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**SAFER ● HEALTHIER ● PEOPLE**

**Instruction Manual**

**Part 20**

ICD-10 Cause-of-Death Querying, 2006

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U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES

Centers for Disease Control and Prevention

National Center for Health Statistics

**Instruction Manual**

**Part 20**

ICD-10 Cause-of-Death Querying, 2006

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U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES

Centers for Disease Control and Prevention

National Center for Health Statistics

Hyattsville, Maryland

October 2005

Acknowledgments

This instruction manual update was prepared by the Division of Vital
Statistics (DVS) under the general direction of Robert N. Anderson,
Ph.D., Chief of the Mortality Statistics Branch (MSB). Donna L. Hoyert,
Ph.D. (MSB) updated the content; Donna Glenn and Julia Raynor (DVS)
provided review of the instruction manual.

Questions regarding this manual and related processing problems should
be directed to the Mortality Statistics Branch, 3311 Toledo Road, Room
7318, Hyattsville, Maryland 20782 or the Mortality Medical
Classification Branch, Division of Vital Statistics, National Center for
Health Statistics, P.O. Box 12214, Research Triangle Park, North
Carolina 27709. Questions concerning interpretation of mortality data
should be referred to the Mortality Statistics Branch as well.

Major Revisions from Previous Manual

1.  Substituted 1989 certificate forms with 2003 certificate forms

2.  In Appendix A, Table 1, deleted I25.2 and expanded codes to include
    K63.5 and W46.

3.  In Appendix A, Table 2, revised to reflect changes in improbable
    sequence instructions in ICD-10.

Contents

[Section]{.underline} [Page]{.underline}

I. Introduction 1

Basics of medical certification 3

Completing a cause-of-death statement 8

Additional aids 8

II\. Who Carries Out the Query 10

III\. Use of Querying 11

IV\. How Much to Query 12

V. Levels of Querying 13

Priority Level 1 15

Priority Level 2 17

Priority Level 3 17

Priority Level 4 18

Priority Level 5 18

Priority Level 6 19

Fetal death 19

Sample letters 20

VI\. Evaluation of the Query Program 21

References 22

Appendix A- Specific Guidelines for When to Query

Table 1. Priority Levels for querying by ICD-10 Category 23

Order of entry of causes of death

Table 2. Priority Levels for improbable sequences in Part I of the death
certificate 56

Table 3. Priority Levels for durations 62

Table 4. Priority Levels for placement and numbering of conditions 64

Appendix B- Sample Query Letters

Query Letter 1 67

Query Letter 2 71

Query Letter 3 77

Query Letter 4 83

Query Letter 5 89

Query Letter 6 95

Query Letter 7 101

Query Letter 8 107

Query Letter 9 113

Query Letter 10 119

Query Letter 11 145

Appendix C- Infrequent and Rare Causes of Death 151

Appendix D- ICD-10 Codes Selected for Querying for HIV Under Priority
Level 1g 153

**Cause-of-death Querying**

I. Introduction

Cause-of-death querying is a process by which the State health
department contacts the medical certifier who completed the
cause-of-death statement and asks for clarification or further
information so that resulting mortality statistics may be as complete
and accurate as possible. The purpose of querying is two-fold: 1) to
obtain information needed to properly code and classify the cause of
death and 2) to educate the certifier about the proper method of
completing medical certifications of death. Querying is one of the most
important ways to improve the quality of cause-of-death data. It must
therefore, be viewed as an integral part of any State's vital statistics
activity.

This manual has been revised for use with the 2003 U.S. Standard
Certificate of Death and to accommodate some updates to the
*International Classification of Diseases (ICD-10)*. The general
principles and procedures outlined in this manual are the same as in the
previous manual for the Tenth Revision of the ICD. While there are new
items on the certificate related to tobacco, pregnancy, and
transportation injuries that relate to cause, the suggested queries in
this manual are built around the cause-of-death codes. Suggestions
intended to minimize item non-response for the tobacco, pregnancy, and
transportation items are described in the Edit Specifications for the
Death Certificate posted at http://www.cdc.gov/nchs/vital_certs_rev.htm.

Querying is an essential part of the vital registration process (1-2),
so both local registrars and registration personnel in the State health
department should be thoroughly knowledgeable of the laws, procedures,
and other requirements for death registration, querying, and death
certificate amendment. This manual is for those who have the
responsibility for the acceptance and registration of death
certificates, primarily at the State level, and any key staff who have
been designated as responsible for communicating with medical certifiers
about the accuracy and completeness of the cause-of-death statement. The
manual is restricted to the medical certification portion of the record.
Querying procedures for the demographic items on the death certificate
are addressed in a companion manual entitled "Guidelines for
Implementing Field and Query Programs for Registration of Births and
Deaths" (Part 18).

Several levels of querying (levels 1 through 6) are offered in this
manual; a minimal level of querying (Priority Level 1) is necessary to
produce cause-of-death statistics. It is estimated that Level 1 querying
would involve about five percent of a State's death records. However,
higher levels of querying are desirable to ensure specificity and
completeness in the physicians' statements of cause of death. Not every
State will be able to devote the same amount of effort to querying;
however, it is hoped that each registration area will elect to query at
the maximum level consistent with their resources and that all
registration areas will query at least at Priority Level 1. We believe
that previous versions of this manual were of assistance to the States
in developing their own query programs, and we hope that this will as
well.

In developing query procedures, consideration must also be given to the
various uses of the death certificate. Cause-of-death data are important
for statistical uses in the following ways: surveillance, research,
design of public health and medical interventions, and funding decisions
for research and development. Cause-of-death data also have legal and
administrative uses. For example, in the case of accidents, the
additional information requested such as the time and place and the
manner in which the injury occurred can be important in court cases,
insurance claims, etc. The Priority Levels in this manual focus on
improving the usefulness of the data for statistical purposes. States
may wish to query other items that are legally or administratively
important in the particular State.

Normally, cause-of-death queries are directed to the certifier
(attending physician, medical examiner, coroner) who originally provided
the information in the medical section of the death certificate.
However, if the death occurred in a hospital, it is also possible to
obtain additional information from the hospital files to further clarify
the cause of death. For legal reasons, no changes or additions should be
made on the face of the original record without the approval of the
legally designated certifier. If the cause-of-death statement is
substantially changed, the certifying physician should be encouraged to
file an amended certificate. The procedures for filing amended
certificates vary by State.

While querying has an immediate goal of clarifying the cause of death
for individual records, it has a broader goal of educating physicians on
how to complete a medical certification. The following section addresses
some basics on medical certification.

[Basics of medical certification]{.underline}

The medical certification section of the U.S. Standard Certificate of
Death (Figure 1) is designed to collect an underlying cause of death;
that 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. The certification section of
the death certificate follows the format recommended by the World Health
Organization in the *International Classification of Diseases* to
facilitate reporting of the underlying cause of death by listing the
immediate cause of death on the top line of Part I followed by
antecedent causes in proper sequence, with the reported underlying cause
being the last entry in Part I (Figure 2). Part II (Other Significant
Conditions)

Figure 1. **U.S. STANDARD CERTIFICATE OF DEATH**

LOCAL FILE NO. STATE FILE NO.

<table style="width:100%;">
<colgroup>
<col style="width: 5%" />
<col style="width: 3%" />
<col style="width: 11%" />
<col style="width: 2%" />
<col style="width: 3%" />
<col style="width: 1%" />
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<col style="width: 4%" />
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<col style="width: 1%" />
<col style="width: 2%" />
<col style="width: 1%" />
<col style="width: 4%" />
<col style="width: 10%" />
</colgroup>
<tbody>
<tr class="odd">
<td rowspan="14"><blockquote>
<p><strong>NAME OF DECEDENT
____________________________________________</strong></p>
<p><strong>For use by physician or institution</strong></p>
</blockquote></td>
<td rowspan="14"><blockquote>
<p><strong>To Be Completed/ Verified By:</strong></p>
<p><strong>FUNERAL DIRECTOR:</strong></p>
</blockquote></td>
<td colspan="18">1. DECEDENT’S LEGAL NAME (Include AKA’s if any) (First,
Middle, Last)</td>
<td colspan="2">2. SEX</td>
<td colspan="11">3. SOCIAL SECURITY NUMBER</td>
</tr>
<tr class="even">
<td rowspan="2"><p>4a. AGE-Last Birthday</p>
<p>(Years)</p></td>
<td colspan="5">4b. UNDER 1 YEAR</td>
<td colspan="8">4c. UNDER 1 DAY</td>
<td colspan="5" rowspan="2">5. DATE OF BIRTH (Mo/Day/Yr)</td>
<td colspan="12" rowspan="2">6. BIRTHPLACE (City and State or Foreign
Country)</td>
</tr>
<tr class="odd">
<td colspan="2">Months</td>
<td colspan="3">Days</td>
<td>Hours</td>
<td colspan="7">Minutes</td>
</tr>
<tr class="even">
<td colspan="6">7a. RESIDENCE-STATE</td>
<td colspan="11">7b. COUNTY</td>
<td colspan="14">7c. CITY OR TOWN</td>
</tr>
<tr class="odd">
<td colspan="9">7d. STREET AND NUMBER</td>
<td colspan="7">7e. APT. NO.</td>
<td colspan="5">7f. ZIP CODE</td>
<td colspan="10">7g. INSIDE CITY LIMITS?  Yes  No</td>
</tr>
<tr class="even">
<td colspan="3"><p>8. EVER IN US ARMED FORCES?</p>
<p> Yes  No</p></td>
<td colspan="14"><p>9. MARITAL STATUS AT TIME OF DEATH</p>
<p> Married  Married, but separated  Widowed</p>
<p> Divorced  Never Married  Unknown</p></td>
<td colspan="14">10. SURVIVING SPOUSE’S NAME (If wife, give name prior
to first marriage)</td>
</tr>
<tr class="odd">
<td colspan="18">11. FATHER’S NAME (First, Middle, Last)</td>
<td colspan="13">12. MOTHER’S NAME PRIOR TO FIRST MARRIAGE (First,
Middle, Last)</td>
</tr>
<tr class="even">
<td colspan="4">13a. INFORMANT’S NAME</td>
<td colspan="14">13b. RELATIONSHIP TO DECEDENT</td>
<td colspan="13">13c. MAILING ADDRESS (Street and Number, City, State,
Zip Code)</td>
</tr>
<tr class="odd">
<td colspan="31">14. PLACE OF DEATH (Check only one: see
instructions)</td>
</tr>
<tr class="even">
<td colspan="13"><p>IF DEATH OCCURRED IN A HOSPITAL:</p>
<p> Inpatient  Emergency Room/Outpatient  Dead on Arrival</p></td>
<td colspan="18"><p>IF DEATH OCCURRED SOMEWHERE OTHER THAN A
HOSPITAL:</p>
<p> Hospice facility  Nursing home/Long term care facility 
Decedent’s home  Other (Specify):</p></td>
</tr>
<tr class="odd">
<td colspan="11">15. FACILITY NAME (If not institution, give street
&amp; number)</td>
<td colspan="16">16. CITY OR TOWN , STATE, AND ZIP CODE</td>
<td colspan="4">17. COUNTY OF DEATH</td>
</tr>
<tr class="even">
<td colspan="10"><p>18. METHOD OF DISPOSITION:  Burial  Cremation</p>
<p> Donation  Entombment  Removal from State</p>
<p> Other (Specify):_____________________________</p></td>
<td colspan="21">19. PLACE OF DISPOSITION (Name of cemetery, crematory,
other place)</td>
</tr>
<tr class="odd">
<td colspan="8">20. LOCATION-CITY, TOWN, AND STATE</td>
<td colspan="23">21. NAME AND COMPLETE ADDRESS OF FUNERAL FACILITY</td>
</tr>
<tr class="even">
<td colspan="25">22. SIGNATURE OF FUNERAL SERVICE LICENSEE OR OTHER
AGENT</td>
<td colspan="6">23. LICENSE NUMBER (Of Licensee)</td>
</tr>
<tr class="odd">
<td rowspan="13"></td>
<td rowspan="13"><blockquote>
<p><strong>To Be Completed By:</strong></p>
<p><strong>MEDICAL CERTIFIER</strong></p>
</blockquote></td>
<td colspan="15"><strong>ITEMS 24-28 MUST BE COMPLETED BY PERSON WHO
PRONOUNCES OR CERTIFIES DEATH</strong></td>
<td colspan="13">24. DATE PRONOUNCED DEAD (Mo/Day/Yr)</td>
<td colspan="3">25. TIME PRONOUNCED DEAD</td>
</tr>
<tr class="even">
<td colspan="17">26. SIGNATURE OF PERSON PRONOUNCING DEATH (Only when
applicable)</td>
<td colspan="9">27. LICENSE NUMBER</td>
<td colspan="5">28. DATE SIGNED (Mo/Day/Yr)</td>
</tr>
<tr class="odd">
<td colspan="12"><p>29. ACTUAL OR PRESUMED DATE OF DEATH</p>
<p>(Mo/Day/Yr) (Spell Month)</p></td>
<td colspan="10">30. ACTUAL OR PRESUMED TIME OF DEATH</td>
<td colspan="9"><p>31. WAS MEDICAL EXAMINER OR</p>
<p>CORONER CONTACTED?  Yes  No</p></td>
</tr>
<tr class="even">
<td colspan="30"><p><strong>CAUSE OF DEATH (See instructions and
examples)</strong></p>
<p>32. <strong>PART I.</strong> Enter the <u>chain of
events</u>--diseases, injuries, or complications--that directly caused
the death. DO NOT enter terminal events such as cardiac</p>
<p>arrest, respiratory arrest, or ventricular fibrillation without
showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line.
Add additional</p>
<p>lines if necessary.</p>
<p>IMMEDIATE CAUSE (Final</p>
<p>disease or condition <strong>---------&gt;</strong>
a._____________________________________________________________________________________________________________</p>
<p>resulting in death) Due to (or as a consequence of):</p>
<p>Sequentially list conditions,
b._____________________________________________________________________________________________________________</p>
<p>if any, leading to the cause Due to (or as a consequence of):</p>
<p>listed on line a. Enter the</p>
<p><strong>UNDERLYING CAUSE</strong>
c._____________________________________________________________________________________________________________</p>
<p>(disease or injury that Due to (or as a consequence of):</p>
<p>initiated the events resulting</p>
<p>in death) <strong>LAST</strong>
d._____________________________________________________________________________________________________________</p></td>
<td><p>Approximate interval:</p>
<p>Onset to death</p>
<p>_____________</p>
<p>_____________</p>
<p>_____________</p>
<p>_____________</p></td>
</tr>
<tr class="odd">
<td colspan="23" rowspan="2"><strong>PART II.</strong> Enter other
<u>significant conditions contributing to death</u> but not resulting in
the underlying cause given in PART I</td>
<td colspan="8"><p>33. WAS AN AUTOPSY PERFORMED?</p>
<p> Yes  No</p></td>
</tr>
<tr class="even">
<td colspan="8"><p>34. WERE AUTOPSY FINDINGS AVAILABLE TO</p>
<p>COMPLETE THE CAUSE OF DEATH?  Yes  No</p></td>
</tr>
<tr class="odd">
<td colspan="5"><p>35. DID TOBACCO USE CONTRIBUTE</p>
<p>TO DEATH?</p>
<p> Yes  Probably</p>
<p> No  Unknown</p></td>
<td colspan="15"><p>36. IF FEMALE:</p>
<p> Not pregnant within past year</p>
<p> Pregnant at time of death</p>
<p> Not pregnant, but pregnant within 42 days of death</p>
<p> Not pregnant, but pregnant 43 days to 1 year before death</p>
<p> Unknown if pregnant within the past year</p></td>
<td colspan="11"><p>37. MANNER OF DEATH</p>
<p> Natural  Homicide</p>
<p> Accident  Pending Investigation</p>
<p> Suicide  Could not be determined</p></td>
</tr>
<tr class="even">
<td colspan="2"><p>38. DATE OF INJURY</p>
<p>(Mo/Day/Yr) (Spell Month)</p></td>
<td colspan="5">39. TIME OF INJURY</td>
<td colspan="22">40. PLACE OF INJURY (e.g., Decedent’s home;
construction site; restaurant; wooded area)</td>
<td colspan="2"><p>41. INJURY AT WORK?</p>
<p> Yes  No</p></td>
</tr>
<tr class="odd">
<td colspan="31"><p>42. LOCATION OF INJURY: State: City or Town:</p>
<p>Street &amp; Number: Apartment No.: Zip Code:</p></td>
</tr>
<tr class="even">
<td colspan="24">43. DESCRIBE HOW INJURY OCCURRED:</td>
<td colspan="7"><p>44. IF TRANSPORTATION INJURY, SPECIFY:</p>
<p> Driver/Operator</p>
<p> Passenger</p>
<p> Pedestrian</p>
<p> Other (Specify)</p></td>
</tr>
<tr class="odd">
<td colspan="31"><p>45. CERTIFIER (Check only one):</p>
<p> Certifying physician-To the best of my knowledge, death occurred
due to the cause(s) and manner stated.</p>
<p> Pronouncing &amp; Certifying physician-To the best of my knowledge,
death occurred at the time, date, and place, and due to the cause(s) and
manner stated.</p>
<p> Medical Examiner/Coroner-On the basis of examination, and/or
investigation, in my opinion, death occurred at the time, date, and
place, and due to the cause(s) and manner stated.</p>
<p>Signature of
certifier:_____________________________________________________________________________</p></td>
</tr>
<tr class="even">
<td colspan="31">46. NAME, ADDRESS, AND ZIP CODE OF PERSON COMPLETING
CAUSE OF DEATH (Item 32)</td>
</tr>
<tr class="odd">
<td colspan="2">47. TITLE OF CERTIFIER</td>
<td colspan="10">48. LICENSE NUMBER</td>
<td colspan="9">49. DATE CERTIFIED (Mo/Day/Yr)</td>
<td colspan="10">50. <strong>FOR REGISTRAR ONLY</strong>- DATE FILED
(Mo/Day/Yr)</td>
</tr>
<tr class="even">
<td rowspan="3"></td>
<td rowspan="3"><blockquote>
<p><strong>To Be Completed By:</strong></p>
<p><strong>FUNERAL DIRECTOR</strong></p>
</blockquote></td>
<td colspan="6"><p>51. DECEDENT’S EDUCATION-Check the box that best
describes the highest degree or level of school completed at the time of
death.</p>
<p> 8th grade or less</p>
<p> 9th - 12th grade; no diploma</p>
<p> High school graduate or GED completed</p>
<p> Some college credit, but no degree</p>
<p> Associate degree (e.g., AA, AS)</p>
<p> Bachelor’s degree (e.g., BA, AB, BS)</p>
<p> Master’s degree (e.g., MA, MS, MEng,</p>
<p>MEd, MSW, MBA)</p>
<p> Doctorate (e.g., PhD, EdD) or</p>
<p>Professional degree (e.g., MD, DDS,</p>
<p>DVM, LLB, JD)</p></td>
<td colspan="14"><p>52. DECEDENT OF HISPANIC ORIGIN? Check the box</p>
<p>that best describes whether the decedent is</p>
<p>Spanish/Hispanic/Latino. Check the “No” box if</p>
<p>decedent is not Spanish/Hispanic/Latino.</p>
<p> No, not Spanish/Hispanic/Latino</p>
<p> Yes, Mexican, Mexican American, Chicano</p>
<p> Yes, Puerto Rican</p>
<p> Yes, Cuban</p>
<p> Yes, other Spanish/Hispanic/Latino</p>
<p>(Specify) __________________________</p></td>
<td colspan="11"><p>53. DECEDENT’S RACE (Check one or more races to
indicate what the</p>
<p>decedent considered himself or herself to be)</p>
<p> White</p>
<p> Black or African American</p>
<p> American Indian or Alaska Native</p>
<p>(Name of the enrolled or principal tribe) _______________</p>
<p> Asian Indian</p>
<p> Chinese</p>
<p> Filipino</p>
<p> Japanese</p>
<p> Korean</p>
<p> Vietnamese</p>
<p> Other Asian (Specify)__________________________________________</p>
<p> Native Hawaiian</p>
<p> Guamanian or Chamorro</p>
<p> Samoan</p>
<p> Other Pacific Islander
(Specify)_________________________________</p>
<p> Other (Specify)___________________________________________</p></td>
</tr>
<tr class="odd">
<td colspan="31">54. DECEDENT’S USUAL OCCUPATION (Indicate type of work
done during most of working life. DO NOT USE RETIRED).</td>
</tr>
<tr class="even">
<td colspan="31">55. KIND OF BUSINESS/INDUSTRY</td>
</tr>
</tbody>
</table>

allows the physician to list any other medically important disease or
condition that was present at the time of death and which may have
contributed to death but was not a direct link in the chain of events
directly leading to death. Multiple causes of death include each of the
causes reported on the death certificate in Parts I or II.

Underlying cause is the item most commonly used in tabulation and
analysis. As stated earlier, underlying cause data are important for
surveillance, research, design of public health and medical
interventions, and funding decisions for research and development.
Multiple cause data are an important supplement to underlying cause data
and can provide additional analytical information.

It is very important that all physicians, medical examiners, or coroners
who may be certifying deaths be properly oriented to the principles of
medical certification, the manner in which the statements are to be
entered, and the importance of completeness, accuracy, and specificity
in

+-------------------+----------------------+---+------------+-------+
| **CAUSE OF DEATH  |                      |   |            | A     |
| (See instructions |                      |   |            | pprox |
| and examples)**   |                      |   |            | imate |
|                   |                      |   |            | inte  |
| 32\. **PART I.**  |                      |   |            | rval: |
| Enter the [chain  |                      |   |            |       |
| of                |                      |   |            | Onset |
| events]{.under    |                      |   |            | to    |
| line}\--diseases, |                      |   |            | death |
| injuries, or      |                      |   |            |       |
| com               |                      |   |            | [Time |
| plications\--that |                      |   |            | i     |
| directly caused   |                      |   |            | nterv |
| the death. DO NOT |                      |   |            | al]{. |
| enter terminal    |                      |   |            | under |
| events such as    |                      |   |            | line} |
| cardiac           |                      |   |            |       |
|                   |                      |   |            | [Time |
| arrest,           |                      |   |            | i     |
| respiratory       |                      |   |            | nterv |
| arrest, or        |                      |   |            | al]{. |
| ventricular       |                      |   |            | under |
| fibrillation      |                      |   |            | line} |
| without showing   |                      |   |            |       |
| the etiology. DO  |                      |   |            | [Time |
| NOT ABBREVIATE.   |                      |   |            | i     |
| Enter only one    |                      |   |            | nterv |
| cause on a line.  |                      |   |            | al]{. |
| Add additional    |                      |   |            | under |
|                   |                      |   |            | line} |
| lines if          |                      |   |            |       |
| necessary.        |                      |   |            | [Time |
|                   |                      |   |            | i     |
| IMMEDIATE CAUSE   |                      |   |            | nterv |
| (Final            |                      |   |            | al]{. |
|                   |                      |   |            | under |
| disease or        |                      |   |            | line} |
| condition         |                      |   |            |       |
| **\-\-            |                      |   |            |       |
| \-\-\-\-\-\--\>** |                      |   |            |       |
| a. [Immediate     |                      |   |            |       |
| cause of          |                      |   |            |       |
| death\_\_\_\_\_\  |                      |   |            |       |
| _\_\_\_\_\_\_\_\_ |                      |   |            |       |
| \_\_\_\_\_\_\_\_\ |                      |   |            |       |
| _\_\_\_\_\_\_\_\_ |                      |   |            |       |
| \_\_\_\_\_\_\_\_\ |                      |   |            |       |
| _\_\_\_\_\_\_\_\_ |                      |   |            |       |
| \_\_\_\_\_\_\_\_\ |                      |   |            |       |
| _\_\_\_\_\_\_\_\_ |                      |   |            |       |
| \_\_\_\_\_\_\_\_\ |                      |   |            |       |
| _\_\_\_\_\_\_\_\_ |                      |   |            |       |
| \_\_]{.underline} |                      |   |            |       |
|                   |                      |   |            |       |
| resulting in      |                      |   |            |       |
| death) Due to (or |                      |   |            |       |
| as a consequence  |                      |   |            |       |
| of):              |                      |   |            |       |
|                   |                      |   |            |       |
| Sequentially list |                      |   |            |       |
| conditions, b.    |                      |   |            |       |
| [Intermediate     |                      |   |            |       |
| cause             |                      |   |            |       |
| \_\_\_\_\_\_\     |                      |   |            |       |
| _\_\_\_\_\_\_\_\_ |                      |   |            |       |
| \_\_\_\_\_\_\_\_\ |                      |   |            |       |
| _\_\_\_\_\_\_\_\_ |                      |   |            |       |
| \_\_\_\_\_\_\_\_\ |                      |   |            |       |
| _\_\_\_\_\_\_\_\_ |                      |   |            |       |
| \_\_\_\_\_\_\_\_\ |                      |   |            |       |
| _\_\_\_\_\_\_\_\_ |                      |   |            |       |
| \_\_\_\_\_\_\_\_\ |                      |   |            |       |
| _\_\_\_\_\_\_\_\_ |                      |   |            |       |
| \_\_]{.underline} |                      |   |            |       |
|                   |                      |   |            |       |
| if any, leading   |                      |   |            |       |
| to the cause Due  |                      |   |            |       |
| to (or as a       |                      |   |            |       |
| consequence of):  |                      |   |            |       |
|                   |                      |   |            |       |
| listed on line a. |                      |   |            |       |
| Enter the         |                      |   |            |       |
|                   |                      |   |            |       |
| **UNDERLYING      |                      |   |            |       |
| CAUSE** c.        |                      |   |            |       |
| [Intermediate     |                      |   |            |       |
| cause             |                      |   |            |       |
| \_\_              |                      |   |            |       |
| \_\_\_\_\_\_\_\_\ |                      |   |            |       |
| _\_\_\_\_\_\_\_\_ |                      |   |            |       |
| \_\_\_\_\_\_\_\_\ |                      |   |            |       |
| _\_\_\_\_\_\_\_\_ |                      |   |            |       |
| \_\_\_\_\_\_\_\_\ |                      |   |            |       |
| _\_\_\_\_\_\_\_\_ |                      |   |            |       |
| \_\_\_\_\_\_\_\_\ |                      |   |            |       |
| _\_\_\_\_\_\_\_\_ |                      |   |            |       |
| \_\_\_\_\_\_\_\_\ |                      |   |            |       |
| _\_\_\_\_\_\_\_\_ |                      |   |            |       |
| \_\_]{.underline} |                      |   |            |       |
|                   |                      |   |            |       |
| (disease or       |                      |   |            |       |
| injury that Due   |                      |   |            |       |
| to (or as a       |                      |   |            |       |
| consequence of):  |                      |   |            |       |
|                   |                      |   |            |       |
| initiated the     |                      |   |            |       |
| events resulting  |                      |   |            |       |
|                   |                      |   |            |       |
| in death)         |                      |   |            |       |
| **LAST** d.       |                      |   |            |       |
| [Underlying cause |                      |   |            |       |
| \                 |                      |   |            |       |
| _\_\_\_\_\_\_\_\_ |                      |   |            |       |
| \_\_\_\_\_\_\_\_\ |                      |   |            |       |
| _\_\_\_\_\_\_\_\_ |                      |   |            |       |
| \_\_\_\_\_\_\_\_\ |                      |   |            |       |
| _\_\_\_\_\_\_\_\_ |                      |   |            |       |
| \_\_\_\_\_\_\_\_\ |                      |   |            |       |
| _\_\_\_\_\_\_\_\_ |                      |   |            |       |
| \_\_\_\_\_\_\_\_\ |                      |   |            |       |
| _\_\_\_\_\_\_\_\_ |                      |   |            |       |
| \_\_]{.underline} |                      |   |            |       |
+-------------------+----------------------+---+------------+-------+
| **PART II.**      |                      |   | 33\. WAS   |       |
| Enter other       |                      |   | AN AUTOPSY |       |
| [significant      |                      |   | PERFORMED? |       |
| conditions        |                      |   |            |       |
| contributing to   |                      |   |  Yes  No |       |
| d                 |                      |   |            |       |
| eath]{.underline} |                      |   |            |       |
| but not resulting |                      |   |            |       |
| in the underlying |                      |   |            |       |
| cause given in    |                      |   |            |       |
| PART I            |                      |   |            |       |
|                   |                      |   |            |       |
| Contributory      |                      |   |            |       |
| cause(s), if any  |                      |   |            |       |
+-------------------+----------------------+---+------------+-------+
|                   |                      |   | 34\. WERE  |       |
|                   |                      |   | AUTOPSY    |       |
|                   |                      |   | FINDINGS   |       |
|                   |                      |   | AVAILABLE  |       |
|                   |                      |   | TO         |       |
|                   |                      |   |            |       |
|                   |                      |   | COMPLETE   |       |
|                   |                      |   | THE CAUSE  |       |
|                   |                      |   | OF DEATH?  |       |
|                   |                      |   |  Yes  No |       |
+-------------------+----------------------+---+------------+-------+
| 35\. DID TOBACCO  | 36\. IF FEMALE:      | 3 |            |       |
| USE CONTRIBUTE TO |                      | 7 |            |       |
| DEATH?            |  Not pregnant       | \ |            |       |
|                   | within past year     | . |            |       |
|  Yes  Probably  |                      | M |            |       |
|                   |  Pregnant at time   | A |            |       |
|  No  Unknown    | of death             | N |            |       |
|                   |                      | N |            |       |
|                   |  Not pregnant, but  | E |            |       |
|                   | pregnant within 42   | R |            |       |
|                   | days of death        | O |            |       |
|                   |                      | F |            |       |
|                   |  Not pregnant, but  | D |            |       |
|                   | pregnant 43 days to  | E |            |       |
|                   | 1 year before death  | A |            |       |
|                   |                      | T |            |       |
|                   |  Unknown if         | H |            |       |
|                   | pregnant within the  |   |            |       |
|                   | past year            |  |            |       |
|                   |                      | N |            |       |
|                   |                      | a |            |       |
|                   |                      | t |            |       |
|                   |                      | u |            |       |
|                   |                      | r |            |       |
|                   |                      | a |            |       |
|                   |                      | l |            |       |
|                   |                      |  |            |       |
|                   |                      | H |            |       |
|                   |                      | o |            |       |
|                   |                      | m |            |       |
|                   |                      | i |            |       |
|                   |                      | c |            |       |
|                   |                      | i |            |       |
|                   |                      | d |            |       |
|                   |                      | e |            |       |
|                   |                      |   |            |       |
|                   |                      |  |            |       |
|                   |                      | A |            |       |
|                   |                      | c |            |       |
|                   |                      | c |            |       |
|                   |                      | i |            |       |
|                   |                      | d |            |       |
|                   |                      | e |            |       |
|                   |                      | n |            |       |
|                   |                      | t |            |       |
|                   |                      |  |            |       |
|                   |                      | P |            |       |
|                   |                      | e |            |       |
|                   |                      | n |            |       |
|                   |                      | d |            |       |
|                   |                      | i |            |       |
|                   |                      | n |            |       |
|                   |                      | g |            |       |
|                   |                      | I |            |       |
|                   |                      | n |            |       |
|                   |                      | v |            |       |
|                   |                      | e |            |       |
|                   |                      | s |            |       |
|                   |                      | t |            |       |
|                   |                      | i |            |       |
|                   |                      | g |            |       |
|                   |                      | a |            |       |
|                   |                      | t |            |       |
|                   |                      | i |            |       |
|                   |                      | o |            |       |
|                   |                      | n |            |       |
|                   |                      |   |            |       |
|                   |                      |  |            |       |
|                   |                      | S |            |       |
|                   |                      | u |            |       |
|                   |                      | i |            |       |
|                   |                      | c |            |       |
|                   |                      | i |            |       |
|                   |                      | d |            |       |
|                   |                      | e |            |       |
|                   |                      |  |            |       |
|                   |                      | C |            |       |
|                   |                      | o |            |       |
|                   |                      | u |            |       |
|                   |                      | l |            |       |
|                   |                      | d |            |       |
|                   |                      | n |            |       |
|                   |                      | o |            |       |
|                   |                      | t |            |       |
|                   |                      | b |            |       |
|                   |                      | e |            |       |
|                   |                      | d |            |       |
|                   |                      | e |            |       |
|                   |                      | t |            |       |
|                   |                      | e |            |       |
|                   |                      | r |            |       |
|                   |                      | m |            |       |
|                   |                      | i |            |       |
|                   |                      | n |            |       |
|                   |                      | e |            |       |
|                   |                      | d |            |       |
+-------------------+----------------------+---+------------+-------+

Figure 2.

+-------------------+----------------------+---+------------+-------+
| **CAUSE OF DEATH  |                      |   |            | A     |
| (See instructions |                      |   |            | pprox |
| and examples)**   |                      |   |            | imate |
|                   |                      |   |            | inte  |
| 32\. **PART I.**  |                      |   |            | rval: |
| Enter the [chain  |                      |   |            |       |
| of                |                      |   |            | Onset |
| events]{.under    |                      |   |            | to    |
| line}\--diseases, |                      |   |            | death |
| injuries, or      |                      |   |            |       |
| com               |                      |   |            | [Min  |
| plications\--that |                      |   |            | utes\ |
| directly caused   |                      |   |            | _\_\_ |
| the death. DO NOT |                      |   |            | \_]{. |
| enter terminal    |                      |   |            | under |
| events such as    |                      |   |            | line} |
| cardiac           |                      |   |            |       |
|                   |                      |   |            | [6    |
| arrest,           |                      |   |            | da    |
| respiratory       |                      |   |            | ys\_\ |
| arrest, or        |                      |   |            | _\_\_ |
| ventricular       |                      |   |            | \_]{. |
| fibrillation      |                      |   |            | under |
| without showing   |                      |   |            | line} |
| the etiology. DO  |                      |   |            |       |
| NOT ABBREVIATE.   |                      |   |            | [6    |
| Enter only one    |                      |   |            | da    |
| cause on a line.  |                      |   |            | ys\_\ |
| Add additional    |                      |   |            | _\_\_ |
|                   |                      |   |            | \_]{. |
| lines if          |                      |   |            | under |
| necessary.        |                      |   |            | line} |
|                   |                      |   |            |       |
| IMMEDIATE CAUSE   |                      |   |            | [7    |
| (Final            |                      |   |            | y     |
|                   |                      |   |            | ears\ |
| disease or        |                      |   |            | _\_\_ |
| condition         |                      |   |            | \_]{. |
| **\-\-            |                      |   |            | under |
| \-\-\-\-\-\--\>** |                      |   |            | line} |
| a. [Rupture of    |                      |   |            |       |
| myocardium        |                      |   |            |       |
| \_\_\_\_\_\_\_\   |                      |   |            |       |
| _\_\_\_\_\_\_\_\_ |                      |   |            |       |
| \_\_\_\_\_\_\_\_\ |                      |   |            |       |
| _\_\_\_\_\_\_\_\_ |                      |   |            |       |
| \_\_\_\_\_\_\_\_\ |                      |   |            |       |
| _\_\_\_\_\_\_\_\_ |                      |   |            |       |
| \_\_\_\_\_\_\_\_\ |                      |   |            |       |
| _\_\_\_\_\_\_\_\_ |                      |   |            |       |
| \_\_\_\_\_\_\_\_\ |                      |   |            |       |
| _\_\_\_\_\_\_\_\_ |                      |   |            |       |
| \_\_]{.underline} |                      |   |            |       |
|                   |                      |   |            |       |
| resulting in      |                      |   |            |       |
| death) Due to (or |                      |   |            |       |
| as a consequence  |                      |   |            |       |
| of):              |                      |   |            |       |
|                   |                      |   |            |       |
| Sequentially list |                      |   |            |       |
| conditions, b.    |                      |   |            |       |
| [Acute myocardial |                      |   |            |       |
| in                |                      |   |            |       |
| farction\_\_\_\_\ |                      |   |            |       |
| _\_\_\_\_\_\_\_\_ |                      |   |            |       |
| \_\_\_\_\_\_\_\_\ |                      |   |            |       |
| _\_\_\_\_\_\_\_\_ |                      |   |            |       |
| \_\_\_\_\_\_\_\_\ |                      |   |            |       |
| _\_\_\_\_\_\_\_\_ |                      |   |            |       |
| \_\_\_\_\_\_\_\_\ |                      |   |            |       |
| _\_\_\_\_\_\_\_\_ |                      |   |            |       |
| \_\_\_\_\_\_\_\_\ |                      |   |            |       |
| _\_\_\_\_\_\_\_\_ |                      |   |            |       |
| \_\_]{.underline} |                      |   |            |       |
|                   |                      |   |            |       |
| if any, leading   |                      |   |            |       |
| to the cause Due  |                      |   |            |       |
| to (or as a       |                      |   |            |       |
| consequence of):  |                      |   |            |       |
|                   |                      |   |            |       |
| listed on line a. |                      |   |            |       |
| Enter the         |                      |   |            |       |
|                   |                      |   |            |       |
| **UNDERLYING      |                      |   |            |       |
| CAUSE** c.        |                      |   |            |       |
| [Coronary artery  |                      |   |            |       |
| th                |                      |   |            |       |
| rombosis\_\_\_\_\ |                      |   |            |       |
| _\_\_\_\_\_\_\_\_ |                      |   |            |       |
| \_\_\_\_\_\_\_\_\ |                      |   |            |       |
| _\_\_\_\_\_\_\_\_ |                      |   |            |       |
| \_\_\_\_\_\_\_\_\ |                      |   |            |       |
| _\_\_\_\_\_\_\_\_ |                      |   |            |       |
| \_\_\_\_\_\_\_\_\ |                      |   |            |       |
| _\_\_\_\_\_\_\_\_ |                      |   |            |       |
| \_\_\_\_\_\_\_\_\ |                      |   |            |       |
| _\_\_\_\_\_\_\_\_ |                      |   |            |       |
| \_\_]{.underline} |                      |   |            |       |
|                   |                      |   |            |       |
| (disease or       |                      |   |            |       |
| injury that Due   |                      |   |            |       |
| to (or as a       |                      |   |            |       |
| consequence of):  |                      |   |            |       |
|                   |                      |   |            |       |
| initiated the     |                      |   |            |       |
| events resulting  |                      |   |            |       |
|                   |                      |   |            |       |
| in death)         |                      |   |            |       |
| **LAST** d.       |                      |   |            |       |
| [Atherosclerotic  |                      |   |            |       |
| coronary artery   |                      |   |            |       |
| disease\_         |                      |   |            |       |
| \_\_\_\_\_\_\_\_\ |                      |   |            |       |
| _\_\_\_\_\_\_\_\_ |                      |   |            |       |
| \_\_\_\_\_\_\_\_\ |                      |   |            |       |
| _\_\_\_\_\_\_\_\_ |                      |   |            |       |
| \_\_\_\_\_\_\_\_\ |                      |   |            |       |
| _\_\_\_\_\_\_\_\_ |                      |   |            |       |
| \_\_\_\_\_\_\_\_\ |                      |   |            |       |
| _\_\_\_\_\_\_\_\_ |                      |   |            |       |
| \_\_]{.underline} |                      |   |            |       |
+-------------------+----------------------+---+------------+-------+
| **PART II.**      |                      |   | 33\. WAS   |       |
| Enter other       |                      |   | AN AUTOPSY |       |
| [significant      |                      |   | PERFORMED? |       |
| conditions        |                      |   |            |       |
| contributing to   |                      |   | ■Yes  No  |       |
| d                 |                      |   |            |       |
| eath]{.underline} |                      |   |            |       |
| 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  | 36\. IF FEMALE:      | 3 |            |       |
| USE CONTRIBUTE TO |                      | 7 |            |       |
| DEATH?            | ■ Not pregnant       | \ |            |       |
|                   | within past year     | . |            |       |
| ■ Yes  Probably  |                      | M |            |       |
|                   |  Pregnant at time   | A |            |       |
|  No  Unknown    | of death             | N |            |       |
|                   |                      | N |            |       |
|                   |  Not pregnant, but  | E |            |       |
|                   | pregnant within 42   | R |            |       |
|                   | days of death        | O |            |       |
|                   |                      | F |            |       |
|                   |  Not pregnant, but  | D |            |       |
|                   | pregnant 43 days to  | E |            |       |
|                   | 1 year before death  | A |            |       |
|                   |                      | T |            |       |
|                   |  Unknown if         | H |            |       |
|                   | pregnant within the  |   |            |       |
|                   | past year            | ■ |            |       |
|                   |                      | N |            |       |
|                   |                      | a |            |       |
|                   |                      | t |            |       |
|                   |                      | u |            |       |
|                   |                      | r |            |       |
|                   |                      | a |            |       |
|                   |                      | l |            |       |
|                   |                      |  |            |       |
|                   |                      | H |            |       |
|                   |                      | o |            |       |
|                   |                      | m |            |       |
|                   |                      | i |            |       |
|                   |                      | c |            |       |
|                   |                      | i |            |       |
|                   |                      | d |            |       |
|                   |                      | e |            |       |
|                   |                      |   |            |       |
|                   |                      |  |            |       |
|                   |                      | A |            |       |
|                   |                      | c |            |       |
|                   |                      | c |            |       |
|                   |                      | i |            |       |
|                   |                      | d |            |       |
|                   |                      | e |            |       |
|                   |                      | n |            |       |
|                   |                      | t |            |       |
|                   |                      |  |            |       |
|                   |                      | P |            |       |
|                   |                      | e |            |       |
|                   |                      | n |            |       |
|                   |                      | d |            |       |
|                   |                      | i |            |       |
|                   |                      | n |            |       |
|                   |                      | g |            |       |
|                   |                      | I |            |       |
|                   |                      | n |            |       |
|                   |                      | v |            |       |
|                   |                      | e |            |       |
|                   |                      | s |            |       |
|                   |                      | t |            |       |
|                   |                      | i |            |       |
|                   |                      | g |            |       |
|                   |                      | a |            |       |
|                   |                      | t |            |       |
|                   |                      | i |            |       |
|                   |                      | o |            |       |
|                   |                      | n |            |       |
|                   |                      |   |            |       |
|                   |                      |  |            |       |
|                   |                      | S |            |       |
|                   |                      | u |            |       |
|                   |                      | i |            |       |
|                   |                      | c |            |       |
|                   |                      | i |            |       |
|                   |                      | d |            |       |
|                   |                      | e |            |       |
|                   |                      |  |            |       |
|                   |                      | C |            |       |
|                   |                      | o |            |       |
|                   |                      | u |            |       |
|                   |                      | l |            |       |
|                   |                      | d |            |       |
|                   |                      | n |            |       |
|                   |                      | o |            |       |
|                   |                      | t |            |       |
|                   |                      | b |            |       |
|                   |                      | e |            |       |
|                   |                      | d |            |       |
|                   |                      | e |            |       |
|                   |                      | t |            |       |
|                   |                      | e |            |       |
|                   |                      | r |            |       |
|                   |                      | m |            |       |
|                   |                      | i |            |       |
|                   |                      | n |            |       |
|                   |                      | e |            |       |
|                   |                      | d |            |       |
+-------------------+----------------------+---+------------+-------+

listing the causes of death. Even the most conscientious physician
sometimes has a difficult time in distinguishing between those
conditions that should be included in the causal chain versus those
conditions not in the chain but medically important and relevant. The
cause-of-death

+-----------------------------------------------------------------------+
| **Figure 3. Completing a cause-of-death statement: Basic concepts**   |
+-----------------------------------------------------------------------+
| 1)  Deaths known or suspected of having been caused by injury or      |
|     poisoning should be reported to the medical examiner or coroner,  |
|     and you will complete the death certificate if the medical        |
|     examiner or coroner doesn't accept the case.                      |
|                                                                       |
| 2)  The cause-of-death information should be your best medical        |
|     opinion.                                                          |
|                                                                       |
| 3)  Only one condition should be listed per line in Part I.           |
|     Additional lines may be added if necessary.                       |
|                                                                       |
| 4)  Each condition in Part I should cause the one above it.           |
|                                                                       |
| 5)  Abbreviations and parentheses should be avoided in reporting      |
|     causes.                                                           |
|                                                                       |
| 6)  Provide the best estimate of the interval between the presumed    |
|     onset of each condition and death. The terms "approximately" or   |
|     "unknown" may be used. Do not leave the interval blank; if        |
|     unknown, indicate that it is unknown.                             |
|                                                                       |
| 7)  If additional medical information or autopsy findings become      |
|     available that would change the cause of death originally         |
|     reported, the original death certificate should be amended by the |
|     certifying physician by following the procedures in place in your |
|     State.                                                            |
|                                                                       |
| 8)  Report each disease, abnormality, injury, or poisoning that you   |
|     believe adversely affected the decedent. A condition can be       |
|     listed as "probable" even if it has not been definitively         |
|     diagnosed.                                                        |
|                                                                       |
| 9)  A complete sequence should be reported in Part I that explains    |
|     why the patient died. The sequence may be an etiological or       |
|     pathological sequence as well as a sequence in which an earlier   |
|     condition is believed to have prepared the way for a subsequent   |
|     cause by damage to tissues or impairment of function.             |
|                                                                       |
| 10) No entry is necessary on lines (b), (c), and (d) if a single      |
|     cause of death reported on line (a) describes completely the      |
|     train of events resulting in death.                               |
|                                                                       |
| 11) If two or more possible sequences resulted in death, report in    |
|     Part I the one that, in your opinion, most directly caused death. |
|     Report in Part II the other conditions or diseases.               |
|                                                                       |
| 12) A specific cause of death should be reported in the last entry in |
|     Part I so there is no ambiguity about the etiology of this cause. |
|                                                                       |
| 13) Conditions or diseases in Part II should contribute to death but  |
|     not result in the last entry in Part I.                           |
|                                                                       |
| 14) Mechanistic terminal events such as respiratory arrest, asystole, |
|     cardiac arrest, cardio-respiratory arrest, ventricular            |
|     fibrillation, and electromechanical dissociation should not be    |
|     the only condition included in the cause-of-death statement and   |
|     are unlikely to be the underlying cause.                          |
|                                                                       |
| 15) Always report an etiology for organ system failure such as        |
|     congestive heart failure, hepatic failure, renal failure, or      |
|     respiratory failure on the lines beneath it.                      |
|                                                                       |
| 16) If, in your opinion, the use of alcohol, tobacco, other substance |
|     by the decedent, or a recent pregnancy or injury caused or        |
|     contributed to death, then this condition should be reported.     |
|                                                                       |
| 17) A primary site and/or histological type should be specified for   |
|     neoplasms or specify that site and type are unknown.              |
|                                                                       |
| 18) For deaths resulting from injuries, always report the fatal       |
|     injury event, the trauma, and the impairment of function.         |
|                                                                       |
| 19) Injury items (38-43 in Figure 1) should have some sort of entry   |
|     if the manner has been reported as accident, homicide, or         |
|     suicide.                                                          |
+-----------------------------------------------------------------------+

certification constitutes a medical-legal opinion, not necessarily an
absolute fact, since it is not always possible to make a precise
determination of interacting diseases or conditions. Thus, "to the best
of my knowledge" is included in the certification statement, since the
certifier is considered to be in a better position than anyone else to
make a judgment as to the chain of events leading to death, but he/she
cannot always be presumed to have a clear cut "absolute answer".

In certifying causes of death, several kinds of errors or oversights are
frequently made, often due to the physicians not understanding how to
complete the certification of death. One of the most common errors is
the listing of causes in incorrect or illogical order, or the listing of
more than one disease or condition on the same line. Another frequent
error is omitting the interval between onset and death, the hour of
death, and whether an autopsy was performed.

[Completing a cause-of-death statement]{.underline}

Figure 3 shows some basic guidelines to certifying physicians on how to
complete a cause-of-death statement.

[Additional Aids]{.underline}

On occasion, it may be beneficial for the certifier physician to discuss
medical certification of death with a member of the State health
department staff before certifying a cause of death. It is helpful to
provide a telephone number and the name of an individual who can provide
answers to the certifier's questions. Needless to say, the person to
whom such calls are referred must have a familiarity with medical
terminology and of the pathology and etiology of morbid conditions.

Additional instructional material on writing cause-of-death statements
is available; widespread knowledge and use of these materials by
physicians could reduce many reporting problems and the need for
extensive querying. The sample letters include a very short reference to
the resources, but maximum benefit would probably be gained by providing
the certifying physician a packet of instructional material including,
at least, items 2, 3, and 4 below:

> 1\. Applicable State resources
>
> 2\. Instructions for completing the cause-of-death section of the
> death certificate (laminated plastic card or pocket size folder
> available from NCHS, also at
> [http://www.cdc.gov/nchs/data/dvs/blue_form.pdf]{.underline})
>
> 3\. Instructions for completing the cause-of-death section of the
> death certificate for injury and poisoning (laminated plastic card or
> pocket size folder available from NCHS, also at
> [http://www.cdc.gov/nchs/data/dvs/red_form.pdf]{.underline})
>
> 4\. Physicians' Handbook on Medical Certification of Death (available
> from NCHS, also at <http://www.cdc.gov/nchs/data/misc/hb_cod.pdf>)
>
> 5\. Medical examiners' and coroners' handbook on death registration
> and fetal death reporting (available from NCHS, also at
> http://www.cdc.gov/nchs/data/misc/hb_me.pdf)
>
> 6\. Possible solutions to common problems in death certification
> (<http://www.cdc.gov/nchs/about/major/dvs/handbk.htm>)
>
> 7\. Tutorial from the National Association of Medical Examiners
> (http://www.thename.org/CauseDeath/COD_main_page.htm)
>
> 8\. *The Medical Cause of Death Manual* (3) edited by Randy Hanzlick:
> can be ordered from the College of American Pathologists (800-323-4040
> ext. 7531 for information and credit card orders). The product code
> number is B260.

9\. *Cause-of-Death Statements and Certification of Natural and
Unnatural Deaths* edited by Randy Hanzlick: can be ordered from the
College of American Pathologists (800-323-4040 ext. 7531 for information
and credit card orders). The product code number is BK7261.

Enlisting the cooperation of the State and local medical societies to
conduct some instructional/educational sessions on completing death
certificates should be considered, especially if a local region makes a
disproportionate number of errors. Local medical schools should also be
approached about the possibility of including training on death
certification as part of their curriculum.

Training physicians in the proper completion of a death certificate will
work best when the physicians feel that they have a vested interest in
the death certification process. One way of improving the sense of being
vested is to explain how the data is used for health programs and
medical research. Training non-physicians in the proper completion of a
death certificate may be more challenging since they do not have the
medical background that physicians do.

II\. Who Carries Out the Query

States must decide who can best carry out querying. Historically,
nosologists have done the querying, but with the advent of automated
processing, fewer States have nosologists. These States must develop
different mechanisms for querying, perhaps by training other staff to
query. The person who queries records needs to be someone who
understands the content and purpose of the querying manual, which in
turn implies an understanding of coding rules and medical causality.
That person could be an experienced nosologist or a trained statistician
or a medical officer with an understanding of how death certificates
should be completed. Consideration might be given to identifying a
physician on staff in the State health department or under contract who
could provide assistance with the querying process. It is critical that
the person doing the querying have good communication skills as well as
an understanding of why the certificate is being queried (e.g., to
obtain more information or to correct obvious inadequacies).

An area for future development is to develop automated procedures for
querying. NCHS is incorporating Priority Level 1 queries into the
automated mortality medical software, specifically SuperMICAR.
Initially, the system will identify the certificate number, the query
level, and the recommended letter. The State staff can then pull the
record and review the record to determine if a query is needed.
Eventually, the automated system will produce a letter that may be used
to query the record.

III\. Use of Querying

If employed correctly, the query procedure can be a very effective
method of acquainting physicians with the proper methods for certifying
a cause of death. Unfortunately, most physicians do not receive training
on completing death certificates during their formal education;
therefore, querying can help provide them with information to enable
them to certify a death correctly. Many common errors or omissions can
be avoided by consistent querying, if sufficient explanation is
furnished to the certifier to help them modify their approach with
future medical certifications.

The design and wording of form letters used in querying is very
important, not only for obtaining the necessary information for the
death being queried, but to convey to the certifier enough information
so that he/she can correctly certify future cases of the same or similar
types. Questions in query letters need to be specific enough to indicate
what is missing or incorrect and what information is being requested.
The more explicit the letter, the better the response that can be
expected. Examples illustrating the correct certification of specific
causes are shown on the back of the sample form letters in Appendix B;
these examples may serve as guides to the certifier.

[IV. How Much to Query]{.underline}

Querying is a critical part of maintaining and improving data quality.
The official responsible for vital registration and vital statistics
should make a careful appraisal of the type and extent of querying that
has taken place on the cause-of-death statements in his/her own
registration area. Then, a better decision can be made about possible
revisions in current query procedures and practices. Such decisions
should take into account:

> 1\) The importance of querying in improving physicians' practices in
> completing cause-of-death statements
>
> 2\) The importance of querying in improving the particular death
> record under review
>
> 3\) The extent to which staff resources can be devoted to querying
> versus other office activities
>
> 4\) The query method that will be most effective in accomplishing 1)
> and 2) above.

Some records with questionable conditions or situations are easily
identified as good candidates for querying or further investigation.
Situations that need clarification are described in general terms in the
description of the query levels and in specific terms in the four tables
of

Appendix A. The query manual provides general guidelines to what should
be queried but informed judgment must be applied on a case-by-case basis
before sending out a query to a physician.

V. Levels of Querying

Recognizing that the availability of staff and resources to be utilized
for querying varies from State to State, the following levels of
querying have been designed to aid decision makers in developing the
query program for the specific State vital statistics program. The
categories are in priority order ranging from "1\" indicating cases that
should always be queried, to "6\" which is an optional category. To
facilitate referencing, Priority Level 1 is subdivided into categories
a-g. Those categories requiring no querying are indicated by "0\". For
systematic data improvement, the manager should elect to query up to the
highest Priority Level commensurate with the registration area's needs
and resources. Intervening levels should not be skipped. NCHS recommends
that every registration area conduct, as a minimum, the Priority Level 1
queries.

Appendix A presents an operationalization of the recommended Priority
Levels. Table 1 shows specific ICD-10 categories along with a querying
Priority Level and a reference to a sample query letter to use in
querying (Appendix B contains the sample query letters). Table 2
presents specific improbable sequences that should always be queried.
Table 3 lists recommendations for situations in which the duration for a
specified cause is not clear. Table 4 presents selected situations in
which the certifier has reported causes in a way that conflict with the
format of the medical certification section along with a recommended
query level and a reference to a sample query letter. The following
examples illustrate how Appendix A may be used.

> I (a) Pain in joints
>
> \(b\)
>
> \(c\)
>
> The ICD code for this condition is M25.5. Referring to this category
> in table 1 of Appendix A, it specifies that a query should be
> initiated under Priority Level 1c for conditions coded to M15-M25.
> Also, it shows that Query Letter No. 8 on page 107 can be used.
>
> I (a) Pharyngeal cancer
>
> \(b\)
>
> \(c\)
>
> This condition would be coded C14.0. Referring to Appendix A, the
> Priority Level is shown as 5 and Query Letter No. 2 on page 71 could
> be used. If, however, the State queries only through Priority Level 4,
> no letter would be initiated in this case.

Appendix A provides guidelines for querying. Automatic or manual
screening may be used to identify certificates for possible querying.
However, the State should review the certificate more carefully to
determine if the record really should be queried. For example, querying
is not necessary when terms such as "probable," "unknown etiology," and
"unknown site" are stated. In the case of SIDS or SUDI, querying is also
not necessary when a complete investigation has been conducted
([www.cdc.gov/reproductivehealth/SIDS/deathscene.htm](http://www.cdc.gov/reproductivehealth/SIDS/deathscene.htm))
and the National Institute of Child Health and Human Development
criteria have been met for diagnosing SIDS. In these cases, it is clear
that the physician made an effort to provide a clear and complete
etiological sequence.

While the form letters shown in Appendix B are adequate to cover most
situations, there may be times when an original letter should be
written, or additional statements or questions should be included. When
two or more different query levels are applicable for the same record,
the attachments for each query level may be used. It may be clearer to
keep the questions on separate attachments rather than combining
questions from multiple attachments.

[Priority Level 1]{.underline}

Priority Level 1 contains the minimum level of querying that all State
vital statistics programs should use to promote basic integrity of State
and national mortality data. This category is designed to reduce the
frequency with which assumptions must be made to properly assign
multiple cause or underlying cause-of-death codes because of missing or
incorrect information.

**Level 1a: Always query if an infrequent or rare cause appears anywhere
in the medical certification section.**

> Appendix C contains a list of infrequent and rare causes of death in
> the United States. These causes of death occur rarely and/or present
> threats to public health in the United States. As a result, each case
> should be verified to make sure there was no error in certification.
> When NCHS requests confirmation of a rare cause of death, the VSCP
> project director should work with staff to verify that the
> cause‑of‑death coding is correct and obtain corroboration from the
> State Health Officer before signing the confirmation letter. A
> notation of confirmation should also be recorded on the copy of the
> certificate sent to NCHS. In the absence of this notation, the disease
> will be coded as stated; the VSCP project officer will be contacted to
> confirm the accuracy of the certification.
>
> Examples: "Cholera", "plague", "acute poliomyelitis"
>
> See sample query letter number 1.

**Level 1b: Always query neoplasm for a primary site and to determine if
benign or malignant. When a malignant neoplasm is stated to be the
underlying cause of death, it is important to determine the primary
site.**

> Example: I (a) Carcinomatosis
>
> \(b\)
>
> \(c\)
>
> Query to determine primary site.
>
> Example: I (a) Breast tumor
>
> \(b\)
>
> \(c\)
>
> Query to determine if benign or malignant.
>
> See sample query letter number 2.

**Level 1c: Always query when the following are reported alone or as the
underlying cause on the death certificate:**

1.  **conditions that would rarely cause death by themselves (e.g.,
    trivial conditions)**

2.  **symptoms and signs**

3.  **ill-defined conditions**

4.  **mechanisms of death**

> Example: I (a) Myopia
>
> \(b\)
>
> \(c\)
>
> Example I (a) Senility
>
> \(b\)
>
> \(c\)
>
> See sample query letter numbers 4, 6, 8, 9, and 10.

**Level 1d: Always query for the reason for the "surgery or medical
care" when the underlying disease or condition is not reported anywhere
on the death record.**

> Example: I (a) Hemorrhage
>
> \(b\) Surgery
>
> \(c\)
>
> In the above example, the disease or condition requiring the surgery
> should be queried, and also the specific type of surgery performed.
>
> See sample query letter numbers 5 and 10.

**Level 1e: Always query for an external cause when only nature of
injuries, that is, codes classifiable to S00-T98, are reported alone on
the death certificate.**

> Example: I (a) Internal injuries
>
> \(b\)
>
> \(c\)
>
> See sample query letter number 10.

**Level 1f: Query when the sequence arrangement of the reported entries
is questionable. Improbable sequences in part I of the death certificate
are shown in tables 2-4 of Appendix A, pages 56-66, and in the
instructions on "highly improbable" sequences in section III of the NCHS
Instruction manual part 2A.**

> Example: I (a) Pneumonia
>
> \(b\) Hypertension
>
> \(c\) Cardiac hypertrophy due to above
>
> In this example, it is difficult to determine the intent of the
> certifier; therefore, more information is needed.
>
> See sample query letter number 11.

**Level 1g: When any of the selected conditions in Appendix D is
reported, whether in part I or part II on the death certificate, and
there is no mention of HIV (Human immunodeficiency virus) infection,
query for HIV.**

> See sample query letter number 3.

[Priority Level 2]{.underline}

**Priority Level 2 includes conditions not usually considered as the
underlying cause for which querying will help classify the underlying
cause of death more specifically.**

> Example: I (a) Peritonitis
>
> \(b\)
>
> \(c\)
>
> In this example, it is necessary to determine what led to or caused
> the peritonitis- - was it a ruptured appendix, ruptured peptic ulcer,
> so-called "spontaneous peritonitis", other?
>
> See sample query letter numbers 4 and 8.

[Priority Level 3]{.underline}

**Priority Level 3 provides more detailed information that would enable
the cause of death to be classified more accurately and to a more
detailed ICD category.**

> Example: I (a) Chronic liver disease
>
> \(b\)
>
> \(c\)
>
> In this case, the specific type of disease is needed (alcoholic
> cirrhosis, biliary cirrhosis, chronic (or recurrent) hepatitis, etc.)
>
> See sample query letter numbers 4, 7, 8, 9, and 10.

[Priority Level 4]{.underline}

**Priority Level 4 includes:**

1.  **those cases in which the certifier may already provide a logical
    chain of events leading to death but determining the site or
    location of stated diseases or conditions will lead to a more
    precise code (see example below).**

2.  **entries which are unclear and need further explanation (e.g.,
    situations related to placement and numbering of conditions). For a
    list of examples, refer to table 4, Appendix A, beginning on page
    64.**

> Example: I (a) Embolism
>
> \(b\)
>
> \(c\)
>
> A specific site is needed (e.g., brain, lung, coronary arteries), as
> is the source, if known.
>
> See sample query letter numbers 4 and 11.

[Priority Level 5]{.underline}

**Priority Level 5 contains queries which would enable the cause of
death to be coded to a more precise subcategory within the three-digit
category. This level of detail is frequently required for specified
special studies or research projects within a defined reporting area,
but may not be necessary for general querying.**

> Example: I (a) Carcinomatosis
>
> \(b\) Cancer of pancreas
>
> \(c\)
>
> In this case, a query for a more specific site of the pancreas would
> be in order (e.g., body, head, duct, etc.), as well as a query for the
> histologic type of tumor, such as "Adenocarcinoma".
>
> See sample query letter numbers 4 and 10.

[Priority Level 6]{.underline}

**Priority Level 6 reflects the most thorough recommended level of
querying. The conditions in this category are queried for the purpose of
obtaining even more explicit statements, thus eliminating the necessity
of using the assumptions which are allowed under ICD rules.**

> Example: I (a) Tuberculosis
>
> \(b\)
>
> \(c\)
>
> Tuberculosis of the lung is assumed if not otherwise specified.
>
> Example: I (a) Lupus
>
> \(b\)

\(c\)

> Systemic lupus is assumed if not otherwise specified.
>
> See sample query letter numbers 4 and 11.

[Fetal death]{.underline}

The principles and procedures described in this manual are applicable to
fetal deaths. Since many of the same causes may be stated on the fetal
death report, the querying priorities in Appendix A may be followed. The
cause P95 is invalid for mortality records but is valid for fetal
deaths. This cause, P95, is shown in Appendix A for those wanting to use
this manual to query fetal deaths. While the causes of many fetal deaths
are unknown, it is important to capture results from pathological or
histological examinations completed after the fetal death report or
certificate was filed and to remind physicians that casual reporting of
"unknown" as a cause of fetal death is not acceptable.

[Sample letters]{.underline}

  ---------- -------------- ------------------------------------------------ --
  **Guide to                                                                 
  Sample                                                                     
  Query                                                                      
  Letters                                                                    
  Shown in                                                                   
  Appendix                                                                   
  B**                                                                        

  Letter     Query level    General reason for querying                      
  number                                                                     

  1          1a             Rare causes                                      

  2          1b             Cancer                                           

  3          1g             HIV (also see Appendix D)                        

  4          1c,2,3,4,5,6   Etiology, for specific site, and type of disease 

  5          1d             Reason for treatment (medical, surgical,         
                            therapy, medicaments)                            

  6          1c             Mental disorders                                 

  7          3              Type of drug or exposure                         

  8          1c,2,3         Signs, symptoms, non-specific conditions,        
                            trivial conditions, fetal death code P95,        
                            mechanism of death, etc.                         

  9          1c,3           Pregnancy-related conditions                     

  10         1c,1d,1e,3,5   Manner of death and external causes              

  11         1f,4,6         Improbable sequence, duration, placement and     
                            numbering of conditions                          
  ---------- -------------- ------------------------------------------------ --

VI\. Evaluation of the Query Program

To assure that the desired results are being obtained, a periodic
evaluation of the query program should be made. By keeping records of
all queries sent out and returned, it is possible to measure the overall
effectiveness of the program, and also to pinpoint areas in need of a
more concentrated effort.

A rough measure of the improvement in certification may be obtained by
comparing the percent of records requiring a query at the beginning of
the program with the percent required afer the program has been in
effect for several months. Ideally there should be a gradual decline in
the proportion of queries needed as the certifiers become educated as to
the requirements. However, there will always be a need for education
since new physicians will start practicing in the State and physicians
who rarely complete a certificate may need assistance. The rate of
response to the queries and the time lag involved will also make it
possible to determine how much follow-up is needed, either by mail or by
telephone.

A more detailed measure of the effectiveness of the program is made
possible by keeping a record of the types of questions asked. This
information can reveal which types of situations require the most
querying, and also indicates which physicians may require special
attention such as a personal visit. This type of information can be very
valuable when used in conjunction with a field or training program,
especially with the cooperation of the State and/or local medical
society In addition, it is helpful to ascertain the impact of querying
by measuring the difference in the records over time.

The following are illustrations of the types of information that can be
recorded and tabulated periodically for purposes of evaluating the query
program:

A.  Number and percent of queries sent, showing:

    1.  Adequate response

        A.  Changed the underlying cause

        B.  Did not change the underlying cause

        C.  Did not change the underlying cause, but resulted in
            additional cause-of-death information

    2.  Inadequate response (e.g., response doesn't address question)

    3.  No response

```{=html}
<!-- -->
```
A.  Number and percent of follow-up queries, by type of follow up and
    result.

B.  Number and percent of queries sent, by ICD category and Priority
    Level.

C.  Number and percent of queries sent, by individual physician, type of
    certifier, and type of letter.

D.  Number and percent of inadequate or non-responses by type of letter
    used.

E.  Number and rate of ICD code changes made as a result of queries, by
    Priority Level.

In Oregon and Washington, systematic evaluation of the State query
program has confirmed the value of an overall program, identified
effectiveness of querying specific causes, and helped refine specific
wording that works best in query letters (4-5).

[References]{.underline}

1\. Rosenberg, HM. 1989. Improving cause-of-death statistics. *[American
Journal of Public Health]{.underline}*. 79(5): 563-4.

2\. Rosenberg, HM. 1991. The impact of cause‑of‑death querying. *[IIVRS
Technical Paper]{.underline}*, No. 45. International Institute for Vital
Registration and Statistics \[IIVRS\]: Bethesda, Maryland.

3\. Hanzlick, R (Ed.) 1994. *[The Medical Cause of Death
Manual.]{.underline}* Northfield, IL: College of American Pathologists.

4\. Hopkins, DD, Grant-Worley, JA, and Bollinger, TL. 1989. Survey of
cause-of-death query criteria used by State vital statistics programs in
the U.S. and the efficacy of the criteria used by the Oregon vital
statistics program. [*American Journal of Public Health*.]{.underline}
79(5): 570-574.

5\. Hoyert, DL, and Lima A. 2005. Querying of death certificates in the
United States. *Public Health Reports*. 120: 1-9.

