Borough of Steelton, Pennsylvania
Death Certificate Form

The Borough of Steelton, Dauphin County, Pennsylvania, used a standard form to record deaths within its boundaries.  The questions and text below are from a form used in 1892 and 1893, and are transcribed in the same order, and with the same punctuation used on the form.  This transcription can be used for comparison purposes with the extracted data from Death Certificates for African Americans in Steelton, 1892-1893, to determine, for instance, which lines were not filled out by the physician.

Of interest is the list of diseases on the reverse of the form, and instructions on additional information that should be included by the physician filling out the form.  Not all physicians followed these instructions, however.

This item is from the Friends of Midland Archives, Steelton, Pennsylvania.

Front of Form

Form 1
Borough of Steelton, Pa.
Form of a Return of a Death.
No.____
The Special Attention of Physicians is respectfully invited to the Remarks below, and to the List of Diseases on the reverse side.

Certificate of Death.
To the Secretary of Borough Council.

Permit No.
Date of Death 189_
Full Name of Deceased
Sex
Age __Years __Months __Days
Color
Married, Single, Widow, or Widower, [Cross out the words not required in this line.]
Occupation
Birthplace
Duration of Residence in Borough
Nativity of Father____ Nativity of Mother____
When a Minor {Name of Father____ Name of Mother____
Place of Death [Give Street and Number]
Cause of Death {First (Predisposing)____ Second (Immediate)____
Duration of Last Sickness
All of the above information should be furnished by the Physician.
In case of death by communicable disease, please state what, if any, local cause exists to produce the same.

Place of Burial
Date of Burial
{Undertaker
{Place of Business
(signature line) ____M.D.
Address

Extract From Sanitary Ordinance.

     Section 47. Every undertaker or other person who may have charge of the funeral of any dead person shall procure a properly filled out certificate of the death and its probable cause, in accordance with the form prescribed by the Borough Council, and shall present the same to the Secretary of Council, and obtain a burial or transit permit thereupon, at least twenty-four hours before the time appointed for such funeral; and he shall not remove any dead body until such burial or transit permit shall have been procured.

Back of Form

Abcess - Cause, location and mode of death.
*Aneurism - Mode of Death.
Cer. Spin. Meningitis - Variety, whether expidemic or simply inflammatory
Childbirth - Circumstances producing Death.
*Cancer - Variety and seat.
Calculus - Mode of Death.
Detention - Mode of Death.
Disease of Heart - Variety. Valves involved.
Dropsy - Variety and Cause, and Serous Sac involved
Enteritis and Gastro Enteritis - Cause. Whether Diarrhoeal or not.
Erysipelas - Seat and cause.
Fractures - Cause and Mode of Death.
Gangrene - Seat and cause.
Gastritis - Cause.
*Hernia - Variety and Mode of Death.
Insanity - Variety and Mode of Death.
Jaundice - Cause and Mode of Death.
Mania, Acute - Cause and Mode of Death.
Miscarriage - Cause and Mode of Death.
Malignant Pustule - Location and cause.
Malformation - Variety and cause.
Metritis - Variety and cause.
Necrosis - Seat, Cause and Mode of Death.
*Ovarian Tumor - Mode of Death.
Paralysis - Variety and cause.
Peritonitis - Cause.
Phlebitis - Cause.
Pyæmia - Cause. Nature of injury, if any.
Premature Birth - Cause. Foetal age.
Preternatural Birth - Manner of.
Syphilis - Variety, chief location, and mode of death.
Tetanus - Nature of injury, if any.
Ulcer - Nature, chief location, and mode of death.
Violence - Cause, variety, seat, and mode of death.

Specify every Surgical Operation with fatal result.
Mention INTEMPERANCE whenever recognized as having produced or complicated the direct cause of Death.
In Diseases marked thus * state if operation has been performed.
In cases of Death resulting from Violence, state whether Accidental, Homicidal, Suicidal, or in pursuance of Legal Judgment.

Remarks.

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