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L-0.2, r. 1 - Regulation respecting the application of the Act respecting medical laboratories and organ and tissue conservation
Schedule
Disposition versions
SCHEDULE 3
(Revoked)
SCHEDULE 3
(s. 18)
RETURN OF DEATH
SP-3
Return of Death
Management entrusted to the Bureau de la statistique du Québec
Please ype or print in block letters using a ball-point pen.
Do not write in shaded spaces. Press frimly.
PLACE OF DEATH
1. Name of institution where death occurred
2. Code of institution
3. Exact location where death occurred (No, street, municipality, province or country) Postal Code
IDENTIFICATION OF DECREASED (Write the surname and given name(s) according to the act of birth)
4. Surname
5. Usual given name
6. Health insurance No.
7. Birthdate Year Month Day
8. Age at death
If over 1 year
Year(s)
If under 1 year
Month(s) Day(s)
If under 24 hours
Hour(s) Minute(s)
If under 7 days, give weight at birth
Gram
9. Marital status
1 Single (never married)
2 Married
3 Widowed
4 Divorced
5 Legally separated
10. Name of spouse of the deceased
11. If deceased married, give age of spouse
12. Birthplace (Province or country)
13. Language spoken at home
1 French
2 English Other
14. Address of deceased’s domicile (No., street, municipality, province or country) Postal code
15. Surname of mother (according to the act of birth)
16. Usual given name of mother
17. Surname of father
18. Usual given name of father
MEDICAL CERTIFICATION OF DEATH
19. Date and time of death Year Month Day Hour Minute
20. Sex of deceased
1 male
2 Female
9 undetermined
21. Notice to the coroner (see guidelines on back of copy 1)
1 yes
2 No
22. Causes of death Approximate interval between onset and death
1. Disease or condition directly leading to death*
Antecedent causes. Morbid conditions, if any, giving rise to the above cause, stating the underlying conditions last
2. Other signifiant conditions contributing to the death, but not related to the disease or condition causing it
(a) due to (or as consequence of)
(b) due to (or as consequence of)
(c) underlying cause)
* This does not mean the mode of dying. e.g., heart failure, asthenia, etc. It means the disease, injury or complication which caused death.
For office use only
23. Autopsy?
1 Yes
2 No
If yes, does the cause of death stated above take autopsy findings into account?
1 Yes
2 No
24. Presence of radioisotopes
1 Yes
2 No
25. If deceased a women, did the death occur during pregnancy or within 42 days thereafter?
1 Yes
2 No
26. Deceased suffered from a disease that must be declared
1 Yes
2 No
Specify
27. If the case of violent death, check
FOR STATISTICAL USE ONLY
Accident
Suicide
Homicide
28. Place (farm, factory, etc.) and circumstances (drowning, strangulation, etc.)
29. Is author of medical certification a
1 Physician
4 Coroner Other
30. Surname and given name of author of medical certification
31. Tel. No where author can be reached
32. Address (No. street, municipality, province) Postal Code
I have reported, to the best of my knowledge, the causes and the circumstances surrounding the death of this person. The information collected is transmitted to the Bureau de la statistique du Québec, to the ministère de la Santé et des Services sociaux, to the funeral director and to the Registrar of Civil Status. The information is subject to the provisions of the Act respecting Access to documents held by public bodies and the Protection of personal information, except with respect to the Registrar of Civil Status who is not subject to that Act. The conditions are listed on the back of page 2.
33. Signature of author of medical certification
34. Date signed
35. If a physician, give permit No. (Corp. des médecins)
DISPOSAL OF BODY/FUNERAL DIRECTOR
36. Disposal arrangements
1 Burial
2 Cremation
3 Anatomical study
4 Body transported outside Québec
37. Name of funeral home
38. Permit No. (funeral director)
39. Address of funeral home (No., street, municipality, province or country Postal Code
40. Date on which body was handed over Year Month Day
41. Surname and given name of representative of funeral home
42. Signature of representative
SP-3 (93-11)
3-0000000
BUREAU DE LA STATISTIQUE DU QUÉBEC
Return of Death
Management entrusted to the Bureau de la statistique du Québec
Please ype or print in block letters using a ball-point pen.
Do not write in shaded spaces. Press frimly.
