Fill and Sign the Department of Health Memorandum New York State Department of Form

AFFIDAVIT OF CUSTODIAN OF MEDICAL RECORDS STATE OF _____________________ COUNTY OF __________________ I, _________________________________________, am the duly authorized custodian of the medical records of _________________________________________________, and as such have the authority to certify that medical records attached hereto constitute a true and correct copy of the medical records pertaining to the treatment of ________________________________ at your office or institution from the _____ day of ___________, 20___, to the _____ day of ___________, 20___. The attached records were prepared by the personnel of _________________________________________________, staff physicians, or persons acting under the control of either, in the ordinary course of business, at or near the time of treatment reported therein. The reasonable charges incurred by ________________________ in furnishing the copy of these records is $_____________. ________________________________CUSTODIAN SWORN TO AND SUBSCRIBED BEFORE ME, this the ____ day of _________, 20____. _________________________________________ NOTARY PUBLIC (SEAL) My Commission Expires;____________________________
[name, title, date, signature.] the affidavit was not executed or acknowledged by the physician, but it does show his name, address and signature, and a copy was sent to the physician for authentication in the office of the coroner. This copy was examined as is shown in the affidavit, and it is found to be a true and correct copy of the medical record. The certificate was signed by the physician who examined the medical record, by Dr. P. S. Harkos' initials below it, and the signature is "dr. K." when the inquest was called the coroner stated he had examined the record signed by the physician, Dr. S. F. Harkos, and it appeared to him that the record was genuine, correct and genuine, and the doctor had signed it as he claimed he had. The physician admitted to the coroner that he had used chloroform, i. E., chloroform as an anesthetic, at his house, hospital and in the practice of his profession, and that the medical records of his patients who died because of his use of that drug, had been certified by him. He said he had made no false statements in the certificate. Page 367 u. S. 456 the court also ordered that the certificate of the doctor be received in probate, with the certificate of the medical examiner, and the certificate or certificates of any other person who testified at the inquest. The coroner ordered the papers of the inquest to be delivered to the sheriff of the county of New York who immediately forwarded them to mr. S. P. Clark, assistant state attorney for the state of New York who, in accordance with the law of the state of New York as it now exists, certified that they were authentic. The coroner ordered the record to be transmitted to the clerk of the circuit court of the county of new york from which the coroner had his office. The medical examiner for new york, mr. W. C. Clark, stated that he was in agreement with these orders of the coroner of New York, and that it was his opinion that, under all the circumstances of this case, the certificate was reliable. He said he had examined the certificate, and he found it to be a true , correct and genuine. He said he had found it to appear that the time prescribed on the application form (doc. 7, affidavit of the physician attached), i. E., the time for completing the