The CDC U.S. Standard Certificate of Death form is an official document used to record the details surrounding a person's death. This form serves as a vital record, providing essential information for legal and statistical purposes. Understanding how to accurately fill out this form is crucial for ensuring that all necessary information is properly documented.
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The CDC U.S. Standard Certificate of Death form serves as a crucial document in the process of recording vital statistics in the United States. This form captures essential information regarding the deceased, including their full name, date of birth, and place of death. Additionally, it details the cause of death, which is vital for public health monitoring and epidemiological research. The form also requires information about the decedent's parents, marital status, and occupation, all of which contribute to a comprehensive understanding of mortality trends. Furthermore, the certificate must be signed by a licensed medical professional, ensuring that the information provided is accurate and reliable. By standardizing the way death is recorded, this form plays a significant role in the collection of data that informs health policies and practices across the nation.
NAME OF DECEDENT ____________________________________________ For use by physician or institution
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
7g. INSIDE CITY LIMITS? □ Yes □ No
7d.
STREET AND NUMBER
7e. APT. NO.
7f. ZIP CODE
(If wife, give name prior to first marriage)
8.
EVER IN US ARMED FORCES?
9. MARITAL STATUS AT
TIME OF DEATH
10. SURVIVING SPOUSE’S NAME
□ Yes □ No
□ Married
□ Married, but separated □ Widowed
□Divorced □ Never Married □ Unknown
By:
11.
FATHER’S NAME (First, Middle, Last)
12. MOTHER’S NAME PRIOR TO FIRST MARRIAGE (First, Middle, Last)
VerifiedCompleted/BeTo DIRECTOR:FUNERAL
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:
□ 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
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:
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._____________________________________________________________________________________________________________
resulting in death)
Due to (or as a consequence of):
Sequentially list conditions,
b._____________________________________________________________________________________________________________
if any,
leading to the cause
listed on line a. Enter the
UNDERLYING CAUSE
c._____________________________________________________________________________________________________________
(disease or injury that
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
To Be Completed By: MEDICAL CERTIFIER
35. DID TOBACCO USE CONTRIBUTE
36. IF FEMALE:
37. MANNER OF DEATH
TO DEATH?
□ Not pregnant within past year
□ Natural
□ Homicide
□
Yes □
□ Pregnant at time of death
Probably
□ Accident □ Pending Investigation
□ Not pregnant, but pregnant within 42 days of death
No □
Unknown
□ 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?
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
□ White
□ 8th grade or less
decedent is not Spanish/Hispanic/Latino.
Black or African American
□ 9th - 12th grade; no diploma
American Indian or Alaska Native
No, not Spanish/Hispanic/Latino
(Name of the enrolled or principal tribe) _______________
□ High school graduate or GED completed
Asian Indian
To Be Completed By: FUNERAL DIRECTOR
Chinese
□ Some college credit, but no degree
Yes, Mexican, Mexican American, Chicano
Filipino
Japanese
□ Associate degree (e.g., AA, AS)
Yes, Puerto Rican
Korean
Vietnamese
□ Bachelor’s degree (e.g., BA, AB, BS)
Yes, Cuban
Other Asian (Specify)__________________________________________
Native Hawaiian
□ Master’s degree (e.g., MA, MS, MEng,
Guamanian or Chamorro
Yes, other Spanish/Hispanic/Latino
Samoan
MEd, MSW, MBA)
(Specify) __________________________
Other Pacific Islander (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
MEDICAL CERTIFIER INSTRUCTIONS for selected items on U.S. Standard Certificate of Death
(See Physicians’ Handbook or Medical Examiner/Coroner Handbook on Death Registration for instructions on all items)
ITEMS ON WHEN DEATH OCCURRED
Items 24-25 and 29-31 should always be completed. If the facility uses a separate pronouncer or other person to indicate that death has taken place with another person more familiar with the case completing the remainder of the medical portion of the death certificate, the pronouncer completes Items 24-28. If a certifier completes Items 24-25 as well as items 29-49, Items 26-28 may be left blank.
