SAFER I Physicians' Handbook on Medical Certification of Death 2003 Revision i 5 5* DEPARTMENT MAN SERVICES 5 Centers for DI I I a Nat|onaICenI I wh Physicians' Handbook on Medical of Deaih 2003 Revision if DEPARTMENT OF HEALTH AND HUMAN SERVICES fO|' D|?eU5e CONTIOT and Prevenilon National Center |0r Hedllh Maryland 2003 DHHS Publlcailon NO. (PHS) National Center for Health Statistics Edward J. Sondik, Ph.D., Director Jack R. Anderson, Deputy Director Jack R. Anderson, Acting Associate Director for International Statistics Jennifer H. Madans, Ph.D., Associate Director for Science Lawrence H. Cox, Ph.D., Associate Director for Research and Methodology Diane M. Makuc, Dr.P.H., Acting Associate Director for Analysis, Epidemiology, and Health Promotion P. Douglas Williams, Acting Associate Director for Data Standards, Program Development, and Extramural Programs Edward L. Hunter, Associate Director for Planning, Budget, and Legislation Jennifer H. Madans, Ph.D., Acting Associate Director for Vital and Health Statistics Systems Douglas L. Zinn, Acting Associate Director for Management and Operations Charles J. Rothwell, Associate Director for Information Technology and Services Division of Vital Statistics James A. Weed, Ph.D., Acting Director James A. Weed, Ph.D., Acting Chief, Mortality Statistics Branch Preface Th is h a n d b ook con t a in s in s t r u ct ion s for p h ys icia n s on ca u s e-of-d ea t h cer t ifica t ion . It wa s p r ep a r ed b y t h e Dep a r t m en t of Hea lt h a n d Hu m a n S er vices ' Cen t er s for Dis ea s e Con t r ol a n d Pr even t ion 's Na t ion a l Cen t er for Hea lt h S t a t is t ics (NCHS ). Th es e in s t r u ct ion s p er t a in t o t h e 2 0 0 3 r evis ion of t h e U.S . S t a n d a r d Cer t ifica t e of Dea t h a n d t h e 1 9 9 2 r evis ion of t h e Mod el S t a t e Vit a l S t a t is t ics Act a n d Regu la t ion s . Th is h a n d b ook s er ves a s a m od el t h a t ca n b e a d a p t ed b y a n y vit a l s t a t is t ics r egis t r a t ion a r ea . Ot h er h a n d b ook s a n d r efer en ces on p r ep a r in g a n d r egis t er in g vit a l r ecor d s a r e m en t ion ed a t t h e en d of t h e s ect ion on Med ica l Cer t ifica t ion of Dea t h a n d a r e lis t ed in t h e r efer en ces . For m os t of t h es e r es ou r ces , t h e S t a t e vit a l s t a t is t ics office or NCHS ca n p r ovid e a s m a n y cop ies a s d es ir ed . For d et a iled in for m a t ion on com p let in g ot h er it em s on t h e d ea t h cer t ifica t e, r efer t o t h e Medical Examiners' and Coroners' Handbook on Death Registration and Fetal Death Reporting or t h e Funeral Directors' Handbook on Death Registration and Fetal Death Reporting. Keywords: m ed ica l cer t ifica t ion c d ea t h cer t ifica t e c gu id elin es c h a n d b ook iii Acknowledgments Th is p u b lica t ion wa s p r ep a r ed b y s t a ff fr om t h e Divis ion of Vit a l S t a t is t ics led b y Don n a L. Hoyer t , Ph .D., a n d Ar ia ld i M. Min in o, M.P.H. Rob er t N. An d er s on , Ph .D., a ls o con t r ib u t ed t o t h is effor t . Ma r y An n e Fr eed m a n , M.A., t h e Dir ect or of t h e Divis ion of Vit a l S t a t is t ics wh ile t h is p u b lica t ion wa s b ein g p r ep a r ed , r eviewed a n d com m en t ed on t h e con t en t s . E xp er t m ed ica l r eview a n d com m en t s wer e p r ovid ed b y Ra n d y Ha n zlick , M.D.; Gr egor y G. Da vis , M.D.; a n d Lillia n R. Bla ck m on , M.D. Ad d it ion a l m ed ica l in p u t wa s p r ovid ed b y Hen r y Th ied e, M.D.; Ken n et h C. S ch oen d or f, M.D.; a n d S on ja Ra s m u s s en , M.D. Th is h a n d b ook wa s ed it ed b y Dem a r iu s V. Miller, t yp es et b y J a cqu elin e M. Da vis , a n d t h e gr a p h ics p r od u ced b y J a r m ila G. Ogb u r n of t h e Pu b lica t ion s Br a n ch , Divis ion of Da t a S er vices . v Contents Pr efa ce . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Ack n owled gm en t s . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . In t r od u ct ion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Pu r p os e . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Im p or t a n ce of Dea t h Regis t r a t ion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . U.S . S t a n d a r d Cer t ifica t e of Dea t h . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Con fid en t ia lit y of Vit a l Recor d s . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Ph ys icia n 's Res p on s ib ilit y . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Gen er a l In s t r u ct ion s for Com p let in g Dea t h Cer t ifica t es . . . . . . . . . . . . . . Med ica l Cer t ifica t ion of Dea t h . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Pr on ou n cin g Da t e a n d Tim e of Dea t h . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Ca u s e of Dea t h . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Ch a n ges t o Ca u s e of Dea t h . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . In s t r u ct ion s . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Pa r t I of t h e Ca u s e-of-Dea t h S ect ion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Lin e (a ) Im m ed ia t e Ca u s e . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Lin es (b ), (c), a n d (d ) Du e t o (or a s a Con s equ en ce of) . . . . . . . . . . . Ap p r oxim a t e In t er va l Bet ween On s et a n d Dea t h . . . . . . . . . . . . . . . . Pa r t II of t h e Ca u s e-of-Dea t h S ect ion (Ot h er S ign ifica n t Con d it ion s ) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Dou b t a n d Ca u s e of Dea t h . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Ot h er It em s for Med ica l Cer t ifica t ion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Com p let in g t h e Cer t ifier S ect ion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . E xa m p les of Ca u s e-of-Dea t h Cer t ifica t ion . . . . . . . . . . . . . . . . . . . . . . . . Com m on Pr ob lem s in Dea t h Cer t ifica t ion . . . . . . . . . . . . . . . . . . . . . . . . Ad d it ion a l Res ou r ces . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Com p let in g Ot h er It em s on t h e Dea t h Cer t ifica t e . . . . . . . . . . . . . . . . . . . Na m e of Deced en t (Ma r gin ) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Pla ce of Dea t h (It em 1 4 ) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Fa cilit y Na m e (It em s 1 5 -1 7 ) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Da t e Pr on ou n ced Dea d (It em 2 4 ) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Tim e Pr on ou n ced Dea d (It em 2 5 ) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Pr on ou n cin g Ph ys icia n (It em s 2 6 -2 8 ) . . . . . . . . . . . . . . . . . . . . . . . . . . . . Da t e Pr on ou n ced Dea d (It em 2 9 ) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . iii v 1 1 1 3 4 4 7 9 9 9 12 12 12 13 13 14 14 15 15 16 17 31 33 34 34 34 35 36 37 37 38 vii Tim e Pr on ou n ced Dea d (It em 3 0 ) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Wa s Med ica l E xa m in er or Cor on er Con t a ct ed ? (It em 3 1 ) . . . . . . . . . . Ca u s e of Dea t h (It em 3 2 ) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Au t op s y (It em s 3 3 a n d 3 4 ) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Tob a cco Us e Con t r ib u t e t o Dea t h (It em 3 5 ) . . . . . . . . . . . . . . . . . . . . . . . If Fem a le, Pr egn a n cy S t a t u s (It em 3 6 ) . . . . . . . . . . . . . . . . . . . . . . . . . . . . Ma n n er of Dea t h (It em 3 7 ) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Accid en t or In ju r y (It em s 3 8 -4 4 ) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Cer t ifier (It em s 4 5 -4 9 ). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Refer en ces . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Appendixes A. B. Th e U.S . S t a n d a r d Cer t ifica t e of Dea t h . . . . . . . . . . . . . . . . . . . . . . . . Th e Vit a l S t a t is t ics Regis t r a t ion S ys t em in t h e Un it ed S t a t es . . . 39 40 40 41 42 42 42 43 46 49 52 54 viii Introduction Purpose Th is h a n d b ook is d es ign ed t o a cqu a in t p h ys icia n s , m ed ica l s t u d en t s , a n d ot h er s wit h t h e vit a l r egis t r a t ion s ys t em in t h e Un it ed S t a t es a n d t o p r ovid e in s t r u ct ion s for com p let in g a n d filin g d ea t h cer t ifica t es . E m p h a s is is d ir ect ed t owa r d t h e cer t ifica t ion of m ed ica l in for m a t ion , t h e p r im a r y r es p on s ib ilit y of t h e p h ys icia n , a n d a cr it ica l p iece of in for m a t ion on t h e d ea t h cer t ifica t e. Importance of death registration Th e d ea t h cer t ifica t e is a p er m a n en t r ecor d of t h e fa ct of d ea t h , a n d d ep en d in g on t h e S t a t e of d ea t h , m a y b e n eed ed t o get a b u r ia l p er m it . S t a t e la w s p ecifies t h e r equ ir ed t im e for com p let in g a n d filin g t h e d ea t h cer t ifica t e. Th e d ea t h cer t ifica t e p r ovid es im p or t a n t p er s on a l in for m a t ion a b ou t t h e d eced en t a n d a b ou t t h e cir cu m s t a n ces a n d ca u s e of d ea t h . Th is in for m a t ion h a s m a n y u s es r ela t ed t o t h e s et t lem en t of t h e es t a t e a n d p r ovid es fa m ily m em b er s clos u r e, p ea ce of m in d , a n d d ocu m en t a t ion of t h e ca u s e of d ea t h . Th e d ea t h cer t ifica t e is t h e s ou r ce for S t a t e a n d n a t ion a l m or t a lit y s t a t is t ics (figu r es 1 -3 ) a n d is u s ed t o d et er m in e wh ich m ed ica l con d it ion s r eceive r es ea r ch a n d d evelop m en t fu n d in g, t o s et p u b lic h ea lt h goa ls , a n d t o m ea s u r e h ea lt h s t a t u s a t loca l, S t a t e, n a t ion a l, a n d in t er n a t ion a l levels . Th e Cen t er s for Dis ea s e Con t r ol a n d Pr even t ion 's Na t ion a l Cen t er for Hea lt h S t a t is t ics (NCHS ) p u b lis h es s u m m a r y m or t a lit y d a t a in t h e National Vital Statistics Report p u b lica t ion ''Dea t h s : Fin a l d a t a '' a n d on t h e In t er n et a t h t t p :/ / www.cd c.gov/ n ch s (u n d er vit a l s t a t is t ics , m or t a lit y). Th es e m or t a lit y d a t a a r e va lu a b le t o p h ys icia n s in d ir ect ly b y in flu en cin g fu n d in g t h a t s u p p or t s m ed ica l a n d h ea lt h r es ea r ch t h a t m a y a lt er clin ica l p r a ct ice a n d d ir ect ly a s a r es ea r ch t ool. Res ea r ch t op ics in clu d e id en t ifyin g d is ea s e et iology, eva lu a t in g d ia gn os t ic a n d t h er a p eu t ic t ech n iqu es , 1 Under1 1-24 25-44 45-64 65-84 85 ears Not stated year an over 1900 Year death Percent of all deaths NOTE: Deaths in 1900 included 10 sms; andthe District ol columbia2000 included the entire United States. Figure 1. Deaths by age Hein disease Cancer Stroke Respiratory Accidents diseases Tuberculosis Diarrhea Pneumonia All other and influenza 1 900 .C 8 *5 2000 Percent of all deaths Nora: mains in lsoo included 10 states andthe oisinm Qf Columbia. Deans in zona included the entire United sims. Figure 2. Deaths by cause 2 Figure 3. Percent of persons born alive in selected years surviving to specific ages exa m in in g m ed ica l or m en t a l h ea lt h p r ob lem s t h a t m a y b e fou n d a m on g s p ecific gr ou p s of p eop le (1 ), a n d in d ica t in g a r ea s in wh ich m ed ica l r es ea r ch ca n h a ve t h e gr ea t es t im p a ct on r ed u cin g m or t a lit y. An a lys es t yp ica lly focu s on a s in gle con d it ion r ep or t ed on t h e d ea t h cer t ifica t e, b u t s om e a n a lys es d o con s id er a ll con d it ion s m en t ion ed . S u ch a n a lys es a r e im p or t a n t in s t u d yin g cer t a in d is ea s es a n d con d it ion s a n d in in ves t iga t in g r ela t ion s h ip s b et ween con d it ion s r ep or t ed on t h e s a m e d ea t h cer t ifica t e (for exa m p le, t yp es of fa t a l in ju r ies a n d a u t om ob ile cr a s h es or t yp es of in fect ion s a n d HIV). Beca u s e s t a t is t ica l d a t a d er ived fr om d ea t h cer t ifica t es ca n b e n o m or e a ccu r a t e t h a n t h e in for m a t ion on t h e cer t ifica t e, it is ver y im p or t a n t t h a t a ll p er s on s con cer n ed wit h t h e r egis t r a t ion of d ea t h s s t r ive n ot on ly for com p let e r egis t r a t ion , b u t a ls o for a ccu r a cy a n d p r om p t n es s in r ep or t in g t h es e even t s . Fu r t h er m or e, t h e p ot en t ia l u s efu ln es s of d et a iled s p ecific in for m a t ion is gr ea t er t h a n m or e gen er a l in for m a t ion . U.S. Standard Certificate of Death Th e r egis t r a t ion of d ea t h s is a S t a t e fu n ct ion s u p p or t ed b y in d ivid u a l S t a t e la ws a n d r egu la t ion s . Th e or igin a l d ea t h cer t ifica t es a r e filed in t h e S t a t es 3 a n d s t or ed in a ccor d a n ce wit h S t a t e p r a ct ice. E a ch S t a t e h a s a con t r a ct wit h NCHS t h a t a llows t h e Fed er a l Gover n m en t t o u s e in for m a t ion fr om t h e S t a t e r ecor d s t o p r od u ce n a t ion a l vit a l s t a t is t ics . Th e n a t ion a l d a t a p r ogr a m is ca lled t h e Na t ion a l Vit a l S t a t is t ics S ys t em (NVS S ) (2 ,3 ). To en s u r e con s is t en cy in t h e NVS S , NCHS p r ovid es lea d er s h ip a n d coor d in a t ion in t h e d evelop m en t of a s t a n d a r d cer t ifica t e of d ea t h for t h e S t a t es t o u s e a s a m od el. Th e s t a n d a r d cer t ifica t e is r evis ed p er iod ica lly t o en s u r e t h a t t h e d a t a collect ed r ela t e t o cu r r en t a n d a n t icip a t ed n eed s . In t h e r evis ion p r oces s , s t a k eh old er s r eview a n d eva lu a t e ea ch it em on t h e s t a n d a r d cer t ifica t e for it s r egis t r a t ion , lega l, gen ea logica l, s t a t is t ica l, m ed ica l, a n d r es ea r ch va lu e. Th e a s s ocia t ion s on t h e s t a k eh old er p a n el t h a t r ecom m en d ed t h e cu r r en t U.S . S t a n d a r d Cer t ifica t e of Dea t h in clu d ed t h e Am er ica n Med ica l As s ocia t ion , t h e Na t ion a l As s ocia t ion of Med ica l E xa m in er s , t h e College of Am er ica n Pa t h ologis t s , a n d t h e Am er ica n Hos p it a l As s ocia t ion (2 ). Mos t S t a t e cer t ifica t es con for m clos ely in con t en t a n d a r r a n gem en t t o t h e s t a n d a r d . Min or m od ifica t ion s a r e s om et im es n eces s a r y t o com p ly wit h S t a t e la ws or r egu la t ion s or t o m eet s p ecific in for m a t ion n eed s . Ha vin g s im ila r for m s p r om ot es u n ifor m it y of d a t a a n d com p a r a b le n a t ion a l s t a t is t ics . Th ey a ls o a llow t h e com p a r is on of in d ivid u a l S t a t e d a t a wit h n a t ion a l d a t a a n d of in d ivid u a l S t a t e d a t a wit h n a t ion a l d a t a a n d d a t a fr om ot h er S t a t es . Un ifor m it y of d ea t h cer t ifica t es a m on g t h e S t a t es a ls o in cr ea s es t h eir a ccep t a b ilit y a s lega l r ecor d s . Confidentiality of vital records To en cou r a ge a p p r op r ia t e a cces s t o vit a l r ecor d s , NCHS p r om ot es t h e d evelop m en t of m od el vit a l s t a t is t ics la ws con cer n in g con fid en t ia lit y (4 ). S t a t e la ws a n d s u p p or t in g r egu la t ion s d efin e wh ich p er s on s