same 
general principles as the law for registering deaths. 
The specimen form of a law for this purpose presented on pages 5 to 
11 has been approved by the committee on Demography and Statistics 
of the American Public Health Association, the cooperating committee 
of the Conference of State Boards of Health, through its chairman; the 
Surgeon-General of the United States Public Health and Marine- 
Hospital Service, and the Director of the Census. 
Statisticians and students of sociological problems have long since 
recognized the importance of complete, accurate, and uniform records of 
birth; but people generally do not so fully appreciate the immediate 
practical value of such records in the ordinary relations of life. 
The record of the birth of a child must be made by some other person. 
The child is incapable of protecting its future interests at the proper 
time, and some of its most valuable rights and privileges may be placed 
in jeopardy or entirely lost if the registration of its birth is neglected 
by those upon whom it is dependent. 
(3) 4 
Dr. Arthur R. Reynolds, in a public address, alluded to the matter in 
the following words: 
There is hardly a relation of life, from the cradle to the grave, in which the evi- 
dence furnished by an accurate registration of births may not prove to be of the 
greatest value, as, for example, in the matter of descent; in the relations of guar- 
dians and wards; in the disabilities of minors; in the administration of estates, the 
settlement of insurance and pensions, the requirements of foreign countries concern- 
ing residence, marriage, and legacies; in marriage in our own country, in voting, 
and in jury and militia service; in the right to admission and practice in the profes- 
sions and to many public offices; in the enforcement of laws relating to education 
and to child labor, as well as to various matters in the criminal code-the irrespon- 
sibility of children under ten years of age for crime and misdemeanor, the determi- 
nation of the age of consent, etc. As the country becomes more densely settled and 
the struggle for existence sharper, many of these matters which have hitherto been 
of minor significance will take on a deeper meaning and acquire greater impor- 
tance. Hence the urgent necessity for remedyof the defects which prevent a proper 
registration of births. 
Dr. John S. Fulton, in a paper read at the meeting of the American 
Public Health Association, also speaks of the direct interest of the indi- 
vidual citizen as follows: 
The private interest of the citizen in registration of births is indeed superior to his 
interest in registration of deaths, for a greater proportion of his privileges and 
immunities, rights and duties, turning upon the question of his age and his parent- 
age, are definitely conserved by the registration of his birth. 
Some idea of the frequency with which questions arise requiring ref- 
erence to the records of births may be gained from the fact that the 
calls for copies of records or for information contained in them in New 
York city during the year 1902 exceeded 3,000. 
The principal difference between the proposed law for the registration 
of births and the laws now in force lies in the fact that the former 
requires a practically immediate registration of every birth-the limit of 
time allowed for making the return being three days-whereas most of 
the existing laws allow from one month to one year for that purpose. 
It is believed that the extreme length of time allowed by present laws 
for making the return constitutes a grave defect, the direct result of 
which must be an entire failure to report many births, as any extension 
of time encourages procrastination and practically amounts to allowing 
so much additional time to forget to make the return. 
The fact that in certain cases the given name for a child has not been 
selected at the date of its birth, and that the full name is essential to 
the complete record, does not furnish a sufficient reason for postponing 
the returns, as these cases are comparatively few in number and can be 
adequately provided for with little trouble and no delay. The law pro- 
posed covers such cases by providing for a supplemental report, which is 
elsewhere explained.1 
In the pamphlet on legislative requirements for registration of 
vital statistics, previously referred to, it was suggested that in states 
1 See page 7. 5 
having no registration laws the efforts be confined in the first instance 
to securing legislation for the registration of deaths, to be followed, when 
established on an effective basis, by a further law for the registration of 
births, to be conducted by the same organization. In that pamphlet a 
complete draft of a law for registration of deaths was given. For the 
convenience of persons who may wish to follow the procedure there sug- 
gested, a separate draft of a law for registering births, drawn upon similar 
lines, is given below. (Form A.) 
In case, however, it should seem desirable to provide for the registra- 
tion of both births and deaths in the same act, a draft is also given of a 
law which combines the two, on pages n to 21. (Form B.) 
These two forms (A and B) are very specific in their provisions, and 
cover in a definite manner pretty much all of the details involved in the 
proposed system of registration. They are, therefore, rather lengthy and 
may appear to be more complex or intricate than is desirable, but they have 
intentionally been made complete and explicit, owing to the difficulty in 
some places of securing compliance with necessary requirements, unless 
they are definitely provided for in the law itself. Some of the details 
may very properly be regarded as relating to administrative functions, 
the authority for which is sufficiently implied by the more general pro- 
visions to be upheld by the courts when covered only by rules and 
regulations which the state registrar may be specifically empowered to 
make, promulgate, and enforce. Where this is the case, much of the 
matter appearing in Forms A and B may be omitted and left to be pro- 
vided for in the rules and regulations for which authority is given, and 
which will be essential to a greater or less extent, however complete the 
law. 
As an illustration of a less detailed law, a condensed draft (Form C) 
is given on pages 21 to 25. This form may preferably be adopted if, 
under the state constitution, the courts will uphold the validity of the 
clause empowering the state registrar "to make, promulgate, and 
enforce such rules and regulations as he may consider necessary to carry 
out the provisions of this act,'' and will sustain the state registrar in 
cases arising out of violations of the rules and regulations promulgated 
by him. This is a question for the legal officers of the state to decide. 
If there appears to be any doubt as to the probable attitude of the courts 
the more complete form should be selected. 
DRAFTS OF LAWS 
FORM A: LAW PROVIDING FOR THE REGISTRATION OF BIRTHS 
Section i. All births that occur in the state shall be immediately 
registered in the districts where they occur, which primary registration 
districts shall be the same as those provided by law for the registration 
of deaths. Local registrars for deaths shall also be the local registrars 
for births, and the stgte registrar for deaths shall be the state registrar 6 
for births. It shall be the duty of the attending physician or midwife 
to file a certificate of birth, properly and completely filled out in all of 
the particulars required by this act, with the local registrar of the dis- 
trict in which the birth occurred, within three days after the date of 
birth. And if there be no attending physician or midwife, then it shall 
be the duty of the father of the child, or the householder or owner of 
the premises, or manager or superintendent of the public or private 
institution in which the birth occurred, to file said certificate of birth 
with the local registrar within three days after birth. 
SEC. 2. Stillborn children, or those dead at birth, shall be registered 
as births under this act, and also as deaths under the registration law 
for deaths, and a certificate of birth in the usual form shall be filed with 
the local registrar, said certificate to contain, in place of the "full name 
of child," the word "stillbirth." 
Sec. 3. The certificate of birth shall be of the standard form recom- 
mended by the Bureau of the Census and the American Public Health 
Association, and shall contain the following items: 
(1) Place of birth, including state, county, township or town, village 
or city. If in a city, the ward, street, and house number. If in a hos- 
pital or other institution, the name of the same to be given instead of 
the street and house number. 
(2) Full name of child. If the child dies without a name before the 
certificate is filed, enter the words " died unnamed." If the living child 
has not been named at the date of filing the certificate of birth, the space 
for "full name of child " is to be left blank, to be filled out subsequently 
from the supplemental report hereinafter provided for. 
(3) Sex of child. 
(4) Whether a twin, triplet, or other plural birth. A separate certifi- 
cate shall be required for each child in a case of plural birth, giving 
number of child in order of birth. 
(5) Whether legitimate or illegitimate 
(6) Full name of father. 
(7) Residence of father. 
(8) Color or race of father. 
(9) Birthplace of father. 
(10) Age of father at last birthday, in years. 
(11) Occupation of father. 
(12) Maiden name of mother, in full. 
(13) Residence of mother. 
(14) Color or race of mother. 
(15) Birthplace of mother. 
(16) Age of mother at last birthday, in years. 
(17) Occupation of mother. 
(18) Number of child of this mother, and number of children of this 
mother now living. SUPPLEMENTAL REPORT OF BIRTH 
MARGIN RESERVED FOR BINDING 
This supplemental report is to be pasted 
beneath the original 
8-442 & 
V. S. No. 108 
(STATE) 
(This return should preferably be made by the person who made the original) 
Registered Number* 
Place of birth*No,St. 
(Registration district) 
SEX OF CHILD* 
I HEREBY CERTIFY that the child described herein has 
been named : 
Twin,* 
triplet, 
or other? 
rand1 
Number* 
In order 
[ of birth 
DATE OF BIRTH *,, I 90 - 
(Mon tli) (Day) (Year) 
'Given name, in full) 
(Surname) 
FULL* 
NAME 
FATHER 
(Signature) 
FULL* 
MAIDEN 
NAME 
MOTHER 
* These items to be entered by the Registrar before giving out this form 
11-387 
(Physician or midwife) 8-334 a 
, MARGIN RESERVED FOR BINuING. 
V. S. No. 109 
WRITE PLAINLY, WITH UNFADING INK THIS IS A PERMANENT RECORD. 
2T. Ti.-In case of more than one child at a birth, a SEPARATE RETIRE must be made for each, and 
the number of each, in order of birth, stated. 
PLACE OF BIRTH 
census office: 
STANDARD CERTIFICATE OF" BIRTH 
(state:) 
County of 
Township of 
or 
Village of 
or 
City of - 
Registered No. 
(No. 
St.; 
Ward) 
f If child is not yet named, make 
{supplemental report, as directed. 