PLACE OF DEATH
1. Name of institution where death occurred
2. Code of institution
3. Exact location where death occurred (No, street, municipality, province or country) Postal Code
IDENTIFICATION OF DECREASED (Write the surname and given name(s) according to the act of birth)
4. Surname
5. Usual given name
6. Health insurance No.
7. Birthdate Year Month Day
8. Age at death
If over 1 year
Year(s)
If under 1 year
Month(s) Day(s)
If under 24 hours
Hour(s) Minute(s)
If under 7 days, give weight at birth
Gram
9. Marital status
1 Single (never married)
2 Married
3 Widowed
4 Divorced
5 Legally separated
10. Name of spouse of the deceased
11. If deceased married, give age of spouse
12. Birthplace (Province or country)
13. Language spoken at home
1 French
2 English Other
14. Address of deceased’s domicile (No., street, municipality, province or country) Postal code
15. Surname of mother (according to the act of birth)
16. Usual given name of mother
17. Surname of father
18. Usual given name of father
MEDICAL CERTIFICATION OF DEATH
19. Date and time of death Year Month Day Hour Minute
20. Sex of deceased
1 male
2 Female
9 undetermined
21. Notice to the coroner (see guidelines on back of copy 1)
1 yes
2 No
22. Causes of death Approximate interval between onset and death
1. Disease or condition directly leading to death*
Antecedent causes. Morbid conditions, if any, giving rise to the above cause, stating the underlying conditions last
2. Other signifiant conditions contributing to the death, but not related to the disease or condition causing it
(a) due to (or as consequence of)
(b) due to (or as consequence of)
(c) underlying cause)
* This does not mean the mode of dying. e.g., heart failure, asthenia, etc. It means the disease, injury or complication which caused death.
For office use only
23. Autopsy?
1 Yes
2 No
If yes, does the cause of death stated above take autopsy findings into account?
1 Yes
2 No
24. Presence of radioisotopes
1 Yes
2 No
25. If deceased a women, did the death occur during pregnancy or within 42 days thereafter?
1 Yes
2 No
26. Deceased suffered from a disease that must be declared
1 Yes
2 No
Specify
27. If the case of violent death, check
FOR STATISTICAL USE ONLY
Accident
Suicide
Homicide
28. Place (farm, factory, etc.) and circumstances (drowning, strangulation, etc.)
29. Is author of medical certification a
1 Physician
4 Coroner Other
30. Surname and given name of author of medical certification
31. Tel. No where author can be reached
32. Address (No. street, municipality, province) Postal Code
I have reported, to the best of my knowledge, the causes and the circumstances surrounding the death of this person. The information collected is transmitted to the Bureau de la statistique du Québec, to the ministère de la Santé et des Services sociaux, to the funeral director and to the Registrar of Civil Status. The information is subject to the provisions of the Act respecting Access to documents held by public bodies and the Protection of personal information, except with respect to the Registrar of Civil Status who is not subject to that Act. The conditions are listed on the back of page 2.
33. Signature of author of medical certification
34. Date signed
35. If a physician, give permit No. (Corp. des médecins)
DISPOSAL OF BODY/FUNERAL DIRECTOR
36. Disposal arrangements
1 Burial
2 Cremation
3 Anatomical study
4 Body transported outside Québec
37. Name of funeral home
38. Permit No. (funeral director)
39. Address of funeral home (No., street, municipality, province or country Postal Code
40. Date on which body was handed over Year Month Day
41. Surname and given name of representative of funeral home
42. Signature of representative
SP-3 (93-11)
3-0000000
BUREAU DE LA STATISTIQUE DU QUÉBEC
An Act respecting the determination of the causes and circumstances of death (chapter R-0.2)
GUIDELINES
A notice must be sent to the coroner when:
(1) the physician has difficulty establishing the probable causes of death to his satisfaction (when the death occurs in an institution, first inform the director of professional services);
(2) the death occurs in obscure or violent circumstances (sudden death, accident, homicide, suicide, in a fire, in a disaster, etc.);
(3) the identity of the deceased person is unknown;
(4) the death occurs in one of the following places:
Rehabilitation centre
Sheltered workshop
Institution for close treatment
House of detention
Day care centre
Penitentiary
Security unit
Police station
Family-type resource
(5) the body is transported outside Québec.