h a ve a u t h or ized a cces s t o vit a l r ecor d s . S om e S t a t es h a ve few r es t r ict ion s on a cces s t o d ea t h cer t ifica t es . However, t h er e a r e r es t r ict ion s on a cces s t o d ea t h cer t ifica t es in t h e m a jor it y of S t a t es . Lega l s a fegu a r d s t o t h e con fid en t ia lit y of vit a l r ecor d s h a ve b een s t r en gt h en ed over t im e in s om e S t a t es . Physician's responsibility Th e p h ys icia n 's p r in cip a l r es p on s ib ilit y in d ea t h r egis t r a t ion is t o com p let e t h e m ed ica l p a r t of t h e d ea t h cer t ifica t e. In fu lfillin g t h e r ole of t h e cer t ifier (i.e., p er s on com p let in g t h e m ed ica l p a r t of t h e d ea t h cer t ifica t e), t h e p h ys icia n p er for m s t h e fin a l a ct of ca r e t o a p a t ien t b y p r ovid in g clos u r e wit h a well-t h ou gh t -ou t a n d com p let e d ea t h cer t ifica t e t h a t will a llow t h e 4 fa m ily t o clos e t h e p er s on 's a ffa ir s . At t h e s a m e t im e, t h e p h ys icia n p er for m s a s er vice for t h e la r ger com m u n it y. Th e p h ys icia n is t o: + Be fa m ilia r wit h S t a t e a n d loca l r egu la t ion s on m ed ica l cer t ifica t ion s for d ea t h s wit h ou t m ed ica l a t t en d a n ce or in volvin g ext er n a l ca u s es t h a t m a y r equ ir e t h e p h ys icia n t o r ep or t t h e ca s e t o a m ed ica l exa m in er or cor on er. + Com p let e r eleva n t p or t ion s of t h e d ea t h cer t ifica t e. + Deliver t h e s ign ed or elect r on ica lly a u t h en t ica t ed d ea t h cer t ifica t e t o t h e fu n er a l d ir ect or p r om p t ly s o t h a t t h e fu n er a l d ir ect or ca n file it wit h t h e S t a t e or loca l r egis t r a r wit h in t h e S t a t e's p r es cr ib ed t im e p er iod . + As s is t t h e S t a t e or loca l r egis t r a r b y a n s wer in g in qu ir ies p r om p t ly. + Deliver a s u p p lem en t a l r ep or t of ca u s e of d ea t h t o t h e S t a t e vit a l s t a t is t ics office wh en a u t op s y fin d in gs or fu r t h er in ves t iga t ion r evea ls t h e ca u s e of d ea t h t o b e d iffer en t fr om wh a t wa s or igin a lly r ep or t ed . In s om e S t a t es , h os p it a ls a n d ot h er in s t it u t ion s a r e a u t h or ized t o in it ia t e t h e p r ep a r a t ion of t h e d ea t h cer t ifica t e wh en t h e d ea t h occu r r ed in t h a t h os p it a l or in s t it u t ion . In s u ch ca s es , t h e a t t en d in g p h ys icia n will u s u a lly com p let e t h e ca u s e-of-d ea t h s ect ion a n d s ign t h e cer t ifica t e a t t h e h os p it a l or ot h er in s t it u t ion . J u r is d ict ion s wit h elect r on ic r egis t r a t ion s ys t em s m a y h a ve ot h er wa ys t o a u t h en t ica t e t h e cer t ifica t ion t h a n b y u s in g a s ign a t u r e on p a p er. In a few S t a t es , wh en t h e a t t en d in g p h ys icia n (p h ys icia n in ch a r ge of t h e p a t ien t 's ca r e for t h e con d it ion t h a t r es u lt ed in d ea t h ) is n ot a va ila b le a t t h e t im e of d ea t h t o cer t ify t h e ca u s e of d ea t h , a n ot h er p h ys icia n on d u t y a t t h e h os p it a l or ot h er in s t it u t ion m a y p r on ou n ce t h e d eced en t lega lly d ea d ; a n d , wit h t h e p er m is s ion of t h e a t t en d in g p h ys icia n , t h e ''p r on ou n cin g p h ys icia n '' m a y a u t h or ize r elea s e of t h e b od y t o t h e fu n er a l d ir ect or. In s u ch ca s es , t h e a t t en d in g p h ys icia n will cer t ify t h e ca u s e of d ea t h a t a la t er t im e. In a ll ca s es , t h e a t t en d in g p h ys icia n is r es p on s ib le for cer t ifyin g t h e ca u s e of d ea t h . In m os t ca s es , h e or s h e will b ot h p r on ou n ce d ea t h a n d cer t ify t h e ca u s e of d ea t h . On ly in t h e in s t a n ces wh en t h e a t t en d in g p h ys icia n is u n a va ila b le t o cer t ify t h e ca u s e of d ea t h a t t h e t im e of d ea t h , a n d S t a t e la w p r ovid es for a p r on ou n cin g p h ys icia n , will a d iffer en t p h ys icia n p r on ou n ce d ea t h . If com p let ed p r op er ly, t h e ca u s e of d ea t h will com m u n ica t e t h e s a m e es s en t ia l in for m a t ion (1 1 ) t h a t a ca s e h is t or y wou ld . For exa m p le, t h e followin g ca u s e-of-d ea t h s t a t em en t is com p let e: 5 I a ) S ep t ic s h ock b ) In fect ed d ecu b it u s u lcer s c) Com p lica t ion s of cer eb r a l in fa r ct ion d ) Cer eb r a l a r t er y a t h er os cler os is II In s u lin -d ep en d en t d ia b et es m ellit u s If n ot com p let ed p r op er ly, in for m a t ion m a y b e m is s in g fr om t h e ca u s e-ofd ea t h s ect ion , s o s om eon e r ea d in g t h e ca u s e of d ea t h wou ld n ot k n ow wh y t h e con d it ion on t h e lowes t u s ed lin e d evelop ed . For exa m p le: I a ) Pn eu m on ia b ) Ma ln u t r it ion c) II Th is exa m p le d oes n ot exp la in wh a t ca u s ed m a ln u t r it ion . A va r iet y of d iffer en t cir cu m s t a n ces cou ld ca u s e m a ln u t r it ion , s o t h e s t a t em en t is in com p let e a n d a m b igu ou s . In s om e ca s es , t h e p h ys icia n will b e con t a ct ed t o ver ify in for m a t ion r ep or t ed on a d ea t h cer t ifica t e or t o p r ovid e a d d it ion a l in for m a t ion t o cla r ify wh a t wa s m ea n t . Th e or igin a l ca u s e-of-d ea t h s t a t em en t m a y n ot b e wr on g fr om a clin ica l s t a n d p oin t , b u t m a y n ot in clu d e s u fficien t in for m a t ion for a s s ign in g cod es for s t a t is t ica l p u r p os es . Followin g gu id elin es in t h is h a n d b ook s h ou ld m in im ize t h e fr equ en cy wit h wh ich a p h ys icia n will n eed t o s p en d a d d it ion a l t im e a n s wer in g follow-u p qu es t ion s a b ou t a p a t ien t 's ca u s e of d ea t h . 6 General Instructions for Completing Death Certificates Dea t h cer t ifica t es a r e p er m a n en t lega l r ecor d s fr om wh ich officia l cop ies a r e m a d e. It is es s en t ia l t h a t t h e cer t ifica t e b e p r ep a r ed a ccu r a t ely. Fu n er a l d ir ect or s a r e r es p on s ib le for com p let in g m os t of t h e in for m a t ion on t h e d ea t h cer t ifica t e wit h t h e a s s is t a n ce of a n in for m a n t wh o is u s u a lly a fa m ily m em b er. Com p let in g a d ea t h cer t ifica t e in volves t h e followin g gu id elin es : + Us e t h e cu r r en t for m d es ign a t ed b y t h e S t a t e. + Com p let e ea ch it em , followin g t h e s p ecific in s t r u ct ion s for t h a t it em . + Ma k e t h e en t r y legib le. Us e a com p u t er p r in t er wit h h igh r es olu t ion , t yp ewr it er wit h good b la ck r ib b on a n d clea n k eys , or p r in t legib ly u s in g p er m a n en t black in k . + Do n ot u s e a b b r evia t ion s excep t t h os e r ecom m en d ed in t h e s p ecific it em in s t r u ct ion s . + Ver ify wit h t h e in for m a n t t h e s p ellin g of n a m es , es p ecia lly t h os e t h a t h a ve d iffer en t s p ellin gs for t h e s a m e s ou n d (S m it h or S m yt h , Ga il or Ga yle, Wolf or Wolfe, a n d s o for t h ). + Refer p r ob lem s n ot cover ed in t h es e in s t r u ct ion s t o t h e S t a t e office of vit a l s t a t is t ics or t o t h e loca l r egis t r a r. + Ob t a in a ll s ign a t u r es ; r u b b er s t a m p s or ot h er fa cs im ile s ign a t u r es a r e n ot a ccep t a b le. If ju r is d ict ion p r ovid es , a u t h en t ica t e elect r on ica lly. + Do n ot m a k e a lt er a t ion s or er a s u r es . + File t h e or igin a l cer t ifica t e or r ep or t wit h t h e r egis t r a r. Rep r od u ct ion s or d u p lica t es a r e n ot a ccep t a b le. Mos t S t a t es r equ ir e t h a t t h e d ea t h cer t ifica t e b e com p let ed a n d filed wit h in a s p ecified t im e p er iod . Ph ys icia n s a r e exp ect ed t o u s e m ed ica l t r a in in g, k n owled ge of m ed icin e, a va ila b le m ed ica l h is t or y, s ym p t om s , d ia gn os t ic t es t s , a n d a u t op s y r es u lt s , if a va ila b le, t o d et er m in e t h e ca u s e of d ea t h . Gen er a lly, it is p os s ib le t o file a cer t ifica t e wit h t h e ca u s e of d ea t h lis t ed a s p en d in g or p en d in g fu r t h er s t u d y. Th is is es p ecia lly u s efu l wh en a d d it ion a l 7 in ves t iga t ion s u ch a s a u t op s y r es u lt s a r e exp ect ed , b u t it ob liga t es t h e a t t en d in g p h ys icia n t o u p d a t e t h e or igin a l in for m a t ion a ft er t h e a d d it ion a l in for m a t ion b ecom es a va ila b le. 8 Medical Certification of Death Th e p h ys icia n 's p r im a r y r es p on s ib ilit y in d ea t h r egis t r a t ion is p r on ou n cin g t h e d ea t h a n d , wh en h e or s h e is t h e a t t en d in g p h ys icia n , r ep or t in g ca u s e of d ea t h . Th e m ed ica l p a r t of t h e cer t ifica t e in clu d es : + Da t e a n d t im e p r on ou n ced d ea d + Da t e a n d t im e of d ea t h + Qu es t ion on wh et h er t h e ca s e wa s r efer r ed t o t h e m ed ica l exa m in er or cor on er + Ca u s e-of-d ea t h s ect ion in clu d in g ca u s e of d ea t h , m a n n er of d ea t h , t ob a cco u s e, a n d fem a les ' p r egn a n cy s t a t u s it em s + In ju r y it em s for ca s es in volvin g in ju r ies + Cer t ifier s ect ion wit h s ign a t u r es In m os t ca s es , a p h ys icia n will b ot h p r on ou n ce d ea t h a n d cer t ify or r ep or t t h e ca u s e of d ea t h . A d iffer en t p h ys icia n will p r on ou n ce d ea t h on ly wh en t h e a t t en d in g p h ys icia n is u n a va ila b le t o cer t ify t h e ca u s e of d ea t h a t t h e t im e of d ea t h a n d if S t a t e la w p r ovid es for t h is op t ion . If a n in qu ir y is r equ ir ed b y a S t a t e Pos t -Mor t em E xa m in a t ion s Act , a m ed ica l exa m in er or cor on er is r es p on s ib le for d et er m in in g ca u s e of d ea t h (4 ). Pronouncing date and time of death It em s 2 4 a n d 2 5 m u s t b e com p let ed b y t h e p er s on wh o p r on ou n ces d ea t h . Th is m a y b e t h e p r on ou n cin g p h ys icia n , p r on ou n cin g/ cer t ifyin g p h ys icia n , or t h e m ed ica l exa m in er or cor on er. For ca s es in volvin g a p r on ou n cin g p h ys icia n d iffer en t fr om t h e cer t ifyin g p h ys icia n , t h e p r on ou n cin g p h ys icia n m u s t a ls o com p let e it em s 2 6 -2 8 . Cause of death Th is s ect ion m u s t b e com p let ed b y eit h er t h e a t t en d in g p h ys icia n , t h e m ed ica l exa m in er, or t h e cor on er. Th e ca u s e-of-d ea t h s ect ion , a fa cs im ile of wh ich is s h own b elow, follows gu id elin es r ecom m en d ed b y t h e Wor ld Hea lth Or ga n iza tion . An im p or ta n t fea tu r e is th e r ep or ted u n d er lyin g ca u s e 9 of d ea t h d et er m in ed b y t h e cer t ifyin g p h ys icia n a n d d efin ed a s (a ) t h e d is ea s e or in ju r y t h a t in it ia t ed t h e t r a in of m or b id even t s lea d in g d ir ect ly t o d ea t h , or (b ) t h e cir cu m s t a n ces of t h e a ccid en t or violen ce t h a t p r od u ced t h e fa t a l in ju r y. In a d d it ion t o t h e u n d er lyin g ca u s e of d ea t h , t h is s ect ion p r ovid es for r ep or t in g t h e en t ir e s equ en ce of even t s lea d in g t o d ea t h a s well a s ot h er con d it ion s s ign ifica n t ly con t r ib u t in g t o d ea t h (5 ). Th e ca u s e-of-d ea t h s ect ion is d es ign ed t o elicit t h e op in ion of t h e m ed ica l cer t ifier. Ca u s es of d ea t h on t h e d ea t h cer t ifica t e r ep r es en t a m ed ica l op in ion t h a t m igh t va r y a m on g in d ivid u a l p h ys icia n s . A p r op er ly com p let ed ca u s e-of-d ea t h s ect ion p r ovid es a n et iologic exp la n a t ion of t h e or d er, t yp e, a n d a s s ocia t ion of even t s r es u lt in g in d ea t h . Th e in it ia l con d it ion t h a t s t a r t s t h e et iologic s equ en ce is s p ecific if it d oes n ot lea ve a n y d ou b t a s t o wh y it d evelop ed . For exa m p le, s ep s is is n ot s p ecific b eca u s e a n u m b er of d iffer en t con d it ion s m a y h a ve r es u lt ed in s ep s is , wh er ea s h u m a n im m u n od eficien cy vir u s s yn d r om e is s p ecific. In cer t ifyin g t h e ca u s e of d ea t h , a n y d is ea s e, a b n or m a lit y, in ju r y, or p ois on in g, if b elieved t o h a ve a d ver s ely a ffect ed t h e d eced en t , s h ou ld b e r ep or t ed . If t h e u s e of a lcoh ol a n d / or ot h er s u b s t a n ce, a s m ok in g h is t or y, a r ecen t p r egn a n cy, in ju r y, or s u r ger y wa s b elieved t o h a ve con t r ib u t ed t o d ea t h , t h en t h is con d it ion s h ou ld b e r ep or t ed . Th e con d it ion s p r es en t a t t h e t im e of d ea t h m a y b e com p let ely u n r ela t ed , a r is in g in d ep en d en t ly of ea ch ot h er ; t h ey m a y b e ca u s a lly r ela t ed t o ea ch ot h er, t h a t is , on e con d it ion m a y lea d t o a n ot h er wh ich in t u r n lea d s t o a t h ir d con d it ion ; a n d s o for t h . Dea t h m a y a ls o r es u lt fr om t h e com b in ed effect of t wo or m or e con d it ion s . 10 As ca n b e s een , t h e ca u s e-of-d ea t h s ect ion con s is t s of t wo p a r t s . Th e fir s t p a r t is for r ep or t in g t h e s equ en ce of even t s lea d in g t o d ea t h , p r oceed in g b a ck wa r d s fr om t h e fin a l d is ea s e or con d it ion r es u lt in g in d ea t h . S o ea ch con d it ion in Pa r t I s h ou ld ca u s e t h e con d it ion a b ove it . A s p ecific ca u s e of d ea t h s h ou ld b e r ep or t ed in t h e la s t en t r y in Pa r t I s o t h er e is n o a m b igu it y a b ou t t h e et iology of t h is ca u s e. Ot h er s ign ifica n t con d it ion s t h a t con t r ib u t ed t o t h e d ea t h , b u t d id n ot lea d t o t h e u n d er lyin g ca u s e, a r e r ep or t ed in Pa r t II. In a d d it ion , t h er e a r e qu es t ion s r ela t in g t o a u t op s y, m a n n er of d ea t h (for exa m p le, a ccid en t ), a n d in ju r y. Th e ca u s e of d ea t h s h ou ld in clu d e in for m a t ion p r ovid ed b y t h e p a t h ologis t if a n a u t op s y or ot h er t yp e of p os t m or t em exa m in a t ion is d on e. For d ea t h s t h a t h a ve m icr os cop ic exa m in a t ion s p en d in g a t t h e t im e t h e cer t ifica t e is filed , t h e a d d it ion a l in for m a t ion s h ou ld b e r ep or t ed a s s oon a s it is a va ila b le. If t h e p h ys icia n h a s a n y qu es t ion s a b ou t t h e p r oced u r e for d oin g t h is , h e or s h e s h ou ld con t a ct h is or h er S t a t e r egis t r a r. For s t a t is t ica l a n d r es ea r ch p u r p os es , it is im p or t a n t t h a t t h e ca u s es of d ea t h a n d , in p a r t icu la r, t h e u n d er lyin g ca u s e of d ea t h b e r ep or t ed a s s p ecifica lly a n d a s p r ecis ely a s p os s ib le. Ca r efu l r ep or t in g r es u lt s in s t a t is t ics for b ot h u n d er lyin g a n d m u lt ip le ca u s es of d ea t h (i.e., a ll con d it ion s m en t ion ed on a d ea t h cer t ifica t e) r eflect in g t h e b es t m ed ica l op in ion . E ver y ca u s e-of-d ea t h s t a t em en t is cod ed a n d t a b u la t ed in t h e s t a t is t ica l offices a ccor d in g t o t h e la t es t r evis ion of t h e International Classification of Diseases (5 ). Wh en t h er e is a p r ob lem wit h t h e r ep or t ed ca u s e of d ea t h (e.g., wh en a ca u s a l s equ en ce is r ep or t ed in r ever s e or d er ), t h e r u les p r ovid e a con s is t en t wa y t o s elect t h e m os t lik ely u n d er lyin g ca u s e. However, it is b et t er wh en r u les d es ign ed t o com p en s a t e for p oor r ep or t in g a r e n ot in vok ed s o t h a t t h e r u les a r e con fir m in g t h e p h ys icia n 's s t a t em en t r a t h er t h a n im p os in g a s s u m p t ion s a b ou t wh a t t h e p h ys icia n m ea n t . S t a t is t ica lly, m or t a lit y r es ea r ch focu s es on t h e u n d er lyin g ca u s e of d ea t h b eca u s e p u b lic h ea lt h in t er ven t ion s s eek t o b r ea k t h e s equ en ce of ca u s a lly r ela t ed m ed ica l con d it ion s a s ea r ly a s p os s ib le. However, a ll ca u s e in for m a t ion r ep or t ed on d ea t h cer t ifica t es is im p or t a n t a n d is a n a lyzed . In t h e s ect ion s t h a t follow, d et a iled in s t r u ct ion s on h ow t o com p let e Pa r t s I a n d II a r e given . A n u m b er of exa m p les of p r op er ly com p let ed cer t ifica t es wit h ca s e h is t or ies a r e p r ovid ed in t h is s ect ion t o illu s t r a t e h ow t h e ca u s e of d ea t h s h ou ld b e r ep or t ed . S om e com m on p r ob lem s a r e a ls o d is cu s s ed la t er in t h is s ect ion . 