LOCAL FILE NO. STATE FILE NO.
1. DECEDENT’S LEGAL NAME (Include AKA’s if any) (First, Middle, Last)
2. SEX
3. SOCIAL SECURITY NUMBER
4b. UNDER 1 YEAR
4c. UNDER 1 DAY
4a. AGE-Last Birthday
(Years)
Months
Days
Hours
Minutes
5. DATE OF BIRTH (Mo/Day/Yr)
6. BIRTHPLACE (City and State or Foreign Country)
7a. RESIDENCE-STATE
7b. COUNTY
7c. CITY OR TOWN
7d. STREET AND NUMBER
7e. APT. NO.
7f. ZIP CODE
7g. INSIDE CITY LIMITS? □ Yes □ No
8. EVER IN US ARMED FORCES?
□ Yes □ No
9. MARITAL STATUS AT TIME OF DEATH
□ Married □ Married, but separated □ Widowed
□ Divorced □ Never Married □ Unknown
10. SURVIVING SPOUSE’S NAME (If wife, give name prior to first marriage)
11. FATHER’S NAME (First, Middle, Last)
12. MOTHER’S NAME PRIOR TO FIRST MARRIAGE (First, Middle, Last)
13a. INFORMANT’S NAME
13b. RELATIONSHIP TO DECEDENT
13c. MAILING ADDRESS (Street and Number, City, State, Zip Code)
14. PLACE OF DEATH (Check only one: see instructions)
IF DEATH OCCURRED IN A HOSPITAL:
□ Inpatient □ Emergency Room/Outpatient □ Dead on Arrival
IF DEATH OCCURRED SOMEWHERE OTHER THAN A HOSPITAL:
□ Hospice facility □ Nursing home/Long term care facility □ Decedent’s home □ Other (Specify):
15. FACILITY NAME (If not institution, give street & number)
16. CITY OR TOWN , STATE, AND ZIP CODE
17. COUNTY OF DEATH
18. METHOD OF DISPOSITION: □ Burial □ Cremation
□ Donation □ Entombment □ Removal from State
□ Other (Specify):_____________________________
19. PLACE OF DISPOSITION (Name of cemetery, crematory, other place)
20. LOCATION-CITY, TOWN, AND STATE
21. NAME AND COMPLETE ADDRESS OF FUNERAL FACILITY
NAME OF DECEDENT ____________________________________________
For use by physician or institution
To Be Completed/ Verified By:
FUNERAL DIRECTOR:
22. SIGNATURE OF FUNERAL SERVICE LICENSEE OR OTHER AGENT
23. LICENSE NUMBER (Of Licensee)
ITEMS 24-28 MUST BE COMPLETED BY PERSON WHO PRONOUNCES OR CERTIFIES DEATH
24. DATE PRONOUNCED DEAD (Mo/Day/Yr)
25. TIME PRONOUNCED DEAD
26. SIGNATURE OF PERSON PRONOUNCING DEATH (Only when applicable)
27. LICENSE NUMBER
28. DATE SIGNED (Mo/Day/Yr)
29. ACTUAL OR PRESUMED DATE OF DEATH
(Mo/Day/Yr) (Spell Month)
30. ACTUAL OR PRESUMED TIME OF DEATH
31. WAS MEDICAL EXAMINER OR
CORONER CONTACTED? □ Yes □ No
CAUSE OF DEATH (See instructions and examples)
32. PART I. Enter the chain of events--diseases, injuries, or complications--that directly caused the death. DO NOT enter terminal events such as cardiac
arrest, respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional
lines if necessary.
IMMEDIATE CAUSE (Final
disease or condition ---------> a._____________________________________________________________________________________________________________
resulting in death) Due to (or as a consequence of):
Sequentially list conditions, b._____________________________________________________________________________________________________________
if any, leading to the cause Due to (or as a consequence of):
listed on line a. Enter the
UNDERLYING CAUSE c._____________________________________________________________________________________________________________
(disease or injury that Due to (or as a consequence of):
initiated the events resulting
in death) LAST d._____________________________________________________________________________________________________________
Approximate interval:
Onset to death
_____________
_____________
_____________
_____________
33. WAS AN AUTOPSY PERFORMED?
□ Yes □ No
PART II. Enter other significant conditions contributing to death but not resulting in the underlying cause given in PART I
34. WERE AUTOPSY FINDINGS AVAILABLE TO
COMPLETE THE CAUSE OF DEATH? □ Yes □ No
35. DID TOBACCO USE CONTRIBUTE
TO DEATH?
