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Death Certificate Form
Cause-of-death – Background, Examples, and Common Problems
Accurate cause of death information is important
•to the public health community in evaluating and improving the health of all citizens, and
•often to the family, now and in the future, and to the person settling the decedent’s estate.
The cause-of-death section consists of two parts. Part I is for reporting a chain of events leading directly to death, with the immediate cause of death (the final disease, injury, or complication directly causing death) on
line a and the underlying cause of death (the disease or injury that initiated the chain of events that led directly and inevitably to death) on the lowest used line. Part II is for reporting all other significant diseases,
conditions, or injuries that contributed to death but which did not result in the underlying cause of death given in Part I. The cause-of-death information should be YOUR best medical OPINION. A condition can be
listed as “probable” even if it has not been definitively diagnosed.
Examples of properly completed medical certifications
CAUSE OF DEATH (See instructions and examples)
32. PART I. Enter the chain of events--diseases, injuries, or complications--that directly caused the death. DO NOT enter terminal events such as cardiac
arrest, respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional
lines if necessary.
IMMEDIATE CAUSE (Final
disease or condition ---------> a. Rupture of myocardium __________________________________________________________________________________
resulting in death) Due to (or as a consequence of):
Sequentially list conditions, b. Acute myocardial infarction_______________________________________________________________________________
if any, leading to the cause Due to (or as a consequence of):
listed on line a. Enter the
UNDERLYING CAUSE c. Coronary artery thrombosis_______________________________________________________________________________
(disease or injury that Due to (or as a consequence of):
initiated the events resulting
in death) LAST d.
Atherosclerotic coronary artery disease__________________________________________________________________
Approximate interval:
Onset to death
Minutes
6 days
5 years
7 years
33. WAS AN AUTOPSY PERFORMED
Yes No
PART II. Enter other significant conditions contributing to death but not resulting in the underlying cause given in PART I
Diabetes, Chronic obstructive pulmonary disease, smoking
34. WERE AUTOPSY FINDINGS AVAILABLE TO
COMPLETE THE CAUSE OF DEATH Yes No
35. DID TOBACCO USE CONTRIBUTE TO DEATH
Yes Probably
No Unknown
36. IF FEMALE:
Not pregnant within past year
Pregnant at time of death
Not pregnant, but pregnant within 42 days of death
Not pregnant, but pregnant 43 days to 1 year before death
Unknown if pregnant within the past year
37. MANNER OF DEATH
Natural Homicide
Accident Pending Investigation
Suicide Could not be determined
CAUSE OF DEATH (See instructions and examples)
32. PART I. Enter the chain of events--diseases, injuries, or complications--that directly caused the death. DO NOT enter terminal events such as cardiac
arrest, respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional
lines if necessary.
IMMEDIATE CAUSE (Final
disease or condition ---------> a. Aspiration pneumonia_______________________________________________________________
resulting in death) Due to (or as a consequence of):
Sequentially list conditions, b. Complications of coma___________________________________________________________________________________
if any, leading to the cause Due to (or as a consequence of):
listed on line a. Enter the
UNDERLYING CAUSE c. Blunt force injuries________________________________________________________________________________________
(disease or injury that Due to (or as a consequence of):
initiated the events resulting
in death) LAST d. Motor vehicle accident____________________________________________________________________________________
Approximate interval:
Onset to death
2 Days
7 weeks
7 weeks
7 weeks
33. WAS AN AUTOPSY PERFORMED
Yes No
PART II. Enter other significant conditions contributing to death but not resulting in the underlying cause given in PART I
34. WERE AUTOPSY FINDINGS AVAILABLE TO
COMPLETE THE CAUSE OF DEATH Yes No
35. DID TOBACCO USE CONTRIBUTE TO DEATH
Yes Probably
No Unknown
36. IF FEMALE:
Not pregnant within past year
Pregnant at time of death
Not pregnant, but pregnant within 42 days of death
Not pregnant, but pregnant 43 days to 1 year before death
Unknown if pregnant within the past year
37. MANNER OF DEATH
Natural Homicide
Accident Pending Investigation
Suicide Could not be determined
38. DATE OF INJURY
(Mo/Day/Yr) (Spell Month)
August 15, 2003
39. TIME OF INJURY
Approx. 2320
40. PLACE OF INJURY (e.g., Decedent’s home; construction site; restaurant; wooded area)
road side near state highway
41. INJURY AT WORK
Yes No
42. LOCATION OF INJURY: State: Missouri City or Town: near Alexandria
Street & Number: mile marker 17 on state route 46a Apartment No.: Zip Code:
43. DESCRIBE HOW INJURY OCCURRED:
Decedent driver of van, ran off road into tree
44. IF TRANSPORTATION INJURY, SPECIFY:
Driver/Operator
Passenger
Pedestrian
Other (Specify)
Common problems in death certification
The elderly decedent should have a clear and distinct etiological sequence for cause of death, if possible. Terms such as senescence, infirmity, old age, and advanced age have little value for public health or medical
research. Age is recorded elsewhere on the certificate. When a number of conditions resulted in death, the physician should choose the single sequence that, in his or her opinion, best describes the process leading to
death, and place any other pertinent conditions in Part II. If after careful consideration the physician cannot determine a sequence that ends in death, then the medical examiner or coroner should be consulted about
conducting an investigation or providing assistance in completing the cause of death.
