CDC U.S. Standard Certificate of Death Template

The CDC U.S. Standard Certificate of Death form is a vital record used to officially document the details surrounding an individual's death. This form serves as a crucial tool for public health data collection, ensuring accurate reporting and analysis of mortality statistics across the nation. Understanding how to properly fill out this form is essential for families and professionals alike.

To learn more about the process and access the form, please click the button below.

Table of Contents

The CDC U.S. Standard Certificate of Death form plays a crucial role in the documentation of mortality in the United States. This standardized form is designed to collect vital information about deceased individuals, ensuring consistency and accuracy across various jurisdictions. Key sections of the form include personal details of the deceased, such as name, date of birth, and residence, as well as the circumstances surrounding the death, including the date, place, and cause of death. Medical professionals are responsible for certifying the cause of death, which is essential for public health statistics and epidemiological studies. Additionally, the form captures information regarding the decedent's social security number and marital status, which can be important for legal and financial matters. By maintaining a uniform structure, the CDC facilitates the collection of reliable data that supports healthcare policies, research, and resource allocation. Ultimately, the U.S. Standard Certificate of Death form serves as a vital tool for understanding mortality trends and addressing public health challenges.

CDC U.S. Standard Certificate of Death Sample

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

4b. UNDER 1 YEAR 4c. UNDER 1 DAY 4a. AGE-Last Birthday

(Years)

Months Days Hours Minutes

5. DATE OF BIRTH (Mo/Day/Yr)

6. BIRTHPLACE (City and State or Foreign Country)

7a. RESIDENCE-STATE 7b. COUNTY 7c. CITY OR TOWN

7d. STREET AND NUMBER 7e. APT. NO. 7f. ZIP CODE

7g. INSIDE CITY LIMITS? □ Yes □ No

8. EVER IN US ARMED FORCES?

□ Yes □ No

9. MARITAL STATUS AT TIME OF DEATH

□ Married □ Married, but separated □ Widowed

□ Divorced □ Never Married □ Unknown

10. SURVIVING SPOUSE’S NAME (If wife, give name prior to first marriage)

11. FATHER’S NAME (First, Middle, Last)

12. MOTHER’S NAME PRIOR TO FIRST MARRIAGE (First, Middle, Last)

13a. INFORMANT’S NAME

13b. RELATIONSHIP TO DECEDENT

13c. MAILING ADDRESS (Street and Number, City, State, Zip Code)

14. PLACE OF DEATH (Check only one: see instructions)

IF DEATH OCCURRED IN A HOSPITAL:

□ Inpatient □ Emergency Room/Outpatient □ Dead on Arrival

IF DEATH OCCURRED SOMEWHERE OTHER THAN A HOSPITAL:

□ Hospice facility □ Nursing home/Long term care facility □ Decedent’s home □ Other (Specify):

15. FACILITY NAME (If not institution, give street & number)

16. CITY OR TOWN , STATE, AND ZIP CODE

17. COUNTY OF DEATH

18. METHOD OF DISPOSITION: □ Burial □ Cremation

□ Donation □ Entombment □ Removal from State

□ Other (Specify):_____________________________

19. PLACE OF DISPOSITION (Name of cemetery, crematory, other place)

20. LOCATION-CITY, TOWN, AND STATE

21. NAME AND COMPLETE ADDRESS OF FUNERAL FACILITY

NAME OF DECEDENT ____________________________________________

For use by physician or institution

To Be Completed/ Verified By:

FUNERAL DIRECTOR:

22. SIGNATURE OF FUNERAL SERVICE LICENSEE OR OTHER AGENT

23. LICENSE NUMBER (Of Licensee)

ITEMS 24-28 MUST BE COMPLETED BY PERSON

WHO PRONOUNCES OR CERTIFIES DEATH

24. DATE PRONOUNCED DEAD (Mo/Day/Yr)

25. TIME PRONOUNCED DEAD

26. SIGNATURE OF PERSON PRONOUNCING DEATH (Only when applicable)

27. LICENSE NUMBER

28. DATE SIGNED (Mo/Day/Yr)

29. ACTUAL OR PRESUMED DATE OF DEATH

(Mo/Day/Yr) (Spell Month)

30. ACTUAL OR PRESUMED TIME OF DEATH

31. WAS MEDICAL EXAMINER OR

CORONER CONTACTED? □ Yes □ No

CAUSE OF DEATH (See instructions and examples)

32. PART I. Enter the chain of events--diseases, injuries, or complications--that directly caused the death. DO NOT enter terminal events such as cardiac

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

lines if necessary.

