死亡證明翻譯英文模版 中譯英

Medical Certification for Resident's Death   D0017700

The family member shall keep the copy.

Residential Address: No.14 Gangjingyuan Residential Quarter, Zhongshan District, Dalian, LiaoningProvince

In case of  pre-hospital death and unknown death cause, please complete

Investigation Record

Deceased’s Name:

Min Gu

Gender: Male

Nationality: Han

Main Occupation and Job Type: General Manager of Dalian Guofeng Airline Travel Service Co., Ltd.

ID Card No.: 210202194710202215

Current Residential Address: 2-8-1 No.14 Gangjingyuan Residential Quarter, Zhongshan District,Dalian, LiaoningProvince

The deceased’s medical history, signs and symptoms during his lifetime:

 Autopsy:  Yes    No

Marital Status: Married

Education Level: JuniorSchool

Work Unit during His Lifetime: Dalian Guofeng Airline Travel Service Co., Ltd.

Date of Birth: 20 Oct. 1947

Date of Death: 12 Sep. 2011

Chronological Age: 63 years old

Place of Death: Ward of a Hospital

Available Family Member’s Name and Phone: Xiaohong Gu    13322266726

Family Member’s Residential Address or Work Unit: Dalian Guofeng Airline Travel Service Co., Ltd.

Diagnosis of Main Fatal Diseases (please fill in the specific disease names, but do not fill in the signs and symptoms)

I. (a): The direct death-causing diseases or statuses: primary liver cancer, gastrointestinal bleeding and hemorrhagic shock

(b): The (a)-causing diseases or statuses: Decompensated liver cirrhosis after hepatitis, primary liver cancer after intervention

(c): The (b)-causing diseases or statuses: Massive upper gastrointestinal bleeding, hemorrhagic shock and severe anemia

II. Diagnosis of other diseases (other important statuses promoting death but being unrelated to the induction of death)

Approximate time interval from onset to death: One year

Relationship between the Investigated (immediate family member) and the Deceased

The Investigated’s ID Card No.:

Contact Address:

Contact Phone (required):

The Supreme Diagnosis Unit for the Deceased’s Above Diseases during His Lifetime: Provincial-levelHospital

The above information is true! The Investigated’s Signature:

The Supreme Diagnosis Basis for the Deceased’s Above Diseases during His Lifetime: Pathology

Verbal autopsy:

Hospital Admission Number: 1011883   Report Section: MICU  Doctor’s Signature: Lidan Wang  Report Unit (handwriting): MICU   Unit’s Seal: Medical Certification for Dalian Resident's Death, The Affiliated Zhongshan Hospital of Dalian University

The Investigator’s Signature:

Remark                                         Date of Completion: 12 Sep. 2011

Date of Investigation: