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Blank Death Certificate Form: What You Should Know

A. Contributed to death B. contributed to, or was a factor in, a condition C. was the primary cause of death. For example, if you are a victim of a car accident and the driver's  Citation: The death certificate must be valid for two years after the date that the deceased became eligible to receive an individual death certificate  CAUSE OF DEATH (See instructions and examples). 39. PART II. Enter the personal information of the deceased (see examples). 40. PART III. Type the name and the date of death of the individual from the first part of the information on the form as you see it. 41. Enter the name of the individual(s) on the bottom of the form. 42. Type the date of death. 43. Type the cause of death for each individual--if applicable. 44.

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