U.S.

STANDARD CERTIFICATE OF DEATH

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

4a. AGE-Last Birthday 4b. UNDER 1 YEAR 4c. UNDER 1 DAY 5. DATE OF BIRTH (Mo/Day/Yr) 6. BIRTHPLACE (City and State or Foreign Country)
(Years)
Months Days Hours Minutes

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? 9. MARITAL STATUS AT TIME OF DEATH 10. SURVIVING SPOUSE’S NAME (If wife, give name prior to first marriage)
□ Yes □ No □ Married □ Married, but separated □ Widowed
□ Divorced □ Never Married □ Unknown
11. FATHER’S NAME (First, Middle, Last) 12. MOTHER’S NAME PRIOR TO FIRST MARRIAGE (First, Middle, Last)
To Be Completed/ Verified By:
FUNERAL DIRECTOR:
For use by physician or institution

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: IF DEATH OCCURRED SOMEWHERE OTHER THAN A HOSPITAL:
NAME OF DECEDENT

□ Inpatient □ Emergency Room/Outpatient □ Dead on Arrival □ 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 19. PLACE OF DISPOSITION (Name of cemetery, crematory, other place)
□ Donation □ Entombment □ Removal from State
□ Other (Specify):
20. LOCATION-CITY, TOWN, AND STATE 21. NAME AND COMPLETE ADDRESS OF FUNERAL FACILITY

22. SIGNATURE OF FUNERAL SERVICE LICENSEE OR OTHER AGENT 23. LICENSE NUMBER (Of Licensee)

ITEMS 24-28 MUST BE COMPLETED BY PERSON 24. DATE PRONOUNCED DEAD (Mo/Day/Yr) 25. TIME PRONOUNCED DEAD
WHO PRONOUNCES OR CERTIFIES DEATH
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 30. ACTUAL OR PRESUMED TIME OF DEATH 31. WAS MEDICAL EXAMINER OR
(Mo/Day/Yr) (Spell Month) CORONER CONTACTED? □ Yes □ No

CAUSE OF DEATH (See instructions and examples) Approximate

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 interval:
arrest, respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional Onset to death
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.

PART II. Enter other significant conditions contributing to death but not resulting in the underlying cause given in PART I 33. WAS AN AUTOPSY PERFORMED?
□ Yes □ No
34. WERE AUTOPSY FINDINGS AVAILABLE TO
COMPLETE THE CAUSE OF DEATH? □ Yes □ No
35. DID TOBACCO USE CONTRIBUTE 36. IF FEMALE: 37. MANNER OF DEATH
To Be Completed By:
MEDICAL CERTIFIER

TO DEATH? □ Not pregnant within past year

□ Natural □ Homicide
□ Yes □ Probably □ Pregnant at time of death
□ Accident □ Pending Investigation
□ No □ Unknown □ Not pregnant, but pregnant within 42 days of death
□ Suicide □ Could not be determined
□ Not pregnant, but pregnant 43 days to 1 year before death
□ Unknown if pregnant within the past year
38. DATE OF INJURY 39. TIME OF INJURY 40. PLACE OF INJURY (e.g., Decedent’s home; construction site; restaurant; wooded area) 41. INJURY AT WORK?
(Mo/Day/Yr) (Spell Month) □ 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)

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 52. DECEDENT OF HISPANIC ORIGIN? Check the box 53. DECEDENT’S RACE (Check one or more races to indicate what the
that best describes the highest degree or level of that best describes whether the decedent is decedent considered himself or herself to be)
school completed at the time of death. Spanish/Hispanic/Latino. Check the “No” box if
decedent is not Spanish/Hispanic/Latino. □ White
□ 8th grade or less □ Black or African American
□ American Indian or Alaska Native
□ 9th - 12th grade; no diploma (Name of the enrolled or principal tribe)
□ No, not Spanish/Hispanic/Latino □ Asian Indian
□ High school graduate or GED completed □ Chinese
□
FUNERAL DIRECTOR

□ Yes, Mexican, Mexican American, Chicano Filipino

To Be Completed By:

□ Some college credit, but no degree □ Japanese

□ Yes, Puerto Rican
□ Korean
□ Associate degree (e.g., AA, AS) □ Vietnamese
□ Other Asian (Specify)
□ Bachelor’s degree (e.g., BA, AB, BS) □ Yes, Cuban □ Native Hawaiian
□ Guamanian or Chamorro
□ Master’s degree (e.g., MA, MS, MEng, □ Yes, other Spanish/Hispanic/Latino □ Samoan
MEd, MSW, MBA) □ Other Pacific Islander (Specify)
(Specify)
□ Doctorate (e.g., PhD, EdD) or □ Other (Specify)
Professional degree (e.g., MD, DDS,
DVM, LLB, JD)