The infant decedent should have a clear and distinct etiological sequence for cause of death, if possible. “Prematurity” should not be entered without explaining the etiology of prematurity. Maternal conditions may have
initiated or affected the sequence that resulted in infant death, and such maternal causes should be reported in addition to the infant causes on the infant’s death certificate (e.g., Hyaline membrane disease due to
prematurity, 28 weeks due to placental abruption due to blunt trauma to mother’s abdomen).
When SIDS is suspected, a complete investigation should be conducted, typically by a medical examiner or coroner. If the infant is under 1 year of age, no cause of death is determined after scene investigation, clinical
history is reviewed, and a complete autopsy is performed, then the death can be reported as Sudden Infant Death Syndrome.
When processes such as the following are reported, additional information about the etiology should be reported:
Abscess
Abdominal hemorrhage
Adhesions
Adult respiratory distress syndrome
Acute myocardial infarction
Altered mental status
Anemia
Anoxia
Anoxic encephalopathy
Arrhythmia
Ascites
Aspiration
Atrial fibrillation
Bacteremia
Bedridden
Biliary obstruction
Bowel obstruction
Brain injury
Brain stem hern tion ia
Carcinogenesis
Carcinomatosis
Cardiac arrest
Cardiac dysrhythmia
Cardiomyopathy
Cardiopulmonary arrest
Cellulitis
Cerebral edema
Cerebrovascular accident
Cerebellar tonsillar herniation
Chronic bedridden state
Cirrhosis
Coagulopathy
Compression fracture
Congestive heart failure
Convulsions
Decubiti
Dehydration
Dementia (when not
otherw e specified) is
Diarrhea
Disseminated intra vascular
coagulopathy
Dysrhythmia
End-stage liver disease
End-stage renal disease
Epidural hematoma
Exsanguination
Failure to thrive
Fracture
Gangrene
Gastrointestinal hemorrhage
Heart failure
Hemothorax
Hepatic failure
Hepatitis
Hepatorenal syndrome
Hyperglycemia
Hyperkalemia
Hypovolemic shock
Hyponatremia
Hypotension
Immunosuppression
Increased intra cranial pressure
Intra cranial hemorrhage
Malnutrition
Metabolic encephalopathy
Multi-organ failure
Multi-system organ failure
Myocardial infarction
Necrotizing soft-tissue infection
Old age
Open (or closed) head injury
Paralysis
Pancytopenia
Perforated gallbladder
Peritonitis
Pleural effusions
Pneumonia
Pulmonary arrest
Pulmonary edema
Pulmonary embolism
Pulmonary insufficiency
Renal failure
Respiratory arrest
Seizures
Sepsis
Septic shock
Shock
Starvation
Subdural hematoma
Subarachnoid hemorrhage
Sudden death
Thrombocytopenia
Uncal herniation
Urinary tract infection
Ventricular fibrillation
Ventricular tachyc rdia a
Volume depletion
If the certifier is unable to determine the etiology of a process such as those shown above, the process must be qualified as being of an unknown, undetermined, probable, presumed, or unspecified etiology so it is clear
that a distinct etiology was not inadvertently or carelessly omitted.
The following conditions and types of death might seem to be specific or natural but when the medical history is examined further may be found to be complications of an injury or poisoning (possibly occurring long ago).
Such cases should be reported to the medical examiner/coroner.
Asphyxia
Bolus
Choking
Drug or alcohol verdose/drug or o
alcohol abuse
Epidural hematoma
Exsanguination
Fall
Fracture
Hip fracture
Hyperthermia
Hypothermia
Open reduction of fracture
Pulmonary emboli
Seizure disorder
Sepsis
Subarachnoid hemorrhage
Subdural hematoma
Surgery
Thermal burns/chemical burns
REV. 11/2003
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