Fill in a Valid CDC U.S. Standard Certificate of Death Template

The CDC U.S. Standard Certificate of Death form is a vital document used to officially record the details surrounding an individual's death. This standardized form ensures consistency in reporting and helps public health officials track mortality trends. Understanding how to accurately fill out this form is essential for compliance and record-keeping.

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Fill in a Valid CDC U.S. Standard Certificate of Death Template

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The CDC U.S. Standard Certificate of Death form serves as a crucial document in the process of recording and certifying the death of an individual. This form captures essential information such as the decedent's full name, date of birth, and the circumstances surrounding their passing. It includes sections dedicated to the cause of death, which must be detailed by a qualified medical professional, ensuring accuracy and clarity. Additionally, the form requires information about the decedent's residence, marital status, and occupation, offering a comprehensive view of the individual's life. The certificate also mandates the signature of the attending physician or coroner, affirming the legitimacy of the information provided. This standardized approach not only aids in the proper documentation of deaths but also facilitates statistical analysis and public health research, playing a significant role in understanding mortality trends across the United States.

CDC U.S. Standard Certificate of Death Example

NAME OF DECEDENT ____________________________________________ For use by physician or institution

U.S. STANDARD CERTIFICATE OF DEATH

LOCAL FILE NO.

STATE FILE NO.

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)

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

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:

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

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

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?

(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		□ 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

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		a. Rupture of myocardium __________________________________________________________________________________			Minutes
disease	or condition --------->
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		c. Coronary artery thrombosis_______________________________________________________________________________			5 years
UNDERLYING CAUSE
(disease or injury that		Due to (or as a consequence of):
initiated the events resulting		d. Atherosclerotic coronary artery disease__________________________________________________________________			7 years
in death) LAST

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?
Diabetes, Chronic obstructive pulmonary disease, smoking			■ Yes	No
			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

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

a. Aspiration pneumonia_______________________________________________________________

2 Days

disease or condition --------->

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

c. Blunt force injuries________________________________________________________________________________________

7 weeks

UNDERLYING CAUSE

(disease or injury that

Due to (or as a consequence of):

initiated the events resulting

d. Motor vehicle accident____________________________________________________________________________________

in death) LAST

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

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

Yes

Probably

Not pregnant within past year

Natural

Homicide

Pregnant at time of death

■ No

Unknown

Not pregnant, but pregnant within 42 days of death

■ Accident

Pending Investigation

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

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.

REV. 11/2003

Click for CDC U.S. Standard Certificate of Death File

File Breakdown

Fact Name	Description
Standardization	The CDC U.S. Standard Certificate of Death form is used nationwide to ensure consistency in recording death data.
Required Information	The form requires details such as the deceased's name, date of birth, date of death, and cause of death.
State-Specific Forms	Each state may have variations of the form, governed by state laws regarding vital records.
Legal Importance	This form serves as a legal document for various purposes, including settling estates and claiming benefits.

Guide to Using CDC U.S. Standard Certificate of Death

Completing the CDC U.S. Standard Certificate of Death form is a necessary step following the passing of an individual. This form requires accurate information to ensure that all details regarding the deceased are properly recorded. Below are the steps to fill out the form correctly.

Obtain the CDC U.S. Standard Certificate of Death form from your local vital records office or download it from the CDC website.
Enter the full name of the deceased in the designated section.
Provide the date of death, ensuring the month, day, and year are correctly noted.
Fill in the place of death, including the city, county, and state.
Indicate the deceased's gender.
Complete the section for the deceased's date of birth, including the month, day, and year.
List the deceased's usual residence, including the street address, city, state, and zip code.
Provide the marital status of the deceased at the time of death.
Include the name of the surviving spouse, if applicable.
Fill out the deceased's occupation and the kind of business or industry.
Complete the informant's information, including their name, relationship to the deceased, and contact details.
Sign and date the form where indicated.
Submit the completed form to the appropriate local or state vital records office.

After filling out the form, it will need to be submitted for processing. Ensure all information is accurate to avoid delays in obtaining the death certificate.

Get Answers on CDC U.S. Standard Certificate of Death

What is the CDC U.S. Standard Certificate of Death form?

The CDC U.S. Standard Certificate of Death form is an official document used to record the details surrounding an individual's death. This form provides important information such as the deceased's name, date of birth, date of death, and cause of death. It is essential for legal and statistical purposes, helping to ensure accurate records are maintained at both state and national levels.

Who is responsible for completing the death certificate?

