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The CDC U.S. Standard Certificate of Death form plays a crucial role in documenting the end of life and serves as an essential tool for public health data collection. This standardized form captures vital information about the deceased, including personal details such as name, age, and gender, as well as the circumstances surrounding their death. It requires input from various parties, including medical professionals who provide details about the cause of death, which can range from natural causes to accidents or diseases. Additionally, the form includes sections for information about the deceased's residence, marital status, and occupation, all of which contribute to a comprehensive understanding of mortality trends. By ensuring that this information is accurately recorded, the form not only aids in the legal process of death certification but also supports vital statistics that inform public health policies and initiatives across the country.

Form Sample

U.S. STANDARD CERTIFICATE OF DEATH
LOCAL FILE NO. STATE FILE NO.
1. DECEDENT’S LEGAL NAME (Include AKA’s if any) (First, Middle, Last)
2. SEX 3. SOCIAL SECURITY NUMBER
4b. UNDER 1 YEAR 4c. UNDER 1 DAY 4a. AGE-Last Birthday
(Years)
Months Days Hours Minutes
5. DATE OF BIRTH (Mo/Day/Yr)
6. BIRTHPLACE (City and State or Foreign Country)
7a. RESIDENCE-STATE 7b. COUNTY 7c. CITY OR TOWN
7d. STREET AND NUMBER 7e. APT. NO. 7f. ZIP CODE
7g. INSIDE CITY LIMITS? □ Yes □ No
8. EVER IN US ARMED FORCES?
□ Yes □ No
9. MARITAL STATUS AT TIME OF DEATH
□ Married □ Married, but separated □ Widowed
□ Divorced □ Never Married □ Unknown
10. SURVIVING SPOUSE’S NAME (If wife, give name prior to first marriage)
11. FATHER’S NAME (First, Middle, Last)
12. MOTHER’S NAME PRIOR TO FIRST MARRIAGE (First, Middle, Last)
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:
□ Inpatient □ Emergency Room/Outpatient □ Dead on Arrival
IF DEATH OCCURRED SOMEWHERE OTHER THAN A HOSPITAL:
□ 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
□ Donation □ Entombment □ Removal from State
□ Other (Specify):_____________________________
19. PLACE OF DISPOSITION (Name of cemetery, crematory, other place)
20. LOCATION-CITY, TOWN, AND STATE
21. NAME AND COMPLETE ADDRESS OF FUNERAL FACILITY
NAME OF DECEDENT ____________________________________________
For use by physician or institution
To Be Completed/ Verified By:
FUNERAL DIRECTOR:
22. SIGNATURE OF FUNERAL SERVICE LICENSEE OR OTHER AGENT
23. LICENSE NUMBER (Of Licensee)
ITEMS 24-28 MUST BE COMPLETED BY PERSON
WHO PRONOUNCES OR CERTIFIES DEATH
24. DATE PRONOUNCED DEAD (Mo/Day/Yr)
25. TIME PRONOUNCED DEAD
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
(Mo/Day/Yr) (Spell Month)
30. ACTUAL OR PRESUMED TIME OF DEATH
31. WAS MEDICAL EXAMINER OR
CORONER CONTACTED? □ Yes □ No
CAUSE OF DEATH (See instructions and examples)
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
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._____________________________________________________________________________________________________________
Approximate
interval:
Onset to death
_____________
_____________
_____________
_____________
33. WAS AN AUTOPSY PERFORMED?
□ Yes □ No
PART II. Enter other significant conditions contributing to death but not resulting in the underlying cause given in PART I
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
38. DATE OF INJURY
(Mo/Day/Yr) (Spell Month)
39. TIME OF INJURY 40. PLACE OF INJURY (e.g., Decedent’s home; construction site; restaurant; wooded area)
41. INJURY AT WORK?
□ 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)
To Be Completed By:
MEDICAL CERTIFIER
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
that best describes the highest degree or level of
school completed at the time of death.
□ 8th grade or less
□ 9th - 12th grade; no diploma
□ High school graduate or GED completed
□ Some college credit, but no degree
□ Associate degree (e.g., AA, AS)
□ Bachelor’s degree (e.g., BA, AB, BS)
□ Master’s degree (e.g., MA, MS, MEng,
MEd, MSW, MBA)
□ Doctorate (e.g., PhD, EdD) or
Professional degree (e.g., MD, DDS,
DVM, LLB, JD)
52. DECEDENT OF HISPANIC ORIGIN? Check the box
that best describes whether the decedent is
Spanish/Hispanic/Latino. Check the “No” box if
decedent is not Spanish/Hispanic/Latino.
□ No, not Spanish/Hispanic/Latino
□ Yes, Mexican, Mexican American, Chicano
□ Yes, Puerto Rican
□ Yes, Cuban
□ Yes, other Spanish/Hispanic/Latino
(Specify) __________________________
53. DECEDENT’S RACE (Check one or more races to indicate what the
decedent considered himself or herself to be)
□ White
□ Black or African American
□ American Indian or Alaska Native
□ Asian Indian
(Name of the enrolled or principal tribe) _______________
□ Chinese
□ Filipino
□ Japanese
□ Korean
□ Vietnamese
□ Other Asian (Specify)__________________________________________
□ Native Hawaiian
□ Guamanian or Chamorro
□ Samoan
□ Other Pacific Islander (Specify)_________________________________
□ Other (Specify)___________________________________________
