⇒

Blank CDC U.S. Standard Certificate of Death PDF Template

The CDC U.S. Standard Certificate of Death form is a crucial document used to officially record the details of an individual's death. This form captures vital information, including the cause of death, which plays a significant role in public health and legal matters. For a step-by-step guide on how to properly fill out this important document, click the button below.

Make This Document Now

Blank CDC U.S. Standard Certificate of Death PDF Template

Navigation

The CDC U.S. Standard Certificate of Death form serves as a crucial document in public health and legal affairs, capturing key information about individuals at the time of death. This form is central to accurately documenting causes of death, personal data, and other significant details that contribute to vital statistics. These statistics, in turn, inform public health policies, epidemiological research, and a host of legal and familial matters, such as estate settlement and access to benefits. The compilation of this data across the United States aids in detecting public health trends, identifying potential areas for intervention, and improving overall health outcomes. Moreover, the form is standardized to ensure consistency and comparability of data across different jurisdictions, reflecting the critical balance between federal guidance and state-specific considerations in its design and implementation.

Preview - CDC U.S. Standard Certificate of Death Form

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

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

Form Data

Fact Name	Description
Origin	The CDC U.S. Standard Certificate of Death was developed by the National Center for Health Statistics, which is part of the Centers for Disease Control and Prevention (CDC), to standardize death reporting across the United States.
Purpose	Its purpose is to ensure uniformity of data concerning deaths, including causes, locations, and times, which is crucial for public health and epidemiological research.
Implementation	Although the CDC provides a standard form, implementation is at the state level, which means each state can modify the form to some extent to meet local needs and requirements.
State-Specific Laws	Each state has its own set of laws that govern the issuance, completion, and filing of death certificates. These laws dictate who can complete the form, how timely it must be filed, and what it must include.
Revision Cycle	The form undergoes periodic revisions to reflect changes in medical science, technology, and the needs of public health research. Recent versions have included more detailed options for causes of death and demographic information.

Instructions on Utilizing CDC U.S. Standard Certificate of Death

Filling out the CDC U.S. Standard Certificate of Death form is an important step in officially documenting a death. This form is essential for legal and statistical purposes. It helps in the closure of estates, ensures accurate governmental records, and assists in public health research. It's crucial to approach this task with attention to detail to ensure every piece of information is correctly captured. Here is a step-by-step guide to completing the form accurately.

Gather all necessary information before beginning. This includes the deceased’s full name, date and place of birth, Social Security number, address, and information about the parents. Also, details about the cause of death, the time of death, and the attending physician or coroner need to be on hand.
Start with personal information. Fill in the deceased’s full legal name, address, date of birth, Social Security number, and any other personal information required. Accuracy is crucial to ensure records are correctly updated.
Document the death. Enter the date, time, and place of death. Precise details here are necessary for official records and may have implications for legal and estate matters.
Detail cause of death. This part must be completed by a qualified physician or coroner. If you're responsible for this, provide an accurate cause of death in the respective section. If this falls outside your duties, ensure the attending professional completes this part.
Include information about the informer. This section identifies who is providing the information on the deceased. Fill out your relationship to the deceased and your contact details.
Record disposition information. Detail how the body was handled—burial, cremation, donation, etc.—including the date and location. This information is vital for official and family records.
Review the form for accuracy. Before submitting the form, check all entered information to confirm its correctness. Mistakes can cause delays and may require you to fill out the form again.
Submit the form to the appropriate authorities. The specific office or department can vary from state to state, so verify the correct submission destination. This may be a local health department, vital records office, or other designated agency.

After the form is submitted, the official death record will be processed. This record serves numerous purposes, from allowing legal closure of the deceased's affairs to contributing to vital statistics that inform public health policies. While filling out the form may feel daunting, it is a necessary step in ensuring accurate and respectful handling of the final stages of life's administration.

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

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

The CDC U.S. Standard Certificate of Death is a vital record that documents the death of an individual. It serves two primary purposes: legal and statistical. Legally, it finalizes the deceased's affairs, including estate and benefits. Statistically, it aids in health research, tracking disease trends, and setting public health policies.
Who is responsible for completing the death certificate?

