Medical Certificate (Inference) of Resident Death

No.: XXXXXX

District planning code: XXXXXX                                                                                                                           No.: XXXXXX

The third copy: kept by the family of the deceased      Name of deceased XXXXXX           Gender               Male           Nation   Han    Nationality and region                    China                      Age             64 years

Identity document type                              Identity card                               ID number        XXXXXX Household address      XXXXXX

Date of Birth                April 15, 1958        Date of death                             November 22, 2022        Place of death     Peking University Medical Rehabilitation Hospital

Causes of death:         Pancreatic Malignant Tumor        Names of family members                        XXXXXX                 Contact No.:  XXXXXX

Families address or work unit:                                        XXXXXX              Signature of physician:   XXXXXX                 Signature of police

Stamp of Medical and health institute:

Seal: Peking University Medical Rehabilitation Hospital Co., Ltd.

Date: November 23, 2022     Police station opinion: (Stamp):

Date:

Note: 1. The family members of the deceased held the copy of certificate to the public security to affix the seal;  2. The certificate is valid with the signature of doctors and police, the seals of medical and health institutions and police station;  3. The cause of death outside the medical facility is postmortem inference.

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