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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 4
(Revoked)
SCHEDULE 4
(ss. 9 and 58)
DECLARATION OF STILLBIRTH
SP-4
Declaration of Stillbirth
Management entrusted to Bureau de la statistique du Québec
Please type or print in block letters. Do not write in shaded spaces. Press firmly.
Place of delivery
1. Name of hospital where stillbirth occurred Establishment code
2. Exact location where stillbirth occurred (No., street, municipality, country, province or country outside Canada)
PARTICULARS OF PARENTS
Father
3. Father’s surname (if the father is unknown, check (P) here c and proceed to question 9)
4. Given name(s)
6. Birthdate of father Year Month Day
7. Father’s birthplace (Province or country outside Canada)
8. Mother tongue of father
01 French
02 English Other
Mother
9. Mother’s maiden surname as shown on birth certificate
10. Given name(s)
12. Birthdate of mother Year Month Day
13. Mother’s birthplace (Province or country outside Canada)
14. Mother tongue of mother
01 French
02 English Other
15. Mother’s address (No., street, municipality, county, province or country outside Canada) Postal code
16. Language spoken at home
01 French
02 English Other
17. Marital status of mother
1 Single (never married)
2 Married and living with her spouse
3 Widowed
4 Divorced
5 Legally separated
6 Not legally separated
17a. Relationship with partner
1 Living together as a couple
2 Not living together as a couple
18. Number of years mother attended school
19. Number of children previously born (excluding present pregnancy)
Liveborn
Stillborn (500 grams or more)
20. Date of last live birth Year Month Day
21. Date of las marriage Year Month Day
Signature of mother or father
I confirm that the above information is accurate. This information is being sent 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 person responsible for the burial and cremation. The information given is subject to the provisions of the Act respecting access to documents held by public bodies and the protection of personal information. The conditions are listed on the back of copy 2.
21a. Date signed Year Month Day
21b. Signature of mother or father
Medical report
22. Date of delivery Year Month Day
23. Kind of birth
01 Single
02 Twin
Other (Specify)
24. If multiple birth, state whether this stillborn child
1st
2nd
3rd Other (Specify)
25. Sex of stillborn child
1 Male
2 Female
9 Undetermined
26. Weight at birth
grams
27. Duration of pregnancy
completed weeks
28. Causes of stillbirth
1 Disease of condition directly leading to death
Antecedent causes. Morbid conditions, if anyy, giving rise to the above cause, stating the underlying condition last
a) due to (or consequence of)
b) due to (or consequence of)
c) (underlying cause)
2. Other significant conditions contributing to the death, but not related to the disease or condition causing it
29. In your opinion, what is the initial cause of the stillbirth? Check (P) one box only.
c Congenital malformation*
c Infection*
c Erythroblastosis
c Malnutrition of foetus
c Antepartum haemorrhage
c Obstetrical trauma or asphyxia*
c Other*
*Specify
30. Autopsy?
1 yes
2 No
If yes, does the cause of death stated above take account of autopsy findings?
1 Yes
2 No
31. Surname and given name of informant
32. Was the informant a
1 Physician
2 Nurse
Other (Specify)
33. Date signed Year Month Day
34. Signature of informant. I have reported, to the best of my knowledge, the causes and the circumstances surrounding this stillbirth Licence number (Corp. of physicians)
Disposition arrangements/Funeral director
35. Disposition arrangements
1 Burial
2 Cremation
3 Anatomical study
4 Transport of body outside Québec
36. Name of funeral home or hospital Licence number (funeral director)
37. Address of funeral home (No., street, municipality, county, province or country outside Canada)
38. Date on which body was handed over Year Month Day
39. Surname and given name of representative of funeral director
40. Signature of representative
SP-4A (rév 03-89)
1- Bureau de la statistique du Québec
Declaration of Stillbirth
Management entrusted to Bureau de la statistique du Québec
Please type or print in block letters. Do not write in shaded spaces. Press firmly.