ITEMS 24-25, 29-30 – DATE AND TIME OF DEATH
Spell out the name of the month. If the exact date of death is unknown, enter the approximate date. If the date cannot be approximated, enter the date the body is found and identify as date found. Date pronounced and actual date may be the same. Enter the exact hour and minutes according to a 24-hour clock; estimates may be provided with “Approx.” placed before the time.
ITEM 32 – CAUSE OF DEATH (See attached examples)
Take care to make the entry legible. Use a computer printer with high resolution, typewriter with good black ribbon and clean keys, or print legibly using permanent black ink in completing the CAUSE OF DEATH Section. Do not abbreviate conditions entered in section.
Part I (Chain of events leading directly to death)
•Only one cause should be entered on each line. Line (a) MUST ALWAYS have an entry. DO NOT leave blank. Additional lines may be added if necessary.
•If the condition on Line (a) resulted from an underlying condition, put the underlying condition on Line (b), and so on, until the full sequence is reported. ALWAYS enter the underlying cause of death on the lowest used line in Part I.
•For each cause indicate the best estimate of the interval between the presumed onset and the date of death. The terms “unknown” or “approximately” may be used. General terms, such as minutes, hours, or days, are acceptable, if necessary. DO NOT leave blank.
•The terminal event (for example, cardiac arrest or respiratory arrest) should not be used. If a mechanism of death seems most appropriate to you for line (a), then you must always list its cause(s) on the line(s) below it (for example, cardiac arrest due to coronary artery atherosclerosis or cardiac arrest due to blunt impact to chest).
• If an organ system failure such as congestive heart failure, hepatic failure, renal failure, or respiratory failure is listed as a cause of death, always report its etiology on the line(s) beneath it (for example, renal failure due to Type I diabetes mellitus).
•When indicating neoplasms as a cause of death, include the following: 1) primary site or that the primary site is unknown, 2) benign or malignant, 3) cell type or that the cell type is unknown, 4) grade of neoplasm, and 5) part or lobe of organ affected. (For example, a primary well- differentiated squamous cell carcinoma, lung, left upper lobe.)
•Always report the fatal injury (for example, stab wound of chest), the trauma (for example, transection of subclavian vein), and impairment of function (for example, air embolism).
PART II (Other significant conditions)
•Enter all diseases or conditions contributing to death that were not reported in the chain of events in Part I and that did not result in the underlying cause of death. See attached examples.
•If two or more possible sequences resulted in death, or if two conditions seem to have added together, report in Part I the one that, in your opinion, most directly caused death. Report in Part II the other conditions or diseases.
CHANGES TO CAUSE OF DEATH
Should additional medical information or autopsy findings become available that would change the cause of death originally reported, the original death certificate should be amended by the certifying physician by immediately reporting the revised cause of death to the State Vital Records Office.
ITEMS 33-34 - AUTOPSY
•33 - Enter “Yes” if either a partial or full autopsy was performed. Otherwise enter “No.”
•34 - Enter “Yes” if autopsy findings were available to complete the cause of death; otherwise enter “No”. Leave item blank if no autopsy was performed.
ITEM 35 - DID TOBACCO USE CONTRIBUTE TO DEATH?
Check “yes” if, in your opinion, the use of tobacco contributed to death. Tobacco use may contribute to deaths due to a wide variety of diseases; for example, tobacco use contributes to many deaths due to emphysema or lung cancer and some heart disease and cancers of the head and neck. Check “no” if, in your clinical judgment, tobacco use did not contribute to this particular death.
ITEM 36 - IF FEMALE, WAS DECEDENT PREGNANT AT TIME OF DEATH OR WITHIN PAST YEAR?
This information is important in determining pregnancy-related mortality.
ITEM 37 - MANNER OF DEATH
•Always check Manner of Death, which is important: 1) in determining accurate causes of death; 2) in processing insurance claims; and 3) in statistical studies of injuries and death.
•Indicate “Pending investigation” if the manner of death cannot be determined whether due to an accident, suicide, or homicide within the statutory time limit for filing the death certificate. This should be changed later to one of the other terms.