IMMEDIATE CAUSE (Final

disease or condition ---------> a._____________________________________________________________________________________________________________

resulting in death) Due to (or as a consequence of):

Sequentially list conditions, b._____________________________________________________________________________________________________________

if any, leading to the cause Due to (or as a consequence of):

listed on line a. Enter the

UNDERLYING CAUSE c._____________________________________________________________________________________________________________

(disease or injury that Due to (or as a consequence of):

initiated the events resulting

in death) LAST d._____________________________________________________________________________________________________________

Approximate

interval:

Onset to death

_____________

33. WAS AN AUTOPSY PERFORMED?

□ Yes □ No

PART II. Enter other significant conditions contributing to death but not resulting in the underlying cause given in PART I

34. WERE AUTOPSY FINDINGS AVAILABLE TO

COMPLETE THE CAUSE OF DEATH? □ Yes □ No

35. DID TOBACCO USE CONTRIBUTE

TO DEATH?

□ Yes □ Probably

□ No □ Unknown

36. IF FEMALE:

□ Not pregnant within past year

□ Pregnant at time of death

□ Not pregnant, but pregnant within 42 days of death

□ Not pregnant, but pregnant 43 days to 1 year before death

□ Unknown if pregnant within the past year

37. MANNER OF DEATH

□ Natural □ Homicide

□ Accident □ Pending Investigation

□ Suicide □ Could not be determined

38. DATE OF INJURY

(Mo/Day/Yr) (Spell Month)

39. TIME OF INJURY 40. PLACE OF INJURY (e.g., Decedent’s home; construction site; restaurant; wooded area)

41. INJURY AT WORK?

□ Yes □ No

42. LOCATION OF INJURY: State: City or Town:

Street & Number: Apartment No.: Zip Code:

43. DESCRIBE HOW INJURY OCCURRED:

44. IF TRANSPORTATION INJURY, SPECIFY:

□ Driver/Operator

□ Passenger

□ Pedestrian

□ Other (Specify)

45. CERTIFIER (Check only one):

□ Certifying physician-To the best of my knowledge, death occurred due to the cause(s) and manner stated.

□ Pronouncing & Certifying physician-To the best of my knowledge, death occurred at the time, date, and place, and due to the cause(s) and manner stated.

□ Medical Examiner/Coroner-On the basis of examination, and/or investigation, in my opinion, death occurred at the time, date, and place, and due to the cause(s) and manner stated.

Signature of certifier:_____________________________________________________________________________

46. NAME, ADDRESS, AND ZIP CODE OF PERSON COMPLETING CAUSE OF DEATH (Item 32)

To Be Completed By:

MEDICAL CERTIFIER

47. TITLE OF CERTIFIER

48. LICENSE NUMBER

49. DATE CERTIFIED (Mo/Day/Yr)

50. FOR REGISTRAR ONLY- DATE FILED (Mo/Day/Yr)

51. DECEDENT’S EDUCATION-Check the box

that best describes the highest degree or level of

school completed at the time of death.

□ 8th grade or less

□ 9th - 12th grade; no diploma

□ High school graduate or GED completed

□ Some college credit, but no degree

□ Associate degree (e.g., AA, AS)

□ Bachelor’s degree (e.g., BA, AB, BS)

□ Master’s degree (e.g., MA, MS, MEng,

MEd, MSW, MBA)

□ Doctorate (e.g., PhD, EdD) or

Professional degree (e.g., MD, DDS,

DVM, LLB, JD)

52. DECEDENT OF HISPANIC ORIGIN? Check the box

that best describes whether the decedent is

Spanish/Hispanic/Latino. Check the “No” box if

decedent is not Spanish/Hispanic/Latino.