<table>
<colgroup>
<col style="width: 15%" />
<col style="width: 4%" />
<col style="width: 3%" />
<col style="width: 3%" />
<col style="width: 2%" />
<col style="width: 3%" />
<col style="width: 3%" />
<col style="width: 3%" />
<col style="width: 19%" />
<col style="width: 5%" />
<col style="width: 6%" />
<col style="width: 6%" />
<col style="width: 1%" />
<col style="width: 20%" />
</colgroup>
<thead>
<tr class="header">
<th><p>ICD</p>
<p>Category</p></th>
<th colspan="7">Priority Levels</th>
<th>Comments</th>
<th colspan="4">Query Form</th>
<th></th>
</tr>
<tr class="odd">
<th></th>
<th>1</th>
<th>2</th>
<th>3</th>
<th>4</th>
<th>5</th>
<th>6</th>
<th>0</th>
<th></th>
<th>Ltr#</th>
<th>Ques#</th>
<th>Pg#</th>
<th colspan="2"></th>
</tr>
</thead>
<tbody>
<tr class="odd">
<td>A00-A01</td>
<td>1a</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>1</td>
<td></td>
<td>67</td>
<td colspan="2"></td>
</tr>
<tr class="even">
<td>A02-A04</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td colspan="2"></td>
</tr>
<tr class="odd">
<td>A05 (.1)</td>
<td>1a</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>1</td>
<td></td>
<td>67</td>
<td colspan="2"></td>
</tr>
<tr class="even">
<td>A05 (.0, .2-.8)</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td colspan="2"></td>
</tr>
<tr class="odd">
<td>A05 (.9)</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>5</td>
<td></td>
<td></td>
<td></td>
<td>4</td>
<td>4/5</td>
<td>83</td>
<td colspan="2"></td>
</tr>
<tr class="even">
<td>A06</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td colspan="2"></td>
</tr>
<tr class="odd">
<td>A07 (.0-.1)</td>
<td>1a</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>1</td>
<td></td>
<td>67</td>
<td colspan="2"></td>
</tr>
<tr class="even">
<td>A07 (.2)</td>
<td><p>1a</p>
<p>1g</p></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td><p>1</p>
<p>3</p></td>
<td></td>
<td><p>67</p>
<p>77</p></td>
<td colspan="2"></td>
</tr>
<tr class="odd">
<td>A07 (.3)</td>
<td>1g</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>3</td>
<td></td>
<td>77</td>
<td colspan="2"></td>
</tr>
<tr class="even">
<td>A07 (.8-.9)</td>
<td>1a</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>1</td>
<td></td>
<td>67</td>
<td colspan="2"></td>
</tr>
<tr class="odd">
<td>A08-A09</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td colspan="2"></td>
</tr>
<tr class="even">
<td>A16 (.2-.8)</td>
<td>1g</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>3</td>
<td></td>
<td>77</td>
<td colspan="2"></td>
</tr>
<tr class="odd">
<td>A16 (.9)</td>
<td>1g</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>6</td>
<td></td>
<td></td>
<td>3</td>
<td></td>
<td>77</td>
<td colspan="2"></td>
</tr>
<tr class="even">
<td>A17</td>
<td>1g</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>3</td>
<td></td>
<td>77</td>
<td colspan="2"></td>
</tr>
<tr class="odd">
<td><p>A18 (.0-.3,</p>
<p>.5-.8)</p></td>
<td>1g</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>3</td>
<td></td>
<td>77</td>
<td colspan="2"></td>
</tr>
<tr class="even">
<td>A18 (.4)</td>
<td>1g</td>
<td></td>
<td>3</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>Query Lupus, NOS (for query level 3)</td>
<td><p>3</p>
<p>4</p></td>
<td>4/5</td>
<td><p>77</p>
<p>83</p></td>
<td colspan="2"></td>
</tr>
<tr class="odd">
<td>A19</td>
<td>1g</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>3</td>
<td></td>
<td>77</td>
<td colspan="2"></td>
</tr>
<tr class="even">
<td>A20-A25</td>
<td>1a</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>1</td>
<td></td>
<td>67</td>
<td colspan="2"></td>
</tr>
<tr class="odd">
<td>A26</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td colspan="2"></td>
</tr>
<tr class="even">
<td>A27</td>
<td>1a</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>1</td>
<td></td>
<td>67</td>
<td colspan="2"></td>
</tr>
<tr class="odd">
<td>A28</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td colspan="2"></td>
</tr>
<tr class="even">
<td>A30</td>
<td>1a</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>1</td>
<td></td>
<td>67</td>
<td colspan="2"></td>
</tr>
<tr class="odd">
<td>A31 (.0, .8-.9)</td>
<td>1g</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>3</td>
<td></td>
<td>77</td>
<td colspan="2"></td>
</tr>
<tr class="even">
<td>A31 (.1)</td>
<td><p>1c</p>
<p>1g</p></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td><p>8</p>
<p>3</p></td>
<td>1</td>
<td><p>107</p>
<p>77</p></td>
<td colspan="2"></td>
</tr>
<tr class="odd">
<td>A32</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td colspan="2"></td>
</tr>
</tbody>
</table>

<table>
<colgroup>
<col style="width: 20%" />
<col style="width: 5%" />
<col style="width: 4%" />
<col style="width: 4%" />
<col style="width: 3%" />
<col style="width: 4%" />
<col style="width: 4%" />
<col style="width: 4%" />
<col style="width: 24%" />
<col style="width: 7%" />
<col style="width: 8%" />
<col style="width: 8%" />
</colgroup>
<tbody>
<tr class="odd">
<td>A33-A37</td>
<td>1a</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>1</td>
<td></td>
<td>67</td>
</tr>
<tr class="even">
<td><p>ICD</p>
<p>Category</p></td>
<td colspan="7">Priority Levels</td>
<td>Comments</td>
<td colspan="3">Query Form</td>
</tr>
<tr class="odd">
<td></td>
<td>1</td>
<td>2</td>
<td>3</td>
<td>4</td>
<td>5</td>
<td>6</td>
<td>0</td>
<td></td>
<td>Ltr#</td>
<td>Ques#</td>
<td>Pg#</td>
</tr>
<tr class="even">
<td>A38-A39</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td>A40 (.0-.8)</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td>A40 (.9)</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>5</td>
<td></td>
<td></td>
<td></td>
<td>4</td>
<td>5</td>
<td>83</td>
</tr>
<tr class="odd">
<td>A41 (.0-.8)</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td>A41 (.9)</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>5</td>
<td></td>
<td></td>
<td></td>
<td>4</td>
<td>4</td>
<td>83</td>
</tr>
<tr class="odd">
<td>A42-A43</td>
<td>1g</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>3</td>
<td></td>
<td>77</td>
</tr>
<tr class="even">
<td>A44</td>
<td>1a</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>1</td>
<td></td>
<td>67</td>
</tr>
<tr class="odd">
<td><p>A46, A48(.0-.2,</p>
<p>.4-.8)</p></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td>A49</td>
<td></td>
<td></td>
<td></td>
<td>4</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>4</td>
<td>2</td>
<td>83</td>
</tr>
<tr class="odd">
<td>A50</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td>A51</td>
<td>1c</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>8</td>
<td>2</td>
<td>107</td>
</tr>
<tr class="odd">
<td>A52-A55</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td>A56-A64</td>
<td>1c</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>8</td>
<td>1,2</td>
<td>107</td>
</tr>
<tr class="odd">
<td>A65-A70</td>
<td>1a</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>1</td>
<td></td>
<td>67</td>
</tr>
<tr class="even">
<td>A71-A74</td>
<td>1c</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td>A75</td>
<td>1a</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>1</td>
<td></td>
<td>67</td>
</tr>
<tr class="even">
<td>A77 (.0)</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td>A77 (.1-.9)</td>
<td>1a</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>1</td>
<td></td>
<td>67</td>
</tr>
<tr class="even">
<td>A78-A80</td>
<td>1a</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>1</td>
<td></td>
<td>67</td>
</tr>
<tr class="odd">
<td><p>A81 (.0-.1,</p>
<p>.8-.9)</p></td>
<td>1a</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>1</td>
<td></td>
<td>67</td>
</tr>
<tr class="even">
<td>A81 (.2)</td>
<td><p>1a</p>
<p>1g</p></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td><p>1</p>
<p>3</p></td>
<td></td>
<td><p>67</p>
<p>77</p></td>
</tr>
<tr class="odd">
<td>A82</td>
<td>1a</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>1</td>
<td></td>
<td>67</td>
</tr>
<tr class="even">
<td>A83</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td>A84</td>
<td>1a</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>1</td>
<td></td>
<td>67</td>
</tr>
<tr class="even">
<td>A85 (.0-.1, .8)</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td>A85 (.2)</td>
<td>1a</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>1</td>
<td></td>
<td>67</td>
</tr>
<tr class="even">
<td><p>ICD</p>
<p>Category</p></td>
<td colspan="7">Priority Levels</td>
<td>Comments</td>
<td colspan="3">Query Form</td>
</tr>
<tr class="odd">
<td></td>
<td>1</td>
<td>2</td>
<td>3</td>
<td>4</td>
<td>5</td>
<td>6</td>
<td>0</td>
<td></td>
<td>Ltr#</td>
<td>Ques#</td>
<td>Pg#</td>
</tr>
<tr class="even">
<td>A86-A89</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td>A90-A99</td>
<td>1a</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>1</td>
<td></td>
<td>67</td>
</tr>
<tr class="even">
<td><p>B00 (.0, .3-.4,</p>
<p>.7, .9)</p></td>
<td>1g</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>3</td>
<td></td>
<td>77</td>
</tr>
<tr class="odd">
<td>B00 (.1-.2, .5,.8)</td>
<td><p>1c</p>
<p>1g</p></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td><p>8</p>
<p>3</p></td>
<td>1,2</td>
<td><p>107</p>
<p>77</p></td>
</tr>
<tr class="even">
<td>B01</td>
<td>1a</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>1</td>
<td></td>
<td>67</td>
</tr>
<tr class="odd">
<td>B02</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td>B03-B06</td>
<td>1a</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>1</td>
<td></td>
<td>67</td>
</tr>
<tr class="odd">
<td>B07</td>
<td>1c</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>8</td>
<td>1</td>
<td>107</td>
</tr>
<tr class="even">
<td>B08 (.0)</td>
<td>1a</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>1</td>
<td></td>
<td>67</td>
</tr>
<tr class="odd">
<td>B08 (.1-.8)</td>
<td>1c</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>8</td>
<td>1</td>
<td>107</td>
</tr>
<tr class="even">
<td>B09</td>
<td>1c</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>8</td>
<td>1</td>
<td>107</td>
</tr>
<tr class="odd">
<td>B15-B19</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td>B20-24</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td>B25</td>
<td>1g</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>3</td>
<td></td>
<td>77</td>
</tr>
<tr class="even">
<td>B26</td>
<td>1a</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>1</td>
<td></td>
<td>67</td>
</tr>
<tr class="odd">
<td>B27</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td>B30</td>
<td>1c</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>1</td>
<td></td>
<td>67</td>
</tr>
<tr class="odd">
<td>B33 (.0)</td>
<td>1a</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>1</td>
<td></td>
<td>67</td>
</tr>
<tr class="even">
<td>B33 (.1-.8)</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td>B34</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td>B35-B36</td>
<td>1c</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>8</td>
<td>1,2</td>
<td>107</td>
</tr>
<tr class="odd">
<td>B37-B39</td>
<td>1g</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>3</td>
<td></td>
<td>77</td>
</tr>
<tr class="even">
<td>B40-B43</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td>B44-B45</td>
<td>1g</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>3</td>
<td></td>
<td>77</td>
</tr>
<tr class="even">
<td>B46-B47</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td>B48 (.0-.4, .8)</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td><p>ICD</p>
<p>Category</p></td>
<td colspan="7">Priority Levels</td>
<td>Comments</td>
<td colspan="3">Query Form</td>
</tr>
<tr class="odd">
<td></td>
<td>1</td>
<td>2</td>
<td>3</td>
<td>4</td>
<td>5</td>
<td>6</td>
<td>0</td>
<td></td>
<td>Ltr#</td>
<td>Ques#</td>
<td>Pg#</td>
</tr>
<tr class="even">
<td>B48 (.7)</td>
<td>1c</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>8</td>
<td>1</td>
<td>107</td>
</tr>
<tr class="odd">
<td>B49</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td>B50-B57</td>
<td>1a</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>1</td>
<td></td>
<td>67</td>
</tr>
<tr class="odd">
<td>B58-B59</td>
<td>1g</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>3</td>
<td></td>
<td>77</td>
</tr>
<tr class="even">
<td>B60-B64</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td>B65-B74</td>
<td>1a</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>1</td>
<td></td>
<td>67</td>
</tr>
<tr class="even">
<td>B75-B83</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td>B85-B86</td>
<td>1c</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>8</td>
<td>1,2</td>
<td>107</td>
</tr>
<tr class="even">
<td>B87-B94</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td>B99</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td><p>C00 (.0-.4,</p>
<p>.6-.8)</p></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td>C00 (.5, .9)</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>5</td>
<td></td>
<td></td>
<td></td>
<td>2</td>
<td></td>
<td>71</td>
</tr>
<tr class="even">
<td>C01-C05</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td>C06 (.0-.8)</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td>C06 (.9)</td>
<td></td>
<td></td>
<td></td>
<td>4</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>2</td>
<td></td>
<td>71</td>
</tr>
<tr class="odd">
<td>C07-C09</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td>C10 (.0-.8)</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td>C10 (.9)</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>5</td>
<td></td>
<td></td>
<td></td>
<td>2</td>
<td></td>
<td>71</td>
</tr>
<tr class="even">
<td>C11 (.0-.8)</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td>C11 (.9)</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>5</td>
<td></td>
<td></td>
<td></td>
<td>2</td>
<td></td>
<td>71</td>
</tr>
<tr class="even">
<td>C12</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td>C13 (.0-.8)</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td>C13 (.9)</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>5</td>
<td></td>
<td></td>
<td></td>
<td>2</td>
<td></td>
<td>71</td>
</tr>
<tr class="odd">
<td>C14 (.0)</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>5</td>
<td></td>
<td></td>
<td></td>
<td>2</td>
<td></td>
<td>71</td>
</tr>
<tr class="even">
<td>C14 (.2-.8)</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td>C15-C23</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td>C24 (.0-.8)</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td><p>ICD</p>
<p>Category</p></td>
<td colspan="7">Priority Levels</td>
<td>Comments</td>
<td colspan="3">Query Form</td>
</tr>
<tr class="even">
<td></td>
<td>1</td>
<td>2</td>
<td>3</td>
<td>4</td>
<td>5</td>
<td>6</td>
<td>0</td>
<td></td>
<td>Ltr#</td>
<td>Ques#</td>
<td>Pg#</td>
</tr>
<tr class="odd">
<td>C24 (.9)</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>5</td>
<td></td>
<td></td>
<td></td>
<td>2</td>
<td></td>
<td>71</td>
</tr>
<tr class="even">
<td>C25 (.0-.8)</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td>C25 (.9)</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>5</td>
<td></td>
<td></td>
<td></td>
<td>2</td>
<td></td>
<td>71</td>
</tr>
<tr class="even">
<td>C26 (.0-.8)</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td>C26 (.9)</td>
<td></td>
<td></td>
<td></td>
<td>4</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>2</td>
<td></td>
<td>71</td>
</tr>
<tr class="even">
<td>C30</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td>C31 (.0-.8)</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td>C31 (.9)</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>5</td>
<td></td>
<td></td>
<td></td>
<td>2</td>
<td></td>
<td>71</td>
</tr>
<tr class="odd">
<td>C32 (.0-.8)</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td>C32 (.9)</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>5</td>
<td></td>
<td></td>
<td></td>
<td>2</td>
<td></td>
<td>71</td>
</tr>
<tr class="odd">
<td>C33</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td>C34 (.0-.8)</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td>C34 (.9)</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>5</td>
<td></td>
<td></td>
<td></td>
<td>2</td>
<td></td>
<td>71</td>
</tr>
<tr class="even">
<td>C37</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td><p>C38 (.0-.2,</p>
<p>.4-.8)</p></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td>C38 (.3)</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>5</td>
<td></td>
<td></td>
<td></td>
<td>2</td>
<td></td>
<td>71</td>
</tr>
<tr class="odd">
<td>C39</td>
<td></td>
<td></td>
<td></td>
<td>4</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>2</td>
<td></td>
<td>71</td>
</tr>
<tr class="even">
<td>C40</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td>C41 (.0-.8)</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td>C41 (.9)</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>5</td>
<td></td>
<td></td>
<td></td>
<td>2</td>
<td></td>
<td>71</td>
</tr>
<tr class="odd">
<td>C43 (.0-.8)</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td>C43 (.9)</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>5</td>
<td></td>
<td></td>
<td></td>
<td>2</td>
<td></td>
<td>71</td>
</tr>
<tr class="odd">
<td>C44 (.0-.8)</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td>C44 (.9)</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>5</td>
<td></td>
<td></td>
<td></td>
<td>2</td>
<td></td>
<td>71</td>
</tr>
<tr class="odd">
<td>C45 (.0-.7)</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td>C45 (.9)</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>5</td>
<td></td>
<td></td>
<td></td>
<td>2</td>
<td></td>
<td>71</td>
</tr>
<tr class="odd">
<td>C46 (.0-.8)</td>
<td>1g</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>3</td>
<td></td>
<td>77</td>
</tr>
<tr class="even">
<td><p>ICD</p>
<p>Category</p></td>
<td colspan="7">Priority Levels</td>
<td>Comments</td>
<td colspan="3">Query Form</td>
</tr>
<tr class="odd">
<td></td>
<td>1</td>
<td>2</td>
<td>3</td>
<td>4</td>
<td>5</td>
<td>6</td>
<td>0</td>
<td></td>
<td>Ltr#</td>
<td>Ques#</td>
<td>Pg#</td>
</tr>
<tr class="even">
<td>C46 (.9)</td>
<td>1g</td>
<td></td>
<td></td>
<td></td>
<td>5</td>
<td></td>
<td></td>
<td></td>
<td><p>3</p>
<p>2</p></td>
<td></td>
<td><p>77</p>
<p>71</p></td>
</tr>
<tr class="odd">
<td>C47 (.0-.8)</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td>C47 (.9)</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>5</td>
<td></td>
<td></td>
<td></td>
<td>2</td>
<td></td>
<td>71</td>
</tr>
<tr class="odd">
<td>C48 (.0-.1, .8)</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td>C48 (.2)</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>5</td>
<td></td>
<td></td>
<td></td>
<td>2</td>
<td></td>
<td>71</td>
</tr>
<tr class="odd">
<td>C49 (.0-.8)</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td>C49 (.9)</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>5</td>
<td></td>
<td></td>
<td></td>
<td>2</td>
<td></td>
<td>71</td>
</tr>
<tr class="odd">
<td>C50-C56</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td>C57 (.0-.8)</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td>C57 (.9)</td>
<td></td>
<td></td>
<td></td>
<td>4</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>2</td>
<td></td>
<td>71</td>
</tr>
<tr class="even">
<td>C58-C62</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td>C63 (.0-.8)</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td>C63 (.9)</td>
<td></td>
<td></td>
<td></td>
<td>4</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>2</td>
<td></td>
<td>71</td>
</tr>
<tr class="odd">
<td>C64-C67</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td>C68 (.0-.8)</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td>C68 (.9)</td>
<td></td>
<td></td>
<td></td>
<td>4</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>2</td>
<td></td>
<td>71</td>
</tr>
<tr class="even">
<td>C69 (.0-.8)</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td>C69 (.9)</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>5</td>
<td></td>
<td></td>
<td></td>
<td>2</td>
<td></td>
<td>71</td>
</tr>
<tr class="even">
<td>C70</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td>C71 (.0-.8)</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td>C71 (.9)</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>5</td>
<td></td>
<td></td>
<td></td>
<td>2</td>
<td></td>
<td>71</td>
</tr>
<tr class="odd">
<td>C72 (.0-.8)</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td>C72 (.9)</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>5</td>
<td></td>
<td></td>
<td></td>
<td>2</td>
<td></td>
<td>71</td>
</tr>
<tr class="odd">
<td>C73-C74</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td>C75 (.0-.8)</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td>C75 (.9)</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>5</td>
<td></td>
<td></td>
<td></td>
<td>2</td>
<td></td>
<td>71</td>
</tr>
<tr class="even">
<td>C76</td>
<td></td>
<td></td>
<td>3</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>2</td>
<td></td>
<td>71</td>
</tr>
<tr class="odd">
<td><p>ICD</p>
<p>Category</p></td>
<td colspan="7">Priority Levels</td>
<td>Comments</td>
<td colspan="3">Query Form</td>
</tr>
<tr class="even">
<td></td>
<td>1</td>
<td>2</td>
<td>3</td>
<td>4</td>
<td>5</td>
<td>6</td>
<td>0</td>
<td></td>
<td>Ltr#</td>
<td>Ques#</td>
<td>Pg#</td>
</tr>
<tr class="odd">
<td>C77-C80</td>
<td>1b</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>2</td>
<td></td>
<td>71</td>
</tr>
<tr class="even">
<td>C81-C82</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td>C83</td>
<td>1g</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>3</td>
<td></td>
<td>77</td>
</tr>
<tr class="even">
<td>C84</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td>C85</td>
<td>1g</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>3</td>
<td></td>
<td>77</td>
</tr>
<tr class="even">
<td>C88-C94</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td>C95</td>
<td></td>
<td></td>
<td>3</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>2</td>
<td></td>
<td>71</td>
</tr>
<tr class="even">
<td>C96</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td>C97</td>
<td>1b</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>2</td>
<td></td>
<td>71</td>
</tr>
<tr class="even">
<td>D00-D07</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td>D09 (.0-.7)</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td>D09 (.9)</td>
<td></td>
<td></td>
<td></td>
<td>4</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>2</td>
<td></td>
<td>71</td>
</tr>
<tr class="odd">
<td>D10-D12</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td>D13 (.0-.7)</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td>D13 (.9)</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>5</td>
<td></td>
<td></td>
<td></td>
<td>2</td>
<td></td>
<td>71</td>
</tr>
<tr class="even">
<td>D14 (.0-.3)</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td>D14 (.4)</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>5</td>
<td></td>
<td></td>
<td></td>
<td>2</td>
<td></td>
<td>71</td>
</tr>
<tr class="even">
<td>D15 (.0-.7)</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td>D15 (.9)</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>5</td>
<td></td>
<td></td>
<td></td>
<td>2</td>
<td></td>
<td>71</td>
</tr>
<tr class="even">
<td>D16 (.0-.8)</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td>D16 (.9)</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>5</td>
<td></td>
<td></td>
<td></td>
<td>2</td>
<td></td>
<td>71</td>
</tr>
<tr class="even">
<td>D17 (.0-.7)</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td>D17 (.9)</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>5</td>
<td></td>
<td></td>
<td></td>
<td>2</td>
<td></td>
<td>71</td>
</tr>
<tr class="even">
<td>D18</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td>D19 (.0-.7)</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td>D19 (.9)</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>5</td>
<td></td>
<td></td>
<td></td>
<td>2</td>
<td></td>
<td>71</td>
</tr>
<tr class="odd">
<td>D20</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td><p>ICD</p>
<p>Category</p></td>
<td colspan="7">Priority Levels</td>
<td>Comments</td>
<td colspan="3">Query Form</td>
</tr>
<tr class="odd">
<td></td>
<td>1</td>
<td>2</td>
<td>3</td>
<td>4</td>
<td>5</td>
<td>6</td>
<td>0</td>
<td></td>
<td>Ltr#</td>
<td>Ques#</td>
<td>Pg#</td>
</tr>
<tr class="even">
<td>D21 (.0-.6)</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td>D21 (.9)</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>5</td>
<td></td>
<td></td>
<td></td>
<td>2</td>
<td></td>
<td>71</td>
</tr>
<tr class="even">
<td>D22 (.0-.7)</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td>D22 (.9)</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>5</td>
<td></td>
<td></td>
<td></td>
<td>2</td>
<td></td>
<td>71</td>
</tr>
<tr class="even">
<td>D23 (.0-.7)</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td>D23 (.9)</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>5</td>
<td></td>
<td></td>
<td></td>
<td>2</td>
<td></td>
<td>71</td>
</tr>
<tr class="even">
<td>D24-D27</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td>D28 (.0-.7)</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td>D28 (.9)</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>5</td>
<td></td>
<td></td>
<td></td>
<td>2</td>
<td></td>
<td>71</td>
</tr>
<tr class="odd">
<td>D29 (.0-.7)</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td>D29 (.9)</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>5</td>
<td></td>
<td></td>
<td></td>
<td>2</td>
<td></td>
<td>71</td>
</tr>
<tr class="odd">
<td>D30 (.0-.7)</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td>D30 (.9)</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>5</td>
<td></td>
<td></td>
<td></td>
<td>2</td>
<td></td>
<td>71</td>
</tr>
<tr class="odd">
<td>D31 (.0-.6)</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td>D31 (.9)</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>5</td>
<td></td>
<td></td>
<td></td>
<td>2</td>
<td></td>
<td>71</td>
</tr>
<tr class="odd">
<td>D32</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td>D33 (.0-.7)</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td>D33 (.9)</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>5</td>
<td></td>
<td></td>
<td></td>
<td>2</td>
<td></td>
<td>71</td>
</tr>
<tr class="even">
<td>D34</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td>D35 (.0-.8)</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td>D35 (.9)</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>5</td>
<td></td>
<td></td>
<td></td>
<td>2</td>
<td></td>
<td>71</td>
</tr>
<tr class="odd">
<td>D36 (.0-.7)</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td>D36 (.9)</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>5</td>
<td></td>
<td></td>
<td></td>
<td>2</td>
<td></td>
<td>71</td>
</tr>
<tr class="odd">
<td>D37 (.0-.7)</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td>D37 (.9)</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>5</td>
<td></td>
<td></td>
<td></td>
<td>2</td>
<td></td>
<td>71</td>
</tr>
<tr class="odd">
<td>D38 (.0-.5)</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td>D38 (.6)</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>5</td>
<td></td>
<td></td>
<td></td>
<td>2</td>
<td></td>
<td>71</td>
</tr>
<tr class="odd">
<td><p>ICD</p>
<p>Category</p></td>
<td colspan="7">Priority Levels</td>
<td>Comments</td>
<td colspan="3">Query Form</td>
</tr>
<tr class="even">
<td></td>
<td>1</td>
<td>2</td>
<td>3</td>
<td>4</td>
<td>5</td>
<td>6</td>
<td>0</td>
<td></td>
<td>Ltr#</td>
<td>Ques#</td>
<td>Pg#</td>
</tr>
<tr class="odd">
<td>D39 (.0-.7)</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td>D39 (.9)</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>5</td>
<td></td>
<td></td>
<td></td>
<td>2</td>
<td></td>
<td>71</td>
</tr>
<tr class="odd">
<td>D40 (.0-.7)</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td>D40 (.9)</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>5</td>
<td></td>
<td></td>
<td></td>
<td>2</td>
<td></td>
<td>71</td>
</tr>
<tr class="odd">
<td>D41 (.0-.7)</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td>D41 (.9)</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>5</td>
<td></td>
<td></td>
<td></td>
<td>2</td>
<td></td>
<td>71</td>
</tr>
<tr class="odd">
<td>D42</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td><p>D43 (.0-.1,</p>
<p>.3-.7)</p></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td>D43 (.2, .9)</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>5</td>
<td></td>
<td></td>
<td></td>
<td>2</td>
<td></td>
<td>71</td>
</tr>
<tr class="even">
<td>D44 (.0-.8)</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td>D44 (.9)</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>5</td>
<td></td>
<td></td>
<td></td>
<td>2</td>
<td></td>
<td>71</td>
</tr>
<tr class="even">
<td>D45-D46</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td>D47 (.0-.7)</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td>D47 (.9)</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>5</td>
<td></td>
<td></td>
<td></td>
<td>2</td>
<td></td>
<td>71</td>
</tr>
<tr class="odd">
<td>D48 (.0-.7)</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td>D48 (.9)</td>
<td>1b</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>2</td>
<td></td>
<td>71</td>
</tr>
<tr class="odd">
<td>D50-D58</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td>D59 (.0,.2,.4,.6)</td>
<td></td>
<td></td>
<td>3</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>7</td>
<td></td>
<td>101</td>
</tr>
<tr class="odd">
<td><p>D59 (.1,.3,.5,</p>
<p>.8-.9)</p></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td>D60</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td>D61 (.0,.3-.8)</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td>D61 (.1-.2)</td>
<td></td>
<td></td>
<td>3</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>7</td>
<td></td>
<td>101</td>
</tr>
<tr class="odd">
<td>D62</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td>D64 (.0,.3-.8)</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td>D64 (.1)</td>
<td></td>
<td>2</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>4</td>
<td>1</td>
<td>83</td>
</tr>
<tr class="even">
<td>D64 (.2)</td>
<td></td>
<td></td>
<td>3</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>7</td>
<td></td>
<td>101</td>
</tr>
<tr class="odd">
<td><p>ICD</p>
<p>Category</p></td>
<td colspan="7">Priority Levels</td>
<td>Comments</td>
<td colspan="3">Query Form</td>
</tr>
<tr class="even">
<td></td>
<td>1</td>
<td>2</td>
<td>3</td>
<td>4</td>
<td>5</td>
<td>6</td>
<td>0</td>
<td></td>
<td>Ltr#</td>
<td>Ques#</td>
<td>Pg#</td>
</tr>
<tr class="odd">
<td>D64 (.9)</td>
<td></td>
<td></td>
<td>3</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>4</td>
<td>4</td>
<td>83</td>
</tr>
<tr class="even">
<td>D65-D67</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td><p>D68 (.0-.2,</p>
<p>.4-.9)</p></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td>D68 (.3)</td>
<td></td>
<td></td>
<td>3</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>7</td>
<td></td>
<td>101</td>
</tr>
<tr class="odd">
<td><p>D69 (.0-.4,</p>
<p>.6-.8)</p></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td>D69 (.5)</td>
<td></td>
<td></td>
<td>3</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>4</td>
<td>1</td>
<td>83</td>
</tr>
<tr class="odd">
<td>D69 (.9)</td>
<td></td>
<td></td>
<td>3</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td>D70-D73</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td>D74 (.0,.9)</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td>D74 (.8)</td>
<td></td>
<td></td>
<td>3</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>4</td>
<td>4</td>
<td>83</td>
</tr>
<tr class="odd">
<td>D75-D84</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td>D86 (.0-.8)</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td>D86 (.9)</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>5</td>
<td></td>
<td></td>
<td></td>
<td>4</td>
<td>2</td>
<td>83</td>
</tr>
<tr class="even">
<td>D89</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td>E00-E02</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td><p>E03 (.0-.1,</p>
<p>.5-.9)</p></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td>E03 (.2-.4)</td>
<td></td>
<td></td>
<td>3</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>7</td>
<td></td>
<td>101</td>
</tr>
<tr class="even">
<td>E04-E05</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td><p>E06 (.0-.3,</p>
<p>.5-.9)</p></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td>E06 (.4)</td>
<td></td>
<td></td>
<td>3</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>7</td>
<td></td>
<td>101</td>
</tr>
<tr class="odd">
<td>E07</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td>E10-E14</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td>E15</td>
<td></td>
<td></td>
<td>3</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>7</td>
<td></td>
<td>101</td>
</tr>
<tr class="even">
<td>E16 (.0)</td>
<td></td>
<td></td>
<td>3</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>7</td>
<td></td>
<td>101</td>
</tr>
<tr class="odd">
<td>E16 (.1, .3-.9)</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td><p>ICD</p>
<p>Category</p></td>
<td colspan="7">Priority Levels</td>
<td>Comments</td>
<td colspan="3">Query Form</td>
</tr>
<tr class="odd">
<td></td>
<td>1</td>
<td>2</td>
<td>3</td>
<td>4</td>
<td>5</td>
<td>6</td>
<td>0</td>
<td></td>
<td>Ltr#</td>
<td>Ques#</td>
<td>Pg#</td>
</tr>
<tr class="even">
<td>E16 (.2)</td>
<td>1c</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>8</td>
<td>1</td>
<td>107</td>
</tr>
<tr class="odd">
<td>E20-E22</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td>E23 (.0,.2-.7)</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td>E23 (.1)</td>
<td></td>
<td></td>
<td>3</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>7</td>
<td></td>
<td>101</td>
</tr>
<tr class="even">
<td>E24 (.0-.1, .3-.9)</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td>E24 (.2)</td>
<td></td>
<td></td>
<td>3</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>7</td>
<td></td>
<td>101</td>
</tr>
<tr class="even">
<td>E25-E26</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td><p>E27 (.0-.2,</p>
<p>.4-.9)</p></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td>E27 (.3)</td>
<td></td>
<td></td>
<td>3</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>7</td>
<td></td>
<td>101</td>
</tr>
<tr class="odd">
<td>E28-E32</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td>E34 (.0-.8)</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td>E34 (.9)</td>
<td>1c</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>4</td>
<td>3</td>
<td>83</td>
</tr>
<tr class="even">
<td>E40-E46</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td>E50-E64</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td>E65</td>
<td>1c</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>8</td>
<td>2</td>
<td>107</td>
</tr>
<tr class="odd">
<td>E66 (.0, .2-.9)</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td>E66 (.1)</td>
<td></td>
<td></td>
<td>3</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>7</td>
<td></td>
<td>101</td>
</tr>
<tr class="odd">
<td>E67-E88</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td>E89</td>
<td>1d</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>5</td>
<td>1</td>
<td>89</td>
</tr>
<tr class="odd">
<td>F01-F09</td>
<td>1c</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>6</td>
<td></td>
<td>95</td>
</tr>
<tr class="even">
<td>F10-F19</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td>F20-F48</td>
<td>1c</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>6</td>
<td></td>
<td>95</td>
</tr>
<tr class="even">
<td><p>F50 (.0-.3,</p>
<p>.5-.9)</p></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td>F50 (.4)</td>
<td>1c</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>6</td>
<td></td>
<td>95</td>
</tr>
<tr class="even">
<td>F51-F53</td>
<td>1c</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>6</td>
<td></td>
<td>95</td>
</tr>
<tr class="odd">
<td>F54-F55</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td><p>ICD</p>
<p>Category</p></td>
<td colspan="7">Priority Levels</td>
<td>Comments</td>
<td colspan="3">Query Form</td>
</tr>
<tr class="odd">
<td></td>
<td>1</td>
<td>2</td>
<td>3</td>
<td>4</td>
<td>5</td>
<td>6</td>
<td>0</td>
<td></td>
<td>Ltr#</td>
<td>Ques#</td>
<td>Pg#</td>
</tr>
<tr class="even">
<td>F59-F99</td>
<td>1c</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>6</td>
<td></td>
<td>95</td>
</tr>
<tr class="odd">
<td>G00</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td>G03 (.0-.8)</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td>G03 (.9)</td>
<td></td>
<td></td>
<td>3</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>4</td>
<td>4</td>
<td>83</td>
</tr>
<tr class="even">
<td>G04 (.0-.8)</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td>G04 (.9)</td>
<td>1g</td>
<td></td>
<td>3</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td><p>3</p>
<p>4</p></td>
<td>4</td>
<td><p>77</p>
<p>83</p></td>
</tr>
<tr class="even">
<td>G06-G41</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td>G43-G45</td>
<td>1c</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>8</td>
<td>2</td>
<td>107</td>
</tr>
<tr class="even">
<td><p>G47 (.0-.2,</p>
<p>.4, .9)</p></td>
<td>1c</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>8</td>
<td>2</td>
<td>107</td>
</tr>
<tr class="odd">
<td>G47 (.3, .8)</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td>G50-G51</td>
<td>1c</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>8</td>
<td>2</td>
<td>107</td>
</tr>
<tr class="odd">
<td>G52 (.0)</td>
<td>1c</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>8</td>
<td>2</td>
<td>107</td>
</tr>
<tr class="even">
<td>G52 (.1-.8)</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td>G52 (.9)</td>
<td></td>
<td></td>
<td>3</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>4</td>
<td>3</td>
<td>83</td>
</tr>
<tr class="even">
<td>G54</td>
<td>1c</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>8</td>
<td>1,2</td>
<td>107</td>
</tr>
<tr class="odd">
<td>G56-G58</td>
<td>1c</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>8</td>
<td>1,2</td>
<td>107</td>
</tr>
<tr class="even">
<td>G60-G72</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td>G80</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td>G81-G83</td>
<td></td>
<td>2</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>8</td>
<td>1,2</td>
<td>107</td>
</tr>
<tr class="odd">
<td>G90-G92</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td>G93 (.0, .7-.8)</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td>G93 (.4)</td>
<td>1g</td>
<td>2</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td><p>3</p>
<p>4</p></td>
<td>1</td>
<td><p>77</p>
<p>83</p></td>
</tr>
<tr class="even">
<td><p>G93 (.1-.3,</p>
<p>.5-.6)</p></td>
<td></td>
<td>2</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>4</td>
<td>1</td>
<td>83</td>
</tr>
<tr class="odd">
<td>G93 (.9)</td>
<td></td>
<td></td>
<td>3</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>4</td>
<td>3</td>
<td>83</td>
</tr>
<tr class="even">
<td>G95 (.0-.8)</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td><p>ICD</p>
<p>Category</p></td>
<td colspan="7">Priority Levels</td>
<td>Comments</td>
<td colspan="3">Query Form</td>
</tr>
<tr class="even">
<td></td>
<td>1</td>
<td>2</td>
<td>3</td>
<td>4</td>
<td>5</td>
<td>6</td>
<td>0</td>
<td></td>
<td>Ltr#</td>
<td>Ques#</td>
<td>Pg#</td>
</tr>
<tr class="odd">
<td>G95 (.9)</td>
<td>1g</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>3</td>
<td></td>
<td>77</td>
</tr>
<tr class="even">
<td>G96 (.0-.8)</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td>G96 (.9)</td>
<td></td>
<td></td>
<td>3</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>4</td>
<td>3</td>
<td>83</td>
</tr>
<tr class="even">
<td>G97</td>
<td>1d</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>5</td>
<td>1</td>
<td>89</td>
</tr>
<tr class="odd">
<td>G98</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td>H00-H02</td>
<td>1c</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>8</td>
<td>2,3</td>
<td>107</td>
</tr>
<tr class="odd">
<td>H04-H05</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td>H10-H57</td>
<td>1c</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>8</td>
<td>2</td>
<td>107</td>
</tr>
<tr class="odd">
<td>H59</td>
<td>1d</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>5</td>
<td>1</td>
<td>89</td>
</tr>
<tr class="even">
<td>H60-H61</td>
<td>1c</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>8</td>
<td>2,3</td>
<td>107</td>
</tr>
<tr class="odd">
<td>H65-H74</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td>H80-H83</td>
<td>1c</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>8</td>
<td>2,3</td>
<td>107</td>
</tr>
<tr class="odd">
<td>H90-H93</td>
<td>1c</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>8</td>
<td>2</td>
<td>107</td>
</tr>
<tr class="even">
<td>H95</td>
<td>1d</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>5</td>
<td>1</td>
<td>89</td>
</tr>
<tr class="odd">
<td>I00-I22.9</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td><p>I24.1 - I25 (.0-.1,</p>
<p>.3-.9)</p></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td>I26-I42</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td>I44-I45</td>
<td></td>
<td>2</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>4</td>
<td>3</td>
<td>83</td>
</tr>
<tr class="odd">
<td>I46</td>
<td>1c</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>8</td>
<td>1</td>
<td>107</td>
</tr>
<tr class="even">
<td>I47-I50</td>
<td></td>
<td>2</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>4</td>
<td>3</td>
<td>83</td>
</tr>
<tr class="odd">
<td>I51 (.0, .5-.7)</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td><p>I51 (.1-.4,</p>
<p>.8-.9)</p></td>
<td></td>
<td></td>
<td>3</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>4</td>
<td>1</td>
<td>83</td>
</tr>
<tr class="odd">
<td>I60-I64</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td>I67 (.0-.8)</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td>I67 (.9)</td>
<td></td>
<td></td>
<td>3</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>4</td>
<td>3</td>
<td>83</td>
</tr>
<tr class="even">
<td>I69-I71</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td><p>ICD</p>
<p>Category</p></td>
<td colspan="7">Priority Levels</td>
<td>Comments</td>
<td colspan="3">Query Form</td>
</tr>
<tr class="even">
<td></td>
<td>1</td>
<td>2</td>
<td>3</td>
<td>4</td>
<td>5</td>
<td>6</td>
<td>0</td>
<td></td>
<td>Ltr#</td>
<td>Ques#</td>
<td>Pg#</td>
</tr>
<tr class="odd">
<td>I72 (.0-.8)</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td>I72 (.9)</td>
<td></td>
<td></td>
<td></td>
<td>4</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>4</td>
<td>2</td>
<td>83</td>
</tr>
<tr class="odd">
<td>I73</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td>I74 (.0-.8)</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td>I74 (.9)</td>
<td></td>
<td></td>
<td></td>
<td>4</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>4</td>
<td>2</td>
<td>83</td>
</tr>
<tr class="even">
<td>I77-I78</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td>I80 (.0-.8)</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td>I80 (.9)</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>5</td>
<td></td>
<td></td>
<td></td>
<td>4</td>
<td>2</td>
<td>83</td>
</tr>
<tr class="odd">
<td>I81</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td>I82 (.0-.8)</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td>I82 (.9)</td>
<td></td>
<td></td>
<td></td>
<td>4</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>4</td>
<td>2</td>
<td>83</td>
</tr>
<tr class="even">
<td>I83</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td><p>I84 (.0-.1,</p>
<p>.3-.5, .7-.8)</p></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td>I84 (.2,.6,.9)</td>
<td>1c</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>8</td>
<td>2</td>
<td>107</td>
</tr>
<tr class="odd">
<td>I85 (.0)</td>
<td></td>
<td>2</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>8</td>
<td>1</td>
<td>107</td>
</tr>
<tr class="even">
<td>I85 (.9)</td>
<td>1c</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>8</td>
<td>1,2</td>
<td>107</td>
</tr>
<tr class="odd">
<td>I86-I89</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td>I95</td>
<td></td>
<td>2</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>8</td>
<td>1</td>
<td>107</td>
</tr>
<tr class="odd">
<td>I97</td>
<td>1d</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>5</td>
<td></td>
<td>89</td>
</tr>
<tr class="even">
<td>I99</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td>J00</td>
<td>1c</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>8</td>
<td>1,2</td>
<td>107</td>
</tr>
<tr class="even">
<td>J01-J05</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td>J06</td>
<td>1c</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>8</td>
<td>1,2</td>
<td>107</td>
</tr>
<tr class="even">
<td>J10-J22</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td>J30</td>
<td>1c</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>8</td>
<td>1,2</td>
<td>107</td>
</tr>
<tr class="even">
<td>J31-J32</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td>J33</td>
<td>1c</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>8</td>
<td>2</td>
<td>107</td>
</tr>
<tr class="even">
<td><p>ICD</p>
<p>Category</p></td>
<td colspan="7">Priority Levels</td>
<td>Comments</td>
<td colspan="3">Query Form</td>
</tr>
<tr class="odd">
<td></td>
<td>1</td>
<td>2</td>
<td>3</td>
<td>4</td>
<td>5</td>
<td>6</td>
<td>0</td>
<td></td>
<td>Ltr#</td>
<td>Ques#</td>
<td>Pg#</td>
</tr>
<tr class="even">
<td><p>J34 (.0-.1,</p>
<p>.3-.8)</p></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td>J34 (.2)</td>
<td>1c</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>8</td>
<td>1</td>
<td>107</td>
</tr>
<tr class="even">
<td>J35</td>
<td>1c</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>8</td>
<td>2</td>
<td>107</td>
</tr>
<tr class="odd">
<td>J36-J38</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td>J39 (.0-.8)</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td>J39 (.9)</td>
<td></td>
<td></td>
<td>3</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>4</td>
<td>3</td>
<td>83</td>
</tr>
<tr class="even">
<td>J40-J63</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td>J64</td>
<td></td>
<td></td>
<td>3</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>4</td>
<td>3</td>
<td>83</td>
</tr>
<tr class="even">
<td>J65-J69</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td>J70</td>
<td></td>
<td></td>
<td>3</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>7</td>
<td>1,2</td>
<td>101</td>
</tr>
<tr class="even">
<td>J80</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td>J81</td>
<td></td>
<td>2</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>4</td>
<td>1</td>
<td>83</td>
</tr>
<tr class="even">
<td>J82-J94</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td>J95</td>
<td>1d</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>5</td>
<td>1</td>
<td>89</td>
</tr>
<tr class="even">
<td>J96</td>
<td>1c</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>8</td>
<td>1</td>
<td>107</td>
</tr>
<tr class="odd">
<td>J98 (.0, .2-.8)</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td>J98 (.1)</td>
<td></td>
<td>2</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>8</td>
<td>1</td>
<td>107</td>
</tr>
<tr class="odd">
<td>J98 (.9)</td>
<td></td>
<td></td>
<td>3</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>4</td>
<td>3</td>
<td>83</td>
</tr>
<tr class="even">
<td>K00-K01</td>
<td>1c</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>8</td>
<td>1,2</td>
<td>107</td>
</tr>
<tr class="odd">
<td>K02</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td>K03</td>
<td>1c</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>8</td>
<td>1,2</td>
<td>107</td>
</tr>
<tr class="odd">
<td>K04-K05</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td>K06-K14</td>
<td>1c</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>8</td>
<td>1,2</td>
<td>107</td>
</tr>
<tr class="odd">
<td>K20-K30</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td>K31 (.0-.8)</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td>K31 (.9)</td>
<td></td>
<td></td>
<td>3</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>4</td>
<td>3</td>
<td>83</td>
</tr>
<tr class="even">
<td>K35-K51</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td><p>ICD</p>
<p>Category</p></td>
<td colspan="7">Priority Levels</td>
<td>Comments</td>
<td colspan="3">Query Form</td>
</tr>
<tr class="even">
<td></td>
<td>1</td>
<td>2</td>
<td>3</td>
<td>4</td>
<td>5</td>
<td>6</td>
<td>0</td>
<td></td>
<td>Ltr#</td>
<td>Ques#</td>
<td>Pg#</td>
</tr>
<tr class="odd">
<td>K52 (.0-.8)</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td>K52 (.9)</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>6</td>
<td></td>
<td></td>
<td>4</td>
<td>4</td>
<td>83</td>
</tr>
<tr class="odd">
<td>K55-K61</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td>K62 (.0-.4)</td>
<td>1c</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>8</td>
<td>2</td>
<td>107</td>
</tr>
<tr class="odd">
<td>K62 (.5-.8)</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td>K62 (.9)</td>
<td></td>
<td></td>
<td>3</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>4</td>
<td>4</td>
<td>83</td>
</tr>
<tr class="odd">
<td>K63 (.0-.3, .5, .8)</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td>K63 (.4)</td>
<td>1c</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>8</td>
<td>2</td>
<td>107</td>
</tr>
<tr class="odd">
<td>K63 (.9)</td>
<td></td>
<td></td>
<td>3</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>4</td>
<td>4</td>
<td>83</td>
</tr>
<tr class="even">
<td>K65</td>
<td></td>
<td>2</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>4</td>
<td>1</td>
<td>83</td>
</tr>
<tr class="odd">
<td>K66-K71</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td>K72</td>
<td>1c</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>4</td>
<td>1</td>
<td>83</td>
</tr>
<tr class="odd">
<td>K73</td>
<td></td>
<td></td>
<td>3</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>4</td>
<td>1</td>
<td>83</td>
</tr>
<tr class="even">
<td>K74-K75</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td>K76 (.0)</td>
<td>1c</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>8</td>
<td>2</td>
<td>107</td>
</tr>
<tr class="even">
<td>K76 (.1-.8)</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td>K76 (.9)</td>
<td></td>
<td></td>
<td>3</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>4</td>
<td>4</td>
<td>83</td>
</tr>
<tr class="even">
<td>K80-K81</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td>K82 (.0-.8)</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td>K82 (.9)</td>
<td></td>
<td></td>
<td>3</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>4</td>
<td>3</td>
<td>83</td>
</tr>
<tr class="odd">
<td>K83-K85</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td>K86 (.0-.8)</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td>K86 (.9)</td>
<td></td>
<td></td>
<td></td>
<td>4</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>4</td>
<td>3</td>
<td>83</td>
</tr>
<tr class="even">
<td>K90 (.0-.8)</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td>K90 (.9)</td>
<td></td>
<td></td>
<td>3</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>4</td>
<td>3</td>
<td>83</td>
</tr>
<tr class="even">
<td>K91</td>
<td>1d</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>5</td>
<td></td>
<td>89</td>
</tr>
<tr class="odd">
<td>K92 (.0-.2)</td>
<td></td>
<td>2</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>4</td>
<td>1</td>
<td>83</td>
</tr>
<tr class="even">
<td><p>ICD</p>
<p>Category</p></td>
<td colspan="7">Priority Levels</td>
<td>Comments</td>
<td colspan="3">Query Form</td>
</tr>
<tr class="odd">
<td></td>
<td>1</td>
<td>2</td>
<td>3</td>
<td>4</td>
<td>5</td>
<td>6</td>
<td>0</td>
<td></td>
<td>Ltr#</td>
<td>Ques#</td>
<td>Pg#</td>
</tr>
<tr class="even">
<td>K92 (.8)</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td>K92 (.9)</td>
<td></td>
<td></td>
<td>3</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>4</td>
<td>3</td>
<td>83</td>
</tr>
<tr class="even">
<td>L00</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td>L01-L02</td>
<td>1c</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>8</td>
<td>2</td>
<td>107</td>
</tr>
<tr class="even">
<td>L03-L04</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td>L05-L08</td>
<td>1c</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>8</td>
<td>2</td>
<td>107</td>
</tr>
<tr class="even">
<td>L10-L13</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td>L20-L25</td>
<td>1c</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>8</td>
<td>2</td>
<td>107</td>
</tr>
<tr class="even">
<td>L26</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td>L27-L30</td>
<td>1c</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>8</td>
<td>2</td>
<td>107</td>
</tr>
<tr class="even">
<td>L40-L41</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td>L42-L44</td>
<td>1c</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>8</td>
<td>2</td>
<td>107</td>
</tr>
<tr class="even">
<td>L50</td>
<td>1c</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>8</td>
<td>2</td>
<td>107</td>
</tr>
<tr class="odd">
<td>L51-L53</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td>L55 (.0, .8-.9)</td>
<td>1c</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>8</td>
<td>2</td>
<td>107</td>
</tr>
<tr class="odd">
<td>L55 (.1, .2)</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td>L56-L87</td>
<td>1c</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>8</td>
<td>2</td>
<td>107</td>
</tr>
<tr class="odd">
<td>L88-L89</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td>L90-L95</td>
<td>1c</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>8</td>
<td>2</td>
<td>107</td>
</tr>
<tr class="odd">
<td>L97</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td><p>L98</p>
<p>(.0-.1, .5-.9)</p></td>
<td>1c</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>8</td>
<td>2</td>
<td>107</td>
</tr>
<tr class="odd">
<td>L98 (.2-.4)</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td>M00-M13</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td>M15-M25</td>
<td>1c</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>8</td>
<td>1,2</td>
<td>107</td>
</tr>
<tr class="even">
<td>M30-M34</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td><p>M35 (.0-.2,</p>
<p>.4-.6, .8-.9)</p></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td><p>ICD</p>
<p>Category</p></td>
<td colspan="7">Priority Levels</td>
<td>Comments</td>
<td colspan="3">Query Form</td>
</tr>
<tr class="odd">
<td></td>
<td>1</td>
<td>2</td>
<td>3</td>
<td>4</td>
<td>5</td>
<td>6</td>
<td>0</td>
<td></td>
<td>Ltr#</td>
<td>Ques#</td>
<td>Pg#</td>
</tr>
<tr class="even">
<td>M35 (.3, .7)</td>
<td>1c</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>8</td>
<td>1,2</td>
<td>107</td>
</tr>
<tr class="odd">
<td>M40-M45</td>
<td>1c</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>8</td>
<td>2</td>
<td>107</td>
</tr>
<tr class="even">
<td><p>M46 (.0-.1, .4,</p>
<p>.8-.9)</p></td>
<td>1c</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>8</td>
<td>2</td>
<td>107</td>
</tr>
<tr class="odd">
<td>M46 (.2-.3, .5)</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td>M47-M54</td>
<td>1c</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>8</td>
<td>2</td>
<td>107</td>
</tr>
<tr class="odd">
<td>M60 (.0)</td>
<td></td>
<td></td>
<td>3</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>7</td>
<td></td>
<td>101</td>
</tr>
<tr class="even">
<td>M60 (.1-.9)</td>
<td>1c</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>8</td>
<td>2</td>
<td>107</td>
</tr>
<tr class="odd">
<td>M61</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td><p>M62 (.0-.1,</p>
<p>.4-.9)</p></td>
<td>1c</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>8</td>
<td>2</td>
<td>107</td>
</tr>
<tr class="odd">
<td>M62 (.2-.3)</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td>M65-M79</td>
<td>1c</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>8</td>
<td>2</td>
<td>107</td>
</tr>
<tr class="odd">
<td><p>M80 (.0, .2,</p>
<p>.5-.9)</p></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td>M80 (.1, .3)</td>
<td></td>
<td></td>
<td>3</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>5</td>
<td>1</td>
<td>89</td>
</tr>
<tr class="odd">
<td>M80 (.4)</td>
<td></td>
<td></td>
<td>3</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>7</td>
<td></td>
<td>101</td>
</tr>
<tr class="even">
<td>M81</td>
<td>1c</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>8</td>
<td>2</td>
<td>107</td>
</tr>
<tr class="odd">
<td><p>M83 (.0-.4,</p>
<p>.8-.9)</p></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td>M83 (.5)</td>
<td></td>
<td></td>
<td>3</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>7</td>
<td></td>
<td>101</td>
</tr>
<tr class="odd">
<td>M84</td>
<td>1c</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>8</td>
<td>2</td>
<td>107</td>
</tr>
<tr class="even">
<td>M85-M88</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td>M89</td>
<td>1c</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>8</td>
<td>2</td>
<td>107</td>
</tr>
<tr class="even">
<td>M91-M94</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td>M95</td>
<td>1c</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>8</td>
<td>2</td>
<td>107</td>
</tr>
<tr class="even">
<td>M96</td>
<td>1d</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>5</td>
<td>1</td>
<td>89</td>
</tr>
<tr class="odd">
<td>M99</td>
<td>1c</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>8</td>
<td>2</td>
<td>107</td>
</tr>
<tr class="even">
<td>N00-N07</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td><p>ICD</p>
<p>Category</p></td>
<td colspan="7">Priority Levels</td>
<td>Comments</td>
<td colspan="3">Query Form</td>
</tr>
<tr class="even">
<td></td>
<td>1</td>
<td>2</td>
<td>3</td>
<td>4</td>
<td>5</td>
<td>6</td>
<td>0</td>
<td></td>
<td>Ltr#</td>
<td>Ques#</td>
<td>Pg#</td>
</tr>
<tr class="odd">
<td>N10-N13</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td>N14</td>
<td></td>
<td></td>
<td>3</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>7</td>
<td></td>
<td>101</td>
</tr>
<tr class="odd">
<td>N15</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td>N17 (.0-.8)</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td>N17 (.9)</td>
<td></td>
<td>2</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>4</td>
<td>2</td>
<td>83</td>
</tr>
<tr class="even">
<td>N18 (.0-.8)</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td>N18 (.9)</td>
<td></td>
<td>2</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>4</td>
<td>3</td>
<td>83</td>
</tr>
<tr class="even">
<td>N19</td>
<td></td>
<td>2</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>4</td>
<td>3</td>
<td>83</td>
</tr>
<tr class="odd">
<td>N20-N23</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td>N25-N27</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td>N28 (.0-.8)</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td>N28 (.9)</td>
<td></td>
<td></td>
<td>3</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>4</td>
<td>3</td>
<td>83</td>
</tr>
<tr class="odd">
<td>N30</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
</tbody>
</table>

<table>
<colgroup>
<col style="width: 20%" />
<col style="width: 5%" />
<col style="width: 4%" />
<col style="width: 4%" />
<col style="width: 3%" />
<col style="width: 4%" />
<col style="width: 4%" />
<col style="width: 4%" />
<col style="width: 24%" />
<col style="width: 7%" />
<col style="width: 8%" />
<col style="width: 8%" />
</colgroup>
<tbody>
<tr class="odd">
<td>N31</td>
<td>1c</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>8</td>
<td>1,2</td>
<td>107</td>
</tr>
<tr class="even">
<td>N32 (.0-.8)</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td>N32 (.9)</td>
<td></td>
<td></td>
<td>3</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>4</td>
<td>3</td>
<td>83</td>
</tr>
<tr class="even">
<td>N34</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td>N35</td>
<td></td>
<td>2</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>8</td>
<td>2</td>
<td>107</td>
</tr>
<tr class="even">
<td>N36</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td>N39 (.0, .8)</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td>N39 (.1-.4)</td>
<td>1c</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>8</td>
<td>2</td>
<td>107</td>
</tr>
<tr class="odd">
<td>N39 (.9)</td>
<td></td>
<td></td>
<td>3</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>4</td>
<td>3</td>
<td>83</td>
</tr>
<tr class="even">
<td>N40-N45</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td>N46-N47</td>
<td>1c</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>8</td>
<td>2</td>
<td>107</td>
</tr>
<tr class="even">
<td>N48-N50</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td>N60</td>
<td>1c</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>8</td>
<td>2</td>
<td>107</td>
</tr>
<tr class="even">
<td>N61</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td><p>ICD</p>
<p>Category</p></td>
<td colspan="7">Priority Levels</td>
<td>Comments</td>
<td colspan="3">Query Form</td>
</tr>
<tr class="even">
<td></td>
<td>1</td>
<td>2</td>
<td>3</td>
<td>4</td>
<td>5</td>
<td>6</td>
<td>0</td>
<td></td>
<td>Ltr#</td>
<td>Ques#</td>
<td>Pg#</td>
</tr>
<tr class="odd">
<td>N62-N64</td>
<td>1c</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>8</td>
<td>2</td>
<td>107</td>
</tr>
<tr class="even">
<td>N70-N76</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td>N80-N83</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td>N84-N91</td>
<td>1c</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>8</td>
<td>2</td>
<td>107</td>
</tr>
<tr class="odd">
<td>N92 (.0-.2, .4)</td>
<td></td>
<td>2</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>8</td>
<td>1</td>
<td>107</td>
</tr>
<tr class="even">
<td>N92 (.3, .5-.6)</td>
<td>1c</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>8</td>
<td>2</td>
<td>107</td>
</tr>
<tr class="odd">
<td>N93-N97</td>
<td>1c</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>8</td>
<td>2</td>
<td>107</td>
</tr>
<tr class="even">
<td>N98</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td>N99</td>
<td>1d</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>5</td>
<td></td>
<td>89</td>
</tr>
<tr class="even">
<td>O00-O02</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td>003-O05 (.0-.8)</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td>003-O05 (.9)</td>
<td>1c</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>9</td>
<td>1</td>
<td>113</td>
</tr>
<tr class="odd">
<td>O06 (.0-.8)</td>
<td></td>
<td></td>
<td>3</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>9</td>
<td>1</td>
<td>113</td>
</tr>
<tr class="even">
<td>O06 (.9)</td>
<td>1c</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>9</td>
<td>1,2</td>
<td>113</td>
</tr>
<tr class="odd">
<td>O07 (.0-.8)</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td>O07 (.9)</td>
<td>1c</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>9</td>
<td>1,2</td>
<td>113</td>
</tr>
<tr class="odd">
<td>O08</td>
<td>1c</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>9</td>
<td>1,3</td>
<td>113</td>
</tr>
<tr class="even">
<td>O10-O21</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td>O22 (.0-.1, .4)</td>
<td>1c</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>9</td>
<td>1</td>
<td>113</td>
</tr>
<tr class="even">
<td><p>O22 (.2-.3,</p>
<p>.5-.9)</p></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td>O23-O26</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td>O28</td>
<td>1c</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>8</td>
<td>2</td>
<td>107</td>
</tr>
<tr class="odd">
<td>O29-O43</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td>O44 (.0)</td>
<td>1c</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>9</td>
<td>1</td>
<td>113</td>
</tr>
<tr class="odd">
<td>O44 (.1)</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td><p>ICD</p>
<p>Category</p></td>
<td colspan="7">Priority Levels</td>
<td>Comments</td>
<td colspan="3">Query Form</td>
</tr>
<tr class="odd">
<td></td>
<td>1</td>
<td>2</td>
<td>3</td>
<td>4</td>
<td>5</td>
<td>6</td>
<td>0</td>
<td></td>
<td>Ltr#</td>
<td>Ques#</td>
<td>Pg#</td>
</tr>
<tr class="even">
<td>O45-O46</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td>O47-O48</td>
<td>1c</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>9</td>
<td>1</td>
<td>113</td>
</tr>
<tr class="even">
<td>O60-O69</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td>O70 (.0)</td>
<td>1c</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>9</td>
<td>1</td>
<td>113</td>
</tr>
<tr class="even">
<td>O70 (.1-.9)</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td>O71-O74</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td><p>O75 (.0-.4,</p>
<p>.8-.9)</p></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td>O75 (.5-.7)</td>
<td>1c</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>9</td>
<td>1</td>
<td>113</td>
</tr>
<tr class="even">
<td>O85-O86</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td><p>O87 (.0-.1,</p>
<p>.3-.9)</p></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td>O87 (.2)</td>
<td>1c</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>8</td>
<td>2</td>
<td>107</td>
</tr>
<tr class="odd">
<td>O88-O91</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td>O92</td>
<td>1c</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>8</td>
<td>2</td>
<td>107</td>
</tr>
</tbody>
</table>

<table>
<colgroup>
<col style="width: 20%" />
<col style="width: 5%" />
<col style="width: 4%" />
<col style="width: 4%" />
<col style="width: 3%" />
<col style="width: 4%" />
<col style="width: 4%" />
<col style="width: 4%" />
<col style="width: 24%" />
<col style="width: 7%" />
<col style="width: 8%" />
<col style="width: 8%" />
</colgroup>
<tbody>
<tr class="odd">
<td>O95-O99</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td>P00-P15</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td>P20-P29</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td>P35 (.0)</td>
<td>1a</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>1</td>
<td></td>
<td>67</td>
</tr>
<tr class="odd">
<td>P35 (.1-.9)</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td>P36-P38</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td>P39 (.0-.8)</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td>P39 (.9)</td>
<td></td>
<td></td>
<td>3</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>4</td>
<td>4</td>
<td>83</td>
</tr>
<tr class="odd">
<td>P50-P53</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td>P54 (.0-.8)</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td>P54 (.9)</td>
<td>1c</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>4</td>
<td>4</td>
<td>83</td>
</tr>
<tr class="even">
<td>P55-P61</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td><p>ICD</p>
<p>Category</p></td>
<td colspan="7">Priority Levels</td>
<td>Comments</td>
<td colspan="3">Query Form</td>
</tr>
<tr class="even">
<td></td>
<td>1</td>
<td>2</td>
<td>3</td>
<td>4</td>
<td>5</td>
<td>6</td>
<td>0</td>
<td></td>
<td>Ltr#</td>
<td>Ques#</td>
<td>Pg#</td>
</tr>
<tr class="odd">
<td>P70-P74</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td>P76-P78</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td>P80-P81</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td>P83 (.0-.3, .8)</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td>P83 (.4-.6, .9)</td>
<td>1c</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>8</td>
<td>1,2</td>
<td>107</td>
</tr>
<tr class="even">
<td>P90-P92</td>
<td>1c</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>8</td>
<td>1</td>
<td>107</td>
</tr>
<tr class="odd">
<td>P93</td>
<td></td>
<td></td>
<td>3</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>7</td>
<td></td>
<td>101</td>
</tr>
<tr class="even">
<td>P94</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td>P95<a href="#fn1" class="footnote-ref" id="fnref1"
role="doc-noteref"><sup>1</sup></a></td>
<td>1c</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>4</td>
<td>4</td>
<td>83</td>
</tr>
<tr class="even">
<td>P96 (.0-.8)</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td>P96 (.9)</td>
<td>1c</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>4</td>
<td>3</td>
<td>83</td>
</tr>
<tr class="even">
<td>Q00-Q07</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td>Q10-Q18</td>
<td>1c</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>8</td>
<td>2</td>
<td>107</td>
</tr>
<tr class="even">
<td>Q20-Q28</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td>Q30-Q34</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td>Q35-Q37</td>
<td>1c</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>8</td>
<td>2</td>
<td>107</td>
</tr>
<tr class="odd">
<td>Q38 (.0-.3)</td>
<td>1c</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>8</td>
<td>2</td>
<td>107</td>
</tr>
<tr class="even">
<td>Q38 (.4-.8)</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td>Q39-Q45</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td>Q50-Q54</td>
<td>1c</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>8</td>
<td>2</td>
<td>107</td>
</tr>
<tr class="odd">
<td>Q55-Q56</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td>Q60-Q64</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td>Q65-Q84</td>
<td>1c</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>8</td>
<td>2</td>
<td>107</td>
</tr>
<tr class="even">
<td>Q85 (.0)</td>
<td>1c</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>8</td>
<td>2</td>
<td>107</td>
</tr>
<tr class="odd">
<td>Q85 (.1, .8)</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td><p>ICD</p>
<p>Category</p></td>
<td colspan="7">Priority Levels</td>
<td>Comments</td>
<td colspan="3">Query Form</td>
</tr>
<tr class="odd">
<td></td>
<td>1</td>
<td>2</td>
<td>3</td>
<td>4</td>
<td>5</td>
<td>6</td>
<td>0</td>
<td></td>
<td>Ltr#</td>
<td>Ques#</td>
<td>Pg#</td>
</tr>
<tr class="even">
<td>Q85 (.9)</td>
<td></td>
<td></td>
<td>3</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>4</td>
<td>3</td>
<td>83</td>
</tr>
<tr class="odd">
<td>Q86-Q87</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td>Q89 (.0-.8)</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td>Q89 (.9)</td>
<td></td>
<td></td>
<td>3</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>4</td>
<td>3</td>
<td>83</td>
</tr>
<tr class="even">
<td>Q90-Q99</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td>R00-R63</td>
<td>1c</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>8</td>
<td>1</td>
<td>107</td>
</tr>
<tr class="even">
<td>R64</td>
<td><p>1c</p>
<p>1g</p></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td><p>8</p>
<p>3</p></td>
<td>1</td>
<td><p>107</p>
<p>77</p></td>
</tr>
<tr class="odd">
<td>R68-R99</td>
<td>1c</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>8</td>
<td>1</td>
<td>107</td>
</tr>
<tr class="even">
<td>S00</td>
<td><p>1c</p>
<p>1e</p></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>1e if external cause is not stated on the record</td>
<td><p>8</p>
<p>10</p></td>
<td><p>1</p>
<p>1:A,B</p></td>
<td><p>107</p>
<p>119</p></td>
</tr>
<tr class="odd">
<td><p>S01-S03</p>
<p>S04 (.0-.8)</p></td>
<td>1e</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td>1e if external cause is not stated on the record</td>
<td>10</td>
<td>1:A,B</td>
<td>119</td>
</tr>
<tr class="even">
<td>S04 (.9)</td>
<td>1e</td>
<td></td>
<td></td>
<td>4</td>
<td></td>
<td></td>
<td></td>
<td>1e if external cause is not stated on the record</td>
<td><p>10</p>
<p>4</p></td>
<td><p>1:A,B</p>
<p>3</p></td>
<td><p>119</p>
<p>83</p></td>
</tr>
<tr class="odd">
<td>S05 (.0-.1)</td>
<td><p>1c</p>
<p>1e</p></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>1e if external cause is not stated on the record</td>
<td><p>8</p>
<p>10</p></td>
<td><p>1</p>
<p>1:A,B</p></td>
<td><p>107</p>
<p>119</p></td>
</tr>
<tr class="even">
<td><p>S05 (.2-.9)</p>
<p>S06-S09</p></td>
<td>1e</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td>1e if external cause is not stated on the record</td>
<td>10</td>
<td>1:A,B</td>
<td>119</td>
</tr>
<tr class="odd">
<td>S10</td>
<td><p>1c</p>
<p>1e</p></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>1e if external cause is not stated on the record</td>
<td><p>8</p>
<p>10</p></td>
<td><p>1</p>
<p>1:A,B</p></td>
<td><p>107</p>
<p>119</p></td>
</tr>
<tr class="even">
<td>S11-S19</td>
<td>1e</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td>1e if external cause is not stated on the record</td>
<td>10</td>
<td>1:A,B</td>
<td>119</td>
</tr>
</tbody>
</table>
<aside id="footnotes" class="footnotes footnotes-end-of-document"
role="doc-endnotes">
<hr />
<ol>
<li id="fn1"><p>P95: this code is valid only for fetal deaths<a
href="#fnref1" class="footnote-back" role="doc-backlink">↩︎</a></p></li>
</ol>
</aside>