11 Changes to cause of death S h ou ld a d d it ion a l m ed ica l in for m a t ion or a u t op s y fin d in gs b ecom e a va ila b le t h a t wou ld ch a n ge t h e ca u s e or ca u s es of d ea t h or igin a lly r ep or t ed , t h e cer t ifyin g p h ys icia n s h ou ld a m en d t h e or igin a l d ea t h cer t ifica t e b y immediately r ep or tin g th e r evis ed ca u s e of d ea th to th e Sta te vita l r ecor d s office or loca l r egis t r a r. Instructions Th e ca u s e-of-d ea t h s ect ion con s is t s of t wo p a r t s . Part I is for r ep or t in g a ch a in of even t s lea d in g d ir ect ly t o d ea t h , wit h t h e immediate cause of d ea t h (t h e fin a l d is ea s e, in ju r y, or com p lica t ion d ir ect ly ca u s in g d ea t h ) on lin e (a ) a n d t h e underlying cause of d ea t h (t h e d is ea s e or in ju r y t h a t in it ia t ed t h e ch a in of even t s t h a t led d ir ect ly a n d in evit a b ly t o d ea t h ) on t h e lowes t u s ed lin e. Part II is for r ep or t in g a ll ot h er s ign ifica n t d is ea s es , con d it ion s , or in ju r ies t h a t con t r ib u t ed t o d ea t h b u t wh ich d id n ot r es u lt in t h e u n d er lyin g ca u s e of d ea t h given in Part I. The cause-of-death information should be the physician's best medical OPINION. Rep or t ea ch d is ea s e, a b n or m a lit y, in ju r y, or p ois on in g t h a t t h e p h ys icia n b elieves a d ver s ely a ffect ed t h e d eced en t . A con d it ion ca n b e lis t ed a s ''p r ob a b le'' if it h a s n ot b een d efin it ively d ia gn os ed . If a n or ga n s ys t em fa ilu r e s u ch a s con ges t ive h ea r t fa ilu r e, h ep a t ic fa ilu r e, r en a l fa ilu r e, or r es p ir a t or y fa ilu r e is lis t ed a s a ca u s e of d ea t h , a lwa ys r ep or t it s et iology on t h e lin e(s ) b en ea t h it (for exa m p le, r en a l fa ilu r e due to Typ e I d ia b et es m ellit u s ). Wh en in d ica t in g n eop la s m s a s a ca u s e of d ea t h , in clu d e t h e followin g: 1 ) p r im a r y s it e or t h a t t h e p r im a r y s it e is u n k n own , 2 ) b en ign or m a lign a n t , 3 ) cell t yp e or t h a t t h e cell t yp e is u n k n own , 4 ) gr a d e of n eop la s m , a n d 5 ) p a r t or lob e of or ga n a ffect ed . (For exa m p le, a p r im a r y well-d iffer en t ia t ed s qu a m ou s cell ca r cin om a , lu n g, left u p p er lob e.) For ea ch fa t a l in ju r y (for exa m p le, s t a b wou n d of ch es t ), a lwa ys r ep or t t h e t r a u m a (for exa m p le, t r a n s ect ion of s u b cla via n vein ), a n d im p a ir m en t of fu n ct ion (for exa m p le, a ir em b olis m ) t h a t con t r ib u t ed t o d ea t h . Part I of the cause-of-death section On ly one ca u s e is t o b e en t er ed on ea ch lin e of Pa r t I. Ad d it ion a l lin es s h ou ld b e a d d ed b et ween t h e p r in t ed lin es wh en n eces s a r y. For ea ch ca u s e, in d ica t e in t h e s p a ce p r ovid ed t h e a p p r oxim a t e in t er va l b et ween t h e d a t e of onset (n ot n eces s a r ily t h e d a t e of d ia gn os is ) a n d t h e d a t e of d ea t h . 12 For cla r it y, d o n ot u s e p a r en t h et ica l s t a t em en t s a n d a b b r evia t ion s wh en r ep or t in g t h e ca u s e of d ea t h . Th e u n d er lyin g ca u s e of d ea t h s h ou ld b e en t er ed on t h e LOWE S T LINE US E D IN PAR T I. Th e u n d er lyin g ca u s e of d ea t h is t h e d is ea s e or in ju r y t h a t s t a r t ed t h e s equ en ce of even t s lea d in g d ir ect ly t o d ea t h or t h e cir cu m s t a n ces of t h e a ccid en t or violen ce t h a t p r od u ced t h e fa t a l in ju r y. In t h e ca s e of a violen t d ea t h , t h e for m of ext er n a l violen ce or a ccid en t is a n t eced en t t o a n in ju r y en t er ed , a lt h ou gh t h e t wo even t s m a y b e a lm os t s im u lt a n eou s . Line (a) immediate cause In Pa r t I, t h e im m ed ia t e ca u s e of d ea t h is r ep or t ed on lin e (a ). Th is is t h e fin a l d is ea s e, in ju r y, or com p lica t ion d ir ect ly ca u s in g t h e d ea t h . An im m ed ia t e ca u s e of d ea t h m u s t a lwa ys b e r ep or t ed on lin e (a ). It ca n b e t h e s ole en t r y in t h e ca u s e-of-d ea t h s ect ion if t h a t con d it ion is t h e on ly con d it ion ca u s in g t h e d ea t h . Th e im m ed ia t e ca u s e d oes n ot m ea n t h e m ech a n is m of d ea t h or t er m in a l even t (for exa m p le, ca r d ia c a r r es t or r es p ir a t or y a r r es t ). Th e m ech a n is m of d ea t h (for exa m p le, ca r d ia c or r es p ir a t or y a r r es t ) s h ou ld n ot b e r ep or t ed a s t h e im m ed ia t e ca u s e of d ea t h a s it is a s t a t em en t n ot s p ecifica lly r ela t ed t o t h e d is ea s e p r oces s , a n d it m er ely a t t es t s t o t h e fa ct of d ea t h . Th er efor e, t h e m ech a n is m of d ea t h p r ovid es n o a d d it ion a l in for m a t ion on t h e ca u s e of d ea t h . Lines (b), (c), and (d) due to (or as a consequence of) On lin e (b ) r ep or t t h e d is ea s e, in ju r y, or com p lica t ion , if a n y, t h a t ga ve r is e t o t h e im m ed ia t e ca u s e of d ea t h r ep or t ed on lin e (a ). If t h is in t u r n r es u lt ed fr om a fu r t h er con d it ion , r ecor d t h a t con d it ion on lin e (c). If t h is in t u r n r es u lt ed fr om a fu r t h er con d it ion , r ecor d t h a t con d it ion on lin e (d ). For a s m a n y con d it ion s a s a r e in volved , wr it e t h e fu ll s equ en ce, on e con d it ion p er lin e, wit h t h e m os t r ecen t con d it ion a t t h e t op , a n d t h e u n d er lyin g ca u s e of d ea t h r ep or t ed on t h e lowes t lin e u s ed in Pa r t I. If m or e t h a n fou r lin es a r e n eed ed , a d d a d d it ion a l lin es (wr it in g ''d u e t o'' b et ween con d it ion s on t h e s a m e lin e is t h e s a m e a s d r a win g a n a d d it ion a l lin e) r a t h er t h a n u s in g s p a ce in Pa r t II t o con t in u e t h e s equ en ce. Th e followin g cer t ifica t ion is a n exa m p le in wh ich a n a d d it ion a l lin e wa s n eces s a r y. 13 Th e wor d s ''d u e t o (or a s a con s equ en ce of),'' wh ich a r e p r in t ed b et ween t h e lin es of Pa r t I, a p p ly n ot on ly in s equ en ces wit h a n et iologica l or p a t h ologica l b a s is a n d u s u a lly a ch r on ologica l t im e or d er in g, b u t a ls o t o s equ en ces in wh ich a n a n t eced en t con d it ion is b elieved t o h a ve p r ep a r ed t h e wa y for a s u b s equ en t ca u s e b y d a m a ge t o t is s u es or im p a ir m en t of fu n ct ion . If t h e im m ed ia t e ca u s e of d ea t h a r os e a s a com p lica t ion of or fr om a n er r or or a ccid en t in s u r ger y or ot h er m ed ica l p r oced u r e or t r ea t m en t , it is im p or t a n t t o r ep or t wh a t con d it ion wa s b ein g t r ea t ed , wh a t m ed ica l p r oced u r e wa s p er for m ed , wh a t t h e com p lica t ion or er r or wa s , a n d wh a t t h e r es u lt of t h e com p lica t ion or er r or wa s . Approximate interval between onset and death S p a ce is p r ovid ed t o t h e r igh t of lin es (a ), (b ), (c), a n d (d ) for r ecor d in g t h e in t er va l b et ween t h e p r es u m ed on s et of t h e con d it ion (n ot t h e d ia gn os is of t h e con d it ion ) a n d t h e d a t e of d ea t h . Th is s h ou ld b e en t er ed for all con d it ion s in Pa r t I. Th es e in t er va ls u s u a lly a r e es t a b lis h ed b y t h e p h ys icia n on t h e b a s is of a va ila b le in for m a t ion . In s om e ca s es t h e in t er va l will h a ve t o b e es t im a t ed . Th e t er m s ''u n k n own '' or ''a p p r oxim a t ely'' m a y b e u s ed . Gen er a l t er m s , s u ch a s m in u t es , h ou r s , or d a ys , a r e a ccep t a b le, if n eces s a r y. If t h e t im e of on s et is en t ir ely u n k n own , s t a t e t h a t t h e in t er va l is ''Un k n own .'' Do n ot lea ve t h es e it em s b la n k . Th is in for m a t ion is u s efu l in cod in g cer t a in d is ea s es a n d a ls o p r ovid es a u s efu l ch eck on t h e a ccu r a cy of t h e r ep or t ed s equ en ce of con d it ion s . Part II of the cause-of-death section (other significant conditions) All ot h er im p or t a n t d is ea s es or con d it ion s t h a t wer e p r es en t a t t h e t im e of d ea t h a n d t h a t m a y h a ve con t r ib u t ed t o t h e d ea t h , b u t d id n ot lea d t o t h e 14 u n d er lyin g ca u s e of d ea t h lis t ed in Pa r t I or wer e n ot r ep or t ed in t h e ch a in of even t s in Pa r t I, s h ou ld b e r ecor d ed on t h es e lin es . (Mor e t h a n on e con d it ion ca n b e r ep or t ed p er lin e in Pa r t II.) Mu lt ip le con d it ion s a n d s equ en ces of con d it ion s r es u lt in g in d ea t h a r e com m on , p a r t icu la r ly a m on g t h e eld er ly. Wh en t h er e a r e t wo or m or e p os s ib le s equ en ces r es u lt in g in d ea t h , or if t wo con d it ion s s eem t o h a ve a d d ed t oget h er, ch oos e a n d r ep or t in Pa r t I t h e s equ en ce t h ou gh t t o h a ve h a d t h e gr ea t es t im p a ct . Ot h er con d it ion s or con d it ion s fr om t h e ot h er s equ en ce(s ) s h ou ld b e r ep or t ed in Pa r t II. For exa m p le, in t h e ca s e of a d ia b et ic m a le wit h ch r on ic is ch em ic h ea r t d is ea s e wh o d ies fr om p n eu m on ia , h is cer t ifyin g p h ys icia n m u s t ch oos e t h e s equ en ce of con d it ion s t h a t h a d t h e gr ea t es t im p a ct a n d r ep or t t h is s equ en ce in Pa r t I. On e p os s ib le s equ en ce t h a t t h e cer t ifier m igh t r ep or t wou ld b e p n eu m on ia d u e t o d ia b et es m ellit u s in Pa r t I wit h ch r on ic is ch em ic h ea r t d is ea s e r ep or t ed in Pa r t II. An ot h er p os s ib ilit y wou ld b e p n eu m on ia d u e t o t h e ch r on ic is ch em ic h ea r t d is ea s e en t er ed in Pa r t I wit h d ia b et es m ellit u s r ep or t ed in Pa r t II. Or t h e cer t ifier m igh t con s id er t h e p n eu m on ia t o b e d u e t o t h e is ch em ic h ea r t d is ea s e t h a t wa s d u e t o t h e d ia b et es m ellit u s a n d r ep or t t h is en t ir e s equ en ce in Pa r t I. Beca u s e t h es e t h r ee d iffer en t p os s ib ilit ies wou ld b e cod ed ver y d iffer en t ly, it is im p or t a n t for t h e cer t ifyin g p h ys icia n t o d ecid e wh ich s equ en ce m os t a ccu r a t ely d es cr ib es t h e con d it ion s ca u s in g d ea t h . Doubt and cause of death In ca s es of d ou b t , it m a y b e n eces s a r y t o u s e qu a lifyin g p h r a s es in eit h er Pa r t I or Pa r t II t o r eflect u n cer t a in t y a s t o wh ich con d it ion s led t o d ea t h . In ca s es wh er e t h e cer t ifier is u n a b le t o es t a b lis h a ca u s e of d ea t h b a s ed u p on r ea s on a b le m ed ica l cer t a in t y, h e or s h e s h ou ld en t er ''Un k n own '' in t h e ca u s e-of-d ea t h s ect ion . However, t h is s h ou ld b e s h own on ly a ft er a ll effor t s h a ve b een m a d e t o d et er m in e t h e ca u s e of d ea t h . An a u t op s y s h ou ld b e p er for m ed , if p os s ib le. Other items for medical certification Th e r em a in in g it em s t h a t r equ ir e t h e p h ys icia n 's cer t ifica t ion r ela t e t o a u t op s y, m a n n er of d ea t h , in ju r y, fem a le d eced en t 's p r egn a n cy s t a t u s , if t ob a cco u s e con t r ib u t ed t o d ea t h , a n d wh et h er t h e ca s e wa s r efer r ed t o t h e m ed ica l exa m in er or cor on er. Th e p h ys icia n s h ou ld in d ica t e wh et h er a n a u t op s y wa s p er for m ed a n d wh et h er t h e fin d in gs wer e a va ila b le t o com p let e t h e ca u s e of d ea t h . If a d d it ion a l m ed ica l in for m a t ion or a u t op s y fin d in gs a r e r eceived a ft er t h e 15 physician has certified the cause of death and he or she determines the cause to be different from what was originally entered on the death certificate, the original certificate should be amended by filing a supplemental report of cause of death with the State registrar. Information on the proper form to use and procedure to follow can be obtained from the State registrar. In most cases the manner of death will be checked ''Natural.'' In those cases when an accident, suicide, or homicide has occurred, the medical examiner or coroner must be notified. If the medical examiner or coroner does not assume jurisdiction, the physician should check the appropriate manner of death and describe the injury and accident. Completing the certifier section Physicians can play different roles in medical certification. A pronouncing physician is a physician who determines that the decedent is legally dead, but was not in charge of the patient's care for the illness or condition that resulted in death. The attending physician is responsible for completing the cause-of-death section (item 32). If a pronouncing physician is involved, the attending physician plays the role of a certifying physician. If no pronouncing physician is involved, the attending physician plays the role of both the pronouncing and certifying physician. The medical examiner or coroner investigates certain types of deaths according to State law and complete the cause of death for these cases. The following chart specifies the items to be completed by each type of medical certifier. MEDICAL CERTIFICATION Medical certifier Pronouncing physician Certifying physician Pronouncing and certifying physician Medical examiner or coroner Complete items 24-31 32-37, 45-49 (sometimes 38-44) 24, 25, 29-37, and 45-49 (sometimes 38-44) 24, 25, 29, 30, and 32-49 The attending physician is usually in a better position than any other individual to make a judgment as to which of the conditions led directly to death and to state the antecedent conditions, if any, that gave rise to this cause. 