Place of delivery
1. Name of hospital where stillbirth occurred Establishment code
2. Exact location where stillbirth occurred (No., street, municipality, country, province or country outside Canada)
PARTICULARS OF PARENTS
Father
3. Father’s surname (if the father is unknown, check (P) here c and proceed to question 9)
4. Given name(s)
6. Birthdate of father Year Month Day
7. Father’s birthplace (Province or country outside Canada)
8. Mother tongue of father
01 French
02 English Other
Mother
9. Mother’s maiden surname as shown on birth certificate
10. Given name(s)
12. Birthdate of mother Year Month Day
13. Mother’s birthplace (Province or country outside Canada)
14. Mother tongue of mother
01 French
02 English Other
15. Mother’s address (No., street, municipality, county, province or country outside Canada) Postal code
16. Language spoken at home
01 French
02 English Other
17. Marital status of mother
1 Single (never married)
2 Married and living with her spouse
3 Widowed
4 Divorced
5 Legally separated
6 Not legally separated
17a. Relationship with partner
1 Living together as a couple
2 Not living together as a couple
18. Number of years mother attended school
19. Number of children previously born (excluding present pregnancy)
Liveborn
Stillborn (500 grams or more)
20. Date of last live birth Year Month Day
21. Date of las marriage Year Month Day
Signature of mother or father
I confirm that the above information is accurate. This information is being sent 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 person responsible for the burial and cremation. The information given is subject to the provisions of the Act respecting access to documents held by public bodies and the protection of personal information. The conditions are listed on the back of copy 2.
21a. Date signed Year Month Day
21b. Signature of mother or father
Medical report
22. Date of delivery Year Month Day
23. Kind of birth
01 Single
02 Twin
Other (Specify)
24. If multiple birth, state whether this stillborn child
1st
2nd
3rd Other (Specify)
25. Sex of stillborn child
1 Male
2 Female
9 Undetermined
26. Weight at birth
grams
27. Duration of pregnancy
completed weeks
28. Causes of stillbirth
1 Disease of condition directly leading to death
Antecedent causes. Morbid conditions, if anyy, giving rise to the above cause, stating the underlying condition last
a) due to (or consequence of)
b) due to (or consequence of)
c) (underlying cause)
2. Other significant conditions contributing to the death, but not related to the disease or condition causing it
29. In your opinion, what is the initial cause of the stillbirth? Check (P) one box only.
c Congenital malformation*
c Infection*
c Erythroblastosis
c Malnutrition of foetus
c Antepartum haemorrhage
c Obstetrical trauma or asphyxia*
c Other*
*Specify
30. Autopsy?
1 yes
2 No
If yes, does the cause of death stated above take account of autopsy findings?
1 Yes
2 No
31. Surname and given name of informant
32. Was the informant a
1 Physician
2 Nurse
Other (Specify)
33. Date signed Year Month Day
34. Signature of informant. I have reported, to the best of my knowledge, the causes and the circumstances surrounding this stillbirth Licence number (Corp. of physicians)
Disposition arrangements/Funeral director
35. Disposition arrangements
1 Burial
2 Cremation
3 Anatomical study
4 Transport of body outside Québec
36. Name of funeral home or hospital Licence number (funeral director)
37. Address of funeral home (No., street, municipality, county, province or country outside Canada)
38. Date on which body was handed over Year Month Day
39. Surname and given name of representative of funeral director
40. Signature of representative
SP-4A (rév 03-89)
1- Bureau de la statistique du Québec
ATTESTATION OF DECLARATION OF STILLBIRTH
SP-4
Attestation of Declaration of Stillbirth
Management entrusted to Bureau de la statistique du Québec
Please type or print in block letters. Do not write in shaded spaces. Press firmly.