(6) the body comes from outside Québec and the probable causes of death have not been established or the death occurs in obscure or violent circumstances.
Note: These guidelines do not replace the Act or the regulations thereunder.
For further information, contact the coroner:
Montréal and immediate vicinity: 514-873-1845
Québec and immediate vicinity: 418-643-1845
Other regions: inquire at the nearest police station or consult Communication-Québec in your area (see blue pages of the telephone directory under the heading Communications).
RETURN OF DEATH
SP-3
Return of Death
Management entrusted to the Bureau de la statistique du Québec
Please ype or print in block letters using a ball-point pen.
Do not write in shaded spaces. Press frimly.
PLACE OF DEATH
1. Name of institution where death occurred
2. Code of institution
3. Exact location where death occurred (No, street, municipality, province or country) Postal Code
IDENTIFICATION OF DECREASED (Write the surname and given name(s) according to the act of birth)
4. Surname
5. Usual given name
6. Health insurance No.
7. Birthdate Year Month Day
8. Age at death
If over 1 year
Year(s)
If under 1 year
Month(s) Day(s)
If under 24 hours
Hour(s) Minute(s)
If under 7 days, give weight at birth
Gram
9. Marital status
1 Single (never married)
2 Married
3 Widowed
4 Divorced
5 Legally separated
10. Name of spouse of the deceased
11. If deceased married, give age of spouse
12. Birthplace (Province or country)
13. Language spoken at home
1 French
2 English Other
14. Address of deceased’s domicile (No., street, municipality, province or country) Postal code
15. Surname of mother (according to the act of birth)
16. Usual given name of mother
17. Surname of father
18. Usual given name of father
MEDICAL CERTIFICATION OF DEATH
19. Date and time of death Year Month Day Hour Minute
20. Sex of deceased
1 male
2 Female
9 undetermined
21. Notice to the coroner (see guidelines on back of copy 1)
1 yes
2 No
22. Causes of death Approximate interval between onset and death
1. Disease or condition directly leading to death*
Antecedent causes. Morbid conditions, if any, giving rise to the above cause, stating the underlying conditions last
2. Other signifiant conditions contributing to the death, but not related to the disease or condition causing it
(a) due to (or as consequence of)
(b) due to (or as consequence of)
(c) underlying cause)
* This does not mean the mode of dying. e.g., heart failure, asthenia, etc. It means the disease, injury or complication which caused death.
For office use only
23. Autopsy?
1 Yes
2 No
If yes, does the cause of death stated above take autopsy findings into account?
1 Yes
2 No
24. Presence of radioisotopes
1 Yes
2 No
25. If deceased a women, did the death occur during pregnancy or within 42 days thereafter?
1 Yes
2 No
26. Deceased suffered from a disease that must be declared
1 Yes
2 No
Specify
27. If the case of violent death, check
FOR STATISTICAL USE ONLY
Accident
Suicide
Homicide
28. Place (farm, factory, etc.) and circumstances (drowning, strangulation, etc.)
29. Is author of medical certification a
1 Physician
4 Coroner Other
30. Surname and given name of author of medical certification
31. Tel. No where author can be reached
32. Address (No. street, municipality, province) Postal Code
I have reported, to the best of my knowledge, the causes and the circumstances surrounding the death of this person. The information collected is transmitted to the Bureau de la statistique du Québec, to the ministère de la Santé et des Services sociaux, to the funeral director and to the Registrar of Civil Status. The information is subject to the provisions of the Act respecting Access to documents held by public bodies and the Protection of personal information, except with respect to the Registrar of Civil Status who is not subject to that Act. The conditions are listed on the back of page 2.
33. Signature of author of medical certification
34. Date signed
35. If a physician, give permit No. (Corp. des médecins)
DISPOSAL OF BODY/FUNERAL DIRECTOR
36. Disposal arrangements
1 Burial
2 Cremation
3 Anatomical study
4 Body transported outside Québec
37. Name of funeral home
38. Permit No. (funeral director)
39. Address of funeral home (No., street, municipality, province or country Postal Code
40. Date on which body was handed over Year Month Day
41. Surname and given name of representative of funeral home
42. Signature of representative
SP-3 (93-11)
3-0000000
DOSSIER MÉDICAL OU DOSSIER DU CORONER
Return of Death
Management entrusted to the Bureau de la statistique du Québec
Please ype or print in block letters using a ball-point pen.