<table>
<colgroup>
<col style="width: 20%" />
<col style="width: 5%" />
<col style="width: 4%" />
<col style="width: 4%" />
<col style="width: 3%" />
<col style="width: 4%" />
<col style="width: 4%" />
<col style="width: 4%" />
<col style="width: 24%" />
<col style="width: 7%" />
<col style="width: 8%" />
<col style="width: 8%" />
</colgroup>
<tbody>
<tr class="odd">
<td>S20</td>
<td><p>1c</p>
<p>1e</p></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>1e if external cause is not stated on the record</td>
<td><p>8</p>
<p>10</p></td>
<td><p>1</p>
<p>1:A,B</p></td>
<td><p>107</p>
<p>119</p></td>
</tr>
<tr class="even">
<td>S21-S29</td>
<td>1e</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td>1e if external cause is not stated on the record</td>
<td>10</td>
<td>1:A,B</td>
<td>119</td>
</tr>
<tr class="odd">
<td>S30</td>
<td><p>1c</p>
<p>1e</p></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>1e if external cause is not stated on the record</td>
<td><p>8</p>
<p>10</p></td>
<td><p>1</p>
<p>1:A,B</p></td>
<td><p>107</p>
<p>119</p></td>
</tr>
<tr class="even">
<td>S31-S39</td>
<td>1e</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td>1e if external cause is not stated on the record</td>
<td>10</td>
<td>1:A,B</td>
<td>119</td>
</tr>
<tr class="odd">
<td>S40</td>
<td><p>1c</p>
<p>1e</p></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>1e if external cause is not stated on the record</td>
<td><p>8</p>
<p>10</p></td>
<td><p>1</p>
<p>1:A,B</p></td>
<td><p>107</p>
<p>119</p></td>
</tr>
<tr class="even">
<td>S41-S49</td>
<td>1e</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td>1e if external cause is not stated on the record</td>
<td>10</td>
<td>1:A,B</td>
<td>119</td>
</tr>
<tr class="odd">
<td>S50</td>
<td><p>1c</p>
<p>1e</p></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>1e if external cause is not stated on the record</td>
<td><p>8</p>
<p>10</p></td>
<td><p>1</p>
<p>1:A,B</p></td>
<td><p>107</p>
<p>119</p></td>
</tr>
<tr class="even">
<td><p>ICD</p>
<p>Category</p></td>
<td colspan="7">Priority Levels</td>
<td>Comments</td>
<td colspan="3">Query Form</td>
</tr>
<tr class="odd">
<td></td>
<td>1</td>
<td>2</td>
<td>3</td>
<td>4</td>
<td>5</td>
<td>6</td>
<td>0</td>
<td></td>
<td>Ltr#</td>
<td>Ques#</td>
<td>Pg#</td>
</tr>
<tr class="even">
<td>S51-S59</td>
<td>1e</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td>1e if external cause is not stated on the record</td>
<td>10</td>
<td>1:A,B</td>
<td>119</td>
</tr>
<tr class="odd">
<td>S60</td>
<td><p>1c</p>
<p>1e</p></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>1e if external cause is not stated on the record</td>
<td><p>8</p>
<p>10</p></td>
<td><p>2</p>
<p>1:A,B</p></td>
<td><p>107</p>
<p>119</p></td>
</tr>
<tr class="even">
<td>S61-S69</td>
<td>1e</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td>1e if external cause is not stated on the record</td>
<td>10</td>
<td>1:A,B</td>
<td>119</td>
</tr>
<tr class="odd">
<td>S70</td>
<td><p>1c</p>
<p>1e</p></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>1e if external cause is not stated on the record</td>
<td><p>8</p>
<p>10</p></td>
<td><p>2</p>
<p>1:A,B</p></td>
<td><p>107</p>
<p>119</p></td>
</tr>
<tr class="even">
<td>S71-S79</td>
<td>1e</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td>1e if external cause is not stated on the record</td>
<td>10</td>
<td>1:A,B</td>
<td>119</td>
</tr>
<tr class="odd">
<td>S80</td>
<td><p>1c</p>
<p>1e</p></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>1e if external cause is not stated on the record</td>
<td><p>8</p>
<p>10</p></td>
<td><p>2</p>
<p>1:A,B</p></td>
<td><p>107</p>
<p>119</p></td>
</tr>
<tr class="even">
<td>S81-S89</td>
<td>1e</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td>1e if external cause is not stated on the record</td>
<td>10</td>
<td>1:A,B</td>
<td>119</td>
</tr>
<tr class="odd">
<td>S90</td>
<td><p>1c</p>
<p>1e</p></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>1e if external cause is not stated on the record</td>
<td><p>8</p>
<p>10</p></td>
<td><p>2</p>
<p>1:A,B</p></td>
<td><p>107</p>
<p>119</p></td>
</tr>
<tr class="even">
<td>S91-S99</td>
<td>1e</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td>1e if external cause is not stated on the record</td>
<td>10</td>
<td>1:A,B</td>
<td>119</td>
</tr>
<tr class="odd">
<td>T00</td>
<td><p>1c</p>
<p>1e</p></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>1e if external cause is not stated on the record</td>
<td><p>8</p>
<p>10</p></td>
<td><p>2</p>
<p>1:A,B</p></td>
<td><p>107</p>
<p>119</p></td>
</tr>
<tr class="even">
<td>T01-T05 (.0-.8)</td>
<td>1e</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td>1e if external cause is not stated on the record</td>
<td>10</td>
<td>1:A,B</td>
<td>119</td>
</tr>
<tr class="odd">
<td>T01-T05 (.9)</td>
<td>1e</td>
<td></td>
<td></td>
<td>4</td>
<td></td>
<td></td>
<td></td>
<td>1e if external cause is not stated on the record</td>
<td><p>10</p>
<p>4</p></td>
<td><p>1:A,B</p>
<p>3</p></td>
<td><p>119</p>
<p>83</p></td>
</tr>
<tr class="even">
<td>T06</td>
<td>1e</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td>1e if external cause is not stated on the record</td>
<td>10</td>
<td>1:A,B</td>
<td>119</td>
</tr>
<tr class="odd">
<td>T07</td>
<td>1e</td>
<td></td>
<td>3</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>1e if external cause is not stated on the record</td>
<td><p>10</p>
<p>4</p></td>
<td><p>1:A,B</p>
<p>2,3</p></td>
<td><p>119</p>
<p>83</p></td>
</tr>
<tr class="even">
<td>T08</td>
<td>1e</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td>1e if external cause is not stated on the record</td>
<td>10</td>
<td>1:A,B</td>
<td>119</td>
</tr>
<tr class="odd">
<td>T09 (.0)</td>
<td><p>1c</p>
<p>1e</p></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>1e if external cause is not stated on the record</td>
<td><p>8</p>
<p>10</p></td>
<td><p>2</p>
<p>1:A,B</p></td>
<td><p>107</p>
<p>119</p></td>
</tr>
<tr class="even">
<td>T09 (.1-.9)</td>
<td>1e</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td>1e if external cause is not stated on the record</td>
<td>10</td>
<td>1:A,B</td>
<td>119</td>
</tr>
<tr class="odd">
<td>T10</td>
<td>1e</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td>1e if external cause is not stated on the record</td>
<td>10</td>
<td>1:A,B</td>
<td>119</td>
</tr>
<tr class="even">
<td>T11 (.0)</td>
<td><p>1c</p>
<p>1e</p></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>1e if external cause is not stated on the record</td>
<td><p>8</p>
<p>10</p></td>
<td><p>2</p>
<p>1:A,B</p></td>
<td><p>107</p>
<p>119</p></td>
</tr>
<tr class="odd">
<td>T11 (.1-.9)</td>
<td>1e</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td>1e if external cause is not stated on the record</td>
<td>10</td>
<td>1:A,B</td>
<td>119</td>
</tr>
<tr class="even">
<td><p>ICD</p>
<p>Category</p></td>
<td colspan="7">Priority Levels</td>
<td>Comments</td>
<td colspan="3">Query Form</td>
</tr>
<tr class="odd">
<td></td>
<td>1</td>
<td>2</td>
<td>3</td>
<td>4</td>
<td>5</td>
<td>6</td>
<td>0</td>
<td></td>
<td>Ltr#</td>
<td>Ques#</td>
<td>Pg#</td>
</tr>
<tr class="even">
<td>T12</td>
<td>1e</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td>1e if external cause is not stated on the record</td>
<td>10</td>
<td>1:A,B</td>
<td>119</td>
</tr>
<tr class="odd">
<td>T13 (.0)</td>
<td><p>1c</p>
<p>1e</p></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>1e if external cause is not stated on the record</td>
<td><p>8</p>
<p>10</p></td>
<td><p>2</p>
<p>1:A,B</p></td>
<td><p>107</p>
<p>119</p></td>
</tr>
<tr class="even">
<td>T13 (.1-.9)</td>
<td>1e</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td>1e if external cause is not stated on the record</td>
<td>10</td>
<td>1:A,B</td>
<td>119</td>
</tr>
<tr class="odd">
<td>T14 (.0)</td>
<td><p>1c</p>
<p>1e</p></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>1e if external cause is not stated on the record</td>
<td><p>8</p>
<p>10</p></td>
<td><p>2</p>
<p>1:A,B</p></td>
<td><p>107</p>
<p>119</p></td>
</tr>
<tr class="even">
<td>T14 (.1-.9)</td>
<td>1e</td>
<td></td>
<td></td>
<td>4</td>
<td></td>
<td></td>
<td></td>
<td>1e if external cause is not stated on the record</td>
<td><p>10</p>
<p>4</p></td>
<td><p>1:A,B</p>
<p>2</p></td>
<td><p>119</p>
<p>83</p></td>
</tr>
<tr class="odd">
<td>T15-T19</td>
<td>1e</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td>1e if external cause is not stated on the record</td>
<td>10</td>
<td>1:A,B</td>
<td>119</td>
</tr>
<tr class="even">
<td>T20-T25(.0,.2-.7)</td>
<td>1e</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td>1e if external cause is not stated on the record</td>
<td>10</td>
<td>1:A,B</td>
<td>119</td>
</tr>
<tr class="odd">
<td>T20-T25 (.1)</td>
<td><p>1c</p>
<p>1e</p></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>1e if external cause is not stated on the record</td>
<td><p>8</p>
<p>10</p></td>
<td><p>2</p>
<p>1:A,B</p></td>
<td><p>107</p>
<p>119</p></td>
</tr>
<tr class="even">
<td>T26-T35</td>
<td>1e</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td>1e if external cause is not stated on the record</td>
<td>10</td>
<td>1:A,B</td>
<td>119</td>
</tr>
<tr class="odd">
<td>T36-T37 (.0-.8)</td>
<td>1e</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td>1e if external cause is not stated on the record</td>
<td>10</td>
<td>1:A,B</td>
<td>119</td>
</tr>
<tr class="even">
<td>T36-T37 (.9)</td>
<td>1e</td>
<td></td>
<td></td>
<td></td>
<td>5</td>
<td></td>
<td></td>
<td>1e if external cause is not stated on the record</td>
<td><p>10</p>
<p>10</p></td>
<td><p>1:A,B</p>
<p>1:D</p></td>
<td>119</td>
</tr>
<tr class="odd">
<td>T50-T75</td>
<td>1e</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td>1e if external cause is not stated on the record</td>
<td>10</td>
<td>1:A,B</td>
<td>119</td>
</tr>
<tr class="even">
<td>T78 (.0-.8)</td>
<td>1e</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td>1e if external cause is not stated on the record</td>
<td>10</td>
<td>1:A,B</td>
<td>119</td>
</tr>
<tr class="odd">
<td>T78 (.9)</td>
<td>1e</td>
<td></td>
<td>3</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>1e if external cause is not stated on the record</td>
<td><p>10</p>
<p>10</p></td>
<td><p>1:A,B</p>
<p>1:C</p></td>
<td>119</td>
</tr>
<tr class="even">
<td>T79</td>
<td>1e</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td>1e if external cause is not stated on the record</td>
<td>10</td>
<td>1:A,B</td>
<td>119</td>
</tr>
<tr class="odd">
<td>T80-T88</td>
<td><p>1d</p>
<p><u>or</u></p>
<p>1e</p></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td>1d <u>or</u> 1e if reason for treatment, or external cause is not
stated on the record respectively</td>
<td><p>10</p>
<p><u>or</u></p>
<p>10</p></td>
<td><p>1:C</p>
<p><u>or</u></p>
<p>1:A,B</p></td>
<td>119</td>
</tr>
<tr class="even">
<td><p>T90-T97</p>
<p>T98 (.0-.2)</p></td>
<td>1e</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td>1e if external cause is not stated on the record</td>
<td>10</td>
<td>1:A,B</td>
<td>119</td>
</tr>
</tbody>
</table>

<table>
<colgroup>
<col style="width: 20%" />
<col style="width: 5%" />
<col style="width: 4%" />
<col style="width: 4%" />
<col style="width: 3%" />
<col style="width: 4%" />
<col style="width: 4%" />
<col style="width: 4%" />
<col style="width: 25%" />
<col style="width: 6%" />
<col style="width: 10%" />
<col style="width: 7%" />
</colgroup>
<tbody>
<tr class="odd">
<td><p>ICD</p>
<p>Category</p></td>
<td colspan="7">Priority Levels</td>
<td>Comments</td>
<td colspan="3">Query Form</td>
</tr>
<tr class="even">
<td></td>
<td>1</td>
<td>2</td>
<td>3</td>
<td>4</td>
<td>5</td>
<td>6</td>
<td>0</td>
<td></td>
<td>Ltr#</td>
<td>Ques#</td>
<td>Pg#</td>
</tr>
<tr class="odd">
<td>T98 (.3)</td>
<td><p>1d</p>
<p>or1e</p></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td>1d or 1e if reason for treatment, or external cause is not stated on
the record respectively</td>
<td><p>10</p>
<p><u>or</u></p>
<p>10</p></td>
<td><p>1:C</p>
<p><u>or</u></p>
<p>1:A,B</p></td>
<td>119</td>
</tr>
<tr class="even">
<td>V01-V06 (.0-.1)</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td>V01-V06 (.9)</td>
<td></td>
<td></td>
<td>3</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>10</td>
<td>4:B</td>
<td>119</td>
</tr>
<tr class="even">
<td>V09</td>
<td></td>
<td></td>
<td>3</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>10</td>
<td>4:B/C</td>
<td>119</td>
</tr>
<tr class="odd">
<td><p>V10-V18</p>
<p>(.0-.1, .3-.5)</p></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td>V10-V18 (.2,.9)</td>
<td></td>
<td></td>
<td>3</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>10</td>
<td>4:D)3)a</td>
<td>119</td>
</tr>
<tr class="odd">
<td>V19</td>
<td></td>
<td></td>
<td>3</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>10</td>
<td><p>4:C</p>
<p>4:D)3)a</p></td>
<td>119</td>
</tr>
<tr class="even">
<td><p>V20-V28</p>
<p>(.0-.1, .3-.5)</p></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td>V20-V28 (.2,.9)</td>
<td></td>
<td></td>
<td>3</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>10</td>
<td>4:D)3)a</td>
<td>119</td>
</tr>
<tr class="even">
<td>V29</td>
<td></td>
<td></td>
<td>3</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>10</td>
<td><p>4:C</p>
<p>4:D)3)a</p></td>
<td>119</td>
</tr>
</tbody>
</table>

<table>
<colgroup>
<col style="width: 20%" />
<col style="width: 5%" />
<col style="width: 4%" />
<col style="width: 4%" />
<col style="width: 3%" />
<col style="width: 4%" />
<col style="width: 4%" />
<col style="width: 4%" />
<col style="width: 25%" />
<col style="width: 6%" />
<col style="width: 10%" />
<col style="width: 7%" />
</colgroup>
<tbody>
<tr class="odd">
<td><p>V30-V38</p>
<p>(.0-.2, .4-.7)</p></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td>V30-V38 (.3,.9)</td>
<td></td>
<td></td>
<td>3</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>10</td>
<td>4:D)3)a</td>
<td>119</td>
</tr>
<tr class="odd">
<td>V39</td>
<td></td>
<td></td>
<td>3</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>10</td>
<td><p>4:C</p>
<p>4:D)3)a</p></td>
<td>119</td>
</tr>
<tr class="even">
<td><p>V40-V48</p>
<p>(.0-.2, .4-.7)</p></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td>V40-V48 (.3,.9)</td>
<td></td>
<td></td>
<td>3</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>10</td>
<td>4:D)3)a</td>
<td>119</td>
</tr>
<tr class="even">
<td>V49</td>
<td></td>
<td></td>
<td>3</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>10</td>
<td><p>4:C</p>
<p>4:D)3)a</p></td>
<td>119</td>
</tr>
<tr class="odd">
<td><p>V50-V58</p>
<p>(.0-.2, .4-.7)</p></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td>V50-V58 (.3,.9)</td>
<td></td>
<td></td>
<td>3</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>10</td>
<td>4:D)3)a</td>
<td>119</td>
</tr>
<tr class="odd">
<td>V59</td>
<td></td>
<td></td>
<td>3</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>10</td>
<td><p>4:C</p>
<p>4:D)3)a</p></td>
<td>119</td>
</tr>
<tr class="even">
<td><p>V60-V68</p>
<p>(.0-.2, .4-.7)</p></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td><p>ICD</p>
<p>Category</p></td>
<td colspan="7">Priority Levels</td>
<td>Comments</td>
<td colspan="3">Query Form</td>
</tr>
<tr class="even">
<td></td>
<td>1</td>
<td>2</td>
<td>3</td>
<td>4</td>
<td>5</td>
<td>6</td>
<td>0</td>
<td></td>
<td>Ltr#</td>
<td>Ques#</td>
<td>Pg#</td>
</tr>
<tr class="odd">
<td>V60-V68 (.3,.9)</td>
<td></td>
<td></td>
<td>3</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>10</td>
<td>4:D)3)a</td>
<td>119</td>
</tr>
<tr class="even">
<td>V69</td>
<td></td>
<td></td>
<td>3</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>10</td>
<td><p>4:C</p>
<p>4:D)3)a</p></td>
<td>119</td>
</tr>
<tr class="odd">
<td><p>V70-V78</p>
<p>(.0-.2, .4-.7)</p></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td>V70-V78 (.3,.9)</td>
<td></td>
<td></td>
<td>3</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>10</td>
<td>4:D)3)a</td>
<td>119</td>
</tr>
<tr class="odd">
<td>V79</td>
<td></td>
<td></td>
<td>3</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>10</td>
<td><p>4:C</p>
<p>4:D)3)a</p></td>
<td>119</td>
</tr>
<tr class="even">
<td>V80 (.0-.8)</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td>V80 (.9)</td>
<td></td>
<td></td>
<td>3</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>10</td>
<td><p>4:C</p>
<p>4:D:2,3a</p></td>
<td>119</td>
</tr>
<tr class="even">
<td>V81 (.0-.8)</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td>V81 (.9)</td>
<td></td>
<td></td>
<td>3</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>10</td>
<td><p>4:C</p>
<p>4:D:1,2</p></td>
<td>119</td>
</tr>
<tr class="even">
<td>V82 (.0-.8)</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
</tbody>
</table>

<table>
<colgroup>
<col style="width: 20%" />
<col style="width: 5%" />
<col style="width: 4%" />
<col style="width: 4%" />
<col style="width: 3%" />
<col style="width: 4%" />
<col style="width: 4%" />
<col style="width: 4%" />
<col style="width: 25%" />
<col style="width: 6%" />
<col style="width: 10%" />
<col style="width: 7%" />
</colgroup>
<tbody>
<tr class="odd">
<td>V82 (.9)</td>
<td></td>
<td></td>
<td>3</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>10</td>
<td><p>4:C</p>
<p>4:D:2,3</p></td>
<td>119</td>
</tr>
<tr class="even">
<td><p>V83-V86</p>
<p>(.0-.2, .4-.7)</p></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td>V83-V86 (.3,.9)</td>
<td></td>
<td></td>
<td>3</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>10</td>
<td>4:D:2,3,4</td>
<td>119</td>
</tr>
<tr class="even">
<td>V87-V88</td>
<td></td>
<td></td>
<td>3</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>10</td>
<td>4:D)3</td>
<td>119</td>
</tr>
<tr class="odd">
<td>V89</td>
<td></td>
<td></td>
<td>3</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>10</td>
<td>4:A,C,D</td>
<td>119</td>
</tr>
<tr class="even">
<td>V90-V93 (.0-.8)</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td>V90-V93 (.9)</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>5</td>
<td></td>
<td></td>
<td></td>
<td>10</td>
<td>4:A</td>
<td>119</td>
</tr>
<tr class="even">
<td>V94</td>
<td></td>
<td></td>
<td>3</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>10</td>
<td>4:A,D</td>
<td>119</td>
</tr>
<tr class="odd">
<td>V95-V96 (.0-.8)</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td>V95-V96 (.9)</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>5</td>
<td></td>
<td></td>
<td></td>
<td>10</td>
<td>4:A</td>
<td>119</td>
</tr>
<tr class="odd">
<td>V97-V98</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td>V99</td>
<td>1e</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>10</td>
<td>4</td>
<td>119</td>
</tr>
</tbody>
</table>

<table>
<colgroup>
<col style="width: 20%" />
<col style="width: 5%" />
<col style="width: 4%" />
<col style="width: 4%" />
<col style="width: 3%" />
<col style="width: 4%" />
<col style="width: 4%" />
<col style="width: 4%" />
<col style="width: 25%" />
<col style="width: 6%" />
<col style="width: 10%" />
<col style="width: 7%" />
</colgroup>
<tbody>
<tr class="odd">
<td><p>ICD</p>
<p>Category</p></td>
<td colspan="7">Priority Levels</td>
<td>Comments</td>
<td colspan="3">Query Form</td>
</tr>
<tr class="even">
<td></td>
<td>1</td>
<td>2</td>
<td>3</td>
<td>4</td>
<td>5</td>
<td>6</td>
<td>0</td>
<td></td>
<td>Ltr#</td>
<td>Ques#</td>
<td>Pg#</td>
</tr>
<tr class="odd">
<td>W00-W18(.0-.8)<sup>2</sup></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td>W00-W18 (.9)<a href="#fn1" class="footnote-ref" id="fnref1"
role="doc-noteref"><sup>1</sup></a></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>5</td>
<td></td>
<td></td>
<td></td>
<td>10</td>
<td></td>
<td>119</td>
</tr>
<tr class="odd">
<td>W19 <sup>2</sup></td>
<td></td>
<td></td>
<td>3</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>10</td>
<td>3</td>
<td>119</td>
</tr>
<tr class="even">
<td>W20-W46(.0-.8)<sup>2</sup></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td>W20-W46 (.9)<sup>2</sup></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>5</td>
<td></td>
<td></td>
<td></td>
<td>10</td>
<td></td>
<td>119</td>
</tr>
<tr class="even">
<td>W49 <sup>2</sup></td>
<td></td>
<td></td>
<td>3</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>10</td>
<td></td>
<td>119</td>
</tr>
<tr class="odd">
<td>W50-W60(.0-.8)<sup>2</sup></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td>W50-W60 (.9)<sup>2</sup></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>5</td>
<td></td>
<td></td>
<td></td>
<td>10</td>
<td></td>
<td>119</td>
</tr>
<tr class="odd">
<td>W64 <sup>2</sup></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>5</td>
<td></td>
<td></td>
<td></td>
<td>10</td>
<td></td>
<td>119</td>
</tr>
<tr class="even">
<td>W65-W73(.0-.8)<sup>2</sup></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td>W65-W73 (.9)<sup>2</sup></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>5</td>
<td></td>
<td></td>
<td></td>
<td>10</td>
<td></td>
<td>119</td>
</tr>
<tr class="even">
<td>W74 <sup>2</sup></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>5</td>
<td></td>
<td></td>
<td></td>
<td>10</td>
<td></td>
<td>119</td>
</tr>
<tr class="odd">
<td>W75-W83(.0-.8)<sup>2</sup></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td>W75-W83 (.9)<sup>2</sup></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>5</td>
<td></td>
<td></td>
<td></td>
<td>10</td>
<td></td>
<td>119</td>
</tr>
<tr class="odd">
<td>W84 <sup>2</sup></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>10</td>
<td></td>
<td>119</td>
</tr>
<tr class="even">
<td>W85-W86(.0-.8)<sup>2</sup></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td>W85-W86 (.9)<sup>2</sup></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>5</td>
<td></td>
<td></td>
<td></td>
<td>10</td>
<td></td>
<td>119</td>
</tr>
<tr class="even">
<td>W87 <sup>2</sup></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>5</td>
<td></td>
<td></td>
<td></td>
<td>10</td>
<td></td>
<td>119</td>
</tr>
<tr class="odd">
<td>W88-W90(.0-.8)<sup>2</sup></td>
<td>1a</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>1</td>
<td></td>
<td>67</td>
</tr>
<tr class="even">
<td>W88-W90 (.9)<sup>2</sup></td>
<td>1a</td>
<td></td>
<td></td>
<td></td>
<td>5</td>
<td></td>
<td></td>
<td></td>
<td><p>1</p>
<p>10</p></td>
<td></td>
<td><p>67</p>
<p>119</p></td>
</tr>
<tr class="odd">
<td><p>ICD</p>
<p>Category</p></td>
<td colspan="7">Priority Levels</td>
<td>Comments</td>
<td colspan="3">Query Form</td>
</tr>
<tr class="even">
<td></td>
<td>1</td>
<td>2</td>
<td>3</td>
<td>4</td>
<td>5</td>
<td>6</td>
<td>0</td>
<td></td>
<td>Ltr#</td>
<td>Ques#</td>
<td>Pg#</td>
</tr>
<tr class="odd">
<td>W91 <sup>2</sup></td>
<td>1a</td>
<td></td>
<td></td>
<td></td>
<td>5</td>
<td></td>
<td></td>
<td></td>
<td><p>1</p>
<p>10</p></td>
<td></td>
<td><p>67</p>
<p>119</p></td>
</tr>
<tr class="even">
<td>W93-W94(.0-.8)<sup>2</sup></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td>W93-W94 (.9)<sup>2</sup></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>5</td>
<td></td>
<td></td>
<td></td>
<td>10</td>
<td></td>
<td>119</td>
</tr>
<tr class="even">
<td>W99 <sup>2</sup></td>
<td></td>
<td></td>
<td>3</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>10</td>
<td></td>
<td>119</td>
</tr>
<tr class="odd">
<td>X00-X08(.0-.8)<sup>2</sup></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td>X00-X08 (.9)<sup>2</sup></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>5</td>
<td></td>
<td></td>
<td></td>
<td>10</td>
<td></td>
<td>119</td>
</tr>
<tr class="odd">
<td>X09 <sup>2</sup></td>
<td></td>
<td></td>
<td>3</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>10</td>
<td>2</td>
<td>119</td>
</tr>
<tr class="even">
<td>X10-X18(.0-.8)<sup>2</sup></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td>X10-X18 (.9)<sup>2</sup></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>5</td>
<td></td>
<td></td>
<td></td>
<td>10</td>
<td></td>
<td>119</td>
</tr>
</tbody>
</table>
<aside id="footnotes" class="footnotes footnotes-end-of-document"
role="doc-endnotes">
<hr />
<ol>
<li id="fn1"><p>W00-Y34, except Y06._, and Y07._: The 4<sup>th</sup>
digits for these codes are designated for place of occurrence. The
“place-of-occurrence” codes are to be treated as separate codes that
have their own data tape field. They are not part of the ICD-10
cause-of-death codes.<a href="#fnref1" class="footnote-back"
role="doc-backlink">↩︎</a></p></li>
</ol>
</aside>

<table>
<colgroup>
<col style="width: 20%" />
<col style="width: 5%" />
<col style="width: 4%" />
<col style="width: 4%" />
<col style="width: 3%" />
<col style="width: 4%" />
<col style="width: 4%" />
<col style="width: 4%" />
<col style="width: 25%" />
<col style="width: 6%" />
<col style="width: 10%" />
<col style="width: 7%" />
</colgroup>
<tbody>
<tr class="odd">
<td>X19 <sup>2</sup></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>5</td>
<td></td>
<td></td>
<td></td>
<td>10</td>
<td></td>
<td>119</td>
</tr>
<tr class="even">
<td>X20-X28(.0-.8)<sup>2</sup></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td>X20-X28 (.9)<sup>2</sup></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>5</td>
<td></td>
<td></td>
<td></td>
<td>10</td>
<td></td>
<td>119</td>
</tr>
<tr class="even">
<td>X29 <sup>2</sup></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>5</td>
<td></td>
<td></td>
<td></td>
<td>10</td>
<td></td>
<td>119</td>
</tr>
<tr class="odd">
<td>X30-X38(.0-.8)<sup>2</sup></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td>X30-X38 (.9)<sup>2</sup></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>5</td>
<td></td>
<td></td>
<td></td>
<td>10</td>
<td></td>
<td>119</td>
</tr>
<tr class="odd">
<td>X39 <sup>2</sup></td>
<td></td>
<td></td>
<td>3</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>10</td>
<td></td>
<td>119</td>
</tr>
<tr class="even">
<td>X40-X48(.0-.8)<sup>2</sup></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td>X40-X48 (.9)<sup>2</sup></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>5</td>
<td></td>
<td></td>
<td></td>
<td>10</td>
<td></td>
<td>119</td>
</tr>
<tr class="even">
<td>X49 <sup>2</sup></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>5</td>
<td></td>
<td></td>
<td></td>
<td>10</td>
<td>1D</td>
<td>119</td>
</tr>
<tr class="odd">
<td>X50-X58(.0-.8)<sup>2</sup></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td>X50-X58 (.9)<sup>2</sup></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>5</td>
<td></td>
<td></td>
<td></td>
<td>10</td>
<td></td>
<td>119</td>
</tr>
<tr class="odd">
<td>X59 <sup>2</sup></td>
<td></td>
<td></td>
<td>3</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>10</td>
<td>1D</td>
<td>119</td>
</tr>
<tr class="even">
<td colspan="12"><sup>2</sup> W00-Y34, except Y06._, and Y07._: The
4<sup>th</sup> digits for these codes are designated for place of
occurrence. The “place-of-occurrence” codes are to be treated as
separate codes that have their own data tape field. They are not part of
the ICD-10 cause-of-death codes.</td>
</tr>
<tr class="odd">
<td><p>ICD</p>
<p>Category</p></td>
<td colspan="7">Priority Levels</td>
<td>Comments</td>
<td colspan="3">Query Form</td>
</tr>
<tr class="even">
<td></td>
<td>1</td>
<td>2</td>
<td>3</td>
<td>4</td>
<td>5</td>
<td>6</td>
<td>0</td>
<td></td>
<td>Ltr#</td>
<td>Ques#</td>
<td>Pg#</td>
</tr>
<tr class="odd">
<td>X60-X73(.0-.8)<sup>2</sup></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td>X60-X73 (.9)<sup>2</sup></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>5</td>
<td></td>
<td></td>
<td></td>
<td>10</td>
<td></td>
<td>119</td>
</tr>
<tr class="odd">
<td>X74 <sup>2</sup></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>5</td>
<td></td>
<td></td>
<td></td>
<td>10</td>
<td>3</td>
<td>119</td>
</tr>
<tr class="even">
<td>X75-X83(.0-.8)<sup>2</sup></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td>X75-X83 (.9)<sup>2</sup></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>5</td>
<td></td>
<td></td>
<td></td>
<td>10</td>
<td></td>
<td>119</td>
</tr>
<tr class="even">
<td>X84 <sup>2</sup></td>
<td>1e</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>10</td>
<td>3</td>
<td>119</td>
</tr>
<tr class="odd">
<td>X85-X89(.0-.8)<sup>2</sup></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td>X85-X89 (.9)<sup>2</sup></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>5</td>
<td></td>
<td></td>
<td></td>
<td>10</td>
<td></td>
<td>119</td>
</tr>
<tr class="odd">
<td>X90 <sup>2</sup></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>5</td>
<td></td>
<td></td>
<td></td>
<td>10</td>
<td>1D</td>
<td>119</td>
</tr>
<tr class="even">
<td>X91-X94(.0-.8)<sup>2</sup></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td>X91-X94 (.9)<sup>2</sup></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>5</td>
<td></td>
<td></td>
<td></td>
<td>10</td>
<td></td>
<td>119</td>
</tr>
</tbody>
</table>

<table>
<colgroup>
<col style="width: 20%" />
<col style="width: 5%" />
<col style="width: 4%" />
<col style="width: 4%" />
<col style="width: 3%" />
<col style="width: 4%" />
<col style="width: 4%" />
<col style="width: 4%" />
<col style="width: 25%" />
<col style="width: 6%" />
<col style="width: 10%" />
<col style="width: 7%" />
</colgroup>
<tbody>
<tr class="odd">
<td>X95 <sup>2</sup></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>5</td>
<td></td>
<td></td>
<td></td>
<td>10</td>
<td>3</td>
<td>119</td>
</tr>
<tr class="even">
<td>X96-Y05(.0-.8)<sup>2</sup></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td>X96-Y05 (.9)<sup>2</sup></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>5</td>
<td></td>
<td></td>
<td></td>
<td>10</td>
<td></td>
<td>119</td>
</tr>
<tr class="even">
<td>Y06-Y07 (.0-.8)</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td>Y06-Y07 (.9)</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>5</td>
<td></td>
<td></td>
<td></td>
<td>10</td>
<td></td>
<td>119</td>
</tr>
<tr class="even">
<td>Y08 (.0-.8)<sup>2</sup></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td>Y08 (.9)<sup>2</sup></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>5</td>
<td></td>
<td></td>
<td></td>
<td>10</td>
<td></td>
<td>119</td>
</tr>
<tr class="even">
<td>Y09 <sup>2</sup></td>
<td></td>
<td></td>
<td>3</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>10</td>
<td>2</td>
<td>119</td>
</tr>
<tr class="odd">
<td>Y10-Y18(.0-.8)<sup>2</sup></td>
<td></td>
<td></td>
<td>3</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td><p>Y10-Y34:</p>
<p>Query for mannner of death (accident,homicide,
suicide,natural)</p></td>
<td>10</td>
<td>1A</td>
<td>119</td>
</tr>
<tr class="even">
<td>Y10-Y18 (.9)<sup>2</sup></td>
<td></td>
<td></td>
<td>3</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>10</td>
<td>1A</td>
<td>119</td>
</tr>
<tr class="odd">
<td>Y19 <sup>2</sup></td>
<td></td>
<td></td>
<td>3</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>10</td>
<td>1:A,D</td>
<td>119</td>
</tr>
<tr class="even">
<td colspan="12"><sup>2</sup> W00-Y34, except Y06._, and Y07._: The
4<sup>th</sup> digits for these codes are designated for place of
occurrence. The “place-of-occurrence” codes are to be treated as
separate codes that have their own data tape field. They are not part of
the ICD-10 cause-of-death codes.</td>
</tr>
<tr class="odd">
<td><p>ICD</p>
<p>Category</p></td>
<td colspan="7">Priority Levels</td>
<td>Comments</td>
<td colspan="3">Query Form</td>
</tr>
<tr class="even">
<td></td>
<td>1</td>
<td>2</td>
<td>3</td>
<td>4</td>
<td>5</td>
<td>6</td>
<td>0</td>
<td></td>
<td>Ltr#</td>
<td>Ques#</td>
<td>Pg#</td>
</tr>
<tr class="odd">
<td>Y20-Y33(.0-.8)<sup>2</sup></td>
<td></td>
<td></td>
<td>3</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>10</td>
<td>1A</td>
<td>119</td>
</tr>
<tr class="even">
<td>Y20-Y33 (.9)<sup>2</sup></td>
<td></td>
<td></td>
<td>3</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>10</td>
<td>1A</td>
<td>119</td>
</tr>
<tr class="odd">
<td>Y34 <sup>2</sup></td>
<td>1e</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>10</td>
<td>1:A,B</td>
<td>119</td>
</tr>
<tr class="even">
<td>Y35</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td>Y36(.0-.4,.6-.8)</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td>Y36 (.5)</td>
<td>1a</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>1</td>
<td></td>
<td>67</td>
</tr>
<tr class="odd">
<td>Y36 (.9)</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>5</td>
<td></td>
<td></td>
<td></td>
<td>10</td>
<td></td>
<td>119</td>
</tr>
<tr class="even">
<td>Y40-Y43 (.0-.8)</td>
<td>1d</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td>1d if reason for medical care not stated on record</td>
<td>10</td>
<td>1C</td>
<td>119</td>
</tr>
<tr class="odd">
<td>Y40-Y43 (.9)</td>
<td>1d</td>
<td></td>
<td></td>
<td></td>
<td>5</td>
<td></td>
<td></td>
<td>1d if reason for medical care not stated on record</td>
<td>10</td>
<td>1:C,D</td>
<td>119</td>
</tr>
<tr class="even">
<td>Y44 (.0-.7)</td>
<td>1d</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td>1d if reason for medical care not stated on record</td>
<td>10</td>
<td>1C</td>
<td>119</td>
</tr>
<tr class="odd">
<td>Y44 (.9)</td>
<td>1d</td>
<td></td>
<td></td>
<td></td>
<td>5</td>
<td></td>
<td></td>
<td>1d if reason for medical care not stated on record</td>
<td>10</td>
<td>1:C,D</td>
<td>119</td>
</tr>
<tr class="even">
<td>Y45 (.0-.7)</td>
<td>1d</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td>1d if reason for medical care not stated on record</td>
<td>10</td>
<td>1C</td>
<td>119</td>
</tr>
<tr class="odd">
<td>Y45 (.9)</td>
<td>1d</td>
<td></td>
<td></td>
<td></td>
<td>5</td>
<td></td>
<td></td>
<td>1d if reason for medical care not stated on record</td>
<td>10</td>
<td>1:C,D</td>
<td>119</td>
</tr>
<tr class="even">
<td>Y46(.0-.5,.7-.8)</td>
<td>1d</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td>1d if reason for medical care not stated on record</td>
<td>10</td>
<td>1C</td>
<td>119</td>
</tr>
<tr class="odd">
<td>Y46 (.6)</td>
<td>1d</td>
<td></td>
<td></td>
<td></td>
<td>5</td>
<td></td>
<td></td>
<td>1d if reason for medical care not stated on record</td>
<td>10</td>
<td>1:C,D</td>
<td>119</td>
</tr>
<tr class="even">
<td>Y47 (.0-.8)</td>
<td>1d</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td>1d if reason for medical care not stated on record</td>
<td>10</td>
<td>1C</td>
<td>119</td>
</tr>
<tr class="odd">
<td>Y47 (.9)</td>
<td>1d</td>
<td></td>
<td></td>
<td></td>
<td>5</td>
<td></td>
<td></td>
<td>1d if reason for medical care not stated on record</td>
<td>10</td>
<td>1:C,D</td>
<td>119</td>
</tr>
<tr class="even">
<td>Y48</td>
<td>1d</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td>1d if reason for medical care not stated on record</td>
<td>10</td>
<td>1C</td>
<td>119</td>
</tr>
<tr class="odd">
<td>Y49-Y53 (.0-.8)</td>
<td>1d</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td>1d if reason for medical care not stated on record</td>
<td>10</td>
<td>1C</td>
<td>119</td>
</tr>
<tr class="even">
<td>Y49-Y53 (.9)</td>
<td>1d</td>
<td></td>
<td></td>
<td></td>
<td>5</td>
<td></td>
<td></td>
<td>1d if reason for medical care not stated on record</td>
<td>10</td>
<td>1:C,D</td>
<td>119</td>
</tr>
<tr class="odd">
<td>Y54</td>
<td>1d</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td>1d if reason for medical care not stated on record</td>
<td>10</td>
<td>1C</td>
<td>119</td>
</tr>
<tr class="even">
<td colspan="12"><sup>2</sup> W00-Y34, except Y06._, and Y07._: The
4<sup>th</sup> digits for these codes are designated for place of
occurrence. The “place-of-occurrence” codes are to be treated as
separate codes that have their own data tape field. They are not part of
the ICD-10 cause-of-death codes.</td>
</tr>
<tr class="odd">
<td><p>ICD</p>
<p>Category</p></td>
<td colspan="7">Priority Levels</td>
<td>Comments</td>
<td colspan="3">Query Form</td>
</tr>
<tr class="even">
<td></td>
<td>1</td>
<td>2</td>
<td>3</td>
<td>4</td>
<td>5</td>
<td>6</td>
<td>0</td>
<td></td>
<td>Ltr#</td>
<td>Ques#</td>
<td>Pg#</td>
</tr>
<tr class="odd">
<td>Y55 (.0-.6)</td>
<td>1d</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td>1d if reason for medical care not stated on record</td>
<td>10</td>
<td>1C</td>
<td>119</td>
</tr>
<tr class="even">
<td>Y55 (.7)</td>
<td>1d</td>
<td></td>
<td></td>
<td></td>
<td>5</td>
<td></td>
<td></td>
<td>1d if reason for medical care not stated on record</td>
<td>10</td>
<td>1:C,D</td>
<td>119</td>
</tr>
<tr class="odd">
<td>Y56-Y57 (.0-.8)</td>
<td>1d</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td>1d if reason for medical care not stated on record</td>
<td>10</td>
<td>1C</td>
<td>119</td>
</tr>
<tr class="even">
<td>Y56-Y57 (.9)</td>
<td>1d</td>
<td></td>
<td></td>
<td></td>
<td>5</td>
<td></td>
<td></td>
<td>1d if reason for medical care not stated on record</td>
<td>10</td>
<td>1:C,D</td>
<td>119</td>
</tr>
<tr class="odd">
<td>Y58 (.0-.8)</td>
<td><p>1a</p>
<p>1d</p></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>1d if reason for medical care not stated on record</td>
<td>10</td>
<td>1C</td>
<td>119</td>
</tr>
<tr class="even">
<td>Y58 (.9)</td>
<td><p>1a</p>
<p>1d</p></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>5</td>
<td>1d if reason for medical care not stated on record</td>
<td>10</td>
<td>1:C,D</td>
<td>119</td>
</tr>
<tr class="odd">
<td>Y59 (.0-.3)</td>
<td><p>1a</p>
<p>1d</p></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>1d if reason for medical care not stated on record</td>
<td>10</td>
<td>1C</td>
<td>119</td>
</tr>
<tr class="even">
<td>Y59 (.8)</td>
<td>1d</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td>1d if reason for medical care not stated on record</td>
<td>10</td>
<td>1C</td>
<td>119</td>
</tr>
<tr class="odd">
<td>Y59 (.9)</td>
<td>1d</td>
<td></td>
<td></td>
<td></td>
<td>5</td>
<td></td>
<td></td>
<td>1d if reason for medical care not stated on record</td>
<td>10</td>
<td>1:C,D</td>
<td>119</td>
</tr>
<tr class="even">
<td>Y60-Y62 (.0-.8)</td>
<td>1d</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td>1d if reason for medical care not stated on record</td>
<td>10</td>
<td>1C</td>
<td>119</td>
</tr>
<tr class="odd">
<td>Y60-Y62 (.9)</td>
<td>1d</td>
<td></td>
<td></td>
<td></td>
<td>5</td>
<td></td>
<td></td>
<td>1d if reason for medical care not stated on record</td>
<td>10</td>
<td>1:C,D</td>
<td>119</td>
</tr>
<tr class="even">
<td>Y63(.0-.1,.4-.9)</td>
<td>1d</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td>1d if reason for medical care not stated on record</td>
<td>10</td>
<td>1C</td>
<td>119</td>
</tr>
<tr class="odd">
<td>Y63 (.2-.3)</td>
<td><p>1a</p>
<p>1d</p></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>1d if reason for medical care not stated on record</td>
<td><p>1</p>
<p>10</p></td>
<td>1C</td>
<td><p>67</p>
<p>119</p></td>
</tr>
<tr class="even">
<td>Y64 (.0-.8)</td>
<td>1d</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td>1d if reason for medical care not stated on record</td>
<td>10</td>
<td>1C</td>
<td>119</td>
</tr>
<tr class="odd">
<td>Y64 (.9)</td>
<td>1d</td>
<td></td>
<td></td>
<td></td>
<td>5</td>
<td></td>
<td></td>
<td>1d if reason for medical care not stated on record</td>
<td>10</td>
<td>1C,9</td>
<td>119</td>
</tr>
<tr class="even">
<td>Y65-Y66</td>
<td>1d</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td>1d if reason for medical care not stated on record</td>
<td>10</td>
<td>1C</td>
<td>119</td>
</tr>
<tr class="odd">
<td>Y69</td>
<td>1d</td>
<td></td>
<td>3</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>1d if reason for medical care not stated on record</td>
<td>10</td>
<td>1C,9</td>
<td>119</td>
</tr>
<tr class="even">
<td>Y70-Y81</td>
<td>1d</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td>1d if reason for medical care not stated on record</td>
<td>10</td>
<td>1C</td>
<td>119</td>
</tr>
<tr class="odd">
<td>Y82</td>
<td>1d</td>
<td></td>
<td></td>
<td></td>
<td>5</td>
<td></td>
<td></td>
<td>1d if reason for medical care not stated on record</td>
<td>10</td>
<td>1:C,D</td>
<td>119</td>
</tr>
<tr class="even">
<td>Y83 (.0-.8)</td>
<td>1d</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td>1d if reason for medical care not stated on record</td>
<td>10</td>
<td>1:C,D</td>
<td>119</td>
</tr>
<tr class="odd">
<td><p>ICD</p>
<p>Category</p></td>
<td colspan="7">Priority Levels</td>
<td>Comments</td>
<td colspan="3">Query Form</td>
</tr>
<tr class="even">
<td></td>
<td>1</td>
<td>2</td>
<td>3</td>
<td>4</td>
<td>5</td>
<td>6</td>
<td>0</td>
<td></td>
<td>Ltr#</td>
<td>Ques#</td>
<td>Pg#</td>
</tr>
<tr class="odd">
<td>Y83 (.9)</td>
<td>1d</td>
<td></td>
<td></td>
<td></td>
<td>5</td>
<td></td>
<td></td>
<td>1d if reason for medical care not stated on record</td>
<td>10</td>
<td>1:C,D</td>
<td>119</td>
</tr>
<tr class="even">
<td><p>Y84</p>
<p>(.0-.1, .3-.8)</p></td>
<td>1d</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td>1d if reason for medical care not stated on record</td>
<td>10</td>
<td>1C</td>
<td>119</td>
</tr>
<tr class="odd">
<td>Y84 (.2)</td>
<td><p>1a</p>
<p>1d</p></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>1d if reason for medical care not stated on record</td>
<td><p>1</p>
<p>10</p></td>
<td>1C</td>
<td><p>67</p>
<p>119</p></td>
</tr>
<tr class="even">
<td>Y84 (.9)</td>
<td>1d</td>
<td></td>
<td></td>
<td></td>
<td>5</td>
<td></td>
<td></td>
<td>1d if reason for medical care not stated on record</td>
<td>10</td>
<td>1:C,D</td>
<td>119</td>
</tr>
<tr class="odd">
<td>Y85-Y86</td>
<td>1e</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td>1e if nature of external cause not stated on record</td>
<td>10</td>
<td>2 and/or 4</td>
<td>119</td>
</tr>
<tr class="even">
<td>Y87 (.0)</td>
<td>1e</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td>1e if nature of external cause not stated on record</td>
<td>10</td>
<td></td>
<td>119</td>
</tr>
<tr class="odd">
<td>Y87 (.1)</td>
<td>1e</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td>1e if nature of external cause not stated on record</td>
<td>10</td>
<td></td>
<td>119</td>
</tr>
<tr class="even">
<td>Y87 (.2)</td>
<td>1e</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td>1e if nature of external cause not stated on record</td>
<td>10</td>
<td></td>
<td>119</td>
</tr>
<tr class="odd">
<td>Y88 (.0)</td>
<td>1e</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td>1e if nature of external cause not stated on record</td>
<td>10</td>
<td><p>4 and/or</p>
<p>1D</p></td>
<td>119</td>
</tr>
<tr class="even">
<td>Y88 (.1)</td>
<td>1e</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td>1e if nature of external cause not stated on record</td>
<td>10</td>
<td><p>4 and/or</p>
<p>1C</p></td>
<td>119</td>
</tr>
<tr class="odd">
<td>Y88 (.2)</td>
<td>1e</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td>1e if nature of external cause not stated on record</td>
<td>10</td>
<td><p>4 and/or</p>
<p>1D</p></td>
<td>119</td>
</tr>
<tr class="even">
<td>Y88 (.3)</td>
<td>1e</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td>1e if nature of external cause not stated on record</td>
<td>10</td>
<td><p>4 and/or</p>
<p>1C</p></td>
<td>119</td>
</tr>
<tr class="odd">
<td>Y89 (.0-.9)</td>
<td>1e</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>0</td>
<td>1e if nature of external cause not stated on record</td>
<td>10</td>
<td></td>
<td>119</td>
</tr>
</tbody>
</table>

For an interpretation of the 'highly improbable' rule, refer to
Instruction manual part 2A, section III. Items 14 and 15 below exclude a
few additional codes according to NCHS coding procedures (see
Instruction Manual part 2a).

<table>
<colgroup>
<col style="width: 29%" />
<col style="width: 4%" />
<col style="width: 4%" />
<col style="width: 4%" />
<col style="width: 4%" />
<col style="width: 4%" />
<col style="width: 4%" />
<col style="width: 3%" />
<col style="width: 6%" />
<col style="width: 6%" />
<col style="width: 5%" />
<col style="width: 1%" />
<col style="width: 20%" />
</colgroup>
<tbody>
<tr class="odd">
<td>Improbable Sequence</td>
<td colspan="7">Priority Levels</td>
<td colspan="4">Query Form</td>
<td></td>
</tr>
<tr class="even">
<td></td>
<td>1</td>
<td>2</td>
<td>3</td>
<td>4</td>
<td>5</td>
<td>6</td>
<td>0</td>
<td>Ltr#</td>
<td>Ques#</td>
<td>Pg#</td>
<td colspan="2"></td>
</tr>
<tr class="odd">
<td><p>1. Hemophilia classifiable to D66, D67, D68.0-D68.2 reported due
to any other disease.</p>
<p>Example:</p>
<p>I (a) Hemophilia B</p>
<p>(b) ASHD</p></td>
<td>1f</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>11</td>
<td></td>
<td>145</td>
<td colspan="2"></td>
</tr>
<tr class="even">
<td><p>2. Influenza classifiable to J10-J11 reported due to any other
disease.</p>
<p>Example:</p>
<p>I (a) Influenza</p>
<p>(b) Acute pancreatitis</p></td>
<td>1f</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>11</td>
<td></td>
<td>145</td>
<td colspan="2"></td>
</tr>
<tr class="odd">
<td><p>3. Rheumatic fever (I00‑I02) or rheumatic heart disease (I05‑I09)
reported due to any disease other than scarlet fever (A38),
streptococcal septicemia (A40.‑), streptococcal sore throat (J02.0) and
acute tonsillitis (J03.‑).</p>
<p>Example:</p>
<p>I (a) Heart failure</p>
<p>(b) Rheumatic fever</p>
<p>(c) Cancer of the lung</p></td>
<td>1f</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>11</td>
<td></td>
<td>145</td>
<td colspan="2"></td>
</tr>
<tr class="even">
<td><p>4. Any cerebrovascular disease (I60‑I69) reported due to a
disease of the digestive system (K00‑K92).</p>
<p>Example:</p>
<p>I (a) Respiratory failure</p>
<p>(b) Cerebrovascular insufficiency</p>
<p>(c) Acute appendicitis</p></td>
<td>1f</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>11</td>
<td></td>
<td>145</td>
<td colspan="2"></td>
</tr>
<tr class="odd">
<td>Improbable Sequence</td>
<td colspan="7">Priority Levels</td>
<td colspan="3">Query Form</td>
<td colspan="2"></td>
</tr>
<tr class="even">
<td></td>
<td>1</td>
<td>2</td>
<td>3</td>
<td>4</td>
<td>5</td>
<td>6</td>
<td>0</td>
<td>Ltr#</td>
<td>Ques#</td>
<td>Pg#</td>
<td colspan="2"></td>
</tr>
<tr class="odd">
<td><p>5. Cerebral infarction due to:</p>
<p>thrombosis of precerebral arteries (I63.0); unspecified occlusion of
precerebral arteries (I63.2); thrombosis of cerebral arteries (I63.5);
unspecified occlusion of cerebral arteries (I63.5); cerebral venous
thrombosis, nonpyogenic (I63.6); other cerebral infarction (I63.8);
cerebral infarction, unspecified (I63.9); stroke, not specified as
hemorrhage or infarction (I64); other cerebrovascular disease (I67);
sequela of stroke, not specified as hemorrhage or infarction (I69.4);
sequela of other and unspecified cerebrovascular diseases (I69.8)</p>
<p>reported as “due to” endocarditis (I05-I08, I09.1, I33-I38).</p></td>
<td>1f</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>11</td>
<td></td>
<td>145</td>
<td colspan="2"></td>
</tr>
<tr class="even">
<td><p>6. Occlusion and stenosis of precerebral arteries, not resulting
in cerebral infarction (I65), <em>except</em> embolism occlusion and
stenosis of cerebral arteries, not resulting in cerebral infarction
(I66) <em>except</em> embolism sequela of cerebral infarction (I69.3),
<em>except</em> embolism</p>
<p>reported as “due to” endocarditis (I05-I08, I09.1, I33-I38).</p></td>
<td>1f</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>11</td>
<td></td>
<td>145</td>
<td colspan="2"></td>
</tr>
</tbody>
</table>

<table>
<colgroup>
<col style="width: 38%" />
<col style="width: 5%" />
<col style="width: 5%" />
<col style="width: 5%" />
<col style="width: 5%" />
<col style="width: 5%" />
<col style="width: 5%" />
<col style="width: 4%" />
<col style="width: 8%" />
<col style="width: 8%" />
<col style="width: 7%" />
</colgroup>
<tbody>
<tr class="odd">
<td>Improbable Sequence</td>
<td colspan="7">Priority Levels</td>
<td colspan="3">Query Form</td>
</tr>
<tr class="even">
<td></td>
<td>1</td>
<td>2</td>
<td>3</td>
<td>4</td>
<td>5</td>
<td>6</td>
<td>0</td>
<td>Ltr#</td>
<td>Ques#</td>
<td>Pg#</td>
</tr>
<tr class="odd">
<td><p>7. Chronic ischemic heart disease (I20, I25) reported due to any
neoplasm (C00-D48).</p>
<p>Example:</p>
<p>I (a) Coronary artery disease</p>
<p>(b) Carcinomatosis</p>
<p>(c) Carcinoma of the face</p></td>
<td>1f</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>11</td>
<td></td>
<td>145</td>
</tr>
<tr class="even">
<td><p>8. Any condition described as arteriosclerotic [atherosclerotic]
reported due to any neoplasm (C00-D48).</p>
<p>Example:</p>
<p>I (a) ASHD</p>
<p>(b) Acute myeloid leukemia.</p></td>
<td>1f</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>11</td>
<td></td>
<td>145</td>
</tr>
<tr class="odd">
<td><p>9. Any hypertensive disease reported due to any neoplasm
(C00-D48) except carcinoid tumors or endocrine and renal neoplasms.</p>
<p>Example:</p>
<p>I (a) Hypertension</p>
<p>(b) Malignant neoplasm of the throat</p></td>
<td>1f</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>11</td>
<td></td>
<td>145</td>
</tr>
</tbody>
</table>

<table>
<colgroup>
<col style="width: 38%" />
<col style="width: 5%" />
<col style="width: 5%" />
<col style="width: 5%" />
<col style="width: 5%" />
<col style="width: 5%" />
<col style="width: 5%" />
<col style="width: 4%" />
<col style="width: 8%" />
<col style="width: 8%" />
<col style="width: 7%" />
</colgroup>
<tbody>
<tr class="odd">
<td>Improbable Sequence</td>
<td colspan="7">Priority Levels</td>
<td colspan="3">Query Form</td>
</tr>
<tr class="even">
<td></td>
<td>1</td>
<td>2</td>
<td>3</td>
<td>4</td>
<td>5</td>
<td>6</td>
<td>0</td>
<td>Ltr#</td>
<td>Ques#</td>
<td>Pg#</td>
</tr>
<tr class="odd">
<td><p>10. An infectious or parasitic disease (A00‑B99) reported due to
any disease outside this chapter, except situations I, II, III, and
IV:</p>
<p>I. The following may be accepted as due to any other disease.</p>
<p>* diarrhea and gastroenteritis of</p>
<p>presumed infectious origin (A09, B94.8)</p>
<p>* septicemia (A40‑A41, B94.8)</p>
<p>* erysipelas (A46, B94.8)</p>
<p>* gas gangrene (A48.0, B94.8)</p>
<p>* Vincent's angina (A69.1, B94.8)</p>
<p>* mycoses (B35‑B49, B94.8)</p>
<p>II. Any infectious disease, except A81.1, may be accepted as "due to"
immunosuppression by chemicals (chemotherapy) and radiation; and
infectious diseases classified to A00-B19 or B25-B64 reported as due to
malignant neoplasms.</p>
<p>III. Any infectious disease due to disorders of immune mechanism such
as HIV or AIDS.</p>
<p>IV. Varicella and zoster infections (B01‑B02) may be accepted as "due
to" diabetes, tuberculosis and lymphoproliferative neoplasms.</p>
<p>Example:</p>
<p>I (a) Cholera</p>
<p>(b) Myocarditis</p></td>
<td>1f</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>11</td>
<td></td>
<td>145</td>
</tr>
</tbody>
</table>

<table>
<colgroup>
<col style="width: 38%" />
<col style="width: 5%" />
<col style="width: 5%" />
<col style="width: 5%" />
<col style="width: 5%" />
<col style="width: 5%" />
<col style="width: 5%" />
<col style="width: 4%" />
<col style="width: 8%" />
<col style="width: 8%" />
<col style="width: 7%" />
</colgroup>
<tbody>
<tr class="odd">
<td>Improbable Sequence</td>
<td colspan="7">Priority Levels</td>
<td colspan="3">Query Form</td>
</tr>
<tr class="even">
<td></td>
<td>1</td>
<td>2</td>
<td>3</td>
<td>4</td>
<td>5</td>
<td>6</td>
<td>0</td>
<td>Ltr#</td>
<td>Ques#</td>
<td>Pg#</td>
</tr>
<tr class="odd">
<td><p>11. A malignant neoplasm classifiable to C00-C97 reported due to
any disease, except HIV</p>
<p>Example:</p>
<p>I.(a) Multiple myeloma</p>
<p>(b) Emphysema</p></td>
<td>1f</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>11</td>
<td></td>
<td>145</td>
</tr>
<tr class="even">
<td><p>12. Diabetes (E10‑E14) reported due to any disease except
hemochromatosis (E83.1), diseases of pancreas (K85‑K86), pancreatic
neoplasms (C25.‑, D13.6, D13.7, D37.7), and malnutrition (E40‑E46).</p>
<p>Example:</p>
<p>I.(a) Heart failure</p>
<p>(b) Diabetes with coma</p>
<p>(c) Gastric ulcer</p></td>
<td>1f</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>11</td>
<td></td>
<td>145</td>
</tr>
<tr class="odd">
<td><p>13. Congenital malformations (Q00-Q99) reported due to any other
disease, including immaturity, except chromosome abnormality or
congenital malformation syndrome; pulmonary hypoplasia due to congenital
anomaly.</p>
<p>Example:</p>
<p>I.(a) Spina bifida</p>
<p>(b) Pneumonia</p></td>
<td>1f</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>11</td>
<td></td>
<td>145</td>
</tr>
<tr class="even">
<td><p>14. An injury classifiable to Chapter 19 (S00-T98) except
T17.2-T17.9 (foreign body in respiratory tract), reported due to a
disease condition (A00-R99).</p>
<p>Example:</p>
<p>I.(a) Fracture of the neck</p>
<p>(b) Influenza</p></td>
<td>1f</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>11</td>
<td></td>
<td>145</td>
</tr>
</tbody>
</table>

<table>
<colgroup>
<col style="width: 38%" />
<col style="width: 5%" />
<col style="width: 5%" />
<col style="width: 5%" />
<col style="width: 5%" />
<col style="width: 5%" />
<col style="width: 5%" />
<col style="width: 4%" />
<col style="width: 8%" />
<col style="width: 8%" />
<col style="width: 7%" />
</colgroup>
<tbody>
<tr class="odd">
<td>Improbable Sequence</td>
<td colspan="7">Priority Levels</td>
<td colspan="3">Query Form</td>
</tr>
<tr class="even">
<td></td>
<td>1</td>
<td>2</td>
<td>3</td>
<td>4</td>
<td>5</td>
<td>6</td>
<td>0</td>
<td>Ltr#</td>
<td>Ques#</td>
<td>Pg#</td>
</tr>
<tr class="odd">
<td><p>15. Accidents (V01-X59) is reported due to any cause outside this
chapter except:</p>
<p>a) any accident (V01-X59) reported as due to epilepsy (G40-G41),</p>
<p>b) Fall (W00-W19) due to a disorder of bone density (M80-M85),</p>
<p>c) Fall (W00-W19) due to a (pathological) fracture caused by a
disorder of bone density,</p>
<p>d) Asphyxia reported as due to aspiration of mucus, blood (W80) or
vomitus (W78) as a result of disease conditions,</p>
<p>e) Aspiration of food (liquid or solid) of any kind (W79) reported as
due to a disease which affects the ability to swallow.</p>
<p>Example:</p>
<p>I.(a) Heat stroke</p>
<p>(b) Myocardial infarction</p></td>
<td>1f</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>11</td>
<td></td>
<td>145</td>
</tr>
<tr class="even">
<td><p>16. An injury is reported due to a disease condition AND an
external cause that could result in the injury is reported elswhere on
record.</p>
<p>Example:</p>
<p>I.(a) Subdural hematoma</p>
<p>(b) Hypertension</p>
<p>II. Fell and struck head</p></td>
<td>1f</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>11</td>
<td></td>
<td>145</td>
</tr>
<tr class="odd">
<td>17. Suicide (X60-X84) due to any cause</td>
<td>1f</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>11</td>
<td></td>
<td>145</td>
</tr>
</tbody>
</table>

If resource permits, we recommend querying the following types of
cause-of-death statements. When querying is not feasible, refer to the
coding instructions for these situations in Instruction Manual part 2B.

<table>
<colgroup>
<col style="width: 34%" />
<col style="width: 3%" />
<col style="width: 3%" />
<col style="width: 3%" />
<col style="width: 3%" />
<col style="width: 3%" />
<col style="width: 3%" />
<col style="width: 3%" />
<col style="width: 0%" />
<col style="width: 6%" />
<col style="width: 7%" />
<col style="width: 4%" />
<col style="width: 1%" />
<col style="width: 20%" />
</colgroup>
<tbody>
<tr class="odd">
<td>Problem With Duration</td>
<td colspan="7">Priority Levels</td>
<td colspan="5">Query Form</td>
<td></td>
</tr>
<tr class="even">
<td></td>
<td>1</td>
<td>2</td>
<td>3</td>
<td>4</td>
<td>5</td>
<td>6</td>
<td colspan="2">0</td>
<td>Ltr#</td>
<td>Ques#</td>
<td>Pg#</td>
<td colspan="2"></td>
</tr>
<tr class="odd">
<td><p>1. When a congenital malformation classifiable to Q00-Q99 is
reported with a duration less than the age of the decedent.</p>
<p>Example: Age - 50 years</p>
<p>I(a) Heart failure</p>
<p>(b) Polycystic kidney disease 5 yr</p>
<p>(c)</p>
<p>II</p></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>6</td>
<td colspan="2"></td>
<td>11</td>
<td></td>
<td>145</td>
<td colspan="2"></td>
</tr>
<tr class="even">
<td><p>2. When more than one condition is entered on a single line in
Part I with only one duration.</p>
<p>Examples:</p>
<p>I(a) ASHD with M.I. 2 yrs.</p>
<p>(b)</p>
<p>(c)</p>
<p>I(a) Coma</p>
<p>(b) Gen. A.S. with CVA 5 yrs.</p></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>6</td>
<td colspan="2"></td>
<td>11</td>
<td></td>
<td>145</td>
<td colspan="2"></td>
</tr>
</tbody>
</table>

<table style="width:100%;">
<colgroup>
<col style="width: 44%" />
<col style="width: 4%" />
<col style="width: 4%" />
<col style="width: 4%" />
<col style="width: 4%" />
<col style="width: 4%" />
<col style="width: 4%" />
<col style="width: 4%" />
<col style="width: 8%" />
<col style="width: 9%" />
<col style="width: 5%" />
</colgroup>
<tbody>
<tr class="odd">
<td><p>3. When the duration of an entity in a due to position is shorter
than that of an entity reported on a line above it.</p>
<p>Examples:</p>
<p>I(a) Pneumonia days</p>
<p>(b) CVA 2 yrs.</p>
<p>(C) ASHD 1 yr.</p>
<p>I(a) Arteriosclerosis 5 yrs.</p>
<p>(b) Cerebral arterio 3 yrs.</p>
<p>(c) Hypertension 2 yrs.</p></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>6</td>
<td></td>
<td>11</td>
<td></td>
<td>145</td>
</tr>
</tbody>
</table>

<table style="width:100%;">
<colgroup>
<col style="width: 44%" />
<col style="width: 4%" />
<col style="width: 4%" />
<col style="width: 4%" />
<col style="width: 4%" />
<col style="width: 4%" />
<col style="width: 4%" />
<col style="width: 4%" />
<col style="width: 8%" />
<col style="width: 9%" />
<col style="width: 5%" />
</colgroup>
<tbody>
<tr class="odd">
<td>Problem With Duration</td>
<td colspan="7">Priority Levels</td>
<td colspan="3">Query Form</td>
</tr>
<tr class="even">
<td></td>
<td>1</td>
<td>2</td>
<td>3</td>
<td>4</td>
<td>5</td>
<td>6</td>
<td>0</td>
<td>Ltr#</td>
<td>Ques#</td>
<td>Pg#</td>
</tr>
<tr class="odd">
<td><p>4. When the certifier enters conflicting durations for a single
condition on a line in Part I.</p>
<p>Example: <u>Duration</u></p>
<p>I(a) Coronary occlusion weeks|6 mos.</p>
<p>(b)</p>
<p>(c)</p></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>6</td>
<td></td>
<td>11</td>
<td></td>
<td>145</td>
</tr>
</tbody>
</table>

If resource permits, we recommend querying the following types of
cause-of-death statements. When querying is not feasible, refer to the
coding instructions for these situations in Instruction Manual part 2B.

<table>
<colgroup>
<col style="width: 34%" />
<col style="width: 3%" />
<col style="width: 3%" />
<col style="width: 3%" />
<col style="width: 3%" />
<col style="width: 3%" />
<col style="width: 3%" />
<col style="width: 3%" />
<col style="width: 0%" />
<col style="width: 6%" />
<col style="width: 5%" />
<col style="width: 6%" />
<col style="width: 1%" />
<col style="width: 20%" />
</colgroup>
<tbody>
<tr class="odd">
<td>Problem with Placement and Numbering of Conditions</td>
<td colspan="7">Priority Levels</td>
<td colspan="5">Query Form</td>
<td></td>
</tr>
<tr class="even">
<td></td>
<td>1</td>
<td>2</td>
<td>3</td>
<td>4</td>
<td>5</td>
<td>6</td>
<td colspan="2">0</td>
<td>Ltr#</td>
<td>Ques#</td>
<td>Pg#</td>
<td colspan="2"></td>
</tr>
<tr class="odd">
<td><p>1. When a condition is reported on the certificate above line
(a).</p>
<p>Example:</p>
<p>Cardiac arrest</p>
<p>I(a) ASHD</p>
<p>(b) A.S.</p>
<p>(c) Hypertension</p></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>6</td>
<td colspan="2"></td>
<td>11</td>
<td></td>
<td>145</td>
<td colspan="2"></td>
</tr>
<tr class="even">
<td><p>2. When conditions are reported between lines I(a) and I(b) or
I(b) and I(c).</p>
<p>Example:</p>
<p>I(a) Cardiac arrest</p>
<p>(b) Pulmonary edema, Pneumonia</p>
<p>CHF</p>
<p>(c) Hypertension</p></td>
<td></td>
<td></td>
<td></td>
<td>4</td>
<td></td>
<td></td>
<td colspan="2"></td>
<td>11</td>
<td></td>
<td>145</td>
<td colspan="2"></td>
</tr>
<tr class="odd">
<td><p>3. When the certifier has entered conditions on lines (a), (b),
and (c) and has made a statement that (c) was “due to above”.</p>
<p>Example:</p>
<p>I(a) Pneumonia</p>
<p>(b) Hypertension</p>
<p>(c) Cardiac hypertrophy due to</p>
<p>above</p></td>
<td></td>
<td></td>
<td></td>
<td>4</td>
<td></td>
<td></td>
<td colspan="2"></td>
<td>11</td>
<td></td>
<td>145</td>
<td colspan="2"></td>
</tr>
<tr class="even">
<td><p>4. When the certifier has reported that a condition in Part II
was “caused by above”.</p>
<p>Example:</p>
<p>I(a) Hypotension</p>
<p>(b) Arteriosclerosis</p>
<p>(c)</p>
<p>II Mesenteric thrombosis caused by</p>
<p>Above</p></td>
<td></td>
<td></td>
<td></td>
<td>4</td>
<td></td>
<td></td>
<td colspan="2"></td>
<td>11</td>
<td></td>
<td>145</td>
<td colspan="2"></td>
</tr>
<tr class="odd">
<td>Problem with Placement and Numbering of Conditions</td>
<td colspan="8">Priority Levels</td>
<td colspan="3">Query Form</td>
<td colspan="2"></td>
</tr>
<tr class="even">
<td></td>
<td>1</td>
<td>2</td>
<td>3</td>
<td>4</td>
<td>5</td>
<td>6</td>
<td colspan="2">0</td>
<td>Ltr#</td>
<td>Ques#</td>
<td>Pg#</td>
<td colspan="2"></td>
</tr>
<tr class="odd">
<td><p>5. When the certifier has marked through lines (a), (b), and (c)
or the printed “due to or as a consequence of” which is interpreted to
mean that none of the conditions in Part I are causally related.</p>
<p>Examples:</p>
<p><del>I(a)</del> Gastrointestinal hemorrhage</p>
<p><del>(b)</del> Gastric ulcer</p>
<p><del>(c)</del></p>
<p>II Arteriosclerosis</p>
<p>I(a) Congestive heart failure</p>
<p><del>(b)</del> ASHD</p>
<p>(c)</p>
<p>II Pneumonia</p>
<p>I(a) Malnutrition</p>
<p><del>due to or as a consequence of</del></p>
<p>(b) Carcinoma of liver</p>
<p><del>due to or as a consequence of</del></p>
<p>(c) Carcinoma of pancreas</p></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>6</td>
<td colspan="2"></td>
<td>11</td>
<td></td>
<td>145</td>
<td colspan="2"></td>
</tr>
<tr class="even">
<td><p>6. When the certifier has marked through the printed “Part
II”.</p>
<p>Example:</p>
<p>I(a) Pulmonary embolism</p>
<p>(b) Heart disease</p>
<p>(c)</p>
<p><del>II</del> Hypertension</p></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>6</td>
<td colspan="2"></td>
<td>11</td>
<td></td>
<td>145</td>
<td colspan="2"></td>
</tr>
<tr class="odd">
<td><p>7. When the certifier has numbered all causes on lines in Part I
(i.e., 1, 2, 3, etc.).</p>
<p>Example:</p>
<p>I(a) 1.Pneumonia 2.C.H.F.</p>
<p>(b) 3.Pulmonary edema</p>
<p>(c) 4.Myocarditis</p></td>
<td></td>
<td></td>
<td></td>
<td>4</td>
<td></td>
<td></td>
<td colspan="2"></td>
<td>11</td>
<td></td>
<td>145</td>
<td colspan="2"></td>
</tr>
<tr class="even">
<td>Problem with Placement and Numbering of Conditions</td>
<td colspan="8">Priority Levels</td>
<td colspan="3">Query Form</td>
<td colspan="2"></td>
</tr>
<tr class="odd">
<td></td>
<td>1</td>
<td>2</td>
<td>3</td>
<td>4</td>
<td>5</td>
<td>6</td>
<td colspan="2">0</td>
<td>Ltr#</td>
<td>Ques#</td>
<td>Pg#</td>
<td colspan="2"></td>
</tr>
<tr class="even">
<td><p>8. When the certifier has numbered part of the causes in Part
I.</p>
<p>Example:</p>
<p>I(a) 1.Acidosis</p>
<p>(b) 2.Coma</p>
<p>(c) Cerebral arteriosclerosis</p></td>
<td></td>
<td></td>
<td></td>
<td>4</td>
<td></td>
<td></td>
<td colspan="2"></td>
<td>11</td>
<td></td>
<td>145</td>
<td colspan="2"></td>
</tr>
<tr class="odd">
<td><p>9. When the causes in Part I are numbered and one of the numbered
causes is stated or implied as due to another cause.</p>
<p>Example:</p>
<p>I(a) 1.Uremia due to nephritis</p>
<p>(b) 2.Hypertension</p>
<p>(c) 3.Arteriosclerosis</p></td>
<td></td>
<td></td>
<td></td>
<td>4</td>
<td></td>
<td></td>
<td colspan="2"></td>
<td>11</td>
<td></td>
<td>145</td>
<td colspan="2"></td>
</tr>
<tr class="even">
<td><p>10. When the certifier has used arrows to indicate moving
conditions from Part I to Part II and more than one condition is entered
on the line.</p>
<p>Examples:</p>
<p>I(a) ASHD</p>
<p>(b) Gen. Art.</p>
<p>(c) Parkinson dis. Encephalopathy</p>
<p>II |</p>
<p><img src="media/image4.wmf"
style="width:0.775in;height:0.15833in" /></p>
<p>I(a) Cardiorespiratory failure</p>
<p>(b) CVA</p>
<p>(c) G.I. hemorrhage gastric ulcer</p>
<p>II |</p>
<p><img src="media/image5.wmf"
style="width:0.80833in;height:0.15833in" /></p></td>
<td></td>
<td></td>
<td></td>
<td>4</td>
<td></td>
<td></td>
<td colspan="2"></td>
<td>11</td>
<td></td>
<td>145</td>
<td colspan="2"></td>
</tr>
</tbody>
</table>

[Appendix B]{.underline}

Query Letter 1

(Rare Causes)

(Letterhead)

Dear Doctor \_\_\_\_\_\_\_\_

We are writing this letter to obtain additional information about the
cause of death that you certified for
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_, who died
\_\_\_\_\_\_\_\_\_\_\_\_\_. Please answer the questions shown in the
attachment.

Accurate cause-of-death information is essential, not only to the family
of the decedent, but also for medical research, funding, and resource
allocation in our State and at the national level.

In this particular death, we wish to ensure that the cause of death is
correct. The reported cause is one of the causes that we always try to
verify, either because the cause is rarely reported on a death
certificate or may present threats to public health in the United
States. We appreciate your help in verifying the condition on this death
certificate and look forward to your prompt reply.

If you have any questions, please contact
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_.