16 Beca u s e t h e it em s com p let ed b y t h e p r on ou n cin g or p r on ou n cin g a n d cer t ifyin g p h ys icia n , a n d m ed ica l exa m in er or cor on er d iffer, s ep a r a t e s t a t em en t s a r e p r ovid ed t h a t s p ecify t o wh a t in for m a t ion ea ch p h ys icia n is a t t es t in g. Th is a gr eem en t is d en ot ed wh en ea ch p h ys icia n s ign s t h e com p let ed s t a t em en t , a d d in g h is or h er d egr ee or t it le a n d licen s e n u m b er. Cer t a in ju r is d ict ion s m a y p r ovid e for elect r on ic a u t h en t ica t ion in s t ea d of a s ign a t u r e on t h e p a p er d ocu m en t . Th e d a t e of cer t ifica t ion a n d m a ilin g a d d r es s of t h e p h ys icia n s h ou ld a ls o b e p r ovid ed . Examples of cause-of-death certification Case history no. 1 S h or t ly a ft er d in n er on t h e d a y p r ior t o a d m is s ion t o t h e h os p it a l, t h is 4 8 -yea r -old m a le d evelop ed a cr a m p in g, ep iga s t r ic p a in , wh ich r a d ia t ed t o h is b a ck , followed b y n a u s ea a n d vom it in g. Th e p a in wa s n ot r elieved b y p os it ion a l ch a n ges or a n t a cid s . Th e p a in p er s is t ed , a n d 2 4 h ou r s a ft er it s on s et , t h e p a t ien t s ou gh t m ed ica l a t t en t ion . He h a d a 1 0 -yea r h is t or y of exces s ive a lcoh ol con s u m p t ion a n d a 2 -yea r h is t or y of fr equ en t ep is od es of s im ila r ep iga s t r ic p a in . Th e p a t ien t d en ied d ia r rh ea , con s t ip a t ion , h em a t em es is , or m elen a . Th e p a t ien t wa s a d m it t ed t o t h e h os p it a l wit h a d ia gn os is of a n a cu t e exa cer b a t ion of ch r on ic p a n cr ea t it is . Ra d iologica l fin d in gs in clu d ed a d u od en a l ileu s a n d p a n cr ea t ic ca lcifica t ion . S er u m a m yla s e wa s 4 ,0 3 2 u n it s p er lit er. Th e d a y a ft er a d m is s ion , t h e p a t ien t s eem ed t o im p r ove. However, t h a t even in g h e b eca m e d is or ien t ed , r es t les s , a n d h yp ot en s ive. Des p it e in t r a ven ou s flu id s a n d va s op r es s or s , t h e p a t ien t r em a in ed h yp ot en s ive a n d d ied . Au t op s y fin d in gs r evea led m a n y a r ea s of fib r os is in t h e p a n cr ea s wit h t h e r em a in in g a r ea s s h owin g m u lt ip le foci of a cu t e in fla m m a t ion a n d n ecr os is . 17 Notes on death certification: Duodenal ileus and pancreatic calcification are nonspecific processes and neither could be listed as an underlying cause of death. Case history no. 2 A 6 8 -yea r -old m a le wa s a d m it t ed t o t h e h os p it a l wit h p r ogr es s ive r igh t lower qu a d r a n t p a in of s ever a l week s ' d u r a t ion . Th e p a t ien t h a d los t a p p r oxim a t ely 4 0 p ou n d s , wit h p r ogr es s ive wea k n es s a n d m a la is e. On p h ys ica l exa m in a t ion , t h e p a t ien t h a d a n en la r ged liver s p a n t h a t wa s fou r fin ger b r ea d t h s b elow t h e r igh t cos t a l m a r gin . Rect a l exa m in a t ion wa s n or m a l a n d s t ool wa s n ega t ive for occu lt b lood . Rou t in e la b or a t or y s t u d ies wer e wit h in n or m a l lim it s . A ch es t x r a y a n d b a r iu m en em a wer e n ega t ive. His E KG s h owed a r igh t b u n d le b r a n ch b lock . CT s ca n s h owed n u m er ou s m a s s es wit h in b ot h lob es of t h e liver. A n eed le b iop s y of t h e liver wa s d ia gn os t ic of m od er a t ely d iffer en t ia t ed h ep a t ocellu la r ca r cin om a , a n d t h e p a t ien t wa s s t a r t ed on ch em ot h er a p y. Th r ee m on t h s a ft er t h e d ia gn os is , t h e p a t ien t d evelop ed s h a r p d im in u t ion of liver fu n ct ion a s well a s a d eep ven ou s t h r om b os is of h is left t h igh , a n d h e wa s a d m it t ed t o t h e h os p it a l. On h is t h ir d d a y, t h e p a t ien t d evelop ed a p u lm on a r y em b olis m a n d d ied 3 0 m in u t es la t er . 18 Case history no. 3 Th is 7 5 -yea r -old m a le wa s a d m it t ed t o t h e h os p it a l com p la in in g of s ever e ch es t p a in . He h a d a 1 0 -yea r h is t or y of a r t er ios cler ot ic h ea r t d is ea s e wit h E KG fin d in gs of m yoca r d ia l is ch em ia a n d s ever a l ep is od es of con ges t ive h ea r t fa ilu r e con tr olled b y d igita lis p r ep a r a tion s a n d d iu r etics . Five m on th s b efor e t h is a d m is s ion , t h e p a t ien t wa s fou n d t o b e a n em ic, wit h a n h em a t ocr it of 1 7 , a n d t o h a ve occu lt b lood in t h e s t ool. A b a r iu m en em a r evea led a la r ge p olyp oid m a s s in t h e cecu m d ia gn os ed a s ca r cin om a b y b iop s y. Beca u s e of t h e p a t ien t 's ca r d ia c s t a t u s , h e wa s n ot con s id er ed t o b e a s u r gica l ca n d id a t e. In s t ea d , h e wa s t r ea t ed wit h a 5 -week cou r s e of r a d ia t ion t h er a p y a n d p er iod ic p a ck ed r ed cell t r a n s fu s ion s . He com p let ed t h is cou r s e 3 m on t h s b efor e t h is h os p it a l a d m is s ion . On t h is a d m is s ion t h e E KG wa s d ia gn os t ic of a n a cu t e a n t er ior wa ll m yoca r d ia l in fa r ct ion . He exp ir ed 2 d a ys la t er . 19 Notes on death certification: Acute myocardial infarction, listed in Part I line (a) as the immediate cause of death, is a direct consequence of arteriosclerotic heart disease, the underlying cause listed in Part I line (b). Carcinoma of cecum is listed in Part II because it caused anemia and weakened the patient, but it did not cause arteriosclerotic heart disease. Congestive heart failure is listed in Part II because it also weakened the patient. Although it was caused by the arteriosclerotic heart disease, it was not part of the causal sequence leading to the acute myocardial infarction. Case history no. 4 A 6 8 -yea r -old fem a le wa s a d m it t ed t o t h e ICU wit h d ys p n ea a n d m od er a t e r et r os t er n a l p a in of 5 -h ou r s d u r a t ion , wh ich d id n ot r es p on d t o n it r oglycer in . Th er e wa s a p a s t h is t or y of ob es it y, n on in s u lin -d ep en d en t d ia b et es m ellit u s , h yp er t en s ion , a n d ep is od es of n on exer t ion a l ch es t p a in , d ia gn os ed a s a n gin a p ect or is , for 8 yea r s . Over t h e fir s t 7 2 h ou r s , s h e d evelop ed a s ign ifica n t eleva tion of th e MB is oen zym e of cr ea tin e p h os p h ok in a s e, con fir m in g a n a cu t e m yoca r d ia l in fa r ct ion . A Typ e II s econ d -d egr ee AV b lock d evelop ed , a n d a t em p or a r y p a cem a k er wa s p u t in p la ce. S h e s u b s equ en t ly d evelop ed d ys p n ea wit h flu id r et en t ion a n d ca r d iom ega ly on ch es t r a d iogr a p h . S h e im p r oved wit h d iu r et ics . On t h e s even t h h os p it a l d a y, d u r in g a m b u la t ion , s h e s u d d en ly d evelop ed ch es t p a in a n d in cr ea s ed d ys p n ea . An a cu t e p u lm on a r y em b olis m wa s s u s p ect ed a n d in t r a ven ou s h ep a r in wa s s t a r t ed . Th e d ia gn os is of p u lm on a r y em b olis m wa s con fir m ed b y a ven t ila t ion / p er fu s ion s ca n a s well a s a r t er ia l b lood ga s m ea s u r em en t s . On e h ou r la t er, s h e b eca m e u n r es p on s ive a n d r es u s cit a t ion effor t s wer e u n s u cces s fu l. 20 Notes on death certification: In this case, noninsulin-dependent diabetes mellitus, obesity, hypertension, and congestive heart failure would all be considered factors that contributed to the death. However, they would not be in the direct causal sequence of Part I, so they would be placed in Part II. Case history no. 5 A 7 8 -yea r -old fem a le wit h a t em p er a t u r e of 1 0 2 .6 ? F wa s a d m it t ed t o t h e h os p it a l fr om a n u r s in g h om e. S h e fir s t b eca m e a r es id en t of t h e n u r s in g h om e 2 yea r s ea r lier followin g a cer eb r ova s cu la r a ccid en t , wh ich left h er wit h a r es id u a l left h em ip a r es is . Over t h e n ext yea r, s h e b eca m e in cr ea s in gly d ep en d en t on ot h er s t o h elp wit h h er a ct ivit ies of d a ily livin g, even tu a lly r equ irin g a n in -d wellin g b la d d er ca th eter 6 m on th s b efor e th e cu rr en t a d m is s ion . For t h e 3 d a ys p r ior t o a d m is s ion , s h e wa s n ot ed t o h a ve los t h er a p p et it e a n d t o h a ve b ecom e in cr ea s in gly wit h d r a wn . On a d m is s ion t o t h e h os p it a l h er leu k ocyt e cou n t wa s 1 9 ,7 0 0 , s h e h a d p yu r ia , a n d gr a m -n ega t ive r od s wer e s een on a gr a m s t a in of u r in e. Am p icillin a n d gen t a m icin wer e a d m in is t er ed in t r a ven ou s ly. On t h e t h ir d h os p it a l d a y, a d m is s ion b lood cu lt u r es t u r n ed p os it ive for Pseudomonas aeruginosa, wh ich wa s r es is t a n t t o a m p icillin a n d gen t a m icin . An t ib iot ic t h er a p y wa s ch a n ged t o t ica r cillin cla vu la n a t e, t o wh ich t h e or ga n is m wa s s en s it ive. Des p it e t h e a n t ib iot ics a n d in t r a ven ou s flu id s u p p or t , t h e p a t ien t 's fever p er s is t ed . On t h e fou r t h h os p it a l d a y, s h e b eca m e h yp ot en s ive a n d d ied . Th is ca s e illu s t r a t es t h a t a d d it ion a l lin es m a y b e a d d ed t o Pa r t I. 21 Case history no. 6 A 3 4 -yea r -old m a le wa s a d m it t ed t o t h e h os p it a l wit h s ever e s h or t n es s of b r ea t h . He h a d a 9 -m on t h h is t or y of u n in t en t ion a l weigh t los s , n igh t s wea t s , a n d d ia r rh ea . Th e p a t ien t h a d n o h is t or y of a n y m ed ica l con d it ion t h a t wou ld ca u s e im m u n od eficien cy. An E lis a t es t a n d con fir m a t or y Wes t er n Blot t es t for h u m a n im m u n od eficien cy vir u s (HIV) wer e p os it ive. T-lym p h ocyt e t es t s in d ica t ed a low T h elp er -s u p p r es s or r a t io. A lu n g b iop s y wa s p os it ive for p n eu m ocys t is ca r in ii p n eu m on ia (PCP), in d ica t in g a d ia gn os is of a cqu ir ed im m u n od eficien cy s yn d r om e (AIDS ). Th e p a t ien t 's p n eu m on ia r es p on d ed t o p en t a m id in e t h er a p y, a n d t h e p a t ien t wa s d is ch a r ged . Th e p a t ien t h a d t wo a d d it ion a l a d m is s ion s for PCP. S even t een m on t h s a ft er t h e p a t ien t wa s fir s t d is cover ed t o b e HIV p os it ive, h e a ga in d evelop ed PCP b u t d id n ot r es p on d t o t h er a p y. He d ied 2 week s la t er . 22 Notes on death certification: By definition, AIDS is due to HIV infection; even though it may seem redundant to specify HIV infection in the causal sequence death, it is desirable to do so. HIV infection and AIDS are not synonymous, and there is a variable clinical course between the time of HIV infection and onset of AIDS. Case history no. 7 A 7 5 -yea r -old m a le h a d a 1 0 -yea r h is t or y of ch r on ic b r on ch it is a s s ocia t ed wit h s m ok in g t wo p a ck s of ciga r et t es a d a y for m or e t h a n 4 0 yea r s . Wh en s een b y h is p h ys icia n a p p r oxim a t ely 2 yea r s p r ior t o h is t er m in a l ep is od e, h e h a d m od er a t ely r ed u ced FE V1 a n d FVC wit h n o r es p on s e t o b r on ch od ila t or s . Du r in g h is la s t yea r, h e r equ ir ed cor t icos t er oid s t o p r even t wh eezin g a n d cou gh in g a t n igh t ; h owever, h e wa s u n a b le t o r ed u ce h is s m ok in g t o les s t h a n on e p a ck of ciga r et t es p er d a y. Wh en s een 3 m on t h s p r ior t o h is t er m in a l ep is od e, h e h a d s ign ifica n t ly r ed u ced FE V1 a n d FVC wit h n o r es p on s e t o b r on ch od ila t or s . He a wok e on e even in g com p la in in g t o h is wife a b ou t cou gh in g a n d wor s en in g s h or t n es s of b r ea t h . He wa s t a k en t o t h e em er gen cy r oom wh er e h e wa s fou n d t o h a ve a n a cu t e exa cer b a t ion of ob s t r u ct ive a ir wa y d is ea s e. He wa s a d m it t ed t o t h e h os p it a l. At t h e p a t ien t 's r equ es t , n o m ech a n ica l ven t ila t ion wa s em p loyed , a n d h e d ied 1 2 h ou r s la t er in r es p ir a t or y a r r es t . 23 Notes on death certification: In this case, respiratory arrest is considered a mechanism of death, and it would not be listed as the Immediate Cause of Death. Case history no. 8 A 7 5 -yea r -old fem a le h a d a 1 5 -yea r h is t or y of n on in s u lin -d ep en d en t d ia b et es m ellit u s , a 1 3 -yea r h is t or y of m ild h yp er t en s ion t r ea t ed wit h t h ia zid e d iu r et ics , a n d a n u n com p lica t ed m yoca r d ia l in fa r ct ion 6 yea r s p r ior t o t h e p r es en t illn es s . S h e wa s fou n d d is or ien t ed in h er a p a r t m en t a n d b r ou gh t t o t h e h os p it a l. On a d m is s ion s h e wa s n ot ed t o b e u n r es p on s ive, wit h ou t foca l n eu r ologic s ign s , a n d s ever ely d eh yd r a t ed wit h a b lood p r es s u r e of 9 0 / 6 0 . In it ia l la b or a t or y t es t s d is clos ed s ever e h yp er glycem ia , h yp er os m ola r it y, a zot em ia , a n d m ild k et os is wit h ou t a cid os is . A d ia gn os is of h yp er os m ola r n on k et ot ic com a wa s m a d e. Th e p a t ien t wa s vigor ou s ly t r ea t ed wit h flu id s , elect r olyt es , in s u lin , a n d b r oa d -s p ect r u m a n t ib iot ics , a lt h ou gh n o s ou r ce for in fect ion wa s d ocu m en t ed . Wit h in 7 2 h ou r s , t h e p a t ien t 's h yp er os m ola r, h yp er glycem ic s t a t e wa s r es olved . However, s h e r em a in ed a n u r ic wit h p r ogr es s ive a zot em ia . At t em p t s a t r en a l d ia lys is wer e u n s u cces s fu l, a n d t h e p a t ien t d ied on t h e 8 t h h os p it a l d a y in s ever e r en a l fa ilu r e. 24 Notes on death certification: In this case, hypertension and a previous myocardial infarction would both be considered factors that contributed to the death. However, they would not be in the direct causal sequence of Part I, so they would be placed in Part II. Case history no. 9 Th is 5 3 -yea r -old m a le wa s a d m it t ed t o t h e h os p it a l followin g 2 d a ys of in t er m it t en t m id ep iga s t r ic a n d left -s id ed ch es t p a in . Th e p a in r a d ia t ed t o h is left a r m a n d wa s a ccom p a n ied b y n a u s ea a n d vom it in g. He ga ve a h is t or y t h a t in clu d ed 2 yea r s of occa s ion a l ch es t d is com for t , a n ea r s yn cop a l ep is od e 6 m on t h s p r ior, h yp er t en s ion , a 3 0 -yea r h is t or y of on e-p a ck p er -d a y ciga r et t e s m ok in g, con gen it a l b lin d n es s , a n d in s u lin -d ep en d en t d ia b et es m ellit u s . He wa s n ot ed t o b e m a r k ed ly ob es e a n d t o h a ve s ever e h yp er ch oles t er olem ia . At t h e t im e of a d m is s ion , h is en zym e s t u d ies wer e n or m a l, b u t t h e E KG s u gges t ed m yoca r d ia l is ch em ia . Two d a ys la t er, h e exp er ien ced a n ep is od e of s ever e ch es t p a in t h a t d id n ot r es p on d t o n it r oglycer in a n d wa s a ccom p a n ied b y S T-s egm en t eleva t ion . A ca r d ia c ca t h et er iza t ion d em on s t r a t ed s ever e m u lt ives s el cor on a r y a r t er y s t en os is . He u n d er wen t qu a d r u p le cor on a r y a r t er y b yp a s s s u r ger y. S h or t ly, a ft er b ein g t a k en off t h e ca r d iop u lm on a r y b yp a s s m a ch in e, h e wen t in t o ca r d ia c a r r es t . As r es u s cit a t ion wa s b ein g a t t em p t ed b y op en ca r d ia c m a s s a ge, a r u p t u r e d evelop ed in h is left ven t r icu la r wa ll t h a t r es u lt ed in r a p id exs a n gu in a t ion a n d d ea t h . 