54. DECEDENT’S USUAL OCCUPATION (Indicate type of work done during most of working life. DO NOT USE RETIRED).
To Be Completed By:
FUNERAL DIRECTOR
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)
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
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. Rupture of myocardium __________________________________________________________________________________
resulting in death) Due to (or as a consequence of):
Sequentially list conditions, b. Acute myocardial infarction_______________________________________________________________________________
if any, leading to the cause Due to (or as a consequence of):
listed on line a. Enter the
UNDERLYING CAUSE c. Coronary artery thrombosis_______________________________________________________________________________
(disease or injury that Due to (or as a consequence of):
initiated the events resulting
in death) LAST d.
Atherosclerotic coronary artery disease__________________________________________________________________
Approximate interval:
Onset to death
Minutes
6 days
5 years
7 years
33. WAS AN AUTOPSY PERFORMED?
■ Yes No
PART II. Enter other significant conditions contributing to death but not resulting in the underlying cause given in PART I
Diabetes, Chronic obstructive pulmonary disease, smoking
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)
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
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. Aspiration pneumonia_______________________________________________________________
resulting in death) Due to (or as a consequence of):
Sequentially list conditions, b. Complications of coma___________________________________________________________________________________
if any, leading to the cause Due to (or as a consequence of):
listed on line a. Enter the
UNDERLYING CAUSE c. Blunt force injuries________________________________________________________________________________________
(disease or injury that Due to (or as a consequence of):
initiated the events resulting
in death) LAST d. Motor vehicle accident____________________________________________________________________________________
Approximate interval:
Onset to death
2 Days
7 weeks
7 weeks
7 weeks
33. WAS AN AUTOPSY PERFORMED?
■ Yes No
PART II. Enter other significant conditions contributing to death but not resulting in the underlying cause given in PART I
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
38. DATE OF INJURY
(Mo/Day/Yr) (Spell Month)
August 15, 2003
39. TIME OF INJURY
Approx. 2320
40. PLACE OF INJURY (e.g., Decedent’s home; construction site; restaurant; wooded area)
road side near state highway
41. INJURY AT WORK?
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:
Decedent driver of van, ran off road into tree
44. IF TRANSPORTATION INJURY, SPECIFY:
■ 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
Abdominal hemorrhage
Adhesions
Adult respiratory distress syndrome
Acute myocardial infarction
Altered mental status
Anemia
Anoxia
Anoxic encephalopathy
Arrhythmia
Ascites
Aspiration
Atrial fibrillation
Bacteremia
Bedridden
Biliary obstruction
Bowel obstruction
Brain injury
Brain stem hern tion ia
Carcinogenesis
Carcinomatosis
Cardiac arrest
Cardiac dysrhythmia
Cardiomyopathy
Cardiopulmonary arrest
Cellulitis
Cerebral edema
Cerebrovascular accident
Cerebellar tonsillar herniation
Chronic bedridden state
Cirrhosis
Coagulopathy
Compression fracture
Congestive heart failure
Convulsions
Decubiti
Dehydration
Dementia (when not
otherw e specified) is
Diarrhea
Disseminated intra vascular
coagulopathy
Dysrhythmia
End-stage liver disease
End-stage renal disease
Epidural hematoma
Exsanguination
Failure to thrive
Fracture
Gangrene
Gastrointestinal hemorrhage
Heart failure
Hemothorax
Hepatic failure
Hepatitis
Hepatorenal syndrome
Hyperglycemia
Hyperkalemia
Hypovolemic shock
Hyponatremia
Hypotension
Immunosuppression
Increased intra cranial pressure
Intra cranial hemorrhage
Malnutrition
Metabolic encephalopathy
Multi-organ failure
Multi-system organ failure
Myocardial infarction
Necrotizing soft-tissue infection
Old age
Open (or closed) head injury
Paralysis
Pancytopenia
Perforated gallbladder
Peritonitis
Pleural effusions
Pneumonia
Pulmonary arrest
Pulmonary edema
Pulmonary embolism
Pulmonary insufficiency
Renal failure
Respiratory arrest
Seizures
Sepsis
Septic shock
Shock
Starvation
Subdural hematoma
Subarachnoid hemorrhage
Sudden death
Thrombocytopenia
Uncal herniation
Urinary tract infection
Ventricular fibrillation
Ventricular tachyc rdia a
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
Bolus
Choking
Drug or alcohol verdose/drug or o
alcohol abuse
Epidural hematoma
Exsanguination
Fall
Fracture
Hip fracture
Hyperthermia
Hypothermia
Open reduction of fracture
Pulmonary emboli
Seizure disorder
Sepsis
Subarachnoid hemorrhage
Subdural hematoma
Surgery
Thermal burns/chemical burns
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: T
his 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