Sincerely,

State Registrar/Vital Statistics Cooperative Program

Attachment

**Rare Cause Query**

+-------------------+----------------------+---+------------+-------+
| **CAUSE OF DEATH  |                      |   |            | A     |
| (See instructions |                      |   |            | pprox |
| and examples)**   |                      |   |            | imate |
|                   |                      |   |            | inte  |
| 32\. **PART I.**  |                      |   |            | rval: |
| Enter the [chain  |                      |   |            |       |
| of                |                      |   |            | Onset |
| events]{.under    |                      |   |            | to    |
| line}\--diseases, |                      |   |            | death |
| injuries, or      |                      |   |            |       |
| com               |                      |   |            | \_\   |
| plications\--that |                      |   |            | _\_\_ |
| directly caused   |                      |   |            | [\_\_ |
| the death. DO NOT |                      |   |            | \_\_\ |
| enter terminal    |                      |   |            | _\_\_ |
| events such as    |                      |   |            | \_]{. |
| cardiac           |                      |   |            | under |
|                   |                      |   |            | line} |
| arrest,           |                      |   |            |       |
| respiratory       |                      |   |            | \_\   |
| arrest, or        |                      |   |            | _\_\_ |
| ventricular       |                      |   |            | [\_\_ |
| fibrillation      |                      |   |            | \_\_\ |
| without showing   |                      |   |            | _\_\_ |
| the etiology. DO  |                      |   |            | \_]{. |
| NOT ABBREVIATE.   |                      |   |            | under |
| Enter only one    |                      |   |            | line} |
| cause on a line.  |                      |   |            |       |
| Add additional    |                      |   |            | \_\   |
|                   |                      |   |            | _\_\_ |
| lines if          |                      |   |            | [\_   |
| necessary.        |                      |   |            | \_\_\ |
|                   |                      |   |            | _\_\_ |
| IMMEDIATE CAUSE   |                      |   |            | \_]{. |
| (Final            |                      |   |            | under |
|                   |                      |   |            | line} |
| disease or        |                      |   |            |       |
| condition         |                      |   |            | \_\   |
| **\-\-            |                      |   |            | _\_\_ |
| \-\-\-\-\-\--\>** |                      |   |            | [\_\_ |
| a.                |                      |   |            | \_\_\ |
| \_\_\_\_\_\_\_\_  |                      |   |            | _\_\_ |
| [\_\_\_\_\_ \_\_  |                      |   |            | \_]{. |
| \_\_              |                      |   |            | under |
| \_\_\_\_\_\_\_\_\ |                      |   |            | line} |
| _\_\_\_\_\_\_\_\_ |                      |   |            |       |
| \_\_\_\_\_\_\_\_\ |                      |   |            |       |
| _\_\_\_\_\_\_\_\_ |                      |   |            |       |
| \_\_\_\_\_\_\_\_\ |                      |   |            |       |
| _\_\_\_\_\_\_\_\_ |                      |   |            |       |
| \_\_\_\_\_\_\_\_\ |                      |   |            |       |
| _\_\_\_\_\_\_\_\_ |                      |   |            |       |
| \_\_\_\_\_\_\_\_\ |                      |   |            |       |
| _\_\_\_\_\_\_\_\_ |                      |   |            |       |
| \_\_]{.underline} |                      |   |            |       |
|                   |                      |   |            |       |
| resulting in      |                      |   |            |       |
| death) Due to (or |                      |   |            |       |
| as a consequence  |                      |   |            |       |
| of):              |                      |   |            |       |
|                   |                      |   |            |       |
| Sequentially list |                      |   |            |       |
| conditions, b.    |                      |   |            |       |
| \_\_\_\           |                      |   |            |       |
| _\_\_\_\_\_\_\_\_ |                      |   |            |       |
| [\_\_\_\_\_       |                      |   |            |       |
| \_\_\_\_\_\_\     |                      |   |            |       |
| _\_\_\_\_\_\_\_\_ |                      |   |            |       |
| \_\_\_\_\_\_\_\_\ |                      |   |            |       |
| _\_\_\_\_\_\_\_\_ |                      |   |            |       |
| \_\_\_\_\_\_\_\_\ |                      |   |            |       |
| _\_\_\_\_\_\_\_\_ |                      |   |            |       |
| \_\_\_\_\_\_\_\_\ |                      |   |            |       |
| _\_\_\_\_\_\_\_\_ |                      |   |            |       |
| \_\_\_\_\_\_\_\_\ |                      |   |            |       |
| _\_\_\_\_\_\_\_\_ |                      |   |            |       |
| \_\_]{.underline} |                      |   |            |       |
|                   |                      |   |            |       |
| if any, leading   |                      |   |            |       |
| to the cause Due  |                      |   |            |       |
| to (or as a       |                      |   |            |       |
| consequence of):  |                      |   |            |       |
|                   |                      |   |            |       |
| listed on line a. |                      |   |            |       |
| Enter the         |                      |   |            |       |
|                   |                      |   |            |       |
| **UNDERLYING      |                      |   |            |       |
| CAUSE** c.        |                      |   |            |       |
| \_\_\_\           |                      |   |            |       |
| _\_\_\_\_\_\_\_\_ |                      |   |            |       |
| [\_\_\_\_\_       |                      |   |            |       |
| \_\_              |                      |   |            |       |
| \_\_\_\_\_\_\_\_\ |                      |   |            |       |
| _\_\_\_\_\_\_\_\_ |                      |   |            |       |
| \_\_\_\_\_\_\_\_\ |                      |   |            |       |
| _\_\_\_\_\_\_\_\_ |                      |   |            |       |
| \_\_\_\_\_\_\_\_\ |                      |   |            |       |
| _\_\_\_\_\_\_\_\_ |                      |   |            |       |
| \_\_\_\_\_\_\_\_\ |                      |   |            |       |
| _\_\_\_\_\_\_\_\_ |                      |   |            |       |
| \_\_\_\_\_\_\_\_\ |                      |   |            |       |
| _\_\_\_\_\_\_\_\_ |                      |   |            |       |
| \_\_]{.underline} |                      |   |            |       |
|                   |                      |   |            |       |
| (disease or       |                      |   |            |       |
| injury that Due   |                      |   |            |       |
| to (or as a       |                      |   |            |       |
| consequence of):  |                      |   |            |       |
|                   |                      |   |            |       |
| initiated the     |                      |   |            |       |
| events resulting  |                      |   |            |       |
|                   |                      |   |            |       |
| in death)         |                      |   |            |       |
| **LAST** d.       |                      |   |            |       |
| \_\               |                      |   |            |       |
| _\_\_\_\_\_\_\_\_ |                      |   |            |       |
| [\_\_\_\_\_       |                      |   |            |       |
| \                 |                      |   |            |       |
| _\_\_\_\_\_\_\_\_ |                      |   |            |       |
| \_\_\_\_\_\_\_\_\ |                      |   |            |       |
| _\_\_\_\_\_\_\_\_ |                      |   |            |       |
| \_\_\_\_\_\_\_\_\ |                      |   |            |       |
| _\_\_\_\_\_\_\_\_ |                      |   |            |       |
| \_\_\_\_\_\_\_\_\ |                      |   |            |       |
| _\_\_\_\_\_\_\_\_ |                      |   |            |       |
| \_\_\_\_\_\_\_\_\ |                      |   |            |       |
| _\_\_\_\_\_\_\_\_ |                      |   |            |       |
| \_\_]{.underline} |                      |   |            |       |
+-------------------+----------------------+---+------------+-------+
| **PART II.**      |                      |   | 33\. WAS   |       |
| Enter other       |                      |   | AN AUTOPSY |       |
| [significant      |                      |   | PERFORMED? |       |
| conditions        |                      |   |            |       |
| contributing to   |                      |   |  Yes  No |       |
| d                 |                      |   |            |       |
| eath]{.underline} |                      |   |            |       |
| 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  | 36\. IF FEMALE:      | 3 |            |       |
| USE CONTRIBUTE TO |                      | 7 |            |       |
| DEATH?            |  Not pregnant       | \ |            |       |
|                   | within past year     | . |            |       |
|  Yes  Probably  |                      | M |            |       |
|                   |  Pregnant at time   | A |            |       |
|  No  Unknown    | of death             | N |            |       |
|                   |                      | N |            |       |
|                   |  Not pregnant, but  | E |            |       |
|                   | pregnant within 42   | R |            |       |
|                   | days of death        | O |            |       |
|                   |                      | F |            |       |
|                   |  Not pregnant, but  | D |            |       |
|                   | pregnant 43 days to  | E |            |       |
|                   | 1 year before death  | A |            |       |
|                   |                      | T |            |       |
|                   |  Unknown if         | H |            |       |
|                   | pregnant within the  |   |            |       |
|                   | past year            |  |            |       |
|                   |                      | N |            |       |
|                   |                      | a |            |       |
|                   |                      | t |            |       |
|                   |                      | u |            |       |
|                   |                      | r |            |       |
|                   |                      | a |            |       |
|                   |                      | l |            |       |
|                   |                      |  |            |       |
|                   |                      | H |            |       |
|                   |                      | o |            |       |
|                   |                      | m |            |       |
|                   |                      | i |            |       |
|                   |                      | c |            |       |
|                   |                      | i |            |       |
|                   |                      | d |            |       |
|                   |                      | e |            |       |
|                   |                      |   |            |       |
|                   |                      |  |            |       |
|                   |                      | A |            |       |
|                   |                      | c |            |       |
|                   |                      | c |            |       |
|                   |                      | i |            |       |
|                   |                      | d |            |       |
|                   |                      | e |            |       |
|                   |                      | n |            |       |
|                   |                      | t |            |       |
|                   |                      |  |            |       |
|                   |                      | P |            |       |
|                   |                      | e |            |       |
|                   |                      | n |            |       |
|                   |                      | d |            |       |
|                   |                      | i |            |       |
|                   |                      | n |            |       |
|                   |                      | g |            |       |
|                   |                      | I |            |       |
|                   |                      | n |            |       |
|                   |                      | v |            |       |
|                   |                      | e |            |       |
|                   |                      | s |            |       |
|                   |                      | t |            |       |
|                   |                      | i |            |       |
|                   |                      | g |            |       |
|                   |                      | a |            |       |
|                   |                      | t |            |       |
|                   |                      | i |            |       |
|                   |                      | o |            |       |
|                   |                      | n |            |       |
|                   |                      |   |            |       |
|                   |                      |  |            |       |
|                   |                      | S |            |       |
|                   |                      | u |            |       |
|                   |                      | i |            |       |
|                   |                      | c |            |       |
|                   |                      | i |            |       |
|                   |                      | d |            |       |
|                   |                      | e |            |       |
|                   |                      |  |            |       |
|                   |                      | C |            |       |
|                   |                      | o |            |       |
|                   |                      | u |            |       |
|                   |                      | l |            |       |
|                   |                      | d |            |       |
|                   |                      | n |            |       |
|                   |                      | o |            |       |
|                   |                      | t |            |       |
|                   |                      | b |            |       |
|                   |                      | e |            |       |
|                   |                      | d |            |       |
|                   |                      | e |            |       |
|                   |                      | t |            |       |
|                   |                      | e |            |       |
|                   |                      | r |            |       |
|                   |                      | m |            |       |
|                   |                      | i |            |       |
|                   |                      | n |            |       |
|                   |                      | e |            |       |
|                   |                      | d |            |       |
+-------------------+----------------------+---+------------+-------+

1\. Is the stated cause of death,
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_,
correctly reported?

Yes\_\_\_\_\_\_\_ No\_\_\_\_\_\_\_\_\_

2\. If yes, please state how the stated disease was confirmed:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

(laboratory test, history, clinical evidence, and/or others. If
applicable, please state name of laboratory test, and/or source of
evidence)

3\. If no, please state the correct cause of death:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

4\. Was this condition active or current? Yes\_\_\_\_\_\_\_
No\_\_\_\_\_\_\_\_\_

5\. Was the condition cured, old, or healed? Yes\_\_\_\_\_\_\_
No\_\_\_\_\_\_\_\_\_

[, M.D.]{.underline}

(Signature of Certifying Physician)

Please provide your office
phone:\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
fax:\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**Available Resources to Assist With Medical Certification of Causes of
Death**![](media/image6.wmf){width="8.016666666666667in"
height="8.333333333333333e-2in"}

Your State vital statistics office should be able to assist with
questions related to writing cause-of-death statements. Additional
instructional material on writing cause-of-death statements including
handbooks, summary instructions, and tutorials are available online at
www.thename.org or www.cdc.gov/nchswww/about/major/dvs/handbk.htm, or by
request from NCHS, Room 7318, 3311 Toledo Road, Hyattsville, Maryland
20782-2003 (301-458-4333).

Query Letter 2

(Neoplasms)

(Letterhead)

Dear Doctor \_\_\_\_\_\_\_\_

We are writing this letter to obtain additional information about the
cause of death that you certified for
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_, who died
\_\_\_\_\_\_\_\_\_\_\_\_\_.

Accurate cause-of-death information is essential, not only to the family
of the decedent, but also for medical research, funding, and resource
allocation in our State and at the national level.

In this particular cancer death, we wish to ensure that sufficient
information is available on the nature of the neoplasm. In order to
classify this death properly in our statistics, would you please supply
the information on the attachment? We want to assure you that the
information you provide us is confidential and will be handled
accordingly.

If you have any question or would like to know more about various
methods for certifying a cause-of-death statement, please contact
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_.
Instructions and an example of a properly completed death certificate
are provided with the attached material.

We appreciate your attention and prompt reply.

Sincerely,

State Registrar/Vital Statistics Cooperative Program

Attachment

Neoplasm query

+-------------------+----------------------+---+------------+-------+
| **CAUSE OF DEATH  |                      |   |            | A     |
| (See instructions |                      |   |            | pprox |
| and examples)**   |                      |   |            | imate |
|                   |                      |   |            | inte  |
| 32\. **PART I.**  |                      |   |            | rval: |
| Enter the [chain  |                      |   |            |       |
| of                |                      |   |            | Onset |
| events]{.under    |                      |   |            | to    |
| line}\--diseases, |                      |   |            | death |
| injuries, or      |                      |   |            |       |
| com               |                      |   |            | \_\   |
| plications\--that |                      |   |            | _\_\_ |
| directly caused   |                      |   |            | [\_\_ |
| the death. DO NOT |                      |   |            | \_\_\ |
| enter terminal    |                      |   |            | _\_\_ |
| events such as    |                      |   |            | \_]{. |
| cardiac           |                      |   |            | under |
|                   |                      |   |            | line} |
| arrest,           |                      |   |            |       |
| respiratory       |                      |   |            | \_\   |
| arrest, or        |                      |   |            | _\_\_ |
| ventricular       |                      |   |            | [\_\_ |
| fibrillation      |                      |   |            | \_\_\ |
| without showing   |                      |   |            | _\_\_ |
| the etiology. DO  |                      |   |            | \_]{. |
| NOT ABBREVIATE.   |                      |   |            | under |
| Enter only one    |                      |   |            | line} |
| cause on a line.  |                      |   |            |       |
| Add additional    |                      |   |            | \_\   |
|                   |                      |   |            | _\_\_ |
| lines if          |                      |   |            | [\_   |
| necessary.        |                      |   |            | \_\_\ |
|                   |                      |   |            | _\_\_ |
| IMMEDIATE CAUSE   |                      |   |            | \_]{. |
| (Final            |                      |   |            | under |
|                   |                      |   |            | line} |
| disease or        |                      |   |            |       |
| condition         |                      |   |            | \_\   |
| **\-\-            |                      |   |            | _\_\_ |
| \-\-\-\-\-\--\>** |                      |   |            | [\_\_ |
| a.                |                      |   |            | \_\_\ |
| \_\_\_\_\_\_\_\_  |                      |   |            | _\_\_ |
| [\_\_\_\_\_ \_\_  |                      |   |            | \_]{. |
| \_\_              |                      |   |            | under |
| \_\_\_\_\_\_\_\_\ |                      |   |            | line} |
| _\_\_\_\_\_\_\_\_ |                      |   |            |       |
| \_\_\_\_\_\_\_\_\ |                      |   |            |       |
| _\_\_\_\_\_\_\_\_ |                      |   |            |       |
| \_\_\_\_\_\_\_\_\ |                      |   |            |       |
| _\_\_\_\_\_\_\_\_ |                      |   |            |       |
| \_\_\_\_\_\_\_\_\ |                      |   |            |       |
| _\_\_\_\_\_\_\_\_ |                      |   |            |       |
| \_\_\_\_\_\_\_\_\ |                      |   |            |       |
| _\_\_\_\_\_\_\_\_ |                      |   |            |       |
| \_\_]{.underline} |                      |   |            |       |
|                   |                      |   |            |       |
| resulting in      |                      |   |            |       |
| death) Due to (or |                      |   |            |       |
| as a consequence  |                      |   |            |       |
| of):              |                      |   |            |       |
|                   |                      |   |            |       |
| Sequentially list |                      |   |            |       |
| conditions, b.    |                      |   |            |       |
| \_\_\_\           |                      |   |            |       |
| _\_\_\_\_\_\_\_\_ |                      |   |            |       |
| [\_\_\_\_\_       |                      |   |            |       |
| \_\_\_\_\_\_\     |                      |   |            |       |
| _\_\_\_\_\_\_\_\_ |                      |   |            |       |
| \_\_\_\_\_\_\_\_\ |                      |   |            |       |
| _\_\_\_\_\_\_\_\_ |                      |   |            |       |
| \_\_\_\_\_\_\_\_\ |                      |   |            |       |
| _\_\_\_\_\_\_\_\_ |                      |   |            |       |
| \_\_\_\_\_\_\_\_\ |                      |   |            |       |
| _\_\_\_\_\_\_\_\_ |                      |   |            |       |
| \_\_\_\_\_\_\_\_\ |                      |   |            |       |
| _\_\_\_\_\_\_\_\_ |                      |   |            |       |
| \_\_]{.underline} |                      |   |            |       |
|                   |                      |   |            |       |
| if any, leading   |                      |   |            |       |
| to the cause Due  |                      |   |            |       |
| to (or as a       |                      |   |            |       |
| consequence of):  |                      |   |            |       |
|                   |                      |   |            |       |
| listed on line a. |                      |   |            |       |
| Enter the         |                      |   |            |       |
|                   |                      |   |            |       |
| **UNDERLYING      |                      |   |            |       |
| CAUSE** c.        |                      |   |            |       |
| \_\_\_\           |                      |   |            |       |
| _\_\_\_\_\_\_\_\_ |                      |   |            |       |
| [\_\_\_\_\_       |                      |   |            |       |
| \_\_              |                      |   |            |       |
| \_\_\_\_\_\_\_\_\ |                      |   |            |       |
| _\_\_\_\_\_\_\_\_ |                      |   |            |       |
| \_\_\_\_\_\_\_\_\ |                      |   |            |       |
| _\_\_\_\_\_\_\_\_ |                      |   |            |       |
| \_\_\_\_\_\_\_\_\ |                      |   |            |       |
| _\_\_\_\_\_\_\_\_ |                      |   |            |       |
| \_\_\_\_\_\_\_\_\ |                      |   |            |       |
| _\_\_\_\_\_\_\_\_ |                      |   |            |       |
| \_\_\_\_\_\_\_\_\ |                      |   |            |       |
| _\_\_\_\_\_\_\_\_ |                      |   |            |       |
| \_\_]{.underline} |                      |   |            |       |
|                   |                      |   |            |       |
| (disease or       |                      |   |            |       |
| injury that Due   |                      |   |            |       |
| to (or as a       |                      |   |            |       |
| consequence of):  |                      |   |            |       |
|                   |                      |   |            |       |
| initiated the     |                      |   |            |       |
| events resulting  |                      |   |            |       |
|                   |                      |   |            |       |
| in death)         |                      |   |            |       |
| **LAST** d.       |                      |   |            |       |
| \_\               |                      |   |            |       |
| _\_\_\_\_\_\_\_\_ |                      |   |            |       |
| [\_\_\_\_\_       |                      |   |            |       |
| \                 |                      |   |            |       |
| _\_\_\_\_\_\_\_\_ |                      |   |            |       |
| \_\_\_\_\_\_\_\_\ |                      |   |            |       |
| _\_\_\_\_\_\_\_\_ |                      |   |            |       |
| \_\_\_\_\_\_\_\_\ |                      |   |            |       |
| _\_\_\_\_\_\_\_\_ |                      |   |            |       |
| \_\_\_\_\_\_\_\_\ |                      |   |            |       |
| _\_\_\_\_\_\_\_\_ |                      |   |            |       |
| \_\_\_\_\_\_\_\_\ |                      |   |            |       |
| _\_\_\_\_\_\_\_\_ |                      |   |            |       |
| \_\_]{.underline} |                      |   |            |       |
+-------------------+----------------------+---+------------+-------+
| **PART II.**      |                      |   | 33\. WAS   |       |
| Enter other       |                      |   | AN AUTOPSY |       |
| [significant      |                      |   | PERFORMED? |       |
| conditions        |                      |   |            |       |
| contributing to   |                      |   |  Yes  No |       |
| d                 |                      |   |            |       |
| eath]{.underline} |                      |   |            |       |
| 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  | 36\. IF FEMALE:      | 3 |            |       |
| USE CONTRIBUTE TO |                      | 7 |            |       |
| DEATH?            |  Not pregnant       | \ |            |       |
|                   | within past year     | . |            |       |
|  Yes  Probably  |                      | M |            |       |
|                   |  Pregnant at time   | A |            |       |
|  No  Unknown    | of death             | N |            |       |
|                   |                      | N |            |       |
|                   |  Not pregnant, but  | E |            |       |
|                   | pregnant within 42   | R |            |       |
|                   | days of death        | O |            |       |
|                   |                      | F |            |       |
|                   |  Not pregnant, but  | D |            |       |
|                   | pregnant 43 days to  | E |            |       |
|                   | 1 year before death  | A |            |       |
|                   |                      | T |            |       |
|                   |  Unknown if         | H |            |       |
|                   | pregnant within the  |   |            |       |
|                   | past year            |  |            |       |
|                   |                      | N |            |       |
|                   |                      | a |            |       |
|                   |                      | t |            |       |
|                   |                      | u |            |       |
|                   |                      | r |            |       |
|                   |                      | a |            |       |
|                   |                      | l |            |       |
|                   |                      |  |            |       |
|                   |                      | H |            |       |
|                   |                      | o |            |       |
|                   |                      | m |            |       |
|                   |                      | i |            |       |
|                   |                      | c |            |       |
|                   |                      | i |            |       |
|                   |                      | d |            |       |
|                   |                      | e |            |       |
|                   |                      |   |            |       |
|                   |                      |  |            |       |
|                   |                      | A |            |       |
|                   |                      | c |            |       |
|                   |                      | c |            |       |
|                   |                      | i |            |       |
|                   |                      | d |            |       |
|                   |                      | e |            |       |
|                   |                      | n |            |       |
|                   |                      | t |            |       |
|                   |                      |  |            |       |
|                   |                      | P |            |       |
|                   |                      | e |            |       |
|                   |                      | n |            |       |
|                   |                      | d |            |       |
|                   |                      | i |            |       |
|                   |                      | n |            |       |
|                   |                      | g |            |       |
|                   |                      | I |            |       |
|                   |                      | n |            |       |
|                   |                      | v |            |       |
|                   |                      | e |            |       |
|                   |                      | s |            |       |
|                   |                      | t |            |       |
|                   |                      | i |            |       |
|                   |                      | g |            |       |
|                   |                      | a |            |       |
|                   |                      | t |            |       |
|                   |                      | i |            |       |
|                   |                      | o |            |       |
|                   |                      | n |            |       |
|                   |                      |   |            |       |
|                   |                      |  |            |       |
|                   |                      | S |            |       |
|                   |                      | u |            |       |
|                   |                      | i |            |       |
|                   |                      | c |            |       |
|                   |                      | i |            |       |
|                   |                      | d |            |       |
|                   |                      | e |            |       |
|                   |                      |  |            |       |
|                   |                      | C |            |       |
|                   |                      | o |            |       |
|                   |                      | u |            |       |
|                   |                      | l |            |       |
|                   |                      | d |            |       |
|                   |                      | n |            |       |
|                   |                      | o |            |       |
|                   |                      | t |            |       |
|                   |                      | b |            |       |
|                   |                      | e |            |       |
|                   |                      | d |            |       |
|                   |                      | e |            |       |
|                   |                      | t |            |       |
|                   |                      | e |            |       |
|                   |                      | r |            |       |
|                   |                      | m |            |       |
|                   |                      | i |            |       |
|                   |                      | n |            |       |
|                   |                      | e |            |       |
|                   |                      | d |            |       |
+-------------------+----------------------+---+------------+-------+

Was the neoplasm,
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

1\. Malignant\_\_\_, Benign\_\_\_, Undetermined\_\_\_

2\. Primary site \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

3\. More detailed site or part of organ
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

4\. Histologic type, if
known\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

5.Other
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

[, M.D.]{.underline}

(Signature of Certifying Physician)

Please provide your office
phone:\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
fax:\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

(Please see other side)

Instructions on Medical Certification of Causes of Death

[Example of properly completed medical certification]{.underline}

+-------------------+----------------------+---+-------------+--------+
| **CAUSE OF DEATH  |                      |   |             | Appro  |
| (See instructions |                      |   |             | ximate |
| and examples)**   |                      |   |             | int    |
|                   |                      |   |             | erval: |
| 32\. **PART I.**  |                      |   |             |        |
| Enter the [chain  |                      |   |             | Onset  |
| of                |                      |   |             | to     |
| events]{.under    |                      |   |             | death  |
| line}\--diseases, |                      |   |             |        |
| injuries, or      |                      |   |             | [25    |
| com               |                      |   |             | hours] |
| plications\--that |                      |   |             | {.unde |
| directly caused   |                      |   |             | rline} |
| the death. DO NOT |                      |   |             |        |
| enter terminal    |                      |   |             | [3     |
| events such as    |                      |   |             | m      |
| cardiac           |                      |   |             | onths] |
|                   |                      |   |             | {.unde |
| arrest,           |                      |   |             | rline} |
| respiratory       |                      |   |             |        |
| arrest, or        |                      |   |             | [7     |
| ventricular       |                      |   |             | m      |
| fibrillation      |                      |   |             | onths] |
| without showing   |                      |   |             | {.unde |
| the etiology. DO  |                      |   |             | rline} |
| NOT ABBREVIATE.   |                      |   |             |        |
| Enter only one    |                      |   |             | \_     |
| cause on a line.  |                      |   |             | [\     |
| Add additional    |                      |   |             | _\_\_\ |
|                   |                      |   |             | _\_\_] |
| lines if          |                      |   |             | {.unde |
| necessary.        |                      |   |             | rline} |
|                   |                      |   |             |        |
| IMMEDIATE CAUSE   |                      |   |             |        |
| (Final            |                      |   |             |        |
|                   |                      |   |             |        |
| disease or        |                      |   |             |        |
| condition         |                      |   |             |        |
| **\-\-            |                      |   |             |        |
| \-\-\-\-\-\--\>** |                      |   |             |        |
| a. [Pneumonia     |                      |   |             |        |
| \_\_\_\_\         |                      |   |             |        |
| _\_\_\_\_\_\_\_\_ |                      |   |             |        |
| \_\_\_\_\_\_\_\_\ |                      |   |             |        |
| _\_\_\_\_\_\_\_\_ |                      |   |             |        |
| \_\_\_\_\_\_\_\_\ |                      |   |             |        |
| _\_\_\_\_\_\_\_\_ |                      |   |             |        |
| \_\_\_\_\_\_\_\_\ |                      |   |             |        |
| _\_\_\_\_\_\_\_\_ |                      |   |             |        |
| \_\_\_\_\_\_\_\_\ |                      |   |             |        |
| _\_\_\_\_\_\_\_\_ |                      |   |             |        |
| \_\_]{.underline} |                      |   |             |        |
|                   |                      |   |             |        |
| resulting in      |                      |   |             |        |
| death) Due to (or |                      |   |             |        |
| as a consequence  |                      |   |             |        |
| of):              |                      |   |             |        |
|                   |                      |   |             |        |
| Sequentially list |                      |   |             |        |
| conditions, b.    |                      |   |             |        |
| [Metastatic       |                      |   |             |        |
| carcinoma to the  |                      |   |             |        |
| liver\_\_         |                      |   |             |        |
| \_\_\_\_\_\_\_\_\ |                      |   |             |        |
| _\_\_\_\_\_\_\_\_ |                      |   |             |        |
| \_\_\_\_\_\_\_\_\ |                      |   |             |        |
| _\_\_\_\_\_\_\_\_ |                      |   |             |        |
| \_\_\_\_\_\_\_\_\ |                      |   |             |        |
| _\_\_\_\_\_\_\_\_ |                      |   |             |        |
| \_\_\_\_\_\_\_\_\ |                      |   |             |        |
| _\_\_\_\_\_\_\_\_ |                      |   |             |        |
| \_\_]{.underline} |                      |   |             |        |
|                   |                      |   |             |        |
| if any, leading   |                      |   |             |        |
| to the cause Due  |                      |   |             |        |
| to (or as a       |                      |   |             |        |
| consequence of):  |                      |   |             |        |
|                   |                      |   |             |        |
| listed on line a. |                      |   |             |        |
| Enter the         |                      |   |             |        |
|                   |                      |   |             |        |
| **UNDERLYING      |                      |   |             |        |
| CAUSE** c.        |                      |   |             |        |
| [Adenocarcinoma   |                      |   |             |        |
| of the head of    |                      |   |             |        |
| the               |                      |   |             |        |
| pan               |                      |   |             |        |
| creas\_\_\_\_\_\_ |                      |   |             |        |
| \_\_\_\_\_\_\_\_\ |                      |   |             |        |
| _\_\_\_\_\_\_\_\_ |                      |   |             |        |
| \_\_\_\_\_\_\_\_\ |                      |   |             |        |
| _\_\_\_\_\_\_\_\_ |                      |   |             |        |
| \_\_\_\_\_\_\_\_\ |                      |   |             |        |
| _\_\_\_\_\_\_\_\_ |                      |   |             |        |
| \_\_]{.underline} |                      |   |             |        |
|                   |                      |   |             |        |
| (disease or       |                      |   |             |        |
| injury that Due   |                      |   |             |        |
| to (or as a       |                      |   |             |        |
| consequence of):  |                      |   |             |        |
|                   |                      |   |             |        |
| initiated the     |                      |   |             |        |
| events resulting  |                      |   |             |        |
|                   |                      |   |             |        |
| in death)         |                      |   |             |        |
| **LAST** d.       |                      |   |             |        |
| [\_\_\_\_\_\_\_\_ |                      |   |             |        |
| \_\_\_\_\_\_\_\_\ |                      |   |             |        |
| _\_\_\_\_\_\_\_\_ |                      |   |             |        |
| \_\_\_\_\_\_\_\_\ |                      |   |             |        |
| _\_\_\_\_\_\_\_\_ |                      |   |             |        |
| \_\_\_\_\_\_\_\_\ |                      |   |             |        |
| _\_\_\_\_\_\_\_\_ |                      |   |             |        |
| \_\_\_\_\_\_\_\_\ |                      |   |             |        |
| _\_\_\_\_\_\_\_\_ |                      |   |             |        |
| \_\_\_\_\_\_\_\_\ |                      |   |             |        |
| _\_\_\_\_\_\_\_\_ |                      |   |             |        |
| \_\_]{.underline} |                      |   |             |        |
+-------------------+----------------------+---+-------------+--------+
| **PART II.**      |                      |   | 33\. WAS AN |        |
| Enter other       |                      |   | AUTOPSY     |        |
| [significant      |                      |   | PERFORMED?  |        |
| conditions        |                      |   |             |        |
| contributing to   |                      |   |  Yes ■ No  |        |
| d                 |                      |   |             |        |
| eath]{.underline} |                      |   |             |        |
| 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  | 36\. IF FEMALE:      | 3 |             |        |
| USE CONTRIBUTE TO |                      | 7 |             |        |
| DEATH?            | ■ Not pregnant       | \ |             |        |
|                   | within past year     | . |             |        |
|  Yes  Probably  |                      | M |             |        |
|                   |  Pregnant at time   | A |             |        |
| ■ No  Unknown    | of death             | N |             |        |
|                   |                      | N |             |        |
|                   |  Not pregnant, but  | E |             |        |
|                   | pregnant within 42   | R |             |        |
|                   | days of death        | O |             |        |
|                   |                      | F |             |        |
|                   |  Not pregnant, but  | D |             |        |
|                   | pregnant 43 days to  | E |             |        |
|                   | 1 year before death  | A |             |        |
|                   |                      | T |             |        |
|                   |  Unknown if         | H |             |        |
|                   | pregnant within the  |   |             |        |
|                   | past year            | ■ |             |        |
|                   |                      | N |             |        |
|                   |                      | a |             |        |
|                   |                      | t |             |        |
|                   |                      | u |             |        |
|                   |                      | r |             |        |
|                   |                      | a |             |        |
|                   |                      | l |             |        |
|                   |                      |  |             |        |
|                   |                      | H |             |        |
|                   |                      | o |             |        |
|                   |                      | m |             |        |
|                   |                      | i |             |        |
|                   |                      | c |             |        |
|                   |                      | i |             |        |
|                   |                      | d |             |        |
|                   |                      | e |             |        |
|                   |                      |   |             |        |
|                   |                      |  |             |        |
|                   |                      | A |             |        |
|                   |                      | c |             |        |
|                   |                      | c |             |        |
|                   |                      | i |             |        |
|                   |                      | d |             |        |
|                   |                      | e |             |        |
|                   |                      | n |             |        |
|                   |                      | t |             |        |
|                   |                      |  |             |        |
|                   |                      | P |             |        |
|                   |                      | e |             |        |
|                   |                      | n |             |        |
|                   |                      | d |             |        |
|                   |                      | i |             |        |
|                   |                      | n |             |        |
|                   |                      | g |             |        |
|                   |                      | I |             |        |
|                   |                      | n |             |        |
|                   |                      | v |             |        |
|                   |                      | e |             |        |
|                   |                      | s |             |        |
|                   |                      | t |             |        |
|                   |                      | i |             |        |
|                   |                      | g |             |        |
|                   |                      | a |             |        |
|                   |                      | t |             |        |
|                   |                      | i |             |        |
|                   |                      | o |             |        |
|                   |                      | n |             |        |
|                   |                      |   |             |        |
|                   |                      |  |             |        |
|                   |                      | S |             |        |
|                   |                      | u |             |        |
|                   |                      | i |             |        |
|                   |                      | c |             |        |
|                   |                      | i |             |        |
|                   |                      | d |             |        |
|                   |                      | e |             |        |
|                   |                      |  |             |        |
|                   |                      | C |             |        |
|                   |                      | o |             |        |
|                   |                      | u |             |        |
|                   |                      | l |             |        |
|                   |                      | d |             |        |
|                   |                      | n |             |        |
|                   |                      | o |             |        |
|                   |                      | t |             |        |
|                   |                      | b |             |        |
|                   |                      | e |             |        |
|                   |                      | d |             |        |
|                   |                      | e |             |        |
|                   |                      | t |             |        |
|                   |                      | e |             |        |
|                   |                      | r |             |        |
|                   |                      | m |             |        |
|                   |                      | i |             |        |
|                   |                      | n |             |        |
|                   |                      | e |             |        |
|                   |                      | d |             |        |
+-------------------+----------------------+---+-------------+--------+

**ITEM 32 -- CAUSE OF DEATH (See example above)**

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.

Take care to make the entry legible. Use a computer printer with high
resolution, typewriter with good black ribbon and clean keys, or print
legibly using permanent **black** ink in completing the CAUSE OF DEATH
Section. **Do** **not** **abbreviate** conditions entered in section.

**[Part I]{.underline} (Chain of events leading directly to death)**

•Only **one** cause should be entered on each line. [Line
(a)]{.underline} **MUST ALWAYS** have an entry. **DO NOT** leave blank.
Additional lines may be added if necessary.

•If the condition on [Line (a)]{.underline} resulted from an underlying
condition, put the underlying condition on [Line (b)]{.underline}, and
so on, until the full sequence is reported. **ALWAYS** enter the
**underlying cause of death** on the [lowest used line]{.underline} in
Part I.

•For each cause indicate the best estimate of the interval between the
presumed onset and the date of death. The terms "unknown" or
"approximately" may be used. General terms, such as minutes, hours, or
days, are acceptable, if necessary. **DO NOT** leave blank.

•The terminal event (for example, cardiac arrest or respiratory arrest)
should not be used. If a mechanism of death seems most appropriate to
you for line (a), then you must always list its cause(s) on the line(s)
below it (for example, cardiac arrest **due to** coronary artery
atherosclerosis *or* cardiac arrest **due to** blunt impact to chest).

• If an organ system failure such as congestive heart failure, hepatic
failure, renal failure, or respiratory failure is listed as a cause of
death, always report its etiology on the line(s) beneath it (for
example, renal failure **due to** Type I diabetes mellitus).

•When indicating neoplasms as a cause of death, include the
following: 1) primary site *or* that the primary site is unknown, 2)
benign or malignant, 3) cell type *or* that the cell type is unknown, 4)
grade of neoplasm, and 5) part or lobe of organ affected. (For example,
a primary well-differentiated squamous cell carcinoma, lung, left upper
lobe.)

•Always report the fatal injury (for example, stab wound of chest), the
trauma (for example, transection of subclavian vein), and impairment of
function (for example, air embolism).

**Part II (Other significant conditions)**

•Enter all diseases or conditions contributing to death that were not
reported in the chain of events in Part I and that did not result in the
**underlying cause of death**.

•If two or more possible sequences resulted in death, or if two
conditions seem to have added together, report in Part I the one that,
in your opinion, most directly caused death. Report in Part II the other
conditions or diseases.

**CHANGES TO CAUSE OF DEATH**

Should additional medical information or autopsy findings become
available that would change the cause of death originally reported, the
original death certificate should be amended by the certifying physician
by **immediately** reporting the revised cause of death to the State
Vital Records Office.

**ITEMS ON WHEN DEATH OCCURRED**

Items 24-25 and 29-31 should always be completed. If the facility uses a
separate pronouncer or other person to indicate that death has taken
place with another person more familiar with the case completing the
remainder of the medical portion of the death certificate, the
pronouncer completes Items 24-28. If a certifier completes Items 24-25
as well as items 29-49, Items 26-28 may be left blank.

**ITEMS 24-25, 29-30 -- DATE AND TIME OF DEATH**

Spell out the name of the month. If the exact date of death is unknown,
enter the **approximate** date. If the date cannot be approximated,
enter the date the body is found and identify as **date found**. Date
pronounced and actual date may be the same. Enter the exact hour and
minutes according to a 24-hour clock; estimates may be provided with
"Approx." placed before the time.

**ITEMS 33-34 - AUTOPSY**

•33 - Enter "Yes" if either a partial or full autopsy was performed.
Otherwise enter "No."

•34 - Enter "Yes" if autopsy findings were available to complete the
cause of death; otherwise enter "No". Leave item blank if no autopsy was
performed.

**ITEM 35 - DID TOBACCO USE CONTRIBUTE TO DEATH?**

Check "yes" if, in your opinion, the use of tobacco contributed to
death. Tobacco use may contribute to deaths due to a wide variety of
diseases; for example, tobacco use contributes to many deaths due to
emphysema or lung cancer and some heart disease and cancers of the head
and neck. Check "no" if, in your clinical judgment, tobacco use did not
contribute to this particular death.

**ITEM 36 - IF FEMALE, WAS DECEDENT PREGNANT AT TIME OF DEATH OR WITHIN
PAST YEAR?**

This information is important in determining pregnancy-related
mortality.

**ITEM 37 - MANNER OF DEATH**

•Always check Manner of Death, which is important: 1) in determining
accurate causes of death; 2) in processing insurance claims; and 3) in
statistical studies of injuries and death.

•Indicate "Pending investigation" if the manner of death cannot be
determined whether due to an accident, suicide, or homicide within the
statutory time limit for filing the death certificate. This should be
changed later to one of the other terms.

•Indicate "Could not be Determined" **ONLY** when it is impossible to
determine the manner of death.

**ITEMS 38-44 - ACCIDENT OR INJURY -- to be filled out in all cases of
deaths due to injury or poisoning.**

•38 - Enter the exact month, day, and year of injury. Spell out the name
of the month. **DO NOT** use a number for the month. (Remember, the date
of injury may differ from the date of death.) Estimates may be provided
with "Approx." placed before the date.

•39 **-** Enter the exact hour and minutes of injury or use your best
estimate. Use a 24-hour clock.

•40 - Enter the general place (such as restaurant, vacant lot, or home)
where the injury occurred. **DO NOT** enter firm or organization names.
(For example, enter "factory", **not** "Standard Manufacturing, Inc." )

•41 - Complete if anything other than natural disease is mentioned in
Part I or Part II of the medical certification, including homicides,
suicides, and accidents. This includes all motor vehicle deaths. The
item **[must]{.underline}** be completed for decedents ages 14 years or
over and may be completed for those less than 14 years of age if
warranted. Enter "Yes" if the injury occurred at work. Otherwise enter
"No". An injury may occur at work regardless of whether the injury
occurred in the course of the decedent's "usual" occupation. Examples of
injury at work and injury not at work follow:

+-----------------------------------+-----------------------------------+
| **Injury at work**                | **Injury [not]{.underline} at     |
|                                   | work**                            |
| Injury while working or in        |                                   |
| vocational training on job        | Injury while engaged in personal  |
| premises                          | recreational activity on job      |
|                                   | premises                          |
| Injury while on break or at lunch |                                   |
| or in parking lot on job premises | Injury while a visitor (not on    |
|                                   | official work business) to job    |
| Injury while working for pay or   | premises                          |
| compensation, including at home   |                                   |
|                                   | Homemaker working at homemaking   |
| Injury while working as a         | activities                        |
| volunteer law enforcement         |                                   |
| official etc.                     | Student in school                 |
|                                   |                                   |
| Injury while traveling on         | Working for self for no profit    |
| business, including to/from       | (mowing yard, repairing own roof, |
| business contacts                 | hobby)                            |
|                                   |                                   |
|                                   | Commuting to or from work         |
+-----------------------------------+-----------------------------------+

•42 - Enter the complete address where the injury occurred including zip
code.

•43 - Enter a brief but specific and clear description of how the injury
occurred. Explain the circumstances or cause of the injury. Specify
**type** **of** **gun** or **type of vehicle** (e.g., car, bulldozer,
train, etc.) when relevant to circumstances. Indicate if more than one
vehicle involved; specify type of vehicle decedent was in.

•44 -Specify role of decedent (e.g. driver, passenger). Driver/operator
and passenger should be designated for modes other than motor vehicles
such as bicycles. Other applies to watercraft, aircraft, animal, or
people attached to outside of vehicles (e.g. surfers).

[Rationale]{.underline}: Motor vehicle accidents are a major cause of
unintentional deaths; details will help determine effectiveness of
current safety features and laws.

**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:]{.underline}**

+-------------+-------------+-------------+-------------+-------------+
| Abscess     | Car         | D           | H           | Pulmonary   |
|             | cinomatosis | isseminated | yponatremia | arrest      |
| Abdominal   |             | intra       |             |             |
| hemorrhage  | Cardiac     | vascular    | Hypotension | Pulmonary   |
|             | arrest      |             |             | edema       |
| Adhesions   |             | c           | Immuno      |             |
|             | Cardiac     | oagulopathy | suppression | Pulmonary   |
| Adult       | dysrhythmia |             |             | embolism    |
| respiratory |             | Dysrhythmia | Increased   |             |
| distress    | Car         |             | intra       | Pulmonary   |
| syndrome    | diomyopathy | End-stage   | cranial     | in          |
|             |             | liver       | pressure    | sufficiency |
| Acute       | Card        | disease     |             |             |
| myocardial  | iopulmonary |             | Intra       | Renal       |
| infarction  | arrest      | End-stage   | cranial     | failure     |
|             |             | renal       | hemorrhage  |             |
| Altered     | Cellulitis  | disease     |             | Respiratory |
| mental      |             |             | M           | arrest      |
| status      | Cerebral    | Epidural    | alnutrition |             |
|             | edema       | hematoma    |             | Seizures    |
| Anemia      |             |             | Metabolic   |             |
|             | Cere        | Exs         | enc         | Sepsis      |
| Anoxia      | brovascular | anguination | ephalopathy |             |
|             | accident    |             |             | Septic      |
| Anoxic      |             | Failure to  | Multi-organ | shock       |
| enc         | Cerebellar  | thrive      | failure     |             |
| ephalopathy | tonsillar   |             |             | Shock       |
|             | herniation  | Fracture    | M           |             |
| Arrhythmia  |             |             | ulti-system | Starvation  |
|             | Chronic     | Gangrene    | organ       |             |
| Ascites     | bedridden   |             | failure     | Subdural    |
|             | state       | Gastr       |             | hematoma    |
| Aspiration  |             | ointestinal | Myocardial  |             |
|             | Cirrhosis   | hemorrhage  | infarction  | S           |
| Atrial      |             |             |             | ubarachnoid |
| f           | C           | Heart       | Necrotizing | hemorrhage  |
| ibrillation | oagulopathy | failure     | soft-tissue |             |
|             |             |             | infection   | Sudden      |
| Bacteremia  | Compression | Hemothorax  |             | death       |
|             | fracture    |             | Old age     |             |
| Bedridden   |             | Hepatic     |             | Throm       |
|             | Congestive  | failure     | Open (or    | bocytopenia |
| Biliary     | heart       |             | closed)     |             |
| obstruction | failure     | Hepatitis   | head injury | Uncal       |
|             |             |             |             | herniation  |
| Bowel       | Convulsions | Hepatorenal | Paralysis   |             |
| obstruction |             | syndrome    |             | Urinary     |
|             | Decubiti    |             | P           | tract       |
| Brain       |             | Hy          | ancytopenia | infection   |
| injury      | Dehydration | perglycemia |             |             |
|             |             |             | Perforated  | Ventricular |
| Brain stem  | Dementia    | H           | gallbladder | f           |
| herniation  | (when not   | yperkalemia |             | ibrillation |
|             |             |             | Peritonitis |             |
| Car         | otherwise   | Hypovolemic |             | Ventricular |
| cinogenesis | specified)  | shock       | Pleural     | tachycardia |
|             |             |             | effusions   |             |
|             | Diarrhea    |             |             | Volume      |
|             |             |             | Pneumonia   | 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    | Epidural    | Hip         | Pulmonary   | Subdural    |
|             | hematoma    | fracture    | emboli      | hematoma    |
| Bolus       |             |             |             |             |
|             | Exs         | H           | Seizure     | Surgery     |
| Choking     | anguination | yperthermia | disorder    |             |
|             |             |             |             | Thermal     |
| Drug or     | Fall        | Hypothermia | Sepsis      | bur         |
| alcohol     |             |             |             | ns/chemical |
| ov          | Fracture    | Open        | S           | burns       |
| erdose/drug |             | reduction   | ubarachnoid |             |
| or          |             | of fracture | hemorrhage  |             |
|             |             |             |             |             |
| alcohol     |             |             |             |             |
| abuse       |             |             |             |             |
+-------------+-------------+-------------+-------------+-------------+

Contact your State vital statistics office for questions related to
writing cause-of-death statements. Additional instructional material on
writing cause-of-death statements including handbooks, summary
instructions, and tutorials are available online at www.thename.org or
www.cdc.gov/nchswww/about/major/dvs/handbk.htm, or by request from NCHS,
Room 7318, 3311 Toledo Road, Hyattsville, Maryland 20782-2003.

QUERY LETTER 3

(Query for HIV)

(Letterhead)

Dear Doctor \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

We are writing this letter to obtain additional information about the
cause of death that you certified for
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_, who died
\_\_\_\_\_\_\_\_\_\_\_\_\_.

Accurate cause-of-death information is essential, not only to the family
of the decedent, but also for medical research, funding, and resource
allocation in our State and at the national level.

In this particular death, we are requesting additional information on
HIV status. Certain conditions are frequently associated with HIV
infection. In order to classify this death properly in our statistics,
would you please supply the information on the attachment? We want to
assure you that the information you provide us is confidential and will
be handled accordingly.

If you have any question or would like to know more about various
methods for certifying a cause-of-death statement, please contact
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_.
Instructions and an example of a properly completed death certificate
are provided with the attached material.

We appreciate your attention and prompt reply.

Sincerely,

State Registrar/Vital Statistics Cooperative Program

Attachment

HIV Query

+-------------------+----------------------+---+------------+-------+
| **CAUSE OF DEATH  |                      |   |            | A     |
| (See instructions |                      |   |            | pprox |
| and examples)**   |                      |   |            | imate |
|                   |                      |   |            | inte  |
| 32\. **PART I.**  |                      |   |            | rval: |
| Enter the [chain  |                      |   |            |       |
| of                |                      |   |            | Onset |
| events]{.under    |                      |   |            | to    |
| line}\--diseases, |                      |   |            | death |
| injuries, or      |                      |   |            |       |
| com               |                      |   |            | \_\   |
| plications\--that |                      |   |            | _\_\_ |
| directly caused   |                      |   |            | [\_\_ |
| the death. DO NOT |                      |   |            | \_\_\ |
| enter terminal    |                      |   |            | _\_\_ |
| events such as    |                      |   |            | \_]{. |
| cardiac           |                      |   |            | under |
|                   |                      |   |            | line} |
| arrest,           |                      |   |            |       |
| respiratory       |                      |   |            | \_\   |
| arrest, or        |                      |   |            | _\_\_ |
| ventricular       |                      |   |            | [\_\_ |
| fibrillation      |                      |   |            | \_\_\ |
| without showing   |                      |   |            | _\_\_ |
| the etiology. DO  |                      |   |            | \_]{. |
| NOT ABBREVIATE.   |                      |   |            | under |
| Enter only one    |                      |   |            | line} |
| cause on a line.  |                      |   |            |       |
| Add additional    |                      |   |            | \_\   |
|                   |                      |   |            | _\_\_ |
| lines if          |                      |   |            | [\_   |
| necessary.        |                      |   |            | \_\_\ |
|                   |                      |   |            | _\_\_ |
| IMMEDIATE CAUSE   |                      |   |            | \_]{. |
| (Final            |                      |   |            | under |
|                   |                      |   |            | line} |
| disease or        |                      |   |            |       |
| condition         |                      |   |            | \_\   |
| **\-\-            |                      |   |            | _\_\_ |
| \-\-\-\-\-\--\>** |                      |   |            | [\_\_ |
| a.                |                      |   |            | \_\_\ |
| \_\_\_\_\_\_\_\_  |                      |   |            | _\_\_ |
| [\_\_\_\_\_ \_\_  |                      |   |            | \_]{. |
| \_\_              |                      |   |            | under |
| \_\_\_\_\_\_\_\_\ |                      |   |            | line} |
| _\_\_\_\_\_\_\_\_ |                      |   |            |       |
| \_\_\_\_\_\_\_\_\ |                      |   |            |       |
| _\_\_\_\_\_\_\_\_ |                      |   |            |       |
| \_\_\_\_\_\_\_\_\ |                      |   |            |       |
| _\_\_\_\_\_\_\_\_ |                      |   |            |       |
| \_\_\_\_\_\_\_\_\ |                      |   |            |       |
| _\_\_\_\_\_\_\_\_ |                      |   |            |       |
| \_\_\_\_\_\_\_\_\ |                      |   |            |       |
| _\_\_\_\_\_\_\_\_ |                      |   |            |       |
| \_\_]{.underline} |                      |   |            |       |
|                   |                      |   |            |       |
| resulting in      |                      |   |            |       |
| death) Due to (or |                      |   |            |       |
| as a consequence  |                      |   |            |       |
| of):              |                      |   |            |       |
|                   |                      |   |            |       |
| Sequentially list |                      |   |            |       |
| conditions, b.    |                      |   |            |       |
| \_\_\_\           |                      |   |            |       |
| _\_\_\_\_\_\_\_\_ |                      |   |            |       |
| [\_\_\_\_\_       |                      |   |            |       |
| \_\_\_\_\_\_\     |                      |   |            |       |
| _\_\_\_\_\_\_\_\_ |                      |   |            |       |
| \_\_\_\_\_\_\_\_\ |                      |   |            |       |
| _\_\_\_\_\_\_\_\_ |                      |   |            |       |
| \_\_\_\_\_\_\_\_\ |                      |   |            |       |
| _\_\_\_\_\_\_\_\_ |                      |   |            |       |
| \_\_\_\_\_\_\_\_\ |                      |   |            |       |
| _\_\_\_\_\_\_\_\_ |                      |   |            |       |
| \_\_\_\_\_\_\_\_\ |                      |   |            |       |
| _\_\_\_\_\_\_\_\_ |                      |   |            |       |
| \_\_]{.underline} |                      |   |            |       |
|                   |                      |   |            |       |
| if any, leading   |                      |   |            |       |
| to the cause Due  |                      |   |            |       |
| to (or as a       |                      |   |            |       |
| consequence of):  |                      |   |            |       |
|                   |                      |   |            |       |
| listed on line a. |                      |   |            |       |
| Enter the         |                      |   |            |       |
|                   |                      |   |            |       |
| **UNDERLYING      |                      |   |            |       |
| CAUSE** c.        |                      |   |            |       |
| \_\_\_\           |                      |   |            |       |
| _\_\_\_\_\_\_\_\_ |                      |   |            |       |
| [\_\_\_\_\_       |                      |   |            |       |
| \_\_              |                      |   |            |       |
| \_\_\_\_\_\_\_\_\ |                      |   |            |       |
| _\_\_\_\_\_\_\_\_ |                      |   |            |       |
| \_\_\_\_\_\_\_\_\ |                      |   |            |       |
| _\_\_\_\_\_\_\_\_ |                      |   |            |       |
| \_\_\_\_\_\_\_\_\ |                      |   |            |       |
| _\_\_\_\_\_\_\_\_ |                      |   |            |       |
| \_\_\_\_\_\_\_\_\ |                      |   |            |       |
| _\_\_\_\_\_\_\_\_ |                      |   |            |       |
| \_\_\_\_\_\_\_\_\ |                      |   |            |       |
| _\_\_\_\_\_\_\_\_ |                      |   |            |       |
| \_\_]{.underline} |                      |   |            |       |
|                   |                      |   |            |       |
| (disease or       |                      |   |            |       |
| injury that Due   |                      |   |            |       |
| to (or as a       |                      |   |            |       |
| consequence of):  |                      |   |            |       |
|                   |                      |   |            |       |
| initiated the     |                      |   |            |       |
| events resulting  |                      |   |            |       |
|                   |                      |   |            |       |
| in death)         |                      |   |            |       |
| **LAST** d.       |                      |   |            |       |
| \_\               |                      |   |            |       |
| _\_\_\_\_\_\_\_\_ |                      |   |            |       |
| [\_\_\_\_\_       |                      |   |            |       |
| \                 |                      |   |            |       |
| _\_\_\_\_\_\_\_\_ |                      |   |            |       |
| \_\_\_\_\_\_\_\_\ |                      |   |            |       |
| _\_\_\_\_\_\_\_\_ |                      |   |            |       |
| \_\_\_\_\_\_\_\_\ |                      |   |            |       |
| _\_\_\_\_\_\_\_\_ |                      |   |            |       |
| \_\_\_\_\_\_\_\_\ |                      |   |            |       |
| _\_\_\_\_\_\_\_\_ |                      |   |            |       |
| \_\_\_\_\_\_\_\_\ |                      |   |            |       |
| _\_\_\_\_\_\_\_\_ |                      |   |            |       |
| \_\_]{.underline} |                      |   |            |       |
+-------------------+----------------------+---+------------+-------+
| **PART II.**      |                      |   | 33\. WAS   |       |
| Enter other       |                      |   | AN AUTOPSY |       |
| [significant      |                      |   | PERFORMED? |       |
| conditions        |                      |   |            |       |
| contributing to   |                      |   |  Yes  No |       |
| d                 |                      |   |            |       |
| eath]{.underline} |                      |   |            |       |
| 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  | 36\. IF FEMALE:      | 3 |            |       |
| USE CONTRIBUTE TO |                      | 7 |            |       |
| DEATH?            |  Not pregnant       | \ |            |       |
|                   | within past year     | . |            |       |
|  Yes  Probably  |                      | M |            |       |
|                   |  Pregnant at time   | A |            |       |
|  No  Unknown    | of death             | N |            |       |
|                   |                      | N |            |       |
|                   |  Not pregnant, but  | E |            |       |
|                   | pregnant within 42   | R |            |       |
|                   | days of death        | O |            |       |
|                   |                      | F |            |       |
|                   |  Not pregnant, but  | D |            |       |
|                   | pregnant 43 days to  | E |            |       |
|                   | 1 year before death  | A |            |       |
|                   |                      | T |            |       |
|                   |  Unknown if         | H |            |       |
|                   | pregnant within the  |   |            |       |
|                   | past year            |  |            |       |
|                   |                      | N |            |       |
|                   |                      | a |            |       |
|                   |                      | t |            |       |
|                   |                      | u |            |       |
|                   |                      | r |            |       |
|                   |                      | a |            |       |
|                   |                      | l |            |       |
|                   |                      |  |            |       |
|                   |                      | H |            |       |
|                   |                      | o |            |       |
|                   |                      | m |            |       |
|                   |                      | i |            |       |
|                   |                      | c |            |       |
|                   |                      | i |            |       |
|                   |                      | d |            |       |
|                   |                      | e |            |       |
|                   |                      |   |            |       |
|                   |                      |  |            |       |
|                   |                      | A |            |       |
|                   |                      | c |            |       |
|                   |                      | c |            |       |
|                   |                      | i |            |       |
|                   |                      | d |            |       |
|                   |                      | e |            |       |
|                   |                      | n |            |       |
|                   |                      | t |            |       |
|                   |                      |  |            |       |
|                   |                      | P |            |       |
|                   |                      | e |            |       |
|                   |                      | n |            |       |
|                   |                      | d |            |       |
|                   |                      | i |            |       |
|                   |                      | n |            |       |
|                   |                      | g |            |       |
|                   |                      | I |            |       |
|                   |                      | n |            |       |
|                   |                      | v |            |       |
|                   |                      | e |            |       |
|                   |                      | s |            |       |
|                   |                      | t |            |       |
|                   |                      | i |            |       |
|                   |                      | g |            |       |
|                   |                      | a |            |       |
|                   |                      | t |            |       |
|                   |                      | i |            |       |
|                   |                      | o |            |       |
|                   |                      | n |            |       |
|                   |                      |   |            |       |
|                   |                      |  |            |       |
|                   |                      | S |            |       |
|                   |                      | u |            |       |
|                   |                      | i |            |       |
|                   |                      | c |            |       |
|                   |                      | i |            |       |
|                   |                      | d |            |       |
|                   |                      | e |            |       |
|                   |                      |  |            |       |
|                   |                      | C |            |       |
|                   |                      | o |            |       |
|                   |                      | u |            |       |
|                   |                      | l |            |       |
|                   |                      | d |            |       |
|                   |                      | n |            |       |
|                   |                      | o |            |       |
|                   |                      | t |            |       |
|                   |                      | b |            |       |
|                   |                      | e |            |       |
|                   |                      | d |            |       |
|                   |                      | e |            |       |
|                   |                      | t |            |       |
|                   |                      | e |            |       |
|                   |                      | r |            |       |
|                   |                      | m |            |       |
|                   |                      | i |            |       |
|                   |                      | n |            |       |
|                   |                      | e |            |       |
|                   |                      | d |            |       |
+-------------------+----------------------+---+------------+-------+

1\. Please check all that apply.

Was there any evidence of HIV infection? Yes\_\_\_, No\_\_\_

Was there any evidence of HIV disease? Yes\_\_\_, No\_\_\_

HIV status is not known. \_\_\_\_\_\_

Provide any other pertinent information
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

2\. Other
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

[, M.D.]{.underline}

(Signature of Certifying Physician)

Please provide your office
phone:\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
fax:\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

(Please see other side)

Instructions on Medical Certification of Causes of Death

[Example of properly completed medical certification]{.underline}

+-------------------+------------------------+---+-------------+--------+
| **CAUSE OF DEATH  |                        |   |             | Appro  |
| (See instructions |                        |   |             | ximate |
| and examples)**   |                        |   |             | int    |
|                   |                        |   |             | erval: |
| 32\. **PART I.**  |                        |   |             |        |
| Enter the [chain  |                        |   |             | Onset  |
| of                |                        |   |             | to     |
| events]{.under    |                        |   |             | death  |
| line}\--diseases, |                        |   |             |        |
| injuries, or      |                        |   |             | [Mi    |
| com               |                        |   |             | nutes] |
| plications\--that |                        |   |             | {.unde |
| directly caused   |                        |   |             | rline} |
| the death. DO NOT |                        |   |             |        |
| enter terminal    |                        |   |             | [      |
| events such as    |                        |   |             | weeks] |
| cardiac           |                        |   |             | {.unde |
|                   |                        |   |             | rline} |
| arrest,           |                        |   |             |        |
| respiratory       |                        |   |             | 2      |
| arrest, or        |                        |   |             | [      |
| ventricular       |                        |   |             | years] |
| fibrillation      |                        |   |             | {.unde |
| without showing   |                        |   |             | rline} |
| the etiology. DO  |                        |   |             |        |
| NOT ABBREVIATE.   |                        |   |             | [7     |
| Enter only one    |                        |   |             | years] |
| cause on a line.  |                        |   |             | {.unde |
| Add additional    |                        |   |             | rline} |
|                   |                        |   |             |        |
| lines if          |                        |   |             |        |
| necessary.        |                        |   |             |        |
|                   |                        |   |             |        |
| IMMEDIATE CAUSE   |                        |   |             |        |
| (Final            |                        |   |             |        |
|                   |                        |   |             |        |
| disease or        |                        |   |             |        |
| condition         |                        |   |             |        |
| **\-\-            |                        |   |             |        |
| \-\-\-\-\-\--\>** |                        |   |             |        |
| a. [Bilateral     |                        |   |             |        |
| pneumothoraces\_\ |                        |   |             |        |
| _\_\_\_\_\_\_\_\_ |                        |   |             |        |
| \_\_\_\_\_\_\_\_\ |                        |   |             |        |
| _\_\_\_\_\_\_\_\_ |                        |   |             |        |
| \_\_\_\_\_\_\_\_\ |                        |   |             |        |
| _\_\_\_\_\_\_\_\_ |                        |   |             |        |
| \_\_\_\_\_\_\_\_\ |                        |   |             |        |
| _\_\_\_\_\_\_\_\_ |                        |   |             |        |
| \_\_\_\_\_\_\_\_\ |                        |   |             |        |
| _\_\_\_\_\_\_\_\_ |                        |   |             |        |
| \_\_]{.underline} |                        |   |             |        |
|                   |                        |   |             |        |
| resulting in      |                        |   |             |        |
| death) Due to (or |                        |   |             |        |
| as a consequence  |                        |   |             |        |
| of):              |                        |   |             |        |
|                   |                        |   |             |        |
| Sequentially list |                        |   |             |        |
| conditions, b.    |                        |   |             |        |
| [Pneumocystis     |                        |   |             |        |
| carinii           |                        |   |             |        |
| pn                |                        |   |             |        |
| eumonia\_\_\_\_\_ |                        |   |             |        |
| \_\_\_\_\_\_\_\_\ |                        |   |             |        |
| _\_\_\_\_\_\_\_\_ |                        |   |             |        |
| \_\_\_\_\_\_\_\_\ |                        |   |             |        |
| _\_\_\_\_\_\_\_\_ |                        |   |             |        |
| \_\_\_\_\_\_\_\_\ |                        |   |             |        |
| _\_\_\_\_\_\_\_\_ |                        |   |             |        |
| \_\_\_\_\_\_\_\_\ |                        |   |             |        |
| _\_\_\_\_\_\_\_\_ |                        |   |             |        |
| \_\_]{.underline} |                        |   |             |        |
|                   |                        |   |             |        |
| if any, leading   |                        |   |             |        |
| to the cause Due  |                        |   |             |        |
| to (or as a       |                        |   |             |        |
| consequence of):  |                        |   |             |        |
|                   |                        |   |             |        |
| listed on line a. |                        |   |             |        |
| Enter the         |                        |   |             |        |
|                   |                        |   |             |        |
| **UNDERLYING      |                        |   |             |        |
| CAUSE** c.        |                        |   |             |        |
| [Acquired         |                        |   |             |        |
| immunodeficiency\ |                        |   |             |        |
| _\_\_\_\_\_\_\_\_ |                        |   |             |        |
| \_\_\_\_\_\_\_\_\ |                        |   |             |        |
| _\_\_\_\_\_\_\_\_ |                        |   |             |        |
| \_\_\_\_\_\_\_\_\ |                        |   |             |        |
| _\_\_\_\_\_\_\_\_ |                        |   |             |        |
| \_\_\_\_\_\_\_\_\ |                        |   |             |        |
| _\_\_\_\_\_\_\_\_ |                        |   |             |        |
| \_\_\_\_\_\_\_\_\ |                        |   |             |        |
| _\_\_\_\_\_\_\_\_ |                        |   |             |        |
| \_\_]{.underline} |                        |   |             |        |
|                   |                        |   |             |        |
| (disease or       |                        |   |             |        |
| injury that Due   |                        |   |             |        |
| to (or as a       |                        |   |             |        |
| consequence of):  |                        |   |             |        |
|                   |                        |   |             |        |
| initiated the     |                        |   |             |        |
| events resulting  |                        |   |             |        |
|                   |                        |   |             |        |
| in death)         |                        |   |             |        |
| **LAST** d.       |                        |   |             |        |
| [Human            |                        |   |             |        |
| immunodeficiency  |                        |   |             |        |
| virus             |                        |   |             |        |
| i                 |                        |   |             |        |
| nfection\_\_\_\_\ |                        |   |             |        |
| _\_\_\_\_\_\_\_\_ |                        |   |             |        |
| \_\_\_\_\_\_\_\_\ |                        |   |             |        |
| _\_\_\_\_\_\_\_\_ |                        |   |             |        |
| \_\_\_\_\_\_\_\_\ |                        |   |             |        |
| _\_\_\_\_\_\_\_\_ |                        |   |             |        |
| \_\_\_\_\_\_\_\_\ |                        |   |             |        |
| _\_\_\_\_\_\_\_\_ |                        |   |             |        |
| \_\_]{.underline} |                        |   |             |        |
+-------------------+------------------------+---+-------------+--------+
| **PART II.**      |                        |   | 33\. WAS AN |        |
| Enter other       |                        |   | AUTOPSY     |        |
| [significant      |                        |   | PERFORMED?  |        |
| conditions        |                        |   |             |        |
| contributing to   |                        |   |  Yes ■ No  |        |
| d                 |                        |   |             |        |
| eath]{.underline} |                        |   |             |        |
| 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  | 36\. IF FEMALE:        | 3 |             |        |
| USE CONTRIBUTE TO |                        | 7 |             |        |
| DEATH?            |  Not pregnant within  | \ |             |        |
|                   | past year              | . |             |        |
|  Yes Probably |                        | M |             |        |
|                   | Pregnant at time of  | A |             |        |
| ■ No Unknown   | death                  | N |             |        |
|                   |                        | N |             |        |
|                   | Not pregnant, but    | E |             |        |
|                   | pregnant within 42     | R |             |        |
|                   | days of death          | O |             |        |
|                   |                        | F |             |        |
|                   | Not pregnant, but    | D |             |        |
|                   | pregnant 43 days to 1  | E |             |        |
|                   | year before death      | A |             |        |
|                   |                        | T |             |        |
|                   | ■ Unknown if pregnant  | H |             |        |
|                   | within the past year   |   |             |        |
|                   |                        | ■ |             |        |
|                   |                        | N |             |        |
|                   |                        | a |             |        |
|                   |                        | t |             |        |
|                   |                        | u |             |        |
|                   |                        | r |             |        |
|                   |                        | a |             |        |
|                   |                        | l |             |        |
|                   |                        |  |             |        |
|                   |                        |  |             |        |
|                   |                        | H |             |        |
|                   |                        | o |             |        |
|                   |                        | m |             |        |
|                   |                        | i |             |        |
|                   |                        | c |             |        |
|                   |                        | i |             |        |
|                   |                        | d |             |        |
|                   |                        | e |             |        |
|                   |                        |   |             |        |
|                   |                        |  |             |        |
|                   |                        |  |             |        |
|                   |                        | A |             |        |
|                   |                        | c |             |        |
|                   |                        | c |             |        |
|                   |                        | i |             |        |
|                   |                        | d |             |        |
|                   |                        | e |             |        |
|                   |                        | n |             |        |
|                   |                        | t |             |        |
|                   |                        |  |             |        |
|                   |                        |  |             |        |
|                   |                        | P |             |        |
|                   |                        | e |             |        |
|                   |                        | n |             |        |
|                   |                        | d |             |        |
|                   |                        | i |             |        |
|                   |                        | n |             |        |
|                   |                        | g |             |        |
|                   |                        | I |             |        |
|                   |                        | n |             |        |
|                   |                        | v |             |        |
|                   |                        | e |             |        |
|                   |                        | s |             |        |
|                   |                        | t |             |        |
|                   |                        | i |             |        |
|                   |                        | g |             |        |
|                   |                        | a |             |        |
|                   |                        | t |             |        |
|                   |                        | i |             |        |
|                   |                        | o |             |        |
|                   |                        | n |             |        |
|                   |                        |   |             |        |
|                   |                        |  |             |        |
|                   |                        |  |             |        |
|                   |                        | S |             |        |
|                   |                        | u |             |        |
|                   |                        | i |             |        |
|                   |                        | c |             |        |
|                   |                        | i |             |        |
|                   |                        | d |             |        |
|                   |                        | e |             |        |
|                   |                        |  |             |        |
|                   |                        |  |             |        |
|                   |                        |  |             |        |
|                   |                        | C |             |        |
|                   |                        | o |             |        |
|                   |                        | u |             |        |
|                   |                        | l |             |        |
|                   |                        | d |             |        |
|                   |                        | n |             |        |
|                   |                        | o |             |        |
|                   |                        | t |             |        |
|                   |                        | b |             |        |
|                   |                        | e |             |        |
|                   |                        | d |             |        |
|                   |                        | e |             |        |
|                   |                        | t |             |        |
|                   |                        | e |             |        |
|                   |                        | r |             |        |
|                   |                        | m |             |        |
|                   |                        | i |             |        |
|                   |                        | n |             |        |
|                   |                        | e |             |        |
|                   |                        | d |             |        |
+-------------------+------------------------+---+-------------+--------+

**ITEM 32 -- CAUSE OF DEATH (See example above)**

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.

Take care to make the entry legible. Use a computer printer with high
resolution, typewriter with good black ribbon and clean keys, or print
legibly using permanent **black** ink in completing the CAUSE OF DEATH
Section. **Do** **not** **abbreviate** conditions entered in section.

**[Part I]{.underline} (Chain of events leading directly to death)**

•Only **one** cause should be entered on each line. [Line
(a)]{.underline} **MUST ALWAYS** have an entry. **DO NOT** leave blank.
Additional lines may be added if necessary.

•If the condition on [Line (a)]{.underline} resulted from an underlying
condition, put the underlying condition on [Line (b)]{.underline}, and
so on, until the full sequence is reported. **ALWAYS** enter the
**underlying cause of death** on the [lowest used line]{.underline} in
Part I.

•For each cause indicate the best estimate of the interval between the
presumed onset and the date of death. The terms "unknown" or
"approximately" may be used. General terms, such as minutes, hours, or
days, are acceptable, if necessary. **DO NOT** leave blank.

•The terminal event (for example, cardiac arrest or respiratory arrest)
should not be used. If a mechanism of death seems most appropriate to
you for line (a), then you must always list its cause(s) on the line(s)
below it (for example, cardiac arrest **due to** coronary artery
atherosclerosis *or* cardiac arrest **due to** blunt impact to chest).

• If an organ system failure such as congestive heart failure, hepatic
failure, renal failure, or respiratory failure is listed as a cause of
death, always report its etiology on the line(s) beneath it (for
example, renal failure **due to** Type I diabetes mellitus).

•When indicating neoplasms as a cause of death, include the
following: 1) primary site *or* that the primary site is unknown, 2)
benign or malignant, 3) cell type *or* that the cell type is unknown, 4)
grade of neoplasm, and 5) part or lobe of organ affected. (For example,
a primary well-differentiated squamous cell carcinoma, lung, left upper
lobe.)