Do not write in shaded spaces. Press frimly.
PLACE OF DEATH
1. Name of institution where death occurred
2. Code of institution
3. Exact location where death occurred (No, street, municipality, province or country) Postal Code
IDENTIFICATION OF DECREASED (Write the surname and given name(s) according to the act of birth)
4. Surname
5. Usual given name
6. Health insurance No.
7. Birthdate Year Month Day
8. Age at death
If over 1 year
Year(s)
If under 1 year
Month(s) Day(s)
If under 24 hours
Hour(s) Minute(s)
If under 7 days, give weight at birth
Gram
9. Marital status
1 Single (never married)
2 Married
3 Widowed
4 Divorced
5 Legally separated
10. Name of spouse of the deceased
11. If deceased married, give age of spouse
12. Birthplace (Province or country)
13. Language spoken at home
1 French
2 English Other
14. Address of deceased’s domicile (No., street, municipality, province or country) Postal code
15. Surname of mother (according to the act of birth)
16. Usual given name of mother
17. Surname of father
18. Usual given name of father
MEDICAL CERTIFICATION OF DEATH
19. Date and time of death Year Month Day Hour Minute
20. Sex of deceased
1 male
2 Female
9 undetermined
21. Notice to the coroner (see guidelines on back of copy 1)
1 yes
2 No
22. Causes of death Approximate interval between onset and death
1. Disease or condition directly leading to death*
Antecedent causes. Morbid conditions, if any, giving rise to the above cause, stating the underlying conditions last
2. Other signifiant conditions contributing to the death, but not related to the disease or condition causing it
(a) due to (or as consequence of)
(b) due to (or as consequence of)
(c) underlying cause)
* This does not mean the mode of dying. e.g., heart failure, asthenia, etc. It means the disease, injury or complication which caused death.
For office use only
23. Autopsy?
1 Yes
2 No
If yes, does the cause of death stated above take autopsy findings into account?
1 Yes
2 No
24. Presence of radioisotopes
1 Yes
2 No
25. If deceased a women, did the death occur during pregnancy or within 42 days thereafter?
1 Yes
2 No
26. Deceased suffered from a disease that must be declared
1 Yes
2 No
Specify
27. If the case of violent death, check
FOR STATISTICAL USE ONLY
Accident
Suicide
Homicide
28. Place (farm, factory, etc.) and circumstances (drowning, strangulation, etc.)
29. Is author of medical certification a
1 Physician
4 Coroner Other
30. Surname and given name of author of medical certification
31. Tel. No where author can be reached
32. Address (No. street, municipality, province) Postal Code
I have reported, to the best of my knowledge, the causes and the circumstances surrounding the death of this person. The information collected is transmitted to the Bureau de la statistique du Québec, to the ministère de la Santé et des Services sociaux, to the funeral director and to the Registrar of Civil Status. The information is subject to the provisions of the Act respecting Access to documents held by public bodies and the Protection of personal information, except with respect to the Registrar of Civil Status who is not subject to that Act. The conditions are listed on the back of page 2.
33. Signature of author of medical certification
34. Date signed
35. If a physician, give permit No. (Corp. des médecins)
DISPOSAL OF BODY/FUNERAL DIRECTOR
36. Disposal arrangements
1 Burial
2 Cremation
3 Anatomical study
4 Body transported outside Québec
37. Name of funeral home
38. Permit No. (funeral director)
39. Address of funeral home (No., street, municipality, province or country Postal Code
40. Date on which body was handed over Year Month Day
41. Surname and given name of representative of funeral home
42. Signature of representative
SP-3 (93-11)
3-0000000
DOSSIER MÉDICAL OU DOSSIER DU CORONER
Pursuant to sections 64 and 65 of the Act respecting Access to documents held by public bodies and the Protection of personal information (chapter A-2.1)
Please note that:
(1) The information requested on this form is gathered on behalf of the Bureau de la statistique du Québec (117, rue Saint-André, Québec), the ministère de la Santé et des Services sociaux (1075, chemin Sainte-Foy, Québec) and the funeral director.
