
| Ontario Vital Statistics Death Registration Form | ||
| 1869-1895 | ||
| General No. | General No. | |
| Microfilm # | ||
| Registration # | ||
| County | ||
| Division | ||
| Name and Surname of Deceased | ||
| When Died | ||
| Sex - Male or Female | ||
| Age | ||
| Rank or Profession | ||
| Where Born | ||
| Certified Cause of Death, and duration of illness | ||
| Name of Physician, if any | ||
| Signature, description and residence of informant | ||
| When Registered | ||
| Religious Denomination of Deceased | ||
| Signature of Registrar | ||
| Remarks | ||
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