•Indicate “Could not be Determined” ONLY when it is impossible to determine the manner of death.
ITEMS 38-44 - ACCIDENT OR INJURY – to be filled out in all cases of deaths due to injury or poisoning.
•38 - Enter the exact month, day, and year of injury. Spell out the name of the month. DO NOT use a number for the month. (Remember, the date of injury may differ from the date of death.) Estimates may be provided with “Approx.” placed before the date.
•39 - Enter the exact hour and minutes of injury or use your best estimate. Use a 24-hour clock.
•40 - Enter the general place (such as restaurant, vacant lot, or home) where the injury occurred. DO NOT enter firm or organization names. (For example, enter “factory”, not “Standard Manufacturing, Inc.” )
•41 - Complete if anything other than natural disease is mentioned in Part I or Part II of the medical certification, including homicides, suicides, and accidents. This includes all motor vehicle deaths. The item must be completed for decedents ages 14 years or over and may be completed for those less than 14 years of age if warranted. Enter “Yes” if the injury occurred at work. Otherwise enter “No”. An injury may occur at work regardless of whether the injury occurred in the course of the decedent’s “usual” occupation. Examples of injury at work and injury not at work follow:
Injury at work
Injury not at work
Injury while working or in vocational training on job premises
Injury while engaged in personal recreational activity on job premises
Injury while on break or at lunch or in parking lot on job premises
Injury while a visitor (not on official work business) to job premises
Injury while working for pay or compensation, including at home
Homemaker working at homemaking activities
Injury while working as a volunteer law enforcement official etc.
Student in school
Injury while traveling on business, including to/from business contacts
Working for self for no profit (mowing yard, repairing own roof, hobby)
Commuting to or from work
•42 - Enter the complete address where the injury occurred including zip code.
•43 - Enter a brief but specific and clear description of how the injury occurred. Explain the circumstances or cause of the injury. Specify type of gun or type of vehicle (e.g., car, bulldozer, train, etc.) when relevant to circumstances. Indicate if more than one vehicle involved; specify type of vehicle decedent was in.
•44 -Specify role of decedent (e.g. driver, passenger). Driver/operator and passenger should be designated for modes other than motor vehicles such as bicycles. Other applies to watercraft, aircraft, animal, or people attached to outside of vehicles (e.g. surfers).
Rationale: Motor vehicle accidents are a major cause of unintentional deaths; details will help determine effectiveness of current safety features and laws.
REFERENCES
For more information on how to complete the medical certification section of the death certificate, refer to tutorial at http://www.TheNAME.org and resources including instructions and handbooks available by request from NCHS, Room 7318, 3311 Toledo Road, Hyattsville, Maryland 20782- 2003 or at www.cdc.gov/nchs/about/major/dvs/handbk.htm
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:
a. Rupture of myocardium __________________________________________________________________________________
disease
or condition --------->
resulting
in death)
b. Acute myocardial infarction_______________________________________________________________________________
6 days
if any, leading to the cause
c. Coronary artery thrombosis_______________________________________________________________________________
5 years
d. Atherosclerotic coronary artery disease__________________________________________________________________
7 years
Diabetes, Chronic obstructive pulmonary disease, smoking
■ Yes
No
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
■ Natural
Homicide
Accident
Pending Investigation
Suicide
Could not be determined
a. Aspiration pneumonia_______________________________________________________________
2 Days
b. Complications of coma___________________________________________________________________________________
7 weeks
c. Blunt force injuries________________________________________________________________________________________
d. Motor vehicle accident____________________________________________________________________________________
COMPLETE THE CAUSE OF DEATH? ■ Yes No
35. DID TOBACCO USE CONTRIBUTE TO DEATH?
37.
