Fetus Recorded District New York State De Fof Health I Local Registrar Copy — ,
Residence District REPORT OF FETAL DEATH
Spontaneous Termination of Pregnancy I_
1 A.Date of Termination: 2.Sex: 3A.Is Fetus: 38.If Not Single: 4A.Place of Termination:(cci.knon)
Clinic Ea 9
N MM DO YYYV MaleI�I Female iXAnCm S gle Twin Other Specity Fret Second Other Specify Hospital Residence p,gpfNce C�nfef Other Seedy
P. ,. ( , '.:_a� Galt ❑2 ❑3 o ■2 ❑ ❑t ❑2 ❑ t 02 ❑s 04 El
4B.Facility Name:of not Mary give address) 4C.Inpatient? 4D.County of Termination: E.Locality:(Gawk one and specify)
U. No Yes coty Village Town 4
NOTE: Registrar, maintain a count of the fetal death reports you
received during the month. Destroy this report at the end of
month in which it was received.
2 9A.Print Name of Attending Physician(If Different from Certifier): 98.Title:
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0~C 10A.I certify that the stated Information concerning this fetal death is true to the best of my knowledge and belief. MM DO YYrr
W W pnysicien'e ► �'I ' I 1 I I _') (.= .0 t'f
J U Signature: �., ' '� � '(.. � i ti
a' 10B.Print Name of Certifying Physician: 10C.Title: )
O I
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11A.FETAL DEATH WAS CAUSED BY:(Enter only One cause per rare) SPECIFY FETAL OR MATERNAL i
PART I-Immediate Cause:
►i (A) `j i-' r t�
w �, ) ,�� t
D
a
Due to or as a Consequence of:
t— (B)
LL ;
u Due to or as a Consequence of:
O (C)
Iii
s PART II-Other Fetal or Maternal Conditions Not Related to Cause Given in PART I: 118.Fetus Died: At 11C.Autopsy? 11 D.If yes,were autopsy
Before La0Or Dunno,p,Labor Der Unknown No Yes findings used'? No Yes
✓ ❑r I�z s ❑a ❑o ❑, ❑o ❑+r 1
12A,Burial,Cremation,Removal or Other Disposition:(specry) 128.Place of Burial,Cremation,Removal or 12C.Location:(Clryor Town and State) ,:_,_
Funeral Director Z Mk{ DO YYYY Other Disposition: .
must complies. IC C� "4`�7./(' r•2 /..r- -'-/ l' .+t I_ ,<.. (w�o"i •£sJf r ���, lx /r' wf:1,../ tl,,`,t Al
i3A.Name and Address of Funeral Home' 138.Registration Number:
Items 12.14 If (0 �'1 0 ,c'(e ,; ! f-it, o
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potionaretw `2 l fl r / (•r.r / f'c t,l�<��l/ r,r� ,' `7�r �` f '
Is b pay or - 14A.Name of Funeral Director: _ 14B.Si nature,fif Funeral Director:, r' 14C.Registration Number:
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