Place of delivery
1. Name of hospital where stillbirth occurred Establishment code
2. Exact location where stillbirth occurred (No., street, municipality, country, province or country outside Canada)
PARTICULARS OF PARENTS
Father
3. Father’s surname (if the father is unknown, check (P) here c and proceed to question 9)
4. Given name(s)
6. Birthdate of father Year Month Day
7. Father’s birthplace (Province or country outside Canada)
8. Mother tongue of father
01 French
02 English Other
Mother
9. Mother’s maiden surname as shown on birth certificate
10. Given name(s)
12. Birthdate of mother Year Month Day
13. Mother’s birthplace (Province or country outside Canada)
14. Mother tongue of mother
01 French
02 English Other
15. Mother’s address (No., street, municipality, county, province or country outside Canada) Postal code
16. Language spoken at home
01 French
02 English Other
17. Marital status of mother
1 Single (never married)
2 Married and living with her spouse
3 Widowed
4 Divorced
5 Legally separated
6 Not legally separated
17a. Relationship with partner
1 Living together as a couple
2 Not living together as a couple
18. Number of years mother attended school
19. Number of children previously born (excluding present pregnancy)
Liveborn
Stillborn (500 grams or more)
20. Date of last live birth Year Month Day
21. Date of las marriage Year Month Day
Signature of mother or father
I confirm that the above information is accurate. This information is being sent 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 person responsible for the burial and cremation. The information given is subject to the provisions of the Act respecting access to documents held by public bodies and the protection of personal information. The conditions are listed on the back of copy 2.
21a. Date signed Year Month Day
21b. Signature of mother or father
Medical report
22. Date of delivery Year Month Day
23. Kind of birth
01 Single
02 Twin
Other (Specify)
24. If multiple birth, state whether this stillborn child
1st
2nd
3rd Other (Specify)
25. Sex of stillborn child
1 Male
2 Female
9 Undetermined
26. Weight at birth
grams
27. Duration of pregnancy
completed weeks
28. Causes of stillbirth
1 Disease of condition directly leading to death
Antecedent causes. Morbid conditions, if any, giving rise to the above cause, stating the underlying condition last
a) due to (or consequence of)
b) due to (or consequence of)
c) (underlying cause)
2. Other significant conditions contributing to the death, but not related to the disease or condition causing it
29. In your opinion, what is the initial cause of the stillbirth? Check (P) one box only.
c Congenital malformation*
c Infection*
c Erythroblastosis
c Malnutrition of foetus
c Antepartum haemorrhage
c Obstetrical trauma or asphyxia*
c Other*
*Specify
30. Autopsy?
1 yes
2 No
If yes, does the cause of death stated above take account of autopsy findings?
1 Yes
2 No
31. Surname and given name of informant
32. Was the informant a
1 Physician
2 Nurse
Other (Specify)
33. Date signed Year Month Day
34. Signature of informant. I have reported, to the best of my knowledge, the causes and the circumstances surrounding this stillbirth Licence number (Corp. of physicians)
Disposition arrangements/Funeral director
35. Disposition arrangements
1 Burial
2 Cremation
3 Anatomical study
4 Transport of body outside Québec
36. Name of funeral home or hospital Licence number (funeral director)
37. Address of funeral home (No., street, municipality, county, province or country outside Canada)
38. Date on which body was handed over Year Month Day
39. Surname and given name of representative of funeral director
40. Signature of representative
SP-4A (rév 03-89)
2- Medical record
Attestation of Declaration of Stillbirth
Management entrusted to Bureau de la statistique du Québec
Please type or print in block letters. Do not write in shaded spaces. Press firmly.
Place of delivery
1. Name of hospital where stillbirth occurred Establishment code
2. Exact location where stillbirth occurred (No., street, municipality, country, province or country outside Canada)
PARTICULARS OF PARENTS
Father
3. Father’s surname (if the father is unknown, check (P) here c and proceed to question 9)
4. Given name(s)
6. Birthdate of father Year Month Day
7. Father’s birthplace (Province or country outside Canada)
8. Mother tongue of father
01 French
02 English Other
Mother
9. Mother’s maiden surname as shown on birth certificate
10. Given name(s)
12. Birthdate of mother Year Month Day
13. Mother’s birthplace (Province or country outside Canada)
14. Mother tongue of mother
01 French
02 English Other
15. Mother’s address (No., street, municipality, county, province or country outside Canada) Postal code
16. Language spoken at home
01 French
02 English Other
17. Marital status of mother
1 Single (never married)
2 Married and living with her spouse
3 Widowed
4 Divorced
5 Legally separated
6 Not legally separated
17a. Relationship with partner
1 Living together as a couple
2 Not living together as a couple
18. Number of years mother attended school
19. Number of children previously born (excluding present pregnancy)
Liveborn
Stillborn (500 grams or more)
20. Date of last live birth Year Month Day
21. Date of las marriage Year Month Day
Signature of mother or father
I confirm that the above information is accurate. This information is being sent 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 person responsible for the burial and cremation. The information given is subject to the provisions of the Act respecting access to documents held by public bodies and the protection of personal information. The conditions are listed on the back of copy 2.
