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township, or other primary division). By immediate registration is meant registration before the interment or removal of the body. NOTE.-Without immediate record at the time and place of death there can be no accurate and complete registration. The farther the time and place of the record are removed from the time and place of the occurrence, the greater will be the inevitable error. Wherever any latitude beyond the date of burial has been allowed, the registration of deaths has always resulted in failure. The collection of statistics by any sort of post-funeral enumeration can not possibly be better than fragmentary, and therefore, of little use to the sanitarian. The records lose by delay their chief importance to the citizen in the protection of his private interests; for records admitted in court as prima facie evidence have greatest weight when they have been made at the time and place of death and by competent persons having first-hand knowledge of the facts.

2. CERTIFICATES OF DEATH SHOULD BE REQUIRED. The primary record of a death should consist of a certificate of prescribed form including, as a minimum requirement, all of the data necessary for the mortality statistics of the United States. Census.

NOTE. The items required for the census statistics should appear in every instance, because each of them is essential to the compilation of uniform tables for the different states and cities. To these may be added such other items as may be required by peculiar local conditions. Experience has shown that definite information in excess of that called for by the approved form of certificate is difficult to obtain, while less will not serve the reasonable needs of statisticians or of the citizens who consult the records.

3. BURIAL OR REMOVAL PERMITS ARE ESSENTIAL TO THE

ENFORCEMENT OF THE LAW.

No dead body should be removed from the place of death, interred, cremated, or otherwise disposed of, unless such action is authorized by a burial or removal permit, based upon a satisfactory certificate of death and signed by the local registrar.

NOTE. The requirement that a certificate shall be filed for each death can not be enforced in practice except by the additional provision that no body shall be removed or interred without a permit issued by the local registrar after receiving and approving the death certificate.

The burial permit is the sine qua non of registration. It implies that the death has been accounted for according to law and it fastens the record to the time and place of the event. A registration law without a burial or removal permit provision is scarcely better than no law.

The precise form for this blank is not important, the chief requirements being that it shall identify the decedent; give the place, date and cause of death; and be attested by the signature of the local registrar as evidence that the death certificate has been filed and recorded. A good example of a complete form, used in Michigan, is shown in the appendix.

4.

EFFICIENT LOCAL REGISTRARS ARE NECESSARY. There should be an efficient local registrar in each city, village, town or township, or other local political district, whose duty it should be to receive and approve certificates of death and to issue burial or removal permits for all deaths that occur in his jurisdiction. He should be properly compensated, and should be required to enforce the law in his own district under penalty for neglect. He should also be required to make returns to the central registration office, and the time and manner of making such returns should be expressly designated by law.

NOTE. Local registrars should be selected solely with reference to their special fitness for the work, and a competent and efficient registrar should remain undisturbed in his position as long as practicable. Inefficient or negligent registrars should be subject to removal by the central registration authority.

It is highly desirable that local registrars take an active interest in the work of registration to insure that their records are full, complete and readily available for consultation. They may also greatly advance the purposes of registration in their communities by proper explanation.

5. THE RESPONSIBILITY FOR REPORTING DEATHS TO THE LOCAL REGISTRAR SHOULD BE FIXED.

The responsibility for obtaining and filing the original record of death with the local registrar should be fixed by the law. The best results are obtained when this duty is imposed upon the undertaker or other person having charge of the interment, removal, or other disposition of the body. He should therefore be made primarily responsible, under penalty for neglect, for presenting the certificate of death and obtaining the burial or removal permit before the body is disposed of.

The attending physician, coroner, health officer, or other official, should be required to certify the cause of death and to furnish, upon demand, any other information he may possess that is required to complete the record of the case. The personal data relating to the decedent may be supplied by any member of the family, next of kin, landlord or person in charge of the premises on which the death occurred, and they, and all other persons cognizant of the facts, should be required to furnish such information to the undertaker, physician, or other person preparing the return. The name and address of the person furnishing the personal data should appear in the return.

NOTE. The undertaker is made primarily responsible for obtaining and filing the record because it is he who proposes to remove the natural evidence of death, that is, the body. He, however, is obliged to depend upon others for a correct statement of the facts and there

fore all persons having knowledge of the case should be required to assist in the completion of the return.

While the undertaker's responsibility is primary, it is not exclusive, and the state may lay correlative responsibilities upon any or all persons concerned in the removal or burial of a human body, e. g., upon the next of kin, the householder, physician, minister, sexton, express agent, transportation agent, coroner or any other person controlling or directing, in whole or in part, the removal or burial.