MANNER OF DEATH
Yes
Not pregnant within past year
Natural
Pregnant at time of death
■ No
■ Accident
Not pregnant, but pregnant 43 days to 1 year before death
Unknown if pregnant within the past year
39. TIME OF INJURY
Approx. 2320
road side near state highway
August 15, 2003
Yes ■ No
State: Missouri
City or Town: near Alexandria
Street & Number: mile marker 17 on state route 46a
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
Hip fracture
Pulmonary emboli
Bolus
Hyperthermia
Seizure disorder
Surgery
Choking
Fall
Hypothermia
Thermal burns/chemical burns
Drug or alcohol overdose/drug or
Open reduction of fracture
alcohol abuse
FUNERAL DIRECTOR INSTRUCTIONS for selected items on U.S.
Standard Certificate of Death (For additional information concerning all items on certificate see Funeral Directors’ Handbook on Death Registration)
ITEM 1. DECEDENT’S LEGAL NAME
Include any other names used by decedent, if substantially different from the legal name, after the abbreviation AKA (also known as) e.g. Samuel Langhorne Clemens AKA Mark Twain, but not Jonathon Doe AKA John Doe
ITEM 5. DATE OF BIRTH
Enter the full name of the month (January, February, March etc.) Do not use a number or abbreviation to designate the month.
ITEM 7A-G. RESIDENCE OF DECEDENT (information divided into seven categories)
Residence of decedent is the place where the decedent actually resided. The place of residence is not necessarily the same as “home state” or “legal residence”. Never enter a temporary residence such as one used during a visit, business trip, or vacation. Place of residence during a tour of military duty or during attendance at college is considered permanent and should be entered as the place of residence. If the decedent had been living in a facility where an individual usually resides for a long period of time, such as a group home, mental institution, nursing home, penitentiary, or hospital for the chronically ill, report the location of that facility in item 7. If the decedent was an infant who never resided at home, the place of residence is that of the parent(s) or legal guardian. Never use an acute care hospital’s location as the place of residence for any infant. If Canadian residence, please specify Province instead of State.
ITEM 10. SURVIVING SPOUSE’S NAME
If the decedent was married at the time of death, enter the full name of the surviving spouse. If the surviving spouse is the wife, enter her name prior to first marriage. This item is used in establishing proper insurance settlements and other survivor benefits.
ITEM 12. MOTHER’S NAME PRIOR TO FIRST MARRIAGE
Enter the name used prior to first marriage, commonly known as the maiden name. This name is useful because it remains constant throughout life.
ITEM 14. PLACE OF DEATH
The place where death is pronounced should be considered the place where death occurred. If the place of death is unknown but the body is found in your State, the certificate of death should be completed and filed in accordance with the laws of your State. Enter the place where the body is found as the place of death.
ITEM 51. DECEDENT’S EDUCATION (Check appropriate box on death certificate)
Check the box that corresponds to the highest level of education that the decedent completed. Information in this section will not appear on the certified copy of the death certificate. This information is used to study the relationship between mortality and education (which roughly corresponds with socioeconomic status). This information is valuable in medical studies of causes of death and in programs to prevent illness and death.
ITEM 52. WAS DECEDENT OF HISPANIC ORIGIN? (Check “No” or appropriate “Yes” box)
Check “No” or check the “Yes” box that best corresponds with the decedent’s ethnic Spanish identity as given by the informant. Note that “Hispanic” is not a race and item 53 must also be completed. Do not leave this item blank. With respect to this item, “Hispanic” refers to people whose origins are from Spain, Mexico, or the Spanish-speaking Caribbean Islands or countries of Central or South America. Origin includes ancestry, nationality, and lineage. There is no set rule about how many generations are to be taken into account in determining Hispanic origin; it may be based on the country of origin of a parent, grandparent, or some far-removed ancestor. Although the prompts include the major Hispanic groups, other groups may be specified under “other”. “Other” may also be used for decedents of multiple Hispanic origin (e.g. Mexican-Puerto Rican). Information in this section will not appear on the certified copy of the death certificate. This information is needed to identify health problems in a large minority population in the United States. Identifying health problems will make it possible to target public health resources to this important segment of our population.