□ No, not Spanish/Hispanic/Latino

□ Yes, Mexican, Mexican American, Chicano

□ Yes, Puerto Rican

□ Yes, Cuban

□ Yes, other Spanish/Hispanic/Latino

(Specify) __________________________

53. DECEDENT’S RACE (Check one or more races to indicate what the

decedent considered himself or herself to be)

□ White

□ Black or African American

□ American Indian or Alaska Native

□ Asian Indian

(Name of the enrolled or principal tribe) _______________

□ Chinese

□ Filipino

□ Japanese

□ Korean

□ Vietnamese

□ Other Asian (Specify)__________________________________________

□ Native Hawaiian

□ Guamanian or Chamorro

□ Samoan

□ Other Pacific Islander (Specify)_________________________________

□ Other (Specify)___________________________________________

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

To Be Completed By:

FUNERAL DIRECTOR

55. KIND OF BUSINESS/INDUSTRY

REV. 11/2003

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)

32. PART I. Enter the chain of events--diseases, injuries, or complications--that directly caused the death. DO NOT enter terminal events such as cardiac

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

lines if necessary.

IMMEDIATE CAUSE (Final

disease or condition ---------> a. Rupture of myocardium __________________________________________________________________________________

resulting in death) Due to (or as a consequence of):

Sequentially list conditions, b. Acute myocardial infarction_______________________________________________________________________________

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_______________________________________________________________________________

(disease or injury that Due to (or as a consequence of):

initiated the events resulting

in death) LAST d.

Atherosclerotic coronary artery disease__________________________________________________________________

Approximate interval:

Onset to death

Minutes

6 days

5 years

7 years

33. WAS AN AUTOPSY PERFORMED?

■ Yes  No

PART II. Enter other significant conditions contributing to death but not resulting in the underlying cause given in PART I

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?

■ 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)

32. PART I. Enter the chain of events--diseases, injuries, or complications--that directly caused the death. DO NOT enter terminal events such as cardiac

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

lines if necessary.

IMMEDIATE CAUSE (Final

disease or condition ---------> a. Aspiration pneumonia_______________________________________________________________

resulting in death) Due to (or as a consequence of):

Sequentially list conditions, b. Complications of coma___________________________________________________________________________________

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________________________________________________________________________________________

(disease or injury that Due to (or as a consequence of):

initiated the events resulting

in death) LAST d. Motor vehicle accident____________________________________________________________________________________

Approximate interval:

Onset to death

2 Days

7 weeks

33. WAS AN AUTOPSY PERFORMED?

■ Yes  No

PART II. Enter other significant conditions contributing to death but not resulting in the underlying cause given in PART I

34. WERE AUTOPSY FINDINGS AVAILABLE TO

COMPLETE THE CAUSE OF DEATH? ■ Yes  No

35. DID TOBACCO USE CONTRIBUTE TO DEATH?

 Yes  Probably

■ No  Unknown

36. IF FEMALE:

 Not pregnant within past year

 Pregnant at time of death

 Not pregnant, but pregnant within 42 days of death

 Not pregnant, but pregnant 43 days to 1 year before death

 Unknown if pregnant within the past year

37. MANNER OF DEATH

 Natural  Homicide

■ Accident  Pending Investigation

 Suicide  Could not be determined

38. DATE OF INJURY

(Mo/Day/Yr) (Spell Month)

August 15, 2003

39. TIME OF INJURY

Approx. 2320

40. PLACE OF INJURY (e.g., Decedent’s home; construction site; restaurant; wooded area)

road side near state highway

41. INJURY AT WORK?

 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:

Decedent driver of van, ran off road into tree

44. IF TRANSPORTATION INJURY, SPECIFY:

■ 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

Abdominal hemorrhage

Adhesions

Adult respiratory distress syndrome

Acute myocardial infarction

Altered mental status

Anemia

Anoxia

Anoxic encephalopathy

Arrhythmia

Ascites

Aspiration

Atrial fibrillation

Bacteremia

Bedridden

Biliary obstruction

Bowel obstruction

Brain injury

Brain stem hern tion ia

Carcinogenesis

Carcinomatosis

Cardiac arrest

Cardiac dysrhythmia

Cardiomyopathy

Cardiopulmonary arrest

Cellulitis

Cerebral edema

Cerebrovascular accident

Cerebellar tonsillar herniation

Chronic bedridden state

Cirrhosis

Coagulopathy

Compression fracture

Congestive heart failure

Convulsions

Decubiti

Dehydration

Dementia (when not

otherw e specified) is

Diarrhea

Disseminated intra vascular

coagulopathy

Dysrhythmia

End-stage liver disease

End-stage renal disease

Epidural hematoma

Exsanguination

Failure to thrive

Fracture

Gangrene

Gastrointestinal hemorrhage

Heart failure

Hemothorax

Hepatic failure

Hepatitis

Hepatorenal syndrome

Hyperglycemia

Hyperkalemia

Hypovolemic shock

Hyponatremia

Hypotension

Immunosuppression

Increased intra cranial pressure

Intra cranial hemorrhage

Malnutrition

Metabolic encephalopathy

Multi-organ failure

Multi-system organ failure

Myocardial infarction

Necrotizing soft-tissue infection

Old age

Open (or closed) head injury

Paralysis

Pancytopenia

Perforated gallbladder

Peritonitis

Pleural effusions

Pneumonia

Pulmonary arrest

Pulmonary edema

Pulmonary embolism

Pulmonary insufficiency

Renal failure

Respiratory arrest

Seizures

Sepsis

Septic shock

Shock

Starvation

Subdural hematoma

Subarachnoid hemorrhage

Sudden death

Thrombocytopenia

Uncal herniation

Urinary tract infection

Ventricular fibrillation

Ventricular tachyc rdia a

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

Bolus

Choking

Drug or alcohol verdose/drug or o

alcohol abuse

Epidural hematoma

Exsanguination

Fall

Fracture

Hip fracture

Hyperthermia

Hypothermia

Open reduction of fracture

Pulmonary emboli

Seizure disorder

Sepsis

Subarachnoid hemorrhage

Subdural hematoma

Surgery

Thermal burns/chemical burns

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: T

his 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

▼ CDC U.S. Standard Certificate of Death PDF Form

Document Attributes

Fact Name	Description
Purpose	The CDC U.S. Standard Certificate of Death form is used to document the details surrounding a person's death.
Standardization	This form provides a standardized method for reporting death information across the United States.
Required Information	It requires details such as the decedent's name, date of birth, date of death, and cause of death.
State Variations	Each state may have its own version of the form, which complies with local laws and regulations.
Governing Laws	In California, for example, the form is governed by California Health and Safety Code Section 102825.
Filing Requirements	The completed form must be filed with the appropriate state or local vital records office.
Electronic Submission	Many states allow for electronic submission of death certificates to streamline the process.
Confidentiality	Information on the certificate is generally considered confidential and is protected by privacy laws.
Importance for Statistics	This form is crucial for public health statistics and tracking mortality trends in the U.S.

CDC U.S. Standard Certificate of Death: Usage Instruction

Filling out the CDC U.S. Standard Certificate of Death form is an important task that requires careful attention to detail. Once completed, this form will be submitted to the appropriate authorities to officially record the death. Here’s how to go about it.

Begin by gathering all necessary information about the deceased, including their full name, date of birth, and place of birth.
Fill in the date of death, ensuring accuracy with the day, month, and year.
Provide the location where the death occurred, including the city and state.
Complete the section regarding the cause of death. This may require input from a medical professional.
Include the deceased’s social security number, if applicable.
Fill in the information about the informant, who is usually a family member or someone close to the deceased. This includes their name, relationship to the deceased, and contact information.
Sign and date the form as the informant, confirming that the information provided is accurate to the best of your knowledge.
Review the entire form for any errors or missing information before submitting it.

After completing the form, it should be submitted to the local vital records office. They will process it and ensure that the death is officially recorded. This step is crucial for legal purposes and for the family’s future needs.