25 Notes on death certification: In this case, insulin-dependent diabetes mellitus, cigarette smoking, hypertension, and hypercholesterolemia would all be considered factors that contributed to the death. However, they would not be in the direct causal sequence of Part I, so they would be placed in Part II. The surgery probably played a role in death but did not cause the coronary artery disease, so it is also listed in Part II. Case history no. 10 A 1 ,4 8 0 -gr a m m a le in fa n t wa s b or n a t 3 2 -week s ges t a t ion t o a 2 0 -yea r -old p r im ip a r ou s wom a n . Newb or n s cr een in g fou n d eleva t ed levels of im m u n or ea ct ive t r yp s in ogen in t h e b lood . Th e in fa n t d evelop ed r es p ir a t or y d is t r es s s yn d r om e a n d r equ ir ed m ech a n ica l ven t ila t ion for 7 d a ys . Des p it e r eceivin g a d equ a t e ca lor ies for gr owt h , t h e in fa n t ga in ed weigh t p oor ly a n d h a d p er s is t en t d ia r rh ea . S t ea t or rh ea wa s con fir m ed u p on m icr os cop ic exa m in a t ion . Res u lt s fr om a s wea t ch lor id e t es t given on t h e 2 1 s t d a y a ft er b ir t h wer e n ega t ive, b u t t h e p a t ien t h a d a n eleva t ed s wea t ch lor id e con cen t r a t ion of 8 5 m illim oles p er lit er wh en t h e t es t wa s r ep ea t ed a t 3 5 d a ys of a ge. On t h e 3 7 t h d a y a ft er b ir t h , t h e in fa n t b eca m e let h a r gic a n d wa s n ot ed t o b e ed em a t ou s . E s ch er ich ia coli wa s cu lt u r ed fr om t h e in fa n t 's cer eb r a l s p in a l flu id , t ot a l s er u m p r ot ein s wer e r ep or t ed t o b e low, a n d clot t in g s t u d ies wer e p r olon ged . Th e in fa n t d ied a t 4 5 d a ys of a ge d es p it e a p p r op r ia t e life-s a vin g effor t s . Gr os s a u t op s y con fir m ed t h e clin ica l im p r es s ion of cys t ic fib r os is . 26 Notes on death certification: In this case, prematurity, malabsorption, respiratory distress syndrome, and failure to thrive would all be considered factors that contributed to the death. However, they would not be in the direct causal sequence of Part I, so they would be placed in Part II. Case history no. 11 A 3 0 -yea r -old , gr a vid a -s ix, p a r a -five, wit h a h is t or y of ges t a t ion a l h yp er t en s ion , r ep or t ed t o t h e em er gen cy r oom a t 3 6 week s ges t a t ion wit h com p la in t s of a b d om in a l cr a m p in g a n d ligh t va gin a l b leed in g d u r in g t h e p a s t 1 2 h ou r s . At t im e of fir s t a s s es s m en t , fet a l h ea r t t on es wer e d et ect ed . Th e u t er u s wa s t en s e, ir r it a b le, a n d t en d er. Th e m ot h er wa s h yp ot en s ive wit h t a ch yca r d ia . A p r es u m p t ive d ia gn os is of a b r u p t io p la cen t a wa s m a d e, a n d a n em er gen cy ces a r ea n s ect ion wa s p er for m ed u n d er gen er a l a n es t h es ia . Th e b a b y wa s s t illb or n . Th e m ot h er con t in u ed t o b leed fr om h er u t er u s a n d p h leb ot om y s it es a n d wen t in t o p r ofou n d s h ock s econ d a r y t o d is s em in a t ed in t r a va s cu la r coa gu la t ion . Des p it e a d m in is t r a t ion of b lood a n d clot tin g fa ctors , in tra va s cu la r p r es s u r e cou ld n ot b e m a in ta in ed , a n d th e m oth er d ied on t h e op er a t in g t a b le. Ma t er n a l a u t op s y con fir m ed t h e clin ica l d ia gn os is . A d ea t h cer t ifica t e wou ld b e com p let ed for t h e m ot h er a n d a fet a l d ea t h r ep or t for t h e fet u s . Th e ca u s e of fet a l d ea t h is r ep or t ed u s in g a d iffer en t for m a t . Plea s e r efer t o t h e Medical Examiners' and Coroners' Handbook on Death Registration and Fetal Death Reporting for fu r t h er in for m a t ion . 27 Ma t er n a l d ea t h cer t ifica t e: Notes on death certification: In this case, gestational hypertension would be considered a factor that contributed to the death. However, it would not be in the direct causal sequence of Part I, so it would be placed in Part II. 28 Fet a l d ea t h r ep or t : Case history no. 12 A 9 2 -yea r -old m a le wa s fou n d d ea d in b ed . He h a d n o s ign ifica n t m ed ica l h is t or y. Au t op s y d is clos ed m in im a l cor on a r y d is ea s e a n d gen er a lized a t r op h ic ch a n ges com m on ly a s s ocia t ed wit h a gin g. No s p ecific ca u s e of d ea t h wa s id en t ified . Toxicology wa s n ega t ive. 29 Note: In some cases, no overwhelming cause presents itself. It is acceptable to indicate that a thorough investigation was performed; however, no cause could be determined. Case history no. 13 A 1 0 2 -yea r -old fem a le wa s b r ou gh t t o t h e h os p it a l b eca u s e h er wor d com b in a t ion s wer e n ot com p r eh en s ib le. However, a t a d m is s ion , h er s en t en ces wer e lu cid . S h e wa s p la ced on b lood a n t icoa gu la n t s . S h e h a d a h is t or y of a r t h r it is , h yp er t en s ion , b lock ed a r t er ies , cor on a r y t h r om b os is (2 5 yea r s b efor e), s t r ok e (1 0 yea r s b efor e), p er iod ic TIAs (8 -yea r p er iod ), a n d con ges t ive h ea r t fa ilu r e (h os p it a lized 6 yea r s b efor e). On t h e fou r t h d a y in t h e h os p it a l, a colon os cop y in d ica t ed in t er n a l b leed in g, s o t h e a n t icoa gu la n t wa s d is con t in u ed . S h e wa s r elea s ed fr om t h e h os p it a l a ft er 7 d a ys . Aft er d is ch a r ge, la n gu a ge a n d m ot or s k ills wer e im p a ir ed a lt h ou gh fu n ct ion in g wa s b et t er ea r lier in t h e d a y; m or eover, h er leg color a t ion s t a r t ed ch a n gin g. Aft er a week a t h om e, t h e wom a n wa s r e-a d m it t ed t o t h e h os p it a l followin g a s p ell of vom it in g. Va s cu la r im a gin g in d ica t ed t h a t cir cu la t ion wa s b lock ed a t t h e gr oin , t h er e wa s n o im p r ovem en t in la n gu a ge, a b ilit y t o ea t a n d k eep food d own d et er ior a t ed , a n d h ea r t r a t e p er iod ica lly wa s a r r yt h m ic wit h p er iod s of t h ir d -d egr ee h ea r t b lock . Aft er a week of h os p it a liza t ion , s h e wa s s en t h om e u n d er h os p ice ca r e a n d d ied 2 d a ys la t er. Her a t t en d in g p h ys icia n com p let ed t h e d ea t h cer t ifica t e. 30 Common problems in death certification Oft en s ever a l a ccep t a b le wa ys of wr it in g a ca u s e-of-d ea t h s t a t em en t exis t . Op t im a lly, a cer t ifier will b e a b le t o p r ovid e a s im p le d es cr ip t ion of t h e p r oces s lea d in g t o d ea t h t h a t is et iologica lly clea r a n d b e con fid en t t h a t t h is is t h e cor r ect s equ en ce of ca u s es . However, r ea lis t ica lly, d es cr ip t ion of t h e p r oces s is s om et im es d ifficu lt b eca u s e t h e cer t ifier is not certain. In t h is ca s e, t h e cer t ifier s h ou ld t h in k t h r ou gh t h e ca u s es a b ou t wh ich h e/ s h e is con fid en t a n d wh a t p os s ib le et iologies cou ld h a ve r es u lt ed in t h es e con d it ion s . Th e cer t ifier s h ou ld s elect t h e ca u s es t h a t a r e s u s p ect ed t o h a ve b een in volved a n d u s e wor d s s u ch a s ''p r ob a b le'' or ''p r es u m ed '' t o in d ica t e t h a t t h e d es cr ip t ion p r ovid ed is n ot com p let ely cer t a in . If t h e in it ia t in g con d it ion r ep or t ed on t h e d ea t h cer t ifica t e cou ld h a ve a r is en fr om a p r e-exis t in g con d it ion , b u t t h e cer t ifier ca n n ot d et er m in e t h e et iology, h e/ s h e s h ou ld s t a t e t h a t t h e et iology is u n k n own , u n d et er m in ed , or u n s p ecified , s o it is clea r t h a t t h e cer t ifier d id n ot h a ve en ou gh in for m a t ion t o p r ovid e even a qu a lified et iology. Rep or t in g a ca u s e of d ea t h a s u n k n own s h ou ld b e a la s t r es or t . Th e elderly decedent s h ou ld h a ve a clea r a n d d is t in ct et iologica l s equ en ce for ca u s e of d ea t h , if p os s ib le. Ter m s s u ch a s s en es cen ce, in fir m it y, old a ge, a n d a d va n ced a ge h a ve lit t le va lu e for p u b lic h ea lt h or m ed ica l r es ea r ch . Age is r ecor d ed els ewh er e on t h e cer t ifica t e. Wh en a n u m b er of con d it ion s r es u lt ed in d ea t h , t h e p h ys icia n s h ou ld ch oos e t h e s in gle s equ en ce t h a t , in h is or h er op in ion , b es t d es cr ib es t h e p r oces s lea d in g t o d ea t h , a n d p la ce a n y ot h er p er t in en t con d it ion s in Pa r t II. ''Mu lt ip le s ys t em fa ilu r e'' cou ld b e in clu d ed in Pa r t II, b u t t h e s ys t em s n eed t o b e s p ecified t o en s u r e t h a t t h e in for m a t ion is ca p t u r ed . If a ft er ca r efu l 31 con s id er a t ion , t h e p h ys icia n ca n n ot d et er m in e a s equ en ce t h a t en d s in d ea t h , t h en t h e m ed ica l exa m in er or cor on er s h ou ld b e con s u lt ed a b ou t con d u ct in g a n in ves t iga t ion or p r ovid in g a s s is t a n ce in com p let in g t h e ca u s e of d ea t h . Th e infant decedent s h ou ld h a ve a clea r a n d d is t in ct et iologica l s equ en ce for ca u s e of d ea t h , if p os s ib le. ''Pr em a t u r it y'' s h ou ld n ot b e en t er ed wit h ou t exp la in in g t h e et iology of p r em a t u r it y. Ma t er n a l con d it ion s m a y h a ve in it ia t ed or a ffect ed t h e s equ en ce t h a t r es u lt ed in in fa n t d ea t h , a n d s u ch m a t er n a l ca u s es s h ou ld b e r ep or t ed in a d d it ion t o t h e in fa n t ca u s es on t h e in fa n t 's d ea t h cer t ifica t e (e.g., h ya lin e m em b r a n e d is ea s e due to p r em a t u r it y, 2 8 week s due to p la cen t a l a b r u p t ion due to b lu n t t r a u m a t o m ot h er 's a b d om en ). Wh en Sudden Infant Death Syndrome (S IDS ) is s u s p ect ed , a com p let e in ves t iga t ion s h ou ld b e con d u ct ed , t yp ica lly b y a m ed ica l exa m in er or cor on er. If t h e in fa n t is u n d er 1 yea r of a ge, n o ca u s e of d ea t h is d et er m in ed a ft er s cen e in ves t iga t ion , r eview of clin ica l h is t or y, a n d a com p let e a u t op s y. Th e d ea t h t h en ca n b e r ep or t ed a s S IDS . Refer t o t h e Medical Examiners' and Coroners' Handbook on Death Registration and Fetal Death Reporting for m or e in for m a t ion . Mos t cer t ifier s will fin d t h em s elves , a t s om e p oin t , in t h e cir cu m s t a n ce in wh ich t h ey a r e unable to provide a simple description of the process of death. In t h is s it u a t ion , t h e cer t ifier s h ou ld t r y t o p r ovid e a clea r s equ en ce, qu a lify t h e ca u s es a b ou t wh ich h e/ s h e is u n cer t a in , a n d b e a b le t o exp la in t h e cer t ifica t ion ch os en . 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 herniation 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 otherwise specified) 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 Multiorgan failure Multisystem organ failure Myocardial infarction Necrotizing soft-tissue infection Old age Open (or closed) head injury Pancytopenia Paralysis 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 tachycardia Volume depletion 32 If t h e cer t ifier is u n a b le t o d et er m in e t h e et iology of a p r oces s s u ch a s t h os e s h own a b ove, t h e p r oces s m u s t b e qu a lified a s b ein g of a n u n k n own , u n d et er m in ed , p r ob a b le, p r es u m ed , or u n s p ecified et iology s o it is clea r t h a t a d is t in ct et iology wa s n ot in a d ver t en t ly or ca r eles s ly om it t ed . Th e followin g con d it ion s a n d t yp es of d ea t h m igh t s eem t o b e s p ecific or n a t u r a l. However, wh en t h e m ed ica l h is t or y is exa m in ed fu r t h er it m a y b e fou n d t o b e com p lica t ion s of a n in ju r y or p ois on in g (p os s ib ly occu r r in g lon g a go). S u ch ca s es s h ou ld b e r ep or t ed t o t h e m ed ica l exa m in er or cor on er. Asphyxia Bolus Choking Drug or alcohol overdose/drug or 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 Additional resources In a d d it ion t o t h e s er ies of h a n d b ook s , a d d it ion a l r es ou r ces in clu d e m a n u a ls , gu id elin es , a n d Web s it es (7 -1 5 ). Res ou r ces on com p let in g d ea t h cer t ifica t es s h ou ld b e k ep t wit h or n ea r b la n k d ea t h cer t ifica t es for ea s y r efer en ce. Ad d it ion a l cop ies of gover n m en t -p r od u ced r es ou r ces a r e a va ila b le fr om t h e S t a t e vit a l s t a t is t ics offices , t h e Na t ion a l Cen t er for Hea lt h S t a t is t ics , a n d t h e In t er n et a t h t t p :/ / www.cd c.gov/ n ch s (u n d er vit a l s t a t is t ics , m or t a lit y, wr it in g ca u s e-of-d ea t h s t a t em en t s ). 33 Completing Other Items on the Death Certificate These instructions pertain to the 2003 revision of the U.S. Standard Certificate of Death. NAME OF DECEDENT: For use by physician or institution Th e left -h a n d m a r gin of t h e cer t ifica t e con t a in s a lin e wh er e t h e p h ys icia n or h os p it a l ca n wr it e in t h e n a m e of t h e d eced en t . Th is a llows t h e h os p it a l t o a s s is t in com p let in g t h e d ea t h cer t ifica t e b efor e t h e b od y is r em oved b y t h e fu n er a l d ir ect or. However, b eca u s e t h e fu n er a l d ir ect or is r es p on s ib le for com p let ion of t h e p er s on a l in for m a t ion a b ou t t h e d eced en t a n d b eca u s e t h e h os p it a l fr equ en t ly d oes n ot h a ve t h e com p let e lega l n a m e of t h e d eced en t , t h e h os p it a l or p h ys icia n s h ou ld en t er t h e n a m e t h ey h a ve for t h e d eced en t in t h is it em . Th e fu n er a l d ir ect or will t h en en t er t h e fu ll lega l n a m e in it em 1 . 14. PLACE OF DEATH (Check only one; see instructions) Ch eck t h e t yp e of p la ce wh er e t h e d eced en t wa s p r on ou n ced d ea d . Hospital deaths If t h e d eced en t wa s p r on ou n ced d ea d in a h os p it a l, ch eck t h e b ox in d ica t in g t h e d eced en t 's s t a t u s a t t h e h os p it a l: In p a t ien t , E m er gen cy Room / Ou tp a tien t (ER) or Dea d on Arriva l (DOA). Hos p ita ls a r e licen s ed in s titu tion s p r ovid in g p a t ien t s d ia gn os t ic a n d t h er a p eu t ic s er vices b y a m ed ica l s t a ff. Nonhospital deaths If t h e d eced en t wa s p r on ou n ced d ea d s om ewh er e els e, ch eck t h e b ox in d ica t in g wh et h er p r on ou n cem en t occu r r ed a t a Hos p ice fa cilit y, Nu r s in g h om e/ Lon g-t er m ca r e fa cilit y, Deced en t 's h om e, or ot h er loca t ion . Hos p ice fa cilit y r efer s t o a licen s ed in s t it u t ion p r ovid in g h os p ice ca r e (e.g., p a llia t ive a n d s u p p or t ive ca r e for t h e d yin g), n ot t o h os p ice ca r e t h a t m igh t b e p r ovid ed in a n u m b er of d iffer en t s et t in gs , in clu d in g a p a t ien t 's h om e. 34 If d ea t h wa s p r on ou n ced a t a licen s ed lon g-t er m ca r e fa cilit y, ch eck t h e b ox t h a t in d ica t es Nu r s in g h om e/ Lon g t er m ca r e fa cilit y. A lon g-t er m ca r e fa cilit y is n ot a h os p it a l, b u t p r ovid es p a t ien t ca r e b eyon d cu s t od ia l ca r e (e.g., n u r s in g h om e, s k illed n u r s in g fa cilit y, lon g-t er m ca r e fa cilit ies , con va les cen t ca r e fa cilit y, ext en d ed ca r e fa cilit y, in t er m ed ia t e ca r e fa cilit y, r es id en t ia l ca r e fa cilit y, con gr ega t e ca r e fa cilit y). If d ea t h wa s p r on ou n ced in t h e d eced en t 's h om e, ch eck t h e b ox t h a t in d ica t es d eced en t 's h om e. A d eced en t 's h om e in clu d es in d ep en d en t livin g u n it s in clu d in g p r iva t e h om es , a p a r t m en t s , b u n ga lows , a n d cot t a ges . If d ea th wa s p r on ou n ced a t a licen s ed a m b u la tor y/ s u r gica l cen ter, or p h a n a ge, p r is on wa r d , p u b lic b u ild in g, b ir t h in g cen t er, fa cilit ies offer in g h ou s in g a n d cu s t od ia l ca r e, b u t n ot p a t ien t ca r e (e.g., b oa r d a n d ca r e h om e, gr ou p h om e, cu s t od ia l ca r e fa cilit y, fos t er h om e), ch eck ''Ot h er (S p ecify).'' If ''Ot h er (S p ecify)'' is ch eck ed , s p ecify wh er e d ea t h wa s lega lly p r on ou n ced , s u ch a s a p r is on wa r d , p h ys icia n 's office, t h e h igh wa y wh er e a t r a ffic a ccid en t occu r r ed , a ves s el, or p h a n a ge, gr ou p h om e, or a t wor k . If t h e p la ce of d ea t h is u n k n own , b u t t h e b od y is fou n d in a S t a t e, en t er t h e p la ce wh er e t h e b od y is fou n d a s t h e p la ce of d ea t h . 