21a. Date signed Year Month Day
21b. Signature of mother or father
Medical report
22. Date of delivery Year Month Day
23. Kind of birth
01 Single
02 Twin
Other (Specify)
24. If multiple birth, state whether this stillborn child
1st
2nd
3rd Other (Specify)
25. Sex of stillborn child
1 Male
2 Female
9 Undetermined
26. Weight at birth
grams
27. Duration of pregnancy
completed weeks
28. Causes of stillbirth
1 Disease of condition directly leading to death
Antecedent causes. Morbid conditions, if any, giving rise to the above cause, stating the underlying condition last
a) due to (or consequence of)
b) due to (or consequence of)
c) (underlying cause)
2. Other significant conditions contributing to the death, but not related to the disease or condition causing it
29. In your opinion, what is the initial cause of the stillbirth? Check (P) one box only.
c Congenital malformation*
c Infection*
c Erythroblastosis
c Malnutrition of foetus
c Antepartum haemorrhage
c Obstetrical trauma or asphyxia*
c Other*
*Specify
30. Autopsy?
1 yes
2 No
If yes, does the cause of death stated above take account of autopsy findings?
1 Yes
2 No
31. Surname and given name of informant
32. Was the informant a
1 Physician
2 Nurse
Other (Specify)
33. Date signed Year Month Day
34. Signature of informant. I have reported, to the best of my knowledge, the causes and the circumstances surrounding this stillbirth Licence number (Corp. of physicians)
Disposition arrangements/Funeral director
35. Disposition arrangements
1 Burial
2 Cremation
3 Anatomical study
4 Transport of body outside Québec
36. Name of funeral home or hospital Licence number (funeral director)
37. Address of funeral home (No., street, municipality, county, province or country outside Canada)
38. Date on which body was handed over Year Month Day
39. Surname and given name of representative of funeral director
40. Signature of representative
SP-4A (rév 03-89)
2- Medical record
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-Andre, Québec), the ministère de la Santé et des Services sociaux (1075, chemin Sainte-Foy, Québec), the funeral director and the person responsible for burial and cremation.
(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 Stillbirth File used in planning, managing, controlling and assessing programs. Copies of the form are sent, for administrative purposes, to the funeral director and to the person responsible for burial and cremation.
(3) This information will be accessible to:
· the Bureau de la statistique du Québec, the ministère de la Santé et des Services sociaux, the funeral director and the responsible for burial and cremation employees within the context of their work;
· any other user meeting the requirements of this Act and of the Public Health Protection Act.
(4) The information requested in this form is mandatory.
(5) The Public Health Protection Act provides for penalties in case of a false declaration or of a refusal to supply the requested information.
(6) Sections 83 to 102 of the Act provide for the 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, or if its collection is not authorized by the Act.
ATTESTATION OF DECLARATION OF STILLBIRTH
SP-4
Attestation of Declaration of Stillbirth
Management entrusted to Bureau de la statistique du Québec
Please type or print in block letters. Do not write in shaded spaces. Press firmly.
Place of delivery
1. Name of hospital where stillbirth occurred Establishment code
2. Exact location where stillbirth occurred (No., street, municipality, country, province or country outside Canada)
PARTICULARS OF PARENTS
Father
3. Father’s surname (if the father is unknown, check (P) here c and proceed to question 9)
4. Given name(s)
Mother
9. Mother’s maiden surname as shown on birth certificate
10. Given name(s)
15. Mother’s address (No., street, municipality, county, province or country outside Canada) Postal code
Signature of mother or father
I confirm that the above information is accurate. This information is being sent 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 person responsible for the burial and cremation. The information given is subject to the provisions of the Act respecting access to documents held by public bodies and the protection of personal information. The conditions are listed on the back of copy 2.