(2) The information gathered for the Bureau de la statistique du Québec is used for administrative and statistical purposes. The information transmitted to the ministère de la Santé et des Services sociaux is included in the death file used in planning, managing, controlling and assessing programs. The copy given to the funeral director is used for administrative purposes.
(3) This information will be accessible to:
· employees of the Bureau de la statistique du Québec, the ministère de la Santé et des Services sociaux and the funeral director within the context of their work;
· any other user meeting the requirements of the Act referred to in the heading and of the Public Health Protection Act (chapter P-35).
(4) Sections 83 to 102 of the Act referred to in the heading provide for a right of access to the information contained in this form and the right to have the information corrected if it is inaccurate, incomplete or equivocal.
(5) The information requested in this form is mandatory.
(6) The Public Health Protection Act provides for penalties in the case of a false declaration or of a refusal to supply the requested information.
RETURN OF DEATH
SP-3
Return of Death
Management entrusted to the Bureau de la statistique du Québec
Please ype or print in block letters using a ball-point pen.
Do not write in shaded spaces. Press frimly.
PLACE OF DEATH
1. Name of institution where death occurred
2. Code of institution
3. Exact location where death occurred (No, street, municipality, province or country) Postal Code
IDENTIFICATION OF DECREASED (Write the surname and given name(s) according to the act of birth)
4. Surname
5. Usual given name
6. Health insurance No.
7. Birthdate Year Month Day
8. Age at death
If over 1 year
Year(s)
If under 1 year
Month(s) Day(s)
If under 24 hours
Hour(s) Minute(s)
If under 7 days, give weight at birth
Gram
9. Marital status
1 Single (never married)
2 Married
3 Widowed
4 Divorced
5 Legally separated
10. Name of spouse of the deceased
11. If deceased married, give age of spouse
12. Birthplace (Province or country)
13. Language spoken at home
1 French
2 English Other
14. Address of deceased’s domicile (No., street, municipality, province or country) Postal code
15. Surname of mother (according to the act of birth)
16. Usual given name of mother
17. Surname of father
18. Usual given name of father
MEDICAL CERTIFICATION OF DEATH
19. Date and time of death Year Month Day Hour Minute
20. Sex of deceased
1 male
2 Female
9 undetermined
21. Notice to the coroner (see guidelines on back of copy 1)
1 yes
2 No
22. Causes of death Approximate interval between onset and death
1. Disease or condition directly leading to death*
Antecedent causes. Morbid conditions, if any, giving rise to the above cause, stating the underlying conditions last
2. Other signifiant conditions contributing to the death, but not related to the disease or condition causing it
(a) due to (or as consequence of)
(b) due to (or as consequence of)
(c) underlying cause)
* This does not mean the mode of dying. e.g., heart failure, asthenia, etc. It means the disease, injury or complication which caused death.
For office use only
23. Autopsy?
1 Yes
2 No
If yes, does the cause of death stated above take autopsy findings into account?
1 Yes
2 No
24. Presence of radioisotopes
1 Yes
2 No
25. If deceased a women, did the death occur during pregnancy or within 42 days thereafter?
1 Yes
2 No
26. Deceased suffered from a disease that must be declared
1 Yes
2 No
Specify
27. If the case of violent death, check
FOR STATISTICAL USE ONLY
Accident
Suicide
Homicide
28. Place (farm, factory, etc.) and circumstances (drowning, strangulation, etc.)
29. Is author of medical certification a
1 Physician
4 Coroner Other
30. Surname and given name of author of medical certification
31. Tel. No where author can be reached
32. Address (No. street, municipality, province) Postal Code
I have reported, to the best of my knowledge, the causes and the circumstances surrounding the death of this person. The information collected is transmitted to the Bureau de la statistique du Québec, to the ministère de la Santé et des Services sociaux, to the funeral director and to the Registrar of Civil Status. The information is subject to the provisions of the Act respecting Access to documents held by public bodies and the Protection of personal information, except with respect to the Registrar of Civil Status who is not subject to that Act. The conditions are listed on the back of page 2.