15. FACILITY NAME (If not an institution, give street and number) Institution deaths If t h e d ea t h occu r r ed in a h os p it a l, en t er t h e fu ll n a m e of t h e h os p it a l. If d ea t h occu r r ed en r ou t e t o or on a r r iva l a t a h os p it a l, en t er t h e fu ll n a m e of t h e h os p it a l. Dea t h s t h a t occu r in a n a m b u la n ce or em er gen cy s qu a d veh icle en r ou t e t o a h os p it a l fa ll in t h is ca t egor y. If t h e d ea t h occu r r ed in a n ot h er t yp e of in s t it u t ion s u ch a s a n u r s in g h om e, en t er t h e n a m e of t h e in s t it u t ion wh er e t h e d eced en t d ied . Noninstitution deaths If t h e d ea t h occu r r ed a t h om e, en t er t h e h ou s e n u m b er a n d s t r eet n a m e. If t h e d ea t h occu r r ed a t s om e p la ce ot h er t h a n t h os e d es cr ib ed a b ove, en t er t h e n u m b er a n d s t r eet n a m e of t h e p la ce or b u ild in g (if a t a b u ild in g) wh er e t h e d eced en t d ied . If t h e d ea t h occu r r ed on a m ovin g con veya n ce, en t er t h e n a m e of t h e ves s el, for exa m p le, S.S. Olive Seas (a t s ea ) or ''E a s t er n Air lin es Fligh t 2 9 6 (in fligh t ).'' 35 16. CITY OR TOWN, STATE, AND ZIP CODE E n t er t h e n a m e of t h e cit y, t own , villa ge, or loca t ion , S t a t e, a n d zip cod e wh er e d ea t h occu r r ed . 17. COUNTY OF DEATH E n t er t h e n a m e of t h e cou n t y of t h e in s t it u t ion or a d d r es s given in it em 1 5 wh er e d ea t h occu r r ed . If t h e d ea t h occu r r ed on a m ovin g con veya n ce in t h e Un it ed S t a t es a n d t h e b od y is fir s t r em oved fr om t h e con veya n ce in t h is S t a t e, com p let e a d ea t h cer t ifica t e a n d en t er a s t h e p la ce of d ea t h t h e a d d r es s wh er e t h e b od y wa s fir s t r em oved fr om t h e con veya n ce. If t h e d ea t h occu r r ed on a m ovin g con veya n ce in in t er n a t ion a l wa t er s , in t er n a t ion a l a ir s p a ce, or in a for eign cou n t r y or it s a ir s p a ce, a n d t h e b od y is fir s t r em oved fr om t h e con veya n ce in t h is S t a t e, r egis t er t h e d ea t h in t h is S ta te, b u t en t er th e a ctu a l p la ce of d ea th in s ofa r a s ca n b e d eter m in ed . These items are used to identify the place of death to determine who has jurisdiction for deaths that legally require investigation by a medical examiner or coroner. These items are also used for research and statistics comparing hospital and nonhospital deaths. Valuable information is also provided for health planning and the utilization of health facilities. Items on when death occurred It em s 2 4 a n d 2 5 a n d 2 9 -3 1 s h ou ld a lwa ys b e com p let ed . If t h e fa cilit y u s es a s ep a r a t e p r on ou n cer or ot h er p er s on t o in d ica t e t h a t d ea t h h a s t a k en p la ce wit h a n ot h er p er s on m or e fa m ilia r wit h t h e ca s e com p let in g t h e r em a in d er of t h e m ed ica l p or t ion of t h e d ea t h cer t ifica t e, t h e pronouncer com p let es It em s 2 4 -2 8 . In a ll ot h er ca s es , t h e certifier com p let es It em s 2 4 , 2 5 , 2 9 -3 7 , a n d 4 5 -4 9 , a n d It em s 2 6 -2 8 a r e left b la n k . 24. DATE PRONOUNCED DEAD (Month, Day, and Year) E n t er t h e exa ct m on t h , d a y, a n d fou r -d igit yea r t h a t t h e d eced en t wa s p r on ou n ced d ea d . Com p let e t h is it em even wh en it is t h e s a m e a s It em 2 9 , t h e a ct u a l or p r es u m ed d a t e. E n t er t h e fu ll n a m e of t h e m on t h --J a n u a r y, Feb r u a r y, Ma r ch , et c. Do n ot u s e a n u m b er or a b b r evia t ion t o d es ign a t e t h e m on t h . This is used to identify the date the decedent was legally pronounced dead. This information is very helpful in those cases where a body of a person who has been dead for some time is found and the death is pronounced by a medical examiner or coroner. 36 25. TIME PRONOUNCED DEAD Enter the exact time (hour and minute using a 24-hour clock) the decedent was pronounced dead according to local time. If daylight saving time is the official prevailing time where death occurs, it should be used to record the time of death. Be sure to indicate the time using a 24-hour clock. 24-hour clock 0000 (medical facilities); 2400 (military facilities) 0100 0200 0300 0400 0500 0600 0700 0800 0900 1000 1100 1200 1300 1400 1500 1600 1700 1800 1900 2000 2100 2200 2300 12-hour clock 12 midnight 1:00 a.m. 2:00 a.m. 3:00 a.m. 4:00 a.m. 5:00 a.m. 6:00 a.m. 7:00 a.m. 8:00 a.m. 9:00 a.m. 10:00 a.m 11:00 a.m. 12 noon 1:00 p.m. 2:00 p.m. 3:00 p.m. 4:00 p.m. 5:00 p.m. 6:00 p.m. 7:00 p.m. 8:00 p.m. 9:00 p.m. 10:00 p.m. 11:00 p.m A death that occurs at 2400 or 0000 midnight belongs to the start of the new day. One minute after 12 midnight is entered as 0001 of the new day. If the exact time of death is unknown, the time should be approximated by the person who pronounces the body dead. ''Approx'' should be placed before the time. 26-28 PRONOUNCING PHYSICIAN ONLY Items 26-28 are to be completed only when the physician responsible for completing the medical certification of cause of death is not available at the time of death to certify the cause of death and when State law provides for a pronouncing physician. In this situation, a pronouncing physician is the person who determines that the decedent is legally dead, but who was not in charge of the patient's care for the illness or condition that resulted 37 in d ea t h . Th is h os p it a l p h ys icia n cer t ifies t o t h e fa ct a n d t im e of d ea t h (It em s 2 4 a n d 2 5 ) a n d s ign s a n d d a t es t h e d ea t h cer t ifica t e (It em s 2 6 -2 8 ) s o t h e b od y ca n b e r elea s ed t o t h e fu n er a l d ir ect or wh en t h e a t t en d in g p h ys icia n is n ot a va ila b le. Th e a t t en d in g p h ys icia n is s t ill r es p on s ib le for com p let in g t h e ca u s e-of-d ea t h s ect ion (It em 3 2 ). S ee Pa r t II of t h is h a n d b ook for a m or e d et a iled d is cu s s ion of t h e com p let ion of It em 3 2 . COMPLE TE ITE MS 2 6 -2 8 ONLY WHE N CE R TIFYING PHYS ICIAN IS NOT AVAILABLE AT TIME OF DE ATH CE R TIFY CAUS E OF DE ATH 26. SIGNATURE OF PERSON PRONOUNCING DEATH (Only when applicable) Ob t a in t h e s ign a t u r e a n d t h e d egr ee or t it le of t h e p h ys icia n wh o p r on ou n ces d ea t h in in k . Th is p h ys icia n cer t ifies t o t h e t im e, d a t e, a n d p la ce of d ea t h on ly. Ru b b er s t a m p s or fa cs im ile s ign a t u r es a r e n ot p er m it t ed on p a p er cer t ifica t es . J u r is d ict ion s wit h elect r on ic d ea t h cer t ifica t es m a y h a ve ot h er wa ys t o a u t h en t ica t e t h e cer t ifica t ion t h a n b y u s in g a s ign a t u r e. 27. LICENSE NUMBER (Only when applicable) E n t er t h e S t a t e licen s e n u m b er of t h e p h ys icia n wh o p r on ou n ces d ea t h . 28. DATE SIGNED (Month, Day, and Year) (Only when applicable) E n t er t h e exa ct m on t h , d a y, a n d yea r t h a t t h e p r on ou n cin g p h ys icia n s ign s t h e cer t ifica t e. Do n ot u s e a n u m b er t o d es ign a t e t h e m on t h . IF THE ATTE NDING PHYS ICIAN IS AVAILABLE TO CE R TIFY THE FACT OF DE ATH, ITE MS 2 6 -2 8 S HOULD NOT BE COMPLE TE D; IF AVAILABLE , THE ATTE NDING PHYS ICIAN S HOULD COMPLE TE ITE MS 2 4 , 2 5 , 2 9 -3 7 , AND 4 5 -4 9 AS BOTH PRONOUNCING AND CE R TIFYING PHYS ICIAN. This information is useful for the quality control program indicating that the medical certification was provided by the attending physician. Item s 2 4 a n d 2 5 m u s t b e com p leted b y th e p er s on wh o p r on ou n ces d ea th -- t h e p r on ou n cin g p h ys icia n , p r on ou n cin g/ cer t ifyin g p h ys icia n , or m ed ica l exa m in er or cor on er. 29. ACTUAL OR PRESUMED DATE OF DEATH (Month, Day, and Year) E n t er t h e exa ct m on t h , d a y, a n d yea r t h a t d ea t h occu r r ed . E n t er t h e fu ll n a m e of t h e m on t h --J a n u a r y, Feb r u a r y, Ma r ch , et c. Do n ot u s e a n u m b er or a b b r evia t ion t o d es ign a t e t h e m on t h . 38 Pay particular attention to the entry of month, day, and year when the death occurs around midnight or December 31. Consider a death at midnight to have occurred at the beginning of the next day rather than the end of the previous day. For example, the date for a death that occurs at 11:59 p.m. or 2359 on December 31 should be recorded as December 31 while those occurring the next minute 0000 should be recorded as January 1. If the exact date of death is unknown, it should be approximated by the person completing the medical certification. ''Approx'' should be placed before the date. If date cannot be determined by approximating, the date found should be entered and identified as such. This item is used in conjunction with the hour of death to establish the exact time of death of the decedent. Epidemiologists also use date of death in conjunction with the cause-of-death section for research on intervals between injuries, onset of conditions, and death. 30. ACTUAL OR PRESUMED TIME OF DEATH Enter the exact time (hour and minute using a 24-hour clock) of death according to local time. If daylight saving time is the official prevailing time where death occurs, it should be used to record the time of death. Be sure to indicate the time using a 24-hour clock. 24-hour clock 0000 (medical facilities); 2400 (military facilities) 0100 0200 0300 0400 0500 0600 0700 0800 0900 1000 1100 1200 1300 1400 1500 1600 1700 1800 1900 2000 2100 2200 2300 12-hour clock 12 midnight 1:00 a.m. 2:00 a.m. 3:00 a.m. 4:00 a.m. 5:00 a.m. 6:00 a.m. 7:00 a.m. 8:00 a.m. 9:00 a.m. 10:00 a.m 11:00 a.m. 12 noon 1:00 p.m. 2:00 p.m. 3:00 p.m. 4:00 p.m. 5:00 p.m. 6:00 p.m. 7:00 p.m. 8:00 p.m. 9:00 p.m. 10:00 p.m. 11:00 p.m 39 A d ea t h t h a t occu r s a t 2 4 0 0 or 0 0 0 0 m id n igh t b elon gs t o t h e s t a r t of t h e n ew d a y. On e m in u t e a ft er 1 2 m id n igh t is en t er ed a s 0 0 0 1 of t h e n ew d a y. If t h e exa ct t im e of d ea t h is u n k n own , t h e t im e s h ou ld b e a p p r oxim a t ed b y t h e p er s on wh o cer t ifies t h e d ea t h . ''Ap p r ox'' s h ou ld b e p la ced b efor e t h e t im e. This item establishes the exact time of death, which is important in inheritance cases when there is a question of who died first. This is often important in the case of multiple deaths in the same family. 31. WAS MEDICAL EXAMINER OR CORONER CONTACTED? E n t er ''Yes '' if t h e m ed ica l exa m in er or cor on er wa s con t a ct ed in r efer en ce t o t h is ca s e. Ot h er wis e en t er ''No.'' Do n ot lea ve t h is it em b la n k . In ca s es of a ccid en t , s u icid e, or h om icid e, t h e m ed ica l exa m in er or cor on er m u s t b e n ot ified . This item records whether the medical examiner or coroner was informed when the circumstances require such action. In such cases, the physician must ensure that this is done. 32. CAUSE OF DEATH Det a iled in s t r u ct ion s for t h is it em , t oget h er wit h ca s e r ecor d s , a r e con t a in ed in t h e s ect ion on Med ica l Cer t ifica t ion of Dea t h in t h is h a n d b ook . Th es e it em s a r e t o b e com p let ed b y t h e a t t en d in g p h ys icia n or m ed ica l exa m in er or cor on er cer t ifyin g or r ep or t in g h is or h er op in ion on t h e ca u s e of d ea t h . 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. Th e ca u s e of d ea t h m ea n s t h e d is ea s e, a b n or m a lit y, in ju r y, or p ois on in g t h a t ca u s ed t h e d ea t h , n ot t h e m ech a n is m of d ea t h , s u ch a s ca r d ia c or r es p ir a t or y a r r es t , s h ock , or h ea r t fa ilu r e. 40 In Pa r t I, t h e im m ed ia t e ca u s e of d ea t h (fin a l d is ea s e or con d it ion r es u lt in g in d ea t h ) is r ep or t ed on lin e (a ). An t eced en t con d it ion s , if a n y, t h a t ga ve r is e t o t h e ca u s e a r e r ep or t ed on lin es (b ), (c), a n d (d ). Th e u n d er lyin g ca u s e (d is ea s e or in ju r y t h a t in it ia t ed even t s r es u lt in g in d ea t h ) s h ou ld b e r ep or t ed on t h e la s t lin e u s ed in Pa r t I. No en t r y is n eces s a r y on lin es (b ), (c), a n d (d ) if t h e im m ed ia t e ca u s e of d ea t h on lin e (a ) d es cr ib es com p let ely t h e s equ en ce of even t s . ONLY ONE CAUS E S HOULD BE E NTE RE D ON A LINE . Pr ovid e t h e b es t es t im a t e of t h e in t er va l b et ween t h e on s et of ea ch con d it ion a n d d ea t h . Do n ot lea ve t h e s p a ce for t h e in t er va l b la n k ; if u n k n own , s o s p ecify. Part II. Enter other significant conditions contributing to death but not resulting in the underlying cause given in Part I. In Pa r t II, en t er ot h er im p or t a n t d is ea s es or con d it ion s t h a t con t r ib u t ed t o d ea t h b u t d id n ot r es u lt in t h e u n d er lyin g ca u s e of d ea t h given in Pa r t I. Cause of death is the most important statistical research item on the death certificate. It provides medical information that serves as a basis for describing trends in human health and mortality and for analyzing the conditions leading to death. Mortality statistics provide a basis for epidemiological studies that focus on leading causes of death by age, race, or sex (for example, HIV, heart disease, and cancer). They also provide a basis for research in disease etiology and evaluation of diagnostic techniques, which in turn lead to improvements in patient care. All conditions reported are important and are analyzed. For example, analyses may examine associations between conditions reported on the same death certificates such as types of conditions reported in combination with hepatitis. 33. WAS AN AUTOPSY PERFORMED? E n t er ''Yes '' if a p a r t ia l or com p let e a u t op s y wa s p er for m ed . Ot h er wis e en t er ''No.'' An autopsy is important in giving additional insight into the conditions that lead to death. This additional information is particularly important in arriving at the immediate and underlying causes when the cause is not immediately clear. 