ITEM 53. RACE (Check appropriate box or boxes on death certificate)
Enter the race of the decedent as stated by the informant. Hispanic is not a race; information on Hispanic ethnicity is collected separately in item
52.American Indian and Alaska Native refer only to those native to North and South America (including Central America) and does not include Asian Indian. Please specify the name of enrolled or principal tribe (e.g., Navajo, Cheyenne, etc.) for the American Indian or Alaska Native. For Asians check Asian Indian, Chinese, Filipino, Japanese, Korean, Vietnamese, or specify other Asian group; for Pacific Islanders check Guamanian or Chamorro, Samoan, or specify other Pacific Island group. If the decedent was of mixed race, enter each race (e.g., Samoan- Chinese-Filipino or White, American Indian). Information in this section will not appear on the certified copy of the death certificate.
Race is essential for identifying specific mortality patterns and leading causes of death among different racial groups. It is also used to determine if specific health programs are needed in particular areas and to make population estimates.
ITEMS 54 AND 55. OCCUPATION AND INDUSTRY
Questions concerning occupation and industry must be completed for all decedents 14 years of age or older. This information is useful in studying deaths related to jobs and in identifying any new risks. For example, the link between lung disease and lung cancer and asbestos exposure in jobs such as shipbuilding or construction was made possible by this sort of information on death certificates. Information in this
section will not appear on the certified copy of the death certificate.
ITEM 54. DECEDENT’S USUAL OCCUPATION
Enter the usual occupation of the decedent. This is not necessarily the last occupation of the decedent. Never enter “retired”. Give kind of work decedent did during most of his or her working life, such as claim adjuster, farmhand, coal miner, janitor, store manager, college professor, or civil engineer. If the decedent was a homemaker at the time of death but had worked outside the household during his or her working life, enter that occupation. If the decedent was a homemaker during most of his or her working life, and never worked outside the household, enter “homemaker”. Enter “student” if the decedent was a student at the time of death and was never regularly employed or employed full time during his or her working life. Information in this section will not appear on the certified copy of the death certificate.
ITEM 55. KIND OF BUSINESS/INDUSTRY
Kind of business to which occupation in item 54 is related, such as insurance, farming, coal mining, hardware store, retail clothing, university, or government. DO NOT enter firm or organization names. If decedent was a homemaker as indicated in item 54, then enter either “own home” or “someone else’s home” as appropriate. If decedent was a student as indicated in item 54, then enter type of school, such as high school or college, in item 55. Information in this section will not appear on the certified copy of the death certificate.
NOTE: This recommended standard death certificate is the result of an extensive evaluation process. Information on the process and resulting
recommendations as well as plans for future activities is available on the Internet at: http://www.cdc.gov/nchs/vital_certs_rev.htm.
Filling out the CDC U.S. Standard Certificate of Death form is a crucial task that requires attention to detail. Once completed, this form will need to be submitted to the appropriate local or state authorities. It is essential to ensure all information is accurate and complete to avoid delays in processing.
What is the CDC U.S. Standard Certificate of Death form?
The CDC U.S. Standard Certificate of Death form is a legal document used to officially record a person's death in the United States. It serves several purposes, including providing vital statistics for public health, facilitating the settlement of estates, and assisting in the identification of deceased individuals. This form is standardized across states, ensuring consistency in the information collected and reported. Each state may have specific requirements, but the core elements of the form remain uniform nationwide.
What information is required on the death certificate?
The death certificate includes various pieces of information. Key details typically encompass the decedent's full name, date of birth, date of death, place of death, and the cause of death. Additionally, it requires information about the deceased's parents, including their names and birthplaces. The certificate also captures the decedent's marital status and occupation at the time of death. Accurate information is crucial, as it impacts statistical data and can affect legal matters related to the deceased.
Who is responsible for completing the death certificate?
The responsibility for completing the death certificate generally falls to the attending physician or medical examiner who was involved in the individual's care at the time of death. In cases where an autopsy is performed, the medical examiner or coroner will typically handle the completion. Family members or funeral directors may also assist in gathering necessary information. It is important that the form is filled out accurately and submitted in a timely manner to ensure proper registration of the death.