FULL NAME OF CHILD 
Sex of 
Child 
Twin, 
Triplet, 
or other? 
and 
Number 
in order 
of birth 
Legiti- 
mate 7 
Date of 
birth , , 190 
(Month) (Day) (Year) 
FULL 
NAME 
FATHER 
FULL 
MAIDEN 
NAME 
MOTHER 
RESIDENCE 
RESIDENCE 
COLOR 
AGE AT LAST 
BIRTHDAY 
(Years) 
COLOR 
AGE AT LAST 
BIRTHDAY 
(Years) 
BIRTHPLACE 
BIRTHPLACE 
OCCUPATION 
OCCUPATION 
Number of child of this m other - 
Number of children, of this mother, now living 
CERTIFICATE OF ATTENDING PHYSICIAN OR MIDWIFE* 
I hereby certify that I attended the birth of this child, and that it occurred on 
, 190 
> at 
M. 
*When there was no attending physician 
or midwife, then the father, householder, 
etc., should make this return. 
(Signature) 
(Physician or midwife) 
Given name added from a supplemental 
Address 
report 
, 190 
Filed 
, 190 
REGISTRAR. 
11-385 
REGISTRAR. 7 
(19) Certificate of attending physician or midwife as to attendance at 
birth, including statement of year, month, day, and hour of birth, and 
whether the child was alive or dead at birth. This certificate shall be 
signed by the attending physician or midwife, with date of signature 
and address. If there was no physician or midwife in attendance, then 
the father of the child, or the householder or owner of the premises, or 
manager or superintendent of the public or private institution in which 
the birth occurred, or other competent person whose duty it shall become 
to file the certificate of birth as provided in section one of this act, shall 
draw a line through the words "I hereby certify that I attended the 
birth of above child," and shall write in lieu thereof the words ''no 
physician or midwife," filling out the remainder of the certificate in 
regard to the year, month, day, and hour of birth, and signing the cer- 
tificate as father, householder, owner of premises, manager or superin- 
tendent of institution, as the case may be, with his address. 
(20) Exact date of filing in office of local registrar, attested by his 
official signature and registered number of birth, as hereinafter provided. 
The certificate shall be written legibly in unfading black ink, and no 
certificate shall be held to be complete and correct that does not supply 
all of the items of information specified herein or satisfactorily account 
for the omission of any of said items. 
SEC. 4. The local registrar shall supply blanks and instructions, as 
directed by the state registrar, to physicians, midwives, and to other 
persons requiring them. He shall carefully examine each certificate of 
birth when presented for record to see that it has been made out in 
accordance with the provisions of this act and the instructions of the 
state registrar, and if any certificate is incomplete or unsatisfactory, he 
shall immediately notify the informant and require him to supply the 
missing items if they can be obtained. If it is impossible to obtain any 
such item, then the local registrar shall fill the blank space with the 
word ''unknown." When any certificate of birth of a living child is 
presented without statement of the given name, then the local registrar 
shall make out and deliver to the informant a special blank for the sup- 
plemental report of the given name of the child, which shall be filled 
out as directed and returned to the registrar as soon as such child 
shall be named. The original certificate of birth shall not be considered 
complete until the supplemental report is filed or the blank returned 
with the statement " died unnamed." The local registrar shall imme- 
diately number each certificate of birth when filed with him, whether 
complete or incomplete, beginning with ''number one," for the first 
birth that occurs in his district in each calendar year, and sign his name 
as registrar in attest of the date of filing in his office. He shall make a 
complete and accurate copy of each certificate registered by him, upon a 
form identical with the original, to be filed and permanently preserved 
in his office, as the local record of such birth, in such manner as directed 8 
by the .state registrar. And he shall, on the fifth day of each month, at 
the time of making his monthly report of deaths, transmit to the state 
registrar all original certificates of birth registered by him for the pre- 
ceding calendar month, together with any delayed certificates and sup- 
plemental reports for preceding months. And if no births occurred in 
any month, he shall, on the fifth day of the following month, report 
that fact to the state registrar in such manner as the state registrar shall 
direct. 
SEC. 5. The state registrar shall prepare, print, and supply to all 
registrars all blanks and forms used in registering, recording, and pre- 
serving the returns, or in otherwise carrying out the purposes of this act, 
and shall prepare and issue such detailed instructions as may be required 
to secure the uniform observance of its provisions and the maintenance 
of a perfect system of registration, and no other blanks shall be used 
than those supplied by the state registrar. He shall carefully examine 
the certificates received monthly from the local registrars, and if any 
such are incomplete or unsatisfactory he shall require such further 
information to be furnished as may be necessary to make the record 
complete and satisfactory. And all physicians, midwives, or other inform- 
ants, and all other persons having knowledge of the facts, are hereby 
required to furnish such information as they may possess regarding any 
birth, upon demand of the state registrar, in person, by mail, or through 
the local registrar. He shall further arrange, bind, and permanently 
preserve the certificates in a systematic manner, and shall prepare and 
maintain a comprehensive and continuous card index of all births regis- 
tered, the cards to show the name of child, place and date of birth, 
number of certificate, and the volume in which it is contained. And he 
is hereby empowered to make, promulgate, and enforce such rules and 
regulations as he may consider necessary to carry out the provisions of 
this act. 
Sec. 6. Each local registrar shall be entitled to be paid the sum of 
[twenty-five] cents for each birth certificate properly and completely 
made out and registered with him, and correctly copied and duly trans- 
mitted by him to the state registrar as required by section four of this 
act. In case no births occurred during a calendar month, the local reg- 
istrar shall be entitled to be paid the sum of [twenty-five] cents for each 
report to that effect promptly made in accordance with the directions of 
the state registrar. All amounts payable to any registrar under the 
provisions of this section shall be paid by the treasurer of the county in 
which the registration district is located upon certification by the state 
registrar. 
Sec. 7. Each physician, midwife, father of child, householder or 
Owner of premises, manager or superintendent of public or private 
institution, or other person acting as informant and filing with the 
local registrar within three days after the birth of a child a proper cer- 9 
tificate of birth, correctly and legibly made out in unfading black ink 
and containing all the items required by section three of this act, shall 
be entitled to receive the sum of [twenty-five] cents, to be paid by the 
treasurer of the county upon certification by the state registrar. Only 
one certificate shall be received for the birth of the same child, and the 
order of right to file the certificate shall be the same as the order of 
responsibility for filing as herein given and in section one of this act. 
Certificates in which certain items are omitted, including the given 
name of the child, shall be regarded as incomplete and shall not be enti- 
tled to payment until the missing information, when possible to obtain, 
is supplied. And the state registrar shall annually certify to the treas- 
urers of the several counties the number of births registered, with the 
names of the persons reporting them and the amounts due each at the 
rate fixed herein. 
Note.-It is considered desirable by some authorities to offer inducements for the 
return of births by payment of a small fee for each birth reported, but while it may 
prove an incentive in some cases, the main reliance for complete returns must rest 
upon enforcement of the compulsory requirements of the law, and the provisions for 
payment may be retained or omitted as preferred. 
Sec. 8. The state registrar shall, upon request, furnish any applicant 
a certified copy of the record of any birth registered under the provisions 
of this act, for the making and certification of which he shall be entitled to 
a fee of [fifty] cents, to be paid by the applicant. And any such copy of 
the record of a birth, when properly certified by the state registrar to be 
a true copy thereof, shall be prima facie evidence in all courts and places 
of the facts therein stated. For any search of the files and records, 
when no certified copy is made, the state registrar shall be entitled to a fee 
of [fifty] cents for each hour or fractional hour of time of search, to be 
paid by the applicant. And the state registrar shall keep a true and 
correct account of all fees by him received under these provisions, and 
turn them over to the state treasurer. 
SEC. 9. All superintendents or managers or other persons in charge 
of hospitals or lying-in institutions, to which women resort for confine- 
ment, are hereby required to make a record of all of the personal and 
statistical particulars relative to the inmates of their institutions, there 
residing for the purpose of confinement, at the date of taking effect of 
this act, that are required in the form of certificate herein provided for, 
as directed by the state registrar. And thereafter such record shall be by 
them made, for all future inmates, at the time of admission. 
Sec. io. Every physician and midwife shall without delay register his 
or her name, address, and occupation with the local registrar of the 
registration district in which he or she resides or may hereafter establish 
a residence, and shall thereupon be supplied by the local registrar with 
a copy of this act, together with such rules and regulations as may be 
prepared by the state registrar relative to its enforcement. Within 
95°7~06 2 IO 
thirty clays after the close of each calendar year each local registrar shall 
make a return to the state registrar of all physicians and midwives who 
have registered in his district during the preceding calendar year, and in 
certifying names for payment for certificates of birth filed, the state 
registrar shall not include any physicians or midwives who have not 
complied with the requirements of this section: Provided, That no fee 
or other compensation shall be charged by local registrars to physicians 
or midwives for registering their names under this section or making 
returns thereof to the state registrar. 
SEC. ii.1 Any physician or midwife in attendance upon a case of con- 
finement, or any other person charged with responsibility for reporting 
births, in the order named in section one of this act, who shall neglect or 
refuse to file a proper certificate of birth with the local registrar within 
the time required by this act, shall be deemed guilty of a misdemeanor, 
and, upon conviction thereof, shall be fined not less than five dollars nor 
more than fifty dollars. 