•Always report the fatal injury (for example, stab wound of chest), the
trauma (for example, transection of subclavian vein), and impairment of
function (for example, air embolism).

**Part II (Other significant conditions)**

•Enter all diseases or conditions contributing to death that were not
reported in the chain of events in Part I and that did not result in the
**underlying cause of death**.

•If two or more possible sequences resulted in death, or if two
conditions seem to have added together, report in Part I the one that,
in your opinion, most directly caused death. Report in Part II the other
conditions or diseases.

**CHANGES TO CAUSE OF DEATH**

Should additional medical information or autopsy findings become
available that would change the cause of death originally reported, the
original death certificate should be amended by the certifying physician
by **immediately** reporting the revised cause of death to the State
Vital Records Office.

**ITEMS ON WHEN DEATH OCCURRED**

Items 24-25 and 29-31 should always be completed. If the facility uses a
separate pronouncer or other person to indicate that death has taken
place with another person more familiar with the case completing the
remainder of the medical portion of the death certificate, the
pronouncer completes Items 24-28. If a certifier completes Items 24-25
as well as items 29-49, Items 26-28 may be left blank.

**ITEMS 24-25, 29-30 -- DATE AND TIME OF DEATH**

Spell out the name of the month. If the exact date of death is unknown,
enter the **approximate** date. If the date cannot be approximated,
enter the date the body is found and identify as **date found**. Date
pronounced and actual date may be the same. Enter the exact hour and
minutes according to a 24-hour clock; estimates may be provided with
"Approx." placed before the time.

**ITEMS 33-34 - AUTOPSY**

•33 - Enter "Yes" if either a partial or full autopsy was performed.
Otherwise enter "No."

•34 - Enter "Yes" if autopsy findings were available to complete the
cause of death; otherwise enter "No". Leave item blank if no autopsy was
performed.

**ITEM 35 - DID TOBACCO USE CONTRIBUTE TO DEATH?**

Check "yes" if, in your opinion, the use of tobacco contributed to
death. Tobacco use may contribute to deaths due to a wide variety of
diseases; for example, tobacco use contributes to many deaths due to
emphysema or lung cancer and some heart disease and cancers of the head
and neck. Check "no" if, in your clinical judgment, tobacco use did not
contribute to this particular death.

**ITEM 36 - IF FEMALE, WAS DECEDENT PREGNANT AT TIME OF DEATH OR WITHIN
PAST YEAR?**

This information is important in determining pregnancy-related
mortality.

**ITEM 37 - MANNER OF DEATH**

•Always check Manner of Death, which is important: 1) in determining
accurate causes of death; 2) in processing insurance claims; and 3) in
statistical studies of injuries and death.

•Indicate "Pending investigation" if the manner of death cannot be
determined whether due to an accident, suicide, or homicide within the
statutory time limit for filing the death certificate. This should be
changed later to one of the other terms.

•Indicate "Could not be Determined" **ONLY** when it is impossible to
determine the manner of death.

**ITEMS 38-44 - ACCIDENT OR INJURY -- to be filled out in all cases of
deaths due to injury or poisoning.**

•38 - Enter the exact month, day, and year of injury. Spell out the name
of the month. **DO NOT** use a number for the month. (Remember, the date
of injury may differ from the date of death.) Estimates may be provided
with "Approx." placed before the date.

•39 **-** Enter the exact hour and minutes of injury or use your best
estimate. Use a 24-hour clock.

•40 - Enter the general place (such as restaurant, vacant lot, or home)
where the injury occurred. **DO NOT** enter firm or organization names.
(For example, enter "factory", **not** "Standard Manufacturing, Inc.")

•41 - Complete if anything other than natural disease is mentioned in
Part I or Part II of the medical certification, including homicides,
suicides, and accidents. This includes all motor vehicle deaths. The
item **[must]{.underline}** be completed for decedents ages 14 years or
over and may be completed for those less than 14 years of age if
warranted. Enter "Yes" if the injury occurred at work. Otherwise enter
"No". An injury may occur at work regardless of whether the injury
occurred in the course of the decedent's "usual" occupation. Examples of
injury at work and injury not at work follow:

+-----------------------------------+-----------------------------------+
| **Injury at work**                | **Injury [not]{.underline} at     |
|                                   | work**                            |
| Injury while working or in        |                                   |
| vocational training on job        | Injury while engaged in personal  |
| premises                          | recreational activity on job      |
|                                   | premises                          |
| Injury while on break or at lunch |                                   |
| or in parking lot on job premises | Injury while a visitor (not on    |
|                                   | official work business) to job    |
| Injury while working for pay or   | premises                          |
| compensation, including at home   |                                   |
|                                   | Homemaker working at homemaking   |
| Injury while working as a         | activities                        |
| volunteer law enforcement         |                                   |
| official etc.                     | Student in school                 |
|                                   |                                   |
| Injury while traveling on         | Working for self for no profit    |
| business, including to/from       | (mowing yard, repairing own roof, |
| business contacts                 | hobby)                            |
|                                   |                                   |
|                                   | Commuting to or from work         |
+-----------------------------------+-----------------------------------+

•42 - Enter the complete address where the injury occurred including zip
code.

•43 - Enter a brief but specific and clear description of how the injury
occurred. Explain the circumstances or cause of the injury. Specify
**type** **of** **gun** or **type of vehicle** (e.g., car, bulldozer,
train, etc.) when relevant to circumstances. Indicate if more than one
vehicle involved; specify type of vehicle decedent was in.

•44 -Specify role of decedent (e.g. driver, passenger). Driver/operator
and passenger should be designated for modes other than motor vehicles
such as bicycles. Other applies to watercraft, aircraft, animal, or
people attached to outside of vehicles (e.g. surfers).

[Rationale]{.underline}: Motor vehicle accidents are a major cause of
unintentional deaths; details will help determine effectiveness of
current safety features and laws.

**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:]{.underline}**

+-------------+-------------+-------------+-------------+-------------+
| Abscess     | Car         | D           | H           | Pulmonary   |
|             | cinomatosis | isseminated | yponatremia | arrest      |
| Abdominal   |             | intra       |             |             |
| hemorrhage  | Cardiac     | vascular    | Hypotension | Pulmonary   |
|             | arrest      |             |             | edema       |
| Adhesions   |             | c           | Immuno      |             |
|             | Cardiac     | oagulopathy | suppression | Pulmonary   |
| Adult       | dysrhythmia |             |             | embolism    |
| respiratory |             | Dysrhythmia | Increased   |             |
| distress    | Car         |             | intra       | Pulmonary   |
| syndrome    | diomyopathy | End-stage   | cranial     | in          |
|             |             | liver       | pressure    | sufficiency |
| Acute       | Card        | disease     |             |             |
| myocardial  | iopulmonary |             | Intra       | Renal       |
| infarction  | arrest      | End-stage   | cranial     | failure     |
|             |             | renal       | hemorrhage  |             |
| Altered     | Cellulitis  | disease     |             | Respiratory |
| mental      |             |             | M           | arrest      |
| status      | Cerebral    | Epidural    | alnutrition |             |
|             | edema       | hematoma    |             | Seizures    |
| Anemia      |             |             | Metabolic   |             |
|             | Cere        | Exs         | enc         | Sepsis      |
| Anoxia      | brovascular | anguination | ephalopathy |             |
|             | accident    |             |             | Septic      |
| Anoxic      |             | Failure to  | Multi-organ | shock       |
| enc         | Cerebellar  | thrive      | failure     |             |
| ephalopathy | tonsillar   |             |             | Shock       |
|             | herniation  | Fracture    | M           |             |
| Arrhythmia  |             |             | ulti-system | Starvation  |
|             | Chronic     | Gangrene    | organ       |             |
| Ascites     | bedridden   |             | failure     | Subdural    |
|             | state       | Gastr       |             | hematoma    |
| Aspiration  |             | ointestinal | Myocardial  |             |
|             | Cirrhosis   | hemorrhage  | infarction  | S           |
| Atrial      |             |             |             | ubarachnoid |
| f           | C           | Heart       | Necrotizing | hemorrhage  |
| ibrillation | oagulopathy | failure     | soft-tissue |             |
|             |             |             | infection   | Sudden      |
| Bacteremia  | Compression | Hemothorax  |             | death       |
|             | fracture    |             | Old age     |             |
| Bedridden   |             | Hepatic     |             | Throm       |
|             | Congestive  | failure     | Open (or    | bocytopenia |
| Biliary     | heart       |             | closed)     |             |
| obstruction | failure     | Hepatitis   | head injury | Uncal       |
|             |             |             |             | herniation  |
| Bowel       | Convulsions | Hepatorenal | Paralysis   |             |
| obstruction |             | syndrome    |             | Urinary     |
|             | Decubiti    |             | P           | tract       |
| Brain       |             | Hy          | ancytopenia | infection   |
| injury      | Dehydration | perglycemia |             |             |
|             |             |             | Perforated  | Ventricular |
| Brain stem  | Dementia    | H           | gallbladder | f           |
| herniation  | (when not   | yperkalemia |             | ibrillation |
|             |             |             | Peritonitis |             |
| Car         | otherwise   | Hypovolemic |             | Ventricular |
| cinogenesis | specified)  | shock       | Pleural     | tachycardia |
|             |             |             | effusions   |             |
|             | Diarrhea    |             |             | Volume      |
|             |             |             | Pneumonia   | 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    | Epidural    | Hip         | Pulmonary   | Subdural    |
|             | hematoma    | fracture    | emboli      | hematoma    |
| Bolus       |             |             |             |             |
|             | Exs         | H           | Seizure     | Surgery     |
| Choking     | anguination | yperthermia | disorder    |             |
|             |             |             |             | Thermal     |
| Drug or     | Fall        | Hypothermia | Sepsis      | bur         |
| alcohol     |             |             |             | ns/chemical |
| ov          | Fracture    | Open        | S           | burns       |
| erdose/drug |             | reduction   | ubarachnoid |             |
| or          |             | of fracture | hemorrhage  |             |
|             |             |             |             |             |
| alcohol     |             |             |             |             |
| abuse       |             |             |             |             |
+-------------+-------------+-------------+-------------+-------------+

Contact your State vital statistics office for questions related to
writing cause-of-death statements. Additional instructional material on
writing cause-of-death statements including handbooks, summary
instructions, and tutorials are available online at www.thename.org or
www.cdc.gov/nchswww/about/major/dvs/handbk.htm, or by request from NCHS,
Room 7318, 3311 Toledo Road, Hyattsville, Maryland 20782-2003.

Query Letter 4

(More Specific Information)

(Letterhead)

Dear Doctor \_\_\_\_\_\_\_\_

We are writing this letter to obtain additional information about the
cause of death that you certified for
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_, who died
\_\_\_\_\_\_\_\_\_\_\_\_\_.

Accurate cause-of-death information is essential, not only to the family
of the decedent, but also for medical research, funding, and resource
allocation in our State and at the national level.

In this particular death, we are requesting more specific information.
In order to classify this death properly in our statistics, would you
please supply the information on the attachment? We want to assure you
that the information you provide us is confidential and will be handled
accordingly.

If you have any question or would like to know more about various
methods for certifying a cause-of-death statement, please contact
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_.
Instructions and an example of a properly completed death certificate
are provided with the attached material.

We appreciate your attention and prompt reply.

Sincerely,

State Registrar/Vital Statistics Cooperative Program

Attachment

Query for Additional Information

+-------------------+----------------------+---+------------+-------+
| **CAUSE OF DEATH  |                      |   |            | A     |
| (See instructions |                      |   |            | pprox |
| and examples)**   |                      |   |            | imate |
|                   |                      |   |            | inte  |
| 32\. **PART I.**  |                      |   |            | rval: |
| Enter the [chain  |                      |   |            |       |
| of                |                      |   |            | Onset |
| events]{.under    |                      |   |            | to    |
| line}\--diseases, |                      |   |            | death |
| injuries, or      |                      |   |            |       |
| com               |                      |   |            | \_\   |
| plications\--that |                      |   |            | _\_\_ |
| directly caused   |                      |   |            | [\_\_ |
| the death. DO NOT |                      |   |            | \_\_\ |
| enter terminal    |                      |   |            | _\_\_ |
| events such as    |                      |   |            | \_]{. |
| cardiac           |                      |   |            | under |
|                   |                      |   |            | line} |
| arrest,           |                      |   |            |       |
| respiratory       |                      |   |            | \_\   |
| arrest, or        |                      |   |            | _\_\_ |
| ventricular       |                      |   |            | [\_\_ |
| fibrillation      |                      |   |            | \_\_\ |
| without showing   |                      |   |            | _\_\_ |
| the etiology. DO  |                      |   |            | \_]{. |
| NOT ABBREVIATE.   |                      |   |            | under |
| Enter only one    |                      |   |            | line} |
| cause on a line.  |                      |   |            |       |
| Add additional    |                      |   |            | \_\   |
|                   |                      |   |            | _\_\_ |
| lines if          |                      |   |            | [\_   |
| necessary.        |                      |   |            | \_\_\ |
|                   |                      |   |            | _\_\_ |
| IMMEDIATE CAUSE   |                      |   |            | \_]{. |
| (Final            |                      |   |            | under |
|                   |                      |   |            | line} |
| disease or        |                      |   |            |       |
| condition         |                      |   |            | \_\   |
| **\-\-            |                      |   |            | _\_\_ |
| \-\-\-\-\-\--\>** |                      |   |            | [\_\_ |
| a.                |                      |   |            | \_\_\ |
| \_\_\_\_\_\_\_\_  |                      |   |            | _\_\_ |
| [\_\_\_\_\_ \_\_  |                      |   |            | \_]{. |
| \_\_              |                      |   |            | under |
| \_\_\_\_\_\_\_\_\ |                      |   |            | line} |
| _\_\_\_\_\_\_\_\_ |                      |   |            |       |
| \_\_\_\_\_\_\_\_\ |                      |   |            |       |
| _\_\_\_\_\_\_\_\_ |                      |   |            |       |
| \_\_\_\_\_\_\_\_\ |                      |   |            |       |
| _\_\_\_\_\_\_\_\_ |                      |   |            |       |
| \_\_\_\_\_\_\_\_\ |                      |   |            |       |
| _\_\_\_\_\_\_\_\_ |                      |   |            |       |
| \_\_\_\_\_\_\_\_\ |                      |   |            |       |
| _\_\_\_\_\_\_\_\_ |                      |   |            |       |
| \_\_]{.underline} |                      |   |            |       |
|                   |                      |   |            |       |
| resulting in      |                      |   |            |       |
| death) Due to (or |                      |   |            |       |
| as a consequence  |                      |   |            |       |
| of):              |                      |   |            |       |
|                   |                      |   |            |       |
| Sequentially list |                      |   |            |       |
| conditions, b.    |                      |   |            |       |
| \_\_\_\           |                      |   |            |       |
| _\_\_\_\_\_\_\_\_ |                      |   |            |       |
| [\_\_\_\_\_       |                      |   |            |       |
| \_\_\_\_\_\_\     |                      |   |            |       |
| _\_\_\_\_\_\_\_\_ |                      |   |            |       |
| \_\_\_\_\_\_\_\_\ |                      |   |            |       |
| _\_\_\_\_\_\_\_\_ |                      |   |            |       |
| \_\_\_\_\_\_\_\_\ |                      |   |            |       |
| _\_\_\_\_\_\_\_\_ |                      |   |            |       |
| \_\_\_\_\_\_\_\_\ |                      |   |            |       |
| _\_\_\_\_\_\_\_\_ |                      |   |            |       |
| \_\_\_\_\_\_\_\_\ |                      |   |            |       |
| _\_\_\_\_\_\_\_\_ |                      |   |            |       |
| \_\_]{.underline} |                      |   |            |       |
|                   |                      |   |            |       |
| if any, leading   |                      |   |            |       |
| to the cause Due  |                      |   |            |       |
| to (or as a       |                      |   |            |       |
| consequence of):  |                      |   |            |       |
|                   |                      |   |            |       |
| listed on line a. |                      |   |            |       |
| Enter the         |                      |   |            |       |
|                   |                      |   |            |       |
| **UNDERLYING      |                      |   |            |       |
| CAUSE** c.        |                      |   |            |       |
| \_\_\_\           |                      |   |            |       |
| _\_\_\_\_\_\_\_\_ |                      |   |            |       |
| [\_\_\_\_\_       |                      |   |            |       |
| \_\_              |                      |   |            |       |
| \_\_\_\_\_\_\_\_\ |                      |   |            |       |
| _\_\_\_\_\_\_\_\_ |                      |   |            |       |
| \_\_\_\_\_\_\_\_\ |                      |   |            |       |
| _\_\_\_\_\_\_\_\_ |                      |   |            |       |
| \_\_\_\_\_\_\_\_\ |                      |   |            |       |
| _\_\_\_\_\_\_\_\_ |                      |   |            |       |
| \_\_\_\_\_\_\_\_\ |                      |   |            |       |
| _\_\_\_\_\_\_\_\_ |                      |   |            |       |
| \_\_\_\_\_\_\_\_\ |                      |   |            |       |
| _\_\_\_\_\_\_\_\_ |                      |   |            |       |
| \_\_]{.underline} |                      |   |            |       |
|                   |                      |   |            |       |
| (disease or       |                      |   |            |       |
| injury that Due   |                      |   |            |       |
| to (or as a       |                      |   |            |       |
| consequence of):  |                      |   |            |       |
|                   |                      |   |            |       |
| initiated the     |                      |   |            |       |
| events resulting  |                      |   |            |       |
|                   |                      |   |            |       |
| in death)         |                      |   |            |       |
| **LAST** d.       |                      |   |            |       |
| \_\               |                      |   |            |       |
| _\_\_\_\_\_\_\_\_ |                      |   |            |       |
| [\_\_\_\_\_       |                      |   |            |       |
| \                 |                      |   |            |       |
| _\_\_\_\_\_\_\_\_ |                      |   |            |       |
| \_\_\_\_\_\_\_\_\ |                      |   |            |       |
| _\_\_\_\_\_\_\_\_ |                      |   |            |       |
| \_\_\_\_\_\_\_\_\ |                      |   |            |       |
| _\_\_\_\_\_\_\_\_ |                      |   |            |       |
| \_\_\_\_\_\_\_\_\ |                      |   |            |       |
| _\_\_\_\_\_\_\_\_ |                      |   |            |       |
| \_\_\_\_\_\_\_\_\ |                      |   |            |       |
| _\_\_\_\_\_\_\_\_ |                      |   |            |       |
| \_\_]{.underline} |                      |   |            |       |
+-------------------+----------------------+---+------------+-------+
| **PART II.**      |                      |   | 33\. WAS   |       |
| Enter other       |                      |   | AN AUTOPSY |       |
| [significant      |                      |   | PERFORMED? |       |
| conditions        |                      |   |            |       |
| contributing to   |                      |   |  Yes  No |       |
| d                 |                      |   |            |       |
| eath]{.underline} |                      |   |            |       |
| 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  | 36\. IF FEMALE:      | 3 |            |       |
| USE CONTRIBUTE TO |                      | 7 |            |       |
| DEATH?            |  Not pregnant       | \ |            |       |
|                   | within past year     | . |            |       |
|  Yes  Probably  |                      | M |            |       |
|                   |  Pregnant at time   | A |            |       |
|  No  Unknown    | of death             | N |            |       |
|                   |                      | N |            |       |
|                   |  Not pregnant, but  | E |            |       |
|                   | pregnant within 42   | R |            |       |
|                   | days of death        | O |            |       |
|                   |                      | F |            |       |
|                   |  Not pregnant, but  | D |            |       |
|                   | pregnant 43 days to  | E |            |       |
|                   | 1 year before death  | A |            |       |
|                   |                      | T |            |       |
|                   |  Unknown if         | H |            |       |
|                   | pregnant within the  |   |            |       |
|                   | past year            |  |            |       |
|                   |                      | N |            |       |
|                   |                      | a |            |       |
|                   |                      | t |            |       |
|                   |                      | u |            |       |
|                   |                      | r |            |       |
|                   |                      | a |            |       |
|                   |                      | l |            |       |
|                   |                      |  |            |       |
|                   |                      | H |            |       |
|                   |                      | o |            |       |
|                   |                      | m |            |       |
|                   |                      | i |            |       |
|                   |                      | c |            |       |
|                   |                      | i |            |       |
|                   |                      | d |            |       |
|                   |                      | e |            |       |
|                   |                      |   |            |       |
|                   |                      |  |            |       |
|                   |                      | A |            |       |
|                   |                      | c |            |       |
|                   |                      | c |            |       |
|                   |                      | i |            |       |
|                   |                      | d |            |       |
|                   |                      | e |            |       |
|                   |                      | n |            |       |
|                   |                      | t |            |       |
|                   |                      |  |            |       |
|                   |                      | P |            |       |
|                   |                      | e |            |       |
|                   |                      | n |            |       |
|                   |                      | d |            |       |
|                   |                      | i |            |       |
|                   |                      | n |            |       |
|                   |                      | g |            |       |
|                   |                      | I |            |       |
|                   |                      | n |            |       |
|                   |                      | v |            |       |
|                   |                      | e |            |       |
|                   |                      | s |            |       |
|                   |                      | t |            |       |
|                   |                      | i |            |       |
|                   |                      | g |            |       |
|                   |                      | a |            |       |
|                   |                      | t |            |       |
|                   |                      | i |            |       |
|                   |                      | o |            |       |
|                   |                      | n |            |       |
|                   |                      |   |            |       |
|                   |                      |  |            |       |
|                   |                      | S |            |       |
|                   |                      | u |            |       |
|                   |                      | i |            |       |
|                   |                      | c |            |       |
|                   |                      | i |            |       |
|                   |                      | d |            |       |
|                   |                      | e |            |       |
|                   |                      |  |            |       |
|                   |                      | C |            |       |
|                   |                      | o |            |       |
|                   |                      | u |            |       |
|                   |                      | l |            |       |
|                   |                      | d |            |       |
|                   |                      | n |            |       |
|                   |                      | o |            |       |
|                   |                      | t |            |       |
|                   |                      | b |            |       |
|                   |                      | e |            |       |
|                   |                      | d |            |       |
|                   |                      | e |            |       |
|                   |                      | t |            |       |
|                   |                      | e |            |       |
|                   |                      | r |            |       |
|                   |                      | m |            |       |
|                   |                      | i |            |       |
|                   |                      | n |            |       |
|                   |                      | e |            |       |
|                   |                      | d |            |       |
+-------------------+----------------------+---+------------+-------+

Is this condition,
[\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_]{.underline},
secondary to another condition?

Yes\_\_\_, No\_\_\_

If Yes, please indicate the primary condition
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

2\. Is there a known specific site of the condition,
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
?

Yes[\_ \_]{.underline}, Unknown[\_\_\_]{.underline}

If Yes, please state
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

3\. If known, please state a more specific type of the condition,
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_, or part of this
organ or site.

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

4\. If known, please state the type or etiology of this condition,
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_,
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

[, M.D.]{.underline}

(Signature of Certifying Physician)

Please provide your office
phone:\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
fax:\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

(Please see other side)

Instructions on Medical Certification of Causes of Death

[Example of properly completed medical certification]{.underline}

+-------------------+----------------------+---+-------------+--------+
| **CAUSE OF DEATH  |                      |   |             | Appro  |
| (See instructions |                      |   |             | ximate |
| and examples)**   |                      |   |             | int    |
|                   |                      |   |             | erval: |
| 32\. **PART I.**  |                      |   |             |        |
| Enter the [chain  |                      |   |             | Onset  |
| of                |                      |   |             | to     |
| events]{.under    |                      |   |             | death  |
| line}\--diseases, |                      |   |             |        |
| injuries, or      |                      |   |             | [1     |
| com               |                      |   |             | week]  |
| plications\--that |                      |   |             | {.unde |
| directly caused   |                      |   |             | rline} |
| the death. DO NOT |                      |   |             |        |
| enter terminal    |                      |   |             | [6     |
| events such as    |                      |   |             | m      |
| cardiac           |                      |   |             | onths] |
|                   |                      |   |             | {.unde |
| arrest,           |                      |   |             | rline} |
| respiratory       |                      |   |             |        |
| arrest, or        |                      |   |             | [6     |
| ventricular       |                      |   |             | m      |
| fibrillation      |                      |   |             | onths] |
| without showing   |                      |   |             | {.unde |
| the etiology. DO  |                      |   |             | rline} |
| NOT ABBREVIATE.   |                      |   |             |        |
| Enter only one    |                      |   |             | [\_ye  |
| cause on a line.  |                      |   |             | ars\_] |
| Add additional    |                      |   |             | {.unde |
|                   |                      |   |             | rline} |
| lines if          |                      |   |             |        |
| necessary.        |                      |   |             |        |
|                   |                      |   |             |        |
| IMMEDIATE CAUSE   |                      |   |             |        |
| (Final            |                      |   |             |        |
|                   |                      |   |             |        |
| disease or        |                      |   |             |        |
| condition         |                      |   |             |        |
| **\-\-            |                      |   |             |        |
| \-\-\-\-\-\--\>** |                      |   |             |        |
| a. [Pneumonia     |                      |   |             |        |
| \_\_\_\_\_\_\_\_  |                      |   |             |        |
| \_\_\_\_\_\_\_\_\ |                      |   |             |        |
| _\_\_\_\_\_\_\_\_ |                      |   |             |        |
| \_\_\_\_\_\_\_\_\ |                      |   |             |        |
| _\_\_\_\_\_\_\_\_ |                      |   |             |        |
| \_\_\_\_\_\_\_\_\ |                      |   |             |        |
| _\_\_\_\_\_\_\_\_ |                      |   |             |        |
| \_\_\_\_\_\_\_\_\ |                      |   |             |        |
| _\_\_\_\_\_\_\_\_ |                      |   |             |        |
| \_\_\_\_\_\_\_\_\ |                      |   |             |        |
| _\_\_\_\_\_\_\_\_ |                      |   |             |        |
| \_\_]{.underline} |                      |   |             |        |
|                   |                      |   |             |        |
| resulting in      |                      |   |             |        |
| death) Due to (or |                      |   |             |        |
| as a consequence  |                      |   |             |        |
| of):              |                      |   |             |        |
|                   |                      |   |             |        |
| Sequentially list |                      |   |             |        |
| conditions, b.    |                      |   |             |        |
| [Right Hemiplegia |                      |   |             |        |
| \_\_\             |                      |   |             |        |
| _\_\_\_\_\_\_\_\_ |                      |   |             |        |
| \_\_\_\_\_\_\_\_\ |                      |   |             |        |
| _\_\_\_\_\_\_\_\_ |                      |   |             |        |
| \_\_\_\_\_\_\_\_\ |                      |   |             |        |
| _\_\_\_\_\_\_\_\_ |                      |   |             |        |
| \_\_\_\_\_\_\_\_\ |                      |   |             |        |
| _\_\_\_\_\_\_\_\_ |                      |   |             |        |
| \_\_\_\_\_\_\_\_\ |                      |   |             |        |
| _\_\_\_\_\_\_\_\_ |                      |   |             |        |
| \_\_]{.underline} |                      |   |             |        |
|                   |                      |   |             |        |
| if any, leading   |                      |   |             |        |
| to the cause Due  |                      |   |             |        |
| to (or as a       |                      |   |             |        |
| consequence of):  |                      |   |             |        |
|                   |                      |   |             |        |
| listed on line a. |                      |   |             |        |
| Enter the         |                      |   |             |        |
|                   |                      |   |             |        |
| **UNDERLYING      |                      |   |             |        |
| CAUSE** c.        |                      |   |             |        |
| [Cerebral         |                      |   |             |        |
| thromb            |                      |   |             |        |
| osis\_\_\_\_\_\_\ |                      |   |             |        |
| _\_\_\_\_\_\_\_\_ |                      |   |             |        |
| \_\_\_\_\_\_\_\_\ |                      |   |             |        |
| _\_\_\_\_\_\_\_\_ |                      |   |             |        |
| \_\_\_\_\_\_\_\_\ |                      |   |             |        |
| _\_\_\_\_\_\_\_\_ |                      |   |             |        |
| \_\_\_\_\_\_\_\_\ |                      |   |             |        |
| _\_\_\_\_\_\_\_\_ |                      |   |             |        |
| \_\_\_\_\_\_\_\_\ |                      |   |             |        |
| _\_\_\_\_\_\_\_\_ |                      |   |             |        |
| \_\_]{.underline} |                      |   |             |        |
|                   |                      |   |             |        |
| (disease or       |                      |   |             |        |
| injury that Due   |                      |   |             |        |
| to (or as a       |                      |   |             |        |
| consequence of):  |                      |   |             |        |
|                   |                      |   |             |        |
| initiated the     |                      |   |             |        |
| events resulting  |                      |   |             |        |
|                   |                      |   |             |        |
| in death)         |                      |   |             |        |
| **LAST** d.       |                      |   |             |        |
| [Cerebral artery  |                      |   |             |        |
| atherosclerosis   |                      |   |             |        |
| \_\_\_\_\_\_\_\   |                      |   |             |        |
| _\_\_\_\_\_\_\_\_ |                      |   |             |        |
| \_\_\_\_\_\_\_\_\ |                      |   |             |        |
| _\_\_\_\_\_\_\_\_ |                      |   |             |        |
| \_\_\_\_\_\_\_\_\ |                      |   |             |        |
| _\_\_\_\_\_\_\_\_ |                      |   |             |        |
| \_\_\_\_\_\_\_\_\ |                      |   |             |        |
| _\_\_\_\_\_\_\_\_ |                      |   |             |        |
| \_\_]{.underline} |                      |   |             |        |
+-------------------+----------------------+---+-------------+--------+
| **PART II.**      |                      |   | 33\. WAS AN |        |
| Enter other       |                      |   | AUTOPSY     |        |
| [significant      |                      |   | PERFORMED?  |        |
| conditions        |                      |   |             |        |
| contributing to   |                      |   |  Yes ■ No  |        |
| d                 |                      |   |             |        |
| eath]{.underline} |                      |   |             |        |
| but not resulting |                      |   |             |        |
| in the underlying |                      |   |             |        |
| cause given in    |                      |   |             |        |
| PART I            |                      |   |             |        |
|                   |                      |   |             |        |
| Hypertension      |                      |   |             |        |
+-------------------+----------------------+---+-------------+--------+
|                   |                      |   | 34\. WERE   |        |
|                   |                      |   | AUTOPSY     |        |
|                   |                      |   | FINDINGS    |        |
|                   |                      |   | AVAILABLE   |        |
|                   |                      |   | TO          |        |
|                   |                      |   |             |        |
|                   |                      |   | COMPLETE    |        |
|                   |                      |   | THE CAUSE   |        |
|                   |                      |   | OF DEATH?  |        |
|                   |                      |   | Yes ■ No    |        |
+-------------------+----------------------+---+-------------+--------+
| 35\. DID TOBACCO  | 36\. IF FEMALE:      | 3 |             |        |
| USE CONTRIBUTE TO |                      | 7 |             |        |
| DEATH?            |  Not pregnant       | \ |             |        |
|                   | within past year     | . |             |        |
|  Yes Probably |                      | M |             |        |
|                   | Pregnant at time  | A |             |        |
| ■ No Unknown   | of death             | N |             |        |
|                   |                      | N |             |        |
|                   | Not pregnant, but | E |             |        |
|                   | pregnant within 42   | R |             |        |
|                   | days of death        | O |             |        |
|                   |                      | F |             |        |
|                   | Not pregnant, but | D |             |        |
|                   | pregnant 43 days to  | E |             |        |
|                   | 1 year before death  | A |             |        |
|                   |                      | T |             |        |
|                   | Unknown if        | H |             |        |
|                   | pregnant within the  |   |             |        |
|                   | past year            | ■ |             |        |
|                   |                      | N |             |        |
|                   |                      | a |             |        |
|                   |                      | t |             |        |
|                   |                      | u |             |        |
|                   |                      | r |             |        |
|                   |                      | a |             |        |
|                   |                      | l |             |        |
|                   |                      |  |             |        |
|                   |                      |  |             |        |
|                   |                      | H |             |        |
|                   |                      | o |             |        |
|                   |                      | m |             |        |
|                   |                      | i |             |        |
|                   |                      | c |             |        |
|                   |                      | i |             |        |
|                   |                      | d |             |        |
|                   |                      | e |             |        |
|                   |                      |   |             |        |
|                   |                      |  |             |        |
|                   |                      |  |             |        |
|                   |                      |  |             |        |
|                   |                      | A |             |        |
|                   |                      | c |             |        |
|                   |                      | c |             |        |
|                   |                      | i |             |        |
|                   |                      | d |             |        |
|                   |                      | e |             |        |
|                   |                      | n |             |        |
|                   |                      | t |             |        |
|                   |                      |  |             |        |
|                   |                      |  |             |        |
|                   |                      | P |             |        |
|                   |                      | e |             |        |
|                   |                      | n |             |        |
|                   |                      | d |             |        |
|                   |                      | i |             |        |
|                   |                      | n |             |        |
|                   |                      | g |             |        |
|                   |                      | I |             |        |
|                   |                      | n |             |        |
|                   |                      | v |             |        |
|                   |                      | e |             |        |
|                   |                      | s |             |        |
|                   |                      | t |             |        |
|                   |                      | i |             |        |
|                   |                      | g |             |        |
|                   |                      | a |             |        |
|                   |                      | t |             |        |
|                   |                      | i |             |        |
|                   |                      | o |             |        |
|                   |                      | n |             |        |
|                   |                      |   |             |        |
|                   |                      |  |             |        |
|                   |                      |  |             |        |
|                   |                      |  |             |        |
|                   |                      | S |             |        |
|                   |                      | u |             |        |
|                   |                      | i |             |        |
|                   |                      | c |             |        |
|                   |                      | i |             |        |
|                   |                      | d |             |        |
|                   |                      | e |             |        |
|                   |                      |  |             |        |
|                   |                      |  |             |        |
|                   |                      | C |             |        |
|                   |                      | o |             |        |
|                   |                      | u |             |        |
|                   |                      | l |             |        |
|                   |                      | d |             |        |
|                   |                      | n |             |        |
|                   |                      | o |             |        |
|                   |                      | t |             |        |
|                   |                      | b |             |        |
|                   |                      | e |             |        |
|                   |                      | d |             |        |
|                   |                      | e |             |        |
|                   |                      | t |             |        |
|                   |                      | e |             |        |
|                   |                      | r |             |        |
|                   |                      | m |             |        |
|                   |                      | i |             |        |
|                   |                      | n |             |        |
|                   |                      | e |             |        |
|                   |                      | d |             |        |
+-------------------+----------------------+---+-------------+--------+

**ITEM 32 -- CAUSE OF DEATH (See example above)**

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.

Take care to make the entry legible. Use a computer printer with high
resolution, typewriter with good black ribbon and clean keys, or print
legibly using permanent **black** ink in completing the CAUSE OF DEATH
Section. **Do** **not** **abbreviate** conditions entered in section.

**[Part I]{.underline} (Chain of events leading directly to death)**

•Only **one** cause should be entered on each line. [Line
(a)]{.underline} **MUST ALWAYS** have an entry. **DO NOT** leave blank.
Additional lines may be added if necessary.

•If the condition on [Line (a)]{.underline} resulted from an underlying
condition, put the underlying condition on [Line (b)]{.underline}, and
so on, until the full sequence is reported. **ALWAYS** enter the
**underlying cause of death** on the [lowest used line]{.underline} in
Part I.

•For each cause indicate the best estimate of the interval between the
presumed onset and the date of death. The terms "unknown" or
"approximately" may be used. General terms, such as minutes, hours, or
days, are acceptable, if necessary. **DO NOT** leave blank.

•The terminal event (for example, cardiac arrest or respiratory arrest)
should not be used. If a mechanism of death seems most appropriate to
you for line (a), then you must always list its cause(s) on the line(s)
below it (for example, cardiac arrest **due to** coronary artery
atherosclerosis *or* cardiac arrest **due to** blunt impact to chest).

• If an organ system failure such as congestive heart failure, hepatic
failure, renal failure, or respiratory failure is listed as a cause of
death, always report its etiology on the line(s) beneath it (for
example, renal failure **due to** Type I diabetes mellitus).

•When indicating neoplasms as a cause of death, include the
following: 1) primary site *or* that the primary site is unknown, 2)
benign or malignant, 3) cell type *or* that the cell type is unknown, 4)
grade of neoplasm, and 5) part or lobe of organ affected. (For example,
a primary well-differentiated squamous cell carcinoma, lung, left upper
lobe.)

•Always report the fatal injury (for example, stab wound of chest), the
trauma (for example, transection of subclavian vein), and impairment of
function (for example, air embolism).

**Part II (Other significant conditions)**

•Enter all diseases or conditions contributing to death that were not
reported in the chain of events in Part I and that did not result in the
**underlying cause of death**.

•If two or more possible sequences resulted in death, or if two
conditions seem to have added together, report in Part I the one that,
in your opinion, most directly caused death. Report in Part II the other
conditions or diseases.

**CHANGES TO CAUSE OF DEATH**

Should additional medical information or autopsy findings become
available that would change the cause of death originally reported, the
original death certificate should be amended by the certifying physician
by **immediately** reporting the revised cause of death to the State
Vital Records Office.

**ITEMS ON WHEN DEATH OCCURRED**

Items 24-25 and 29-31 should always be completed. If the facility uses a
separate pronouncer or other person to indicate that death has taken
place with another person more familiar with the case completing the
remainder of the medical portion of the death certificate, the
pronouncer completes Items 24-28. If a certifier completes Items 24-25
as well as items 29-49, Items 26-28 may be left blank.

**ITEMS 24-25, 29-30 -- DATE AND TIME OF DEATH**

Spell out the name of the month. If the exact date of death is unknown,
enter the **approximate** date. If the date cannot be approximated,
enter the date the body is found and identify as **date found**. Date
pronounced and actual date may be the same. Enter the exact hour and
minutes according to a 24-hour clock; estimates may be provided with
"Approx." placed before the time.

**ITEMS 33-34 - AUTOPSY**

•33 - Enter "Yes" if either a partial or full autopsy was performed.
Otherwise enter "No."

•34 - Enter "Yes" if autopsy findings were available to complete the
cause of death; otherwise enter "No". Leave item blank if no autopsy was
performed.

**ITEM 35 - DID TOBACCO USE CONTRIBUTE TO DEATH?**

Check "yes" if, in your opinion, the use of tobacco contributed to
death. Tobacco use may contribute to deaths due to a wide variety of
diseases; for example, tobacco use contributes to many deaths due to
emphysema or lung cancer and some heart disease and cancers of the head
and neck. Check "no" if, in your clinical judgment, tobacco use did not
contribute to this particular death.

**ITEM 36 - IF FEMALE, WAS DECEDENT PREGNANT AT TIME OF DEATH OR WITHIN
PAST YEAR?**

This information is important in determining pregnancy-related
mortality.

**ITEM 37 - MANNER OF DEATH**

•Always check Manner of Death, which is important: 1) in determining
accurate causes of death; 2) in processing insurance claims; and 3) in
statistical studies of injuries and death.

•Indicate "Pending investigation" if the manner of death cannot be
determined whether due to an accident, suicide, or homicide within the
statutory time limit for filing the death certificate. This should be
changed later to one of the other terms.

•Indicate "Could not be Determined" **ONLY** when it is impossible to
determine the manner of death.

**ITEMS 38-44 - ACCIDENT OR INJURY -- to be filled out in all cases of
deaths due to injury or poisoning.**

•38 - Enter the exact month, day, and year of injury. Spell out the name
of the month. **DO NOT** use a number for the month. (Remember, the date
of injury may differ from the date of death.) Estimates may be provided
with "Approx." placed before the date.

•39 **-** Enter the exact hour and minutes of injury or use your best
estimate. Use a 24-hour clock.

•40 - Enter the general place (such as restaurant, vacant lot, or home)
where the injury occurred. **DO NOT** enter firm or organization names.
(For example, enter "factory", **not** "Standard Manufacturing, Inc." )

•41 - Complete if anything other than natural disease is mentioned in
Part I or Part II of the medical certification, including homicides,
suicides, and accidents. This includes all motor vehicle deaths. The
item **[must]{.underline}** be completed for decedents ages 14 years or
over and may be completed for those less than 14 years of age if
warranted. Enter "Yes" if the injury occurred at work. Otherwise enter
"No". An injury may occur at work regardless of whether the injury
occurred in the course of the decedent's "usual" occupation. Examples of
injury at work and injury not at work follow:

+-----------------------------------+-----------------------------------+
| **Injury at work**                | **Injury [not]{.underline} at     |
|                                   | work**                            |
| Injury while working or in        |                                   |
| vocational training on job        | Injury while engaged in personal  |
| premises                          | recreational activity on job      |
|                                   | premises                          |
| Injury while on break or at lunch |                                   |
| or in parking lot on job premises | Injury while a visitor (not on    |
|                                   | official work business) to job    |
| Injury while working for pay or   | premises                          |
| compensation, including at home   |                                   |
|                                   | Homemaker working at homemaking   |
| Injury while working as a         | activities                        |
| volunteer law enforcement         |                                   |
| official etc.                     | Student in school                 |
|                                   |                                   |
| Injury while traveling on         | Working for self for no profit    |
| business, including to/from       | (mowing yard, repairing own roof, |
| business contacts                 | hobby)                            |
|                                   |                                   |
|                                   | Commuting to or from work         |
+-----------------------------------+-----------------------------------+

•42 - Enter the complete address where the injury occurred including zip
code.

•43 - Enter a brief but specific and clear description of how the injury
occurred. Explain the circumstances or cause of the injury. Specify
**type** **of** **gun** or **type of vehicle** (e.g., car, bulldozer,
train, etc.) when relevant to circumstances. Indicate if more than one
vehicle involved; specify type of vehicle decedent was in.

•44 -Specify role of decedent (e.g. driver, passenger). Driver/operator
and passenger should be designated for modes other than motor vehicles
such as bicycles. Other applies to watercraft, aircraft, animal, or
people attached to outside of vehicles (e.g. surfers).

[Rationale]{.underline}: Motor vehicle accidents are a major cause of
unintentional deaths; details will help determine effectiveness of
current safety features and laws.

**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:]{.underline}**

+-------------+-------------+-------------+-------------+-------------+
| Abscess     | Car         | D           | H           | Pulmonary   |
|             | cinomatosis | isseminated | yponatremia | arrest      |
| Abdominal   |             | intra       |             |             |
| hemorrhage  | Cardiac     | vascular    | Hypotension | Pulmonary   |
|             | arrest      |             |             | edema       |
| Adhesions   |             | c           | Immuno      |             |
|             | Cardiac     | oagulopathy | suppression | Pulmonary   |
| Adult       | dysrhythmia |             |             | embolism    |
| respiratory |             | Dysrhythmia | Increased   |             |
| distress    | Car         |             | intra       | Pulmonary   |
| syndrome    | diomyopathy | End-stage   | cranial     | in          |
|             |             | liver       | pressure    | sufficiency |
| Acute       | Card        | disease     |             |             |
| myocardial  | iopulmonary |             | Intra       | Renal       |
| infarction  | arrest      | End-stage   | cranial     | failure     |
|             |             | renal       | hemorrhage  |             |
| Altered     | Cellulitis  | disease     |             | Respiratory |
| mental      |             |             | M           | arrest      |
| status      | Cerebral    | Epidural    | alnutrition |             |
|             | edema       | hematoma    |             | Seizures    |
| Anemia      |             |             | Metabolic   |             |
|             | Cere        | Exs         | enc         | Sepsis      |
| Anoxia      | brovascular | anguination | ephalopathy |             |
|             | accident    |             |             | Septic      |
| Anoxic      |             | Failure to  | Multi-organ | shock       |
| enc         | Cerebellar  | thrive      | failure     |             |
| ephalopathy | tonsillar   |             |             | Shock       |
|             | herniation  | Fracture    | M           |             |
| Arrhythmia  |             |             | ulti-system | Starvation  |
|             | Chronic     | Gangrene    | organ       |             |
| Ascites     | bedridden   |             | failure     | Subdural    |
|             | state       | Gastr       |             | hematoma    |
| Aspiration  |             | ointestinal | Myocardial  |             |
|             | Cirrhosis   | hemorrhage  | infarction  | S           |
| Atrial      |             |             |             | ubarachnoid |
| f           | C           | Heart       | Necrotizing | hemorrhage  |
| ibrillation | oagulopathy | failure     | soft-tissue |             |
|             |             |             | infection   | Sudden      |
| Bacteremia  | Compression | Hemothorax  |             | death       |
|             | fracture    |             | Old age     |             |
| Bedridden   |             | Hepatic     |             | Throm       |
|             | Congestive  | failure     | Open (or    | bocytopenia |
| Biliary     | heart       |             | closed)     |             |
| obstruction | failure     | Hepatitis   | head injury | Uncal       |
|             |             |             |             | herniation  |
| Bowel       | Convulsions | Hepatorenal | Paralysis   |             |
| obstruction |             | syndrome    |             | Urinary     |
|             | Decubiti    |             | P           | tract       |
| Brain       |             | Hy          | ancytopenia | infection   |
| injury      | Dehydration | perglycemia |             |             |
|             |             |             | Perforated  | Ventricular |
| Brain stem  | Dementia    | H           | gallbladder | f           |
| herniation  | (when not   | yperkalemia |             | ibrillation |
|             |             |             | Peritonitis |             |
| Car         | otherwise   | Hypovolemic |             | Ventricular |
| cinogenesis | specified)  | shock       | Pleural     | tachycardia |
|             |             |             | effusions   |             |
|             | Diarrhea    |             |             | Volume      |
|             |             |             | Pneumonia   | 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    | Epidural    | Hip         | Pulmonary   | Subdural    |
|             | hematoma    | fracture    | emboli      | hematoma    |
| Bolus       |             |             |             |             |
|             | Exs         | H           | Seizure     | Surgery     |
| Choking     | anguination | yperthermia | disorder    |             |
|             |             |             |             | Thermal     |
| Drug or     | Fall        | Hypothermia | Sepsis      | bur         |
| alcohol     |             |             |             | ns/chemical |
| ov          | Fracture    | Open        | S           | burns       |
| erdose/drug |             | reduction   | ubarachnoid |             |
| or          |             | of fracture | hemorrhage  |             |
|             |             |             |             |             |
| alcohol     |             |             |             |             |
| abuse       |             |             |             |             |
+-------------+-------------+-------------+-------------+-------------+

Contact your State vital statistics office for questions related to
writing cause-of-death statements. Additional instructional material on
writing cause-of-death statements including handbooks, summary
instructions, and tutorials are available online at www.thename.org or
www.cdc.gov/nchswww/about/major/dvs/handbk.htm, or by request from NCHS,
Room 7318, 3311 Toledo Road, Hyattsville, Maryland 20782-2003.

Query Letter 5

(Reason for Treatment)

(Letterhead)

Dear Doctor \_\_\_\_\_\_\_\_

We are writing this letter to obtain additional information about the
cause of death that you certified for
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_, who died
\_\_\_\_\_\_\_\_\_\_\_\_\_.

Accurate cause-of-death information is essential, not only to the family
of the decedent, but also for medical research, funding, and resource
allocation in our State and at the national level.

In this particular death, we need to know the condition that required
the treatment in order to classify the cause of death correctly in our
statistical records. In order to classify this death properly in our
statistics, would you please supply the information on the attachment?
We want to assure you that the information you provide us is
confidential and will be handled accordingly.

If you have any question or would like to know more about various
methods for certifying a cause-of-death statement, please contact
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_.
Instructions and an example of a properly completed death certificate
are provided with the attached material.

We appreciate your attention and prompt reply.

Sincerely,

State Registrar/Vital Statistics Cooperative Program

Attachment

Reason for treatment query

+----------+-------+---+-----------------------+----+--------+---+---+-----+
| **CAUSE  |       |   |                       |    |        |   |   | Ap  |
| OF DEATH |       |   |                       |    |        |   |   | pro |
| (See     |       |   |                       |    |        |   |   | xim |
| inst     |       |   |                       |    |        |   |   | ate |
| ructions |       |   |                       |    |        |   |   | int |
| and      |       |   |                       |    |        |   |   | erv |
| exa      |       |   |                       |    |        |   |   | al: |
| mples)** |       |   |                       |    |        |   |   |     |
|          |       |   |                       |    |        |   |   | On  |
| 32\.     |       |   |                       |    |        |   |   | set |
| **PART   |       |   |                       |    |        |   |   | to  |
| I.**     |       |   |                       |    |        |   |   | de  |
| Enter    |       |   |                       |    |        |   |   | ath |
| the      |       |   |                       |    |        |   |   |     |
| [chain   |       |   |                       |    |        |   |   | [\  |
| of       |       |   |                       |    |        |   |   | _\_ |
| events]  |       |   |                       |    |        |   |   | \_\ |
| {.underl |       |   |                       |    |        |   |   | _\_ |
| ine}\--d |       |   |                       |    |        |   |   | \_] |
| iseases, |       |   |                       |    |        |   |   | {.u |
| i        |       |   |                       |    |        |   |   | nde |
| njuries, |       |   |                       |    |        |   |   | rli |
| or       |       |   |                       |    |        |   |   | ne} |
| comp     |       |   |                       |    |        |   |   |     |
| lication |       |   |                       |    |        |   |   | [\  |
| s\--that |       |   |                       |    |        |   |   | _\_ |
| directly |       |   |                       |    |        |   |   | \_\ |
| caused   |       |   |                       |    |        |   |   | _\_ |
| the      |       |   |                       |    |        |   |   | \_] |
| death.   |       |   |                       |    |        |   |   | {.u |
| DO NOT   |       |   |                       |    |        |   |   | nde |
| enter    |       |   |                       |    |        |   |   | rli |
| terminal |       |   |                       |    |        |   |   | ne} |
| events   |       |   |                       |    |        |   |   |     |
| such as  |       |   |                       |    |        |   |   | [\  |
| cardiac  |       |   |                       |    |        |   |   | _\_ |
|          |       |   |                       |    |        |   |   | \_\ |
| arrest,  |       |   |                       |    |        |   |   | _\_ |
| res      |       |   |                       |    |        |   |   | \_] |
| piratory |       |   |                       |    |        |   |   | {.u |
| arrest,  |       |   |                       |    |        |   |   | nde |
| or       |       |   |                       |    |        |   |   | rli |
| ven      |       |   |                       |    |        |   |   | ne} |
| tricular |       |   |                       |    |        |   |   |     |
| fibr     |       |   |                       |    |        |   |   | [\  |
| illation |       |   |                       |    |        |   |   | _\_ |
| without  |       |   |                       |    |        |   |   | \_\ |
| showing  |       |   |                       |    |        |   |   | _\_ |
| the      |       |   |                       |    |        |   |   | \_] |
| e        |       |   |                       |    |        |   |   | {.u |
| tiology. |       |   |                       |    |        |   |   | nde |
| DO NOT   |       |   |                       |    |        |   |   | rli |
| ABB      |       |   |                       |    |        |   |   | ne} |
| REVIATE. |       |   |                       |    |        |   |   |     |
| Enter    |       |   |                       |    |        |   |   |     |
| only one |       |   |                       |    |        |   |   |     |
| cause on |       |   |                       |    |        |   |   |     |
| a line.  |       |   |                       |    |        |   |   |     |
| Add      |       |   |                       |    |        |   |   |     |
| ad       |       |   |                       |    |        |   |   |     |
| ditional |       |   |                       |    |        |   |   |     |
|          |       |   |                       |    |        |   |   |     |
| lines if |       |   |                       |    |        |   |   |     |
| ne       |       |   |                       |    |        |   |   |     |
| cessary. |       |   |                       |    |        |   |   |     |
|          |       |   |                       |    |        |   |   |     |
| I        |       |   |                       |    |        |   |   |     |
| MMEDIATE |       |   |                       |    |        |   |   |     |
| CAUSE    |       |   |                       |    |        |   |   |     |
| (Final   |       |   |                       |    |        |   |   |     |
|          |       |   |                       |    |        |   |   |     |
| disease  |       |   |                       |    |        |   |   |     |
| or       |       |   |                       |    |        |   |   |     |
| c        |       |   |                       |    |        |   |   |     |
| ondition |       |   |                       |    |        |   |   |     |
| **\-\-\  |       |   |                       |    |        |   |   |     |
| -\-\-\-\ |       |   |                       |    |        |   |   |     |
| -\--\>** |       |   |                       |    |        |   |   |     |
| a.       |       |   |                       |    |        |   |   |     |
| \_       |       |   |                       |    |        |   |   |     |
| \_\_\_\_ |       |   |                       |    |        |   |   |     |
| \_\_\_\_ |       |   |                       |    |        |   |   |     |
| \_\_\_\_ |       |   |                       |    |        |   |   |     |
| [\_\     |       |   |                       |    |        |   |   |     |
| _\_\_\_\ |       |   |                       |    |        |   |   |     |
| _\_\_\_\ |       |   |                       |    |        |   |   |     |
| _\_\_\_\ |       |   |                       |    |        |   |   |     |
| _\_\_\_\ |       |   |                       |    |        |   |   |     |
| _\_\_\_\ |       |   |                       |    |        |   |   |     |
| _\_\_\_\ |       |   |                       |    |        |   |   |     |
| _\_\_\_\ |       |   |                       |    |        |   |   |     |
| _\_\_\_\ |       |   |                       |    |        |   |   |     |
| _\_\_\_\ |       |   |                       |    |        |   |   |     |
| _\_\_\_\ |       |   |                       |    |        |   |   |     |
| _\_\_\_\ |       |   |                       |    |        |   |   |     |
| _\_\_\_\ |       |   |                       |    |        |   |   |     |
| _\_\_\_\ |       |   |                       |    |        |   |   |     |
| _\_\_\_\ |       |   |                       |    |        |   |   |     |
| _\_\_\_\ |       |   |                       |    |        |   |   |     |
| _\_]{.un |       |   |                       |    |        |   |   |     |
| derline} |       |   |                       |    |        |   |   |     |
|          |       |   |                       |    |        |   |   |     |
| r        |       |   |                       |    |        |   |   |     |
| esulting |       |   |                       |    |        |   |   |     |
| in       |       |   |                       |    |        |   |   |     |
| death)   |       |   |                       |    |        |   |   |     |
| Due to   |       |   |                       |    |        |   |   |     |
| (or as a |       |   |                       |    |        |   |   |     |
| con      |       |   |                       |    |        |   |   |     |
| sequence |       |   |                       |    |        |   |   |     |
| of):     |       |   |                       |    |        |   |   |     |
|          |       |   |                       |    |        |   |   |     |
| Sequ     |       |   |                       |    |        |   |   |     |
| entially |       |   |                       |    |        |   |   |     |
| list     |       |   |                       |    |        |   |   |     |
| con      |       |   |                       |    |        |   |   |     |
| ditions, |       |   |                       |    |        |   |   |     |
| b.       |       |   |                       |    |        |   |   |     |
| \_\_     |       |   |                       |    |        |   |   |     |
| \_\_\_\_ |       |   |                       |    |        |   |   |     |
| \_\_\_\_ |       |   |                       |    |        |   |   |     |
| \_\_\_\_ |       |   |                       |    |        |   |   |     |
| [\       |       |   |                       |    |        |   |   |     |
| _\_\_\_\ |       |   |                       |    |        |   |   |     |
| _\_\_\_\ |       |   |                       |    |        |   |   |     |
| _\_\_\_\ |       |   |                       |    |        |   |   |     |
| _\_\_\_\ |       |   |                       |    |        |   |   |     |
| _\_\_\_\ |       |   |                       |    |        |   |   |     |
| _\_\_\_\ |       |   |                       |    |        |   |   |     |
| _\_\_\_\ |       |   |                       |    |        |   |   |     |
| _\_\_\_\ |       |   |                       |    |        |   |   |     |
| _\_\_\_\ |       |   |                       |    |        |   |   |     |
| _\_\_\_\ |       |   |                       |    |        |   |   |     |
| _\_\_\_\ |       |   |                       |    |        |   |   |     |
| _\_\_\_\ |       |   |                       |    |        |   |   |     |
| _\_\_\_\ |       |   |                       |    |        |   |   |     |
| _\_\_\_\ |       |   |                       |    |        |   |   |     |
| _\_\_\_\ |       |   |                       |    |        |   |   |     |
| _\_\_\_\ |       |   |                       |    |        |   |   |     |
| _\_\_\_\ |       |   |                       |    |        |   |   |     |
| _\_\_\_\ |       |   |                       |    |        |   |   |     |
| _\_\_\_\ |       |   |                       |    |        |   |   |     |
| _\_\_\_\ |       |   |                       |    |        |   |   |     |
| _\_]{.un |       |   |                       |    |        |   |   |     |
| derline} |       |   |                       |    |        |   |   |     |
|          |       |   |                       |    |        |   |   |     |
| if any,  |       |   |                       |    |        |   |   |     |
| leading  |       |   |                       |    |        |   |   |     |
| to the   |       |   |                       |    |        |   |   |     |
| cause    |       |   |                       |    |        |   |   |     |
| Due to   |       |   |                       |    |        |   |   |     |
| (or as a |       |   |                       |    |        |   |   |     |
| con      |       |   |                       |    |        |   |   |     |
| sequence |       |   |                       |    |        |   |   |     |
| of):     |       |   |                       |    |        |   |   |     |
|          |       |   |                       |    |        |   |   |     |
| listed   |       |   |                       |    |        |   |   |     |
| on line  |       |   |                       |    |        |   |   |     |
| a. Enter |       |   |                       |    |        |   |   |     |
| the      |       |   |                       |    |        |   |   |     |
|          |       |   |                       |    |        |   |   |     |
| **UN     |       |   |                       |    |        |   |   |     |
| DERLYING |       |   |                       |    |        |   |   |     |
| CAUSE**  |       |   |                       |    |        |   |   |     |
| c.       |       |   |                       |    |        |   |   |     |
| \_\_\_\_ |       |   |                       |    |        |   |   |     |
| \_\_\_\_ |       |   |                       |    |        |   |   |     |
| \_\_\_\_ |       |   |                       |    |        |   |   |     |
| [\_\_\   |       |   |                       |    |        |   |   |     |
| _\_\_\_\ |       |   |                       |    |        |   |   |     |
| _\_\_\_\ |       |   |                       |    |        |   |   |     |
| _\_\_\_\ |       |   |                       |    |        |   |   |     |
| _\_\_\_\ |       |   |                       |    |        |   |   |     |
| _\_\_\_\ |       |   |                       |    |        |   |   |     |
| _\_\_\_\ |       |   |                       |    |        |   |   |     |
| _\_\_\_\ |       |   |                       |    |        |   |   |     |
| _\_\_\_\ |       |   |                       |    |        |   |   |     |
| _\_\_\_\ |       |   |                       |    |        |   |   |     |
| _\_\_\_\ |       |   |                       |    |        |   |   |     |
| _\_\_\_\ |       |   |                       |    |        |   |   |     |
| _\_\_\_\ |       |   |                       |    |        |   |   |     |
| _\_\_\_\ |       |   |                       |    |        |   |   |     |
| _\_\_\_\ |       |   |                       |    |        |   |   |     |
| _\_\_\_\ |       |   |                       |    |        |   |   |     |
| _\_\_\_\ |       |   |                       |    |        |   |   |     |
| _\_\_\_\ |       |   |                       |    |        |   |   |     |
| _\_\_\_\ |       |   |                       |    |        |   |   |     |
| _\_\_\_\ |       |   |                       |    |        |   |   |     |
| _\_\_\_\ |       |   |                       |    |        |   |   |     |
| _\_\_\_\ |       |   |                       |    |        |   |   |     |
| _\_]{.un |       |   |                       |    |        |   |   |     |
| derline} |       |   |                       |    |        |   |   |     |
|          |       |   |                       |    |        |   |   |     |
| (disease |       |   |                       |    |        |   |   |     |
| or       |       |   |                       |    |        |   |   |     |
| injury   |       |   |                       |    |        |   |   |     |
| that Due |       |   |                       |    |        |   |   |     |
| to (or   |       |   |                       |    |        |   |   |     |
| as a     |       |   |                       |    |        |   |   |     |
| con      |       |   |                       |    |        |   |   |     |
| sequence |       |   |                       |    |        |   |   |     |
| of):     |       |   |                       |    |        |   |   |     |
|          |       |   |                       |    |        |   |   |     |
| i        |       |   |                       |    |        |   |   |     |
| nitiated |       |   |                       |    |        |   |   |     |
| the      |       |   |                       |    |        |   |   |     |
| events   |       |   |                       |    |        |   |   |     |
| r        |       |   |                       |    |        |   |   |     |
| esulting |       |   |                       |    |        |   |   |     |
|          |       |   |                       |    |        |   |   |     |
| in       |       |   |                       |    |        |   |   |     |
| death)   |       |   |                       |    |        |   |   |     |
| **LAST** |       |   |                       |    |        |   |   |     |
| d.       |       |   |                       |    |        |   |   |     |
| \_       |       |   |                       |    |        |   |   |     |
| \_\_\_\_ |       |   |                       |    |        |   |   |     |
| \_\_\_\_ |       |   |                       |    |        |   |   |     |
| \_\_\_\_ |       |   |                       |    |        |   |   |     |
| [\_\_\   |       |   |                       |    |        |   |   |     |
| _\_\_\_\ |       |   |                       |    |        |   |   |     |
| _\_\_\_\ |       |   |                       |    |        |   |   |     |
| _\_\_\_\ |       |   |                       |    |        |   |   |     |
| _\_\_\_\ |       |   |                       |    |        |   |   |     |
| _\_\_\_\ |       |   |                       |    |        |   |   |     |
| _\_\_\_\ |       |   |                       |    |        |   |   |     |
| _\_\_\_\ |       |   |                       |    |        |   |   |     |
| _\_\_\_\ |       |   |                       |    |        |   |   |     |
| _\_\_\_\ |       |   |                       |    |        |   |   |     |
| _\_\_\_\ |       |   |                       |    |        |   |   |     |
| _\_\_\_\ |       |   |                       |    |        |   |   |     |
| _\_\_\_\ |       |   |                       |    |        |   |   |     |
| _\_\_\_\ |       |   |                       |    |        |   |   |     |
| _\_\_\_\ |       |   |                       |    |        |   |   |     |
| _\_\_\_\ |       |   |                       |    |        |   |   |     |
| _\_\_\_\ |       |   |                       |    |        |   |   |     |
| _\_\_\_\ |       |   |                       |    |        |   |   |     |
| _\_\_\_\ |       |   |                       |    |        |   |   |     |
| _\_\_\_\ |       |   |                       |    |        |   |   |     |
| _\_\_\_\ |       |   |                       |    |        |   |   |     |
| _\_]{.un |       |   |                       |    |        |   |   |     |
| derline} |       |   |                       |    |        |   |   |     |
+----------+-------+---+-----------------------+----+--------+---+---+-----+
| **PART   |       |   |                       |    | 33\.   |   |   |     |
| II.**    |       |   |                       |    | WAS AN |   |   |     |
| Enter    |       |   |                       |    | A      |   |   |     |
| other    |       |   |                       |    | UTOPSY |   |   |     |
| [sig     |       |   |                       |    | PERF   |   |   |     |
| nificant |       |   |                       |    | ORMED? |   |   |     |
| co       |       |   |                       |    |        |   |   |     |
| nditions |       |   |                       |    |  Yes  |   |   |     |
| cont     |       |   |                       |    | No  |   |   |     |
| ributing |       |   |                       |    |        |   |   |     |
| to       |       |   |                       |    |        |   |   |     |
| de       |       |   |                       |    |        |   |   |     |
| ath]{.un |       |   |                       |    |        |   |   |     |
| derline} |       |   |                       |    |        |   |   |     |
| but not  |       |   |                       |    |        |   |   |     |
| r        |       |   |                       |    |        |   |   |     |
| esulting |       |   |                       |    |        |   |   |     |
| in the   |       |   |                       |    |        |   |   |     |
| un       |       |   |                       |    |        |   |   |     |
| derlying |       |   |                       |    |        |   |   |     |
| cause    |       |   |                       |    |        |   |   |     |
| given in |       |   |                       |    |        |   |   |     |
| PART I   |       |   |                       |    |        |   |   |     |
+----------+-------+---+-----------------------+----+--------+---+---+-----+
|          |       |   |                       |    | 34\.   |   |   |     |
|          |       |   |                       |    | WERE   |   |   |     |
|          |       |   |                       |    | A      |   |   |     |
|          |       |   |                       |    | UTOPSY |   |   |     |
|          |       |   |                       |    | FI     |   |   |     |
|          |       |   |                       |    | NDINGS |   |   |     |
|          |       |   |                       |    | AVA    |   |   |     |
|          |       |   |                       |    | ILABLE |   |   |     |
|          |       |   |                       |    | TO     |   |   |     |
|          |       |   |                       |    |        |   |   |     |
|          |       |   |                       |    | CO     |   |   |     |
|          |       |   |                       |    | MPLETE |   |   |     |
|          |       |   |                       |    | THE    |   |   |     |
|          |       |   |                       |    | CAUSE  |   |   |     |
|          |       |   |                       |    | OF     |   |   |     |
|          |       |   |                       |    | DEATH? |   |   |     |
|          |       |   |                       |    |  Yes  |   |   |     |
|          |       |   |                       |    | No  |   |   |     |
+----------+-------+---+-----------------------+----+--------+---+---+-----+
| 35\. DID |       |   | 36\. IF FEMALE:       | 37 |        |   |   |     |
| TOBACCO  |       |   |                       | \. |        |   |   |     |
| USE      |       |   | Not pregnant       | MA |        |   |   |     |
| CO       |       |   | within past year      | NN |        |   |   |     |
| NTRIBUTE |       |   |                       | ER |        |   |   |     |
| TO       |       |   | Pregnant at time   | OF |        |   |   |     |
| DEATH?   |       |   | of death              | D  |        |   |   |     |
|          |       |   |                       | EA |        |   |   |     |
| Yes  |       |   | Not pregnant, but  | TH |        |   |   |     |
|       |       |   | pregnant within 42    |    |        |   |   |     |
| Probably |       |   | days of death         |  |        |   |   |     |
|          |       |   |                       | N |        |   |   |     |
|  No     |       |   | Not pregnant, but  | at |        |   |   |     |
|        |       |   | pregnant 43 days to 1 | ur |        |   |   |     |
| Unknown |       |   | year before death     | al |        |   |   |     |
|          |       |   |                       |   |        |   |   |     |
|          |       |   | Unknown if         |  |        |   |   |     |
|          |       |   | pregnant within the   | Ho |        |   |   |     |
|          |       |   | past year             | mi |        |   |   |     |
|          |       |   |                       | ci |        |   |   |     |
|          |       |   |                       | de |        |   |   |     |
|          |       |   |                       |    |        |   |   |     |
|          |       |   |                       |   |        |   |   |     |
|          |       |   |                       | Ac |        |   |   |     |
|          |       |   |                       | ci |        |   |   |     |
|          |       |   |                       | de |        |   |   |     |
|          |       |   |                       | nt |        |   |   |     |
|          |       |   |                       |  |        |   |   |     |
|          |       |   |                       | P |        |   |   |     |
|          |       |   |                       | en |        |   |   |     |
|          |       |   |                       | di |        |   |   |     |
|          |       |   |                       | ng |        |   |   |     |
|          |       |   |                       | I  |        |   |   |     |
|          |       |   |                       | nv |        |   |   |     |
|          |       |   |                       | es |        |   |   |     |
|          |       |   |                       | ti |        |   |   |     |
|          |       |   |                       | ga |        |   |   |     |
|          |       |   |                       | ti |        |   |   |     |
|          |       |   |                       | on |        |   |   |     |
|          |       |   |                       |    |        |   |   |     |
|          |       |   |                       |  |        |   |   |     |
|          |       |   |                       | S |        |   |   |     |
|          |       |   |                       | ui |        |   |   |     |
|          |       |   |                       | ci |        |   |   |     |
|          |       |   |                       | de |        |   |   |     |
|          |       |   |                       |  |        |   |   |     |
|          |       |   |                       | C |        |   |   |     |
|          |       |   |                       | ou |        |   |   |     |
|          |       |   |                       | ld |        |   |   |     |
|          |       |   |                       | n  |        |   |   |     |
|          |       |   |                       | ot |        |   |   |     |
|          |       |   |                       | be |        |   |   |     |
|          |       |   |                       | de |        |   |   |     |
|          |       |   |                       | te |        |   |   |     |
|          |       |   |                       | rm |        |   |   |     |
|          |       |   |                       | in |        |   |   |     |
|          |       |   |                       | ed |        |   |   |     |
+----------+-------+---+-----------------------+----+--------+---+---+-----+
| 38\.     | 39\.  | 4 |                       |    |        |   | 4 |     |
| DATE OF  | TIME  | 0 |                       |    |        |   | 1 |     |
| INJURY   | OF    | \ |                       |    |        |   | \ |     |
|          | I     | . |                       |    |        |   | . |     |
| (Mo      | NJURY | P |                       |    |        |   | I |     |
| /Day/Yr) |       | L |                       |    |        |   | N |     |
| (Spell   |       | A |                       |    |        |   | J |     |
| Month)   |       | C |                       |    |        |   | U |     |
|          |       | E |                       |    |        |   | R |     |
|          |       | O |                       |    |        |   | Y |     |
|          |       | F |                       |    |        |   | A |     |
|          |       | I |                       |    |        |   | T |     |
|          |       | N |                       |    |        |   | W |     |
|          |       | J |                       |    |        |   | O |     |
|          |       | U |                       |    |        |   | R |     |
|          |       | R |                       |    |        |   | K |     |
|          |       | Y |                       |    |        |   | ? |     |
|          |       | ( |                       |    |        |   |   |     |
|          |       | e |                       |    |        |   |  |     |
|          |       | . |                       |    |        |   |  |     |
|          |       | g |                       |    |        |   |  |     |
|          |       | . |                       |    |        |   |  |     |
|          |       | , |                       |    |        |   |  |     |
|          |       | D |                       |    |        |   |  |     |
|          |       | e |                       |    |        |   |  |     |
|          |       | c |                       |    |        |   |  |     |
|          |       | e |                       |    |        |   |  |     |
|          |       | d |                       |    |        |   | Y |     |
|          |       | e |                       |    |        |   | e |     |
|          |       | n |                       |    |        |   | s |     |
|          |       | t |                       |    |        |   |  |     |
|          |       | ' |                       |    |        |   | N |     |
|          |       | s |                       |    |        |   | o |     |
|          |       | h |                       |    |        |   |   |     |
|          |       | o |                       |    |        |   |   |     |
|          |       | m |                       |    |        |   |   |     |
|          |       | e |                       |    |        |   |   |     |
|          |       | ; |                       |    |        |   |   |     |
|          |       | c |                       |    |        |   |   |     |
|          |       | o |                       |    |        |   |   |     |
|          |       | n |                       |    |        |   |   |     |
|          |       | s |                       |    |        |   |   |     |
|          |       | t |                       |    |        |   |   |     |
|          |       | r |                       |    |        |   |   |     |
|          |       | u |                       |    |        |   |   |     |
|          |       | c |                       |    |        |   |   |     |
|          |       | t |                       |    |        |   |   |     |
|          |       | i |                       |    |        |   |   |     |
|          |       | o |                       |    |        |   |   |     |
|          |       | n |                       |    |        |   |   |     |
|          |       | s |                       |    |        |   |   |     |
|          |       | i |                       |    |        |   |   |     |
|          |       | t |                       |    |        |   |   |     |
|          |       | e |                       |    |        |   |   |     |
|          |       | ; |                       |    |        |   |   |     |
|          |       | r |                       |    |        |   |   |     |
|          |       | e |                       |    |        |   |   |     |
|          |       | s |                       |    |        |   |   |     |
|          |       | t |                       |    |        |   |   |     |
|          |       | a |                       |    |        |   |   |     |
|          |       | u |                       |    |        |   |   |     |
|          |       | r |                       |    |        |   |   |     |
|          |       | a |                       |    |        |   |   |     |
|          |       | n |                       |    |        |   |   |     |
|          |       | t |                       |    |        |   |   |     |
|          |       | ; |                       |    |        |   |   |     |
|          |       | w |                       |    |        |   |   |     |
|          |       | o |                       |    |        |   |   |     |
|          |       | o |                       |    |        |   |   |     |
|          |       | d |                       |    |        |   |   |     |
|          |       | e |                       |    |        |   |   |     |
|          |       | d |                       |    |        |   |   |     |
|          |       | a |                       |    |        |   |   |     |
|          |       | r |                       |    |        |   |   |     |
|          |       | e |                       |    |        |   |   |     |
|          |       | a |                       |    |        |   |   |     |
|          |       | ) |                       |    |        |   |   |     |
+----------+-------+---+-----------------------+----+--------+---+---+-----+
| 42\.     |       |   |                       |    |        |   |   |     |
| LOCATION |       |   |                       |    |        |   |   |     |
| OF       |       |   |                       |    |        |   |   |     |
| INJURY:  |       |   |                       |    |        |   |   |     |
| State:   |       |   |                       |    |        |   |   |     |
| City or  |       |   |                       |    |        |   |   |     |
| Town:    |       |   |                       |    |        |   |   |     |
|          |       |   |                       |    |        |   |   |     |
| Street & |       |   |                       |    |        |   |   |     |
| Number:  |       |   |                       |    |        |   |   |     |
| A        |       |   |                       |    |        |   |   |     |
| partment |       |   |                       |    |        |   |   |     |
| No.: Zip |       |   |                       |    |        |   |   |     |
| Code:    |       |   |                       |    |        |   |   |     |
+----------+-------+---+-----------------------+----+--------+---+---+-----+
| 43\.     |       |   |                       |    |        | 4 |   |     |
| DESCRIBE |       |   |                       |    |        | 4 |   |     |
| HOW      |       |   |                       |    |        | \ |   |     |
| INJURY   |       |   |                       |    |        | . |   |     |
| O        |       |   |                       |    |        | I |   |     |
| CCURRED: |       |   |                       |    |        | F |   |     |
|          |       |   |                       |    |        | T |   |     |
|          |       |   |                       |    |        | R |   |     |
|          |       |   |                       |    |        | A |   |     |
|          |       |   |                       |    |        | N |   |     |
|          |       |   |                       |    |        | S |   |     |
|          |       |   |                       |    |        | P |   |     |
|          |       |   |                       |    |        | O |   |     |
|          |       |   |                       |    |        | R |   |     |
|          |       |   |                       |    |        | T |   |     |
|          |       |   |                       |    |        | A |   |     |
|          |       |   |                       |    |        | T |   |     |
|          |       |   |                       |    |        | I |   |     |
|          |       |   |                       |    |        | O |   |     |
|          |       |   |                       |    |        | N |   |     |
|          |       |   |                       |    |        | I |   |     |
|          |       |   |                       |    |        | N |   |     |
|          |       |   |                       |    |        | J |   |     |
|          |       |   |                       |    |        | U |   |     |
|          |       |   |                       |    |        | R |   |     |
|          |       |   |                       |    |        | Y |   |     |
|          |       |   |                       |    |        | , |   |     |
|          |       |   |                       |    |        | S |   |     |
|          |       |   |                       |    |        | P |   |     |
|          |       |   |                       |    |        | E |   |     |
|          |       |   |                       |    |        | C |   |     |
|          |       |   |                       |    |        | I |   |     |
|          |       |   |                       |    |        | F |   |     |
|          |       |   |                       |    |        | Y |   |     |
|          |       |   |                       |    |        | : |   |     |
|          |       |   |                       |    |        |   |   |     |
|          |       |   |                       |    |        |  |   |     |
|          |       |   |                       |    |        | D |   |     |
|          |       |   |                       |    |        | r |   |     |
|          |       |   |                       |    |        | i |   |     |
|          |       |   |                       |    |        | v |   |     |
|          |       |   |                       |    |        | e |   |     |
|          |       |   |                       |    |        | r |   |     |
|          |       |   |                       |    |        | / |   |     |
|          |       |   |                       |    |        | O |   |     |
|          |       |   |                       |    |        | p |   |     |
|          |       |   |                       |    |        | e |   |     |
|          |       |   |                       |    |        | r |   |     |
|          |       |   |                       |    |        | a |   |     |
|          |       |   |                       |    |        | t |   |     |
|          |       |   |                       |    |        | o |   |     |
|          |       |   |                       |    |        | r |   |     |
|          |       |   |                       |    |        |   |   |     |
|          |       |   |                       |    |        |  |   |     |
|          |       |   |                       |    |        |  |   |     |
|          |       |   |                       |    |        |  |   |     |
|          |       |   |                       |    |        | P |   |     |
|          |       |   |                       |    |        | a |   |     |
|          |       |   |                       |    |        | s |   |     |
|          |       |   |                       |    |        | s |   |     |
|          |       |   |                       |    |        | e |   |     |
|          |       |   |                       |    |        | n |   |     |
|          |       |   |                       |    |        | g |   |     |
|          |       |   |                       |    |        | e |   |     |
|          |       |   |                       |    |        | r |   |     |
|          |       |   |                       |    |        |   |   |     |
|          |       |   |                       |    |        |  |   |     |
|          |       |   |                       |    |        |  |   |     |
|          |       |   |                       |    |        |  |   |     |
|          |       |   |                       |    |        | P |   |     |
|          |       |   |                       |    |        | e |   |     |
|          |       |   |                       |    |        | d |   |     |
|          |       |   |                       |    |        | e |   |     |
|          |       |   |                       |    |        | s |   |     |
|          |       |   |                       |    |        | t |   |     |
|          |       |   |                       |    |        | r |   |     |
|          |       |   |                       |    |        | i |   |     |
|          |       |   |                       |    |        | a |   |     |
|          |       |   |                       |    |        | n |   |     |
|          |       |   |                       |    |        |   |   |     |
|          |       |   |                       |    |        |  |   |     |
|          |       |   |                       |    |        |  |   |     |
|          |       |   |                       |    |        |  |   |     |
|          |       |   |                       |    |        | O |   |     |
|          |       |   |                       |    |        | t |   |     |
|          |       |   |                       |    |        | h |   |     |
|          |       |   |                       |    |        | e |   |     |
|          |       |   |                       |    |        | r |   |     |
|          |       |   |                       |    |        | ( |   |     |
|          |       |   |                       |    |        | S |   |     |
|          |       |   |                       |    |        | p |   |     |
|          |       |   |                       |    |        | e |   |     |
|          |       |   |                       |    |        | c |   |     |
|          |       |   |                       |    |        | i |   |     |
|          |       |   |                       |    |        | f |   |     |
|          |       |   |                       |    |        | y |   |     |
|          |       |   |                       |    |        | ) |   |     |
+----------+-------+---+-----------------------+----+--------+---+---+-----+

