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84
METROPOLITAN BOROUGH OF ST. PANCRAS.
Public Health Department.
Voluntary Notification of Cases of Consumption
(Pulmonary Phthisis).
Sanitary Inspector's Report to Medical Officer of Health.
Bacteriological Examination
of Sputum.
Notification of
Death.
Notification of Disease.
Inspector Date of Visit
Bacteriological Examination of Sputum, No. of Box
Name of Medical Practitioner sent by
Address of ditto
Name, Age, and Sex of Patient
Address of Patient
Disease suspected
Date and hour of receipt of message or report
Report of result
Date and hour sent to Medical Practitioner
Date of receipt of Certificate and entry in Register
Name, Sex, and Age of Patient
Inmate of
If of a Public Institution
Residence removed from and Date of Removal
Suffering from
Public or Private Case
Medical Practitioner certified by
Address of Medical Practitioner
Dates of any previous Notifications
Date and District of Death Return
When and where died
Name, Sex, and Age of Deceased
Occupation
Cause of Death
Certified by
Name, Age, and Sex of Patient
Present Residence
Length of Residence at present Address
Previous Residences
Occupation
Place of Occupation
Date of beginning of Illness (approximate)
Whether ceased Occupation, and since when
Whether and since when confined to house
„ „ „ room
,, ,, ,, bed
Whether in last stage, advanced, pronounced, or incipient
Number of Persons in family—Males Females Children Total
Number of rooms in dwelling