And any registrar who shall neglect or fail to enforce the provisions of 
this act in his district, or shall neglect or refuse to perform any of the 
duties imposed upon him by this act or by the instructions and direc- 
tions of the state registrar, shall be deemed guilty of a misdemeanor, 
and, upon conviction thereof, shall be fined not less than ten dollars or 
more than one hundred dollars. 
And any person who shall willfully alter any certificate of birth, or the 
copy of any certificate of birth on file in the office of the local registrar, 
shall be deemed guilty of a misdemeanor, and, upon conviction thereof, 
shall be fined not less than ten dollars or more than one hundred 
dollars. 
And any other person or persons who shall violate any of the provi- 
sions of this act, or shall willfully neglect or refuse to perform any duties 
imposed upon them by this act, shall be deemed guilty of a misdemeanor, 
and, upon conviction thereof, shall be fined not less than five dollars or 
more than one hundred dollars. 
Sec. 12. Local registrars are hereby charged with the strict and 
thorough enforcement of the provisions of this act in their districts, 
under the supervision and direction of the state registrar. And they 
shall make an immediate report to the state registrar of any violations 
of this law coming to their notice by observation or upon complaint of 
any person or otherwise. The state registrar is hereby charged with the 
thorough and efficient execution of the provisions of this act in every 
part of the state, and with supervisory power over local registrars to the 
end that all of its requirements shall be uniformly complied with. He 
shall have authority to investigate cases of irregularity or violation of 
law, personally or by accredited representative, and all registrars shall 
1 See note on page 21, relative to penalties in the shape of fines. II 
aid him, upon request, in such investigations. When he shall deem it 
necessary, he shall report cases of violation of any of the provisions of 
this act to the prosecuting attorney or official of the proper county or 
municipality, with a statement of the facts and circumstances, and when 
any such case is reported to them by the state registrar all prosecuting 
attorneys or officials acting in such capacity shall forthwith initiate and 
promptly follow up the necessary court proceedings against the parties 
responsible for the alleged violations of law. And upon request of the 
state registrar the attorney-general shall likewise assist in the enforce- 
ment of the provisions of this act. 
FORM B: LAW PROVIDING FOR THE REGISTRATION OF BIRTHS AND 
DEATHS 
Section i. That for the complete and proper registration of births 
and deaths, for legal, sanitary, and statistical purposes, there shall be, 
and hereby is, created and established a state bureau of vital statistics, 
to be under the immediate superintendence of a state registrar, who 
shall be a competent medical practitioner and vital-statistician, and who 
shall be appointed by the governor, by and with the advice and consent 
of the senate. And within thirty days from the date of taking effect 
of this act the governor shall appoint a state registrar, as herein pro- 
vided. The term of office of the state registrar shall be four years from 
the first day of January of the year in which he is appointed. 
SEC. 2. The state registrar shall receive an annual salary of [twenty- 
five hundred] dollars. And he may employ such clerical and other 
assistants as are necessary for the proper performance of the duties of 
the office, and fix their compensation within the amount appropriated 
therefor by the legislature. He shall designate, in writing, one of his 
assistants, who shall possess the powers and perform the duties of the 
state registrar during his absence, illness, or disability, or during a 
vacancy in the office. And he is hereby empowered to make, promul- 
gate, and enforce such rules and regulations as he may consider neces- 
sary to carry out the provisions of this act. 
Sec. 3. That for the purposes of this act the state shall be divided 
into registration districts as follows: Bach incorporated village and city 
and each township, exclusive of any incorporated village or city, shall 
constitute a primary registration district. 
Sec. 4. That the clerk of each township, village, or city shall be the 
local registrar in and for the township, village, or city of which he is 
clerk, and he shall perform all the duties of local registrar, as herein- 
after provided. And he shall immediately appoint, in writing, a deputy, 
who shall be authorized to act in his stead in case of absence, illness, or 
disability: Provided, That in cities where health officers at the date of 
this act are officiating as registrars of deaths under local ordinances, 
Be it enacted, etc. 12 
such health officers shall be continued as registrars in and for such cities. 
And when it may appear necessary for the convenience of the people in 
any township, the local registrar is hereby authorized, with the approval 
of the state registrar, to appoint one or more suitable and proper persons 
to act as subregistrars, who shall be authorized to receive certificates and 
to issue burial or removal permits in and for such portions of the town- 
ship as may be designated. And each subregistrar shall note the date 
each certificate was filed, over his signature, and forward all certificates 
to the registrar of the township within ten days, and in all cases before 
the third day of the following month: Provided, That all subregistrars 
shall be subject to the supervision and control of the state registrar, and 
may be by him removed for neglect or failure to perform their duties in 
accordance with the provisions of this act or the rules and regulations of 
the state registrar, and they shall be liable to the same penalties for 
neglect of duties as the local registrar. 
SEC. 5. That all births that occur in the state shall be immediately 
registered in the districts in which they occur, as hereinafter provided. 
Sec. 6. That the body of any person whose death occurs in the state 
shall not be interred, deposited in a vault or tomb, cremated, or other- 
wise disposed of, or removed from or into any registration district until 
a permit for burial or removal shall have been properly issued by the 
registrar of the registration district in which the death occurs. And no 
such burial or removal permit shall be issued by any registrar until a 
complete and satisfactory certificate and return of the death has been 
filed with him, as hereinafter provided: Provided, That in case of any 
death outside of the state, where the body is accompanied by a removal 
or transit permit issued in accordance with the law and the health regu- 
lations in force where the death occurred, such removal or transit permit 
may be accepted as of the same authority as a permit from the local 
registrar. 
Sec. 7. Stillborn children, or those dead at birth, shall be registered 
as births and also as deaths, and a certificate of both the birth and the 
death shall be filed with the local registrar in the usual form and manner, 
the certificate of birth to contain, in place of the name of the child, the 
word "stillbirth." The medical certificate of the cause of death shall 
be signed by the attending physician, and shall state the cause of death 
as "stillborn"; with the cause of the stillbirth, if known; whether a 
premature birth; and, if born prematurely, the period of uterogestation 
in months, if known; and a burial or removal permit in usual form 
shall be required. 
SEC. 8. That the certificate of death shall be of the standard form 
recommended by the Bureau of the Census and the American Public 
Health Association, and shall contain the following items: 
(1) Place of death, including state, county, township or town, city 
or village. If in a city, the ward, street, and house number. If in a PLACE OF DEATH 
BUREAU OK THE CENSUS 
STANDARD CERTIFICATE OF" DEATH. 
N. B.-Every item of information should be carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should state 
CAUSE OF DEATH in plain terms, that it may be properly classified. The "Special Information" for persons dying 
away from home should be given in every instance. 
County of 
Township of 
or 
Village of - 
or 
City of 
[If death occurs away from 
USUAL RESIDENCE 
give facts called for under 
" Special Information."] 
Registered No. 
(No- 
...St.;. 
.Ward) 
[If death occurred in 
a Hospital or Institution, 
give its NAME instead 
of street and number.] 
WRITE PLAINLY, WITH UNFADING INK-THIS IS A PERMANENT RECORD. 
FULL NAME 
PERSONAL AND STATISTICAL PARTICULARS 
MEDICAL CEliTIFICATE OF DEATH 
MARGIN RESERVED FOR BINDING. 
SEX 
COLOR 
DATE OF DEATH 
DATE OF BIRTH 
(Month) 
(Day) 
.190- 
(Year) 
(Month) 
(Day) 
(Year) 
I HEREBY CERTIFY, That I attended deceased from 
190to 190 
that I last saw halive on 190, 
and that death occurred, on the date stated above, at 
M. The CAUSE OF DEATH was as follows: 
AGE 
-years, 
- months, 
days 
SINGLE, MARRIED, 
WIDOWED, OR DIVORCED 
BIRTHPLACE 
(State or country) 
NAME OF 
FATHER 
BIRTHPLACE 
OF FATHER 
(State or country) 
(duration) 
DAYS 
Contributory 
MAIDEN NAME 
OF MOTHER 
. (duration) - 
DAYS 
BIRTHPLACE 
OF MOTHER 
(State or country) 
(Signed) 
M. D. 
SPECIAL INFORMATION only for Hospitals, Institutions, Transients, 
or Recent Residents. 
190 
(Address) 
OCCUPATION 
THE ABOVE STATED PERSONAL PARTICULARS ARE TRUE TO THE 
BEST OF MY KNOWLEDGE AND BELIEF 
Former or 
Usual Residence.- 
How long at 
Place of Death ?. 
-Days 
Where was disease contracted, 
If not at place of death? 
(Informant) 
PLACE OF BURIAL OR REMOVAL 
DATE OF BURIAL 
8-209. 
V. S. No. 98. 
Filed 
(Address) 
.190- 
190. 
UNDERTAKER 
ADDRESS 
C-277 
Registrar 13 
hospital or other institution, the name of the same to be given instead 
of the street and house number. 
(2 ) bull name of decedent. If an unnamed child, the surname, pre- 
ceded by "unnamed." 
(3) Sex. 
(4) Color or race, as white, black (negro or negro descent), Indian, 
Chinese, Japanese, or other. 
(5) Conjugal condition, as single, married, widowed, or divorced. 
(6) Date of birth, including the year, month, and day. 
(7) Age, in years, months, and days. 
(8) Place of birth: state or foreign country. 
(9) Name of father. 
(10) Birthplace of father: state or foreign country. 