41 34. WERE AUTOPSY FINDINGS AVAILABLE TO COMPLETE THE CAUSE OF DEATH? E n t er ''Yes '' if t h e a u t op s y fin d in gs wer e a va ila b le a t t h e t im e t h a t ca u s e of d ea t h wa s d et er m in ed . Ot h er wis e en t er ''No.'' Lea ve t h is it em b la n k if n o a u t op s y wa s p er for m ed . This information assists in determining whether, for the 9 percent of cases for which an autopsy is done, the information was available to assist in determining the cause of death. Knowing whether the autopsy results were available for determining the cause of death gives insight into the quality of the cause-of-death data. 35. DID TOBACCO USE CONTRIBUTE TO DEATH? Ch eck ''Yes '' if, in the physician's opinion, a n y u s e of t ob a cco or t ob a cco exp os u r e con t r ib u t ed t o d ea t h . For exa m p le, t ob a cco u s e m a y con t r ib u t e t o d ea t h s d u e t o em p h ys em a or lu n g ca n cer. Tob a cco u s e a ls o m a y con t r ib u t e t o s om e h ea r t d is ea s e a n d ca n cer s of t h e h ea d a n d n eck . Tob a cco u s e s h ou ld a ls o b e r ep or t ed in d ea t h s d u e t o fir es s t a r t ed b y s m ok in g. Ch eck ''Yes ,'' if in t h e p h ys icia n 's clin ica l ju d gm en t , t ob a cco u s e con t r ib u t ed t o t h is p a r t icu la r d ea t h . Ch eck ''No,'' if, in t h e p h ys icia n 's op in ion , t h e u s e of t ob a cco d id n ot con t r ib u t e t o d ea t h . 36. IF FEMALE, WAS DECEDENT PREGNANT AT TIME OF DEATH OR WITHIN PAST YEAR? If t h e d eced en t is a fem a le, ch eck t h e a p p r op r ia t e b ox in It em 3 6 . If t h e d eced en t is a m a le, lea ve t h e it em b la n k . If t h e fem a le is eit h er t oo old or t oo you n g t o b e fecu n d , ch eck t h e ''Not p r egn a n t wit h in t h e p a s t yea r '' b ox. This information is important in determining the scale of mortality amongst this population and will be of assistance with maternal mortality review programs. 37. MANNER OF DEATH 42 Com p let e t h is it em for a ll d ea t h s . Ch eck t h e b ox cor r es p on d in g t o t h e m a n n er of d ea t h . Dea t h s n ot d u e t o ext er n a l ca u s es s h ou ld b e id en t ified a s ''Na t u r a l.'' Us u a lly, t h es e a r e t h e on ly t yp es of d ea t h s a p h ys icia n will cer t ify. In d ica t e ''Pen d in g in ves t iga t ion '' if t h e m a n n er of d ea t h ca n n ot b e d et er m in ed t o b e a ccid en t , h om icid e, or s u icid e wit h in t h e s t a t u t or y t im e lim it for filin g t h e d ea t h cer t ifica t e. Th is s h ou ld b e ch a n ged la t er t o on e of t h e ot h er t er m s . In d ica t e ''Cou ld n ot b e d et er m in ed '' ONLY wh en it is im p os s ib le t o d et er m in e t h e m a n n er of d ea t h . In cases of accidental death, this information is used to justify the payment of double indemnity on life insurance policies. It is also used to obtain a more accurate determination of cause of death. All d ea t h s d u e t o ext er n a l ca u s es m u s t b e r efer r ed t o t h e m ed ica l exa m in er or cor on er. If t h e m a n n er of d ea t h ch eck ed in It em 3 7 wa s a n yt h in g ot h er t h a n n a t u r a l, It em s 3 8 -4 4 m u s t b e com p let ed . If a s it u a t ion ever a r is es wh er e t h e p h ys icia n m u s t com p let e t h e ca u s e, m a n n er, a n d cir cu m s t a n ces (It em s 3 2 , 3 7 , a n d 3 8 -4 4 ) of d ea t h in a n a ccid en t a l ca s e, p lea s e r efer t o t h e Medical Examiners' and Coroners' Handbook on Death Registration and Fetal Death Reporting. Ca s e h is t or ies wit h p r op er ly com p let ed d ea t h cer t ifica t es a r e a ls o in clu d ed in t h a t h a n d b ook . Th e Na t ion a l As s ocia t ion of Med ica l E xa m in er s h a ve p u t t oget h er a gu id e on h ow m a n n er of d ea t h m a y b e d et er m in ed (6 ). In cer t a in ca s es , t h er e is a con flict b et ween t h e m a n n er of d ea t h p r efer r ed b y t h e m ed ica l exa m in er com m u n it y a n d t h e d is ea s e cla s s ifica t ion . As a r es u lt , it is im p or t a n t t o s p ecify t h e cir cu m s t a n ces in volved s o t h a t b ot h com m u n it ies a r e a b le t o m a k e u s e of t h e in for m a t ion . 38-44 ACCIDENT OR INJURY--To be filled out in all cases of deaths due to injury or poisoning Com p let e t h es e it em s in ca s es wh er e in ju r y ca u s ed or con t r ib u t ed t o t h e d ea t h . All d ea t h s r es u lt in g fr om in ju r y m u s t b e r ep or t ed t o a m ed ica l exa m in er or cor on er, wh o will u s u a lly cer t ify t o t h e ca u s e of d ea t h . However, t h er e m a y b e in s t a n ces in wh ich a m ed ica l exa m in er or cor on er will n ot a s s u m e ju r is d ict ion a n d t h e a t t en d in g p h ys icia n will cer t ify t o a n a ccid en t a l d ea t h . In t h es e ca s es wh en t h e m a n n er of d ea t h is a n yt h in g ot h er t h a n n a t u r a l, t h e a t t en d in g p h ys icia n is t o com p let e It em s 3 8 -4 4 . 43 38. DATE OF INJURY (Month, Day, and Year) Enter the exact month, day, and year that the injury occurred. Enter the full name of the month--January, February, March, etc. Do not use a number or abbreviation to designate the month. The date of injury may not necessarily be the same as the date of death. Estimates may be provided with ''Approx'' placed before the date. 39. TIME OF INJURY Enter the exact time (hour and minute using a 24-hour clock) when the injury occurred, according to local time. If daylight saving time is the official prevailing time where death occurs, it should be used to record the time of death. Be sure to indicate the time using a 24-hour clock. 24-hour clock 0000 (medical facilities); 2400 (military facilities) 0100 0200 0300 0400 0500 0600 0700 0800 0900 1000 1100 1200 1300 1400 1500 1600 1700 1800 1900 2000 2100 2200 2300 12-hour clock 12 midnight 1:00 a.m. 2:00 a.m. 3:00 a.m. 4:00 a.m. 5:00 a.m. 6:00 a.m. 7:00 a.m. 8:00 a.m. 9:00 a.m. 10:00 a.m 11:00 a.m. 12 noon 1:00 p.m. 2:00 p.m. 3:00 p.m. 4:00 p.m. 5:00 p.m. 6:00 p.m. 7:00 p.m. 8:00 p.m. 9:00 p.m. 10:00 p.m. 11:00 p.m If the exact time of death is unknown, the time should be approximated by the person who certifies the death. ''Approx'' should be placed before the time. The date of injury may differ from the date of death. 44 40. PLACE OF INJURY (e.g., Decedent's home, construction site, restaurant, wooded area) E n t er t h e gen er a l t yp e of p la ce (s u ch a s r es t a u r a n t , va ca n t lot , b a s eb a ll field , con s t r u ct ion s it e, office b u ild in g, or d eced en t 's h om e) wh er e t h e in ju r y occu r r ed . DO NOT en t er fir m or or ga n iza t ion n a m es . (For exa m p le, en t er ''fa ct or y,'' not ''S t a n d a r d Ma n u fa ct u r in g, In c.'') 41. INJURY AT WORK? Com p let e if a n yt h in g ot h er t h a n n a t u r a l d is ea s e is m en t ion ed in Pa r t I or Pa r t II of t h e m ed ica l cer t ifica t ion (It em 3 2 ), in clu d in g h om icid es , s u icid es , a n d a ccid en t s or if a n yt h in g ot h er t h a n ''Na t u r a l'' is ch eck ed for m a n n er of d ea t h (It em 3 7 ). Th is in clu d es a ll m ot or veh icle d ea t h s . Th e it em must b e com p let ed for d eced en t s a ges 1 4 yea r s or over a n d m a y b e com p let ed for t h os e les s t h a n 1 4 yea r s of a ge, if wa r r a n t ed . E n t er ''Yes '' if t h e in ju r y occu r r ed a t wor k . Ot h er wis e en t er ''No.'' An in ju r y m a y occu r a t wor k r ega r d les s of wh et h er t h e in ju r y occu r r ed in t h e cou r s e of t h e d eced en t 's ''u s u a l'' occu p a t ion . E xa m p les of in ju r y a t wor k a n d in ju r y n ot a t wor k follow: Injury at work In ju r y wh ile wor k in g or in voca t ion a l t r a in in g on job p r em is es In ju r y wh ile on b r ea k or a t lu n ch or in p a r k in g lot on job p r em is es In ju r y wh ile wor k in g for p a y or com p en s a t ion , in clu d in g a t h om e In ju r y wh ile wor k in g a s a volu n t eer la w en for cem en t officia l et c. In ju r y wh ile t r a velin g on b u s in es s , in clu d in g t o or fr om b u s in es s con t a ct s Injury not at work In ju r y wh ile en ga ged in p er s on a l r ecr ea t ion a l a ct ivit y on job p r em is es In ju r y wh ile a vis it or (n ot on officia l wor k b u s in es s ) t o job p r em is es Hom em a k er wor k in g a t h om em a k in g a ct ivit ies S t u d en t in s ch ool Wor k in g for s elf for n o p r ofit (m owin g ya r d , r ep a ir in g own r oof, h ob b y) Com m u t in g t o or fr om wor k Th es e gu id elin es wer e d evelop ed join t ly b y: Th e Na t ion a l As s ocia t ion for Pu b lic Hea lt h S t a t is t ics a n d In for m a t ion S ys t em s (NAPHS IS ), t h e Na t ion a l In s t it u t e of Occu p a t ion a l S a fet y a n d Hea lt h (NIOS H), t h e Na t ion a l Cen t er for Hea lt h S t a t is t ics (NCHS ), a n d t h e Na t ion a l Cen t er for E n vir on m en t a l Hea lt h a n d In ju r y Con t r ol (NCE HIC). For qu es t ion s con t a ct t h e S t a t e vit a l s t a t is t ics office. 42. LOCATION OF INJURY (Street and Number, City or Town, State, Apartment No., ZIP Code) E n t er t h e com p let e a d d r es s wh er e t h e in ju r y t ook p la ce, in clu d in g ZIP cod e. Fill in a s m a n y of t h e it em s a s is k n own . 43. DESCRIBE HOW INJURY OCCURRED E n t er, in n a r r a t ive for m , a b r ief b u t s p ecific a n d clea r d es cr ip t ion of h ow t h e in ju r y occu r r ed . E xp la in t h e cir cu m s t a n ces or ca u s e of t h e in ju r y, 45 s u ch a s ''fell off la d d er wh ile p a in t in g h ou s e,'' ''d r iver of ca r r a n off r oa d wa y,'' or ''p a s s en ger in ca r in ca r -t r u ck collis ion .'' S p ecify type of gun (e.g., h a n d gu n , h u n t in g r ifle) or type of vehicle (e.g., ca r, b u lld ozer, t r a in , et c.) wh en r eleva n t t o cir cu m s t a n ces . In d ica t e if m or e t h a n on e veh icle wa s in volved ; s p ecify t yp e of veh icle d eced en t wa s in . For m ot or veh icle a ccid en ts , in d ica te wh eth er th e d eced en t wa s a d r iver, p a s s en ger, or p ed es tr ia n . If k n own , in d ica t e wh a t a ct ivit y t h e d eced en t wa s en ga ged in wh en t h e in ju r y occu r r ed (e.g., p la yin g a s p or t , wor k in g for in com e, h a n gin g ou t a t a b a r ). In cases of accidental death, Items 38-43 are used in justifying the payment of double indemnity on life insurance policies. They are also needed for a more accurate determination of causes of death. Information from these items forms the basis of statistical studies of occupational injuries. 44. IF TRANSPORTATION INJURY, SPECIFY: S p ecify r ole of d eced en t (e.g., d r iver, p a s s en ger ) in t h e t r a n s p or t a t ion a ccid en t . ''Dr iver / Op er a t or '' a n d ''Pa s s en ger '' s h ou ld b e d es ign a t ed for m od es ot h er t h a n m ot or veh icles s u ch a s b icycles . ''Ot h er '' a p p lies t o wa t er cr a ft , a ir cr a ft , a n im a l, or p eop le a t t a ch ed t o ou t s id e of veh icles (e.g., ''s u r fer s '') b u t a r e n ot b on a fid e p a s s en ger s or d r iver s . Details will help assign deaths to categories that may be used to assess trends and effectiveness of safety programs. 45-49 CERTIFIER 45. CERTIFIER (Check only one) Th e Cer t ifyin g p h ys icia n is t h e p er s on wh o d et er m in es t h e ca u s e of d ea t h (It em 3 2 ). Th is b ox s h ou ld b e ch eck ed on ly in t h os e ca s es wh en t h e p er s on 46 wh o is com p let in g t h e m ed ica l cer t ifica t ion of ca u s e of d ea t h is n ot t h e p er s on wh o p r on ou n ced d ea t h (It em s 2 4 a n d 2 5 ). Th e cer t ifyin g p h ys icia n is r es p on s ib le for com p let in g It em s 3 2 -4 9 . Th e Pr on ou n cin g & Cer t ifyin g p h ys icia n b ox s h ou ld b e ch eck ed wh en t h e s a m e p er s on is r es p on s ib le for com p let in g It em s 2 4 t h r ou gh 4 9 , t h a t is , wh en t h e s a m e p h ys icia n h a s b ot h p r on ou n ced d ea t h a n d cer t ified t o t h e ca u s e of d ea t h . If t h is b ox is ch eck ed , It em s 2 6 -2 8 s h ou ld b e left b la n k . Th e Med ica l E xa m in er / Cor on er b ox s h ou ld b e ch eck ed wh en in ves t iga t ion is r equ ir ed b y t h e Pos t Mor t em E xa m in a t ion Act a n d t h e ca u s e of d ea t h is com p let ed b y a m ed ica l exa m in er or cor on er. Th e m ed ica l exa m in er or cor on er is t h en r es p on s ib le for com p let in g It em s 2 4 -4 6 . If t h e a t t en d in g p h ys icia n is a va ila b le t o cer t ify t h e fa ct of d ea t h , It em s 2 6 -2 8 s h ou ld n ot b e com p let ed ; t h e a t t en d in g p h ys icia n s h ou ld t h en com p let e It em s 2 4 , 2 5 , 2 9 -3 7 , a n d 4 5 -4 9 a s b ot h p r on ou n cin g a n d cer t ifyin g p h ys icia n . The two-physician certifier concept allows a hospital physician to certify to only the fact and time of death so the body can be released to the funeral director. The attending physician should complete the cause-of-death section. This certification method should result in improved data on cause of death because the physician having the most knowledge about the case completes the cause-of-death section. Signature of certifier Th e p h ys icia n wh o cer t ifies t o t h e ca u s e of d ea t h in It em 3 2 s ign s t h e cer t ifica t e in p er m a n en t b la ck in k . J u r is d ict ion s wit h a n elect r on ic d ea t h cer t ifica t e m a y a llow elect r on ic a u t h en t ica t ion . Th e d egr ee or t it le of t h e p h ys icia n s h ou ld a ls o b e in d ica t ed . Ru b b er s t a m p s or fa cs im ile s ign a t u r es a r e n ot p er m it t ed . 46. NAME, ADDRESS, AND ZIP CODE OF PERSON COMPLETING CAUSE OF DEATH (ITEM 32) Typ e or p r in t t h e fu ll n a m e a n d a d d r es s of t h e p er s on wh os e s ign a t u r e or a u t h en t ica t ion a p p ea r s in It em 4 5 . This information is used by the State office of vital statistics for querying the certifier when a question about cause of death arises. 48. LICENSE NUMBER E n t er t h e S t a t e licen s e n u m b er of t h e p h ys icia n wh o s ign s or a u t h en t ica t es t h e cer t ifica t e in It em 4 5 . 47 This number assists in State quality control programs when it is necessary to contact the certifier for additional information concerning the death. 49. DATE CERTIFIED (Month, Day, and Year) E n t er t h e exa ct m on t h , d a y, a n d yea r t h a t t h e cer t ifier s ign ed t h e cer t ifica t e. E n t er t h e fu ll n a m e of t h e m on t h --J a n u a r y, Feb r u a r y, Ma r ch , et c. Do n ot u s e a n u m b er or a n a b b r evia t ion t o d es ign a t e t h e m on t h . These items are of legal value in attesting that the medical certification was completed and signed within the time limit required by statute. 48 References 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. Pa t es RD, S cu lly KW, E in b in d er J S , et a l. Ad d in g va lu e t o clin ica l d a t a b y lin k a ge t o a p u b lic d ea t h r egis t r y. Med in fo 2 0 0 1 . Lon d on . 2 0 0 1 . Na t ion a l Cen t er for Hea lt h S t a t is t ics . Rep or t of t h e p a n el t o eva lu a t e t h e U.S . s t a n d a r d cer t ifica t es . Hya t t s ville, Ma r yla n d . 