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Blank CDC U.S. Standard Certificate of Death PDF 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 plays a crucial role in public health data collection and helps ensure accurate mortality statistics. Understanding how to properly fill out this form is essential for legal and administrative purposes; click the button below to learn more about completing it.

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The CDC U.S. Standard Certificate of Death form serves as a crucial document in the process of recording a person's death. This form captures essential information, including the decedent's full name, date of birth, and date of death. It also includes details about the cause of death, which is vital for public health statistics and research. The certificate requires information about the decedent's residence, marital status, and occupation, ensuring a comprehensive record. Additionally, the form must be completed by a qualified medical professional who certifies the cause of death, lending credibility to the information provided. The document is then filed with the appropriate state or local vital records office, playing a significant role in legal and administrative processes following a death. Understanding the elements of this form is important for families, funeral directors, and healthcare providers alike, as it impacts various aspects of estate management, insurance claims, and public health data collection.

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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

➤ PDF File

Form Specifications

Fact Name	Description
Purpose	The CDC U.S. Standard Certificate of Death form is used to document the cause of death and other essential information about the deceased.
Standardization	This form is standardized across the United States to ensure consistency in recording death-related data.
Required Information	The form requires details such as the decedent's name, date of birth, date of death, and place of death.
Medical Certification	A physician or medical examiner must complete the medical certification section, detailing the cause of death.
State-Specific Forms	While the CDC form is standardized, each state may have specific requirements and additional forms governed by state laws.
Legal Importance	The certificate serves as a legal document, necessary for settling estates, claiming life insurance, and other legal matters.
Submission Timeline	Most states require the completed death certificate to be filed within a certain timeframe, often within 5 to 10 days after death.

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

Filling out the CDC U.S. Standard Certificate of Death form is a crucial task that requires attention to detail. Once completed, this form will need to be submitted to the appropriate authorities, ensuring that all necessary information is accurately recorded. Here’s how to fill it out step by step.

Begin by entering the deceased person's full name in the designated section.
Provide the date of death, including the month, day, and year.
Indicate the time of death, specifying whether it was in the morning or evening.
Fill in the place of death, including the city, county, and state.
Record the deceased's age at the time of death.
Note the deceased's gender.
Enter the deceased's race or ethnicity, as applicable.
Provide the marital status of the deceased at the time of death.
List the name of the surviving spouse, if applicable.
Fill in the deceased's occupation and industry.
Record the name of the informant, who is the person providing the information for the certificate.
Include the informant's relationship to the deceased.
Provide the informant's address and contact information.
Sign and date the form where indicated, confirming the accuracy of the information provided.

After completing the form, ensure that all sections are filled out accurately. Review the information for any errors or omissions. Once confirmed, submit the form to the local vital records office or the designated authority for processing.

Your Questions, Answered

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 is essential for legal and administrative purposes, providing vital information about the deceased, including their identity, cause of death, and other relevant circumstances. Each state in the U.S. has adopted this standard format to ensure consistency and accuracy in death reporting.

Who is responsible for completing the death certificate?

What information is required on the death certificate?

How does the death certificate affect legal processes?

Is there a deadline for filing the death certificate?

Can a death certificate be amended after it is filed?

Where can I obtain a copy of the death certificate?

Common mistakes

Not providing complete information. It's essential to fill out every section of the form. Leaving sections blank can lead to delays.
Using incorrect spelling of names. Double-check the spelling of the deceased's name and other important details. Mistakes can cause complications in legal matters.
Failing to include the correct date of death. Ensure that the date is accurate, as this information is critical for record-keeping.
Omitting the cause of death. This section is important for statistical purposes and public health records. Be as specific as possible.
Not having the necessary signatures. Make sure that the required parties sign the form. Missing signatures can invalidate the document.
Using outdated forms. Always check that you are using the most current version of the CDC form. Older versions may not be accepted.
Providing inconsistent information. Ensure that the details match across different sections of the form. Inconsistencies can raise questions.
Ignoring local requirements. Different states may have additional requirements or forms. Check with local authorities to ensure compliance.

Documents used along the form

When dealing with the loss of a loved one, it is important to understand the various forms and documents that may be required alongside the CDC U.S. Standard Certificate of Death. Each document serves a specific purpose and can help facilitate the necessary processes during this challenging time.

Death Notice: This is a public announcement of a person's death, typically published in newspapers or online platforms. It informs the community and can include details about the deceased's life, funeral arrangements, and memorial services.
Obituary: An obituary is a more detailed account of a person's life, often published in newspapers. It usually includes biographical information, achievements, and surviving family members. This document serves to honor the deceased and inform the public about their passing.
Funeral Service Agreement: This document outlines the arrangements made with a funeral home. It details the services to be provided, costs involved, and any specific wishes regarding the funeral or memorial service.
Burial or Cremation Permit: Required by local authorities, this permit allows for the burial or cremation of the deceased. It ensures that all legal requirements are met before proceeding with these final arrangements.
Affidavit of Heirship: This legal document may be necessary to establish the rightful heirs of the deceased's estate. It is often used when there is no will and helps in the distribution of assets.
Will or Trust Document: If the deceased left a will or established a trust, these documents outline how their assets should be distributed. They play a crucial role in the probate process and ensuring that the deceased's wishes are honored.
Social Security Notification: This document is used to notify the Social Security Administration of the individual's death. It may help the family access any benefits or assistance they are entitled to following the loss.