(11) Maiden name of mother. 
(12) Birthplace of mother: state or foreign country. 
(13) Occupation: the occupation to be reported of any person who 
had any remunerative employment, women as well as men. 
(14) Signature and address of informant. 
(15) Date of death, including the year, month, and day. 
(16) Statement of medical attendance on decedent, fact and time of 
death, including the time last seen alive. 
(17) Cause of death, including the primary and immediate causes, and 
contributory causes or complications, if any, and the duration of each. 
(18) Signature and address of physician or official making the medi- 
cal certificate. 
(19) Special information concerning deaths in hospitals and institu- 
tions and of persons dying away from home, including the former or 
usual residence, length of time at place of death, and place where the 
disease was contracted. 
(20) Place of burial or removal. 
(21) Date of burial or removal. 
(22) Signature and address of undertaker. 
(23) Official signature of registrar, with date when certificate was filed 
and registered number. 
The personal and statistical particulars (items 1 to 13) shall be 
authenticated by the signature of the informant, who may be any 
competent person acquainted with the facts. 
The statement of facts relating to the disposition of the body shall be 
signed by the undertaker or person acting as such. 
The medical certificate shall be made and signed by the physician, if 
any, last in attendance on the deceased, who shall specify the time in 
attendance, the time he last saw the deceased alive, and the hour of the 
day at which death occurred. And he shall further state the cause of 
death so as to show the course of disease or sequence of causes resulting 
in death, giving the primary and immediate causes, and also the con- 14 
tributory causes, if any, and the duration of each. Indefinite and unsat- 
isfactory terms indicating only symptoms of disease or conditions 
resulting from disease will not be held sufficient for issuing a burial or 
removal permit, and any certificate containing only such terms, as 
defined by the state registrar, shall be returned to the physician for cor- 
rection and definition. Causes of death which may be the result of 
either disease or violence shall be carefully defined, and, if from violence, 
its nature shall be stated, and whether accidental, suicidal, or homicidal. 
And in case of deaths in hospitals, institutions, or away from home, the 
physician shall furnish the information required under this head (item 
19), and shall state where, in his opinion, the disease was contracted. 
And the cause of death and all other facts required shall in all cases 
be stated in accordance with the rules and regulations of the state 
registrar. 
SEC. 9. In case of any death occurring without medical attendance, 
it shall be the duty of the undertaker to notify the registrar of such 
death, and when so notified the registrar shall inform the local health 
officer and refer the case to him for immediate investigation and certifi- 
cation prior to issuing the permit: Provided, That when the local health 
officer is not a qualified physician, or when there is no such official, and 
in such cases only, the registrar is authorized to make the certificate and 
return from the statement of relatives or other persons having adequate 
knowledge of the facts: Provided further, That if the circumstances of 
the case render it probable that the death was caused by unlawful or 
suspicious means, the registrar shall then refer the case to the coroner 
for his investigation and certification. 
Sec. io. The undertaker, or person acting as undertaker, shall be 
responsible for obtaining and filing the certificate of death with the 
registrar and securing a burial or removal permit prior to any disposi- 
tion of the body. He shall obtain the personal and statistical particu- 
lars required from the person best qualified to supply them over the 
signature and address of his informant. He shall then present the cer- 
tificate to the attending physician, if any, or to the health officer or 
coroner, as directed by the registrar, for the medical certificate of the 
cause of death and other particulars necessary to complete the record, 
as specified in section eight. And he shall then state the facts required 
relative to the date and place of burial over his signature and with his 
address, and present the completed certificate to the registrar within the 
time limit, if any, designated by the local board of health for the issu- 
ance of a burial or removal permit. The undertaker shall deliver the 
burial permit to the sexton or person in charge of the place of burial 
before interring the body, or attach the removal permit to the box con- 
taining the corpse, when shipped by any transportation company, to 
accompany same to destination, when it shall be accepted by the sexton 
as authority for the interment of the body. 15 
Sec. ii. If the interment or other disposition of the body is to be 
made in the registration district in which the death occurred, the word- 
ing of the burial permit may be limited to a statement by the registrar, 
and over his signature, that a satisfactory certificate of death having 
been filed with him as required by law, permission is granted to inter, 
remove, or otherwise dispose of the body of the deceased, stating the 
name, age, sex, cause of death and other necessary details upon the form 
prescribed by the state registrar. But in case the interment or other 
disposition of the body is to be made in some registration district other 
than that in which the death occurred, a complete copy of the certificate 
of death shall be attached to and made a part of the permit. 
SEC. i2. No sexton or person in charge of any premises in which 
interments are made shall inter or permit the interment of any body 
unless it is accompanied by a burial, removal, or transit permit as herein 
provided. And each sexton or person in charge of any burial ground 
shall indorse upon the permit the date of interment, over his signature, 
and shall return all permits, so indorsed, to the local registrar of his 
district within ten days from the date of interment, or within the time 
fixed by the local board of health. He shall also keep a record of all 
interments made in the premises under his charge, stating the name of 
the deceased person, place of death, date of burial, and name and address 
of the undertaker, which record shall at all times be open to public 
inspection. 
SEC. 13. It shall be the duty of the attending physician or midwife 
to file a certificate of birth, properly and completely filled out, giving all 
of the particulars required by this act, with the local registrar of the 
district in which the birth occurred, within three days after the date of 
birth. And if there be no attending physician or midwife, then it shall 
be the duty of the father of the child, householder or owner of the 
premises, manager or superintendent of public or private institution in 
which the birth occurred, to file said certificate of birth with the local 
registrar within three days after the birth. 
SEC. 14. The certificate of birth shall be of the standard form recom- 
mended by the Bureau of the Census, and shall contain the following 
items: 
(1) Place of birth, including state, county, township or town, village 
or city. If in a city, the ward, street, and house number. If in a hos- 
pital or other institution, the name of the same to be given instead of 
the street and house number. 
(2) Full name of child. If the child dies without a name before the 
certificate is filed, enter the words "died unnamed.'' If the living 
child has not been named at the date of filing the certificate of birth, the 
space for "full name of child'' is to be left blank, to be filled out 
subsequently by a supplemental report as hereinafter provided. 
(3) Sex of child. 16 
(4) Whether a twin, triplet, or other plural birth. A separate certifi- 
cate shall be required for each child in a case of plural birth, giving 
number of child in order of birth. 
(5) Whether legitimate or illegitimate. 
(6) Full name of father. 
(7) Residence of father. 
(8) Color or race of father. 
(9) Birthplace of father. 
(10) Age of father at last birthday, in years. 
(11) Occupation of father. 
(12) Maiden name of mother, in full. 
(13) Residence of mother. 
(14) Color or race of mother. 
(15) Birthplace of mother. 
(16) Age of mother at last birthday, in years. 
(17) Occupation of mother. 
(18) Number of child of this mother, and number of children of this 
mother now living. 
(19) Certificate of attending physician or midwife as to attendance at 
birth, including statement of year, month, day, and hour of birth, and 
whether the child was alive or dead at birth. This certificate shall be 
signed by the attending physician or midwife, with date of signature and 
address. If there was no physician or midwife in attendance, then the 
father of the child, householder or owner of the premises, or manager or 
superintendent of public or private institution, or other competent person 
whose duty it shall become to file the certificate of birth as required by 
section thirteen of this act, shall draw a line through the words "I hereby 
certify that I attended the birth of above child," and shall write in lieu 
thereof the words ''no physician or midwife," filling out the remainder 
of the certificate in regard to the year, month, day, and hour of birth, 
and signing the certificate as father, householder, owner of premises, 
manager or superintendent of institution, as the case may be, with his 
address. 
(20) Exact date of filing in office of local registrar, attested by his 
official signature and registered number of birth, as hereinafter pro- 
vided. 
All certificates, either of birth or death, shall be written legibly in 
unfading black ink, and no certificate shall be held to be complete and 
correct that does not supply all of the items of information called for 
therein or satisfactorily account for their omission. 
SEC. 15. When any certificate of birth of a living child is presented 
without statement of the given name, then the local registrar shall make 
out and deliver to the informant a special blank for the supplemental 
report of the given name of the child, which shall be filled out as directed 
and returned to the registrar as soon as the child shall be named. The 
original certificate of birth shall not be considered complete until T7 
the supplemental report is filed or the blank returned with the state- 
ment " died unnamed." 
Sec. i6. Every physician, midwife, and undertaker shall, without 
delay, register his or her name, address, and occupation with the local 
registrar of the district in which he or she resides, or may hereafter 
establish a residence, and shall thereupon be supplied by the local regis- 
trar with a copy of this act, together with such rules and regulations as 
may be prepared by the state registrar relative to its enforcement. 
Within thirty days after the close of each calendar year, each local 
registrar shall make a return to the state registrar of all physicians and 
midwives who have been registered in his district during the whole or 
any part of the preceding calendar year, and in certifying names for pay- 
ment for certificates of birth filed,1 the state registrar shall not include 
any physicians or midwives who have not complied with the require- 
ments of this section: Provided, That no fee or other compensation shall 
be charged by local registrars to physicians, midwives, or undertakers 
for registering their names under this section, or making returns thereof 
to the state registrar. 