2 0 0 0 . (Ad d en d a , 2 0 0 1 ). Het zel AM. His t or y a n d or ga n iza t ion of t h e vit a l s t a t is t ics s ys t em . Na t ion a l Cen t er for Hea lt h S t a t is t ics . Hya t t s ville, Ma r yla n d . 1 9 9 7 . Na t ion a l Cen t er for Hea lt h S t a t is t ics . Mod el S t a t e vit a l s t a t is t ics a ct a n d r egu la t ion s : 1 9 9 2 r evis ion . Hya t t s ville, Ma r yla n d : Pu b lic Hea lt h S er vice. 1 9 9 5 . Wor ld Hea lt h Or ga n iza t ion . In t er n a t ion a l s t a t is t ica l cla s s ifica t ion of d is ea s es a n d r ela t ed h ea lt h p r ob lem s , t en t h r evis ion . Gen eva : Wor ld Hea lt h Or ga n iza t ion . 1 9 9 2 . Ha n zlick R, Hu n s a k er III J H, Da vis G J . A gu id e for m a n n er of d ea t h cla s s ifica t ion . NAME . 2 0 0 2 . Acces s ed a t h t t p :/ / www.t h en a m e.or g/ Lib r a r y/ Ma n n er _ of_d ea t h v1 .p d f on 4 / 1 6 / 2 0 0 2 . Na t ion a l Cen t er for Hea lt h S t a t is t ics . In s t r u ct ion s for com p let in g t h e ca u s eof-d ea t h s ect ion of t h e d ea t h cer t ifica t e. Hya t t s ville, Ma r yla n d : Na t ion a l Cen t er for Hea lt h S t a t is t ics . Acces s ed a t h t t p :/ / www.cd c.gov/ n ch s / a b ou t / m a jor / d vs / h a n d b k .h t m on 4 / 1 6 / 2 0 0 2 . Na t ion a l Cen t er for Hea lt h S t a t is t ics . In s t r u ct ion s for com p let in g t h e ca u s eof-d ea t h s ect ion of t h e d ea t h cer t ifica t e for in ju r y a n d p ois on in g. Hya t t s ville, Ma r yla n d : Na t ion a l Cen t er for Hea lt h S t a t is t ics . Acces s ed a t h t t p :/ / www.cd c. gov/ n ch s / a b ou t / m a jor / d vs / h a n d b k .h t m on 4 / 1 6 / 2 0 0 2 . Na t ion a l Cen t er for Hea lt h S t a t is t ics . Pos s ib le s olu t ion s t o com m on p r ob lem s in d ea t h cer t ifica t ion . Hya t t s ville, Ma r yla n d : Na t ion a l Cen t er for Hea lt h S t a t is tics . Acces s ed a t h ttp :/ / www.cd c.gov/ n ch s / a b ou t/ m a jor / d vs / h a n d b k .h tm on 4/ 16/ 2002. Ha n zlick R. Wr it in g ca u s e-of-d ea t h s t a t em en t s . S t . Lou is , MO: Na t ion a l As s oc ia t ion of Me d ic a l E xa m in e r s . Ac c e s s e d a t h t t p :/ / www. t h e n a m e . or g/ Ca u s eDea t h / COD_m a in _p a ge.h t m on 5 / 7 / 2 0 0 2 . Ha n zlick R (E d ). Th e m ed ica l ca u s e-of-d ea t h m a n u a l. Nor t h field , Illin ois : College of Am er ica n Pa t h ologis t s . Ha n zlick R (E d ). Ca u s e-of-d ea t h s t a t em en t s a n d cer t ifica t ion of n a t u r a l a n d u n n a t u r a l d ea t h s . Nor t h field , Illin ois : College of Am er ica n Pa t h ologis t s . 1 9 9 7 . Texa s Dep a r t m en t of Hea lt h . On lin e CME m ed ica l cer t ifica t ion of ca u s e a n d m a n u a l of d ea th . Acces s ed a t h ttp :/ / www.td h .s ta te.tx.u s / p h p ep / cm e/ cm e_d c/ d efa u lt .h t m l on 4 / 2 0 / 2 0 0 2 . 49 1 4 . Na tion a l Cen ter for Hea lth Sta tis tics . Ca u s e-of-d ea th m od u le. Hya tts ville, Ma ryla n d : Na t ion a l Cen t er for Hea lt h S t a t is t ics . Acces s ed a t h t t p :/ / www.cd c.gov/ n ch s / d a t a / d vs / ed c6 .p d f on 4 / 2 0 / 2 0 0 2 . 1 5 . Na t ion a l Cen t er for Hea lt h S t a t is t ics . Mor t a lit y Web p a ge. Hya t t s ville, Ma r yla n d : Na t ion a l Cen t er for Hea lt h S t a t is t ics . Acces s ed a t h t t p :/ / www.cd c.gov/ n ch s / a b ou t / m a jor / d vs / m or t d a t a .h t m on 4 / 2 0 / 2 0 0 2 . 50 Appendixes A. B. Th e U.S . S t a n d a r d Cer t ifica t e of Dea t h . . . . . . . . . . . . . . . . . . . . . . . . Th e Vit a l S t a t is t ics Regis t r a t ion S ys t em in t h e Un it ed S t a t es . . . 52 54 51 Appendix A U.S. Standard Certificate of Death S, SIANDARD OF DEATH LOCAL FILE NO. STATE FILE NOJann Lmnave =aim=v 123-asfavas Mase 4, 5 Jtiwwt-i>>~ 5 mm, 52 New me iimf Apmzs Fi-mick i emxuw me was View mac 202124934 iwmmt i v- im gg -mm M.m_ 58 w.M~i mUiw..ii~ IQ 1 in 3 5 sianmy Paimcr 3_1 ma ,i i . 3. wmwfi . 2 om ew on . mimi-\, . .2i2~12s>> Wife .f~.w E,Wf_i,,iv 5 im WW iwemwf, fm i, mv. MM i/imfem Mcmanm Hes;-war Frederick 5? Ae 1 I Fvsdanck some ami sem mmgfai imma, we mam same: frederick, Maryland zuziswas wit HF .. Smit, sf witiuge, Robert J. Boone 256911 24.2, WST BE Ev PEQSQN ~3 wrio Pnonounuas on DEATH 'me 25 av -1 mm Kwan Jun. zooMi.-awk |52 my miinmw winswi I wiv; W, Q., mai iimmiim Cm Qsiwe neanmme "ueafuiar 1 dag laik," im ,i,m'm 6 on-an-cismemic nam disease .H., Jiausisx iviail-ins, -M--it K, 5 MW EWMW iw niwm I 1 UMW wh., at 2: iwitu-mu-v Au MLW "ima isei it N6 We GWQM, me 4 wiww Euwm Maimev,-sm; za Pane: Uwe, mrxenw miamiana 29855-Gm; rt FUNERAL RECT os cawnnen As menus: nuuasa 4: wunwm 1299654 June 22 2003 ew- Sw, runes, vase Ju; nscenewrs usuu occupfmow Pumnc :accuuntam Wm or wma nv mp 1559; wnmwum nu ww- .vm fsrb. mr 15mm awfum rwmmu Mm qu mnuwsmn sa cm ms June Afmm Jana mme cum. swim ww-U Mr. Q.. nw As, Wm "mr SSTL Us -5 EWG Q, md-WQ aww. PM 5. v-Dmmim ws wr -wwAppendix B The Vital Statistics Registration System in the United States Th e r egis t r a t ion of b ir t h s , d ea t h s , fet a l d ea t h s , a n d ot h er vit a l even t s 1 in t h e Un it ed S t a t es is a S t a t e a n d loca l fu n ct ion . Th e civil la ws of ever y S t a t e p r ovid e for a con t in u ou s , p er m a n en t , a n d com p u ls or y vit a l r egis t r a t ion s ys t em . E a ch s ys t em d ep en d s t o a ver y gr ea t ext en t u p on t h e con s cien t iou s effor t s of t h e p h ys icia n s , h os p it a l p er s on n el, fu n er a l d ir ect or s , cor on er s , a n d m ed ica l exa m in er s in p r ep a r in g or cer t ifyin g in for m a t ion n eed ed t o com p let e t h e or igin a l r ecor d s . For a gr a p h ic p r es en t a t ion of t h e r egis t r a t ion s ys t em , s ee t h e a ccom p a n yin g ch a r t , ''Th e Vit a l S t a t is t ics Regis t r a t ion S ys t em in t h e Un it ed S t a t es .'' Mos t S t a t es a r e d ivid ed geogr a p h ica lly in t o loca l r egis t r a t ion d is t r ict s or u n it s t o fa cilit a t e t h e collect ion of vit a l r ecor d s . A d is t r ict m a y b e a t own s h ip , villa ge, t own , cit y, cou n t y, or ot h er geogr a p h ic a r ea or a com b in a t ion of t wo or m or e of t h es e a r ea s . In s om e S t a t es , h owever, t h e la w p r ovid es t h a t r ecor d s of b ir t h , d ea t h , a n d / or fet a l d ea t h b e s en t d ir ect ly fr om t h e r ep or t in g s ou r ce (h os p it a l, p h ys icia n , or fu n er a l d ir ect or ) t o t h e S t a t e vit a l s t a t is t ics office. In t h is s ys t em , fu n ct ion s n or m a lly p er for m ed b y a loca l r egis t r a t ion officia l a r e a s s u m ed b y t h e s t a ff of t h e S t a t e office. In S t a t es wit h a loca l r egis t r a r s ys t em , t h e loca l r egis t r a r collect s t h e r ecor d s of even t s occu r r in g in h is or h er a r ea a n d t r a n s m it s t h em t o t h e S t a t e vit a l s t a t is t ics office. Th e loca l r egis t r a r is r equ ir ed t o s ee t h a t a com p let e cer t ifica t e is filed for ea ch even t occu r r in g in t h a t d is t r ict . In m a n y S t a t es , t h is officia l a ls o h a s t h e d u t y of is s u in g b u r ia l-t r a n s it p er m it s t o a u t h or ize t h e d is p os it ion of d ea d h u m a n b od ies . In m a n y S t a t es , t h is officia l is a ls o r equ ir ed t o k eep a file of a ll even t s occu r r in g wit h in h is or h er d is t r ict a n d , if a u t h or ized b y S t a t e la w a n d s u b ject t o t h e r es t r ict ion s on is s u a n ce of cop ies a s s p ecified b y t h e la w, m a y b e p er m it t ed t o is s u e cop ies of t h es e r ecor d s . 1 Vital events are defined as live births, deaths, fetal deaths, marriages, divorces, and induced terminations of pregnancy, together with any change in civil status that may occur during an individual's lifetime. 54 Th e S t a t e vit a l s t a t is t ics office in s p ect s ea ch r ecor d for p r om p t n es s of filin g, com p let en es s , a n d a ccu r a cy of in for m a t ion ; qu er ies for m is s in g or in con s is t en t in for m a t ion ; n u m b er s t h e r ecor d s ; p r ep a r es in d exes ; p r oces s es t h e r ecor d s ; a n d s t or es t h e d ocu m en t s for p er m a n en t r efer en ce a n d s a fek eep in g. S t a t is t ica l in for m a t ion fr om t h e r ecor d s is t a b u la t ed for u s e b y S t a t e a n d loca l h ea lt h d ep a r t m en t s , ot h er gover n m en t a l a gen cies , a n d va r iou s p r iva t e a n d volu n t a r y or ga n iza t ion s . Th e d a t a a r e u s ed t o eva lu a t e h ea lt h p r ob lem s a n d t o p la n p r ogr a m s a n d s er vices for t h e p u b lic. An im p or t a n t fu n ct ion of t h e S t a t e office is t o is s u e cer t ified cop ies of t h e cer t ifica t es t o in d ivid u a ls in n eed of s u ch r ecor d s a n d t o ver ify t h e fa ct s of b ir t h a n d d ea t h for a gen cies r equ ir in g lega l evid en ce of s u ch fa ct s . Th e Cen t er s for Dis ea s e Con t r ol a n d Pr even t ion 's Na t ion a l Cen t er for Hea lt h S t a t is t ics (NCHS ) is ves t ed wit h t h e a u t h or it y for a d m in is t er in g t h e vit a l s t a t is t ics fu n ct ion s a t t h e n a t ion a l level (3 ). E lect r on ic d a t a files d er ived fr om in d ivid u a l r ecor d s r egis t er ed in t h e S t a t e offices or, in a few ca s es , cop ies of t h e in d ivid u a l r ecor d s t h em s elves , a r e t r a n s m it t ed t o NCHS . Fr om t h es e d a t a , m on t h ly, a n n u a l, a n d s p ecia l s t a t is t ica l r ep or t s a r e p r ep a r ed for t h e Un it ed S t a t es a s a wh ole a n d for t h e com p on en t p a r t s --cit ies , cou n t ies , S t a t es , a n d r egion s --b y va r iou s ch a r a ct er is t ics s u ch a s s ex, r a ce, a n d ca u s e of d ea t h . Th es e s t a t is t ics a r e es s en t ia l in t h e field s of s ocia l welfa r e, p u b lic h ea lt h , a n d d em ogr a p h y. Th ey a r e a ls o u s ed for va r iou s a d m in is t r a t ive p u r p os es , in b ot h b u s in es s a n d gover n m en t . NCHS s er ves a s a foca l p oin t , exer cis in g lea d er s h ip in es t a b lis h in g u n ifor m p r a ct ices t h r ou gh m od el la ws , s t a n d a r d cer t ifica t e for m s , h a n d b ook s , a n d ot h er in s t r u ct ion a l m a t er ia ls for t h e con t in u ed im p r ovem en t of t h e vit a l s t a t is t ics s ys t em in t h e Un it ed S t a t es . 55 The Vital Statistics Registration System in the United States Responsible Person or Agency Hospital authority 56 Funeral director Physician or other professional attendant Birth Certificate 1. Completes entire certificate using mother and facility worksheets. 2. Files certificate with local office or State office per State law. Death Certificate When death occurs in hospital, may initiate preparation of certificate: Completes information on name, date, and place of death; obtains certification of cause of death from physician; and gives certificate to funeral director. NOTE: If the attending physician is unavailable to certify to the cause of death, some States allow a hospital physician to certify to only the fact and time of death. With legal pronouncement of the death and permission of the attending physician, the body can then be released to the funeral director. The attending physician still must complete the cause-of-death section prior to final disposition of the body. 1. Obtains personal facts about decedent and completes certificate. 2. Obtains certification of cause of death from attending physician or medical examiner or coroner. 3. Obtains authorization for final disposition per State law. 4. Files certificate with local office or State office per State law. Completes certification of cause of death and signs certificate. Fetal Death Report 1. Completes entire report using patient and facility worksheets. 2. Obtains cause of fetal death from physician. 3. Obtains authorization for final disposition of fetus. 4. Files report with local office or State office per State law. For in-hospital birth, verifies accuracy of medical information and signs certificate. For out-of-hospital birth, duties are same as those for hospital authority, shown above. ? If fetus is to be buried, the funeral director is responsible for obtaining authorization for final disposition. NOTE: In some States, the funeral director, or person acting as such, is responsible for all duties shown above under hospital authority. Provides cause of fetal death and information not available from the medical records. Local office** (may be local registrar or city or county health department) 1. Verifies completeness and accuracy of certificate and queries incomplete or inconsistent certificates. 2. If authorized by State law, makes copy or index for local use. 3. Sends certificates to State registrar. 1. Verifies completeness and accuracy of certificate and queries incomplete or inconsistent certificates. 2. If authorized by State law, makes copy or index for local use. 3. If authorized by State law, issues authorization for final disposition on receipt of completed certificate. 4. Sends certificates to State registrar. If State law requires routing of fetal death reports through local office, the local office performs the same functions as shown for the birth and death certificate. City and county health departments 1. Use data derived from these records in allocating medical and nursing services. 2. Follow up on infectious diseases. 3. Plan programs. 4. Measure effectiveness of services. 5. Conduct research studies. 1. Queries incomplete or inconsistent information. 2. Maintains files for permanent reference and is the source of certified copies. 3. Develops vital statistics for use in planning, evaluating, and administering State and local health activities and for research studies. 4. Compiles health-related statistics for State and civil divisions of State for use of the health department and other agencies and groups interested in the fields of medical science, public health, demography, and social welfare. 5. Sends data for all events filed to the National Center for Health Statistics. 1. Evaluates quality of State vital statistics data and works with States to assure quality. 2. Compiles national statistical data file and runs edits to fully process data. 3. Prepares and publishes national statistics of births, deaths, and fetal deaths; constructs the official U.S. life tables and related actuarial tables. 4. Conducts health and social research studies based on vital records and on sampling surveys linked to records. 5. Conducts research and methodological studies in vital statistics methods, including the technical, administrative, and legal aspects of vital records registration and administration. 6. Maintains a continuing technical assistance program to improve the quality and usefulness of vital statistics. 7. Provides leadership and coordination in the development of standard certificates and report and model laws. State registrar, office of vital statistics Centers for Disease Control and Prevention, National Center for Health Statistics ** Some States do not have local vital registration offices. In these States, the certificates or reports are transmitted directly to the State office of vital statistics. 57 DHHS Publication No. (PHS) 2003-1108 03-0002 (4/2003)