□ Yes □ Probably
□ No □ Unknown
36. IF FEMALE:
□ Not pregnant within past year
□ Pregnant at time of death
□ Not pregnant, but pregnant within 42 days of death
□ Not pregnant, but pregnant 43 days to 1 year before death
□ Unknown if pregnant within the past year
37. MANNER OF DEATH
□ Natural □ Homicide
□ Accident □ Pending Investigation
□ Suicide □ Could not be determined
38. DATE OF INJURY
(Mo/Day/Yr) (Spell Month)
39. TIME OF INJURY
40. PLACE OF INJURY (e.g., Decedent’s home; construction site; restaurant; wooded area)
41. INJURY AT WORK?
□ Yes □ No
42. LOCATION OF INJURY: State: City or Town:
Street & Number: Apartment No.: Zip Code:
43. DESCRIBE HOW INJURY OCCURRED:
44. IF TRANSPORTATION INJURY, SPECIFY:
□ Driver/Operator
□ Passenger
□ Pedestrian
□ Other (Specify)
45. CERTIFIER (Check only one):
□ Certifying physician-To the best of my knowledge, death occurred due to the cause(s) and manner stated.
□ Pronouncing & Certifying physician-To the best of my knowledge, death occurred at the time, date, and place, and due to the cause(s) and manner stated.
□ Medical Examiner/Coroner-On the basis of examination, and/or investigation, in my opinion, death occurred at the time, date, and place, and due to the cause(s) and manner stated.
Signature of certifier:_____________________________________________________________________________
46. NAME, ADDRESS, AND ZIP CODE OF PERSON COMPLETING CAUSE OF DEATH (Item 32)
To Be Completed By:
MEDICAL CERTIFIER
47. TITLE OF CERTIFIER
48. LICENSE NUMBER
49. DATE CERTIFIED (Mo/Day/Yr)
50. FOR REGISTRAR ONLY- DATE FILED (Mo/Day/Yr)
51. DECEDENT’S EDUCATION-Check the box that best describes the highest degree or level of school completed at the time of death.
□ 8th grade or less
□ 9th - 12th grade; no diploma
□ High school graduate or GED completed
□ Some college credit, but no degree
□ Associate degree (e.g., AA, AS)
□ Bachelor’s degree (e.g., BA, AB, BS)
□ Master’s degree (e.g., MA, MS, MEng,
MEd, MSW, MBA)
□ Doctorate (e.g., PhD, EdD) or
Professional degree (e.g., MD, DDS,
DVM, LLB, JD)
52. DECEDENT OF HISPANIC ORIGIN? Check the box
that best describes whether the decedent is
Spanish/Hispanic/Latino. Check the “No” box if
decedent is not Spanish/Hispanic/Latino.
□ No, not Spanish/Hispanic/Latino
□ Yes, Mexican, Mexican American, Chicano
□ Yes, Puerto Rican
□ Yes, Cuban
□ Yes, other Spanish/Hispanic/Latino
(Specify) __________________________
53. DECEDENT’S RACE (Check one or more races to indicate what the
decedent considered himself or herself to be)
□ White
□ Black or African American
□ American Indian or Alaska Native
□ Asian Indian
(Name of the enrolled or principal tribe) _______________
□ Chinese
□ Filipino
□ Japanese
□ Korean
□ Vietnamese
□ Other Asian (Specify)__________________________________________
□ Native Hawaiian
□ Guamanian or Chamorro
□ Samoan
□ Other Pacific Islander (Specify)_________________________________
□ Other (Specify)___________________________________________
54. DECEDENT’S USUAL OCCUPATION (Indicate type of work done during most of working life. DO NOT USE RETIRED).
To Be Completed By:
FUNERAL DIRECTOR
55. KIND OF BUSINESS/INDUSTRY
REV. 11/2003
USEFUL!: CERTIFICATE OF DEATH WHICH IS REALLY EASY TO READ:
to see this certificate in its original size: http://www.dalelange.info/showmedia.php?mediaID=370&all=1