54. DECEDENT’S USUAL OCCUPATION (Indicate type of work done during most of working life. DO NOT USE RETIRED).

55. KIND OF BUSINESS/INDUSTRY

REV. 11/2003
Cause-of-death – Background, Examples, and Common Problems
Accurate cause of death information is important
•to the public health community in evaluating and improving the health of all citizens, and
•often to the family, now and in the future, and to the person settling the decedent’s estate.

The cause-of-death section consists of two parts. Part I is for reporting a chain of events leading directly to death, with the immediate cause of death (the final disease, injury, or complication directly causing death) on
line a and the underlying cause of death (the disease or injury that initiated the chain of events that led directly and inevitably to death) on the lowest used line. Part II is for reporting all other significant diseases,
conditions, or injuries that contributed to death but which did not result in the underlying cause of death given in Part I. The cause-of-death information should be YOUR best medical OPINION. A condition can be
listed as “probable” even if it has not been definitively diagnosed.

Examples of properly completed medical certifications

CAUSE OF DEATH (See instructions and examples) Approximate interval:
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 Onset to death
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. Rupture of myocardium Minutes
resulting in death) Due to (or as a consequence of):

Sequentially list conditions, b. Acute myocardial infarction 6 days

if any, leading to the cause Due to (or as a consequence of):
listed on line a. Enter the
UNDERLYING CAUSE c. Coronary artery thrombosis 5 years
(disease or injury that Due to (or as a consequence of):
initiated the events resulting
in death) LAST d. Atherosclerotic coronary artery disease 7 years

PART II. Enter other significant conditions contributing to death but not resulting in the underlying cause given in PART I 33. WAS AN AUTOPSY PERFORMED?
■ Yes  No
Diabetes, Chronic obstructive pulmonary disease, smoking 34. WERE AUTOPSY FINDINGS AVAILABLE TO
COMPLETE THE CAUSE OF DEATH? ■ Yes  No
35. DID TOBACCO USE CONTRIBUTE TO DEATH? 36. IF FEMALE: 37. MANNER OF DEATH
■ Not pregnant within past year
■ Yes  Probably  Pregnant at time of death ■ Natural  Homicide
 Not pregnant, but pregnant within 42 days of death  Accident  Pending Investigation
 No  Unknown  Not pregnant, but pregnant 43 days to 1 year before death  Suicide  Could not be determined
 Unknown if pregnant within the past year

CAUSE OF DEATH (See instructions and examples) Approximate interval:

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 Onset to death
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. Aspiration pneumonia 2 Days
resulting in death) Due to (or as a consequence of):

Sequentially list conditions, b. Complications of coma 7 weeks

if any, leading to the cause Due to (or as a consequence of):
listed on line a. Enter the
UNDERLYING CAUSE c. Blunt force injuries 7 weeks
(disease or injury that Due to (or as a consequence of):
initiated the events resulting
in death) LAST d. Motor vehicle accident 7 weeks
PART II. Enter other significant conditions contributing to death but not resulting in the underlying cause given in PART I 33. WAS AN AUTOPSY PERFORMED?
■ Yes  No
34. WERE AUTOPSY FINDINGS AVAILABLE TO
COMPLETE THE CAUSE OF DEATH? ■ Yes  No
35. DID TOBACCO USE CONTRIBUTE TO DEATH? 36. IF FEMALE: 37. MANNER OF DEATH
 Not pregnant within past year
 Yes  Probably  Pregnant at time of death  Natural  Homicide
 Not pregnant, but pregnant within 42 days of death ■ Accident  Pending Investigation
■ No  Unknown  Not pregnant, but pregnant 43 days to 1 year before death  Suicide  Could not be determined
 Unknown if pregnant within the past year
38. DATE OF INJURY 39. TIME OF INJURY 40. PLACE OF INJURY (e.g., Decedent’s home; construction site; restaurant; wooded area) 41. INJURY AT WORK?
(Mo/Day/Yr) (Spell Month)
Approx. 2320 road side near state highway
August 15, 2003  Yes ■ No

