BIBLIOGRAPHIC INPUT SHEET TEMPORARY Patterns of mortality ...

370 PatteW n of Mortality in Childhood
Confidential
INTER-AMERICAN INVESTIGATION
OF MORTALITY IN CHILDHOOD
Death page 9
Name of child
Date of
birth
Date of
death
120. Medical certification of cause of death (exact copy)
I a
b
Serial no.
Sex Age at
I ideath __ yrs. __nos._ days hrs.
Duration
Classification
121. SUMMARY
OF INVESTIGATION
Medical interviewer
Underlying cause
Basis for diagnosis
Classification
Associated causes I.
3.
Evaluation of nutrition
Principal collaborator
Underlying cause
Associated causes I.
Z.
3.
IZ2.
ASSIGNMENT
13Y REFEREE
Basis
Special code
for nutritional
status
Basis for diagnosis: I. Autopsy 4.
2. Hospital 5.
3. Clinical, definite 6.
Clinical, questionable
Interview only
Death certificate only