The responsibility for completing the death certificate typically falls to the attending physician or medical examiner. They must provide information regarding the cause of death. However, family members or the funeral director may assist in gathering necessary details to ensure the form is filled out correctly.

What information is required on the death certificate?

The form requires various pieces of information, including:

Full name of the deceased
Date of birth
Date of death
Place of death
Cause of death
Personal details such as the deceased's address and occupation
Information about the informant, who is usually a family member or the funeral director

How is the death certificate used?

The death certificate serves multiple purposes. It is used to settle estates, claim life insurance benefits, and for statistical analysis by health organizations. Additionally, it may be required for various legal matters, including the closure of bank accounts or the transfer of property.

How long does it take to obtain a death certificate?

The time it takes to obtain a death certificate can vary by state and the specific circumstances surrounding the death. Generally, it can take anywhere from a few days to several weeks. It's important to follow up with the local vital records office to ensure the process is moving along smoothly.

Can I obtain a copy of the death certificate?

Yes, copies of the death certificate can usually be obtained through the local vital records office in the state where the death occurred. Typically, you will need to provide identification and possibly pay a small fee. Family members and legal representatives often have the right to request copies.

What should I do if there is an error on the death certificate?

If you notice an error on the death certificate, it’s important to address it promptly. Contact the local vital records office where the certificate was filed. They will provide guidance on the process for making corrections, which may involve submitting a formal request and providing supporting documentation.

Are there different versions of the death certificate?

Yes, there can be different versions of the death certificate. The standard version is used for legal purposes, while some states may offer an informational version that is not valid for legal use. Always check with your state’s vital records office to understand the available options and their uses.

Common mistakes

Filling out the CDC U.S. Standard Certificate of Death form is a crucial task that requires attention to detail. Many individuals make common mistakes that can lead to delays or complications in the processing of the certificate. One frequent error occurs when the cause of death is not clearly stated. It’s essential to provide a precise description of the underlying cause, as well as any contributing factors. Vague language can lead to confusion and may require additional clarification.

Another mistake involves incorrect personal information about the deceased. It is vital to ensure that the name, date of birth, and social security number are accurate. Errors in these details can cause significant issues, especially when the certificate is needed for legal purposes, such as settling an estate. Double-checking this information can save time and prevent future complications.

People often overlook the importance of obtaining the necessary signatures. The form requires signatures from the attending physician or medical examiner, as well as the funeral director. Failing to secure these signatures can result in the certificate being deemed incomplete. It’s advisable to confirm that all required parties have signed before submitting the document.

In addition, individuals sometimes neglect to provide the correct information regarding the deceased's place of residence. This section should reflect the last known address accurately. Incorrect information can lead to misunderstandings or complications in the verification process. Ensuring that this detail is correct is essential for maintaining accurate records.

Lastly, many people fail to keep a copy of the completed form for their records. While it may seem unnecessary at the moment, having a copy can be invaluable for future reference. It can assist in resolving any discrepancies that may arise later on. Keeping thorough records is a best practice that should not be overlooked.

Documents used along the form

The CDC U.S. Standard Certificate of Death form is a crucial document used to officially record a person's death. Along with this form, several other documents may be necessary for various legal, financial, and administrative purposes. Below is a list of common forms and documents often used in conjunction with the death certificate.

Affidavit of Death: This document serves as a sworn statement confirming the death of an individual. It may be used in legal proceedings or to settle estate matters.
Will: A legal document outlining how a deceased person's assets should be distributed. The will is essential for probate proceedings and ensures the deceased's wishes are honored.
Trust Documents: If the deceased had a trust, these documents detail the management and distribution of assets. They play a critical role in estate planning and may bypass probate.
Life Insurance Policies: These documents provide proof of life insurance coverage. Beneficiaries need this information to file claims and receive benefits after the insured's death.
Social Security Administration (SSA) Notification: This document is necessary to inform the SSA of the individual's death, which can affect benefits and eligibility for survivors.
Funeral Home Contract: This contract outlines the services provided by the funeral home. It is important for verifying arrangements and managing expenses related to the funeral.
Medical Records: These records may be needed to confirm the cause of death, especially if there are questions about the circumstances surrounding it.

Having these documents readily available can streamline the process of managing affairs after a death. Each plays a specific role in ensuring that legal and financial matters are addressed appropriately and in accordance with the deceased's wishes.