21a. Date signed Year Month Day
21b. Signature of mother or father
Medical report
22. Date of delivery Year Month Day
23. Kind of birth
01 Single
02 Twin
Other (Specify)
24. If multiple birth, state whether this stillborn child
1st
2nd
3rd Other (Specify)
25. Sex of stillborn child
1 Male
2 Female
9 Undetermined
26. Weight at birth
grams
27. Duration of pregnancy
completed weeks
28. Causes of stillbirth
1 Disease of condition directly leading to death
Antecedent causes. Morbid conditions, if any, giving rise to the above cause, stating the underlying condition last
a) due to (or consequence of)
b) due to (or consequence of)
c) (underlying cause)
2. Other significant conditions contributing to the death, but not related to the disease or condition causing it
29. In your opinion, what is the initial cause of the stillbirth? Check (P) one box only.
c Congenital malformation*
c Infection*
c Erythroblastosis
c Malnutrition of foetus
c Antepartum haemorrhage
c Obstetrical trauma or asphyxia*
c Other*
*Specify
30. Autopsy?
1 yes
2 No
If yes, does the cause of death stated above take account of autopsy findings?
1 Yes
2 No
31. Surname and given name of informant
32. Was the informant a
1 Physician
2 Nurse
Other (Specify)
33. Date signed Year Month Day
34. Signature of informant. I have reported, to the best of my knowledge, the causes and the circumstances surrounding this stillbirth Licence number (Corp. of physicians)
Disposition arrangements/Funeral director
35. Disposition arrangements
1 Burial
2 Cremation
3 Anatomical study
4 Transport of body outside Québec
36. Name of funeral home or hospital Licence number (funeral director)
37. Address of funeral home (No., street, municipality, county, province or country outside Canada)
38. Date on which body was handed over Year Month Day
39. Surname and given name of representative of funeral director
40. Signature of representative
SP-4A (rév 03-89)
3- Funeral director
Attestation of Declaration of Stillbirth
Management entrusted to Bureau de la statistique du Québec
Please type or print in block letters. Do not write in shaded spaces. Press firmly.
Place of delivery
1. Name of hospital where stillbirth occurred Establishment code
2. Exact location where stillbirth occurred (No., street, municipality, country, province or country outside Canada)
PARTICULARS OF PARENTS
Father
3. Father’s surname (if the father is unknown, check (P) here c and proceed to question 9)
4. Given name(s)
Mother
9. Mother’s maiden surname as shown on birth certificate
10. Given name(s)
15. Mother’s address (No., street, municipality, county, province or country outside Canada) Postal code
Signature of mother or father
I confirm that the above information is accurate. This information is being sent 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 person responsible for the burial and cremation. The information given is subject to the provisions of the Act respecting access to documents held by public bodies and the protection of personal information. The conditions are listed on the back of copy 2.
21a. Date signed Year Month Day
21b. Signature of mother or father
Medical report
22. Date of delivery Year Month Day
23. Kind of birth
01 Single
02 Twin
Other (Specify)
24. If multiple birth, state whether this stillborn child
1st
2nd
3rd Other (Specify)
25. Sex of stillborn child
1 Male
2 Female
9 Undetermined
26. Weight at birth
grams
27. Duration of pregnancy
completed weeks
28. Causes of stillbirth
1 Disease of condition directly leading to death
Antecedent causes. Morbid conditions, if any, giving rise to the above cause, stating the underlying condition last
a) due to (or consequence of)
b) due to (or consequence of)
c) (underlying cause)
2. Other significant conditions contributing to the death, but not related to the disease or condition causing it
29. In your opinion, what is the initial cause of the stillbirth? Check (P) one box only.
c Congenital malformation*
c Infection*
c Erythroblastosis
c Malnutrition of foetus
c Antepartum haemorrhage
c Obstetrical trauma or asphyxia*
c Other*
*Specify
30. Autopsy?
1 yes
2 No
If yes, does the cause of death stated above take account of autopsy findings?
