OntarioGenWeb
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Ontario Vital Statistics Death Registration Form
1910-1912/3
   
Microfilm #    
Registration #    
County    
Division    
Full Name of Deceased    
Sex, and Race    
Date of Death    
Date of Birth    
Age and Place of Birth    
Place of Death    
Occupation    
Single, Widowed or Divorced    
Full Name of Father    
Birthplace of Father    
Maiden Name of Mother    
Birthplace of Mother    
Name of Physician who attended Deceased    
Certified by    
Address    
Date    
  Medical Certificate of Death Medical Certificate of Death
Name    
From    
To    
That I last saw h.... alive on    
That the Death occurred on    
Primary Cause of Death    
Duration    
Immediate Cause of Death    
Duration    
Physician's name    
Address    
Date    
     
   
   
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