1\. State the medical condition or injury that necessitated the
treatment, \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

2\. Other
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

[, M.D.]{.underline}

(Signature of Certifying Physician)

Please provide your office
phone:\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
fax:\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

(Please see other side)

Instructions on Medical Certification of Causes of Death

Example of properly completed medical certification

+----------+--------+----+-------------------------+---+---+---+-----+
| **CAUSE  |        |    |                         |   |   |   | Ap  |
| OF DEATH |        |    |                         |   |   |   | pro |
| (See     |        |    |                         |   |   |   | xim |
| inst     |        |    |                         |   |   |   | ate |
| ructions |        |    |                         |   |   |   | int |
| and      |        |    |                         |   |   |   | erv |
| exa      |        |    |                         |   |   |   | al: |
| mples)** |        |    |                         |   |   |   |     |
|          |        |    |                         |   |   |   | On  |
| 32\.     |        |    |                         |   |   |   | set |
| **PART   |        |    |                         |   |   |   | to  |
| I.**     |        |    |                         |   |   |   | de  |
| Enter    |        |    |                         |   |   |   | ath |
| the      |        |    |                         |   |   |   |     |
| [chain   |        |    |                         |   |   |   | [1  |
| of       |        |    |                         |   |   |   | day |
| events]  |        |    |                         |   |   |   | \_] |
| {.underl |        |    |                         |   |   |   | {.u |
| ine}\--d |        |    |                         |   |   |   | nde |
| iseases, |        |    |                         |   |   |   | rli |
| i        |        |    |                         |   |   |   | ne} |
| njuries, |        |    |                         |   |   |   |     |
| or       |        |    |                         |   |   |   | [4  |
| comp     |        |    |                         |   |   |   | d   |
| lication |        |    |                         |   |   |   | ays |
| s\--that |        |    |                         |   |   |   | \_] |
| directly |        |    |                         |   |   |   | {.u |
| caused   |        |    |                         |   |   |   | nde |
| the      |        |    |                         |   |   |   | rli |
| death.   |        |    |                         |   |   |   | ne} |
| DO NOT   |        |    |                         |   |   |   |     |
| enter    |        |    |                         |   |   |   | [6  |
| terminal |        |    |                         |   |   |   | wee |
| events   |        |    |                         |   |   |   | ks] |
| such as  |        |    |                         |   |   |   | {.u |
| cardiac  |        |    |                         |   |   |   | nde |
|          |        |    |                         |   |   |   | rli |
| arrest,  |        |    |                         |   |   |   | ne} |
| res      |        |    |                         |   |   |   |     |
| piratory |        |    |                         |   |   |   | [\  |
| arrest,  |        |    |                         |   |   |   | _\_ |
| or       |        |    |                         |   |   |   | \_\ |
| ven      |        |    |                         |   |   |   | _\_ |
| tricular |        |    |                         |   |   |   | \_] |
| fibr     |        |    |                         |   |   |   | {.u |
| illation |        |    |                         |   |   |   | nde |
| without  |        |    |                         |   |   |   | rli |
| showing  |        |    |                         |   |   |   | ne} |
| the      |        |    |                         |   |   |   |     |
| e        |        |    |                         |   |   |   |     |
| tiology. |        |    |                         |   |   |   |     |
| DO NOT   |        |    |                         |   |   |   |     |
| ABB      |        |    |                         |   |   |   |     |
| REVIATE. |        |    |                         |   |   |   |     |
| Enter    |        |    |                         |   |   |   |     |
| only one |        |    |                         |   |   |   |     |
| cause on |        |    |                         |   |   |   |     |
| a line.  |        |    |                         |   |   |   |     |
| Add      |        |    |                         |   |   |   |     |
| ad       |        |    |                         |   |   |   |     |
| ditional |        |    |                         |   |   |   |     |
|          |        |    |                         |   |   |   |     |
| lines if |        |    |                         |   |   |   |     |
| ne       |        |    |                         |   |   |   |     |
| cessary. |        |    |                         |   |   |   |     |
|          |        |    |                         |   |   |   |     |
| I        |        |    |                         |   |   |   |     |
| MMEDIATE |        |    |                         |   |   |   |     |
| CAUSE    |        |    |                         |   |   |   |     |
| (Final   |        |    |                         |   |   |   |     |
|          |        |    |                         |   |   |   |     |
| disease  |        |    |                         |   |   |   |     |
| or       |        |    |                         |   |   |   |     |
| c        |        |    |                         |   |   |   |     |
| ondition |        |    |                         |   |   |   |     |
| **\-\-\  |        |    |                         |   |   |   |     |
| -\-\-\-\ |        |    |                         |   |   |   |     |
| -\--\>** |        |    |                         |   |   |   |     |
| a.       |        |    |                         |   |   |   |     |
| [P       |        |    |                         |   |   |   |     |
| ulmonary |        |    |                         |   |   |   |     |
| embolism |        |    |                         |   |   |   |     |
| \_\      |        |    |                         |   |   |   |     |
| _\_\_\_\ |        |    |                         |   |   |   |     |
| _\_\_\_\ |        |    |                         |   |   |   |     |
| _\_\_\_\ |        |    |                         |   |   |   |     |
| _\_\_\_\ |        |    |                         |   |   |   |     |
| _\_\_\_\ |        |    |                         |   |   |   |     |
| _\_\_\_\ |        |    |                         |   |   |   |     |
| _\_\_\_\ |        |    |                         |   |   |   |     |
| _\_\_\_\ |        |    |                         |   |   |   |     |
| _\_\_\_\ |        |    |                         |   |   |   |     |
| _\_\_\_\ |        |    |                         |   |   |   |     |
| _\_\_\_\ |        |    |                         |   |   |   |     |
| _\_\_\_\ |        |    |                         |   |   |   |     |
| _\_\_\_\ |        |    |                         |   |   |   |     |
| _\_\_\_\ |        |    |                         |   |   |   |     |
| _\_\_\_\ |        |    |                         |   |   |   |     |
| _\_]{.un |        |    |                         |   |   |   |     |
| derline} |        |    |                         |   |   |   |     |
|          |        |    |                         |   |   |   |     |
| r        |        |    |                         |   |   |   |     |
| esulting |        |    |                         |   |   |   |     |
| in       |        |    |                         |   |   |   |     |
| death)   |        |    |                         |   |   |   |     |
| Due to   |        |    |                         |   |   |   |     |
| (or as a |        |    |                         |   |   |   |     |
| con      |        |    |                         |   |   |   |     |
| sequence |        |    |                         |   |   |   |     |
| of):     |        |    |                         |   |   |   |     |
|          |        |    |                         |   |   |   |     |
| Sequ     |        |    |                         |   |   |   |     |
| entially |        |    |                         |   |   |   |     |
| list     |        |    |                         |   |   |   |     |
| con      |        |    |                         |   |   |   |     |
| ditions, |        |    |                         |   |   |   |     |
| b.       |        |    |                         |   |   |   |     |
| [Cholel  |        |    |                         |   |   |   |     |
| ithotomy |        |    |                         |   |   |   |     |
| \_\      |        |    |                         |   |   |   |     |
| _\_\_\_\ |        |    |                         |   |   |   |     |
| _\_\_\_\ |        |    |                         |   |   |   |     |
| _\_\_\_\ |        |    |                         |   |   |   |     |
| _\_\_\_\ |        |    |                         |   |   |   |     |
| _\_\_\_\ |        |    |                         |   |   |   |     |
| _\_\_\_\ |        |    |                         |   |   |   |     |
| _\_\_\_\ |        |    |                         |   |   |   |     |
| _\_\_\_\ |        |    |                         |   |   |   |     |
| _\_\_\_\ |        |    |                         |   |   |   |     |
| _\_\_\_\ |        |    |                         |   |   |   |     |
| _\_\_\_\ |        |    |                         |   |   |   |     |
| _\_\_\_\ |        |    |                         |   |   |   |     |
| _\_\_\_\ |        |    |                         |   |   |   |     |
| _\_\_\_\ |        |    |                         |   |   |   |     |
| _\_\_\_\ |        |    |                         |   |   |   |     |
| _\_\_\_\ |        |    |                         |   |   |   |     |
| _\_\_\_\ |        |    |                         |   |   |   |     |
| _\_\_\_\ |        |    |                         |   |   |   |     |
| _\_\_\_\ |        |    |                         |   |   |   |     |
| _\_\_\_\ |        |    |                         |   |   |   |     |
| _\_]{.un |        |    |                         |   |   |   |     |
| derline} |        |    |                         |   |   |   |     |
|          |        |    |                         |   |   |   |     |
| if any,  |        |    |                         |   |   |   |     |
| leading  |        |    |                         |   |   |   |     |
| to the   |        |    |                         |   |   |   |     |
| cause    |        |    |                         |   |   |   |     |
| Due to   |        |    |                         |   |   |   |     |
| (or as a |        |    |                         |   |   |   |     |
| con      |        |    |                         |   |   |   |     |
| sequence |        |    |                         |   |   |   |     |
| of):     |        |    |                         |   |   |   |     |
|          |        |    |                         |   |   |   |     |
| listed   |        |    |                         |   |   |   |     |
| on line  |        |    |                         |   |   |   |     |
| a. Enter |        |    |                         |   |   |   |     |
| the      |        |    |                         |   |   |   |     |
|          |        |    |                         |   |   |   |     |
| **UN     |        |    |                         |   |   |   |     |
| DERLYING |        |    |                         |   |   |   |     |
| CAUSE**  |        |    |                         |   |   |   |     |
| c.       |        |    |                         |   |   |   |     |
| [        |        |    |                         |   |   |   |     |
| Calculus |        |    |                         |   |   |   |     |
| of       |        |    |                         |   |   |   |     |
| gallblad |        |    |                         |   |   |   |     |
| der\_\_\ |        |    |                         |   |   |   |     |
| _\_\_\_\ |        |    |                         |   |   |   |     |
| _\_\_\_\ |        |    |                         |   |   |   |     |
| _\_\_\_\ |        |    |                         |   |   |   |     |
| _\_\_\_\ |        |    |                         |   |   |   |     |
| _\_\_\_\ |        |    |                         |   |   |   |     |
| _\_\_\_\ |        |    |                         |   |   |   |     |
| _\_\_\_\ |        |    |                         |   |   |   |     |
| _\_\_\_\ |        |    |                         |   |   |   |     |
| _\_\_\_\ |        |    |                         |   |   |   |     |
| _\_\_\_\ |        |    |                         |   |   |   |     |
| _\_\_\_\ |        |    |                         |   |   |   |     |
| _\_\_\_\ |        |    |                         |   |   |   |     |
| _\_\_\_\ |        |    |                         |   |   |   |     |
| _\_\_\_\ |        |    |                         |   |   |   |     |
| _\_\_\_\ |        |    |                         |   |   |   |     |
| _\_\_\_\ |        |    |                         |   |   |   |     |
| _\_\_\_\ |        |    |                         |   |   |   |     |
| _\_\_\_\ |        |    |                         |   |   |   |     |
| _\_\_\_\ |        |    |                         |   |   |   |     |
| _\_\_\_\ |        |    |                         |   |   |   |     |
| _\_]{.un |        |    |                         |   |   |   |     |
| derline} |        |    |                         |   |   |   |     |
|          |        |    |                         |   |   |   |     |
| (disease |        |    |                         |   |   |   |     |
| or       |        |    |                         |   |   |   |     |
| injury   |        |    |                         |   |   |   |     |
| that Due |        |    |                         |   |   |   |     |
| to (or   |        |    |                         |   |   |   |     |
| as a     |        |    |                         |   |   |   |     |
| con      |        |    |                         |   |   |   |     |
| sequence |        |    |                         |   |   |   |     |
| of):     |        |    |                         |   |   |   |     |
|          |        |    |                         |   |   |   |     |
| i        |        |    |                         |   |   |   |     |
| nitiated |        |    |                         |   |   |   |     |
| the      |        |    |                         |   |   |   |     |
| events   |        |    |                         |   |   |   |     |
| r        |        |    |                         |   |   |   |     |
| esulting |        |    |                         |   |   |   |     |
|          |        |    |                         |   |   |   |     |
| in       |        |    |                         |   |   |   |     |
| death)   |        |    |                         |   |   |   |     |
| **LAST** |        |    |                         |   |   |   |     |
| d.       |        |    |                         |   |   |   |     |
| [\_\_\_\ |        |    |                         |   |   |   |     |
| _\_\_\_\ |        |    |                         |   |   |   |     |
| _\_\_\_\ |        |    |                         |   |   |   |     |
| _\_\_\_\ |        |    |                         |   |   |   |     |
| _\_\_\_\ |        |    |                         |   |   |   |     |
| _\_\_\_\ |        |    |                         |   |   |   |     |
| _\_\_\_\ |        |    |                         |   |   |   |     |
| _\_\_\_\ |        |    |                         |   |   |   |     |
| _\_\_\_\ |        |    |                         |   |   |   |     |
| _\_\_\_\ |        |    |                         |   |   |   |     |
| _\_\_\_\ |        |    |                         |   |   |   |     |
| _\_\_\_\ |        |    |                         |   |   |   |     |
| _\_\_\_\ |        |    |                         |   |   |   |     |
| _\_\_\_\ |        |    |                         |   |   |   |     |
| _\_\_\_\ |        |    |                         |   |   |   |     |
| _\_\_\_\ |        |    |                         |   |   |   |     |
| _\_\_\_\ |        |    |                         |   |   |   |     |
| _\_\_\_\ |        |    |                         |   |   |   |     |
| _\_\_\_\ |        |    |                         |   |   |   |     |
| _\_\_\_\ |        |    |                         |   |   |   |     |
| _\_\_\_\ |        |    |                         |   |   |   |     |
| _\_\_\_\ |        |    |                         |   |   |   |     |
| _\_\_\_\ |        |    |                         |   |   |   |     |
| _\_\_\_\ |        |    |                         |   |   |   |     |
| _\_\_\_\ |        |    |                         |   |   |   |     |
| _\_\_\_\ |        |    |                         |   |   |   |     |
| _\_]{.un |        |    |                         |   |   |   |     |
| derline} |        |    |                         |   |   |   |     |
+----------+--------+----+-------------------------+---+---+---+-----+
| **PART   |        |    |                         | 3 |   |   |     |
| II.**    |        |    |                         | 3 |   |   |     |
| Enter    |        |    |                         | \ |   |   |     |
| other    |        |    |                         | . |   |   |     |
| [sig     |        |    |                         | W |   |   |     |
| nificant |        |    |                         | A |   |   |     |
| co       |        |    |                         | S |   |   |     |
| nditions |        |    |                         | A |   |   |     |
| cont     |        |    |                         | N |   |   |     |
| ributing |        |    |                         | A |   |   |     |
| to       |        |    |                         | U |   |   |     |
| de       |        |    |                         | T |   |   |     |
| ath]{.un |        |    |                         | O |   |   |     |
| derline} |        |    |                         | P |   |   |     |
| but not  |        |    |                         | S |   |   |     |
| r        |        |    |                         | Y |   |   |     |
| esulting |        |    |                         | P |   |   |     |
| in the   |        |    |                         | E |   |   |     |
| un       |        |    |                         | R |   |   |     |
| derlying |        |    |                         | F |   |   |     |
| cause    |        |    |                         | O |   |   |     |
| given in |        |    |                         | R |   |   |     |
| PART I   |        |    |                         | M |   |   |     |
|          |        |    |                         | E |   |   |     |
| Arterios |        |    |                         | D |   |   |     |
| clerotic |        |    |                         | ? |   |   |     |
| heart    |        |    |                         |   |   |   |     |
| disease  |        |    |                         |  |   |   |     |
| --       |        |    |                         | Y |   |   |     |
| E        |        |    |                         | e |   |   |     |
| mphysema |        |    |                         | s |   |   |     |
|          |        |    |                         | ■ |   |   |     |
|          |        |    |                         | N |   |   |     |
|          |        |    |                         | o |   |   |     |
+----------+--------+----+-------------------------+---+---+---+-----+
|          |        |    |                         | 3 |   |   |     |
|          |        |    |                         | 4 |   |   |     |
|          |        |    |                         | \ |   |   |     |
|          |        |    |                         | . |   |   |     |
|          |        |    |                         | W |   |   |     |
|          |        |    |                         | E |   |   |     |
|          |        |    |                         | R |   |   |     |
|          |        |    |                         | E |   |   |     |
|          |        |    |                         | A |   |   |     |
|          |        |    |                         | U |   |   |     |
|          |        |    |                         | T |   |   |     |
|          |        |    |                         | O |   |   |     |
|          |        |    |                         | P |   |   |     |
|          |        |    |                         | S |   |   |     |
|          |        |    |                         | Y |   |   |     |
|          |        |    |                         | F |   |   |     |
|          |        |    |                         | I |   |   |     |
|          |        |    |                         | N |   |   |     |
|          |        |    |                         | D |   |   |     |
|          |        |    |                         | I |   |   |     |
|          |        |    |                         | N |   |   |     |
|          |        |    |                         | G |   |   |     |
|          |        |    |                         | S |   |   |     |
|          |        |    |                         | A |   |   |     |
|          |        |    |                         | V |   |   |     |
|          |        |    |                         | A |   |   |     |
|          |        |    |                         | I |   |   |     |
|          |        |    |                         | L |   |   |     |
|          |        |    |                         | A |   |   |     |
|          |        |    |                         | B |   |   |     |
|          |        |    |                         | L |   |   |     |
|          |        |    |                         | E |   |   |     |
|          |        |    |                         | T |   |   |     |
|          |        |    |                         | O |   |   |     |
|          |        |    |                         |   |   |   |     |
|          |        |    |                         | C |   |   |     |
|          |        |    |                         | O |   |   |     |
|          |        |    |                         | M |   |   |     |
|          |        |    |                         | P |   |   |     |
|          |        |    |                         | L |   |   |     |
|          |        |    |                         | E |   |   |     |
|          |        |    |                         | T |   |   |     |
|          |        |    |                         | E |   |   |     |
|          |        |    |                         | T |   |   |     |
|          |        |    |                         | H |   |   |     |
|          |        |    |                         | E |   |   |     |
|          |        |    |                         | C |   |   |     |
|          |        |    |                         | A |   |   |     |
|          |        |    |                         | U |   |   |     |
|          |        |    |                         | S |   |   |     |
|          |        |    |                         | E |   |   |     |
|          |        |    |                         | O |   |   |     |
|          |        |    |                         | F |   |   |     |
|          |        |    |                         | D |   |   |     |
|          |        |    |                         | E |   |   |     |
|          |        |    |                         | A |   |   |     |
|          |        |    |                         | T |   |   |     |
|          |        |    |                         | H |   |   |     |
|          |        |    |                         | ? |   |   |     |
|          |        |    |                         |  |   |   |     |
|          |        |    |                         | Y |   |   |     |
|          |        |    |                         | e |   |   |     |
|          |        |    |                         | s |   |   |     |
|          |        |    |                         | ■ |   |   |     |
|          |        |    |                         | N |   |   |     |
|          |        |    |                         | o |   |   |     |
+----------+--------+----+-------------------------+---+---+---+-----+
| 35\. DID |        |    | 36\. IF FEMALE:         | 3 |   |   |     |
| TOBACCO  |        |    |                         | 7 |   |   |     |
| USE      |        |    | Not pregnant within   | \ |   |   |     |
| CO       |        |    | past year               | . |   |   |     |
| NTRIBUTE |        |    |                         | M |   |   |     |
| TO       |        |    | Pregnant at time of   | A |   |   |     |
| DEATH?   |        |    | death                   | N |   |   |     |
|          |        |    |                         | N |   |   |     |
| ■ Yes    |        |    | Not pregnant, but     | E |   |   |     |
|       |        |    | pregnant within 42 days | R |   |   |     |
| Probably |        |    | of death                | O |   |   |     |
|          |        |    |                         | F |   |   |     |
|  No     |        |    | Not pregnant, but     | D |   |   |     |
|        |        |    | pregnant 43 days to 1   | E |   |   |     |
| Unknown |        |    | year before death       | A |   |   |     |
|          |        |    |                         | T |   |   |     |
|          |        |    | Unknown if pregnant   | H |   |   |     |
|          |        |    | within the past year    |   |   |   |     |
|          |        |    |                         | ■ |   |   |     |
|          |        |    |                         | N |   |   |     |
|          |        |    |                         | a |   |   |     |
|          |        |    |                         | t |   |   |     |
|          |        |    |                         | u |   |   |     |
|          |        |    |                         | r |   |   |     |
|          |        |    |                         | a |   |   |     |
|          |        |    |                         | l |   |   |     |
|          |        |    |                         |  |   |   |     |
|          |        |    |                         |  |   |   |     |
|          |        |    |                         |  |   |   |     |
|          |        |    |                         | H |   |   |     |
|          |        |    |                         | o |   |   |     |
|          |        |    |                         | m |   |   |     |
|          |        |    |                         | i |   |   |     |
|          |        |    |                         | c |   |   |     |
|          |        |    |                         | i |   |   |     |
|          |        |    |                         | d |   |   |     |
|          |        |    |                         | e |   |   |     |
|          |        |    |                         |   |   |   |     |
|          |        |    |                         |  |   |   |     |
|          |        |    |                         | A |   |   |     |
|          |        |    |                         | c |   |   |     |
|          |        |    |                         | c |   |   |     |
|          |        |    |                         | i |   |   |     |
|          |        |    |                         | d |   |   |     |
|          |        |    |                         | e |   |   |     |
|          |        |    |                         | n |   |   |     |
|          |        |    |                         | t |   |   |     |
|          |        |    |                         |  |   |   |     |
|          |        |    |                         |  |   |   |     |
|          |        |    |                         |  |   |   |     |
|          |        |    |                         | P |   |   |     |
|          |        |    |                         | e |   |   |     |
|          |        |    |                         | n |   |   |     |
|          |        |    |                         | d |   |   |     |
|          |        |    |                         | i |   |   |     |
|          |        |    |                         | n |   |   |     |
|          |        |    |                         | g |   |   |     |
|          |        |    |                         | I |   |   |     |
|          |        |    |                         | n |   |   |     |
|          |        |    |                         | v |   |   |     |
|          |        |    |                         | e |   |   |     |
|          |        |    |                         | s |   |   |     |
|          |        |    |                         | t |   |   |     |
|          |        |    |                         | i |   |   |     |
|          |        |    |                         | g |   |   |     |
|          |        |    |                         | a |   |   |     |
|          |        |    |                         | t |   |   |     |
|          |        |    |                         | i |   |   |     |
|          |        |    |                         | o |   |   |     |
|          |        |    |                         | n |   |   |     |
|          |        |    |                         |   |   |   |     |
|          |        |    |                         |  |   |   |     |
|          |        |    |                         |  |   |   |     |
|          |        |    |                         |  |   |   |     |
|          |        |    |                         | S |   |   |     |
|          |        |    |                         | u |   |   |     |
|          |        |    |                         | i |   |   |     |
|          |        |    |                         | c |   |   |     |
|          |        |    |                         | i |   |   |     |
|          |        |    |                         | d |   |   |     |
|          |        |    |                         | e |   |   |     |
|          |        |    |                         |  |   |   |     |
|          |        |    |                         |  |   |   |     |
|          |        |    |                         |  |   |   |     |
|          |        |    |                         | C |   |   |     |
|          |        |    |                         | o |   |   |     |
|          |        |    |                         | u |   |   |     |
|          |        |    |                         | l |   |   |     |
|          |        |    |                         | d |   |   |     |
|          |        |    |                         | n |   |   |     |
|          |        |    |                         | o |   |   |     |
|          |        |    |                         | t |   |   |     |
|          |        |    |                         | b |   |   |     |
|          |        |    |                         | e |   |   |     |
|          |        |    |                         | d |   |   |     |
|          |        |    |                         | e |   |   |     |
|          |        |    |                         | t |   |   |     |
|          |        |    |                         | e |   |   |     |
|          |        |    |                         | r |   |   |     |
|          |        |    |                         | m |   |   |     |
|          |        |    |                         | i |   |   |     |
|          |        |    |                         | n |   |   |     |
|          |        |    |                         | e |   |   |     |
|          |        |    |                         | d |   |   |     |
+----------+--------+----+-------------------------+---+---+---+-----+
| 38\.     | 39\.   | 40 |                         |   |   | 4 |     |
| DATE OF  | TIME   | \. |                         |   |   | 1 |     |
| INJURY   | OF     | P  |                         |   |   | \ |     |
|          | INJURY | LA |                         |   |   | . |     |
| (Mo      |        | CE |                         |   |   | I |     |
| /Day/Yr) |        | OF |                         |   |   | N |     |
| (Spell   |        | IN |                         |   |   | J |     |
| Month)   |        | JU |                         |   |   | U |     |
|          |        | RY |                         |   |   | R |     |
|          |        | (e |                         |   |   | Y |     |
|          |        | .g |                         |   |   | A |     |
|          |        | ., |                         |   |   | T |     |
|          |        | De |                         |   |   | W |     |
|          |        | ce |                         |   |   | O |     |
|          |        | de |                         |   |   | R |     |
|          |        | nt |                         |   |   | K |     |
|          |        | 's |                         |   |   | ? |     |
|          |        | h  |                         |   |   |   |     |
|          |        | om |                         |   |   |  |     |
|          |        | e; |                         |   |   |  |     |
|          |        | co |                         |   |   |  |     |
|          |        | ns |                         |   |   |  |     |
|          |        | tr |                         |   |   |  |     |
|          |        | uc |                         |   |   |  |     |
|          |        | ti |                         |   |   |  |     |
|          |        | on |                         |   |   |  |     |
|          |        | s  |                         |   |   |  |     |
|          |        | it |                         |   |   |  |     |
|          |        | e; |                         |   |   |  |     |
|          |        | r  |                         |   |   | Y |     |
|          |        | es |                         |   |   | e |     |
|          |        | ta |                         |   |   | s |     |
|          |        | ur |                         |   |   |  |     |
|          |        | an |                         |   |   | N |     |
|          |        | t; |                         |   |   | o |     |
|          |        | wo |                         |   |   |   |     |
|          |        | od |                         |   |   |   |     |
|          |        | ed |                         |   |   |   |     |
|          |        | a  |                         |   |   |   |     |
|          |        | re |                         |   |   |   |     |
|          |        | a) |                         |   |   |   |     |
+----------+--------+----+-------------------------+---+---+---+-----+
| 42\.     |        |    |                         |   |   |   |     |
| LOCATION |        |    |                         |   |   |   |     |
| OF       |        |    |                         |   |   |   |     |
| INJURY:  |        |    |                         |   |   |   |     |
| State:   |        |    |                         |   |   |   |     |
| City or  |        |    |                         |   |   |   |     |
| Town:    |        |    |                         |   |   |   |     |
|          |        |    |                         |   |   |   |     |
| Street & |        |    |                         |   |   |   |     |
| Number:  |        |    |                         |   |   |   |     |
| A        |        |    |                         |   |   |   |     |
| partment |        |    |                         |   |   |   |     |
| No.: Zip |        |    |                         |   |   |   |     |
| Code:    |        |    |                         |   |   |   |     |
+----------+--------+----+-------------------------+---+---+---+-----+
| 43\.     |        |    |                         |   | 4 |   |     |
| DESCRIBE |        |    |                         |   | 4 |   |     |
| HOW      |        |    |                         |   | \ |   |     |
| INJURY   |        |    |                         |   | . |   |     |
| O        |        |    |                         |   | I |   |     |
| CCURRED: |        |    |                         |   | F |   |     |
|          |        |    |                         |   | T |   |     |
|          |        |    |                         |   | R |   |     |
|          |        |    |                         |   | A |   |     |
|          |        |    |                         |   | N |   |     |
|          |        |    |                         |   | S |   |     |
|          |        |    |                         |   | P |   |     |
|          |        |    |                         |   | O |   |     |
|          |        |    |                         |   | R |   |     |
|          |        |    |                         |   | T |   |     |
|          |        |    |                         |   | A |   |     |
|          |        |    |                         |   | T |   |     |
|          |        |    |                         |   | I |   |     |
|          |        |    |                         |   | O |   |     |
|          |        |    |                         |   | N |   |     |
|          |        |    |                         |   | I |   |     |
|          |        |    |                         |   | N |   |     |
|          |        |    |                         |   | J |   |     |
|          |        |    |                         |   | U |   |     |
|          |        |    |                         |   | R |   |     |
|          |        |    |                         |   | Y |   |     |
|          |        |    |                         |   | , |   |     |
|          |        |    |                         |   | S |   |     |
|          |        |    |                         |   | P |   |     |
|          |        |    |                         |   | E |   |     |
|          |        |    |                         |   | C |   |     |
|          |        |    |                         |   | I |   |     |
|          |        |    |                         |   | F |   |     |
|          |        |    |                         |   | Y |   |     |
|          |        |    |                         |   | : |   |     |
|          |        |    |                         |   |   |   |     |
|          |        |    |                         |   |  |   |     |
|          |        |    |                         |   | D |   |     |
|          |        |    |                         |   | r |   |     |
|          |        |    |                         |   | i |   |     |
|          |        |    |                         |   | v |   |     |
|          |        |    |                         |   | e |   |     |
|          |        |    |                         |   | r |   |     |
|          |        |    |                         |   | / |   |     |
|          |        |    |                         |   | O |   |     |
|          |        |    |                         |   | p |   |     |
|          |        |    |                         |   | e |   |     |
|          |        |    |                         |   | r |   |     |
|          |        |    |                         |   | a |   |     |
|          |        |    |                         |   | t |   |     |
|          |        |    |                         |   | o |   |     |
|          |        |    |                         |   | r |   |     |
|          |        |    |                         |   |   |   |     |
|          |        |    |                         |   |  |   |     |
|          |        |    |                         |   |  |   |     |
|          |        |    |                         |   |  |   |     |
|          |        |    |                         |   | P |   |     |
|          |        |    |                         |   | a |   |     |
|          |        |    |                         |   | s |   |     |
|          |        |    |                         |   | s |   |     |
|          |        |    |                         |   | e |   |     |
|          |        |    |                         |   | n |   |     |
|          |        |    |                         |   | g |   |     |
|          |        |    |                         |   | e |   |     |
|          |        |    |                         |   | r |   |     |
|          |        |    |                         |   |   |   |     |
|          |        |    |                         |   |  |   |     |
|          |        |    |                         |   |  |   |     |
|          |        |    |                         |   |  |   |     |
|          |        |    |                         |   | P |   |     |
|          |        |    |                         |   | e |   |     |
|          |        |    |                         |   | d |   |     |
|          |        |    |                         |   | e |   |     |
|          |        |    |                         |   | s |   |     |
|          |        |    |                         |   | t |   |     |
|          |        |    |                         |   | r |   |     |
|          |        |    |                         |   | i |   |     |
|          |        |    |                         |   | a |   |     |
|          |        |    |                         |   | n |   |     |
|          |        |    |                         |   |   |   |     |
|          |        |    |                         |   |  |   |     |
|          |        |    |                         |   |  |   |     |
|          |        |    |                         |   |  |   |     |
|          |        |    |                         |   | O |   |     |
|          |        |    |                         |   | t |   |     |
|          |        |    |                         |   | h |   |     |
|          |        |    |                         |   | e |   |     |
|          |        |    |                         |   | r |   |     |
|          |        |    |                         |   | ( |   |     |
|          |        |    |                         |   | S |   |     |
|          |        |    |                         |   | p |   |     |
|          |        |    |                         |   | e |   |     |
|          |        |    |                         |   | c |   |     |
|          |        |    |                         |   | i |   |     |
|          |        |    |                         |   | f |   |     |
|          |        |    |                         |   | y |   |     |
|          |        |    |                         |   | ) |   |     |
+----------+--------+----+-------------------------+---+---+---+-----+

**ITEM 32 -- CAUSE OF DEATH (See example above)**

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.

Take care to make the entry legible. Use a computer printer with high
resolution, typewriter with good black ribbon and clean keys, or print
legibly using permanent **black** ink in completing the CAUSE OF DEATH
Section. **Do** **not** **abbreviate** conditions entered in section.

**[Part I]{.underline} (Chain of events leading directly to death)**

•Only **one** cause should be entered on each line. [Line
(a)]{.underline} **MUST ALWAYS** have an entry. **DO NOT** leave blank.
Additional lines may be added if necessary.

•If the condition on [Line (a)]{.underline} resulted from an underlying
condition, put the underlying condition on [Line (b)]{.underline}, and
so on, until the full sequence is reported. **ALWAYS** enter the
**underlying cause of death** on the [lowest used line]{.underline} in
Part I.

•For each cause indicate the best estimate of the interval between the
presumed onset and the date of death. The terms "unknown" or
"approximately" may be used. General terms, such as minutes, hours, or
days, are acceptable, if necessary. **DO NOT** leave blank.

•The terminal event (for example, cardiac arrest or respiratory arrest)
should not be used. If a mechanism of death seems most appropriate to
you for line (a), then you must always list its cause(s) on the line(s)
below it (for example, cardiac arrest **due to** coronary artery
atherosclerosis *or* cardiac arrest **due to** blunt impact to chest).

• If an organ system failure such as congestive heart failure, hepatic
failure, renal failure, or respiratory failure is listed as a cause of
death, always report its etiology on the line(s) beneath it (for
example, renal failure **due to** Type I diabetes mellitus).

•When indicating neoplasms as a cause of death, include the
following: 1) primary site *or* that the primary site is unknown, 2)
benign or malignant, 3) cell type *or* that the cell type is unknown, 4)
grade of neoplasm, and 5) part or lobe of organ affected. (For example,
a primary well-differentiated squamous cell carcinoma, lung, left upper
lobe.)

•Always report the fatal injury (for example, stab wound of chest), the
trauma (for example, transection of subclavian vein), and impairment of
function (for example, air embolism).

**Part II (Other significant conditions)**

•Enter all diseases or conditions contributing to death that were not
reported in the chain of events in Part I and that did not result in the
**underlying cause of death**.

•If two or more possible sequences resulted in death, or if two
conditions seem to have added together, report in Part I the one that,
in your opinion, most directly caused death. Report in Part II the other
conditions or diseases.

**CHANGES TO CAUSE OF DEATH**

Should additional medical information or autopsy findings become
available that would change the cause of death originally reported, the
original death certificate should be amended by the certifying physician
by **immediately** reporting the revised cause of death to the State
Vital Records Office.

**ITEMS ON WHEN DEATH OCCURRED**

Items 24-25 and 29-31 should always be completed. If the facility uses a
separate pronouncer or other person to indicate that death has taken
place with another person more familiar with the case completing the
remainder of the medical portion of the death certificate, the
pronouncer completes Items 24-28. If a certifier completes Items 24-25
as well as items 29-49, Items 26-28 may be left blank.

**ITEMS 24-25, 29-30 -- DATE AND TIME OF DEATH**

Spell out the name of the month. If the exact date of death is unknown,
enter the **approximate** date. If the date cannot be approximated,
enter the date the body is found and identify as **date found**. Date
pronounced and actual date may be the same. Enter the exact hour and
minutes according to a 24-hour clock; estimates may be provided with
"Approx." placed before the time.

**ITEMS 33-34 - AUTOPSY**

•33 - Enter "Yes" if either a partial or full autopsy was performed.
Otherwise enter "No."

•34 - Enter "Yes" if autopsy findings were available to complete the
cause of death; otherwise enter "No". Leave item blank if no autopsy was
performed.

**ITEM 35 - DID TOBACCO USE CONTRIBUTE TO DEATH?**

Check "yes" if, in your opinion, the use of tobacco contributed to
death. Tobacco use may contribute to deaths due to a wide variety of
diseases; for example, tobacco use contributes to many deaths due to
emphysema or lung cancer and some heart disease and cancers of the head
and neck. Check "no" if, in your clinical judgment, tobacco use did not
contribute to this particular death.

**ITEM 36 - IF FEMALE, WAS DECEDENT PREGNANT AT TIME OF DEATH OR WITHIN
PAST YEAR?**

This information is important in determining pregnancy-related
mortality.

**ITEM 37 - MANNER OF DEATH**

•Always check Manner of Death, which is important: 1) in determining
accurate causes of death; 2) in processing insurance claims; and 3) in
statistical studies of injuries and death.

•Indicate "Pending investigation" if the manner of death cannot be
determined whether due to an accident, suicide, or homicide within the
statutory time limit for filing the death certificate. This should be
changed later to one of the other terms.

•Indicate "Could not be Determined" **ONLY** when it is impossible to
determine the manner of death.

**ITEMS 38-44 - ACCIDENT OR INJURY -- to be filled out in all cases of
deaths due to injury or poisoning.**

•38 - Enter the exact month, day, and year of injury. Spell out the name
of the month. **DO NOT** use a number for the month. (Remember, the date
of injury may differ from the date of death.) Estimates may be provided
with "Approx." placed before the date.

•39 **-** Enter the exact hour and minutes of injury or use your best
estimate. Use a 24-hour clock.

•40 - Enter the general place (such as restaurant, vacant lot, or home)
where the injury occurred. **DO NOT** enter firm or organization names.
(For example, enter "factory", **not** "Standard Manufacturing, Inc." )

•41 - Complete if anything other than natural disease is mentioned in
Part I or Part II of the medical certification, including homicides,
suicides, and accidents. This includes all motor vehicle deaths. The
item **[must]{.underline}** be completed for decedents ages 14 years or
over and may be completed for those less than 14 years of age if
warranted. Enter "Yes" if the injury occurred at work. Otherwise enter
"No". An injury may occur at work regardless of whether the injury
occurred in the course of the decedent's "usual" occupation. Examples of
injury at work and injury not at work follow:

+-----------------------------------+-----------------------------------+
| **Injury at work**                | **Injury [not]{.underline} at     |
|                                   | work**                            |
| Injury while working or in        |                                   |
| vocational training on job        | Injury while engaged in personal  |
| premises                          | recreational activity on job      |
|                                   | premises                          |
| Injury while on break or at lunch |                                   |
| or in parking lot on job premises | Injury while a visitor (not on    |
|                                   | official work business) to job    |
| Injury while working for pay or   | premises                          |
| compensation, including at home   |                                   |
|                                   | Homemaker working at homemaking   |
| Injury while working as a         | activities                        |
| volunteer law enforcement         |                                   |
| official etc.                     | Student in school                 |
|                                   |                                   |
| Injury while traveling on         | Working for self for no profit    |
| business, including to/from       | (mowing yard, repairing own roof, |
| business contacts                 | hobby)                            |
|                                   |                                   |
|                                   | Commuting to or from work         |
+-----------------------------------+-----------------------------------+

•42 - Enter the complete address where the injury occurred including zip
code.

•43 - Enter a brief but specific and clear description of how the injury
occurred. Explain the circumstances or cause of the injury. Specify
**type** **of** **gun** or **type of vehicle** (e.g., car, bulldozer,
train, etc.) when relevant to circumstances. Indicate if more than one
vehicle involved; specify type of vehicle decedent was in.

•44 -Specify role of decedent (e.g. driver, passenger). Driver/operator
and passenger should be designated for modes other than motor vehicles
such as bicycles. Other applies to watercraft, aircraft, animal, or
people attached to outside of vehicles (e.g. surfers).

[Rationale]{.underline}: Motor vehicle accidents are a major cause of
unintentional deaths; details will help determine effectiveness of
current safety features and laws.

**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:]{.underline}**

+-------------+-------------+-------------+-------------+-------------+
| Abscess     | Car         | D           | H           | Pulmonary   |
|             | cinomatosis | isseminated | yponatremia | arrest      |
| Abdominal   |             | intra       |             |             |
| hemorrhage  | Cardiac     | vascular    | Hypotension | Pulmonary   |
|             | arrest      |             |             | edema       |
| Adhesions   |             | c           | Immuno      |             |
|             | Cardiac     | oagulopathy | suppression | Pulmonary   |
| Adult       | dysrhythmia |             |             | embolism    |
| respiratory |             | Dysrhythmia | Increased   |             |
| distress    | Car         |             | intra       | Pulmonary   |
| syndrome    | diomyopathy | End-stage   | cranial     | in          |
|             |             | liver       | pressure    | sufficiency |
| Acute       | Card        | disease     |             |             |
| myocardial  | iopulmonary |             | Intra       | Renal       |
| infarction  | arrest      | End-stage   | cranial     | failure     |
|             |             | renal       | hemorrhage  |             |
| Altered     | Cellulitis  | disease     |             | Respiratory |
| mental      |             |             | M           | arrest      |
| status      | Cerebral    | Epidural    | alnutrition |             |
|             | edema       | hematoma    |             | Seizures    |
| Anemia      |             |             | Metabolic   |             |
|             | Cere        | Exs         | enc         | Sepsis      |
| Anoxia      | brovascular | anguination | ephalopathy |             |
|             | accident    |             |             | Septic      |
| Anoxic      |             | Failure to  | Multi-organ | shock       |
| enc         | Cerebellar  | thrive      | failure     |             |
| ephalopathy | tonsillar   |             |             | Shock       |
|             | herniation  | Fracture    | M           |             |
| Arrhythmia  |             |             | ulti-system | Starvation  |
|             | Chronic     | Gangrene    | organ       |             |
| Ascites     | bedridden   |             | failure     | Subdural    |
|             | state       | Gastr       |             | hematoma    |
| Aspiration  |             | ointestinal | Myocardial  |             |
|             | Cirrhosis   | hemorrhage  | infarction  | S           |
| Atrial      |             |             |             | ubarachnoid |
| f           | C           | Heart       | Necrotizing | hemorrhage  |
| ibrillation | oagulopathy | failure     | soft-tissue |             |
|             |             |             | infection   | Sudden      |
| Bacteremia  | Compression | Hemothorax  |             | death       |
|             | fracture    |             | Old age     |             |
| Bedridden   |             | Hepatic     |             | Throm       |
|             | Congestive  | failure     | Open (or    | bocytopenia |
| Biliary     | heart       |             | closed)     |             |
| obstruction | failure     | Hepatitis   | head injury | Uncal       |
|             |             |             |             | herniation  |
| Bowel       | Convulsions | Hepatorenal | Paralysis   |             |
| obstruction |             | syndrome    |             | Urinary     |
|             | Decubiti    |             | P           | tract       |
| Brain       |             | Hy          | ancytopenia | infection   |
| injury      | Dehydration | perglycemia |             |             |
|             |             |             | Perforated  | Ventricular |
| Brain stem  | Dementia    | H           | gallbladder | f           |
| herniation  | (when not   | yperkalemia |             | ibrillation |
|             |             |             | Peritonitis |             |
| Car         | otherwise   | Hypovolemic |             | Ventricular |
| cinogenesis | specified)  | shock       | Pleural     | tachycardia |
|             |             |             | effusions   |             |
|             | Diarrhea    |             |             | Volume      |
|             |             |             | Pneumonia   | 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    | Epidural    | Hip         | Pulmonary   | Subdural    |
|             | hematoma    | fracture    | emboli      | hematoma    |
| Bolus       |             |             |             |             |
|             | Exs         | H           | Seizure     | Surgery     |
| Choking     | anguination | yperthermia | disorder    |             |
|             |             |             |             | Thermal     |
| Drug or     | Fall        | Hypothermia | Sepsis      | bur         |
| alcohol     |             |             |             | ns/chemical |
| ov          | Fracture    | Open        | S           | burns       |
| erdose/drug |             | reduction   | ubarachnoid |             |
| or          |             | of fracture | hemorrhage  |             |
|             |             |             |             |             |
| alcohol     |             |             |             |             |
| abuse       |             |             |             |             |
+-------------+-------------+-------------+-------------+-------------+

Contact your State vital statistics office for questions related to
writing cause-of-death statements. Additional instructional material on
writing cause-of-death statements including handbooks, summary
instructions, and tutorials are available online at www.thename.org or
www.cdc.gov/nchswww/about/major/dvs/handbk.htm, or by request from NCHS,
Room 7318, 3311 Toledo Road, Hyattsville, Maryland 20782-2003.

Query Letter 6

(Mental Disorders)

(Letterhead)

Dear Doctor \_\_\_\_\_\_\_\_

We are writing this letter to obtain additional information about the
cause of death that you certified for
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_, who died
\_\_\_\_\_\_\_\_\_\_\_\_\_.

Accurate cause-of-death information is essential, not only to the family
of the decedent, but also for medical research, funding, and resource
allocation in our State and at the national level.

In this particular death, we need to know whether a specific life
threatening condition was associated with the reported mental disorder.
In order to classify this death properly in our statistics, would you
please supply the information on the attachment? We want to assure you
that the information you provide us is confidential and will be handled
accordingly.

If you have any question or would like to know more about various
methods for certifying a cause-of-death statement, please contact
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_.
Instructions and an example of a properly completed death certificate
are provided with the attached material.

We appreciate your attention and prompt reply.

Sincerely,

State Registrar/Vital Statistics Cooperative Program

Attachment

Mental Disorder Query

+-------------------+----------------------+---+------------+-------+
| **CAUSE OF DEATH  |                      |   |            | A     |
| (See instructions |                      |   |            | pprox |
| and examples)**   |                      |   |            | imate |
|                   |                      |   |            | inte  |
| 32\. **PART I.**  |                      |   |            | rval: |
| Enter the [chain  |                      |   |            |       |
| of                |                      |   |            | Onset |
| events]{.under    |                      |   |            | to    |
| line}\--diseases, |                      |   |            | death |
| injuries, or      |                      |   |            |       |
| com               |                      |   |            | \_\   |
| plications\--that |                      |   |            | _\_\_ |
| directly caused   |                      |   |            | [\_\_ |
| the death. DO NOT |                      |   |            | \_\_\ |
| enter terminal    |                      |   |            | _\_\_ |
| events such as    |                      |   |            | \_]{. |
| cardiac           |                      |   |            | under |
|                   |                      |   |            | line} |
| arrest,           |                      |   |            |       |
| respiratory       |                      |   |            | \_\   |
| arrest, or        |                      |   |            | _\_\_ |
| ventricular       |                      |   |            | [\_\_ |
| fibrillation      |                      |   |            | \_\_\ |
| without showing   |                      |   |            | _\_\_ |
| the etiology. DO  |                      |   |            | \_]{. |
| NOT ABBREVIATE.   |                      |   |            | under |
| Enter only one    |                      |   |            | line} |
| cause on a line.  |                      |   |            |       |
| Add additional    |                      |   |            | \_\   |
|                   |                      |   |            | _\_\_ |
| lines if          |                      |   |            | [\_   |
| necessary.        |                      |   |            | \_\_\ |
|                   |                      |   |            | _\_\_ |
| IMMEDIATE CAUSE   |                      |   |            | \_]{. |
| (Final            |                      |   |            | under |
|                   |                      |   |            | line} |
| disease or        |                      |   |            |       |
| condition         |                      |   |            | \_\   |
| **\-\-            |                      |   |            | _\_\_ |
| \-\-\-\-\-\--\>** |                      |   |            | [\_\_ |
| a.                |                      |   |            | \_\_\ |
| \_\_\_\_\_\_\_\_  |                      |   |            | _\_\_ |
| [\_\_\_\_\_ \_\_  |                      |   |            | \_]{. |
| \_\_              |                      |   |            | under |
| \_\_\_\_\_\_\_\_\ |                      |   |            | line} |
| _\_\_\_\_\_\_\_\_ |                      |   |            |       |
| \_\_\_\_\_\_\_\_\ |                      |   |            |       |
| _\_\_\_\_\_\_\_\_ |                      |   |            |       |
| \_\_\_\_\_\_\_\_\ |                      |   |            |       |
| _\_\_\_\_\_\_\_\_ |                      |   |            |       |
| \_\_\_\_\_\_\_\_\ |                      |   |            |       |
| _\_\_\_\_\_\_\_\_ |                      |   |            |       |
| \_\_\_\_\_\_\_\_\ |                      |   |            |       |
| _\_\_\_\_\_\_\_\_ |                      |   |            |       |
| \_\_]{.underline} |                      |   |            |       |
|                   |                      |   |            |       |
| resulting in      |                      |   |            |       |
| death) Due to (or |                      |   |            |       |
| as a consequence  |                      |   |            |       |
| of):              |                      |   |            |       |
|                   |                      |   |            |       |
| Sequentially list |                      |   |            |       |
| conditions, b.    |                      |   |            |       |
| \_\_\_\           |                      |   |            |       |
| _\_\_\_\_\_\_\_\_ |                      |   |            |       |
| [\_\_\_\_\_       |                      |   |            |       |
| \_\_\_\_\_\_\     |                      |   |            |       |
| _\_\_\_\_\_\_\_\_ |                      |   |            |       |
| \_\_\_\_\_\_\_\_\ |                      |   |            |       |
| _\_\_\_\_\_\_\_\_ |                      |   |            |       |
| \_\_\_\_\_\_\_\_\ |                      |   |            |       |
| _\_\_\_\_\_\_\_\_ |                      |   |            |       |
| \_\_\_\_\_\_\_\_\ |                      |   |            |       |
| _\_\_\_\_\_\_\_\_ |                      |   |            |       |
| \_\_\_\_\_\_\_\_\ |                      |   |            |       |
| _\_\_\_\_\_\_\_\_ |                      |   |            |       |
| \_\_]{.underline} |                      |   |            |       |
|                   |                      |   |            |       |
| if any, leading   |                      |   |            |       |
| to the cause Due  |                      |   |            |       |
| to (or as a       |                      |   |            |       |
| consequence of):  |                      |   |            |       |
|                   |                      |   |            |       |
| listed on line a. |                      |   |            |       |
| Enter the         |                      |   |            |       |
|                   |                      |   |            |       |
| **UNDERLYING      |                      |   |            |       |
| CAUSE** c.        |                      |   |            |       |
| \_\_\_\           |                      |   |            |       |
| _\_\_\_\_\_\_\_\_ |                      |   |            |       |
| [\_\_\_\_\_       |                      |   |            |       |
| \_\_              |                      |   |            |       |
| \_\_\_\_\_\_\_\_\ |                      |   |            |       |
| _\_\_\_\_\_\_\_\_ |                      |   |            |       |
| \_\_\_\_\_\_\_\_\ |                      |   |            |       |
| _\_\_\_\_\_\_\_\_ |                      |   |            |       |
| \_\_\_\_\_\_\_\_\ |                      |   |            |       |
| _\_\_\_\_\_\_\_\_ |                      |   |            |       |
| \_\_\_\_\_\_\_\_\ |                      |   |            |       |
| _\_\_\_\_\_\_\_\_ |                      |   |            |       |
| \_\_\_\_\_\_\_\_\ |                      |   |            |       |
| _\_\_\_\_\_\_\_\_ |                      |   |            |       |
| \_\_]{.underline} |                      |   |            |       |
|                   |                      |   |            |       |
| (disease or       |                      |   |            |       |
| injury that Due   |                      |   |            |       |
| to (or as a       |                      |   |            |       |
| consequence of):  |                      |   |            |       |
|                   |                      |   |            |       |
| initiated the     |                      |   |            |       |
| events resulting  |                      |   |            |       |
|                   |                      |   |            |       |
| in death)         |                      |   |            |       |
| **LAST** d.       |                      |   |            |       |
| \_\               |                      |   |            |       |
| _\_\_\_\_\_\_\_\_ |                      |   |            |       |
| [\_\_\_\_\_       |                      |   |            |       |
| \                 |                      |   |            |       |
| _\_\_\_\_\_\_\_\_ |                      |   |            |       |
| \_\_\_\_\_\_\_\_\ |                      |   |            |       |
| _\_\_\_\_\_\_\_\_ |                      |   |            |       |
| \_\_\_\_\_\_\_\_\ |                      |   |            |       |
| _\_\_\_\_\_\_\_\_ |                      |   |            |       |
| \_\_\_\_\_\_\_\_\ |                      |   |            |       |
| _\_\_\_\_\_\_\_\_ |                      |   |            |       |
| \_\_\_\_\_\_\_\_\ |                      |   |            |       |
| _\_\_\_\_\_\_\_\_ |                      |   |            |       |
| \_\_]{.underline} |                      |   |            |       |
+-------------------+----------------------+---+------------+-------+
| **PART II.**      |                      |   | 33\. WAS   |       |
| Enter other       |                      |   | AN AUTOPSY |       |
| [significant      |                      |   | PERFORMED? |       |
| conditions        |                      |   |            |       |
| contributing to   |                      |   |  Yes  No |       |
| d                 |                      |   |            |       |
| eath]{.underline} |                      |   |            |       |
| 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  | 36\. IF FEMALE:      | 3 |            |       |
| USE CONTRIBUTE TO |                      | 7 |            |       |
| DEATH?            |  Not pregnant       | \ |            |       |
|                   | within past year     | . |            |       |
|  Yes  Probably  |                      | M |            |       |
|                   |  Pregnant at time   | A |            |       |
|  No  Unknown    | of death             | N |            |       |
|                   |                      | N |            |       |
|                   |  Not pregnant, but  | E |            |       |
|                   | pregnant within 42   | R |            |       |
|                   | days of death        | O |            |       |
|                   |                      | F |            |       |
|                   |  Not pregnant, but  | D |            |       |
|                   | pregnant 43 days to  | E |            |       |
|                   | 1 year before death  | A |            |       |
|                   |                      | T |            |       |
|                   |  Unknown if         | H |            |       |
|                   | pregnant within the  |   |            |       |
|                   | past year            |  |            |       |
|                   |                      | N |            |       |
|                   |                      | a |            |       |
|                   |                      | t |            |       |
|                   |                      | u |            |       |
|                   |                      | r |            |       |
|                   |                      | a |            |       |
|                   |                      | l |            |       |
|                   |                      |  |            |       |
|                   |                      | H |            |       |
|                   |                      | o |            |       |
|                   |                      | m |            |       |
|                   |                      | i |            |       |
|                   |                      | c |            |       |
|                   |                      | i |            |       |
|                   |                      | d |            |       |
|                   |                      | e |            |       |
|                   |                      |   |            |       |
|                   |                      |  |            |       |
|                   |                      | A |            |       |
|                   |                      | c |            |       |
|                   |                      | c |            |       |
|                   |                      | i |            |       |
|                   |                      | d |            |       |
|                   |                      | e |            |       |
|                   |                      | n |            |       |
|                   |                      | t |            |       |
|                   |                      |  |            |       |
|                   |                      | P |            |       |
|                   |                      | e |            |       |
|                   |                      | n |            |       |
|                   |                      | d |            |       |
|                   |                      | i |            |       |
|                   |                      | n |            |       |
|                   |                      | g |            |       |
|                   |                      | I |            |       |
|                   |                      | n |            |       |
|                   |                      | v |            |       |
|                   |                      | e |            |       |
|                   |                      | s |            |       |
|                   |                      | t |            |       |
|                   |                      | i |            |       |
|                   |                      | g |            |       |
|                   |                      | a |            |       |
|                   |                      | t |            |       |
|                   |                      | i |            |       |
|                   |                      | o |            |       |
|                   |                      | n |            |       |
|                   |                      |   |            |       |
|                   |                      |  |            |       |
|                   |                      | S |            |       |
|                   |                      | u |            |       |
|                   |                      | i |            |       |
|                   |                      | c |            |       |
|                   |                      | i |            |       |
|                   |                      | d |            |       |
|                   |                      | e |            |       |
|                   |                      |  |            |       |
|                   |                      | C |            |       |
|                   |                      | o |            |       |
|                   |                      | u |            |       |
|                   |                      | l |            |       |
|                   |                      | d |            |       |
|                   |                      | n |            |       |
|                   |                      | o |            |       |
|                   |                      | t |            |       |
|                   |                      | b |            |       |
|                   |                      | e |            |       |
|                   |                      | d |            |       |
|                   |                      | e |            |       |
|                   |                      | t |            |       |
|                   |                      | e |            |       |
|                   |                      | r |            |       |
|                   |                      | m |            |       |
|                   |                      | i |            |       |
|                   |                      | n |            |       |
|                   |                      | e |            |       |
|                   |                      | d |            |       |
+-------------------+----------------------+---+------------+-------+

If death did result from a mental disorder, please state the condition
that resulted from the mental disorder and that caused death:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Otherwise, please state the underlying cause of death that initiated the
chain of events leading to death:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

[, M.D.]{.underline}

(Signature of Certifying Physician)

Please provide your office
phone:\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
fax:\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

(Please see other side)