Document Specifications

Fact Name Description
Purpose The CDC U.S. Standard Certificate of Death form is used to officially document the cause of death and other vital statistics for deceased individuals in the United States.
Standardization This form is standardized across the U.S. to ensure consistency in the reporting of death data, making it easier for public health officials to track mortality trends.
State-Specific Forms While the CDC form serves as a guideline, individual states may have their own specific forms and requirements. For example, California's death certificate is governed by California Health and Safety Code Section 102100.
Filing Requirements The completed death certificate must be filed with the appropriate state office, usually within a specific timeframe, often within five days of the death, to ensure timely processing.

Steps to Filling Out CDC U.S. Standard Certificate of Death

Filling out the CDC U.S. Standard Certificate of Death form is an important task that requires attention to detail. Once completed, this form serves as an official record of a person's death and is essential for various legal and administrative processes. Below are the steps to accurately fill out this form.

  1. Begin with the decedent's information. Enter the full name, including first, middle, and last names.
  2. Provide the date of birth of the deceased. Make sure to use the correct format, typically MM/DD/YYYY.
  3. Next, indicate the date of death. Again, use the MM/DD/YYYY format.
  4. Fill in the place of death. This includes the city, county, and state where the death occurred.
  5. In the cause of death section, provide a clear and concise description. Include both the immediate cause and any underlying conditions.
  6. Complete the decedent's residence information, including the address where the deceased lived at the time of death.
  7. List the informant's information. This is the person who is providing the details for the certificate, such as their name, relationship to the deceased, and contact information.
  8. Sign and date the form where indicated. The signature typically belongs to the informant or the medical professional who certifies the cause of death.

After completing the form, review it carefully for any errors or omissions. Once verified, the form should be submitted to the appropriate local or state vital records office for processing. This ensures that the death is officially recorded and that necessary copies can be obtained for legal and personal purposes.

More About CDC U.S. Standard Certificate of Death

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 a person's death. This form is essential for legal, statistical, and administrative purposes. It ensures that accurate information about the deceased is documented and can be used for various needs, including settling estates and obtaining life insurance benefits.

Who is responsible for completing the death certificate?

What information is required on the death certificate?

How can I obtain a copy of a death certificate?

Is there a time limit for filing a death certificate?

Can I correct information on a death certificate after it has been filed?

Are death certificates public records?

What should I do if I suspect fraud related to a death certificate?

Common mistakes

  1. Incorrect Personal Information: Filling in the deceased's name, date of birth, or other identifying details incorrectly can lead to significant issues. Always double-check spelling and dates.