Completion of the death certificate is a combined effort. Typically, a medical professional, such as a physician, coroner, or medical examiner, certifies the cause of death. Administrative details are usually provided by the funeral director, who gathers information from the family of the deceased and is responsible for filing the completed certificate with the local or state vital statistics office.
How is the cause of death determined?

The cause of death section is divided into two parts: the immediate cause which set off the train of events leading to death, and any underlying causes which initiated this sequence. Medical professionals examine the circumstances and may run tests to accurately determine and record these causes.
What happens if a death occurs without medical personnel present?

If death occurs without medical personnel present, or under conditions that are not natural, a coroner or medical examiner may be called to investigate. They have the authority to order autopsies if needed, determine the cause of death, and complete the death certificate accordingly.
Can a death certificate be amended?

Yes, death certificates can be amended, though the process varies by jurisdiction. Typically, amendments require documentation justifying the change, such as medical records or a coroner's findings. Only certain sections, like cause of death or personal information discrepancies, may be amended.
How does one obtain a copy of a death certificate?

Copies of death certificates can usually be requested from the state or local vital records office where the death was registered. Requirements include submitting a completed application, paying a fee, and providing identification to prove your right to obtain it, which varies depending on your relationship to the deceased.
Why is the accuracy of the death certificate important?

The accuracy of the death certificate is critical for several reasons. It ensures proper handling of the deceased's legacy and informs public health strategies by providing reliable data on mortality trends, causes of death, and population health. Errors can affect estate settlement, research, and health policies.

Common mistakes

Filling out the CDC U.S. Standard Certificate of Death form requires attention to detail and a comprehensive understanding of the requested information. Sadly, errors can occur during this process, complicating and delaying vital legal and administrative procedures. Below are eight common mistakes people often make when completing this crucial document:

Failing to verify personal information: Double-checking the deceased's full name, social security number, date of birth, and other personal details for accuracy is crucial but often overlooked.
Incorrect cause of death detailing: It's important to list the immediate cause, underlying causes, and any contributing factors accurately. Misreporting these details can impact statistical data and may raise legal issues.
Omitting informant's accurate information: The informant is the person providing details about the deceased. Ensuring their name, address, and relationship to the deceased are correct is essential.
Misclassifying marital status: Accurately stating the deceased's marital status at the time of death is essential for legal and record-keeping purposes, yet is often misreported.
Lack of precision in location data: Specificity in reporting the place of death, whether at a hospital, residence, or elsewhere, is required. Vague or incorrect location data can lead to confusion.
Underestimating the importance of the time of death: Precisely recording the time of death is crucial for legal matters, such as determining the validity of a will or life insurance policy, yet this detail is frequently recorded inaccurately.
Skipping details about burial or cremation: Including comprehensive information about the intended burial or cremation services, including location and service provider, is required but often incomplete or omitted.
Not consulting with medical or legal professionals: Errors often stem from the informant's failure to seek advice from professionals when uncertain about the form's requirements, leading to inaccuracies in the completed document.

It's pertinent to approach the task of completing the CDC U.S. Standard Certificate of Death with the seriousness and diligence it deserves. Errors on this document can have far-reaching implications, affecting everything from the memorial service's planning to the settlement of the deceased's estate. By avoiding the mistakes listed, the process of certifying a death can be handled more smoothly and respectfully, ensuring all legal and procedural requirements are met accurately.

Documents used along the form

The death of an individual is a significant event, marking not only a personal loss but also the beginning of various legal and administrative processes. Completing the CDC U.S. Standard Certificate of Death form is a critical step in this journey. However, this form does not stand alone. Numerous other documents are often required or used alongside it to ensure the deceased's affairs are comprehensively managed. Let's explore some of these essential documents.