Instructions on Medical Certification of Causes of Death

Example of properly completed medical certification

+----------+--------+---+---------------------+---+---+---------+---+--------+
| **CAUSE  |        |   |                     |   |   |         |   | Appro  |
| OF DEATH |        |   |                     |   |   |         |   | ximate |
| (See     |        |   |                     |   |   |         |   | int    |
| inst     |        |   |                     |   |   |         |   | erval: |
| ructions |        |   |                     |   |   |         |   |        |
| and      |        |   |                     |   |   |         |   | Onset  |
| exa      |        |   |                     |   |   |         |   | to     |
| mples)** |        |   |                     |   |   |         |   | death  |
|          |        |   |                     |   |   |         |   |        |
| 32\.     |        |   |                     |   |   |         |   | [3     |
| **PART   |        |   |                     |   |   |         |   | days]  |
| I.**     |        |   |                     |   |   |         |   | {.unde |
| Enter    |        |   |                     |   |   |         |   | rline} |
| the      |        |   |                     |   |   |         |   |        |
| [chain   |        |   |                     |   |   |         |   | [15    |
| of       |        |   |                     |   |   |         |   | years] |
| events]  |        |   |                     |   |   |         |   | {.unde |
| {.underl |        |   |                     |   |   |         |   | rline} |
| ine}\--d |        |   |                     |   |   |         |   |        |
| iseases, |        |   |                     |   |   |         |   | \_\_\_ |
| i        |        |   |                     |   |   |         |   | \_\_\_ |
| njuries, |        |   |                     |   |   |         |   | \_\_\_ |
| or       |        |   |                     |   |   |         |   |        |
| comp     |        |   |                     |   |   |         |   | [\_\   |
| lication |        |   |                     |   |   |         |   | _\_\_\ |
| s\--that |        |   |                     |   |   |         |   | _\_\_] |
| directly |        |   |                     |   |   |         |   | {.unde |
| caused   |        |   |                     |   |   |         |   | rline} |
| the      |        |   |                     |   |   |         |   |        |
| death.   |        |   |                     |   |   |         |   |        |
| DO NOT   |        |   |                     |   |   |         |   |        |
| enter    |        |   |                     |   |   |         |   |        |
| terminal |        |   |                     |   |   |         |   |        |
| events   |        |   |                     |   |   |         |   |        |
| such as  |        |   |                     |   |   |         |   |        |
| cardiac  |        |   |                     |   |   |         |   |        |
|          |        |   |                     |   |   |         |   |        |
| arrest,  |        |   |                     |   |   |         |   |        |
| res      |        |   |                     |   |   |         |   |        |
| piratory |        |   |                     |   |   |         |   |        |
| arrest,  |        |   |                     |   |   |         |   |        |
| or       |        |   |                     |   |   |         |   |        |
| ven      |        |   |                     |   |   |         |   |        |
| tricular |        |   |                     |   |   |         |   |        |
| fibr     |        |   |                     |   |   |         |   |        |
| illation |        |   |                     |   |   |         |   |        |
| without  |        |   |                     |   |   |         |   |        |
| showing  |        |   |                     |   |   |         |   |        |
| the      |        |   |                     |   |   |         |   |        |
| e        |        |   |                     |   |   |         |   |        |
| tiology. |        |   |                     |   |   |         |   |        |
| DO NOT   |        |   |                     |   |   |         |   |        |
| ABB      |        |   |                     |   |   |         |   |        |
| REVIATE. |        |   |                     |   |   |         |   |        |
| Enter    |        |   |                     |   |   |         |   |        |
| only one |        |   |                     |   |   |         |   |        |
| cause on |        |   |                     |   |   |         |   |        |
| a line.  |        |   |                     |   |   |         |   |        |
| Add      |        |   |                     |   |   |         |   |        |
| ad       |        |   |                     |   |   |         |   |        |
| ditional |        |   |                     |   |   |         |   |        |
|          |        |   |                     |   |   |         |   |        |
| lines if |        |   |                     |   |   |         |   |        |
| ne       |        |   |                     |   |   |         |   |        |
| cessary. |        |   |                     |   |   |         |   |        |
|          |        |   |                     |   |   |         |   |        |
| I        |        |   |                     |   |   |         |   |        |
| MMEDIATE |        |   |                     |   |   |         |   |        |
| CAUSE    |        |   |                     |   |   |         |   |        |
| (Final   |        |   |                     |   |   |         |   |        |
|          |        |   |                     |   |   |         |   |        |
| disease  |        |   |                     |   |   |         |   |        |
| or       |        |   |                     |   |   |         |   |        |
| c        |        |   |                     |   |   |         |   |        |
| ondition |        |   |                     |   |   |         |   |        |
| **\-\-\  |        |   |                     |   |   |         |   |        |
| -\-\-\-\ |        |   |                     |   |   |         |   |        |
| -\--\>** |        |   |                     |   |   |         |   |        |
| a.       |        |   |                     |   |   |         |   |        |
| [As      |        |   |                     |   |   |         |   |        |
| piration |        |   |                     |   |   |         |   |        |
| pneu     |        |   |                     |   |   |         |   |        |
| monia\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_]{.un |        |   |                     |   |   |         |   |        |
| derline} |        |   |                     |   |   |         |   |        |
|          |        |   |                     |   |   |         |   |        |
| r        |        |   |                     |   |   |         |   |        |
| esulting |        |   |                     |   |   |         |   |        |
| in       |        |   |                     |   |   |         |   |        |
| death)   |        |   |                     |   |   |         |   |        |
| Due to   |        |   |                     |   |   |         |   |        |
| (or as a |        |   |                     |   |   |         |   |        |
| con      |        |   |                     |   |   |         |   |        |
| sequence |        |   |                     |   |   |         |   |        |
| of):     |        |   |                     |   |   |         |   |        |
|          |        |   |                     |   |   |         |   |        |
| Sequ     |        |   |                     |   |   |         |   |        |
| entially |        |   |                     |   |   |         |   |        |
| list     |        |   |                     |   |   |         |   |        |
| con      |        |   |                     |   |   |         |   |        |
| ditions, |        |   |                     |   |   |         |   |        |
| b.       |        |   |                     |   |   |         |   |        |
| [Mental  |        |   |                     |   |   |         |   |        |
| retardat |        |   |                     |   |   |         |   |        |
| ion\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_]{.un |        |   |                     |   |   |         |   |        |
| derline} |        |   |                     |   |   |         |   |        |
|          |        |   |                     |   |   |         |   |        |
| if any,  |        |   |                     |   |   |         |   |        |
| leading  |        |   |                     |   |   |         |   |        |
| to the   |        |   |                     |   |   |         |   |        |
| cause    |        |   |                     |   |   |         |   |        |
| Due to   |        |   |                     |   |   |         |   |        |
| (or as a |        |   |                     |   |   |         |   |        |
| con      |        |   |                     |   |   |         |   |        |
| sequence |        |   |                     |   |   |         |   |        |
| of):     |        |   |                     |   |   |         |   |        |
|          |        |   |                     |   |   |         |   |        |
| listed   |        |   |                     |   |   |         |   |        |
| on line  |        |   |                     |   |   |         |   |        |
| a. Enter |        |   |                     |   |   |         |   |        |
| the      |        |   |                     |   |   |         |   |        |
|          |        |   |                     |   |   |         |   |        |
| **UN     |        |   |                     |   |   |         |   |        |
| DERLYING |        |   |                     |   |   |         |   |        |
| CAUSE**  |        |   |                     |   |   |         |   |        |
| c.       |        |   |                     |   |   |         |   |        |
| \_\_\_\_ |        |   |                     |   |   |         |   |        |
| \_\_\_\_ |        |   |                     |   |   |         |   |        |
| \_\_\_\_ |        |   |                     |   |   |         |   |        |
| \_\_\_\_ |        |   |                     |   |   |         |   |        |
| \_\_\_\_ |        |   |                     |   |   |         |   |        |
| \_[\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_]{.un |        |   |                     |   |   |         |   |        |
| derline} |        |   |                     |   |   |         |   |        |
|          |        |   |                     |   |   |         |   |        |
| (disease |        |   |                     |   |   |         |   |        |
| or       |        |   |                     |   |   |         |   |        |
| injury   |        |   |                     |   |   |         |   |        |
| that Due |        |   |                     |   |   |         |   |        |
| to (or   |        |   |                     |   |   |         |   |        |
| as a     |        |   |                     |   |   |         |   |        |
| con      |        |   |                     |   |   |         |   |        |
| sequence |        |   |                     |   |   |         |   |        |
| of):     |        |   |                     |   |   |         |   |        |
|          |        |   |                     |   |   |         |   |        |
| i        |        |   |                     |   |   |         |   |        |
| nitiated |        |   |                     |   |   |         |   |        |
| the      |        |   |                     |   |   |         |   |        |
| events   |        |   |                     |   |   |         |   |        |
| r        |        |   |                     |   |   |         |   |        |
| esulting |        |   |                     |   |   |         |   |        |
|          |        |   |                     |   |   |         |   |        |
| in       |        |   |                     |   |   |         |   |        |
| death)   |        |   |                     |   |   |         |   |        |
| **LAST** |        |   |                     |   |   |         |   |        |
| d.       |        |   |                     |   |   |         |   |        |
| [\       |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_]{.un |        |   |                     |   |   |         |   |        |
| derline} |        |   |                     |   |   |         |   |        |
+----------+--------+---+---------------------+---+---+---------+---+--------+
| **PART   |        |   |                     |   | 3 |         |   |        |
| II.**    |        |   |                     |   | 3 |         |   |        |
| Enter    |        |   |                     |   | \ |         |   |        |
| other    |        |   |                     |   | . |         |   |        |
| [sig     |        |   |                     |   | W |         |   |        |
| nificant |        |   |                     |   | A |         |   |        |
| co       |        |   |                     |   | S |         |   |        |
| nditions |        |   |                     |   | A |         |   |        |
| cont     |        |   |                     |   | N |         |   |        |
| ributing |        |   |                     |   | A |         |   |        |
| to       |        |   |                     |   | U |         |   |        |
| de       |        |   |                     |   | T |         |   |        |
| ath]{.un |        |   |                     |   | O |         |   |        |
| derline} |        |   |                     |   | P |         |   |        |
| but not  |        |   |                     |   | S |         |   |        |
| r        |        |   |                     |   | Y |         |   |        |
| esulting |        |   |                     |   | P |         |   |        |
| in the   |        |   |                     |   | E |         |   |        |
| un       |        |   |                     |   | R |         |   |        |
| derlying |        |   |                     |   | F |         |   |        |
| cause    |        |   |                     |   | O |         |   |        |
| given in |        |   |                     |   | R |         |   |        |
| PART I   |        |   |                     |   | M |         |   |        |
|          |        |   |                     |   | E |         |   |        |
|          |        |   |                     |   | D |         |   |        |
|          |        |   |                     |   | ? |         |   |        |
|          |        |   |                     |   |   |         |   |        |
|          |        |   |                     |   | ■ |         |   |        |
|          |        |   |                     |   | Y |         |   |        |
|          |        |   |                     |   | e |         |   |        |
|          |        |   |                     |   | s |         |   |        |
|          |        |   |                     |   |  |         |   |        |
|          |        |   |                     |   |  |         |   |        |
|          |        |   |                     |   |  |         |   |        |
|          |        |   |                     |   | N |         |   |        |
|          |        |   |                     |   | o |         |   |        |
+----------+--------+---+---------------------+---+---+---------+---+--------+
|          |        |   |                     |   | 3 |         |   |        |
|          |        |   |                     |   | 4 |         |   |        |
|          |        |   |                     |   | \ |         |   |        |
|          |        |   |                     |   | . |         |   |        |
|          |        |   |                     |   | W |         |   |        |
|          |        |   |                     |   | E |         |   |        |
|          |        |   |                     |   | R |         |   |        |
|          |        |   |                     |   | E |         |   |        |
|          |        |   |                     |   | A |         |   |        |
|          |        |   |                     |   | U |         |   |        |
|          |        |   |                     |   | T |         |   |        |
|          |        |   |                     |   | O |         |   |        |
|          |        |   |                     |   | P |         |   |        |
|          |        |   |                     |   | S |         |   |        |
|          |        |   |                     |   | Y |         |   |        |
|          |        |   |                     |   | F |         |   |        |
|          |        |   |                     |   | I |         |   |        |
|          |        |   |                     |   | N |         |   |        |
|          |        |   |                     |   | D |         |   |        |
|          |        |   |                     |   | I |         |   |        |
|          |        |   |                     |   | N |         |   |        |
|          |        |   |                     |   | G |         |   |        |
|          |        |   |                     |   | S |         |   |        |
|          |        |   |                     |   | A |         |   |        |
|          |        |   |                     |   | V |         |   |        |
|          |        |   |                     |   | A |         |   |        |
|          |        |   |                     |   | I |         |   |        |
|          |        |   |                     |   | L |         |   |        |
|          |        |   |                     |   | A |         |   |        |
|          |        |   |                     |   | B |         |   |        |
|          |        |   |                     |   | L |         |   |        |
|          |        |   |                     |   | E |         |   |        |
|          |        |   |                     |   | T |         |   |        |
|          |        |   |                     |   | O |         |   |        |
|          |        |   |                     |   |   |         |   |        |
|          |        |   |                     |   | C |         |   |        |
|          |        |   |                     |   | O |         |   |        |
|          |        |   |                     |   | M |         |   |        |
|          |        |   |                     |   | P |         |   |        |
|          |        |   |                     |   | L |         |   |        |
|          |        |   |                     |   | E |         |   |        |
|          |        |   |                     |   | T |         |   |        |
|          |        |   |                     |   | E |         |   |        |
|          |        |   |                     |   | T |         |   |        |
|          |        |   |                     |   | H |         |   |        |
|          |        |   |                     |   | E |         |   |        |
|          |        |   |                     |   | C |         |   |        |
|          |        |   |                     |   | A |         |   |        |
|          |        |   |                     |   | U |         |   |        |
|          |        |   |                     |   | S |         |   |        |
|          |        |   |                     |   | E |         |   |        |
|          |        |   |                     |   | O |         |   |        |
|          |        |   |                     |   | F |         |   |        |
|          |        |   |                     |   | D |         |   |        |
|          |        |   |                     |   | E |         |   |        |
|          |        |   |                     |   | A |         |   |        |
|          |        |   |                     |   | T |         |   |        |
|          |        |   |                     |   | H |         |   |        |
|          |        |   |                     |   | ? |         |   |        |
|          |        |   |                     |   |  |         |   |        |
|          |        |   |                     |   | Y |         |   |        |
|          |        |   |                     |   | e |         |   |        |
|          |        |   |                     |   | s |         |   |        |
|          |        |   |                     |   | ■ |         |   |        |
|          |        |   |                     |   | N |         |   |        |
|          |        |   |                     |   | o |         |   |        |
+----------+--------+---+---------------------+---+---+---------+---+--------+
| 35\. DID |        | 3 |                     | 3 |   |         |   |        |
| TOBACCO  |        | 6 |                     | 7 |   |         |   |        |
| USE      |        | \ |                     | \ |   |         |   |        |
| CO       |        | . |                     | . |   |         |   |        |
| NTRIBUTE |        | I |                     | M |   |         |   |        |
| TO       |        | F |                     | A |   |         |   |        |
| DEATH?   |        | F |                     | N |   |         |   |        |
|          |        | E |                     | N |   |         |   |        |
| Yes   |        | M |                     | E |   |         |   |        |
|       |        | A |                     | R |   |         |   |        |
| Probably |        | L |                     | O |   |         |   |        |
|          |        | E |                     | F |   |         |   |        |
| ■ No     |        | : |                     | D |   |         |   |        |
|        |        |   |                     | E |   |         |   |        |
| Unknown |        | ■ |                     | A |   |         |   |        |
|          |        | N |                     | T |   |         |   |        |
|          |        | o |                     | H |   |         |   |        |
|          |        | t |                     |   |   |         |   |        |
|          |        | p |                     | ■ |   |         |   |        |
|          |        | r |                     | N |   |         |   |        |
|          |        | e |                     | a |   |         |   |        |
|          |        | g |                     | t |   |         |   |        |
|          |        | n |                     | u |   |         |   |        |
|          |        | a |                     | r |   |         |   |        |
|          |        | n |                     | a |   |         |   |        |
|          |        | t |                     | l |   |         |   |        |
|          |        | w |                     |  |   |         |   |        |
|          |        | i |                     |  |   |         |   |        |
|          |        | t |                     |  |   |         |   |        |
|          |        | h |                     | H |   |         |   |        |
|          |        | i |                     | o |   |         |   |        |
|          |        | n |                     | m |   |         |   |        |
|          |        | p |                     | i |   |         |   |        |
|          |        | a |                     | c |   |         |   |        |
|          |        | s |                     | i |   |         |   |        |
|          |        | t |                     | d |   |         |   |        |
|          |        | y |                     | e |   |         |   |        |
|          |        | e |                     |   |   |         |   |        |
|          |        | a |                     |  |   |         |   |        |
|          |        | r |                     | A |   |         |   |        |
|          |        |   |                     | c |   |         |   |        |
|          |        |  |                     | c |   |         |   |        |
|          |        |  |                     | i |   |         |   |        |
|          |        |  |                     | d |   |         |   |        |
|          |        | P |                     | e |   |         |   |        |
|          |        | r |                     | n |   |         |   |        |
|          |        | e |                     | t |   |         |   |        |
|          |        | g |                     |  |   |         |   |        |
|          |        | n |                     |  |   |         |   |        |
|          |        | a |                     |  |   |         |   |        |
|          |        | n |                     | P |   |         |   |        |
|          |        | t |                     | e |   |         |   |        |
|          |        | a |                     | n |   |         |   |        |
|          |        | t |                     | d |   |         |   |        |
|          |        | t |                     | i |   |         |   |        |
|          |        | i |                     | n |   |         |   |        |
|          |        | m |                     | g |   |         |   |        |
|          |        | e |                     | I |   |         |   |        |
|          |        | o |                     | n |   |         |   |        |
|          |        | f |                     | v |   |         |   |        |
|          |        | d |                     | e |   |         |   |        |
|          |        | e |                     | s |   |         |   |        |
|          |        | a |                     | t |   |         |   |        |
|          |        | t |                     | i |   |         |   |        |
|          |        | h |                     | g |   |         |   |        |
|          |        |   |                     | a |   |         |   |        |
|          |        |  |                     | t |   |         |   |        |
|          |        |  |                     | i |   |         |   |        |
|          |        |  |                     | o |   |         |   |        |
|          |        | N |                     | n |   |         |   |        |
|          |        | o |                     |   |   |         |   |        |
|          |        | t |                     |  |   |         |   |        |
|          |        | p |                     |  |   |         |   |        |
|          |        | r |                     |  |   |         |   |        |
|          |        | e |                     | S |   |         |   |        |
|          |        | g |                     | u |   |         |   |        |
|          |        | n |                     | i |   |         |   |        |
|          |        | a |                     | c |   |         |   |        |
|          |        | n |                     | i |   |         |   |        |
|          |        | t |                     | d |   |         |   |        |
|          |        | , |                     | e |   |         |   |        |
|          |        | b |                     |  |   |         |   |        |
|          |        | u |                     |  |   |         |   |        |
|          |        | t |                     |  |   |         |   |        |
|          |        | p |                     | C |   |         |   |        |
|          |        | r |                     | o |   |         |   |        |
|          |        | e |                     | u |   |         |   |        |
|          |        | g |                     | l |   |         |   |        |
|          |        | n |                     | d |   |         |   |        |
|          |        | a |                     | n |   |         |   |        |
|          |        | n |                     | o |   |         |   |        |
|          |        | t |                     | t |   |         |   |        |
|          |        | w |                     | b |   |         |   |        |
|          |        | i |                     | e |   |         |   |        |
|          |        | t |                     | d |   |         |   |        |
|          |        | h |                     | e |   |         |   |        |
|          |        | i |                     | t |   |         |   |        |
|          |        | n |                     | e |   |         |   |        |
|          |        | 4 |                     | r |   |         |   |        |
|          |        | 2 |                     | m |   |         |   |        |
|          |        | d |                     | i |   |         |   |        |
|          |        | a |                     | n |   |         |   |        |
|          |        | y |                     | e |   |         |   |        |
|          |        | s |                     | d |   |         |   |        |
|          |        | o |                     |   |   |         |   |        |
|          |        | f |                     |   |   |         |   |        |
|          |        | d |                     |   |   |         |   |        |
|          |        | e |                     |   |   |         |   |        |
|          |        | a |                     |   |   |         |   |        |
|          |        | t |                     |   |   |         |   |        |
|          |        | h |                     |   |   |         |   |        |
|          |        |   |                     |   |   |         |   |        |
|          |        |  |                     |   |   |         |   |        |
|          |        |  |                     |   |   |         |   |        |
|          |        |  |                     |   |   |         |   |        |
|          |        | N |                     |   |   |         |   |        |
|          |        | o |                     |   |   |         |   |        |
|          |        | t |                     |   |   |         |   |        |
|          |        | p |                     |   |   |         |   |        |
|          |        | r |                     |   |   |         |   |        |
|          |        | e |                     |   |   |         |   |        |
|          |        | g |                     |   |   |         |   |        |
|          |        | n |                     |   |   |         |   |        |
|          |        | a |                     |   |   |         |   |        |
|          |        | n |                     |   |   |         |   |        |
|          |        | t |                     |   |   |         |   |        |
|          |        | , |                     |   |   |         |   |        |
|          |        | b |                     |   |   |         |   |        |
|          |        | u |                     |   |   |         |   |        |
|          |        | t |                     |   |   |         |   |        |
|          |        | p |                     |   |   |         |   |        |
|          |        | r |                     |   |   |         |   |        |
|          |        | e |                     |   |   |         |   |        |
|          |        | g |                     |   |   |         |   |        |
|          |        | n |                     |   |   |         |   |        |
|          |        | a |                     |   |   |         |   |        |
|          |        | n |                     |   |   |         |   |        |
|          |        | t |                     |   |   |         |   |        |
|          |        | 4 |                     |   |   |         |   |        |
|          |        | 3 |                     |   |   |         |   |        |
|          |        | d |                     |   |   |         |   |        |
|          |        | a |                     |   |   |         |   |        |
|          |        | y |                     |   |   |         |   |        |
|          |        | s |                     |   |   |         |   |        |
|          |        | t |                     |   |   |         |   |        |
|          |        | o |                     |   |   |         |   |        |
|          |        | 1 |                     |   |   |         |   |        |
|          |        | y |                     |   |   |         |   |        |
|          |        | e |                     |   |   |         |   |        |
|          |        | a |                     |   |   |         |   |        |
|          |        | r |                     |   |   |         |   |        |
|          |        | b |                     |   |   |         |   |        |
|          |        | e |                     |   |   |         |   |        |
|          |        | f |                     |   |   |         |   |        |
|          |        | o |                     |   |   |         |   |        |
|          |        | r |                     |   |   |         |   |        |
|          |        | e |                     |   |   |         |   |        |
|          |        | d |                     |   |   |         |   |        |
|          |        | e |                     |   |   |         |   |        |
|          |        | a |                     |   |   |         |   |        |
|          |        | t |                     |   |   |         |   |        |
|          |        | h |                     |   |   |         |   |        |
|          |        |   |                     |   |   |         |   |        |
|          |        |  |                     |   |   |         |   |        |
|          |        |  |                     |   |   |         |   |        |
|          |        |  |                     |   |   |         |   |        |
|          |        | U |                     |   |   |         |   |        |
|          |        | n |                     |   |   |         |   |        |
|          |        | k |                     |   |   |         |   |        |
|          |        | n |                     |   |   |         |   |        |
|          |        | o |                     |   |   |         |   |        |
|          |        | w |                     |   |   |         |   |        |
|          |        | n |                     |   |   |         |   |        |
|          |        | i |                     |   |   |         |   |        |
|          |        | f |                     |   |   |         |   |        |
|          |        | p |                     |   |   |         |   |        |
|          |        | r |                     |   |   |         |   |        |
|          |        | e |                     |   |   |         |   |        |
|          |        | g |                     |   |   |         |   |        |
|          |        | n |                     |   |   |         |   |        |
|          |        | a |                     |   |   |         |   |        |
|          |        | n |                     |   |   |         |   |        |
|          |        | t |                     |   |   |         |   |        |
|          |        | w |                     |   |   |         |   |        |
|          |        | i |                     |   |   |         |   |        |
|          |        | t |                     |   |   |         |   |        |
|          |        | h |                     |   |   |         |   |        |
|          |        | i |                     |   |   |         |   |        |
|          |        | n |                     |   |   |         |   |        |
|          |        | t |                     |   |   |         |   |        |
|          |        | h |                     |   |   |         |   |        |
|          |        | e |                     |   |   |         |   |        |
|          |        | p |                     |   |   |         |   |        |
|          |        | a |                     |   |   |         |   |        |
|          |        | s |                     |   |   |         |   |        |
|          |        | t |                     |   |   |         |   |        |
|          |        | y |                     |   |   |         |   |        |
|          |        | e |                     |   |   |         |   |        |
|          |        | a |                     |   |   |         |   |        |
|          |        | r |                     |   |   |         |   |        |
+----------+--------+---+---------------------+---+---+---------+---+--------+
| 38\.     | 39\.   |   | 40\. PLACE OF       |   |   |         | 4 |        |
| DATE OF  | TIME   |   | INJURY (e.g.,       |   |   |         | 1 |        |
| INJURY   | OF     |   | Decedent's home;    |   |   |         | \ |        |
|          | INJURY |   | construction site;  |   |   |         | . |        |
| (Mo      |        |   | restaurant; wooded  |   |   |         | I |        |
| /Day/Yr) |        |   | area)               |   |   |         | N |        |
| (Spell   |        |   |                     |   |   |         | J |        |
| Month)   |        |   |                     |   |   |         | U |        |
|          |        |   |                     |   |   |         | R |        |
|          |        |   |                     |   |   |         | Y |        |
|          |        |   |                     |   |   |         | A |        |
|          |        |   |                     |   |   |         | T |        |
|          |        |   |                     |   |   |         | W |        |
|          |        |   |                     |   |   |         | O |        |
|          |        |   |                     |   |   |         | R |        |
|          |        |   |                     |   |   |         | K |        |
|          |        |   |                     |   |   |         | ? |        |
|          |        |   |                     |   |   |         |   |        |
|          |        |   |                     |   |   |         |  |        |
|          |        |   |                     |   |   |         |  |        |
|          |        |   |                     |   |   |         |  |        |
|          |        |   |                     |   |   |         |  |        |
|          |        |   |                     |   |   |         |  |        |
|          |        |   |                     |   |   |         |  |        |
|          |        |   |                     |   |   |         |  |        |
|          |        |   |                     |   |   |         |  |        |
|          |        |   |                     |   |   |         |  |        |
|          |        |   |                     |   |   |         |  |        |
|          |        |   |                     |   |   |         |  |        |
|          |        |   |                     |   |   |         |  |        |
|          |        |   |                     |   |   |         |  |        |
|          |        |   |                     |   |   |         |  |        |
|          |        |   |                     |   |   |         | Y |        |
|          |        |   |                     |   |   |         | e |        |
|          |        |   |                     |   |   |         | s |        |
|          |        |   |                     |   |   |         |  |        |
|          |        |   |                     |   |   |         | N |        |
|          |        |   |                     |   |   |         | o |        |
+----------+--------+---+---------------------+---+---+---------+---+--------+
| 42\.     |        |   |                     |   |   |         |   |        |
| LOCATION |        |   |                     |   |   |         |   |        |
| OF       |        |   |                     |   |   |         |   |        |
| INJURY:  |        |   |                     |   |   |         |   |        |
| State:   |        |   |                     |   |   |         |   |        |
| City or  |        |   |                     |   |   |         |   |        |
| Town:    |        |   |                     |   |   |         |   |        |
|          |        |   |                     |   |   |         |   |        |
| Street & |        |   |                     |   |   |         |   |        |
| Number:  |        |   |                     |   |   |         |   |        |
| A        |        |   |                     |   |   |         |   |        |
| partment |        |   |                     |   |   |         |   |        |
| No.: Zip |        |   |                     |   |   |         |   |        |
| Code:    |        |   |                     |   |   |         |   |        |
+----------+--------+---+---------------------+---+---+---------+---+--------+
| 43\.     |        |   |                     |   |   | 44\. IF |   |        |
| DESCRIBE |        |   |                     |   |   | TRANSPO |   |        |
| HOW      |        |   |                     |   |   | RTATION |   |        |
| INJURY   |        |   |                     |   |   | INJURY, |   |        |
| O        |        |   |                     |   |   | S       |   |        |
| CCURRED: |        |   |                     |   |   | PECIFY: |   |        |
|          |        |   |                     |   |   |         |   |        |
|          |        |   |                     |   |   |        |   |        |
|          |        |   |                     |   |   | D       |   |        |
|          |        |   |                     |   |   | river/O |   |        |
|          |        |   |                     |   |   | perator |   |        |
|          |        |   |                     |   |   |         |   |        |
|          |        |   |                     |   |   | Pa   |   |        |
|          |        |   |                     |   |   | ssenger |   |        |
|          |        |   |                     |   |   |         |   |        |
|          |        |   |                     |   |   | Ped  |   |        |
|          |        |   |                     |   |   | estrian |   |        |
|          |        |   |                     |   |   |         |   |        |
|          |        |   |                     |   |   |        |   |        |
|          |        |   |                     |   |   | Other |   |        |
|          |        |   |                     |   |   | (S      |   |        |
|          |        |   |                     |   |   | pecify) |   |        |
+----------+--------+---+---------------------+---+---+---------+---+--------+

**ITEM 32 -- CAUSE OF DEATH (See example above)**

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.

Take care to make the entry legible. Use a computer printer with high
resolution, typewriter with good black ribbon and clean keys, or print
legibly using permanent **black** ink in completing the CAUSE OF DEATH
Section. **Do** **not** **abbreviate** conditions entered in section.

**[Part I]{.underline} (Chain of events leading directly to death)**

•Only **one** cause should be entered on each line. [Line
(a)]{.underline} **MUST ALWAYS** have an entry. **DO NOT** leave blank.
Additional lines may be added if necessary.

•If the condition on [Line (a)]{.underline} resulted from an underlying
condition, put the underlying condition on [Line (b)]{.underline}, and
so on, until the full sequence is reported. **ALWAYS** enter the
**underlying cause of death** on the [lowest used line]{.underline} in
Part I.

•For each cause indicate the best estimate of the interval between the
presumed onset and the date of death. The terms "unknown" or
"approximately" may be used. General terms, such as minutes, hours, or
days, are acceptable, if necessary. **DO NOT** leave blank.

•The terminal event (for example, cardiac arrest or respiratory arrest)
should not be used. If a mechanism of death seems most appropriate to
you for line (a), then you must always list its cause(s) on the line(s)
below it (for example, cardiac arrest **due to** coronary artery
atherosclerosis *or* cardiac arrest **due to** blunt impact to chest).

• If an organ system failure such as congestive heart failure, hepatic
failure, renal failure, or respiratory failure is listed as a cause of
death, always report its etiology on the line(s) beneath it (for
example, renal failure **due to** Type I diabetes mellitus).

•When indicating neoplasms as a cause of death, include the
following: 1) primary site *or* that the primary site is unknown, 2)
benign or malignant, 3) cell type *or* that the cell type is unknown, 4)
grade of neoplasm, and 5) part or lobe of organ affected. (For example,
a primary well-differentiated squamous cell carcinoma, lung, left upper
lobe.)

•Always report the fatal injury (for example, stab wound of chest), the
trauma (for example, transection of subclavian vein), and impairment of
function (for example, air embolism).

**Part II (Other significant conditions)**

•Enter all diseases or conditions contributing to death that were not
reported in the chain of events in Part I and that did not result in the
**underlying cause of death**.

•If two or more possible sequences resulted in death, or if two
conditions seem to have added together, report in Part I the one that,
in your opinion, most directly caused death. Report in Part II the other
conditions or diseases.

**CHANGES TO CAUSE OF DEATH**

Should additional medical information or autopsy findings become
available that would change the cause of death originally reported, the
original death certificate should be amended by the certifying physician
by **immediately** reporting the revised cause of death to the State
Vital Records Office.

**ITEMS ON WHEN DEATH OCCURRED**

Items 24-25 and 29-31 should always be completed. If the facility uses a
separate pronouncer or other person to indicate that death has taken
place with another person more familiar with the case completing the
remainder of the medical portion of the death certificate, the
pronouncer completes Items 24-28. If a certifier completes Items 24-25
as well as items 29-49, Items 26-28 may be left blank.

**ITEMS 24-25, 29-30 -- DATE AND TIME OF DEATH**

Spell out the name of the month. If the exact date of death is unknown,
enter the **approximate** date. If the date cannot be approximated,
enter the date the body is found and identify as **date found**. Date
pronounced and actual date may be the same. Enter the exact hour and
minutes according to a 24-hour clock; estimates may be provided with
"Approx." placed before the time.

**ITEMS 33-34 - AUTOPSY**

•33 - Enter "Yes" if either a partial or full autopsy was performed.
Otherwise enter "No."

•34 - Enter "Yes" if autopsy findings were available to complete the
cause of death; otherwise enter "No". Leave item blank if no autopsy was
performed.

**ITEM 35 - DID TOBACCO USE CONTRIBUTE TO DEATH?**

Check "yes" if, in your opinion, the use of tobacco contributed to
death. Tobacco use may contribute to deaths due to a wide variety of
diseases; for example, tobacco use contributes to many deaths due to
emphysema or lung cancer and some heart disease and cancers of the head
and neck. Check "no" if, in your clinical judgment, tobacco use did not
contribute to this particular death.

**ITEM 36 - IF FEMALE, WAS DECEDENT PREGNANT AT TIME OF DEATH OR WITHIN
PAST YEAR?**

This information is important in determining pregnancy-related
mortality.

**ITEM 37 - MANNER OF DEATH**

•Always check Manner of Death, which is important: 1) in determining
accurate causes of death; 2) in processing insurance claims; and 3) in
statistical studies of injuries and death.

•Indicate "Pending investigation" if the manner of death cannot be
determined whether due to an accident, suicide, or homicide within the
statutory time limit for filing the death certificate. This should be
changed later to one of the other terms.

•Indicate "Could not be Determined" **ONLY** when it is impossible to
determine the manner of death.

**ITEMS 38-44 - ACCIDENT OR INJURY -- to be filled out in all cases of
deaths due to injury or poisoning.**

•38 - Enter the exact month, day, and year of injury. Spell out the name
of the month. **DO NOT** use a number for the month. (Remember, the date
of injury may differ from the date of death.) Estimates may be provided
with "Approx." placed before the date.

•39 **-** Enter the exact hour and minutes of injury or use your best
estimate. Use a 24-hour clock.

•40 - Enter the general place (such as restaurant, vacant lot, or home)
where the injury occurred. **DO NOT** enter firm or organization names.
(For example, enter "factory", **not** "Standard Manufacturing, Inc." )

•41 - Complete if anything other than natural disease is mentioned in
Part I or Part II of the medical certification, including homicides,
suicides, and accidents. This includes all motor vehicle deaths. The
item **[must]{.underline}** be completed for decedents ages 14 years or
over and may be completed for those less than 14 years of age if
warranted. Enter "Yes" if the injury occurred at work. Otherwise enter
"No". An injury may occur at work regardless of whether the injury
occurred in the course of the decedent's "usual" occupation. Examples of
injury at work and injury not at work follow:

+-----------------------------------+-----------------------------------+
| **Injury at work**                | **Injury [not]{.underline} at     |
|                                   | work**                            |
| Injury while working or in        |                                   |
| vocational training on job        | Injury while engaged in personal  |
| premises                          | recreational activity on job      |
|                                   | premises                          |
| Injury while on break or at lunch |                                   |
| or in parking lot on job premises | Injury while a visitor (not on    |
|                                   | official work business) to job    |
| Injury while working for pay or   | premises                          |
| compensation, including at home   |                                   |
|                                   | Homemaker working at homemaking   |
| Injury while working as a         | activities                        |
| volunteer law enforcement         |                                   |
| official etc.                     | Student in school                 |
|                                   |                                   |
| Injury while traveling on         | Working for self for no profit    |
| business, including to/from       | (mowing yard, repairing own roof, |
| business contacts                 | hobby)                            |
|                                   |                                   |
|                                   | Commuting to or from work         |
+-----------------------------------+-----------------------------------+

•42 - Enter the complete address where the injury occurred including zip
code.

•43 - Enter a brief but specific and clear description of how the injury
occurred. Explain the circumstances or cause of the injury. Specify
**type** **of** **gun** or **type of vehicle** (e.g., car, bulldozer,
train, etc.) when relevant to circumstances. Indicate if more than one
vehicle involved; specify type of vehicle decedent was in.

•44 -Specify role of decedent (e.g. driver, passenger). Driver/operator
and passenger should be designated for modes other than motor vehicles
such as bicycles. Other applies to watercraft, aircraft, animal, or
people attached to outside of vehicles (e.g. surfers).

[Rationale]{.underline}: Motor vehicle accidents are a major cause of
unintentional deaths; details will help determine effectiveness of
current safety features and laws.

**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:]{.underline}**

+-------------+-------------+-------------+-------------+-------------+
| Abscess     | Car         | D           | H           | Pulmonary   |
|             | cinomatosis | isseminated | yponatremia | arrest      |
| Abdominal   |             | intra       |             |             |
| hemorrhage  | Cardiac     | vascular    | Hypotension | Pulmonary   |
|             | arrest      |             |             | edema       |
| Adhesions   |             | c           | Immuno      |             |
|             | Cardiac     | oagulopathy | suppression | Pulmonary   |
| Adult       | dysrhythmia |             |             | embolism    |
| respiratory |             | Dysrhythmia | Increased   |             |
| distress    | Car         |             | intra       | Pulmonary   |
| syndrome    | diomyopathy | End-stage   | cranial     | in          |
|             |             | liver       | pressure    | sufficiency |
| Acute       | Card        | disease     |             |             |
| myocardial  | iopulmonary |             | Intra       | Renal       |
| infarction  | arrest      | End-stage   | cranial     | failure     |
|             |             | renal       | hemorrhage  |             |
| Altered     | Cellulitis  | disease     |             | Respiratory |
| mental      |             |             | M           | arrest      |
| status      | Cerebral    | Epidural    | alnutrition |             |
|             | edema       | hematoma    |             | Seizures    |
| Anemia      |             |             | Metabolic   |             |
|             | Cere        | Exs         | enc         | Sepsis      |
| Anoxia      | brovascular | anguination | ephalopathy |             |
|             | accident    |             |             | Septic      |
| Anoxic      |             | Failure to  | Multi-organ | shock       |
| enc         | Cerebellar  | thrive      | failure     |             |
| ephalopathy | tonsillar   |             |             | Shock       |
|             | herniation  | Fracture    | M           |             |
| Arrhythmia  |             |             | ulti-system | Starvation  |
|             | Chronic     | Gangrene    | organ       |             |
| Ascites     | bedridden   |             | failure     | Subdural    |
|             | state       | Gastr       |             | hematoma    |
| Aspiration  |             | ointestinal | Myocardial  |             |
|             | Cirrhosis   | hemorrhage  | infarction  | S           |
| Atrial      |             |             |             | ubarachnoid |
| f           | C           | Heart       | Necrotizing | hemorrhage  |
| ibrillation | oagulopathy | failure     | soft-tissue |             |
|             |             |             | infection   | Sudden      |
| Bacteremia  | Compression | Hemothorax  |             | death       |
|             | fracture    |             | Old age     |             |
| Bedridden   |             | Hepatic     |             | Throm       |
|             | Congestive  | failure     | Open (or    | bocytopenia |
| Biliary     | heart       |             | closed)     |             |
| obstruction | failure     | Hepatitis   | head injury | Uncal       |
|             |             |             |             | herniation  |
| Bowel       | Convulsions | Hepatorenal | Paralysis   |             |
| obstruction |             | syndrome    |             | Urinary     |
|             | Decubiti    |             | P           | tract       |
| Brain       |             | Hy          | ancytopenia | infection   |
| injury      | Dehydration | perglycemia |             |             |
|             |             |             | Perforated  | Ventricular |
| Brain stem  | Dementia    | H           | gallbladder | f           |
| herniation  | (when not   | yperkalemia |             | ibrillation |
|             |             |             | Peritonitis |             |
| Car         | otherwise   | Hypovolemic |             | Ventricular |
| cinogenesis | specified)  | shock       | Pleural     | tachycardia |
|             |             |             | effusions   |             |
|             | Diarrhea    |             |             | Volume      |
|             |             |             | Pneumonia   | 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    | Epidural    | Hip         | Pulmonary   | Subdural    |
|             | hematoma    | fracture    | emboli      | hematoma    |
| Bolus       |             |             |             |             |
|             | Exs         | H           | Seizure     | Surgery     |
| Choking     | anguination | yperthermia | disorder    |             |
|             |             |             |             | Thermal     |
| Drug or     | Fall        | Hypothermia | Sepsis      | bur         |
| alcohol     |             |             |             | ns/chemical |
| ov          | Fracture    | Open        | S           | burns       |
| erdose/drug |             | reduction   | ubarachnoid |             |
| or          |             | of fracture | hemorrhage  |             |
|             |             |             |             |             |
| alcohol     |             |             |             |             |
| abuse       |             |             |             |             |
+-------------+-------------+-------------+-------------+-------------+

Contact your State vital statistics office for questions related to
writing cause-of-death statements. Additional instructional material on
writing cause-of-death statements including handbooks, summary
instructions, and tutorials are available online at www.thename.org or
www.cdc.gov/nchswww/about/major/dvs/handbk.htm, or by request from NCHS,
Room 7318, 3311 Toledo Road, Hyattsville, Maryland 20782-2003.

Query Letter 7

(Drugs and Other Agents)

(Letterhead)

Dear Doctor \_\_\_\_\_\_\_\_

We are writing this letter to obtain additional information about the
cause of death that you certified for
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_, who died
\_\_\_\_\_\_\_\_\_\_\_\_\_.

Accurate cause-of-death information is essential, not only to the family
of the decedent, but also for medical research, funding, and resource
allocation in our State and at the national level.

In this particular death, we need additional information about the drugs
associated with the death. In order to classify this death properly in
our statistics, would you please supply the information on the
attachment? We want to assure you that the information you provide us is
confidential and will be handled accordingly.

If you have any question or would like to know more about various
methods for certifying a cause-of-death statement, please contact
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_.
Instructions and an example of a properly completed death certificate
are provided with the attached material.

We appreciate your attention and prompt reply.

Sincerely,

State Registrar/Vital Statistics Cooperative Program

Attachment

Drugs and Other Agents Query

+-------------------+----------------------+---+------------+-------+
| **CAUSE OF DEATH  |                      |   |            | A     |
| (See instructions |                      |   |            | pprox |
| and examples)**   |                      |   |            | imate |
|                   |                      |   |            | inte  |
| 32\. **PART I.**  |                      |   |            | rval: |
| Enter the [chain  |                      |   |            |       |
| of                |                      |   |            | Onset |
| events]{.under    |                      |   |            | to    |
| line}\--diseases, |                      |   |            | death |
| injuries, or      |                      |   |            |       |
| com               |                      |   |            | \_\   |
| plications\--that |                      |   |            | _\_\_ |
| directly caused   |                      |   |            | [\_\_ |
| the death. DO NOT |                      |   |            | \_\_\ |
| enter terminal    |                      |   |            | _\_\_ |
| events such as    |                      |   |            | \_]{. |
| cardiac           |                      |   |            | under |
|                   |                      |   |            | line} |
| arrest,           |                      |   |            |       |
| respiratory       |                      |   |            | \_\   |
| arrest, or        |                      |   |            | _\_\_ |
| ventricular       |                      |   |            | [\_\_ |
| fibrillation      |                      |   |            | \_\_\ |
| without showing   |                      |   |            | _\_\_ |
| the etiology. DO  |                      |   |            | \_]{. |
| NOT ABBREVIATE.   |                      |   |            | under |
| Enter only one    |                      |   |            | line} |
| cause on a line.  |                      |   |            |       |
| Add additional    |                      |   |            | \_\   |
|                   |                      |   |            | _\_\_ |
| lines if          |                      |   |            | [\_   |
| necessary.        |                      |   |            | \_\_\ |
|                   |                      |   |            | _\_\_ |
| IMMEDIATE CAUSE   |                      |   |            | \_]{. |
| (Final            |                      |   |            | under |
|                   |                      |   |            | line} |
| disease or        |                      |   |            |       |
| condition         |                      |   |            | \_\   |
| **\-\-            |                      |   |            | _\_\_ |
| \-\-\-\-\-\--\>** |                      |   |            | [\_\_ |
| a.                |                      |   |            | \_\_\ |
| \_\_\_\_\_\_\_\_  |                      |   |            | _\_\_ |
| [\_\_\_\_\_ \_\_  |                      |   |            | \_]{. |
| \_\_              |                      |   |            | under |
| \_\_\_\_\_\_\_\_\ |                      |   |            | line} |
| _\_\_\_\_\_\_\_\_ |                      |   |            |       |
| \_\_\_\_\_\_\_\_\ |                      |   |            |       |
| _\_\_\_\_\_\_\_\_ |                      |   |            |       |
| \_\_\_\_\_\_\_\_\ |                      |   |            |       |
| _\_\_\_\_\_\_\_\_ |                      |   |            |       |
| \_\_\_\_\_\_\_\_\ |                      |   |            |       |
| _\_\_\_\_\_\_\_\_ |                      |   |            |       |
| \_\_\_\_\_\_\_\_\ |                      |   |            |       |
| _\_\_\_\_\_\_\_\_ |                      |   |            |       |
| \_\_]{.underline} |                      |   |            |       |
|                   |                      |   |            |       |
| resulting in      |                      |   |            |       |
| death) Due to (or |                      |   |            |       |
| as a consequence  |                      |   |            |       |
| of):              |                      |   |            |       |
|                   |                      |   |            |       |
| Sequentially list |                      |   |            |       |
| conditions, b.    |                      |   |            |       |
| \_\_\_\           |                      |   |            |       |
| _\_\_\_\_\_\_\_\_ |                      |   |            |       |
| [\_\_\_\_\_       |                      |   |            |       |
| \_\_\_\_\_\_\     |                      |   |            |       |
| _\_\_\_\_\_\_\_\_ |                      |   |            |       |
| \_\_\_\_\_\_\_\_\ |                      |   |            |       |
| _\_\_\_\_\_\_\_\_ |                      |   |            |       |
| \_\_\_\_\_\_\_\_\ |                      |   |            |       |
| _\_\_\_\_\_\_\_\_ |                      |   |            |       |
| \_\_\_\_\_\_\_\_\ |                      |   |            |       |
| _\_\_\_\_\_\_\_\_ |                      |   |            |       |
| \_\_\_\_\_\_\_\_\ |                      |   |            |       |
| _\_\_\_\_\_\_\_\_ |                      |   |            |       |
| \_\_]{.underline} |                      |   |            |       |
|                   |                      |   |            |       |
| if any, leading   |                      |   |            |       |
| to the cause Due  |                      |   |            |       |
| to (or as a       |                      |   |            |       |
| consequence of):  |                      |   |            |       |
|                   |                      |   |            |       |
| listed on line a. |                      |   |            |       |
| Enter the         |                      |   |            |       |
|                   |                      |   |            |       |
| **UNDERLYING      |                      |   |            |       |
| CAUSE** c.        |                      |   |            |       |
| \_\_\_\           |                      |   |            |       |
| _\_\_\_\_\_\_\_\_ |                      |   |            |       |
| [\_\_\_\_\_       |                      |   |            |       |
| \_\_              |                      |   |            |       |
| \_\_\_\_\_\_\_\_\ |                      |   |            |       |
| _\_\_\_\_\_\_\_\_ |                      |   |            |       |
| \_\_\_\_\_\_\_\_\ |                      |   |            |       |
| _\_\_\_\_\_\_\_\_ |                      |   |            |       |
| \_\_\_\_\_\_\_\_\ |                      |   |            |       |
| _\_\_\_\_\_\_\_\_ |                      |   |            |       |
| \_\_\_\_\_\_\_\_\ |                      |   |            |       |
| _\_\_\_\_\_\_\_\_ |                      |   |            |       |
| \_\_\_\_\_\_\_\_\ |                      |   |            |       |
| _\_\_\_\_\_\_\_\_ |                      |   |            |       |
| \_\_]{.underline} |                      |   |            |       |
|                   |                      |   |            |       |
| (disease or       |                      |   |            |       |
| injury that Due   |                      |   |            |       |
| to (or as a       |                      |   |            |       |
| consequence of):  |                      |   |            |       |
|                   |                      |   |            |       |
| initiated the     |                      |   |            |       |
| events resulting  |                      |   |            |       |
|                   |                      |   |            |       |
| in death)         |                      |   |            |       |
| **LAST** d.       |                      |   |            |       |
| \_\               |                      |   |            |       |
| _\_\_\_\_\_\_\_\_ |                      |   |            |       |
| [\_\_\_\_\_       |                      |   |            |       |
| \                 |                      |   |            |       |
| _\_\_\_\_\_\_\_\_ |                      |   |            |       |
| \_\_\_\_\_\_\_\_\ |                      |   |            |       |
| _\_\_\_\_\_\_\_\_ |                      |   |            |       |
| \_\_\_\_\_\_\_\_\ |                      |   |            |       |
| _\_\_\_\_\_\_\_\_ |                      |   |            |       |
| \_\_\_\_\_\_\_\_\ |                      |   |            |       |
| _\_\_\_\_\_\_\_\_ |                      |   |            |       |
| \_\_\_\_\_\_\_\_\ |                      |   |            |       |
| _\_\_\_\_\_\_\_\_ |                      |   |            |       |
| \_\_]{.underline} |                      |   |            |       |
+-------------------+----------------------+---+------------+-------+
| **PART II.**      |                      |   | 33\. WAS   |       |
| Enter other       |                      |   | AN AUTOPSY |       |
| [significant      |                      |   | PERFORMED? |       |
| conditions        |                      |   |            |       |
| contributing to   |                      |   |  Yes  No |       |
| d                 |                      |   |            |       |
| eath]{.underline} |                      |   |            |       |
| 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  | 36\. IF FEMALE:      | 3 |            |       |
| USE CONTRIBUTE TO |                      | 7 |            |       |
| DEATH?            |  Not pregnant       | \ |            |       |
|                   | within past year     | . |            |       |
|  Yes  Probably  |                      | M |            |       |
|                   |  Pregnant at time   | A |            |       |
|  No  Unknown    | of death             | N |            |       |
|                   |                      | N |            |       |
|                   |  Not pregnant, but  | E |            |       |
|                   | pregnant within 42   | R |            |       |
|                   | days of death        | O |            |       |
|                   |                      | F |            |       |
|                   |  Not pregnant, but  | D |            |       |
|                   | pregnant 43 days to  | E |            |       |
|                   | 1 year before death  | A |            |       |
|                   |                      | T |            |       |
|                   |  Unknown if         | H |            |       |
|                   | pregnant within the  |   |            |       |
|                   | past year            |  |            |       |
|                   |                      | N |            |       |
|                   |                      | a |            |       |
|                   |                      | t |            |       |
|                   |                      | u |            |       |
|                   |                      | r |            |       |
|                   |                      | a |            |       |
|                   |                      | l |            |       |
|                   |                      |  |            |       |
|                   |                      | H |            |       |
|                   |                      | o |            |       |
|                   |                      | m |            |       |
|                   |                      | i |            |       |
|                   |                      | c |            |       |
|                   |                      | i |            |       |
|                   |                      | d |            |       |
|                   |                      | e |            |       |
|                   |                      |   |            |       |
|                   |                      |  |            |       |
|                   |                      | A |            |       |
|                   |                      | c |            |       |
|                   |                      | c |            |       |
|                   |                      | i |            |       |
|                   |                      | d |            |       |
|                   |                      | e |            |       |
|                   |                      | n |            |       |
|                   |                      | t |            |       |
|                   |                      |  |            |       |
|                   |                      | P |            |       |
|                   |                      | e |            |       |
|                   |                      | n |            |       |
|                   |                      | d |            |       |
|                   |                      | i |            |       |
|                   |                      | n |            |       |
|                   |                      | g |            |       |
|                   |                      | I |            |       |
|                   |                      | n |            |       |
|                   |                      | v |            |       |
|                   |                      | e |            |       |
|                   |                      | s |            |       |
|                   |                      | t |            |       |
|                   |                      | i |            |       |
|                   |                      | g |            |       |
|                   |                      | a |            |       |
|                   |                      | t |            |       |
|                   |                      | i |            |       |
|                   |                      | o |            |       |
|                   |                      | n |            |       |
|                   |                      |   |            |       |
|                   |                      |  |            |       |
|                   |                      | S |            |       |
|                   |                      | u |            |       |
|                   |                      | i |            |       |
|                   |                      | c |            |       |
|                   |                      | i |            |       |
|                   |                      | d |            |       |
|                   |                      | e |            |       |
|                   |                      |  |            |       |
|                   |                      | C |            |       |
|                   |                      | o |            |       |
|                   |                      | u |            |       |
|                   |                      | l |            |       |
|                   |                      | d |            |       |
|                   |                      | n |            |       |
|                   |                      | o |            |       |
|                   |                      | t |            |       |
|                   |                      | b |            |       |
|                   |                      | e |            |       |
|                   |                      | d |            |       |
|                   |                      | e |            |       |
|                   |                      | t |            |       |
|                   |                      | e |            |       |
|                   |                      | r |            |       |
|                   |                      | m |            |       |
|                   |                      | i |            |       |
|                   |                      | n |            |       |
|                   |                      | e |            |       |
|                   |                      | d |            |       |
+-------------------+----------------------+---+------------+-------+

1\. Please state the type or name of drug(s) that brought about the
medical complications which led to death.

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

2\. Please state the type or name of other agent(s) or exposure that
brought about the medical complications which led to death.
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

3\. Other
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

[, M.D.]{.underline}

(Signature of Certifying Physician)

Please provide your office
phone:\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
fax:\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

(Please see other side)

Instructions on Medical Certification of Causes of Death

[Example of properly completed medical certification]{.underline}

+------------------+-----------------------+---+---------------+-------+
| **CAUSE OF DEATH |                       |   |               | A     |
| (See             |                       |   |               | pprox |
| instructions and |                       |   |               | imate |
| examples)**      |                       |   |               | inte  |
|                  |                       |   |               | rval: |
| 32\. **PART I.** |                       |   |               |       |
| Enter the [chain |                       |   |               | Onset |
| of               |                       |   |               | to    |
| events]{.underl  |                       |   |               | death |
| ine}\--diseases, |                       |   |               |       |
| injuries, or     |                       |   |               | [2    |
| comp             |                       |   |               | wee   |
| lications\--that |                       |   |               | ks]{. |
| directly caused  |                       |   |               | under |
| the death. DO    |                       |   |               | line} |
| NOT enter        |                       |   |               |       |
| terminal events  |                       |   |               | [7    |
| such as cardiac  |                       |   |               | yea   |
|                  |                       |   |               | rs]{. |
| arrest,          |                       |   |               | under |
| respiratory      |                       |   |               | line} |
| arrest, or       |                       |   |               |       |
| ventricular      |                       |   |               | [7yea |
| fibrillation     |                       |   |               | rs]{. |
| without showing  |                       |   |               | under |
| the etiology. DO |                       |   |               | line} |
| NOT ABBREVIATE.  |                       |   |               |       |
| Enter only one   |                       |   |               | \_    |
| cause on a line. |                       |   |               | [\    |
| Add additional   |                       |   |               | _\_\_ |
|                  |                       |   |               | \_]{. |
| lines if         |                       |   |               | under |
| necessary.       |                       |   |               | line} |
|                  |                       |   |               |       |
| IMMEDIATE CAUSE  |                       |   |               |       |
| (Final           |                       |   |               |       |
|                  |                       |   |               |       |
| disease or       |                       |   |               |       |
| condition        |                       |   |               |       |
| **\-\-\          |                       |   |               |       |
| -\-\-\-\-\--\>** |                       |   |               |       |
| a.               |                       |   |               |       |
| [Staphylococcus  |                       |   |               |       |
| endocarditis     |                       |   |               |       |
| \_\_\_\_\_\_\_\  |                       |   |               |       |
| _\_\_\_\_\_\_\_\ |                       |   |               |       |
| _\_\_\_\_\_\_\_\ |                       |   |               |       |
| _\_\_\_\_\_\_\_\ |                       |   |               |       |
| _\_\_\_\_\_\_\_\ |                       |   |               |       |
| _\_\_\_\_\_\_\_\ |                       |   |               |       |
| _\_\_\_\_\_\_\_\ |                       |   |               |       |
| _\_\_\_\_\_\_\_\ |                       |   |               |       |
| _\_\_\_\_\_\_\_\ |                       |   |               |       |
| _\_]{.underline} |                       |   |               |       |
|                  |                       |   |               |       |
| resulting in     |                       |   |               |       |
| death) Due to    |                       |   |               |       |
| (or as a         |                       |   |               |       |
| consequence of): |                       |   |               |       |
|                  |                       |   |               |       |
| Sequentially     |                       |   |               |       |
| list conditions, |                       |   |               |       |
| b. [Chronic      |                       |   |               |       |
| intravenous      |                       |   |               |       |
| heroin           |                       |   |               |       |
| us               |                       |   |               |       |
| e\_\_\_\_\_\_\_\ |                       |   |               |       |
| _\_\_\_\_\_\_\_\ |                       |   |               |       |
| _\_\_\_\_\_\_\_\ |                       |   |               |       |
| _\_\_\_\_\_\_\_\ |                       |   |               |       |
| _\_\_\_\_\_\_\_\ |                       |   |               |       |
| _\_\_\_\_\_\_\_\ |                       |   |               |       |
| _\_\_\_\_\_\_\_\ |                       |   |               |       |
| _\_\_\_\_\_\_\_\ |                       |   |               |       |
| _\_\_\_\_\_\_\_\ |                       |   |               |       |
| _\_]{.underline} |                       |   |               |       |
|                  |                       |   |               |       |
| if any, leading  |                       |   |               |       |
| to the cause Due |                       |   |               |       |
| to (or as a      |                       |   |               |       |
| consequence of): |                       |   |               |       |
|                  |                       |   |               |       |
| listed on line   |                       |   |               |       |
| a. Enter the     |                       |   |               |       |
|                  |                       |   |               |       |
| **UNDERLYING     |                       |   |               |       |
| CAUSE** c.       |                       |   |               |       |
| [Opiate          |                       |   |               |       |
| addiction        |                       |   |               |       |
| \_\_\_\_\_\_\    |                       |   |               |       |
| _\_\_\_\_\_\_\_\ |                       |   |               |       |
| _\_\_\_\_\_\_\_\ |                       |   |               |       |
| _\_\_\_\_\_\_\_\ |                       |   |               |       |
| _\_\_\_\_\_\_\_\ |                       |   |               |       |
| _\_\_\_\_\_\_\_\ |                       |   |               |       |
| _\_\_\_\_\_\_\_\ |                       |   |               |       |
| _\_\_\_\_\_\_\_\ |                       |   |               |       |
| _\_\_\_\_\_\_\_\ |                       |   |               |       |
| _\_\_\_\_\_\_\_\ |                       |   |               |       |
| _\_]{.underline} |                       |   |               |       |
|                  |                       |   |               |       |
| (disease or      |                       |   |               |       |
| injury that Due  |                       |   |               |       |
| to (or as a      |                       |   |               |       |
| consequence of): |                       |   |               |       |
|                  |                       |   |               |       |
| initiated the    |                       |   |               |       |
| events resulting |                       |   |               |       |
|                  |                       |   |               |       |
| in death)        |                       |   |               |       |
| **LAST** d.      |                       |   |               |       |
| [\_              |                       |   |               |       |
| \_\_\_\_\_\_\_\_ |                       |   |               |       |
| \_\_\_\_\_\_\_\_ |                       |   |               |       |
| \_\_\_\_\_\_\_\_ |                       |   |               |       |
| \_\_\_\_\_\      |                       |   |               |       |
| _\_\_\_\_\_\_\_\ |                       |   |               |       |
| _\_\_\_\_\_\_\_\ |                       |   |               |       |
| _\_\_\_\_\_\_\_\ |                       |   |               |       |
| _\_\_\_\_\_\_\_\ |                       |   |               |       |
| _\_\_\_\_\_\_\_\ |                       |   |               |       |
| _\_\_\_\_\_\_\_\ |                       |   |               |       |
| _\_\_\_\_\_\_\_\ |                       |   |               |       |
| _\_\_\_\_\_\_\_\ |                       |   |               |       |
| _\_]{.underline} |                       |   |               |       |
+------------------+-----------------------+---+---------------+-------+
| **PART II.**     |                       |   | 33\. WAS AN   |       |
| Enter other      |                       |   | AUTOPSY       |       |
| [significant     |                       |   | PERFORMED?    |       |
| conditions       |                       |   |               |       |
| contributing to  |                       |   |  Yes ■ No    |       |
| de               |                       |   |               |       |
| ath]{.underline} |                       |   |               |       |
| 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 | 36\. IF FEMALE:       | 3 |               |       |
| USE CONTRIBUTE   |                       | 7 |               |       |
| TO DEATH?        | ■ Not pregnant within | \ |               |       |
|                  | past year             | . |               |       |
|  Yes            |                       | M |               |       |
| Probably      | Pregnant at time   | A |               |       |
|                  | of death              | N |               |       |
| ■ No Unknown  |                       | N |               |       |
|                  | Not pregnant, but  | E |               |       |
|                  | pregnant within 42    | R |               |       |
|                  | days of death         | O |               |       |
|                  |                       | F |               |       |
|                  | Not pregnant, but  | D |               |       |
|                  | pregnant 43 days to 1 | E |               |       |
|                  | year before death     | A |               |       |
|                  |                       | T |               |       |
|                  | Unknown if         | H |               |       |
|                  | pregnant within the   |   |               |       |
|                  | past year             | ■ |               |       |
|                  |                       | N |               |       |
|                  |                       | a |               |       |
|                  |                       | t |               |       |
|                  |                       | u |               |       |
|                  |                       | r |               |       |
|                  |                       | a |               |       |
|                  |                       | l |               |       |
|                  |                       |  |               |       |
|                  |                       |  |               |       |
|                  |                       | H |               |       |
|                  |                       | o |               |       |
|                  |                       | m |               |       |
|                  |                       | i |               |       |
|                  |                       | c |               |       |
|                  |                       | i |               |       |
|                  |                       | d |               |       |
|                  |                       | e |               |       |
|                  |                       |   |               |       |
|                  |                       |  |               |       |
|                  |                       |  |               |       |
|                  |                       |  |               |       |
|                  |                       | A |               |       |
|                  |                       | c |               |       |
|                  |                       | c |               |       |
|                  |                       | i |               |       |
|                  |                       | d |               |       |
|                  |                       | e |               |       |
|                  |                       | n |               |       |
|                  |                       | t |               |       |
|                  |                       |  |               |       |
|                  |                       |  |               |       |
|                  |                       | P |               |       |
|                  |                       | e |               |       |
|                  |                       | n |               |       |
|                  |                       | d |               |       |
|                  |                       | i |               |       |
|                  |                       | n |               |       |
|                  |                       | g |               |       |
|                  |                       | I |               |       |
|                  |                       | n |               |       |
|                  |                       | v |               |       |
|                  |                       | e |               |       |
|                  |                       | s |               |       |
|                  |                       | t |               |       |
|                  |                       | i |               |       |
|                  |                       | g |               |       |
|                  |                       | a |               |       |
|                  |                       | t |               |       |
|                  |                       | i |               |       |
|                  |                       | o |               |       |
|                  |                       | n |               |       |
|                  |                       |   |               |       |
|                  |                       |  |               |       |
|                  |                       |  |               |       |
|                  |                       |  |               |       |
|                  |                       | S |               |       |
|                  |                       | u |               |       |
|                  |                       | i |               |       |
|                  |                       | c |               |       |
|                  |                       | i |               |       |
|                  |                       | d |               |       |
|                  |                       | e |               |       |
|                  |                       |  |               |       |
|                  |                       |  |               |       |
|                  |                       | C |               |       |
|                  |                       | o |               |       |
|                  |                       | u |               |       |
|                  |                       | l |               |       |
|                  |                       | d |               |       |
|                  |                       | n |               |       |
|                  |                       | o |               |       |
|                  |                       | t |               |       |
|                  |                       | b |               |       |
|                  |                       | e |               |       |
|                  |                       | d |               |       |
|                  |                       | e |               |       |
|                  |                       | t |               |       |
|                  |                       | e |               |       |
|                  |                       | r |               |       |
|                  |                       | m |               |       |
|                  |                       | i |               |       |
|                  |                       | n |               |       |
|                  |                       | e |               |       |
|                  |                       | d |               |       |
+------------------+-----------------------+---+---------------+-------+

**ITEM 32 -- CAUSE OF DEATH (See example above)**

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.

Take care to make the entry legible. Use a computer printer with high
resolution, typewriter with good black ribbon and clean keys, or print
legibly using permanent **black** ink in completing the CAUSE OF DEATH
Section. **Do** **not** **abbreviate** conditions entered in section.

**[Part I]{.underline} (Chain of events leading directly to death)**

•Only **one** cause should be entered on each line. [Line
(a)]{.underline} **MUST ALWAYS** have an entry. **DO NOT** leave blank.
Additional lines may be added if necessary.

•If the condition on [Line (a)]{.underline} resulted from an underlying
condition, put the underlying condition on [Line (b)]{.underline}, and
so on, until the full sequence is reported. **ALWAYS** enter the
**underlying cause of death** on the [lowest used line]{.underline} in
Part I.

•For each cause indicate the best estimate of the interval between the
presumed onset and the date of death. The terms "unknown" or
"approximately" may be used. General terms, such as minutes, hours, or
days, are acceptable, if necessary. **DO NOT** leave blank.

•The terminal event (for example, cardiac arrest or respiratory arrest)
should not be used. If a mechanism of death seems most appropriate to
you for line (a), then you must always list its cause(s) on the line(s)
below it (for example, cardiac arrest **due to** coronary artery
atherosclerosis *or* cardiac arrest **due to** blunt impact to chest).

• If an organ system failure such as congestive heart failure, hepatic
failure, renal failure, or respiratory failure is listed as a cause of
death, always report its etiology on the line(s) beneath it (for
example, renal failure **due to** Type I diabetes mellitus).

•When indicating neoplasms as a cause of death, include the
following: 1) primary site *or* that the primary site is unknown, 2)
benign or malignant, 3) cell type *or* that the cell type is unknown, 4)
grade of neoplasm, and 5) part or lobe of organ affected. (For example,
a primary well-differentiated squamous cell carcinoma, lung, left upper
lobe.)

•Always report the fatal injury (for example, stab wound of chest), the
trauma (for example, transection of subclavian vein), and impairment of
function (for example, air embolism).

**Part II (Other significant conditions)**

•Enter all diseases or conditions contributing to death that were not
reported in the chain of events in Part I and that did not result in the
**underlying cause of death**.

•If two or more possible sequences resulted in death, or if two
conditions seem to have added together, report in Part I the one that,
in your opinion, most directly caused death. Report in Part II the other
conditions or diseases.

**CHANGES TO CAUSE OF DEATH**

Should additional medical information or autopsy findings become
available that would change the cause of death originally reported, the
original death certificate should be amended by the certifying physician
by **immediately** reporting the revised cause of death to the State
Vital Records Office.

**ITEMS ON WHEN DEATH OCCURRED**

Items 24-25 and 29-31 should always be completed. If the facility uses a
separate pronouncer or other person to indicate that death has taken
place with another person more familiar with the case completing the
remainder of the medical portion of the death certificate, the
pronouncer completes Items 24-28. If a certifier completes Items 24-25
as well as items 29-49, Items 26-28 may be left blank.

**ITEMS 24-25, 29-30 -- DATE AND TIME OF DEATH**

Spell out the name of the month. If the exact date of death is unknown,
enter the **approximate** date. If the date cannot be approximated,
enter the date the body is found and identify as **date found**. Date
pronounced and actual date may be the same. Enter the exact hour and
minutes according to a 24-hour clock; estimates may be provided with
"Approx." placed before the time.

**ITEMS 33-34 - AUTOPSY**

•33 - Enter "Yes" if either a partial or full autopsy was performed.
Otherwise enter "No."

•34 - Enter "Yes" if autopsy findings were available to complete the
cause of death; otherwise enter "No". Leave item blank if no autopsy was
performed.

**ITEM 35 - DID TOBACCO USE CONTRIBUTE TO DEATH?**

Check "yes" if, in your opinion, the use of tobacco contributed to
death. Tobacco use may contribute to deaths due to a wide variety of
diseases; for example, tobacco use contributes to many deaths due to
emphysema or lung cancer and some heart disease and cancers of the head
and neck. Check "no" if, in your clinical judgment, tobacco use did not
contribute to this particular death.

**ITEM 36 - IF FEMALE, WAS DECEDENT PREGNANT AT TIME OF DEATH OR WITHIN
PAST YEAR?**

This information is important in determining pregnancy-related
mortality.

**ITEM 37 - MANNER OF DEATH**

•Always check Manner of Death, which is important: 1) in determining
accurate causes of death; 2) in processing insurance claims; and 3) in
statistical studies of injuries and death.

•Indicate "Pending investigation" if the manner of death cannot be
determined whether due to an accident, suicide, or homicide within the
statutory time limit for filing the death certificate. This should be
changed later to one of the other terms.

•Indicate "Could not be Determined" **ONLY** when it is impossible to
determine the manner of death.

**ITEMS 38-44 - ACCIDENT OR INJURY -- to be filled out in all cases of
deaths due to injury or poisoning.**

•38 - Enter the exact month, day, and year of injury. Spell out the name
of the month. **DO NOT** use a number for the month. (Remember, the date
of injury may differ from the date of death.) Estimates may be provided
with "Approx." placed before the date.

•39 **-** Enter the exact hour and minutes of injury or use your best
estimate. Use a 24-hour clock.

•40 - Enter the general place (such as restaurant, vacant lot, or home)
where the injury occurred. **DO NOT** enter firm or organization names.
(For example, enter "factory", **not** "Standard Manufacturing, Inc." )

•41 - Complete if anything other than natural disease is mentioned in
Part I or Part II of the medical certification, including homicides,
suicides, and accidents. This includes all motor vehicle deaths. The
item **[must]{.underline}** be completed for decedents ages 14 years or
over and may be completed for those less than 14 years of age if
warranted. Enter "Yes" if the injury occurred at work. Otherwise enter
"No". An injury may occur at work regardless of whether the injury
occurred in the course of the decedent's "usual" occupation. Examples of
injury at work and injury not at work follow:

+-----------------------------------+-----------------------------------+
| **Injury at work**                | **Injury [not]{.underline} at     |
|                                   | work**                            |
| Injury while working or in        |                                   |
| vocational training on job        | Injury while engaged in personal  |
| premises                          | recreational activity on job      |
|                                   | premises                          |
| Injury while on break or at lunch |                                   |
| or in parking lot on job premises | Injury while a visitor (not on    |
|                                   | official work business) to job    |
| Injury while working for pay or   | premises                          |
| compensation, including at home   |                                   |
|                                   | Homemaker working at homemaking   |
| Injury while working as a         | activities                        |
| volunteer law enforcement         |                                   |
| official etc.                     | Student in school                 |
|                                   |                                   |
| Injury while traveling on         | Working for self for no profit    |
| business, including to/from       | (mowing yard, repairing own roof, |
| business contacts                 | hobby)                            |
|                                   |                                   |
|                                   | Commuting to or from work         |
+-----------------------------------+-----------------------------------+

•42 - Enter the complete address where the injury occurred including zip
code.

•43 - Enter a brief but specific and clear description of how the injury
occurred. Explain the circumstances or cause of the injury. Specify
**type** **of** **gun** or **type of vehicle** (e.g., car, bulldozer,
train, etc.) when relevant to circumstances. Indicate if more than one
vehicle involved; specify type of vehicle decedent was in.

•44 -Specify role of decedent (e.g. driver, passenger). Driver/operator
and passenger should be designated for modes other than motor vehicles
such as bicycles. Other applies to watercraft, aircraft, animal, or
people attached to outside of vehicles (e.g. surfers).

[Rationale]{.underline}: Motor vehicle accidents are a major cause of
unintentional deaths; details will help determine effectiveness of
current safety features and laws.

**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:]{.underline}**

+-------------+-------------+-------------+-------------+-------------+
| Abscess     | Car         | D           | H           | Pulmonary   |
|             | cinomatosis | isseminated | yponatremia | arrest      |
| Abdominal   |             | intra       |             |             |
| hemorrhage  | Cardiac     | vascular    | Hypotension | Pulmonary   |
|             | arrest      |             |             | edema       |
| Adhesions   |             | c           | Immuno      |             |
|             | Cardiac     | oagulopathy | suppression | Pulmonary   |
| Adult       | dysrhythmia |             |             | embolism    |
| respiratory |             | Dysrhythmia | Increased   |             |
| distress    | Car         |             | intra       | Pulmonary   |
| syndrome    | diomyopathy | End-stage   | cranial     | in          |
|             |             | liver       | pressure    | sufficiency |
| Acute       | Card        | disease     |             |             |
| myocardial  | iopulmonary |             | Intra       | Renal       |
| infarction  | arrest      | End-stage   | cranial     | failure     |
|             |             | renal       | hemorrhage  |             |
| Altered     | Cellulitis  | disease     |             | Respiratory |
| mental      |             |             | M           | arrest      |
| status      | Cerebral    | Epidural    | alnutrition |             |
|             | edema       | hematoma    |             | Seizures    |
| Anemia      |             |             | Metabolic   |             |
|             | Cere        | Exs         | enc         | Sepsis      |
| Anoxia      | brovascular | anguination | ephalopathy |             |
|             | accident    |             |             | Septic      |
| Anoxic      |             | Failure to  | Multi-organ | shock       |
| enc         | Cerebellar  | thrive      | failure     |             |
| ephalopathy | tonsillar   |             |             | Shock       |
|             | herniation  | Fracture    | M           |             |
| Arrhythmia  |             |             | ulti-system | Starvation  |
|             | Chronic     | Gangrene    | organ       |             |
| Ascites     | bedridden   |             | failure     | Subdural    |
|             | state       | Gastr       |             | hematoma    |
| Aspiration  |             | ointestinal | Myocardial  |             |
|             | Cirrhosis   | hemorrhage  | infarction  | S           |
| Atrial      |             |             |             | ubarachnoid |
| f           | C           | Heart       | Necrotizing | hemorrhage  |
| ibrillation | oagulopathy | failure     | soft-tissue |             |
|             |             |             | infection   | Sudden      |
| Bacteremia  | Compression | Hemothorax  |             | death       |
|             | fracture    |             | Old age     |             |
| Bedridden   |             | Hepatic     |             | Throm       |
|             | Congestive  | failure     | Open (or    | bocytopenia |
| Biliary     | heart       |             | closed)     |             |
| obstruction | failure     | Hepatitis   | head injury | Uncal       |
|             |             |             |             | herniation  |
| Bowel       | Convulsions | Hepatorenal | Paralysis   |             |
| obstruction |             | syndrome    |             | Urinary     |
|             | Decubiti    |             | P           | tract       |
| Brain       |             | Hy          | ancytopenia | infection   |
| injury      | Dehydration | perglycemia |             |             |
|             |             |             | Perforated  | Ventricular |
| Brain stem  | Dementia    | H           | gallbladder | f           |
| herniation  | (when not   | yperkalemia |             | ibrillation |
|             |             |             | Peritonitis |             |
| Car         | otherwise   | Hypovolemic |             | Ventricular |
| cinogenesis | specified)  | shock       | Pleural     | tachycardia |
|             |             |             | effusions   |             |
|             | Diarrhea    |             |             | Volume      |
|             |             |             | Pneumonia   | 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    | Epidural    | Hip         | Pulmonary   | Subdural    |
|             | hematoma    | fracture    | emboli      | hematoma    |
| Bolus       |             |             |             |             |
|             | Exs         | H           | Seizure     | Surgery     |
| Choking     | anguination | yperthermia | disorder    |             |
|             |             |             |             | Thermal     |
| Drug or     | Fall        | Hypothermia | Sepsis      | bur         |
| alcohol     |             |             |             | ns/chemical |
| ov          | Fracture    | Open        | S           | burns       |
| erdose/drug |             | reduction   | ubarachnoid |             |
| or          |             | of fracture | hemorrhage  |             |
|             |             |             |             |             |
| alcohol     |             |             |             |             |
| abuse       |             |             |             |             |
+-------------+-------------+-------------+-------------+-------------+

Contact your State vital statistics office for questions related to
writing cause-of-death statements. Additional instructional material on
writing cause-of-death statements including handbooks, summary
instructions, and tutorials are available online at www.thename.org or
www.cdc.gov/nchswww/about/major/dvs/handbk.htm, or by request from NCHS,
Room 7318, 3311 Toledo Road, Hyattsville, Maryland 20782-2003.

Query Letter 8

(Ill-defined, Trivial, Etc.)

(Letterhead)

Dear Doctor \_\_\_\_\_\_\_\_

We are writing this letter to obtain additional information about the
cause of death that you certified for
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_, who died
\_\_\_\_\_\_\_\_\_\_\_\_\_.

Accurate cause-of-death information is essential, not only to the family
of the decedent, but also for medical research, funding, and resource
allocation in our State and at the national level.

In this particular death, we need to know if a more serious condition
gave rise to the reported cause of death. In order to classify this
death properly in our statistics, would you please supply the
information on the attachment? We want to assure you that the
information you provide us is confidential and will be handled
accordingly.

If you have any question or would like to know more about various
methods for certifying a cause-of-death statement, please contact
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_. Instructions
and an example of a properly completed death certificate are provided
with the attached material.

We appreciate your attention and prompt reply.