  2. Missing Cause of Death: Omitting the cause of death can create complications. It's essential to provide a clear and accurate account, as this information is crucial for statistical purposes.

  3. Not Including the Informant’s Information: The informant, usually a family member or close friend, must provide their details. This section is often overlooked, but it is vital for verification.

  4. Incorrect Date of Death: Errors in the date of death can affect legal matters and benefits. Ensure that this date is accurate and corresponds with other records.

  5. Failure to Sign the Form: The certificate must be signed by the appropriate authority, such as a physician. Without this signature, the document may be considered invalid.

  6. Neglecting to Check for Additional Requirements: Different states may have specific requirements for death certificates. Always verify if additional documentation or information is necessary.

  7. Using Abbreviations or Nicknames: Avoid using abbreviations or nicknames for names. Full legal names should be used to prevent any confusion.

  8. Not Keeping Copies: Failing to make copies of the completed form can lead to problems later. Always keep a copy for your records and any necessary follow-ups.

Documents used along the form

The CDC U.S. Standard Certificate of Death form is a crucial document used to officially record a person's death. Alongside this form, several other documents may be required to ensure proper processing of the death and related matters. Below is a list of commonly used forms and documents that may accompany the death certificate.

  • Death Notification Form: This form is often required by employers or insurance companies to officially notify them of the death. It typically includes details about the deceased and the date of death.
  • Funeral Home Contract: This document outlines the services provided by the funeral home, including costs and arrangements. It serves as a formal agreement between the family and the funeral service provider.
  • Burial Permit: Issued by local authorities, this permit is necessary for the burial or cremation of the deceased. It ensures that the burial complies with local regulations.
  • Will or Trust Documents: If the deceased had a will or trust, these documents are essential for the distribution of assets. They guide the executor in managing the deceased's estate according to their wishes.
  • Life Insurance Policy: This document provides proof of any life insurance coverage the deceased may have had. It is important for beneficiaries to file claims and receive benefits.
  • Social Security Administration (SSA) Notification: A form or letter notifying the SSA of the death is often required to stop benefits and prevent fraud. This document is critical for the deceased's family members.
  • Medical Records Release Form: In some cases, a release form may be needed to access the deceased's medical records, particularly if there are questions about the cause of death or if the estate is involved in a legal matter.

These documents play an important role in the aftermath of a person's death. They help facilitate various legal, financial, and logistical processes, ensuring that the deceased's affairs are handled appropriately and in accordance with their wishes.

Similar forms

The Certificate of Live Birth serves as a foundational document for individuals, similar to the Certificate of Death. It provides essential information about a person's birth, including date, time, and place of birth, as well as parentage. Both documents are vital for establishing identity and legal status. While the Certificate of Death marks the end of life, the Certificate of Live Birth marks the beginning, creating a full circle of identity documentation.

The Medical Examiner's Report is another document that shares similarities with the CDC U.S. Standard Certificate of Death. This report provides a detailed account of the circumstances surrounding a death, including cause and manner of death. Like the death certificate, it is often required for legal and administrative purposes. Both documents play a crucial role in understanding the events leading to a person's death, offering insights that may be necessary for investigations or insurance claims.

A Funeral Home Disposition Permit is also comparable to the Certificate of Death. This permit is issued by a local authority and allows for the burial or cremation of a deceased individual. It requires information similar to that found on a death certificate, such as the deceased's name, date of death, and place of death. Both documents are essential in the process of handling a deceased person's remains and ensuring that legal protocols are followed during disposition.

The Autopsy Report is another relevant document. It provides a detailed examination of the deceased's body and can reveal important information about the cause of death. This report, like the Certificate of Death, is often used in legal contexts, particularly in cases of suspicious deaths. Both documents serve to clarify the circumstances surrounding a death and can be crucial in legal proceedings or for family closure.

The Social Security Administration (SSA) Death Notification is similar to the Certificate of Death in that it formally informs the government of an individual's passing. This document is necessary for the termination of benefits and can affect various legal and financial matters. Both the SSA notification and the death certificate are used to update records and ensure that the deceased's affairs are settled appropriately.