The information as to the cause of death, which is the vital feature of the return, is almost wholly dependent for completeness and accuracy upon the medical knowledge, carefulness and interest of the physician. Hence physicians should make the most exact statement of the cause and should carefully avoid the use of unmeaning terms. By reason of his relations to the family, the physician frequently has accurate knowledge of the personal data required, and in such cases he should see that the facts are correctly stated. There should be perfect co-operation between physicians and undertakers.

6. THE CENTRAL REGISTRATION OFFICE SHOULD HAVE FULL CONTROL OF THE LOCAL MACHINERY, AND ITS RULES SHOULD HAVE THE EFFECT OF LAW.

The central registration office of the state should have direct supervision and control of all matters relating to local registration. It should be charged with the maintenance of complete records, and with the efficient and uniform enforcement of the law. To this end it should be able to command the assistance of the legal department of the state. It should also be empowered to remove inefficient or negligent local registrars and to appoint others in their stead; to prescribe, print, and distribute the forms of certificates and records for local use; to receive returns from local registrars; and to preserve the records in suitable order for convenient reference.

The rules and regulations promulgated by the central office should be given the force and effect of law.

7.

THE TRANSMISSION AND PRESERVATION OF RECORDS SHOULD
BE PROVIDED for.

A complete, permanent record of each death should be kept in the office of the local registrar and in the central registration office, and provision should be made for indexing the records in strict alphabetical order.

Returns should be made monthly to the central office, and within a certain specified period after the close of each month. This is necessary in order to enable the central office to ascertain the efficiency of local registration, and to scrutinize the certificates and secure corrections, if they are found defective, as soon as possible after the cases are reported.

Returns should be made to the central office in one of these two ways:

a. A copy of each record may be made by the local registrar; in which case the original record will be forwarded to the state office.

b. The original record may be retained by the local registrar; in which case a complete copy should be made in permanent form, certified by the local registrar, and forwarded to the state office. The first mentioned method is considered preferable.

NOTE. These provisions insure available records in both local and state offices. One of these necessarily must be a copy. Both are intended to serve the same purposes, and it is therefore imperative that-whether retained by the local registrar or forwarded to the state office the copy should contain every item of information inIcluded in the original.

8. PENALTIES SHOULD BE PROVIDED.

Penalties should be provided for violation of any of the provisions of the law. Each section should specify the penalties imposed which should be based upon the importance of its requirements.

CO-OPERATION OF OFFICIALS.

Municipal and other local registration offices should co-operate. with the central registration office of the state; state offices should co-operate with the federal offices collecting or using mortality statistics; and all should labor harmoniously, to the end that a reliable and fully satisfactory registration of deaths be extended over the United States at the earliest possible moment.

Whatever variations from approved practice peculiar local conditions may seem to require, it is of prime importance that the registration laws of cach state should harmonize as closely as possible with those of contiguous states. It is, however, both unnecessary and inexpedient to omit any of the preceding provisions for the sake of any apparent local difficulty either within or without a proposed registration area.

A synopsis of the proposed bill is here submitted.

SECTION 1. Places the State Board of Health in charge of the system.

SEC. 2. The Secretary of the board is given general supervision over the central bureau of vital statistics. He shall be a medical practitioner of not less than five years' practice.

SEC. 3. Divides the state into registration districts.

SEC. 4. A local registrar of vital statistics to be appointed for each registration district. He may be removed by the State Board of Health for neglect of duty.

SEC. 5. Forbids burial or removal of body without permit based upon certificate of death.

SEC. 6. Certificates of death of still-born children to be signed by attending physician and not by midwife.

SEC. 7. Contents of certificate of death.

SEC. 8. Providing for signature by undertaker, by local registrar and physician, or other competent informant. Requires undertaker to notify local registrar of deaths without medical attendance, and for investigation of such deaths by health officer

or coroner.

SEC. 9. Imposes duty upon undertaker of obtaining and filing certificate of death and securing burial or removal permit and delivering such permit to person in charge of burial place, etc.

SEC. 10. Contents of burial permit where the interment is to be made within the state.

SEC. 11. Forbids interments without permit, requires sexton to keep record of interments and report same to the local registrar.

SEC. 12. Requires all births to be immediately registered in the districts in which they occur.

SEC. 13. Requires physician or others in attendance to file birth certificates within ten days after date of birth, and imposes duty on local registrar to procure necessary signatures, etc.

SEC. 14. Contents of birth certificates, to be signed by attending physician or other person designated.

SEC. 15. Requires report of name of child to be filed. SEC. 16. Requires every physician, midwife and undertaker to register with the local registrar, and for registration of such names with state registrar.

SEC. 17. Requires managers of hospitals and all institutions, public or private, for treatment of disease, to keep certain statistical records.

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