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New Death Certificate Form: What You Should Know

A. Enter the name and contact information. 32B. Select cause of death, if applicable. DATE OF DEATH -- TYPE OF FUNERAL --  (Check all that apply). 33. A. State the date of death. 33A. Make sure to enter the date of death or death by the month (month Jan. for January) or year (year 2022 for 2006) 33B. If the cause of death is listed, select appropriate date as noted in the table of course of death. A. Cause of death : 1. DIABETES 2. HYPERDEPRESSION 33C. Other. B. Determining age : Enter a range of years that the individual is believed to have been in that age category. DATE OF EXECUTION/MURDER/REVOCATION OF LICENSE/DEATH. 34. A. Type of Executed. 34A. Type of Killed. 34B. If the death occurred within the past year, enter the year of death. (2009 for February 2022 is) 34C. If the death occurred within the past six months, enter the month of death. (2006 for February is) 34D. If the death occurred within the past year and beyond, enter the date the person died. 33. State whether the person was on probation or parole at the time of the offense. 34. Name the court, if applicable. 34A. If the name on the license issued by the state of birth is in a different name than the person's birth name, enter the court issuing the license. 34B. The person's name must match exactly as entered on the license. 34C. If the person's name does not match exactly as entered on the license, enter “unknown”. 34D. If the person's name does match exactly as entered on the license, enter the person's birth name. HISTORY REVISIONS -- REVISIONS -- REVISION OF FORM -- REV. 11/2003 A. Change of name. If the person's name on the license was changed prior to January 1, 2003, state the following information: 1. Name 1. Name as set forth on the license. 2. Address 3, if known. 4. Date of birth. 2 or 3, if applicable. 4C.

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