1 Yes
2 No
31. Surname and given name of informant
32. Was the informant a
1 Physician
2 Nurse
Other (Specify)
33. Date signed Year Month Day
34. Signature of informant. I have reported, to the best of my knowledge, the causes and the circumstances surrounding this stillbirth Licence number (Corp. of physicians)
Disposition arrangements/Funeral director
35. Disposition arrangements
1 Burial
2 Cremation
3 Anatomical study
4 Transport of body outside Québec
36. Name of funeral home or hospital Licence number (funeral director)
37. Address of funeral home (No., street, municipality, county, province or country outside Canada)
38. Date on which body was handed over Year Month Day
39. Surname and given name of representative of funeral director
40. Signature of representative
SP-4A (rév 03-89)
3- Funeral director
ATTESTATION OF DECLARATION OF STILLBIRTH
SP-4
Attestation of Declaration of Stillbirth
Management entrusted to Bureau de la statistique du Québec
Please type or print in block letters. Do not write in shaded spaces. Press firmly.
Place of delivery
1. Name of hospital where stillbirth occurred Establishment code
2. Exact location where stillbirth occurred (No., street, municipality, country, province or country outside Canada)
PARTICULARS OF PARENTS
Father
3. Father’s surname (if the father is unknown, check (P) here c and proceed to question 9)
4. Given name(s)
Mother
9. Mother’s maiden surname as shown on birth certificate
10. Given name(s)
15. Mother’s address (No., street, municipality, county, province or country outside Canada) Postal code
Signature of mother or father
I confirm that the above information is accurate. This information is being sent 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 person responsible for the burial and cremation. The information given is subject to the provisions of the Act respecting access to documents held by public bodies and the protection of personal information. The conditions are listed on the back of copy 2.
21a. Date signed Year Month Day
21b. Signature of mother or father
Medical report
22. Date of delivery Year Month Day
31. Surname and given name of informant
32. Was the informant a
1 Physician
2 Nurse
Other (Specify)
33. Date signed Year Month Day
34. Signature of informant. I have reported, to the best of my knowledge, the causes and the circumstances surrounding this stillbirth Licence number (Corp. of physicians)
Disposition arrangements/Funeral director
35. Disposition arrangements
1 Burial
2 Cremation
3 Anatomical study
4 Transport of body outside Québec
36. Name of cemetery, crematerium or hospital
37. Address of the place of disposal of body (No., street, municipality, county, province or country outside Canada)
38. Date of disposal of body Year Month Day
39. Surname and given name of representative
40. Signature of representative
SP-4A (rév 03-89)
4- Place of disposal
Attestation of Declaration of Stillbirth
Management entrusted to Bureau de la statistique du Québec
Please type or print in block letters. Do not write in shaded spaces. Press firmly.
Place of delivery
1. Name of hospital where stillbirth occurred Establishment code
2. Exact location where stillbirth occurred (No., street, municipality, country, province or country outside Canada)
PARTICULARS OF PARENTS
Father
3. Father’s surname (if the father is unknown, check (P) here c and proceed to question 9)
4. Given name(s)
Mother
9. Mother’s maiden surname as shown on birth certificate
10. Given name(s)
15. Mother’s address (No., street, municipality, county, province or country outside Canada) Postal code
Signature of mother or father
I confirm that the above information is accurate. This information is being sent 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 person responsible for the burial and cremation. The information given is subject to the provisions of the Act respecting access to documents held by public bodies and the protection of personal information. The conditions are listed on the back of copy 2.