33. Signature of author of medical certification
34. Date signed
35. If a physician, give permit No. (Corp. des médecins)
DISPOSAL OF BODY/FUNERAL DIRECTOR
36. Disposal arrangements
1 Burial
2 Cremation
3 Anatomical study
4 Body transported outside Québec
37. Name of funeral home
38. Permit No. (funeral director)
39. Address of funeral home (No., street, municipality, province or country Postal Code
40. Date on which body was handed over Year Month Day
41. Surname and given name of representative of funeral home
42. Signature of representative
SP-3 (93-11)
3-0000000
DIRECTEUR DE FUNÉRAILLES
THIS DOCUMENT IS NOT AN ACT OF CIVIL STATUS
Return of Death
Management entrusted to the Bureau de la statistique du Québec
Please ype or print in block letters using a ball-point pen.
Do not write in shaded spaces. Press frimly.
PLACE OF DEATH
1. Name of institution where death occurred
2. Code of institution
3. Exact location where death occurred (No, street, municipality, province or country) Postal Code
IDENTIFICATION OF DECREASED (Write the surname and given name(s) according to the act of birth)
4. Surname
5. Usual given name
6. Health insurance No.
7. Birthdate Year Month Day
8. Age at death
If over 1 year
Year(s)
If under 1 year
Month(s) Day(s)
If under 24 hours
Hour(s) Minute(s)
If under 7 days, give weight at birth
Gram
9. Marital status
1 Single (never married)
2 Married
3 Widowed
4 Divorced
5 Legally separated
10. Name of spouse of the deceased
11. If deceased married, give age of spouse
12. Birthplace (Province or country)
13. Language spoken at home
1 French
2 English Other
14. Address of deceased’s domicile (No., street, municipality, province or country) Postal code
15. Surname of mother (according to the act of birth)
16. Usual given name of mother
17. Surname of father
18. Usual given name of father
MEDICAL CERTIFICATION OF DEATH
19. Date and time of death Year Month Day Hour Minute
20. Sex of deceased
1 male
2 Female
9 undetermined
21. Notice to the coroner (see guidelines on back of copy 1)
1 yes
2 No
22. Causes of death Approximate interval between onset and death
1. Disease or condition directly leading to death*
Antecedent causes. Morbid conditions, if any, giving rise to the above cause, stating the underlying conditions last
2. Other signifiant conditions contributing to the death, but not related to the disease or condition causing it
(a) due to (or as consequence of)
(b) due to (or as consequence of)
(c) underlying cause)
* This does not mean the mode of dying. e.g., heart failure, asthenia, etc. It means the disease, injury or complication which caused death.
For office use only
23. Autopsy?
1 Yes
2 No
If yes, does the cause of death stated above take autopsy findings into account?
1 Yes
2 No
24. Presence of radioisotopes
1 Yes
2 No
25. If deceased a women, did the death occur during pregnancy or within 42 days thereafter?
1 Yes
2 No
26. Deceased suffered from a disease that must be declared
1 Yes
2 No
Specify
27. If the case of violent death, check
FOR STATISTICAL USE ONLY
Accident
Suicide
Homicide
28. Place (farm, factory, etc.) and circumstances (drowning, strangulation, etc.)
29. Is author of medical certification a
1 Physician
4 Coroner Other
30. Surname and given name of author of medical certification
31. Tel. No where author can be reached
32. Address (No. street, municipality, province) Postal Code
I have reported, to the best of my knowledge, the causes and the circumstances surrounding the death of this person. The information collected is transmitted to the Bureau de la statistique du Québec, to the ministère de la Santé et des Services sociaux, to the funeral director and to the Registrar of Civil Status. The information is subject to the provisions of the Act respecting Access to documents held by public bodies and the Protection of personal information, except with respect to the Registrar of Civil Status who is not subject to that Act. The conditions are listed on the back of page 2.
33. Signature of author of medical certification
34. Date signed
35. If a physician, give permit No. (Corp. des médecins)
DISPOSAL OF BODY/FUNERAL DIRECTOR
36. Disposal arrangements
1 Burial
2 Cremation
3 Anatomical study
4 Body transported outside Québec
37. Name of funeral home
38. Permit No. (funeral director)
39. Address of funeral home (No., street, municipality, province or country Postal Code
40. Date on which body was handed over Year Month Day
41. Surname and given name of representative of funeral home
42. Signature of representative
SP-3 (93-11)
3-0000000
DIRECTEUR DE FUNÉRAILLES
THIS DOCUMENT IS NOT AN ACT OF CIVIL STATUS
General instructions concerning the Return of Death (SP-3) intended for the Bureau de la statistique du Québec
The Return of Death is used in compliance with the regulations made under the Public Health Protection Act (chapter P-35). Pursuant to that Act, the Minister of Health and Social Services has the power to establish and maintain a system for gathering and analysing social, medical and epidemiological data and compile information on births, marriages, divorces, annulments and deaths for demographic purposes. The Bureau de la statistique du Québec is responsible for gathering, processing and using this data under Order in Council 260-85 dated 12 February 1985.