Sec. 17. All superintendents or managers or other persons in charge 
of hospitals, lying-in or other institutions, public or private, to which 
persons resort for treatment of disease, confinement, or are committed by 
process of law, are hereby required to make a record of all of the personal 
and statistical particulars relative to the inmates in their institutions at 
the date of approval of this act that are required in the form of certificate 
herein provided for, as directed by the state registrar. And thereafter 
such record shall be by them made for all future inmates at the time of 
admission. And in case of persons admitted or committed for medical 
treatment of disease the physician in charge shall specify, for entry in 
the record, the nature of the disease and where, in his opinion, it was 
contracted. The personal particulars and information required by this 
section shall be obtained from the individual himself, if it is practicable 
to do so, and when they can not be so obtained they shall be secured in 
as complete a manner as possible from the relatives, friends, or other 
persons acquainted with the facts. 
Sec. 18. [Provision for payment for return of births omitted. See 
note to section seven, Form A, page 9. That section may be inserted 
here if such payment is considered desirable.] 
Sec. 19. The state registrar shall prepare, print, and supply to all 
registrars all blanks and forms used in registering, recording, and pre- 
serving the returns, or in otherwise carrying out the purposes of this 
act, and shall prepare and issue such detailed instructions as may be 
required to secure the uniform observance of its provisions and the main- 
tenance of a perfect system of registration. And no other blanks shall 
1 See note on payment for return of births, page 9. 18 
be used than those supplied by the state registrar. He shall carefully 
examine the certificates received monthly from the local registrars, and 
if any such are incomplete or unsatisfactory he shall require such further 
information to be furnished as may be necessary to make the record 
complete and satisfactory. And all physicians, midwives, informants, 
or undertakers connected with any case, and all other persons having 
knowledge of the facts, are hereby required to furnish such information 
as they may possess regarding any birth or death, upon demand of the 
state registrar, in person, by mail, or through the local registrar. He 
shall further arrange, bind, and permanently preserve the certificates in 
a systematic manner, and shall prepare and maintain a comprehensive 
and continuous card index of all births and deaths registered, the cards 
to show the name of child or deceased, place and date of birth or death, 
number of certificate, and the volume in which it is contained. He 
shall inform all registrars what diseases are to be considered as infec- 
tious, contagious, or communicable and dangerous to the public health, 
as decided by the state board of health, in order that when deaths occur 
from such diseases proper precautions may be taken to prevent the 
spreading of dangerous diseases. 
SEC. 20. That it shall be the duty of the local registrar to supply 
blank forms of certificates to such persons as require them. And he 
shall carefully examine each certificate of birth or death when presented 
for record to see that it has been made out in accordance with the pro- 
visions of this act and the instructions of the state registrar, and if any 
certificate of death is incomplete or unsatisfactory it shall be his duty to 
call attention to the defects in the return and to withhold issuing the 
burial or removal permit until they are corrected. If the certificate of 
death is properly executed and complete, he shall then issue a burial or 
removal permit to the undertaker: Provided, That in case the death 
occurred from some disease that is held by the state board of health to 
be infectious, contagious, or communicable and dangerous to the public 
health, no permit for the removal or other disposition of the body shall 
be granted by the registrar except under such conditions as may be pre- 
scribed by the state and local boards of health. If a certificate of birth 
is incomplete he shall immediately notify the informant and require him 
to supply the missing items if they can be obtained. He shall then num- 
ber consecutively the certificates of birth and of death in two separate 
series, beginning with ' ' number one ' ' for the first birth and the first death 
in each calendar year, and sign his name as registrar in attest of the date 
of filing in his office. He shall also make a complete and accurate copy 
of each birth and death certificate registered by him, upon a form identi- 
cal with the original certificate, to be filed and permanently preserved in 
his office as the local record of such death, in such manner as directed 
by the state registrar. And he shall, on the fifth day of each month, 
transmit to the state registrar all original certificates registered by him 
during the preceding month. And if no births or no deaths occurred in T9 
any month he shall, on the fifth day of the following month, report that 
fact to the state registrar in such manner as the state registrar shall 
direct. 
SEC. 2i. Each local registrar shall be entitled to be paid the sum of 
[twenty-five] cents for each birth and each death certificate properly 
and completely made out and registered with him, and correctly copied 
and duly returned by him to the state registrar, as required by this act: 
Provided, That in cities in which the city clerk or health officer, acting 
as registrar, receives a fixed salary in lieu of fees no further compensa- 
tion shall be paid for the duties required by this act. And in case no 
births or no deaths were registered during any month, the local registrar 
shall be entitled to be paid the suln of [twenty-five] cents for each report 
to that effect promptly made in accordance with the directions of the 
state registrar. All amounts payable to registrars under provisions of 
this section shall be paid by the treasurer of the county in which the 
registration districts are located upon certification by the state registrar. 
And the state registrar shall annually certify to the treasurers of the 
several counties the number of births and deaths registered, with the 
names of the local registrars and the amounts due each at the rates fixed 
herein. 
Sec. 22. The state registrar shall, upon request, furnish any appli- 
cant a certified copy of the record of any birth or death registered under 
provisions of this act, for the making and certification of which he shall 
be entitled to a fee of [fifty] cents, to be paid by the applicant. And any 
such copy of the record of a birth or death, when properly certified by 
the state registrar to be a true copy thereof, shall be prima facie evi- 
dence in all courts and places of the facts therein stated. For any 
search of the files and records, when no certified copy is made, the state 
registrar shall be entitled to a fee of [fifty] cents for each hour or frac- 
tional hour of time of search, to be paid by the applicant. And the 
state registrar shall keep a true and correct account of all fees by him 
received under these provisions, and turn the same over to the state 
treasurer. 
Sec. 23.1 If any physician who was in medical attendance upon any 
deceased person at the time of death shall neglect or refuse to make out 
and deliver to the undertaker, sexton, or other person in charge of the 
interment, removal, or other disposition of the body, upon request, the 
medical certificate of cause of death hereinbefore provided for, he shall be 
deemed guilty of a misdemeanor, and, upon conviction thereof, shall be 
fined not less than five dollars nor more than fifty dollars. And if any 
physician shall willfully or knowingly make a false certification of the 
cause of death in any case, he shall be deemed guilty of a misdemeanor, 
and, upon conviction thereof, shall be fined not less than fiftv dollars 
nor more than two hundred dollars. 
'See note on page 21, relative to penalties in the shape of fines. 20 
And any physician or midwife in attendance upon a case of confine- 
ment, or any other person charged with responsibility for reporting 
births, in the order named in section thirteen of this act, who shall neg- 
lect or refuse to file a proper certificate of birth with the local registrar 
within the time required by this act, shall be deemed guilty of a misde- 
meanor, and, upon conviction thereof, shall be fined not less than five 
dollars nor more than fifty dollars. 
And if any undertaker, sexton, or other person acting as undertaker 
shall inter, remove, or otherwise dispose of the body of any deceased 
person without having received a burial or removal permit as herein 
provided, he shall be deemed guilty of a misdemeanor, and, upon con- 
viction thereof, shall be fined not less than twenty dollars nor more than 
one hundred dollars. 
And any registrar, deputy registrar, or subregistrar who shall neglect 
or fail to enforce the provisions of this act in his district, or shall neglect 
or refuse to perform any of the- duties imposed upon him by this act or 
by the instructions and directions of the state registrar, shall be deemed 
guilty of a misdemeanor, and, upon conviction thereof, shall be fined 
not less than ten dollars nor more than one hundred dollars. 
And any person who shall willfully alter any certificate of birth or death, 
or the copy of any certificate of birth or death, on file in the office of the 
local registrar, shall be deemed guilty of a misdemeanor, and, upon con- 
viction thereof, shall be fined not less than ten dollars nor more than 
one hundred dollars or be imprisoned in the county jail not exceeding 
sixty days, or suffer both fine and imprisonment, in the discretion of the 
court. 
And any other person or persons who shall violate any of the pro- 
visions of this act, or shall willfully neglect or refuse to perform any 
duties imposed upon them by the provisions of this act. shall be deemed 
guilty of a misdemeanor, and, upon conviction thereof, shall be fined not 
less than five dollars nor more than one hundred dollars. 
And any transportation company or common carrier transporting or 
carrying, or accepting through its agents or employees for transportation 
or carriage, the body of any deceased person without an accompanying 
permit issued in accordance with the provisions of this act shall be 
deemed guilty of a misdemeanor, and, upon conviction thereof, shall be 
fined not less than fifty dollars nor more than two hundred dollars: Pro- 
vided, That in case the death occurred outside of the state and the body 
is accompanied by a certificate of death, burial, or removal, or transit 
permit issued in accordance with the law or board of health regulations 
in force where the death occurred, such death certificate, burial, or 
removal, or transit permit may be held to authorize the transportation 
or carriage of the body into or through the state. 
SEC. 24. Local registrars are hereby charged with the strict and 
thorough enforcement of the provisions of this act in their districts, 21 
under the supervision and direction of the state registrar. And they 
shall make an immediate report to the state registrar of any violations of 
this law coming to their notice by observation or upon complaint of any 
person, or otherwise. The state registrar is hereby charged with the 
thorough and efficient execution of the provisions of this act in every 
part of the state, and with supervisory power over local registrars to the 
end that all of the requirements shall be uniformly complied with. He 
shall have authority to investigate cases of irregularity or violation of 
law, personally or by accredited representative, and all registrars shall 
aid him, upon request, in such investigations. When he shall deem it 
necessary, he shall report cases of violation of any of the provisions 
of this act to the prosecuting attorney or official of the proper county or 
municipality, with a statement of the facts and circumstances, and when 
any such case is reported to them by the state registrar, all prosecuting 
attorneys, or officials acting in such capacity, shall forthwith initiate and 
promptly follow up the necessary court proceedings against the parties 
responsible for the alleged violations of law. And upon request of the 
state registrar the attorney-general shall likewise assist in the enforce- 
ment of the provisions of this act. 
