Death Certificate Sample - Free Download
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This HPLHS Prop Document is for entertainment purposes only. It is intended for personal use in role-playing games, and
you are free to customize and print copies for such purposes. Any commercial or illegal use of this digital file or the prop you can
make from it is entirely prohibited. Designed and implemented by Andrew Leman. ©2008 by HPLHS Inc. This work is licensed
under the Creative Commons Attribution-Noncommercial-Share Alike 3.0 United States License. To view a copy of this license,
visit http://creativecommons.org/licenses/by-nc-sa/3.0/us/ or send a letter to Creative Commons, 171 Second Street, Suite 300,
San Francisco, California, 94105, USA. Questions Ask them! firstname.lastname@example.org
This prop is a replica of a genuine vintage death certicate. This is a certied copy of the original docu-
ment, such as might be requested by an investigator after the fact.
Enter information on form using built-in Acrobat form elds (or delete default entries and print prop
“blank”, and enter info using a real typewriter or by hand).
Print on any kind of paper you want. The certicate on page 2 is meant to be printed on plain white or solid
colored paper. The certicate on page 3 is intended for printing on paper with a pre-printed certicate bor-
der, such as can be found at various ofce supply stores.
Add handwritten remarks, rubber stamped dates, and other details for added authenticity. Ideally, an em-
bossed state seal would appear in the lower left corner.
GENERAL INSTRUCTIONS FOR FILLING OUT DEATH CERTIFICATES
The death certicate is designed to identify causes of death and how these conditions related to each other and to the death. The death certicate should
not be used to document the deceased’s entire medical history for posterity. Do not report diseases, injuries, other conditions or circumstances that did
not cause or contribute to death.
Cause(s) of Death. “Cause of death” is a morbid condition or disease process, abnormality, injury or poisoning leading directly or indirectly to death.
Immediate Cause of Death. This is the nal disease or condition that resulted directly in death. Chronologically, it is the last medical condition to occur.
Intermediate Cause(s) of Death. These are conditions that link the immediate cause of death to the underlying cause.
Underlying Cause of Death. This is the disease or injury which “initiated the train of morbid events leading directly to death or the circumstances of the
accident or violence which produced the fatal injury.”
Contributing Cause(s) of Death. “Contributing causes” are diseases, injuries, or other conditions that contributed to the fatal outcome, but did not cause
the condition identied as the underlying cause of death.
Injury. If you report an injury on a death certicate, you are saying it was a cause of death. For purposes of coroner notication, “injury” includes the fol-
LIST OF TERMS THAT DO NOT ADEQUATELY IDENTIFY UNDERLYING CAUSE OF DEATH
Certain terms should not be reported as the only cause(s) of death because they do not identify the underlying cause of death. These terms describe
only symptoms, signs of illness, ill-dened terms, plus secondary conditions. This is not an all-inclusive list.
UNKNOWN AND UNCERTAIN CAUSE OF DEATH
Cause of death is an opinion based upon best available knowledge, but the person who completes the cause of death section and signs the death certi-
cate should be someone who knows the causes of death, including the underlying cause of death. If you know only the probable causes of death, you may
report those. If “unknown” is all you can report, include a statement on the death certicate that explains why the cause of death was unknown.
age, (old) (any)
altered mental status
distress, adult respiratory
failure to thrive
failure, any organ
failure, central nervous system
failure, heart, congestive
failure, multi organ
failure, multi system
gangrene (incl. of site)
increased intracranial pressure
natural causes (unk.)(unspec.)
rapid heart beat
senile debility exhaustion
shutdown of specied organ(s)
slow heart beat
state, chronic bedridden
• trauma from external forces
• other adverse physical effects of externally-caused events
• poisoning, toxicity or overdose of any substance, including
• exposure to natural and environmental forces such as weather
• aspiration, suffocation, strangulation, mechanical obstruction
of breathing including from food, vomitus, secretions (unless
reported due to disease)
• anaphylactic shock and other allergic reactions
• fractures and hematomas from falls or other external forces
• errors and accidents during surgery or other medical care
• starvation, neglect, privation
• contact with venomous or nonvenomous animals, insects, plants,
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