21a. Date signed Year Month Day
21b. Signature of mother or father
Medical report
22. Date of delivery Year Month Day
31. Surname and given name of informant
32. Was the informant a
1 Physician
2 Nurse
Other (Specify)
33. Date signed Year Month Day
34. Signature of informant. I have reported, to the best of my knowledge, the causes and the circumstances surrounding this stillbirth Licence number (Corp. of physicians)
Disposition arrangements/Funeral director
35. Disposition arrangements
1 Burial
2 Cremation
3 Anatomical study
4 Transport of body outside Québec
36. Name of cemetery, crematerium or hospital
37. Address of the place of disposal of body (No., street, municipality, county, province or country outside Canada)
38. Date of disposal of body Year Month Day
39. Surname and given name of representative
40. Signature of representative
SP-4A (rév 03-89)
4- Place of disposal
SP-4 - Instructions
The Declaration of Stillbirth form is applied in compliance with the regulations respecting the Public Health Protection Act (chapter P-35). By virtue of this law, the Minister of Health and Social Services has the power to establish and maintain a system for collecting and analysing social, medical and epidemiological data and, for demographic purposes, to compile date pertinent to birth, marriage, divorce, annulment and death. The Bureau de la statistique du Québec is responsible for gathering, processing and using this date under Order in Council 260-84, dated 12 February 1985.
NOTE
Care should be taken to fill in dates and numbers in the appropriate squares. Mark one or more zeros 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 questions not applicable, draw a horizontal line through the appropriate square(s). Note that all dates should be entered in the following sequence: year, month, day.
Examples:
Stillbirth |0|0|; June 2, 1958 |5|8|0|6|0|2|; 524 grams |0|5|2|4|
The answers must always take into consideration the situation which prevailed at the time of the stillbirth, such as the mother’s home address, civil status, etc.
(1) Mailing of forms
For mailing declarations required by law, stamped addressed envelopes may be obtained from:
Bureau de la statistique du Québec
117, rue Saint-André
Québec (Québec)
G1K 3Y3
(2) Time limit for mailing forms
The following time limit is to be respected for mailing completed forms to the Bureau de la statistique du Québec: 8 days after delivery.
(3) Place of delivery (questions 1 and 2)
If stillbirth did not occur in an establishment, answer question 2 only, giving specifics.
(4) Given name(s) (questions 4 and 10)
This refers to the given name(s) ordinarily used by a person. Double given names, such as David-John or Mary-Ellen, are to be noted in the appropriate space and the two names should be joined by a hyphen. Do not hyphenate other given names.
(5) Name as shown on birth certificate (question 9)
The surname given to a woman at birth, i.e. the maiden name in the case of a married woman. Please avoid using pseudonyms (nicknames).
(6) Mother tongue (questions 8 and 14)
This refers to the first language acquired as a child and still understood. If the first language is no longer understood, give the second language acquired and still understood. If a person gives two answers, please insist that s/he selects the language most often used at childhood.
(7) Language spoken at home (question 16)
If more than one language is spoken at home, give the one most frequently used. List one language only.
(8) Marital status of mother and relationship with partner(questions 17 and 17a)
When a mother states that she is separated, it must be ascertained whether or not she is legally separated. The term relationship with partner is not defined in order to let the parents answer according to their own perception of the concept.
(9) Number of years of schooling (question 18)
Number of school years successfully completed. School years that were not completed or for which no pass marks were obtained at the end of the year should not be counted.
(10) Number of children born previously(question 19)
This question must be answered, regardless of the reply. For women giving birth for the first time, enter zeros in all the appropriate spaces; for those who have given birth before, indicate the number of live births and, if applicable, the number of stillbirths. Indicate stillbirths only if birth weight was 500 grams or more.
(11) Date of last live birth (question 20)
Enter the birth date of the preceding live birth. For women giving birth for the first time, draw a horizontal line through the appropriate square.
(12) Date of last marriage (question 21)
For those who have been married only once, enter the date of that marriage; for those married more than once, the date of the most recent marriage.
(13) Multiple births (questions 23 and 24)
In case of multiple birth, fill in form SP-1, for each liveborn child, and form SP-4 for each stillborn child. As much as possible, all forms reporting multiple births (SP-1, SP-3 or SP-4) should be stapled together.
(14) Birth weight (question 26)
Weight should be given in grams only, never in kilograms.