Death Notification Letter: This document is utilized to formally inform relevant parties of the individual's passing. It could be used with financial institutions, government agencies, or insurance companies to initiate the closure of accounts or to claim benefits.
Last Will and Testament: This legal document outlines the deceased's wishes regarding the distribution of their assets and care of any dependents. It is crucial for probate proceedings.
Probate Court Documents: These are necessary when the deceased's estate goes through probate, the legal process that validates their will and oversees the distribution of the estate.
Trust Documents: If the deceased had established any trusts, these documents are needed to manage and distribute the assets placed in trust according to the deceased’s instructions.
Life Insurance Policies: Essential for claiming life insurance benefits, these documents specify the beneficiaries and the amounts they are entitled to.
Real Estate Deeds: To transfer real estate owned by the deceased, these deeds are required. They prove ownership and can be vital in the distribution of the estate.
Stock and Bond Certificates: If the deceased owned stocks or bonds, these certificates are necessary for transferring ownership to the heirs or selling the securities.
Bank Account Statements: These help in identifying the deceased's assets and settling any outstanding debts or claims against the estate.
Vehicle and Boat Titles: For the transfer of vehicles and boats owned by the deceased, these titles must be presented to the relevant authorities.
Funeral Planning Documents: These may include pre-planned funeral arrangements or personal wishes regarding the funeral service, and they guide the family in organizing the service.

While the death certification process marks the end of a person's life, it also signals the beginning of the critical task of addressing their final affairs. From legal wills to personal letters, each document plays a vital role in ensuring that the deceased's wishes are honored and that the legal aspects of their estate are properly managed. Being familiar with these forms and documents can help streamline the often complex and emotional process of bidding farewell to a loved one.

Similar forms

CDC U.S. Standard Birth Certificate: This document collects vital information about the circumstances of a birth, such as the time, location, parentage, and medical details similar to what the death certificate captures about death events. Both forms are essential for tracking population statistics and are used in public health and demographic studies.
Marriage Certificate: A marriage certificate records the official union of two individuals, detailing the date, location, and parties involved. Like the death certificate, it confirms an important life event and is necessary for legal processes, including name changes, tax filings, and inheritance matters.
Divorce Decree: This document officially ends a marriage under the law, detailing the parties involved, date of dissolution, and terms agreed upon. It is similar to a death certificate as it marks the legal conclusion of a significant life event, impacting legal status and personal records.
Adoption Certificate: An adoption certificate legally records the adoption of a child by their new parents, including names and dates. Like the death certificate, it is a critical document for establishing identity and familial relationships for legal, personal, and inheritance purposes.
Passport Application: Though primarily for travel, a passport application requires rigorous proof of identity, citizenship, and other personal details, akin to the information captured in a death certificate to ascertain a person’s legal status at death for official records.
Social Security Application: Similar to a death certificate, this form collects detailed personal information to establish a person’s eligibility for social security benefits. Both documents serve as official records to support or modify entitlements based on life events.
Driver’s License Application: This form requires proof of identity, age, and residency—details also pertinent in a death certificate. Both are government-issued documents used to verify personal information for legal and administrative purposes.
Medical Records Release Form: A document that authorizes the transfer of an individual's medical history between healthcare providers or to the individual directly. It parallels the death certificate in its role in compiling health-related information, which may include details relevant to the cause of death or conditions leading to it.

Dos and Don'ts

Filling out the CDC U.S. Standard Certificate of Death form is an important task that requires attention to detail and accuracy. Below are nine essential dos and don'ts to consider during this process:

Do verify the decedent’s personal information. Ensure that you have accurate details, including the full name, date of birth, and social security number. This information is critical for record accuracy.
Don’t rush through the process. Take your time to review each section carefully. Mistakes or inaccuracies can lead to issues down the line, both for record-keeping purposes and for the family of the deceased.
Do use medical terminology accurately. When entering the cause of death, ensure that the terms used are medically accurate. This information is vital for public health records and statistical analysis.
Don’t use non-specific terms. Avoid vague terms like “old age” or “natural causes” without further medical details. Specificity is crucial for clarity and useful statistical data.
Do double-check the document for any errors. Before submitting the certificate, review all entries for typos, inaccuracies, or omissions. Ensuring accuracy at this stage can prevent future complications.
Don’t leave sections incomplete. Unless specifically instructed, try to fill out every section of the form. If a section does not apply, confirm whether noting it as “N/A” (not applicable) is appropriate.
Do consult with colleagues or supervisors if uncertain. If there’s any doubt regarding how to fill out certain sections, ask for help. It's better to seek clarification than to make an educated guess.
Don’t forget to sign and date the form. Your signature validates the accuracy of the information provided. Ensure the form is also dated correctly.
Do adhere to state and local requirements. While filling out the CDC U.S. Standard Certificate of Death, keep in mind any additional requirements your jurisdiction might have. Compliance with local laws is just as important as following the federal guidelines.