Sec. 25. All laws and parts of laws inconsistent with the provisions 
of this act are hereby repealed. 
Note.-The penalties specified in section twenty-three are generally limited to 
fines. They may be changed to specify an alternative of imprisonment of from 
thirty to sixty days, or both fine and imprisonment, at discretion of the court, if this 
is considered desirable. It is suggested that, if practicable, fines collected for viola- 
tions of this law should be credited to the funds available for paying expenses of 
registration 
FORM C: CONDENSED LAW FOR REGISTRATION OF BIRTHS AND 
DEATHS 
Section i. That for the complete and proper registration of births 
and deaths, for legal, sanitary, and statistical purposes, there shall be, 
and hereby is, created and established a state bureau of vital statistics, 
to be under the immediate superintendence of a state registrar, who shall 
be a competent medical practitioner and vital-statistician, and who shall 
be appointed by the governor, by and with the advice and consent of 
the senate. And within thirty days from the date of taking effect of 
this act the governor shall appoint a state registrar, as herein provided. 
The term of office of the state registrar shall be four years from the first 
day of January of the year in which he is appointed. 
Sec. 2. The state registrar shall receive an annual salary of [twenty- 
five hundred] dollars. And he may employ such clerical and other 
assistants as are necessary for the proper performance of the duties of 
the office. And he is hereby empowered to make, promulgate, and 
enforce such rules and regulations as he may consider necessary to carry 
out the provisions of this act. 22 
Sec. 3. That for the purposes of this act the state shall be divided 
into registration districts as follows: Each incorporated village and city, 
and each township, exclusive of any incorporated village or city, shall 
constitute a primary registration district. 
SEC. 4. That the clerk of each township, village, or city shall be the 
local registrar in and for the township, village, or city of which he is 
clerk, and he shall perform all the duties of local registrar, as hereinafter 
provided: Provided," That in cities where health officers at the date of 
this act are officiating as registrars of deaths under local ordinances, 
such health officers shall be continued as registrars in and for such 
cities. And when it may appear necessary for the convenience of the 
people in any township, the local registrar is hereby authorized, with 
the approval of the state registrar, to appoint one or more suitable and 
proper persons to act as subregistrars, who shall be authorized to receive 
certificates and to issue burial or removal permits in and for such portions 
of the township as may be designated. 
Sec. 5. That all births in the state shall be immediately registered in 
the districts in which they occur, as hereinafter provided. 
Sec. 6. That the body of any person whose death occurs in the state 
shall not be interred, or otherwise disposed of, or removed from or into 
any registration district until a permit for burial or removal shall have 
been properly issued by the registrar of the district in which the death 
occurs. And no such burial or removal permit shall be issued by any 
registrar until a complete and satisfactory certificate of the death has 
been filed with him, as hereinafter provided. Stillborn children, or 
those dead at birth, shall be registered as births and also as deaths, and 
a certificate of both the birth and the death shall be filed in the usual 
manner. 
SEC. 7. That the forms of certificates employed in registering births 
and deaths under this act shall be the standard forms recommended by 
the Bureau of the Census and the American Public Health Association. 
Sec. 8. That the undertaker, or person acting as undertaker, shall 
be responsible for obtaining and filing the certificate of death with the 
registrar, and securing a burial or removal permit prior to any disposi- 
tion of the body. He shall obtain the personal and statistical particu- 
lars required from the person best qualified to supply them, and present 
the certificate to the attending physician for the medical certificate of the 
cause of death, and he shall then present the completed certificate to the 
registrar to secure the burial or removal permit. The undertaker shall 
deliver the burial permit to the sexton, or person in charge of the place 
of burial, before interring the body. The medical certificate shall be 
made and signed by the physician, if any, last in attendance on the 
deceased, who shall specify the time in attendance, the time he last saw 
the deceased alive, and the hour of the day at which death occurred. 23 
And the cause of death, and all other facts required, shall in all cases be 
stated in accordance with the rules and regulations of the state registrar. 
Sec. 9. In case of any death occurring without medical attendance, 
it shall be the duty of the undertaker to notify the registrar of such 
death, and, when so notified, the registrar shall inform the local health 
officer or coroner and refer the case to him for immediate investigation 
and certification prior to issuing the permit. 
Sec. io. The certificate of birth shall be made and filed by the attend- 
ing physician or midwife within three days after the date of birth. And 
if there be no attending physician or midwife, then it shall be the duty 
of the father of the child, householder or owner of the premises, or the 
head of the hospital or institution in which the birth occurred, to make 
and file the certificate within three days after birth. And if the child 
has not been named at the time the certificate is filed, such supplemental 
report shall be made as may be required under the rules and regulations 
of the state registrar. 
Sec. 11. No sexton or person in charge of any premises in which 
interments are made shall inter or permit the interment of any body 
unless it is accompanied by a burial permit as herein provided. And he 
shall indorse upon the permit the date of interment, over his signature, 
and return all permits to the local registrar of his district within ten days 
from the date of interment. He shall also keep a record of all inter- 
ments made in the premises under his charge, stating the name of the 
deceased person, place of death, date of burial, and name and address of 
the undertaker, which record shall at all times be open to public 
inspection. 
Sec. 12. The state registrar shall prepare, print, and supply to all 
registrars all blanks and forms used in registering, recording, and pre- 
serving the returns or in otherwise carrying out the purposes of this 
act, and shall prepare and issue such rules and regulations as may be 
required to secure the uniform observance of its provisions and the main- 
tenance of a perfect system of registration. He shall arrange, bind, and 
permanently preserve the certificates in a systematic manner, and shall 
prepare and maintain a comprehensive and continuous card index of all 
births and deaths registered. He shall inform all registrars what dis- 
eases are to be considered as infectious, contagious, or communicable, 
and dangerous to the public health, as decided by the state board of 
health, in order that when deaths occur from such diseases proper pre- 
cautions may be taken to prevent the spreading of dangerous diseases. 
And he shall annually certify to the treasurers of the several counties 
the number of births and deaths registered, and the names of the local 
registrars, with the amounts due each, at the rate fixed herein.1 
SEC. 13. That every physician, midwife, and undertaker shall without 
1 See note to section 7, Form A, page 9, as to payment of individuals for report- 
ing births. 24 
delay register his or her name, address, and occupation with the local 
registrar of the district in which he or she resides, or may hereafter 
acquire residence, and shall thereupon be furnished by the registrar a 
copy of this act, and such rules and regulations as may be prepared by 
the state registrar relative to its enforcement. 
SEC. 14. All superintendents or managers, or other persons in charge 
of hospitals or lying-in institutions, public or private, to which persons 
resort for treatment of disease, confinement, or are committed by process 
of law, are hereby required to make a record of all the personal and 
statistical particulars relative to the inmates in their institutions at the 
date of approval of this act, that are required in the form of certificate 
herein provided for, as directed by the state registrar. And thereafter 
such records shall be by them made, for all future inmates, at the time 
of admission. 
Sec. 15. That each local registrar shall be entitled to be paid the sum 
of [twenty-five] cents for each birth and each death certificate completely 
and properly made out and filed with him, to be paid by the treasurer of 
the county upon certification by the state registrar. He shall supply 
blank forms of certificates to such persons as require them, and shall 
carefidly examine the certificates presented for record and require them 
to be properly made out. And he shall keep such records and make 
such returns to the state bureau as may be required by the rules and 
regulations of the state registrar. 
SEC. 16.1 That if any attending physician shall refuse or neglect to 
make the medical certificate of death herein required of him, he shall be 
deemed guilty of a misdemeanor, and, upon conviction thereof, shall be 
fined not less than five dollars nor more than fifty dollars. And if any 
physician shall willfully or knowingly make a false certification of the 
cause of death in any case he shall be deemed guilty of a misdemeanor, 
and, upon conviction thereof, shall be fined not less than fifty dollars 
nor more than two hundred dollars. 
And any physician or midwife, or any other person charged with 
responsibility for reporting births, in the order named in section ten of 
this act, who shall refuse or neglect to make out and file the certificate 
of birth herein required, shall be deemed guilty of a misdemeanor, and, 
upon conviction thereof, shall be fined not less than five dollars nor 
more than fifty dollars. 
And any undertaker, sexton, or other person who shall inter, remove, 
or otherwise dispose of the body of any deceased person, without the 
permit herein provided for, shall be deemed guilty of a misdemeanor, 
and, upon conviction thereof, shall be fined not less than twenty dollars 
nor more than one hundred dollars. 
And any registrar who shall neglect or fail to enforce the provisions" 
1 See note to section 23, Form B, page 21, as to penalties in the shape of fines. 25 
of this act in his district, or shall refuse or neglect to perform any of the 
duties imposed upon him by this act or by the rules and regulations of 
the state registrar, shall be deemed guilty of a misdemeanor, and, upon 
conviction thereof, shall be fined not less than ten dollars nor more than 
one hundred dollars. 