Preliminary notes
· Care should be taken to fill in dates and numbers in the appropriate squares. Mark one zero in each empty space to the left of a figure to show that the figure is complete. All questions must be answered; if the number is zero, mark zero in the appropriate square(s); if the question is not applicable, draw a horizontal line through the appropriate square(s).
· The answers must always reflect the situation at the time of the death, such as the address of the deceased’s domicile, marital status, etc.
DISTRIBUTION OF FORMS
Forms (Return/attestation of death) and return envelopes are available from:
Bureau de la statistique du Québec
117, rue Saint-André
Québec (Québec)
G1K 3Y3
TIME LIMIT FOR MAILING FORMS
A time limit of three (3) days after death is prescribed for mailing the Return of Death to the Bureau de la statistique du Québec.
Questions 1, 2 and 3
Place of death
If death did not occur in an institution, specify the place where the death occurred in question 1 (examples: residence, route 135, St. Lawrence River) and, in question 3, give the address or at least the name of the municipality.
Questions 4, 5, 15, 16, 17 and 18
Surname and given name
In all cases, enter the surname and usual given name which are mentioned in the act of birth. For a married woman, do not use the husband’s name. Do not use nicknames. Compound names, such as Jean-Pierre or Marie-Claude, must be hyphenated. Do not hyphenated other given names.
Question 8
Age at death
Fill in appropriate spaces according to the age of the person at the time of death.
· if 1 year or older, for example: 65 years |0|6|5| year(s)
· if under 1 year, for example: 10 months |1|0|0|0| months, days;
days 4 days |0|0|0|4| months, days;
if under 24 hours, for example: 2 hours |0|2|0|0| hours, minutes;
10 minutes |0|0|1|0| hours, minutes
· if under 1 year, for example: 10 months |1|0|0|0| months, days;
days 4 days |0|0|0|4| months, days;
if under 24 hours, for example: 2 hours |0|2|0|0| hours, minutes;
10 minutes |0|0|1|0| hours, minutes
If the deceased person lived less than 7 days, weight in grams at birth must be given.
Question 9
Marital status of deceased
Persons who are not legally separated are considered married.
Question 10
Name of spouse of deceased
According to the marital status of the deceased, give name of husband or wife if the person was married, and the name of last spouse if the person was widowed, divorced or legally separated.
Question 13
Language spoken at home
If more than one language is spoken at home, give the one most frequently used by the deceased. List one language only.
Question 19
Time of death
Give the time of death as precisely as possible, using the international system. If the exact time is not known, give the assumed or approximate time of death.
Question 26
Diseases that must be declared
See section 28 of the Regulation respecting the application of the Public Health Protection Act (R.R.Q., 1981, c. P-35, r. 1)
Questions 27 and 28
Violent death
For statistical purposes, make sure to indicate (question 27) whether an accident, a homicide or a suicide was involved. Also, specify the circumstances surrounding the death (question 28)and notify the coroner.
For example:
· in the case of a road or traffic accident, indicate whether the deceased person was the driver, a passenger or a pedestrian, and whether the accident was caused by swerving, overturning or collision with a pedestrian, an automobile or any other object, etc.;
· in the case of drowning, indicate whether it occurred during recreational activities or water transport, and specify the circumstances, such as water skiing, failing off a boat, overturning, etc.;
· in the case of intoxication, name the substance or medication (generic or trade name) concerned, and indicate whether or not addiction or chemical dependence was involved.
Question 36
Disposal of body/Funeral director
Do not delay sending the forms even if the place and method of disposal of body are not known.
Questions 37 to 42
Identification of funeral home
the funeral home (funeral director) must always be identified as well as the representative thereof. Identify any other person(s) authorized to take charge of a body not entrusted to a funeral home.