Similar forms

The CDC U.S. Standard Certificate of Death form serves as a crucial document in recording the details surrounding an individual's death. Several other documents share similarities with this form in terms of purpose and content. Here is a list of nine such documents:

Death Certificate (State-Specific): Each state issues its own death certificate, which includes essential details such as the deceased's name, date of birth, and cause of death. Like the CDC form, it serves as an official record.
Medical Examiner's Report: This document is prepared by a medical examiner or coroner. It provides insights into the circumstances of a death, including the cause and manner, paralleling the investigative aspect of the CDC form.
Autopsy Report: An autopsy report details the findings from a post-mortem examination. It includes information about the cause of death, similar to what is recorded on the CDC form.
Funeral Home Disposition Permit: This document is issued by a funeral home and allows for the burial or cremation of a deceased person. It requires information that aligns with the details found on the death certificate.
Burial Transit Permit: This permit is needed when transporting a body for burial. It contains information about the deceased and the destination, echoing the formal nature of the CDC form.
Life Insurance Claim Form: When filing a claim, beneficiaries must provide details about the deceased. This form often requires a death certificate, highlighting the connection between the two documents.
Social Security Administration Death Notification: This document informs the Social Security Administration of a person's passing. It relies on information similar to that found on the CDC form.
Voter Registration Cancellation Form: In some cases, a voter registration cancellation form may be required after a death. This form includes the deceased’s information, akin to the details on the death certificate.
Estate Probate Documents: These documents initiate the legal process of distributing a deceased person's assets. They often reference the death certificate, emphasizing its importance in legal matters.

Each of these documents plays a role in documenting and addressing the realities following a person's death, demonstrating the interconnectedness of legal and personal matters during such a sensitive time.

Dos and Don'ts

When filling out the CDC U.S. Standard Certificate of Death form, it is important to follow certain guidelines to ensure accuracy and compliance. Below are some recommended actions and pitfalls to avoid.

Do ensure all information is accurate and complete. Double-check the details before submission.
Do use clear and legible handwriting if filling out the form by hand. This helps prevent misinterpretation of the information.
Do provide the full name and details of the deceased as they appear on legal documents.
Do consult with a qualified professional if you have questions about specific sections of the form.

Don't leave any required fields blank. Missing information can delay the processing of the certificate.
Don't use abbreviations or slang. Stick to standard terminology to avoid confusion.
Don't alter the form in any way, such as crossing out or erasing information. If a mistake is made, it is better to start over with a new form.
Don't forget to sign and date the form where required. This is essential for validation.

Misconceptions

Understanding the CDC U.S. Standard Certificate of Death form is crucial for many individuals and families. However, several misconceptions can lead to confusion. Here are seven common misunderstandings:

It is only needed for certain types of deaths.
This form is required for all deaths that occur in the U.S., regardless of the circumstances surrounding the death. It provides essential information for public health records.
Only doctors can fill it out.
While a physician usually completes the medical portion, other professionals, such as funeral directors, can assist in filling out the form. Family members may also provide necessary information.
It is not important for legal matters.
The Certificate of Death is a legal document. It serves as proof of death and is often required for settling estates, claiming life insurance, and other legal processes.
All states use the same form.
While the CDC provides a standard template, each state may have specific requirements or variations. It is important to check local regulations.
It can be filled out at any time after death.
There are deadlines for submitting the Certificate of Death, which vary by state. Delays can complicate legal and administrative processes.
Only the cause of death is important.
While the cause of death is significant, other details like the deceased's personal information and demographic data are also crucial for accurate record-keeping.
Once submitted, it cannot be changed.
Corrections can be made to the Certificate of Death, but the process may require additional documentation and can vary by state.

Being aware of these misconceptions can help families navigate the process more effectively during a difficult time.

Key takeaways

When filling out and using the CDC U.S. Standard Certificate of Death form, it is essential to keep several key points in mind. Below are important takeaways to ensure accurate completion and proper use of the form.

Understand the Purpose: The certificate serves as an official document that records the details of a person's death. It is used for legal, statistical, and administrative purposes.
Accurate Information: Ensure that all information provided is accurate. This includes the deceased's full name, date of birth, and cause of death.
Completing the Form: The form must be filled out completely. Missing information can lead to delays in processing and may affect legal matters.
Signature Requirements: The certificate must be signed by the attending physician or medical examiner. This signature verifies the cause of death.
Filing the Certificate: After completion, the certificate should be filed with the appropriate local or state vital records office within a specified timeframe.
Obtaining Copies: Certified copies of the death certificate can be requested for legal purposes, such as settling estates or claiming life insurance.
State-Specific Regulations: Be aware that each state may have specific regulations regarding the completion and filing of the death certificate. Check local guidelines to ensure compliance.