Us Standard Certificate Of Death (Page 4 of 4) in pdf

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:

REV. 11/2003

Us Standard Certificate Of Death Page 4

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