Frequently Asked Questions

What is the CDC U.S. Standard Certificate of Death form?
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 form is essential for legal, administrative, and statistical purposes. It provides a standardized way to collect information about the deceased, including personal details, the cause of death, and other relevant circumstances.
Who is responsible for completing the death certificate?
The responsibility for completing the death certificate typically falls on the attending physician or medical examiner. They are tasked with providing accurate information regarding the cause of death. However, family members or funeral directors may also assist in gathering necessary details to ensure the form is filled out correctly.
Why is it important to file a death certificate?
Filing a death certificate is crucial for several reasons:
- It serves as a legal record of the death.
- It is required for settling the deceased's estate and accessing life insurance benefits.
- It helps public health officials track mortality statistics and causes of death.
Without this document, families may face challenges in managing the deceased's affairs.
How can I obtain a copy of a death certificate?
To obtain a copy of a death certificate, you typically need to contact the vital records office in the state where the death occurred. Many states offer online services, while others may require a written request or an in-person visit. Be prepared to provide identification and relevant details, such as the deceased's full name, date of death, and your relationship to the deceased.
What information is included on the death certificate?
The death certificate includes a variety of information, such as:
- The deceased's full name and personal details
- The date and place of death
- The cause of death, including any contributing factors
- Information about the attending physician or medical examiner
- Details regarding the disposition of the body
This comprehensive information is vital for both legal and public health purposes.
Can a death certificate be amended?
Yes, a death certificate can be amended if errors are discovered after it has been filed. The process for making amendments varies by state, but it generally involves submitting a request along with supporting documentation to the vital records office. Common reasons for amendments include correcting misspelled names or updating the cause of death.

Common mistakes

Filling out the CDC U.S. Standard Certificate of Death form can be a challenging process during an already difficult time. It is essential to ensure accuracy and completeness to prevent any delays or issues in the future. Here are five common mistakes that individuals often make when completing this important document.

One frequent error is providing incomplete information. Each section of the form requires specific details about the deceased, such as their full name, date of birth, and place of death. Omitting any of this information can lead to complications. For instance, if the date of death is missing, it may result in difficulties when obtaining necessary legal documents or benefits.

Another mistake involves incorrect spelling of names. Names should be recorded exactly as they appear on legal documents. A simple misspelling can create confusion and may cause issues with the deceased’s estate or insurance claims. It is advisable to double-check the spelling before submitting the form.

People also often overlook the importance of accurate cause of death information. This section must be filled out with care, as it can affect various legal and medical records. If the cause of death is not clearly stated or is inaccurately reported, it may lead to misunderstandings or complications for the family members left behind.

Additionally, many individuals fail to sign the form or have it signed by the required parties. The signature of the attending physician or medical examiner is crucial for validating the document. Without these signatures, the certificate may be deemed invalid, complicating matters for the family.

Lastly, people sometimes neglect to keep copies of the completed form. It is vital to retain a copy for personal records and future reference. This can be helpful for settling the deceased’s affairs, applying for benefits, or handling estate matters. Not having a copy can lead to additional stress during an already challenging time.

Documents used along the form

The CDC U.S. Standard Certificate of Death form is a crucial document used to officially record the details surrounding an individual's death. Alongside this form, several other documents may be required to ensure proper processing and compliance with legal requirements. Here are five common forms and documents often used in conjunction with the death certificate.

Medical Certificate of Death: This document is completed by a physician or medical examiner. It provides the medical cause of death and any relevant information about the deceased's health prior to death.
Burial Transit Permit: This permit is needed to transport a deceased person for burial or cremation. It is typically issued by the local health department and confirms that the death certificate has been filed.
Affidavit of Heirship: This legal document establishes the rightful heirs of the deceased's estate. It may be required for settling estates, particularly when there is no will.
Will: If the deceased left a will, this document outlines their wishes regarding the distribution of their assets. It is essential for probate proceedings and ensuring that the deceased's intentions are honored.
Death Notice or Obituary: While not a legal requirement, a death notice or obituary is often published in local newspapers or online. This document serves to inform the community about the death and provides details about memorial services.

These documents work together with the CDC U.S. Standard Certificate of Death to ensure that all legal and procedural aspects of a person's passing are addressed. Having the right paperwork in place can ease the process during a difficult time.