Misconceptions

The CDC U.S. Standard Certificate of Death form is a vital document, playing a key role in the collection of national mortality data. However, misconceptions about its content and purpose are common. Highlighting and correcting these misconceptions can help individuals understand the importance of this document and the information it captures.

Misconception 1: The death certificate primarily serves legal purposes. Many people believe the main purpose of the death certificate is to serve as a legal document for the deceased's estate and other post-death arrangements. While it does fulfill this role, its primary purpose is to gather public health data. These data help health professionals and policymakers understand mortality trends, which can inform public health policies and programs.
Misconception 2: Cause of death is always determined by an autopsy. It's a common belief that an autopsy is required to accurately determine and record the cause of death on the certificate. In reality, the certifying physician, coroner, or medical examiner can determine the cause based on medical history, circumstances of death, and, in some cases, laboratory tests, without an autopsy being performed.
Misconception 3: The form is the same in every state. Given the form's title, it's understandable that one might assume it is identical across the U.S. However, while the CDC provides a standard template, each state can modify the form to meet its specific needs and requirements. This can result in variations in the form's appearance and the information requested.
Misconception 4: Personal family information is not important on the death certificate. Some may think the certificate focuses solely on the deceased's medical and death details. However, personal and family information provided on the form, such as race, ethnicity, and marital status, plays a crucial role in epidemiological studies. This data helps researchers identify and analyze health disparities among different population groups.

Key takeaways

The CDC U.S. Standard Certificate of Death is a critical document that requires meticulous attention to detail when being filled out. Here are five key takeaways to ensure the process is handled accurately and efficiently:

Accuracy is paramount. Every detail entered on the form must accurately reflect the deceased's information. This includes full legal name, date of birth, social security number, and cause of death. Mistakes can lead to issues with vital records and may complicate legal matters for the deceased's family.
Understanding the cause of death sections is crucial. The form requires the cause of death to be listed accurately. This includes distinguishing between the immediate cause of death and any underlying conditions that contributed to it. It's essential to be precise to ensure the death is properly classified and recorded.
Timeliness is key. The form must be filled out and filed within the timeframe mandated by state law. Delays can result in penalties for the responsible party, typically the certifying physician, coroner, or medical examiner, and may delay funeral arrangements and other processes.
Confidentiality must be maintained. The information on the death certificate is sensitive. Only authorized individuals should handle the form to protect the deceased's privacy and ensure the information is used appropriately for legal, public health, and statistical purposes.
Follow state-specific instructions. While the CDC provides a standard form, each state may have its own specific instructions or additional requirements for filling out and filing the death certificate. It's essential to be familiar with these state-specific guidelines to avoid errors and ensure compliance.

By adhering to these key takeaways, individuals responsible for completing the CDC U.S. Standard Certificate of Death can do so effectively, ensuring that the process honors the deceased's legacy while meeting all legal and regulatory requirements.

Please rate Blank CDC U.S. Standard Certificate of Death PDF Template Form

4.65

Incredible

17 Votes

Popular PDF Forms

Dol 4n - Part I of the GA Tax Wage Report focuses on listing each employee's Social Security Number, full name, and the total gross wages paid during the quarter, adhering to specific reporting instructions.

Dc 628 - May order payment towards arrears, specifying amounts and intervals, to catch up on missed payments.

Community Service Hours Log - A straightforward template for students to itemize their volunteer service, ensuring clarity and uniformity in reporting.