How can I obtain a copy of a death certificate?
To obtain a copy of a death certificate, individuals typically need to contact the vital records office in the state where the death occurred. Each state has its own procedures and fees for issuing copies. Generally, you will need to provide identification and possibly proof of your relationship to the deceased. Some states allow requests to be made online, while others may require mail or in-person requests. It's advisable to check the specific requirements for the state involved to ensure a smooth process.
Filling out the CDC U.S. Standard Certificate of Death form is a crucial task that requires attention to detail. One common mistake people make is not providing complete information. Every section of the form must be filled out accurately. Omitting details can lead to delays in processing and complications with the deceased’s estate.
Another frequent error is misspelling names. Ensure that the full name of the deceased is written correctly. This includes checking for proper spelling of first, middle, and last names. Incorrect names can create issues with legal documents and records.
People often confuse the date of death. It is essential to double-check this date, as it must reflect the exact day the individual passed away. An incorrect date can complicate matters for family members and affect the timeline for benefits or claims.
Providing inaccurate information about the cause of death is another serious mistake. This section must be filled out with care. If unsure, consult with a medical professional to ensure the details are correct. Misstating the cause can lead to legal ramifications.
Some individuals forget to include the relationship of the informant to the deceased. This information is necessary to establish who is providing the details. Without it, the form may be deemed incomplete.
Another error is neglecting to sign and date the form. The signature of the informant is required to validate the information provided. Failing to do this can result in the form being rejected.
People sometimes overlook the importance of using black or blue ink. The form must be filled out in a way that is legible and clear. Using the wrong ink color can make the document difficult to read and may cause processing issues.
Inaccurate information regarding the deceased's social security number is also a common mistake. This number must be correct to ensure proper identification and processing. Double-check this number before submission.
Finally, failing to keep a copy of the completed form is a mistake that can lead to complications later. Always retain a copy for personal records. This ensures that you have the necessary information on hand if questions arise in the future.
The CDC U.S. Standard Certificate of Death form is a crucial document used to officially record a person's death. Alongside this form, several other documents may be required or helpful in various situations, such as settling estates, arranging funerals, or addressing legal matters. Below is a list of commonly used forms and documents that accompany the death certificate.
Each of these documents plays a significant role in the processes that follow a death. Having them organized can ease the burden on family members during a difficult time and help ensure that all legal and financial matters are addressed appropriately.
The CDC U.S. Standard Certificate of Death form serves a critical role in documenting the details surrounding a person's death. Several other documents share similarities with this form, particularly in their purpose and the information they convey. Here are four such documents:
When filling out the CDC U.S. Standard Certificate of Death form, attention to detail is crucial. Here’s a list of things to keep in mind:
By following these guidelines, you can help ensure that the completion of the death certificate is accurate and efficient.
The CDC U.S. Standard Certificate of Death form is an important document, but there are several misconceptions about it. Here are eight common misunderstandings:
While most deaths do require a certificate, some states may have exceptions, especially for certain types of deaths, such as those that occur in specific circumstances.
Each state has its own version of the death certificate form, although they generally follow the CDC's guidelines. Variations exist in the layout and required information.
While a physician typically provides the medical information, other authorized individuals, such as funeral directors, can assist in completing the form.
In addition to legal needs, death certificates are often required for settling estates, claiming life insurance, and accessing benefits.
Corrections can be made to the certificate if errors are discovered. However, there is a specific process to follow for making these changes.
While death certificates can be accessed by the public, certain information may be restricted to protect privacy, especially for recent deaths.
Some fields on the form are optional, depending on the circumstances of the death and the information available at the time of filing.
An autopsy is not always necessary for a death certificate to be issued. Many deaths are certified without an autopsy, especially if the cause is clear.
Understanding these misconceptions can help individuals navigate the process of obtaining and using a death certificate more effectively.
Filling out the CDC U.S. Standard Certificate of Death form is an important process that requires attention to detail. Here are some key takeaways to keep in mind:
By following these guidelines, you can ensure that the process of completing the death certificate is as smooth as possible during a difficult time.