Similar forms

The CDC U.S. Standard Certificate of Death form serves as a crucial document in the process of recording and certifying a person's death. Several other documents share similarities with this form, primarily in their purpose of providing official information about an individual's death or related circumstances. Below is a list of eight documents that are comparable to the CDC U.S. Standard Certificate of Death form:

Death Certificate (State Variation): Each state has its own version of a death certificate, which includes similar information such as the deceased's name, date of birth, date of death, and cause of death. These documents are essential for legal and administrative purposes.
Medical Examiner's Report: This document is generated by a medical examiner or coroner. It details the circumstances surrounding a death, including findings from an autopsy, if applicable. Like the death certificate, it aims to clarify the cause of death.
Obituary: While not an official document, an obituary serves a similar function in informing the public about a person's death. It typically includes the deceased's life history, family information, and funeral arrangements, paralleling the personal details found in the death certificate.
Funeral Home Record: Funeral homes maintain records of the services they provide. These documents often include details about the deceased, such as their name, date of death, and service arrangements, similar to the information found on the death certificate.
Life Insurance Claim Form: When a policyholder passes away, beneficiaries must submit a claim form to receive benefits. This form often requires a copy of the death certificate, highlighting the importance of verifying the death's occurrence.
Social Security Administration Death Notification: This document is used to report a death to the Social Security Administration. It requires similar information as the death certificate, such as the deceased's Social Security number and date of death.
Will and Testament: A will often includes information about the deceased's estate and may mention the date of death. While primarily focused on the distribution of assets, it serves to confirm the individual's passing.
State Vital Records: These records encompass a range of official documents related to vital events, including births, marriages, and deaths. The format and purpose align closely with the CDC U.S. Standard Certificate of Death form, as they are all part of public health documentation.

Dos and Don'ts

When filling out the CDC U.S. Standard Certificate of Death form, it's important to ensure accuracy and completeness. Here are five things you should and shouldn't do:

Do: Gather all necessary information before starting the form.
Do: Use clear and legible handwriting or type the information if possible.
Do: Double-check all details for accuracy, including names and dates.
Do: Follow the specific instructions provided with the form carefully.
Do: Submit the form in a timely manner to avoid delays in processing.

Don't: Leave any required fields blank; this can cause processing delays.
Don't: Use abbreviations unless specified; clarity is key.
Don't: Provide incorrect information, as this can lead to legal issues.
Don't: Forget to sign and date the form where required.
Don't: Ignore the deadlines for submission; timely filing is crucial.

Misconceptions

Understanding the CDC U.S. Standard Certificate of Death form is essential for many individuals, especially during difficult times. However, several misconceptions often arise regarding this important document. Here are five common misunderstandings:

Only a doctor can complete the form.
While a physician typically provides the medical information, other qualified individuals can also fill out certain sections. This includes funeral directors or, in some cases, family members who have the necessary details.
The form is only needed for legal purposes.
Many people believe the certificate is solely for legal documentation. In reality, it serves multiple purposes, including statistical analysis, public health research, and genealogical records.
All states use the same version of the form.
Though the CDC provides a standard template, each state has the authority to modify the form to meet local requirements. Therefore, the appearance and specific fields may vary from one state to another.
Filing the form is the responsibility of the family.
While families often assist in the process, it is generally the funeral home’s responsibility to file the certificate with the appropriate state office. They are familiar with the requirements and ensure that the form is completed correctly.
Once filed, the certificate cannot be changed.
This is not entirely accurate. Corrections can be made to the certificate if errors are identified after filing. However, the process for making changes may vary by state and typically requires specific documentation.

By clarifying these misconceptions, individuals can better navigate the complexities surrounding the CDC U.S. Standard Certificate of Death form.

Key takeaways

The CDC U.S. Standard Certificate of Death form is a crucial document that serves to officially record the details surrounding an individual's death. Understanding how to accurately fill out and utilize this form can ensure that the information is both complete and compliant with legal requirements. Here are key takeaways regarding the form:

Accurate Information: It is essential to provide precise details about the deceased, including full name, date of birth, and date of death.
Cause of Death: The primary cause of death must be clearly stated, along with any contributing factors. This section is vital for public health statistics.
Medical Certification: A licensed physician or medical examiner must complete the medical certification portion of the form. Their signature validates the cause of death.
Completeness: Ensure that all required fields are filled out. Incomplete forms may delay the processing of the death certificate.
Timeliness: Submit the completed form promptly to the appropriate vital records office. Timely submission is important for legal and administrative purposes.
Legibility: Fill out the form using clear and legible handwriting or type the information. This reduces the likelihood of errors during processing.
Confidentiality: Understand that the information on the death certificate is sensitive. Access to this document is typically restricted to authorized individuals.
Follow-Up: After submission, verify that the death certificate has been processed correctly. Obtain certified copies as needed for legal and personal purposes.