And any other person or persons who shall violate any of the pro- 
visions of this act, or any of the rules and regulations formulated there- 
under by the state registrar, shall be deemed guilty of a misdemeanor, 
and, upon conviction thereof, shall be fined not less than five dollars 
nor more than one hundred dollars. 
Sec. 17. Local registrars are hereby charged with the strict and 
thorough enforcement of the provisions of this act in their districts, 
under the supervision and direction of the state registrar. And they 
shall make an immediate report to the state registrar of any violations 
of this law coming to their notice by observation or upon complaint of 
any person or otherwise. The state registrar is hereby charged with 
the thorough and efficient execution of the provisions of this act in every 
part of the state, and with supervisory power over local registrars, to 
the end that all of the requirements shall be uniformly complied with. 
He shall have authority to investigate cases of irregularity or violation 
of law, personally or by accredited representative, and all registrars shall 
aid him, upon request, in such investigations. When he shall deem it 
necessary he shall report cases of violation of any of the provisions of 
this act to the prosecuting attorney or official of the proper county or 
municipality, with a statement of the facts and circumstances, and when 
any such case is reported to them by the state registrar all prosecuting 
attorneys or officials acting in such capacity shall forthwith initiate and 
promptly follow up the necessary court proceedings against the parties 
responsible for the alleged violations of law. And upon request of the 
state registrar the attorney-general shall likewise assist in the enforce- 
ment of the provisions of this act. 
Sec. 18. All laws and parts of laws inconsistent with the provisions 
of this act are hereby repealed. INFORMATION FOR REGISTRATION OFFICIALS 
STRICT ENFORCEMENT OF LAW ESSENTIAL 
The suggestion that laws for the registration of births and deaths 
should be enacted by each of the states presupposes that public policy 
demands and public opinion will support the rigid enforcement of such 
laws, the object being to secure the proper return of every birth and 
every death-not merely such as may be voluntarily returned without 
recourse to the compulsory provisions. Unless these conditions exist, 
the suggested legislation should be postponed until its necessity is clearly 
recognized and its enactment justified. 
When the law is sufficiently specific in its provisions, and provides 
adequate penalties that can be enforced by the courts for the violation 
of any of them, the responsibility for failure to secure complete and 
proper returns must rest upon the administrative officials. These should 
be and are, in the form of law presented, held to an exact performance 
of every official duty under similar penalties for neglect. 
The principal reason for the failure of complete registration in some of 
the states and cities which now have adequate laws lies in the fact that 
the officials for various reasons are disinclined to coerce delinquents, 
thereby putting a premium upon delinquency and participating in the 
offense. The great majority of local registrars will perform their duties 
faithfully and well when properly instructed and supervised, and the 
great majority of physicians, undertakers, midwives, and other persons 
primarily responsible for making the returns will cheerfully conform to 
the requirements, and need no coercion. There will always be, however, 
a small minority who recognize no obligations and perform no duties that 
they are not compelled to. It is these persons who make trouble, create 
deficiencies in the returns, and impair the value of the records. It is 
from this class of persons that returns are hardest to get and most neces- 
sary to obtain, and it is against them that the compulsory features of the 
law are directed. 
If existing laws do not vest in the officials the authority to demand 
and the power to secure proper returns, they should be amended in such 
particulars. 
The form of law (Form B) for the registration of births and deaths 
given on pages n to 21 provides for the immediate registration of 
both; specifies the facts to be stated to constitute a complete and satisfac- 
tory return; prohibits the removal or burial of any corpse without author- 
(26) 27 
ity of a properly issued permit, based upon a satisfactory certificate of the 
death; imposes the obligation upon physicians, midwives, undertakers, 
and others to make proper returns in each and every case; makes it the 
duty of the local registrar to see that each certificate meets all the require- 
ments of the law and to initiate proceedings against any person neglect- 
ing or refusing to make the returns required of him; makes it the duty 
of the state registrar to see that local registrars discharge all their duties 
in a proper manner, and provides penalties for violation of its provisions 
by any person charged with any responsibility thereunder. Complete 
success can be achieved only by a strict enforcement of the law. 
THE STANDARD CERTIFICATE OF BIRTH 
The Standard Certificate of Birth, a copy of which accompanies this 
circular, was prepared by the Committee on Demography of the Ameri- 
can Public Health Association and is exactly adaptable to the same sys- 
tem of recording, filing, and treatment for statistical and other purposes 
as the Standard Certificate of Death. 
It is somewhat smaller than the standard certificate of death, being 
6 by 8 inches, including i-incli margin for binding, so that the size 
distinguishes it immediately from the certificate of death. Where both 
forms of certificates are being constantly received and are given separate 
serial numbers and must be assorted for filing, the difference in size 
facilitates the processes and prevents confusion. 
The certificate exhibits the order and arrangement of the details which 
the law requires to be stated for each birth, as given below. 
Place of birth.-Under the state system of registration provided by the 
law, the certificate is printed and supplied by the state registrar and is 
to be used in all parts of the state. The " place of birth," therefore, 
means the registration district in which the birth occurs and is recorded. 
This is indicated by the name of the county, town or township, city or 
village, corresponding to such district. Only one of these need be given. 
If the birth occurred in a city, the street, house number, and ward should 
be stated, and if it occurred in a hospital or other institution, the name 
of the institution should be given instead of the street and number. 
The exact place of birth is important for every purpose. 
Full name of child.-This is necessary for identification. If the given 
name has not been selected at the time of the return, provision is made 
for securing it through a supplemental report. 
Sex of child.-Male or female. 
Plural births.-If one of twins, triplets, or other plural birth, the fact 
is to be stated. In all such cases a separate certificate is required for 
each child, and its number in the order of delivery at birth must be stated. 
Matters that are most important to the individual sometimes turn upon 
the question of precedence in case of plural births, and in such cases 28 
each certificate should furnish the evidence that the specified child was 
first, second, or third, etc., as the case may be. 
Legitimacy.-The question should be answered by writing "yes" 
or " no." 
Date of birth.-Give the month, day, and year, as called for. In 
addition, the certificate of the physician or midwife will show the exact 
time of day. 
Information concerning father of child.- The full name, place of resi- 
dence, color, age, and occupation of the father are equally essential. 
Under "birthplace," the exact place of birth should be stated, if known. 
Only state or country are essential for statistical purposes, but for estab- 
lishing the identity of the father and the relationship of the individual 
to others, through him, the most exact information will best serve this 
purpose. 
Information concerning mother of child.-The same details are required 
concerning the mother as the father, except that her full maiden name 
should be given instead of her name by marriage. In addition to these 
facts two items are included for statistical purposes: First, number of 
child of this mother, and, second, number of children of this mother now 
living. These items are independent of the existing marriage, and 
should include all children by a former husband. The first will indicate 
the total number of children borhe by the mother, up to and including 
the one to whom the certificate relates. The second will specify how 
many out of that number were living at the time the reported birth 
occurred. 
Certificate of attending physician or midwife.-The fact of attendance 
and the exact time of birth should be certified to by signature of the 
physician or midwife, and his or her address stated. If there was no 
physician or midwife in attendance, the certificate should be made by 
the next responsible person in the order specified in the law. 
IMPORTANCE OF DETAILS REQUIRED 
Every detail called for by the standard certificate has a specific use in 
one or other of the purposes of registration and should be supplied as 
accurately as possible. It will be clearly apparent that when evidence 
is required from these records to establish age, identity, relationship, or 
descent, as affecting the rights or duties of individuals, these purposes 
will be properly served only when the record is correct and complete, 
and accuracy is equally essential for all other purposes. 
methods of practice 
The system of making and keeping returns of births is the same as 
that outlined for returns of deaths in the pamphlet on practical registra- 
tion methods. Its basis is a uniform state registration service, with a 
central office under a state registrar, which supplies the material, formu- 29 
lates rules, regulations, and instructions for carrying out the law, and 
receives the original certificates transmitted monthly by the local regis- 
trars. The local record of the birth consists of an exact copy of the 
original certificate, made upon an identical form. Where this system is 
employed no book record is required, and to keep one is just so much 
unnecessary labor. 
When a certificate of birth is filed with the local registrar he should 
carefully examine it to see that it is correct and complete. If found 
satisfactory, the date of filing should be entered and the fact attested by 
signature of the registrar. (In places where the number of returns is 
large, an official dating stamp may be used for this purpose.) The cer- 
tificate should then be given its proper serial number (registered 
number) and filed. 
If the child has not been named at the time the certificate is filed, the 
supplemental report, a copy of which also accompanies this circular, 
should be handed to the person presenting the certificate, with instruc- 
tions to fill the blank spaces and return it as soon as the child is named. 
It is essential that each supplemental report be identified with the 
original certificate in the same case, and to insure this the items neces- 
sary to connect the two should invariably be inserted by the registrar 
before giving out the form. These items are indicated by the asterisk (*) 
in the form itself. 
Incomplete returns of this kind-that is those awaiting the supple- 
mental report containing the given name-should be kept separate from 
the regular file, until such supplemental report is received, when the 
given name should be written in upon the original certificate, and the 
addition attested by entry of the fact and date, over the signature of 
the registrar, in the space provided at the bottom of the blank. 
The supplemental report should, in each case, be attached to the 
original to make the record complete. This can best be done by apply- 
ing a small quantity of paste on the binding end of the supplemental 
return (printed side) and attaching it to the back of the original return. 
