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How to prepare US Death Certificate Form

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55. KIND OF BUSINESS/INDUSTRY REV. 11/2003 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. 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. U.S. STANDARD CERTIFICATE OF DEATH 4a. AGE-Last Birthday Years 4b. UNDER 1 YEAR Hours Days 2. SEX Minutes 7b. COUNTY 7d. STREET AND NUMBER 7c. CITY OR TOWN 7e. APT. NO. 8. EVER IN US ARMED FORCES Yes No STATE FILE NO. 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. Such cases should be reported to the medical examiner/coroner. Asphyxia Hip fracture Bolus Hyperthermia Seizure disorder Surgery Choking Fall Thermal burns/chemical burns Drug or alcohol overdose/drug or Open reduction of fracture alcohol abuse 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. U*S* STANDARD CERTIFICATE OF DEATH 4a* AGE-Last Birthday Years 4b. UNDER 1 YEAR Hours Days 2. SEX Minutes 7b. COUNTY 7d. STREET AND NUMBER 7c* CITY OR TOWN 7e. APT. NO. 8. EVER IN US ARMED FORCES Yes No STATE FILE NO. 3. SOCIAL SECURITY NUMBER 5. DATE OF BIRTH Mo/Day/Yr 6. BIRTHPLACE City and State or Foreign Country 4c* UNDER 1 DAY Months 7a* RESIDENCE-STATE To Be Completed/ Verified By FUNERAL DIRECTOR NAME OF DECEDENT For use by physician or institution LOCAL FILE NO.

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