The Will or Testament can also be seen as akin to the Certificate of Death. While the death certificate officially documents the passing, the will outlines the deceased's wishes regarding the distribution of their assets. Both documents are essential in the probate process, guiding how the deceased's estate will be handled after their death. They work together to provide clarity and direction for surviving family members.

The Life Insurance Policy Claim Form is another document that relates closely to the Certificate of Death. When a policyholder passes away, beneficiaries must submit a claim form along with the death certificate to receive benefits. Both documents are crucial in facilitating the transfer of funds and ensuring that the deceased's financial affairs are settled according to their wishes.

Finally, the Veterans Affairs Death Certificate is similar to the CDC U.S. Standard Certificate of Death in that it serves a specific purpose for military personnel. This document is often used to claim benefits or honors due to a deceased veteran. Like the standard death certificate, it includes essential information about the individual’s death, but it also highlights their service to the country, providing a unique context for their passing.

Dos and Don'ts

When filling out the CDC U.S. Standard Certificate of Death form, accuracy and attention to detail are crucial. Here are some important do's and don'ts to keep in mind:

  • Do ensure all information is legible and clear.
  • Do use black or blue ink when completing the form.
  • Do verify the deceased's full name and date of birth for accuracy.
  • Do include the cause of death as specified by the attending physician.
  • Do check for any required signatures before submitting.
  • Don't leave any fields blank unless specifically instructed.
  • Don't use abbreviations that could lead to confusion.
  • Don't forget to double-check the spelling of names and places.
  • Don't submit the form without reviewing it for errors.
  • Don't hesitate to ask for help if you're unsure about any section.

By following these guidelines, you can help ensure that the Certificate of Death is completed correctly and efficiently.

Misconceptions

Understanding the CDC U.S. Standard Certificate of Death form is crucial for accurate record-keeping and reporting. However, several misconceptions can lead to confusion. Here are nine common misconceptions:

  1. It is only needed for legal purposes. Many people believe the certificate is solely for legal matters, but it also serves public health and statistical purposes.
  2. Only a doctor can complete the form. While a physician usually fills it out, other qualified individuals, such as medical examiners or coroners, can also complete the certificate.
  3. It can be filled out anytime after the death. There are strict timelines for completing the certificate. Delays can lead to complications in the burial or cremation process.
  4. All deaths require a death certificate. Some natural deaths, particularly those occurring at home without medical intervention, may not require a formal certificate.
  5. It is not important for family records. The certificate is vital for family records, insurance claims, and settling estates, making it an important document for loved ones.
  6. Only the immediate family can request a copy. In many cases, authorized representatives or legal heirs can also request copies of the death certificate.
  7. Corrections to the form are impossible. Mistakes can be corrected, but there are specific procedures that must be followed to make those changes.
  8. It is the same in every state. Each state has its own regulations and requirements regarding the death certificate, so it is essential to understand local laws.
  9. Once filed, it cannot be accessed. Death certificates are public records, and many states allow access to them under certain conditions.

Being aware of these misconceptions can help ensure that the process surrounding death certificates is handled smoothly and correctly.

Key takeaways

When filling out and using the CDC U.S. Standard Certificate of Death form, it’s important to understand the key components to ensure accuracy and compliance. Here are some essential takeaways:

  • Accuracy is Crucial: Ensure all information is filled out correctly. Mistakes can lead to delays in processing and complications with legal matters.
  • Complete Required Sections: Make sure to complete all mandatory fields. Missing information can result in the form being rejected.
  • Use Clear Language: Write legibly and use clear, concise language. This helps prevent misunderstandings and ensures that the information is easily readable.
  • Consult with a Medical Professional: If unsure about the medical information required, seek guidance from a healthcare provider. Their input is often necessary for accurate completion.
  • Understand the Filing Process: Familiarize yourself with the steps for submitting the form. Each state may have different requirements for filing a death certificate.
  • Keep Copies: Always make copies of the completed form for your records. This can be helpful for future reference or in case of any issues.
  • Check State-Specific Regulations: Be aware that different states may have specific rules regarding the death certificate process. Review your state’s guidelines for any unique requirements.
  • Timeliness Matters: Submit the form as soon as possible. Timely filing can help avoid complications with estate matters and other legal processes.

By keeping these points in mind, you can navigate the process of completing the CDC U.S. Standard Certificate of Death form with confidence and clarity.