42. LOCATION OF INJURY: State: Missouri City or Town: near Alexandria

Street & Number: mile marker 17 on state route 46a Apartment No.: Zip Code:
43. DESCRIBE HOW INJURY OCCURRED: 44. IF TRANSPORTATION INJURY, SPECIFY:

Decedent driver of van, ran off road into tree ■ Driver/Operator

 Passenger
 Pedestrian
 Other (Specify)

Common problems in death certification

The elderly decedent should have a clear and distinct etiological sequence for cause of death, if possible. Terms such as senescence, infirmity, old age, and advanced age have little value for public health or medical
research. Age is recorded elsewhere on the certificate. When a number of conditions resulted in death, the physician should choose the single sequence that, in his or her opinion, best describes the process leading to
death, and place any other pertinent conditions in Part II. If after careful consideration the physician cannot determine a sequence that ends in death, then the medical examiner or coroner should be consulted about
conducting an investigation or providing assistance in completing the cause of death.

The infant decedent should have a clear and distinct etiological sequence for cause of death, if possible. “Prematurity” should not be entered without explaining the etiology of prematurity. Maternal conditions may have
initiated or affected the sequence that resulted in infant death, and such maternal causes should be reported in addition to the infant causes on the infant’s death certificate (e.g., Hyaline membrane disease due to
prematurity, 28 weeks due to placental abruption due to blunt trauma to mother’s abdomen).

When SIDS is suspected, a complete investigation should be conducted, typically by a medical examiner or coroner. If the infant is under 1 year of age, no cause of death is determined after scene investigation, clinical
history is reviewed, and a complete autopsy is performed, then the death can be reported as Sudden Infant Death Syndrome.

When processes such as the following are reported, additional information about the etiology should be reported:
Abscess Carcinomatosis Disseminated intra vascular Hyponatremia Pulmonary arrest
Abdominal hemorrhage Cardiac arrest coagulopathy Hypotension Pulmonary edema
Adhesions Cardiac dysrhythmia Dysrhythmia Immunosuppression Pulmonary embolism
Adult respiratory distress syndrome Cardiomyopathy End-stage liver disease Increased intra cranial pressure Pulmonary insufficiency
Acute myocardial infarction Cardiopulmonary arrest End-stage renal disease Intra cranial hemorrhage Renal failure
Altered mental status Cellulitis Epidural hematoma Malnutrition Respiratory arrest
Anemia Cerebral edema Exsanguination Metabolic encephalopathy Seizures
Anoxia Cerebrovascular accident Failure to thrive Multi-organ failure Sepsis
Anoxic encephalopathy Cerebellar tonsillar herniation Fracture Multi-system organ failure Septic shock
Arrhythmia Chronic bedridden state Gangrene Myocardial infarction Shock
Ascites Cirrhosis Gastrointestinal hemorrhage Necrotizing soft-tissue infection Starvation
Aspiration Coagulopathy Heart failure Old age Subdural hematoma
Atrial fibrillation Compression fracture Hemothorax Open (or closed) head injury Subarachnoid hemorrhage
Bacteremia Congestive heart failure Hepatic failure Paralysis Sudden death
Bedridden Convulsions Hepatitis Pancytopenia Thrombocytopenia
Biliary obstruction Decubiti Hepatorenal syndrome Perforated gallbladder Uncal herniation
Bowel obstruction Dehydration Hyperglycemia Peritonitis Urinary tract infection
Brain injury Dementia (when not Hyperkalemia Pleural effusions Ventricular fibrillation
Brain stem herniation otherwise specified) Hypovolemic shock Pneumonia Ventricular tachycardia
Carcinogenesis Diarrhea Volume depletion

If the certifier is unable to determine the etiology of a process such as those shown above, the process must be qualified as being of an unknown, undetermined, probable, presumed, or unspecified etiology so it is clear
that a distinct etiology was not inadvertently or carelessly omitted.

The following conditions and types of death might seem to be specific or natural but when the medical history is examined further may be found to be complications of an injury or poisoning (possibly occurring long ago).
Such cases should be reported to the medical examiner/coroner.
Asphyxia Epidural hematoma Hip fracture Pulmonary emboli Subdural hematoma
Bolus Exsanguination Hyperthermia Seizure disorder Surgery
Choking Fall Hypothermia Sepsis Thermal burns/chemical burns
Drug or alcohol overdose/drug or Fracture Open reduction of fracture Subarachnoid hemorrhage
alcohol abuse

REV. 11/2003