Understanding these documents can ease the burden during a difficult time. Each plays a significant role in ensuring that legal and personal matters are handled appropriately, allowing families to focus on healing and remembrance.

Similar forms

The CDC U.S. Standard Certificate of Death form shares similarities with several other important documents. Each of these documents serves a unique purpose but contains comparable elements related to personal information, legal requirements, or record-keeping. Below is a list of six documents that exhibit these similarities:

Birth Certificate: Like the death certificate, a birth certificate records essential personal information, including the individual's name, date of birth, and parents' details. Both documents are vital for establishing identity and legal status.
Marriage Certificate: This document certifies the union between two individuals. It includes personal information about both parties and serves as legal proof of marriage, similar to how a death certificate serves as proof of death.
Divorce Decree: A divorce decree finalizes the dissolution of a marriage and contains critical details about the parties involved. Both the divorce decree and death certificate are official records that have legal implications for the individuals named within.
Power of Attorney: This document grants authority to one person to act on behalf of another in legal matters. It includes personal details and signatures, much like the death certificate, which requires specific information for legal and administrative purposes.
Will: A will outlines an individual's wishes regarding the distribution of their estate after death. It includes personal information and must be legally validated, paralleling the requirements of a death certificate.
Medical Report: A medical report documents an individual's health status and can include information about the cause of death. Both the medical report and death certificate provide essential details that may be required for legal and administrative processes.

Dos and Don'ts

Filling out the CDC U.S. Standard Certificate of Death form is a sensitive task. It's important to approach it with care. Here are some guidelines to help you through the process:

Do ensure all information is accurate and complete.
Do use clear and legible handwriting if filling it out by hand.
Do follow the instructions carefully for each section of the form.
Do check for any required signatures before submitting the form.

Don't leave any fields blank unless specifically instructed.
Don't use abbreviations or nicknames; provide full names and details.
Don't submit the form without reviewing it for errors.
Don't forget to keep a copy of the completed form for your records.

Misconceptions

The CDC U.S. Standard Certificate of Death form is a critical document used to record the details surrounding an individual's death. However, several misconceptions exist regarding this form. Below is a list of seven common misunderstandings:

All deaths must be reported using this form. Many believe that every death in the U.S. requires this specific form. In reality, while most states use the CDC form, some may have their own versions or additional requirements.
The form is only necessary for legal purposes. Some individuals think the certificate is solely for legal reasons. However, it also serves public health purposes, helping to track mortality trends and causes of death.
Only medical professionals can fill out the form. There is a misconception that only doctors or coroners can complete the certificate. In fact, while medical professionals typically provide the medical information, funeral directors and other authorized individuals can also assist in completing the form.
Death certificates are not important for personal records. Some people underestimate the importance of a death certificate for personal and family records. This document is often required for settling estates, claiming life insurance, and other legal matters.
Once filed, the information on the form cannot be changed. Many believe that the information submitted is permanent. In truth, corrections can be made if errors are identified, though the process may vary by state.
The cause of death must always be clear and obvious. It is a common misconception that the cause of death must be immediately apparent. In some cases, further investigation or autopsy may be necessary to determine the cause, and this can delay the completion of the certificate.
Death certificates are public documents available to anyone. While death certificates are generally considered public records, access may be restricted in certain states. Eligibility to obtain a copy can depend on the relationship to the deceased or other criteria.

Understanding these misconceptions can help individuals navigate the complexities associated with the CDC U.S. Standard Certificate of Death form more effectively.

Key takeaways

The CDC U.S. Standard Certificate of Death form is a crucial document for recording vital information about a deceased individual. Proper completion and usage of this form ensure accurate data collection and reporting. Here are key takeaways to consider:

Accurate Information is Essential: Ensure that all details, such as the deceased's full name, date of birth, and date of death, are filled in correctly to avoid future complications.
Signatures Matter: The form requires signatures from the attending physician or medical examiner, as well as the informant, who is usually a family member. These signatures validate the information provided.
Timeliness is Key: Submit the completed form to the appropriate local or state vital records office promptly. This is often required within a specific timeframe after the death occurs.
Use Clear Language: Fill out the form using clear and concise language. Avoid abbreviations and ensure that all handwriting is legible to prevent misunderstandings.
Understand the Sections: Familiarize yourself with each section of the form, including demographic information, cause of death, and burial or cremation details. Each part is important for comprehensive record-keeping.
Check for Updates: Regulations and requirements for the death certificate may change. Regularly check for updates from the CDC or local health departments to ensure compliance.