If the supplemental returns are so attached alternately, to the top and 
bottom half of the originals, they will bind in smoothly, without 
' ' bunching. ' ' 
A case should be provided with one or more drawers about 8% inches 
wide by 6% inches deep for filing the certificates until bound. One 
drawer should be reserved for current records, those awaiting supple- 
mental reports being filed at the back, and separated by a division card, 
headed ' ' awaiting supplemental returns. ' ' 
The current returns, to be sent to the state registrar, may be copied 
from time to time, as opportunity offers, and as each is copied it should 
be checked by some distinctive sign to indicate that the copy for the 
local records has been made. The copies of the certificates forming 
the local records should be bound when they accumulate in sufficient 30 
quantity. Five hundred of these make a small and compact volume, 
about 2 inches thick, and 80,000 of them, when bound, require only shelf 
room afforded by a space of 3 by 5 feet. 
The bound volumes may be indexed in the same way as those con- 
taining the records of deaths, described in the pamphlet on practical 
registration methods. 
ADVANTAGES OF UNIFORMITY 
The advantage of uniform certificates and methods in all parts of 
the same state will be at'once appreciated, and a little consideration 
will make it clear that a uniform system in all states will be equally 
advantageous. 
The law requires that each birth or death shall be registered in the 
district where it occurs, and if, as frequently happens, the event occurs 
when the parents or the individual were away from home, good practice 
and the interests of the people also require that the birth or death shall 
also be recorded at the place of residence, if known, as this is generally 
the first point of inquiry of parties seeking information or evidence from 
the records. 
The law provides that in case of removal of a corpse an exact copy of 
the certificate of death shall be attached to and form a part of the permit, 
to be returned to and filed by the registrar of the district in which inter- 
ment is made, which is usually the "home district" of the decedent, 
and it is suggested that an exact copy of the certificate of birth be sent 
to the home district of the parents when the birth occurs elsewhere, 
whether in the same or some other state. 
If each state maintains a similar system of registration and adopts 
the standard certificate, as recommended, this plan will result in a com- 
plete record in both places. The duplication of the cases in the various 
uses to which the records may be put can be easily and effectively 
guarded against by having the copy sent to the home district made 
on different colored paper-say light blue. These copies would be 
of the same size and form as the original return, and can be arranged, 
filed, and bound with the other certificates for the local record, and 
simply passed over in making returns to the state registrar. The color 
wall immediately distinguish ' ' outside ' ' from ' ' local ' ' cases. 
The practice of forwarding copies of records from place of occurrence 
to place of residence is followed in some of the present registration 
states, and it is only necessary that there shall be an exact uniformity 
of size and a similar distinction of color to make the interchange of 
records perfectly adaptable everywhere. 
CHECKS UPON THE RETURN OF BIRTHS 
It has heretofore been very difficult to determine with any certainty 
the degree of completeness with which births are registered in any COPY OF ORIGINAL RETURN 
FOR RECORD ELSEWHERE 
CENSUS office: 
JV. B.-This return is to be received and filed, but is not to be reported to the State Registrar. 
This form, printed on light-blue paper, is suggested for 
use in making copies for record in other districts. The 
color will at once distinguish "outside" from "local" 
STANDARD CERTIFICATE OF BIRTH 
(state:) 
WRITE PLAINLY, WITH UNFADING INK-THIS IS A PERMANENT RECORD. 
PLACE OF BIRTH 
Registered No 
(Kegistration District) 
(No, 
St.; 
Ward) 
MARGIN RESERVED FOR BINDING. 
FULL NAME OF CHILD 
Sex of 
Child 
Twin, 
Triplet, 
or other? 
1 Number 
and ; in order 
L of birth 
Legiti- 
mate? 
Date of 
birth. , 190 
(Month) (Day) (Year) 
MOTHER 
FULL 
NAME 
FATHER 
FULL 
MAIDEN 
NAME 
RESIDENCE 
RESIDENCE 
COLOR 
AGE AT LAST 
BIRTHDAY 
COLOR 
AGE AT LAST 
BIRTHDAY 
BIRTHPLACE 
(Years) 
BIRTHPLACE 
(Years) 
OCCUPATION 
OCCUPATION 
Number of child of this mother 
Number of children, of this mother, now living 
CERTIFICATE OF ATTENDING PHYSICIAN OR MIDWIFE* 
I hereby certify that I attended the birth of this child, and that it occurred on 
) 190 , at 
M. 
*H'hen there was no attending physician 
or midwife, then the father, householder, 
etc., should make this return. 
(Signature) 
(Physician or midwife) 
8-334 b 
V. S. No. 106 
Given name added from a supplemental Address 
report 
, 190 
Filed 
, 190 
REGISTRAR. 
11-386 
REGISTRAR. 31 
locality, owing to the absence of any effective check upon the returns. 
Various expedients have been adopted by officials who wished to supply 
deficiencies and to ascertain delinquents. In some instances assessors, 
directory canvassers, and others have been directed to inquire concerning 
births in each family visited, and have perhaps been provided with lists 
of births registered in their districts to aid them in discovering omissions. 
These and other similar means may be employed when occasion offers, 
but they involve outside inquiry and entail considerable work and per- 
haps considerable expense, which is not always permitted by the funds 
available. 
The greatest part of the deficiency in the registration of births is 
probably due to the neglect of certain physicians and midwives to report 
all or any of their cases. If such delinquents can be located and made 
to conform to the law, this kind of deficiency can be overcome, and, with 
the requirement of immediate registration, which forms the distinctive 
feature of the law presented, it will be quite possible to do this with but 
a small amount of work entirely inside the office. 
The greatest mortality occurs among infants and very young children, 
whose deathswill usually be reported. Of 1,000 children born, from 
150 to 250, according to locality and character of population, die before 
reaching one year of age, and unless the birth and death occur simul- 
taneously, the record of the birth should precede that of the death. 
If, then, when the death is reported of any child-say under one year 
of age-reference is made to the record of births, and it is found that 
there is no corresponding certificate of birth on file, inquiry can at once 
be made and the responsibility for failure to return the birth fixed. 
The proportion of infants dying soon after birth is so large that a 
systematic checking of the birth returns by the record of deaths will 
inevitably expose those physicians and midwives who continually neglect 
to report births, and without any annoyance to those who report them 
promptly and properly. When found, they should first be reminded, 
then warned, and if they persist in neglecting to make returns, they 
should be prosecuted to the full extent of the law. CENSUS PAMPHLETS RELATING TO VITAL STATISTICS 
No. 100. Legislative Requirements for Registration of Vital Statistics. 
No. ioi. Practical Registration Methods. 
No. 102. Relation of Physicians to Mortality Statistics. 
No. 103. Medical Education in Vital Statistics. 
No. 104. Registration of Births and Deaths. 
No. 105. Statistical Treatment of Causes of Death. 
No. 106. Extension of the Registration Area for Births and Deaths. 
Manual of International Classification of Causes of Death. 
Note.-Pamphlets in this list may be obtained upon application to the Director of the Census. 
32 
o COPY OF ORIGINAL RETURN FOR 
RECORD ELSEWHERE 
This form, printed on light-blue paper, is suggested for 
use in making copies for record in other districts. The 
color will at once distinguish "outside" from "local" 
cases. 
CENSUS OFFICE 
STANDARD CERTIFICATE OF- DEATH 
(STATE) 
PLACE OF DEATH 
Registered No. 
MARGIN RESERVED F" O R BINDING. 
WRITE PLAINLY, WITH UNFADING INK-THIS IS A PERMANENT RECORD. 
N. B.-This return is to be received, and filed, but is not to be reported to the State Registrar. 
(No. 
St. 
Ward) 
(Registration District) 
FULL NAME 
PERSONAL AN/) STATISTICAL PARTICULARS 
MEDICAL CERTIFICATE OF DEATH 
SEX 
COLOR 
DATE OF DEATH 
DATE OF BIRTH 
(Month) 
(Day) 
190- 
(Year) 
(Month) 
(Day) 
(Year) 
I HEREBY CERTIFY, That I attended deceased from 
AGE 
190 
to 
190 
years, 
months, 
days 
that I last saw h alive on 190 , 
and that death occurred, on the date stated above, at 
M. The CAUSE OF DEATH was as follows: 
SINGLE, MARRIED, 
WIDOWED, OR DIVORCED 
BIRTHPLACE 
(State or country) 
NAME OF 
FATHER 
BIRTHPLACE 
OF FATHER 
(State or country) 
(duration) 
DAYS 
MAIDEN NAME 
OF MOTHER 
Contributory 
(duration) 
DAYS 
BIRTHPLACE 
OF MOTHER 
(State or country) 
- M. D. 
SPECIAL INFORMATION only for Hospitals, Institutions, Transients, or 
Recent Residents. 
190 
(Address 
OCCUPATION 
THE ABOVE STATED PERSONAL PARTICULARS ARE TRUE TO THE 
BEST OF MY KNOWLEDGE AND BELIEF. 
Farmer or 
Usual Resident 
Where was disease contracted, 
if not at place of death ? . 
How long at 
Place of Death ? 
Days 
(Informant) 
(Address) 
PLACE OF BURIAL OR REMOVAL 
DATE OF BURIAL 
8-209 a 
V. S. No. 107 
! 
r-t 
Filed 
UNDERTAKER 
ADDRESS 
190 
190 
Registrar