Dh Form 434a - Affidavit Of Medical Amendment To Florida Certificate Of Death
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1
2AFFIDAVIT OF MEDICAL AMENDMENT TO
TYPE IN
PERMANENT
FLORIDA CERTIFICATE OF DEATH
BLACK INK
1. DECEDENT’S NAME (First, Middle, Last, Suffix)
5. DATE OF DEATH (Month, Day, Year) 8. COUNTY OF DEATH
9. PLACE OF DEATH
HOSPITAL:
___ Inpatient
___ Emergency Room/Outpatient
___ Dead on Arrival
(Check only one)
NON-HOSPITAL:
___ Hospice Facility
___ Nursing Home/Long Term Care Facility ___ Decedent’s Home
___Other (Specify)
10. FACILITY NAME (If not institution, give street address)
11a. CITY, TOWN, OR LOCATION OF DEATH
11b. INSIDE CITY LIMITS?
____ Yes ____No
30. CERTIFIER:
_____ 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.
(Check One)
_____ Medical Examiner - On the basis of examination, and/or investigation, in my opinion, death occurred at the time, date and place, due to the cause(s) and manner stated.
31a. (Signature and Title of Certifier)
31b. DATE SIGNED (mm/dd/yyyy) 32. TIME OF DEATH (24 hr.) 33. MEDICAL EXAMINER’S CASE NUMBER
PHYSICIAN’S SIGNATURE
___ ___ * ___ ___ * ___ ___ ___ ___ ___
34a. LICENSE NUMBER (of Certifier) 34b. CERTIFIER’S NAME
35. NAME OF ATTENDING PHYSICIAN (If other than Certifier)
36a. CERTIFIER’S - STATE 36b. CITY OR TOWN
36c. STREET ADDRESS
36d. ZIP CODE
39. PROBABLE MANNER OF DEATH
The following are under the jurisdiction of the medical examiner:
40. REPORTED TO THE MEDICAL EXAMINER
___ Natural
____ Accident ____ Suicide ____ Homicide ____ Pending Investigation ____ Undetermined
DUE TO CAUSE OF DEATH? ___ Yes ___ No
41. CAUSE OF DEATH - PART I.
Enter the chain of events - diseases, injuries, or complications - that directly caused the death. Enter only one cause on a line.
Approximate Interval:
(See instructions on back)
DO NOT enter terminal event such as cardiac arrest, respiratory arrest, or ventricular fibrillation without showing the etiology.
Onset to Death
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.
PART II. Other significant conditions contributing to death but not resulting in the underlying cause given in PART I. 42a. WAS AN AUTOPSY
42b. WERE AUTOPSY FINDINGS AVAILABLE
PERFORMED?
TO COMPLETE THE CAUSE OF DEATH?
____ Yes
____ No
___ Yes
___ No
43a. IF SURGERY MENTIONED IN PART I OR II, ENTER REASON FOR SURGERY 43b.DATE OF SURGERY (Mo., Day, Yr.) 44. DID TOBACCO USE CONTRIBUTE TO DEATH?
____ Yes
____ No
____ Probably
____ Unknown
45. IF FEMALE, WAS SHE PREGNANT WITHIN THE PAST YEAR:
___ Yes
____ No
____ Unknown
If Yes, specify timeframe:
____ at time of death
____ within 1 to 42 days of death
___ within 43 days to 1 year of death
46. DATE OF INJURY (Month, Day, Year)
47. TIME OF INJURY (24 hr.)
48. INJURY AT WORK?
49a. LOCATION OF INJURY - STATE
____ Yes ____ No
49b. CITY OR TOWN
49c. STREET ADDRESS
49d. APT. NO. 49e. ZIP CODE
50. DESCRIBE HOW INJURY OCCURRED
51. PLACE OF INJURY (e.g. Decedent’s home,
construction site, restaurant, wooded area)
IF TRANSPORTATION INJURY, 52a. Status of Decedent
___ Driver/Operator
___ Passenger
___ Pedestrian
___ Other (Specify)
52b. Type of Vehicle ___ Car/ Minivan ___ S.U.V. ___ Motorcycle ___ Pickup Truck/ Cargo Van ___ Bus ___ Heavy Transport ___Other (Specify)
THE UNDERSIGNED, BEING FIRST DULY SWORN, STATES THAT THIS AFFIDAVIT IS MADE FOR THE PURPOSE OF AMENDING MEDICAL
CERTIFICATION FOR THE ABOVE NAMED PERSON, AND THAT THE FOLLOWING EXPLANATION IS GIVEN AS THE BASIS OF THIS AMENDMENT:
Signature and Title of Certifier or Attending Physician
DATE SIGNED BY CERTIFIER
NOTARY COMMISSION EXPIRES (AFFIX SEAL)
PHYSICIAN’S SIGNATURE
Signature of Notary
SUBSCRIBED AND SWORN TO BEFORE ME ON
NOTARY’S SIGNATURE
STATE REGISTRAR
DATE FILED BY VITAL STATISTICS
BY
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