Death Certificate Medical Certifier Worksheet
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1Commonwealth of Massachusetts
Registry of Vital Records and Statistics
DEATH CERTIFICATE MEDICAL CERTIFIER WORKSHEET
Form R-360 07012014
Please complete the information pertaining to the decedent as well as the cause of death information as this document will be used to
create the legal death certificate. PLEASE PRINT NEATLY TO HELP WITH DATA ENTRY.
DECEDENT – NAME
FIRST
MIDDLE
LAST
GENERATIONAL ID
PLACE OF DEATH – CITY/TOWN
DATE OF DEATH (Month DD, YYYY)
SEX
DATE OF BIRTH (Month DD, YYYY)
MEDICAL RECORD NUMBER
PLACE OF DEATH
Hospital-Inpatient
Hospital-ER/Outpatient
Hospital-DOA Decedent’s Residence
Hospice Facility
Nursing Home/Long Term Care
Assisted Living Facility or Rest Home
Other _________________________
HOSPITAL OR OTHER INSTITUTION – NAME (
If not in either, provide street and number
)
PART I – CAUSE OF DEATH – SEQUENTIALLY LIST IMMEDIATE CAUSE THEN ANTECEDENT CAUSES THEN UNDERLYING CAUSE
APPX INTERVAL
a) Immediate
Cause
b) Due to
c) Due to
d) Due to
PART II – OTHER SIGNIFICANT CONDITIONS CONTRIBUTING TO DEATH
M.E. NOTIFIED?
AUTOPSY PERFORMED?
Yes
No
M.E. Priv No
AUTOPSY FINDINGS AVAILABLE PRIOR TO COMPLETING CAUSE OF DEATH?
Yes
No
MANNER OF DEATH
M.E. CASE NUMBER
Natural
ALL OTHER MANNER OF DEATH CASES ARE REQUIRED TO BE REFERRED TO THE MEDICAL EXAMINER
TIME OF
AM
AM
MANNER OF DEATH
INJURY AT
DATE OF INJURY (Month DD, YYYY)
APPX
INJURY
WORK?
TIME OF
Accident
Homicide
Suicide Pending investigation
DEATH
PM
PM
Yes
Therapeutic Complication
Could not be determined
Mil.
Mil.
No
Other (Specify)
______________________________
PLACE OF INJURY
TRANSPORTATION INJURY
Driver/Operator Passenger Pedestrian Not Applicable
Other (Specify) __________________________________
LOCATION/ADDRESS OF INJURY
M.E. DATE PRONOUNCED (Month DD, YYYY)
AM PM Military
DESCRIBE HOW INJURY OCCURRED
M.E. TIME PRONOUNCED
IF FEMALE, PREGNANCY STATUS AT TIME OF DEATH
DID TOBACCO USE CONTRIBUTE TO DEATH?
Not pregnant within the past year Pregnant at time of death Not pregnant, but pregnant within 42 days of
Yes
No
death Not pregnant, but pregnant within 43 days to 1 year before death Unknown, if pregnant in past year
Probably Unknown
MEDICAL CERTIFIER INFORMATION – NAME/TITLE
AM PM
HOUR OF DEATH
Military
MEDICAL CERTIFIER INFORMATION – ADDRESS
LICENSE #
MEDICAL CERTIFIER DESIGNATION
Certifier in attendance at time of death Physician in charge of patient’s care Nurse Practitioner in attendance at time of death
Nurse Practitioner in charge of patient’s care
Medical Examiner
MEDICAL CERTIFIER FAX NUMBER TO
MEDICAL CERTIFIER TELEPHONE NUMBER
RECEIVE ATTESTATION FORM
PROVIDER IN CHARGE OF PATIENT’S CARE – NAME/TITLE
R.N. P.A. N.P.
AM
RN/ PA/ NP
IF YES, DATE (Month DD, YYYY)
IF YES,
PRONOUNCER INFORMATION – NAME
TITLE
PRONOUNCEMENT?
TIME
Mil.
PM
Yes
No
DATE SIGNED (Month DD, YYYY)
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) stated
.
Signature and Title of Medical
Certifier Required.
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