Sincerely,

State Registrar/Vital Statistics Cooperative Program

Attachment

Ill-defined or Trivial Query

+-------------------+----------------------+---+------------+-------+
| **CAUSE OF DEATH  |                      |   |            | A     |
| (See instructions |                      |   |            | pprox |
| and examples)**   |                      |   |            | imate |
|                   |                      |   |            | inte  |
| 32\. **PART I.**  |                      |   |            | rval: |
| Enter the [chain  |                      |   |            |       |
| of                |                      |   |            | Onset |
| events]{.under    |                      |   |            | to    |
| line}\--diseases, |                      |   |            | death |
| injuries, or      |                      |   |            |       |
| com               |                      |   |            | \_\   |
| plications\--that |                      |   |            | _\_\_ |
| directly caused   |                      |   |            | [\_\_ |
| the death. DO NOT |                      |   |            | \_\_\ |
| enter terminal    |                      |   |            | _\_\_ |
| events such as    |                      |   |            | \_]{. |
| cardiac           |                      |   |            | under |
|                   |                      |   |            | line} |
| arrest,           |                      |   |            |       |
| respiratory       |                      |   |            | \_\   |
| arrest, or        |                      |   |            | _\_\_ |
| ventricular       |                      |   |            | [\_\_ |
| fibrillation      |                      |   |            | \_\_\ |
| without showing   |                      |   |            | _\_\_ |
| the etiology. DO  |                      |   |            | \_]{. |
| NOT ABBREVIATE.   |                      |   |            | under |
| Enter only one    |                      |   |            | line} |
| cause on a line.  |                      |   |            |       |
| Add additional    |                      |   |            | \_\   |
|                   |                      |   |            | _\_\_ |
| lines if          |                      |   |            | [\_   |
| necessary.        |                      |   |            | \_\_\ |
|                   |                      |   |            | _\_\_ |
| IMMEDIATE CAUSE   |                      |   |            | \_]{. |
| (Final            |                      |   |            | under |
|                   |                      |   |            | line} |
| disease or        |                      |   |            |       |
| condition         |                      |   |            | \_\   |
| **\-\-            |                      |   |            | _\_\_ |
| \-\-\-\-\-\--\>** |                      |   |            | [\_\_ |
| a.                |                      |   |            | \_\_\ |
| \_\_\_\_\_\_\_\_  |                      |   |            | _\_\_ |
| [\_\_\_\_\_ \_\_  |                      |   |            | \_]{. |
| \_\_              |                      |   |            | under |
| \_\_\_\_\_\_\_\_\ |                      |   |            | line} |
| _\_\_\_\_\_\_\_\_ |                      |   |            |       |
| \_\_\_\_\_\_\_\_\ |                      |   |            |       |
| _\_\_\_\_\_\_\_\_ |                      |   |            |       |
| \_\_\_\_\_\_\_\_\ |                      |   |            |       |
| _\_\_\_\_\_\_\_\_ |                      |   |            |       |
| \_\_\_\_\_\_\_\_\ |                      |   |            |       |
| _\_\_\_\_\_\_\_\_ |                      |   |            |       |
| \_\_\_\_\_\_\_\_\ |                      |   |            |       |
| _\_\_\_\_\_\_\_\_ |                      |   |            |       |
| \_\_]{.underline} |                      |   |            |       |
|                   |                      |   |            |       |
| resulting in      |                      |   |            |       |
| death) Due to (or |                      |   |            |       |
| as a consequence  |                      |   |            |       |
| of):              |                      |   |            |       |
|                   |                      |   |            |       |
| Sequentially list |                      |   |            |       |
| conditions, b.    |                      |   |            |       |
| \_\_\_\           |                      |   |            |       |
| _\_\_\_\_\_\_\_\_ |                      |   |            |       |
| [\_\_\_\_\_       |                      |   |            |       |
| \_\_\_\_\_\_\     |                      |   |            |       |
| _\_\_\_\_\_\_\_\_ |                      |   |            |       |
| \_\_\_\_\_\_\_\_\ |                      |   |            |       |
| _\_\_\_\_\_\_\_\_ |                      |   |            |       |
| \_\_\_\_\_\_\_\_\ |                      |   |            |       |
| _\_\_\_\_\_\_\_\_ |                      |   |            |       |
| \_\_\_\_\_\_\_\_\ |                      |   |            |       |
| _\_\_\_\_\_\_\_\_ |                      |   |            |       |
| \_\_\_\_\_\_\_\_\ |                      |   |            |       |
| _\_\_\_\_\_\_\_\_ |                      |   |            |       |
| \_\_]{.underline} |                      |   |            |       |
|                   |                      |   |            |       |
| if any, leading   |                      |   |            |       |
| to the cause Due  |                      |   |            |       |
| to (or as a       |                      |   |            |       |
| consequence of):  |                      |   |            |       |
|                   |                      |   |            |       |
| listed on line a. |                      |   |            |       |
| Enter the         |                      |   |            |       |
|                   |                      |   |            |       |
| **UNDERLYING      |                      |   |            |       |
| CAUSE** c.        |                      |   |            |       |
| \_\_\_\           |                      |   |            |       |
| _\_\_\_\_\_\_\_\_ |                      |   |            |       |
| [\_\_\_\_\_       |                      |   |            |       |
| \_\_              |                      |   |            |       |
| \_\_\_\_\_\_\_\_\ |                      |   |            |       |
| _\_\_\_\_\_\_\_\_ |                      |   |            |       |
| \_\_\_\_\_\_\_\_\ |                      |   |            |       |
| _\_\_\_\_\_\_\_\_ |                      |   |            |       |
| \_\_\_\_\_\_\_\_\ |                      |   |            |       |
| _\_\_\_\_\_\_\_\_ |                      |   |            |       |
| \_\_\_\_\_\_\_\_\ |                      |   |            |       |
| _\_\_\_\_\_\_\_\_ |                      |   |            |       |
| \_\_\_\_\_\_\_\_\ |                      |   |            |       |
| _\_\_\_\_\_\_\_\_ |                      |   |            |       |
| \_\_]{.underline} |                      |   |            |       |
|                   |                      |   |            |       |
| (disease or       |                      |   |            |       |
| injury that Due   |                      |   |            |       |
| to (or as a       |                      |   |            |       |
| consequence of):  |                      |   |            |       |
|                   |                      |   |            |       |
| initiated the     |                      |   |            |       |
| events resulting  |                      |   |            |       |
|                   |                      |   |            |       |
| in death)         |                      |   |            |       |
| **LAST** d.       |                      |   |            |       |
| \_\               |                      |   |            |       |
| _\_\_\_\_\_\_\_\_ |                      |   |            |       |
| [\_\_\_\_\_       |                      |   |            |       |
| \                 |                      |   |            |       |
| _\_\_\_\_\_\_\_\_ |                      |   |            |       |
| \_\_\_\_\_\_\_\_\ |                      |   |            |       |
| _\_\_\_\_\_\_\_\_ |                      |   |            |       |
| \_\_\_\_\_\_\_\_\ |                      |   |            |       |
| _\_\_\_\_\_\_\_\_ |                      |   |            |       |
| \_\_\_\_\_\_\_\_\ |                      |   |            |       |
| _\_\_\_\_\_\_\_\_ |                      |   |            |       |
| \_\_\_\_\_\_\_\_\ |                      |   |            |       |
| _\_\_\_\_\_\_\_\_ |                      |   |            |       |
| \_\_]{.underline} |                      |   |            |       |
+-------------------+----------------------+---+------------+-------+
| **PART II.**      |                      |   | 33\. WAS   |       |
| Enter other       |                      |   | AN AUTOPSY |       |
| [significant      |                      |   | PERFORMED? |       |
| conditions        |                      |   |            |       |
| contributing to   |                      |   |  Yes  No |       |
| d                 |                      |   |            |       |
| eath]{.underline} |                      |   |            |       |
| 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  | 36\. IF FEMALE:      | 3 |            |       |
| USE CONTRIBUTE TO |                      | 7 |            |       |
| DEATH?            |  Not pregnant       | \ |            |       |
|                   | within past year     | . |            |       |
|  Yes  Probably  |                      | M |            |       |
|                   |  Pregnant at time   | A |            |       |
|  No  Unknown    | of death             | N |            |       |
|                   |                      | N |            |       |
|                   |  Not pregnant, but  | E |            |       |
|                   | pregnant within 42   | R |            |       |
|                   | days of death        | O |            |       |
|                   |                      | F |            |       |
|                   |  Not pregnant, but  | D |            |       |
|                   | pregnant 43 days to  | E |            |       |
|                   | 1 year before death  | A |            |       |
|                   |                      | T |            |       |
|                   |  Unknown if         | H |            |       |
|                   | pregnant within the  |   |            |       |
|                   | past year            |  |            |       |
|                   |                      | N |            |       |
|                   |                      | a |            |       |
|                   |                      | t |            |       |
|                   |                      | u |            |       |
|                   |                      | r |            |       |
|                   |                      | a |            |       |
|                   |                      | l |            |       |
|                   |                      |  |            |       |
|                   |                      | H |            |       |
|                   |                      | o |            |       |
|                   |                      | m |            |       |
|                   |                      | i |            |       |
|                   |                      | c |            |       |
|                   |                      | i |            |       |
|                   |                      | d |            |       |
|                   |                      | e |            |       |
|                   |                      |   |            |       |
|                   |                      |  |            |       |
|                   |                      | A |            |       |
|                   |                      | c |            |       |
|                   |                      | c |            |       |
|                   |                      | i |            |       |
|                   |                      | d |            |       |
|                   |                      | e |            |       |
|                   |                      | n |            |       |
|                   |                      | t |            |       |
|                   |                      |  |            |       |
|                   |                      | P |            |       |
|                   |                      | e |            |       |
|                   |                      | n |            |       |
|                   |                      | d |            |       |
|                   |                      | i |            |       |
|                   |                      | n |            |       |
|                   |                      | g |            |       |
|                   |                      | I |            |       |
|                   |                      | n |            |       |
|                   |                      | v |            |       |
|                   |                      | e |            |       |
|                   |                      | s |            |       |
|                   |                      | t |            |       |
|                   |                      | i |            |       |
|                   |                      | g |            |       |
|                   |                      | a |            |       |
|                   |                      | t |            |       |
|                   |                      | i |            |       |
|                   |                      | o |            |       |
|                   |                      | n |            |       |
|                   |                      |   |            |       |
|                   |                      |  |            |       |
|                   |                      | S |            |       |
|                   |                      | u |            |       |
|                   |                      | i |            |       |
|                   |                      | c |            |       |
|                   |                      | i |            |       |
|                   |                      | d |            |       |
|                   |                      | e |            |       |
|                   |                      |  |            |       |
|                   |                      | C |            |       |
|                   |                      | o |            |       |
|                   |                      | u |            |       |
|                   |                      | l |            |       |
|                   |                      | d |            |       |
|                   |                      | n |            |       |
|                   |                      | o |            |       |
|                   |                      | t |            |       |
|                   |                      | b |            |       |
|                   |                      | e |            |       |
|                   |                      | d |            |       |
|                   |                      | e |            |       |
|                   |                      | t |            |       |
|                   |                      | e |            |       |
|                   |                      | r |            |       |
|                   |                      | m |            |       |
|                   |                      | i |            |       |
|                   |                      | n |            |       |
|                   |                      | e |            |       |
|                   |                      | d |            |       |
+-------------------+----------------------+---+------------+-------+

1\. In your opinion, what was the underlying cause of this condition?

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

OR

2\. Did this condition give rise to another more serious condition which
led to death?

If so, please state
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

3.Other
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

[, M.D.]{.underline}

(Signature of Certifying Physician)

Please provide your office
phone:\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
fax:\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

(Please see other side)

Instructions on Medical Certification of Causes of Death

[Example of properly completed medical certification]{.underline}

+-------------------+----------------------+---+-------------+--------+
| **CAUSE OF DEATH  |                      |   |             | Appro  |
| (See instructions |                      |   |             | ximate |
| and examples)**   |                      |   |             | int    |
|                   |                      |   |             | erval: |
| 32\. **PART I.**  |                      |   |             |        |
| Enter the [chain  |                      |   |             | Onset  |
| of                |                      |   |             | to     |
| events]{.under    |                      |   |             | death  |
| line}\--diseases, |                      |   |             |        |
| injuries, or      |                      |   |             | [3     |
| com               |                      |   |             | mi     |
| plications\--that |                      |   |             | nutes] |
| directly caused   |                      |   |             | {.unde |
| the death. DO NOT |                      |   |             | rline} |
| enter terminal    |                      |   |             |        |
| events such as    |                      |   |             | [1     |
| cardiac           |                      |   |             | day\_] |
|                   |                      |   |             | {.unde |
| arrest,           |                      |   |             | rline} |
| respiratory       |                      |   |             |        |
| arrest, or        |                      |   |             | [6     |
| ventricular       |                      |   |             | days]  |
| fibrillation      |                      |   |             | {.unde |
| without showing   |                      |   |             | rline} |
| the etiology. DO  |                      |   |             |        |
| NOT ABBREVIATE.   |                      |   |             | \_     |
| Enter only one    |                      |   |             | [\_\_\ |
| cause on a line.  |                      |   |             | _\_\_] |
| Add additional    |                      |   |             | {.unde |
|                   |                      |   |             | rline} |
| lines if          |                      |   |             |        |
| necessary.        |                      |   |             |        |
|                   |                      |   |             |        |
| IMMEDIATE CAUSE   |                      |   |             |        |
| (Final            |                      |   |             |        |
|                   |                      |   |             |        |
| disease or        |                      |   |             |        |
| condition         |                      |   |             |        |
| **\-\-            |                      |   |             |        |
| \-\-\-\-\-\--\>** |                      |   |             |        |
| a.                |                      |   |             |        |
| [Convulsion\_\    |                      |   |             |        |
| _\_\_\_\_\_\_\_\_ |                      |   |             |        |
| \_\_\_\           |                      |   |             |        |
| _\_\_\_\_\_\_\_\_ |                      |   |             |        |
| \_\_\_\_\_\_\_\_\ |                      |   |             |        |
| _\_\_\_\_\_\_\_\_ |                      |   |             |        |
| \_\_\_\_\_\_\_\_\ |                      |   |             |        |
| _\_\_\_\_\_\_\_\_ |                      |   |             |        |
| \_\_\_\_\_\_\_\_\ |                      |   |             |        |
| _\_\_\_\_\_\_\_\_ |                      |   |             |        |
| \_\_\_\_\_\_\_\_\ |                      |   |             |        |
| _\_\_\_\_\_\_\_\_ |                      |   |             |        |
| \_\_]{.underline} |                      |   |             |        |
|                   |                      |   |             |        |
| resulting in      |                      |   |             |        |
| death) Due to (or |                      |   |             |        |
| as a consequence  |                      |   |             |        |
| of):              |                      |   |             |        |
|                   |                      |   |             |        |
| Sequentially list |                      |   |             |        |
| conditions, b.    |                      |   |             |        |
| [Fever \_\_\_\_\_ |                      |   |             |        |
| \_\_\_\           |                      |   |             |        |
| _\_\_\_\_\_\_\_\_ |                      |   |             |        |
| \_\_\_\_\_\_\_\_\ |                      |   |             |        |
| _\_\_\_\_\_\_\_\_ |                      |   |             |        |
| \_\_\_\_\_\_\_\_\ |                      |   |             |        |
| _\_\_\_\_\_\_\_\_ |                      |   |             |        |
| \_\_\_\_\_\_\_\_\ |                      |   |             |        |
| _\_\_\_\_\_\_\_\_ |                      |   |             |        |
| \_\_\_\_\_\_\_\_\ |                      |   |             |        |
| _\_\_\_\_\_\_\_\_ |                      |   |             |        |
| \_\_]{.underline} |                      |   |             |        |
|                   |                      |   |             |        |
| if any, leading   |                      |   |             |        |
| to the cause Due  |                      |   |             |        |
| to (or as a       |                      |   |             |        |
| consequence of):  |                      |   |             |        |
|                   |                      |   |             |        |
| listed on line a. |                      |   |             |        |
| Enter the         |                      |   |             |        |
|                   |                      |   |             |        |
| **UNDERLYING      |                      |   |             |        |
| CAUSE** c.        |                      |   |             |        |
| [Influenza\_\_\_  |                      |   |             |        |
| \_\_\_\_\_\_\_\_\ |                      |   |             |        |
| _\_\_\_\_\_\_\_\_ |                      |   |             |        |
| \_\_\_\_\_\_\_\_\ |                      |   |             |        |
| _\_\_\_\_\_\_\_\_ |                      |   |             |        |
| \_\_\_\_\_\_\_\_\ |                      |   |             |        |
| _\_\_\_\_\_\_\_\_ |                      |   |             |        |
| \_\_\_\_\_\_\_\_\ |                      |   |             |        |
| _\_\_\_\_\_\_\_\_ |                      |   |             |        |
| \_\_\_\_\_\_\_\_\ |                      |   |             |        |
| _\_\_\_\_\_\_\_\_ |                      |   |             |        |
| \_\_]{.underline} |                      |   |             |        |
|                   |                      |   |             |        |
| (disease or       |                      |   |             |        |
| injury that Due   |                      |   |             |        |
| to (or as a       |                      |   |             |        |
| consequence of):  |                      |   |             |        |
|                   |                      |   |             |        |
| initiated the     |                      |   |             |        |
| events resulting  |                      |   |             |        |
|                   |                      |   |             |        |
| in death)         |                      |   |             |        |
| **LAST** d.       |                      |   |             |        |
| [\_\_\_\_\        |                      |   |             |        |
| _\_\_\_\_\_\_\_\_ |                      |   |             |        |
| \_\_\_\_\_\_\_\_\ |                      |   |             |        |
| _\_\_\_\_\_\_\_\_ |                      |   |             |        |
| \_\_\_\           |                      |   |             |        |
| _\_\_\_\_\_\_\_\_ |                      |   |             |        |
| \_\_\_\_\_\_\_\_\ |                      |   |             |        |
| _\_\_\_\_\_\_\_\_ |                      |   |             |        |
| \_\_\_\_\_\_\_\_\ |                      |   |             |        |
| _\_\_\_\_\_\_\_\_ |                      |   |             |        |
| \_\_\_\_\_\_\_\_\ |                      |   |             |        |
| _\_\_\_\_\_\_\_\_ |                      |   |             |        |
| \_\_]{.underline} |                      |   |             |        |
+-------------------+----------------------+---+-------------+--------+
| **PART II.**      |                      |   | 33\. WAS AN |        |
| Enter other       |                      |   | AUTOPSY     |        |
| [significant      |                      |   | PERFORMED?  |        |
| conditions        |                      |   |             |        |
| contributing to   |                      |   |  Yes ■ No  |        |
| d                 |                      |   |             |        |
| eath]{.underline} |                      |   |             |        |
| but not resulting |                      |   |             |        |
| in the underlying |                      |   |             |        |
| cause given in    |                      |   |             |        |
| PART I            |                      |   |             |        |
|                   |                      |   |             |        |
| Arteriosclerosis, |                      |   |             |        |
| gout              |                      |   |             |        |
+-------------------+----------------------+---+-------------+--------+
|                   |                      |   | 34\. WERE   |        |
|                   |                      |   | AUTOPSY     |        |
|                   |                      |   | FINDINGS    |        |
|                   |                      |   | AVAILABLE   |        |
|                   |                      |   | TO          |        |
|                   |                      |   |             |        |
|                   |                      |   | COMPLETE    |        |
|                   |                      |   | THE CAUSE   |        |
|                   |                      |   | OF DEATH?  |        |
|                   |                      |   | Yes ■ No    |        |
+-------------------+----------------------+---+-------------+--------+
| 35\. DID TOBACCO  | 36\. IF FEMALE:      | 3 |             |        |
| USE CONTRIBUTE TO |                      | 7 |             |        |
| DEATH?            |  Not pregnant       | \ |             |        |
|                   | within past year     | . |             |        |
|  Yes ■ Probably  |                      | M |             |        |
|                   | Pregnant at time  | A |             |        |
| No Unknown  | of death             | N |             |        |
|                   |                      | N |             |        |
|                   | Not pregnant, but | E |             |        |
|                   | pregnant within 42   | R |             |        |
|                   | days of death        | O |             |        |
|                   |                      | F |             |        |
|                   | Not pregnant, but | D |             |        |
|                   | pregnant 43 days to  | E |             |        |
|                   | 1 year before death  | A |             |        |
|                   |                      | T |             |        |
|                   | Unknown if        | H |             |        |
|                   | pregnant within the  |   |             |        |
|                   | past year            | ■ |             |        |
|                   |                      | N |             |        |
|                   |                      | a |             |        |
|                   |                      | t |             |        |
|                   |                      | u |             |        |
|                   |                      | r |             |        |
|                   |                      | a |             |        |
|                   |                      | l |             |        |
|                   |                      |  |             |        |
|                   |                      |  |             |        |
|                   |                      | H |             |        |
|                   |                      | o |             |        |
|                   |                      | m |             |        |
|                   |                      | i |             |        |
|                   |                      | c |             |        |
|                   |                      | i |             |        |
|                   |                      | d |             |        |
|                   |                      | e |             |        |
|                   |                      |   |             |        |
|                   |                      |  |             |        |
|                   |                      |  |             |        |
|                   |                      | A |             |        |
|                   |                      | c |             |        |
|                   |                      | c |             |        |
|                   |                      | i |             |        |
|                   |                      | d |             |        |
|                   |                      | e |             |        |
|                   |                      | n |             |        |
|                   |                      | t |             |        |
|                   |                      |  |             |        |
|                   |                      |  |             |        |
|                   |                      | P |             |        |
|                   |                      | e |             |        |
|                   |                      | n |             |        |
|                   |                      | d |             |        |
|                   |                      | i |             |        |
|                   |                      | n |             |        |
|                   |                      | g |             |        |
|                   |                      | I |             |        |
|                   |                      | n |             |        |
|                   |                      | v |             |        |
|                   |                      | e |             |        |
|                   |                      | s |             |        |
|                   |                      | t |             |        |
|                   |                      | i |             |        |
|                   |                      | g |             |        |
|                   |                      | a |             |        |
|                   |                      | t |             |        |
|                   |                      | i |             |        |
|                   |                      | o |             |        |
|                   |                      | n |             |        |
|                   |                      |   |             |        |
|                   |                      |  |             |        |
|                   |                      |  |             |        |
|                   |                      | S |             |        |
|                   |                      | u |             |        |
|                   |                      | i |             |        |
|                   |                      | c |             |        |
|                   |                      | i |             |        |
|                   |                      | d |             |        |
|                   |                      | e |             |        |
|                   |                      |  |             |        |
|                   |                      |  |             |        |
|                   |                      | C |             |        |
|                   |                      | o |             |        |
|                   |                      | u |             |        |
|                   |                      | l |             |        |
|                   |                      | d |             |        |
|                   |                      | n |             |        |
|                   |                      | o |             |        |
|                   |                      | t |             |        |
|                   |                      | b |             |        |
|                   |                      | e |             |        |
|                   |                      | d |             |        |
|                   |                      | e |             |        |
|                   |                      | t |             |        |
|                   |                      | e |             |        |
|                   |                      | r |             |        |
|                   |                      | m |             |        |
|                   |                      | i |             |        |
|                   |                      | n |             |        |
|                   |                      | e |             |        |
|                   |                      | d |             |        |
+-------------------+----------------------+---+-------------+--------+

**ITEM 32 -- CAUSE OF DEATH (See example above)**

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.

Take care to make the entry legible. Use a computer printer with high
resolution, typewriter with good black ribbon and clean keys, or print
legibly using permanent **black** ink in completing the CAUSE OF DEATH
Section. **Do** **not** **abbreviate** conditions entered in section.

**[Part I]{.underline} (Chain of events leading directly to death)**

•Only **one** cause should be entered on each line. [Line
(a)]{.underline} **MUST ALWAYS** have an entry. **DO NOT** leave blank.
Additional lines may be added if necessary.

•If the condition on [Line (a)]{.underline} resulted from an underlying
condition, put the underlying condition on [Line (b)]{.underline}, and
so on, until the full sequence is reported. **ALWAYS** enter the
**underlying cause of death** on the [lowest used line]{.underline} in
Part I.

•For each cause indicate the best estimate of the interval between the
presumed onset and the date of death. The terms "unknown" or
"approximately" may be used. General terms, such as minutes, hours, or
days, are acceptable, if necessary. **DO NOT** leave blank.

•The terminal event (for example, cardiac arrest or respiratory arrest)
should not be used. If a mechanism of death seems most appropriate to
you for line (a), then you must always list its cause(s) on the line(s)
below it (for example, cardiac arrest **due to** coronary artery
atherosclerosis *or* cardiac arrest **due to** blunt impact to chest).

• If an organ system failure such as congestive heart failure, hepatic
failure, renal failure, or respiratory failure is listed as a cause of
death, always report its etiology on the line(s) beneath it (for
example, renal failure **due to** Type I diabetes mellitus).

•When indicating neoplasms as a cause of death, include the
following: 1) primary site *or* that the primary site is unknown, 2)
benign or malignant, 3) cell type *or* that the cell type is unknown, 4)
grade of neoplasm, and 5) part or lobe of organ affected. (For example,
a primary well-differentiated squamous cell carcinoma, lung, left upper
lobe.)

•Always report the fatal injury (for example, stab wound of chest), the
trauma (for example, transection of subclavian vein), and impairment of
function (for example, air embolism).

**Part II (Other significant conditions)**

•Enter all diseases or conditions contributing to death that were not
reported in the chain of events in Part I and that did not result in the
**underlying cause of death**.

•If two or more possible sequences resulted in death, or if two
conditions seem to have added together, report in Part I the one that,
in your opinion, most directly caused death. Report in Part II the other
conditions or diseases.

**CHANGES TO CAUSE OF DEATH**

Should additional medical information or autopsy findings become
available that would change the cause of death originally reported, the
original death certificate should be amended by the certifying physician
by **immediately** reporting the revised cause of death to the State
Vital Records Office.

**ITEMS ON WHEN DEATH OCCURRED**

Items 24-25 and 29-31 should always be completed. If the facility uses a
separate pronouncer or other person to indicate that death has taken
place with another person more familiar with the case completing the
remainder of the medical portion of the death certificate, the
pronouncer completes Items 24-28. If a certifier completes Items 24-25
as well as items 29-49, Items 26-28 may be left blank.

**ITEMS 24-25, 29-30 -- DATE AND TIME OF DEATH**

Spell out the name of the month. If the exact date of death is unknown,
enter the **approximate** date. If the date cannot be approximated,
enter the date the body is found and identify as **date found**. Date
pronounced and actual date may be the same. Enter the exact hour and
minutes according to a 24-hour clock; estimates may be provided with
"Approx." placed before the time.

**ITEMS 33-34 - AUTOPSY**

•33 - Enter "Yes" if either a partial or full autopsy was performed.
Otherwise enter "No."

•34 - Enter "Yes" if autopsy findings were available to complete the
cause of death; otherwise enter "No". Leave item blank if no autopsy was
performed.

**ITEM 35 - DID TOBACCO USE CONTRIBUTE TO DEATH?**

Check "yes" if, in your opinion, the use of tobacco contributed to
death. Tobacco use may contribute to deaths due to a wide variety of
diseases; for example, tobacco use contributes to many deaths due to
emphysema or lung cancer and some heart disease and cancers of the head
and neck. Check "no" if, in your clinical judgment, tobacco use did not
contribute to this particular death.

**ITEM 36 - IF FEMALE, WAS DECEDENT PREGNANT AT TIME OF DEATH OR WITHIN
PAST YEAR?**

This information is important in determining pregnancy-related
mortality.

**ITEM 37 - MANNER OF DEATH**

•Always check Manner of Death, which is important: 1) in determining
accurate causes of death; 2) in processing insurance claims; and 3) in
statistical studies of injuries and death.

•Indicate "Pending investigation" if the manner of death cannot be
determined whether due to an accident, suicide, or homicide within the
statutory time limit for filing the death certificate. This should be
changed later to one of the other terms.

•Indicate "Could not be Determined" **ONLY** when it is impossible to
determine the manner of death.

**ITEMS 38-44 - ACCIDENT OR INJURY -- to be filled out in all cases of
deaths due to injury or poisoning.**

•38 - Enter the exact month, day, and year of injury. Spell out the name
of the month. **DO NOT** use a number for the month. (Remember, the date
of injury may differ from the date of death.) Estimates may be provided
with "Approx." placed before the date.

•39 **-** Enter the exact hour and minutes of injury or use your best
estimate. Use a 24-hour clock.

•40 - Enter the general place (such as restaurant, vacant lot, or home)
where the injury occurred. **DO NOT** enter firm or organization names.
(For example, enter "factory", **not** "Standard Manufacturing, Inc." )

•41 - Complete if anything other than natural disease is mentioned in
Part I or Part II of the medical certification, including homicides,
suicides, and accidents. This includes all motor vehicle deaths. The
item **[must]{.underline}** be completed for decedents ages 14 years or
over and may be completed for those less than 14 years of age if
warranted. Enter "Yes" if the injury occurred at work. Otherwise enter
"No". An injury may occur at work regardless of whether the injury
occurred in the course of the decedent's "usual" occupation. Examples of
injury at work and injury not at work follow:

+-----------------------------------+-----------------------------------+
| **Injury at work**                | **Injury [not]{.underline} at     |
|                                   | work**                            |
| Injury while working or in        |                                   |
| vocational training on job        | Injury while engaged in personal  |
| premises                          | recreational activity on job      |
|                                   | premises                          |
| Injury while on break or at lunch |                                   |
| or in parking lot on job premises | Injury while a visitor (not on    |
|                                   | official work business) to job    |
| Injury while working for pay or   | premises                          |
| compensation, including at home   |                                   |
|                                   | Homemaker working at homemaking   |
| Injury while working as a         | activities                        |
| volunteer law enforcement         |                                   |
| official etc.                     | Student in school                 |
|                                   |                                   |
| Injury while traveling on         | Working for self for no profit    |
| business, including to/from       | (mowing yard, repairing own roof, |
| business contacts                 | hobby)                            |
|                                   |                                   |
|                                   | Commuting to or from work         |
+-----------------------------------+-----------------------------------+

•42 - Enter the complete address where the injury occurred including zip
code.

•43 - Enter a brief but specific and clear description of how the injury
occurred. Explain the circumstances or cause of the injury. Specify
**type** **of** **gun** or **type of vehicle** (e.g., car, bulldozer,
train, etc.) when relevant to circumstances. Indicate if more than one
vehicle involved; specify type of vehicle decedent was in.

•44 -Specify role of decedent (e.g. driver, passenger). Driver/operator
and passenger should be designated for modes other than motor vehicles
such as bicycles. Other applies to watercraft, aircraft, animal, or
people attached to outside of vehicles (e.g. surfers).

[Rationale]{.underline}: Motor vehicle accidents are a major cause of
unintentional deaths; details will help determine effectiveness of
current safety features and laws.

**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:]{.underline}**

+-------------+-------------+-------------+-------------+-------------+
| Abscess     | Car         | D           | H           | Pulmonary   |
|             | cinomatosis | isseminated | yponatremia | arrest      |
| Abdominal   |             | intra       |             |             |
| hemorrhage  | Cardiac     | vascular    | Hypotension | Pulmonary   |
|             | arrest      |             |             | edema       |
| Adhesions   |             | c           | Immuno      |             |
|             | Cardiac     | oagulopathy | suppression | Pulmonary   |
| Adult       | dysrhythmia |             |             | embolism    |
| respiratory |             | Dysrhythmia | Increased   |             |
| distress    | Car         |             | intra       | Pulmonary   |
| syndrome    | diomyopathy | End-stage   | cranial     | in          |
|             |             | liver       | pressure    | sufficiency |
| Acute       | Card        | disease     |             |             |
| myocardial  | iopulmonary |             | Intra       | Renal       |
| infarction  | arrest      | End-stage   | cranial     | failure     |
|             |             | renal       | hemorrhage  |             |
| Altered     | Cellulitis  | disease     |             | Respiratory |
| mental      |             |             | M           | arrest      |
| status      | Cerebral    | Epidural    | alnutrition |             |
|             | edema       | hematoma    |             | Seizures    |
| Anemia      |             |             | Metabolic   |             |
|             | Cere        | Exs         | enc         | Sepsis      |
| Anoxia      | brovascular | anguination | ephalopathy |             |
|             | accident    |             |             | Septic      |
| Anoxic      |             | Failure to  | Multi-organ | shock       |
| enc         | Cerebellar  | thrive      | failure     |             |
| ephalopathy | tonsillar   |             |             | Shock       |
|             | herniation  | Fracture    | M           |             |
| Arrhythmia  |             |             | ulti-system | Starvation  |
|             | Chronic     | Gangrene    | organ       |             |
| Ascites     | bedridden   |             | failure     | Subdural    |
|             | state       | Gastr       |             | hematoma    |
| Aspiration  |             | ointestinal | Myocardial  |             |
|             | Cirrhosis   | hemorrhage  | infarction  | S           |
| Atrial      |             |             |             | ubarachnoid |
| f           | C           | Heart       | Necrotizing | hemorrhage  |
| ibrillation | oagulopathy | failure     | soft-tissue |             |
|             |             |             | infection   | Sudden      |
| Bacteremia  | Compression | Hemothorax  |             | death       |
|             | fracture    |             | Old age     |             |
| Bedridden   |             | Hepatic     |             | Throm       |
|             | Congestive  | failure     | Open (or    | bocytopenia |
| Biliary     | heart       |             | closed)     |             |
| obstruction | failure     | Hepatitis   | head injury | Uncal       |
|             |             |             |             | herniation  |
| Bowel       | Convulsions | Hepatorenal | Paralysis   |             |
| obstruction |             | syndrome    |             | Urinary     |
|             | Decubiti    |             | P           | tract       |
| Brain       |             | Hy          | ancytopenia | infection   |
| injury      | Dehydration | perglycemia |             |             |
|             |             |             | Perforated  | Ventricular |
| Brain stem  | Dementia    | H           | gallbladder | f           |
| herniation  | (when not   | yperkalemia |             | ibrillation |
|             |             |             | Peritonitis |             |
| Car         | otherwise   | Hypovolemic |             | Ventricular |
| cinogenesis | specified)  | shock       | Pleural     | tachycardia |
|             |             |             | effusions   |             |
|             | Diarrhea    |             |             | Volume      |
|             |             |             | Pneumonia   | 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    | Epidural    | Hip         | Pulmonary   | Subdural    |
|             | hematoma    | fracture    | emboli      | hematoma    |
| Bolus       |             |             |             |             |
|             | Exs         | H           | Seizure     | Surgery     |
| Choking     | anguination | yperthermia | disorder    |             |
|             |             |             |             | Thermal     |
| Drug or     | Fall        | Hypothermia | Sepsis      | bur         |
| alcohol     |             |             |             | ns/chemical |
| ov          | Fracture    | Open        | S           | burns       |
| erdose/drug |             | reduction   | ubarachnoid |             |
| or          |             | of fracture | hemorrhage  |             |
|             |             |             |             |             |
| alcohol     |             |             |             |             |
| abuse       |             |             |             |             |
+-------------+-------------+-------------+-------------+-------------+

Contact your State vital statistics office for questions related to
writing cause-of-death statements. Additional instructional material on
writing cause-of-death statements including handbooks, summary
instructions, and tutorials are available online at www.thename.org or
www.cdc.gov/nchswww/about/major/dvs/handbk.htm, or by request from NCHS,
Room 7318, 3311 Toledo Road, Hyattsville, Maryland 20782-2003.

Query Letter 9

(Pregnancy Related)

(Letterhead)

Dear Doctor \_\_\_\_\_\_\_\_

We are writing this letter to obtain additional information about the
cause of death that you certified for
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_, who died
\_\_\_\_\_\_\_\_\_\_\_\_\_.

Accurate cause-of-death information is essential, not only to the family
of the decedent, but also for medical research, funding, and resource
allocation in our State and at the national level.

In the case of this particular death, we need additional information to
properly classify the maternal death. In order to classify this death
properly in our statistics, would you please supply the information on
the attachment? We want to assure you that the information you provide
us is confidential and will be handled accordingly.

If you have any question or would like to know more about various
methods for certifying a cause-of-death statement, please contact
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_.
Instructions and an example of a properly completed death certificate
are provided with the attached material.

We appreciate your attention and prompt reply.

Sincerely,

State Registrar/Vital Statistics Cooperative Program

Attachment

Pregnancy-related Query

+----------+--------+---+---------------------+---+---+---------+---+--------+
| **CAUSE  |        |   |                     |   |   |         |   | Appro  |
| OF DEATH |        |   |                     |   |   |         |   | ximate |
| (See     |        |   |                     |   |   |         |   | int    |
| inst     |        |   |                     |   |   |         |   | erval: |
| ructions |        |   |                     |   |   |         |   |        |
| and      |        |   |                     |   |   |         |   | Onset  |
| exa      |        |   |                     |   |   |         |   | to     |
| mples)** |        |   |                     |   |   |         |   | death  |
|          |        |   |                     |   |   |         |   |        |
| 32\.     |        |   |                     |   |   |         |   | [\_\_\ |
| **PART   |        |   |                     |   |   |         |   | _\_\_] |
| I.**     |        |   |                     |   |   |         |   | {.unde |
| Enter    |        |   |                     |   |   |         |   | rline} |
| the      |        |   |                     |   |   |         |   |        |
| [chain   |        |   |                     |   |   |         |   | [      |
| of       |        |   |                     |   |   |         |   | \_\_\_ |
| events]  |        |   |                     |   |   |         |   | \_]    |
| {.underl |        |   |                     |   |   |         |   | {.unde |
| ine}\--d |        |   |                     |   |   |         |   | rline} |
| iseases, |        |   |                     |   |   |         |   |        |
| i        |        |   |                     |   |   |         |   | [\_\_  |
| njuries, |        |   |                     |   |   |         |   | \_]    |
| or       |        |   |                     |   |   |         |   | {.unde |
| comp     |        |   |                     |   |   |         |   | rline} |
| lication |        |   |                     |   |   |         |   |        |
| s\--that |        |   |                     |   |   |         |   | [\     |
| directly |        |   |                     |   |   |         |   | _\_\_\ |
| caused   |        |   |                     |   |   |         |   | _\_\_] |
| the      |        |   |                     |   |   |         |   | {.unde |
| death.   |        |   |                     |   |   |         |   | rline} |
| DO NOT   |        |   |                     |   |   |         |   |        |
| enter    |        |   |                     |   |   |         |   |        |
| terminal |        |   |                     |   |   |         |   |        |
| events   |        |   |                     |   |   |         |   |        |
| such as  |        |   |                     |   |   |         |   |        |
| cardiac  |        |   |                     |   |   |         |   |        |
|          |        |   |                     |   |   |         |   |        |
| arrest,  |        |   |                     |   |   |         |   |        |
| res      |        |   |                     |   |   |         |   |        |
| piratory |        |   |                     |   |   |         |   |        |
| arrest,  |        |   |                     |   |   |         |   |        |
| or       |        |   |                     |   |   |         |   |        |
| ven      |        |   |                     |   |   |         |   |        |
| tricular |        |   |                     |   |   |         |   |        |
| fibr     |        |   |                     |   |   |         |   |        |
| illation |        |   |                     |   |   |         |   |        |
| without  |        |   |                     |   |   |         |   |        |
| showing  |        |   |                     |   |   |         |   |        |
| the      |        |   |                     |   |   |         |   |        |
| e        |        |   |                     |   |   |         |   |        |
| tiology. |        |   |                     |   |   |         |   |        |
| DO NOT   |        |   |                     |   |   |         |   |        |
| ABB      |        |   |                     |   |   |         |   |        |
| REVIATE. |        |   |                     |   |   |         |   |        |
| Enter    |        |   |                     |   |   |         |   |        |
| only one |        |   |                     |   |   |         |   |        |
| cause on |        |   |                     |   |   |         |   |        |
| a line.  |        |   |                     |   |   |         |   |        |
| Add      |        |   |                     |   |   |         |   |        |
| ad       |        |   |                     |   |   |         |   |        |
| ditional |        |   |                     |   |   |         |   |        |
|          |        |   |                     |   |   |         |   |        |
| lines if |        |   |                     |   |   |         |   |        |
| ne       |        |   |                     |   |   |         |   |        |
| cessary. |        |   |                     |   |   |         |   |        |
|          |        |   |                     |   |   |         |   |        |
| I        |        |   |                     |   |   |         |   |        |
| MMEDIATE |        |   |                     |   |   |         |   |        |
| CAUSE    |        |   |                     |   |   |         |   |        |
| (Final   |        |   |                     |   |   |         |   |        |
|          |        |   |                     |   |   |         |   |        |
| disease  |        |   |                     |   |   |         |   |        |
| or       |        |   |                     |   |   |         |   |        |
| c        |        |   |                     |   |   |         |   |        |
| ondition |        |   |                     |   |   |         |   |        |
| **\-\-\  |        |   |                     |   |   |         |   |        |
| -\-\-\-\ |        |   |                     |   |   |         |   |        |
| -\--\>** |        |   |                     |   |   |         |   |        |
| a.       |        |   |                     |   |   |         |   |        |
| [\_\_    |        |   |                     |   |   |         |   |        |
| \_\_\_\_ |        |   |                     |   |   |         |   |        |
| \_\      |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_]{.un |        |   |                     |   |   |         |   |        |
| derline} |        |   |                     |   |   |         |   |        |
|          |        |   |                     |   |   |         |   |        |
| r        |        |   |                     |   |   |         |   |        |
| esulting |        |   |                     |   |   |         |   |        |
| in       |        |   |                     |   |   |         |   |        |
| death)   |        |   |                     |   |   |         |   |        |
| Due to   |        |   |                     |   |   |         |   |        |
| (or as a |        |   |                     |   |   |         |   |        |
| con      |        |   |                     |   |   |         |   |        |
| sequence |        |   |                     |   |   |         |   |        |
| of):     |        |   |                     |   |   |         |   |        |
|          |        |   |                     |   |   |         |   |        |
| Sequ     |        |   |                     |   |   |         |   |        |
| entially |        |   |                     |   |   |         |   |        |
| list     |        |   |                     |   |   |         |   |        |
| con      |        |   |                     |   |   |         |   |        |
| ditions, |        |   |                     |   |   |         |   |        |
| b.       |        |   |                     |   |   |         |   |        |
| [        |        |   |                     |   |   |         |   |        |
| \_\_\_\_ |        |   |                     |   |   |         |   |        |
| \_\_\_\_ |        |   |                     |   |   |         |   |        |
| \_\      |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_]{.un |        |   |                     |   |   |         |   |        |
| derline} |        |   |                     |   |   |         |   |        |
|          |        |   |                     |   |   |         |   |        |
| if any,  |        |   |                     |   |   |         |   |        |
| leading  |        |   |                     |   |   |         |   |        |
| to the   |        |   |                     |   |   |         |   |        |
| cause    |        |   |                     |   |   |         |   |        |
| Due to   |        |   |                     |   |   |         |   |        |
| (or as a |        |   |                     |   |   |         |   |        |
| con      |        |   |                     |   |   |         |   |        |
| sequence |        |   |                     |   |   |         |   |        |
| of):     |        |   |                     |   |   |         |   |        |
|          |        |   |                     |   |   |         |   |        |
| listed   |        |   |                     |   |   |         |   |        |
| on line  |        |   |                     |   |   |         |   |        |
| a. Enter |        |   |                     |   |   |         |   |        |
| the      |        |   |                     |   |   |         |   |        |
|          |        |   |                     |   |   |         |   |        |
| **UN     |        |   |                     |   |   |         |   |        |
| DERLYING |        |   |                     |   |   |         |   |        |
| CAUSE**  |        |   |                     |   |   |         |   |        |
| c.       |        |   |                     |   |   |         |   |        |
| [        |        |   |                     |   |   |         |   |        |
| \_\_\_\_ |        |   |                     |   |   |         |   |        |
| \_\_\    |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_]{.un |        |   |                     |   |   |         |   |        |
| derline} |        |   |                     |   |   |         |   |        |
|          |        |   |                     |   |   |         |   |        |
| (disease |        |   |                     |   |   |         |   |        |
| or       |        |   |                     |   |   |         |   |        |
| injury   |        |   |                     |   |   |         |   |        |
| that Due |        |   |                     |   |   |         |   |        |
| to (or   |        |   |                     |   |   |         |   |        |
| as a     |        |   |                     |   |   |         |   |        |
| con      |        |   |                     |   |   |         |   |        |
| sequence |        |   |                     |   |   |         |   |        |
| of):     |        |   |                     |   |   |         |   |        |
|          |        |   |                     |   |   |         |   |        |
| i        |        |   |                     |   |   |         |   |        |
| nitiated |        |   |                     |   |   |         |   |        |
| the      |        |   |                     |   |   |         |   |        |
| events   |        |   |                     |   |   |         |   |        |
| r        |        |   |                     |   |   |         |   |        |
| esulting |        |   |                     |   |   |         |   |        |
|          |        |   |                     |   |   |         |   |        |
| in       |        |   |                     |   |   |         |   |        |
| death)   |        |   |                     |   |   |         |   |        |
| **LAST** |        |   |                     |   |   |         |   |        |
| d.       |        |   |                     |   |   |         |   |        |
| [\_\_    |        |   |                     |   |   |         |   |        |
| \_\_\_\_ |        |   |                     |   |   |         |   |        |
| \_\_\    |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_]{.un |        |   |                     |   |   |         |   |        |
| derline} |        |   |                     |   |   |         |   |        |
+----------+--------+---+---------------------+---+---+---------+---+--------+
| **PART   |        |   |                     |   | 3 |         |   |        |
| II.**    |        |   |                     |   | 3 |         |   |        |
| Enter    |        |   |                     |   | \ |         |   |        |
| other    |        |   |                     |   | . |         |   |        |
| [sig     |        |   |                     |   | W |         |   |        |
| nificant |        |   |                     |   | A |         |   |        |
| co       |        |   |                     |   | S |         |   |        |
| nditions |        |   |                     |   | A |         |   |        |
| cont     |        |   |                     |   | N |         |   |        |
| ributing |        |   |                     |   | A |         |   |        |
| to       |        |   |                     |   | U |         |   |        |
| de       |        |   |                     |   | T |         |   |        |
| ath]{.un |        |   |                     |   | O |         |   |        |
| derline} |        |   |                     |   | P |         |   |        |
| but not  |        |   |                     |   | S |         |   |        |
| r        |        |   |                     |   | Y |         |   |        |
| esulting |        |   |                     |   | P |         |   |        |
| in the   |        |   |                     |   | E |         |   |        |
| un       |        |   |                     |   | R |         |   |        |
| derlying |        |   |                     |   | F |         |   |        |
| cause    |        |   |                     |   | O |         |   |        |
| given in |        |   |                     |   | R |         |   |        |
| PART I   |        |   |                     |   | M |         |   |        |
|          |        |   |                     |   | E |         |   |        |
|          |        |   |                     |   | D |         |   |        |
|          |        |   |                     |   | ? |         |   |        |
|          |        |   |                     |   |   |         |   |        |
|          |        |   |                     |   |  |         |   |        |
|          |        |   |                     |   | Y |         |   |        |
|          |        |   |                     |   | e |         |   |        |
|          |        |   |                     |   | s |         |   |        |
|          |        |   |                     |   |  |         |   |        |
|          |        |   |                     |   |  |         |   |        |
|          |        |   |                     |   |  |         |   |        |
|          |        |   |                     |   | N |         |   |        |
|          |        |   |                     |   | o |         |   |        |
+----------+--------+---+---------------------+---+---+---------+---+--------+
|          |        |   |                     |   | 3 |         |   |        |
|          |        |   |                     |   | 4 |         |   |        |
|          |        |   |                     |   | \ |         |   |        |
|          |        |   |                     |   | . |         |   |        |
|          |        |   |                     |   | W |         |   |        |
|          |        |   |                     |   | E |         |   |        |
|          |        |   |                     |   | R |         |   |        |
|          |        |   |                     |   | E |         |   |        |
|          |        |   |                     |   | A |         |   |        |
|          |        |   |                     |   | U |         |   |        |
|          |        |   |                     |   | T |         |   |        |
|          |        |   |                     |   | O |         |   |        |
|          |        |   |                     |   | P |         |   |        |
|          |        |   |                     |   | S |         |   |        |
|          |        |   |                     |   | Y |         |   |        |
|          |        |   |                     |   | F |         |   |        |
|          |        |   |                     |   | I |         |   |        |
|          |        |   |                     |   | N |         |   |        |
|          |        |   |                     |   | D |         |   |        |
|          |        |   |                     |   | I |         |   |        |
|          |        |   |                     |   | N |         |   |        |
|          |        |   |                     |   | G |         |   |        |
|          |        |   |                     |   | S |         |   |        |
|          |        |   |                     |   | A |         |   |        |
|          |        |   |                     |   | V |         |   |        |
|          |        |   |                     |   | A |         |   |        |
|          |        |   |                     |   | I |         |   |        |
|          |        |   |                     |   | L |         |   |        |
|          |        |   |                     |   | A |         |   |        |
|          |        |   |                     |   | B |         |   |        |
|          |        |   |                     |   | L |         |   |        |
|          |        |   |                     |   | E |         |   |        |
|          |        |   |                     |   | T |         |   |        |
|          |        |   |                     |   | O |         |   |        |
|          |        |   |                     |   |   |         |   |        |
|          |        |   |                     |   | C |         |   |        |
|          |        |   |                     |   | O |         |   |        |
|          |        |   |                     |   | M |         |   |        |
|          |        |   |                     |   | P |         |   |        |
|          |        |   |                     |   | L |         |   |        |
|          |        |   |                     |   | E |         |   |        |
|          |        |   |                     |   | T |         |   |        |
|          |        |   |                     |   | E |         |   |        |
|          |        |   |                     |   | T |         |   |        |
|          |        |   |                     |   | H |         |   |        |
|          |        |   |                     |   | E |         |   |        |
|          |        |   |                     |   | C |         |   |        |
|          |        |   |                     |   | A |         |   |        |
|          |        |   |                     |   | U |         |   |        |
|          |        |   |                     |   | S |         |   |        |
|          |        |   |                     |   | E |         |   |        |
|          |        |   |                     |   | O |         |   |        |
|          |        |   |                     |   | F |         |   |        |
|          |        |   |                     |   | D |         |   |        |
|          |        |   |                     |   | E |         |   |        |
|          |        |   |                     |   | A |         |   |        |
|          |        |   |                     |   | T |         |   |        |
|          |        |   |                     |   | H |         |   |        |
|          |        |   |                     |   | ? |         |   |        |
|          |        |   |                     |   |  |         |   |        |
|          |        |   |                     |   | Y |         |   |        |
|          |        |   |                     |   | e |         |   |        |
|          |        |   |                     |   | s |         |   |        |
|          |        |   |                     |   |  |         |   |        |
|          |        |   |                     |   |  |         |   |        |
|          |        |   |                     |   |  |         |   |        |
|          |        |   |                     |   | N |         |   |        |
|          |        |   |                     |   | o |         |   |        |
+----------+--------+---+---------------------+---+---+---------+---+--------+
| 35\. DID |        | 3 |                     | 3 |   |         |   |        |
| TOBACCO  |        | 6 |                     | 7 |   |         |   |        |
| USE      |        | \ |                     | \ |   |         |   |        |
| CO       |        | . |                     | . |   |         |   |        |
| NTRIBUTE |        | I |                     | M |   |         |   |        |
| TO       |        | F |                     | A |   |         |   |        |
| DEATH?   |        | F |                     | N |   |         |   |        |
|          |        | E |                     | N |   |         |   |        |
| Yes   |        | M |                     | E |   |         |   |        |
|       |        | A |                     | R |   |         |   |        |
| Probably |        | L |                     | O |   |         |   |        |
|          |        | E |                     | F |   |         |   |        |
|  No     |        | : |                     | D |   |         |   |        |
|         |        |   |                     | E |   |         |   |        |
| Unknown |        |  |                     | A |   |         |   |        |
|          |        |  |                     | T |   |         |   |        |
|          |        |  |                     | H |   |         |   |        |
|          |        | N |                     |   |   |         |   |        |
|          |        | o |                     |  |   |         |   |        |
|          |        | t |                     |  |   |         |   |        |
|          |        | p |                     |  |   |         |   |        |
|          |        | r |                     | N |   |         |   |        |
|          |        | e |                     | a |   |         |   |        |
|          |        | g |                     | t |   |         |   |        |
|          |        | n |                     | u |   |         |   |        |
|          |        | a |                     | r |   |         |   |        |
|          |        | n |                     | a |   |         |   |        |
|          |        | t |                     | l |   |         |   |        |
|          |        | w |                     |  |   |         |   |        |
|          |        | i |                     |  |   |         |   |        |
|          |        | t |                     |  |   |         |   |        |
|          |        | h |                     | H |   |         |   |        |
|          |        | i |                     | o |   |         |   |        |
|          |        | n |                     | m |   |         |   |        |
|          |        | p |                     | i |   |         |   |        |
|          |        | a |                     | c |   |         |   |        |
|          |        | s |                     | i |   |         |   |        |
|          |        | t |                     | d |   |         |   |        |
|          |        | y |                     | e |   |         |   |        |
|          |        | e |                     |   |   |         |   |        |
|          |        | a |                     |  |   |         |   |        |
|          |        | r |                     | A |   |         |   |        |
|          |        |   |                     | c |   |         |   |        |
|          |        |  |                     | c |   |         |   |        |
|          |        |  |                     | i |   |         |   |        |
|          |        |  |                     | d |   |         |   |        |
|          |        | P |                     | e |   |         |   |        |
|          |        | r |                     | n |   |         |   |        |
|          |        | e |                     | t |   |         |   |        |
|          |        | g |                     |  |   |         |   |        |
|          |        | n |                     |  |   |         |   |        |
|          |        | a |                     |  |   |         |   |        |
|          |        | n |                     | P |   |         |   |        |
|          |        | t |                     | e |   |         |   |        |
|          |        | a |                     | n |   |         |   |        |
|          |        | t |                     | d |   |         |   |        |
|          |        | t |                     | i |   |         |   |        |
|          |        | i |                     | n |   |         |   |        |
|          |        | m |                     | g |   |         |   |        |
|          |        | e |                     | I |   |         |   |        |
|          |        | o |                     | n |   |         |   |        |
|          |        | f |                     | v |   |         |   |        |
|          |        | d |                     | e |   |         |   |        |
|          |        | e |                     | s |   |         |   |        |
|          |        | a |                     | t |   |         |   |        |
|          |        | t |                     | i |   |         |   |        |
|          |        | h |                     | g |   |         |   |        |
|          |        |   |                     | a |   |         |   |        |
|          |        |  |                     | t |   |         |   |        |
|          |        |  |                     | i |   |         |   |        |
|          |        |  |                     | o |   |         |   |        |
|          |        | N |                     | n |   |         |   |        |
|          |        | o |                     |   |   |         |   |        |
|          |        | t |                     |  |   |         |   |        |
|          |        | p |                     |  |   |         |   |        |
|          |        | r |                     |  |   |         |   |        |
|          |        | e |                     | S |   |         |   |        |
|          |        | g |                     | u |   |         |   |        |
|          |        | n |                     | i |   |         |   |        |
|          |        | a |                     | c |   |         |   |        |
|          |        | n |                     | i |   |         |   |        |
|          |        | t |                     | d |   |         |   |        |
|          |        | , |                     | e |   |         |   |        |
|          |        | b |                     |  |   |         |   |        |
|          |        | u |                     |  |   |         |   |        |
|          |        | t |                     |  |   |         |   |        |
|          |        | p |                     | C |   |         |   |        |
|          |        | r |                     | o |   |         |   |        |
|          |        | e |                     | u |   |         |   |        |
|          |        | g |                     | l |   |         |   |        |
|          |        | n |                     | d |   |         |   |        |
|          |        | a |                     | n |   |         |   |        |
|          |        | n |                     | o |   |         |   |        |
|          |        | t |                     | t |   |         |   |        |
|          |        | w |                     | b |   |         |   |        |
|          |        | i |                     | e |   |         |   |        |
|          |        | t |                     | d |   |         |   |        |
|          |        | h |                     | e |   |         |   |        |
|          |        | i |                     | t |   |         |   |        |
|          |        | n |                     | e |   |         |   |        |
|          |        | 4 |                     | r |   |         |   |        |
|          |        | 2 |                     | m |   |         |   |        |
|          |        | d |                     | i |   |         |   |        |
|          |        | a |                     | n |   |         |   |        |
|          |        | y |                     | e |   |         |   |        |
|          |        | s |                     | d |   |         |   |        |
|          |        | o |                     |   |   |         |   |        |
|          |        | f |                     |   |   |         |   |        |
|          |        | d |                     |   |   |         |   |        |
|          |        | e |                     |   |   |         |   |        |
|          |        | a |                     |   |   |         |   |        |
|          |        | t |                     |   |   |         |   |        |
|          |        | h |                     |   |   |         |   |        |
|          |        |   |                     |   |   |         |   |        |
|          |        |  |                     |   |   |         |   |        |
|          |        |  |                     |   |   |         |   |        |
|          |        |  |                     |   |   |         |   |        |
|          |        | N |                     |   |   |         |   |        |
|          |        | o |                     |   |   |         |   |        |
|          |        | t |                     |   |   |         |   |        |
|          |        | p |                     |   |   |         |   |        |
|          |        | r |                     |   |   |         |   |        |
|          |        | e |                     |   |   |         |   |        |
|          |        | g |                     |   |   |         |   |        |
|          |        | n |                     |   |   |         |   |        |
|          |        | a |                     |   |   |         |   |        |
|          |        | n |                     |   |   |         |   |        |
|          |        | t |                     |   |   |         |   |        |
|          |        | , |                     |   |   |         |   |        |
|          |        | b |                     |   |   |         |   |        |
|          |        | u |                     |   |   |         |   |        |
|          |        | t |                     |   |   |         |   |        |
|          |        | p |                     |   |   |         |   |        |
|          |        | r |                     |   |   |         |   |        |
|          |        | e |                     |   |   |         |   |        |
|          |        | g |                     |   |   |         |   |        |
|          |        | n |                     |   |   |         |   |        |
|          |        | a |                     |   |   |         |   |        |
|          |        | n |                     |   |   |         |   |        |
|          |        | t |                     |   |   |         |   |        |
|          |        | 4 |                     |   |   |         |   |        |
|          |        | 3 |                     |   |   |         |   |        |
|          |        | d |                     |   |   |         |   |        |
|          |        | a |                     |   |   |         |   |        |
|          |        | y |                     |   |   |         |   |        |
|          |        | s |                     |   |   |         |   |        |
|          |        | t |                     |   |   |         |   |        |
|          |        | o |                     |   |   |         |   |        |
|          |        | 1 |                     |   |   |         |   |        |
|          |        | y |                     |   |   |         |   |        |
|          |        | e |                     |   |   |         |   |        |
|          |        | a |                     |   |   |         |   |        |
|          |        | r |                     |   |   |         |   |        |
|          |        | b |                     |   |   |         |   |        |
|          |        | e |                     |   |   |         |   |        |
|          |        | f |                     |   |   |         |   |        |
|          |        | o |                     |   |   |         |   |        |
|          |        | r |                     |   |   |         |   |        |
|          |        | e |                     |   |   |         |   |        |
|          |        | d |                     |   |   |         |   |        |
|          |        | e |                     |   |   |         |   |        |
|          |        | a |                     |   |   |         |   |        |
|          |        | t |                     |   |   |         |   |        |
|          |        | h |                     |   |   |         |   |        |
|          |        |   |                     |   |   |         |   |        |
|          |        |  |                     |   |   |         |   |        |
|          |        |  |                     |   |   |         |   |        |
|          |        |  |                     |   |   |         |   |        |
|          |        | U |                     |   |   |         |   |        |
|          |        | n |                     |   |   |         |   |        |
|          |        | k |                     |   |   |         |   |        |
|          |        | n |                     |   |   |         |   |        |
|          |        | o |                     |   |   |         |   |        |
|          |        | w |                     |   |   |         |   |        |
|          |        | n |                     |   |   |         |   |        |
|          |        | i |                     |   |   |         |   |        |
|          |        | f |                     |   |   |         |   |        |
|          |        | p |                     |   |   |         |   |        |
|          |        | r |                     |   |   |         |   |        |
|          |        | e |                     |   |   |         |   |        |
|          |        | g |                     |   |   |         |   |        |
|          |        | n |                     |   |   |         |   |        |
|          |        | a |                     |   |   |         |   |        |
|          |        | n |                     |   |   |         |   |        |
|          |        | t |                     |   |   |         |   |        |
|          |        | w |                     |   |   |         |   |        |
|          |        | i |                     |   |   |         |   |        |
|          |        | t |                     |   |   |         |   |        |
|          |        | h |                     |   |   |         |   |        |
|          |        | i |                     |   |   |         |   |        |
|          |        | n |                     |   |   |         |   |        |
|          |        | t |                     |   |   |         |   |        |
|          |        | h |                     |   |   |         |   |        |
|          |        | e |                     |   |   |         |   |        |
|          |        | p |                     |   |   |         |   |        |
|          |        | a |                     |   |   |         |   |        |
|          |        | s |                     |   |   |         |   |        |
|          |        | t |                     |   |   |         |   |        |
|          |        | y |                     |   |   |         |   |        |
|          |        | e |                     |   |   |         |   |        |
|          |        | a |                     |   |   |         |   |        |
|          |        | r |                     |   |   |         |   |        |
+----------+--------+---+---------------------+---+---+---------+---+--------+
| 38\.     | 39\.   |   | 40\. PLACE OF       |   |   |         | 4 |        |
| DATE OF  | TIME   |   | INJURY (e.g.,       |   |   |         | 1 |        |
| INJURY   | OF     |   | Decedent's home;    |   |   |         | \ |        |
|          | INJURY |   | construction site;  |   |   |         | . |        |
| (Mo      |        |   | restaurant; wooded  |   |   |         | I |        |
| /Day/Yr) |        |   | area)               |   |   |         | N |        |
| (Spell   |        |   |                     |   |   |         | J |        |
| Month)   |        |   |                     |   |   |         | U |        |
|          |        |   |                     |   |   |         | R |        |
|          |        |   |                     |   |   |         | Y |        |
|          |        |   |                     |   |   |         | A |        |
|          |        |   |                     |   |   |         | T |        |
|          |        |   |                     |   |   |         | W |        |
|          |        |   |                     |   |   |         | O |        |
|          |        |   |                     |   |   |         | R |        |
|          |        |   |                     |   |   |         | K |        |
|          |        |   |                     |   |   |         | ? |        |
|          |        |   |                     |   |   |         |   |        |
|          |        |   |                     |   |   |         |  |        |
|          |        |   |                     |   |   |         |  |        |
|          |        |   |                     |   |   |         |  |        |
|          |        |   |                     |   |   |         |  |        |
|          |        |   |                     |   |   |         |  |        |
|          |        |   |                     |   |   |         |  |        |
|          |        |   |                     |   |   |         |  |        |
|          |        |   |                     |   |   |         |  |        |
|          |        |   |                     |   |   |         |  |        |
|          |        |   |                     |   |   |         |  |        |
|          |        |   |                     |   |   |         |  |        |
|          |        |   |                     |   |   |         |  |        |
|          |        |   |                     |   |   |         | Y |        |
|          |        |   |                     |   |   |         | e |        |
|          |        |   |                     |   |   |         | s |        |
|          |        |   |                     |   |   |         |  |        |
|          |        |   |                     |   |   |         | N |        |
|          |        |   |                     |   |   |         | o |        |
+----------+--------+---+---------------------+---+---+---------+---+--------+
| 42\.     |        |   |                     |   |   |         |   |        |
| LOCATION |        |   |                     |   |   |         |   |        |
| OF       |        |   |                     |   |   |         |   |        |
| INJURY:  |        |   |                     |   |   |         |   |        |
| State:   |        |   |                     |   |   |         |   |        |
| City or  |        |   |                     |   |   |         |   |        |
| Town:    |        |   |                     |   |   |         |   |        |
|          |        |   |                     |   |   |         |   |        |
| Street & |        |   |                     |   |   |         |   |        |
| Number:  |        |   |                     |   |   |         |   |        |
| A        |        |   |                     |   |   |         |   |        |
| partment |        |   |                     |   |   |         |   |        |
| No.: Zip |        |   |                     |   |   |         |   |        |
| Code:    |        |   |                     |   |   |         |   |        |
+----------+--------+---+---------------------+---+---+---------+---+--------+
| 43\.     |        |   |                     |   |   | 44\. IF |   |        |
| DESCRIBE |        |   |                     |   |   | TRANSPO |   |        |
| HOW      |        |   |                     |   |   | RTATION |   |        |
| INJURY   |        |   |                     |   |   | INJURY, |   |        |
| O        |        |   |                     |   |   | S       |   |        |
| CCURRED: |        |   |                     |   |   | PECIFY: |   |        |
|          |        |   |                     |   |   |         |   |        |
|          |        |   |                     |   |   |        |   |        |
|          |        |   |                     |   |   | D       |   |        |
|          |        |   |                     |   |   | river/O |   |        |
|          |        |   |                     |   |   | perator |   |        |
|          |        |   |                     |   |   |         |   |        |
|          |        |   |                     |   |   | Pa   |   |        |
|          |        |   |                     |   |   | ssenger |   |        |
|          |        |   |                     |   |   |         |   |        |
|          |        |   |                     |   |   | Ped  |   |        |
|          |        |   |                     |   |   | estrian |   |        |
|          |        |   |                     |   |   |         |   |        |
|          |        |   |                     |   |   |        |   |        |
|          |        |   |                     |   |   | Other |   |        |
|          |        |   |                     |   |   | (S      |   |        |
|          |        |   |                     |   |   | pecify) |   |        |
+----------+--------+---+---------------------+---+---+---------+---+--------+

1\. What was the complication of the pregnancy (or a concomitant disease
or injury) that initiated the chain of events leading to death?

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

2\. Was the abortion spontaneous \_\_\_?, legally induced\_\_\_?,
therapeutic \_\_\_? other\_\_\_?

3\. Other
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

[, M.D.]{.underline}

(Signature of Certifying Physician)

Please provide your office
phone:\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
fax:\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

(Please see other side)

Instructions on Medical Certification of Causes of Death

Example of properly completed medical certification

+----------+--------+---+---------------------+---+---+---------+---+--------+
| **CAUSE  |        |   |                     |   |   |         |   | Appro  |
| OF DEATH |        |   |                     |   |   |         |   | ximate |
| (See     |        |   |                     |   |   |         |   | int    |
| inst     |        |   |                     |   |   |         |   | erval: |
| ructions |        |   |                     |   |   |         |   |        |
| and      |        |   |                     |   |   |         |   | Onset  |
| exa      |        |   |                     |   |   |         |   | to     |
| mples)** |        |   |                     |   |   |         |   | death  |
|          |        |   |                     |   |   |         |   |        |
| 32\.     |        |   |                     |   |   |         |   | [10    |
| **PART   |        |   |                     |   |   |         |   | mi     |
| I.**     |        |   |                     |   |   |         |   | nutes] |
| Enter    |        |   |                     |   |   |         |   | {.unde |
| the      |        |   |                     |   |   |         |   | rline} |
| [chain   |        |   |                     |   |   |         |   |        |
| of       |        |   |                     |   |   |         |   | [1     |
| events]  |        |   |                     |   |   |         |   | day\_] |
| {.underl |        |   |                     |   |   |         |   | {.unde |
| ine}\--d |        |   |                     |   |   |         |   | rline} |
| iseases, |        |   |                     |   |   |         |   |        |
| i        |        |   |                     |   |   |         |   | [1     |
| njuries, |        |   |                     |   |   |         |   | day\_] |
| or       |        |   |                     |   |   |         |   | {.unde |
| comp     |        |   |                     |   |   |         |   | rline} |
| lication |        |   |                     |   |   |         |   |        |
| s\--that |        |   |                     |   |   |         |   | [\     |
| directly |        |   |                     |   |   |         |   | _\_\_\ |
| caused   |        |   |                     |   |   |         |   | _\_\_] |
| the      |        |   |                     |   |   |         |   | {.unde |
| death.   |        |   |                     |   |   |         |   | rline} |
| DO NOT   |        |   |                     |   |   |         |   |        |
| enter    |        |   |                     |   |   |         |   |        |
| terminal |        |   |                     |   |   |         |   |        |
| events   |        |   |                     |   |   |         |   |        |
| such as  |        |   |                     |   |   |         |   |        |
| cardiac  |        |   |                     |   |   |         |   |        |
|          |        |   |                     |   |   |         |   |        |
| arrest,  |        |   |                     |   |   |         |   |        |
| res      |        |   |                     |   |   |         |   |        |
| piratory |        |   |                     |   |   |         |   |        |
| arrest,  |        |   |                     |   |   |         |   |        |
| or       |        |   |                     |   |   |         |   |        |
| ven      |        |   |                     |   |   |         |   |        |
| tricular |        |   |                     |   |   |         |   |        |
| fibr     |        |   |                     |   |   |         |   |        |
| illation |        |   |                     |   |   |         |   |        |
| without  |        |   |                     |   |   |         |   |        |
| showing  |        |   |                     |   |   |         |   |        |
| the      |        |   |                     |   |   |         |   |        |
| e        |        |   |                     |   |   |         |   |        |
| tiology. |        |   |                     |   |   |         |   |        |
| DO NOT   |        |   |                     |   |   |         |   |        |
| ABB      |        |   |                     |   |   |         |   |        |
| REVIATE. |        |   |                     |   |   |         |   |        |
| Enter    |        |   |                     |   |   |         |   |        |
| only one |        |   |                     |   |   |         |   |        |
| cause on |        |   |                     |   |   |         |   |        |
| a line.  |        |   |                     |   |   |         |   |        |
| Add      |        |   |                     |   |   |         |   |        |
| ad       |        |   |                     |   |   |         |   |        |
| ditional |        |   |                     |   |   |         |   |        |
|          |        |   |                     |   |   |         |   |        |
| lines if |        |   |                     |   |   |         |   |        |
| ne       |        |   |                     |   |   |         |   |        |
| cessary. |        |   |                     |   |   |         |   |        |
|          |        |   |                     |   |   |         |   |        |
| I        |        |   |                     |   |   |         |   |        |
| MMEDIATE |        |   |                     |   |   |         |   |        |
| CAUSE    |        |   |                     |   |   |         |   |        |
| (Final   |        |   |                     |   |   |         |   |        |
|          |        |   |                     |   |   |         |   |        |
| disease  |        |   |                     |   |   |         |   |        |
| or       |        |   |                     |   |   |         |   |        |
| c        |        |   |                     |   |   |         |   |        |
| ondition |        |   |                     |   |   |         |   |        |
| **\-\-\  |        |   |                     |   |   |         |   |        |
| -\-\-\-\ |        |   |                     |   |   |         |   |        |
| -\--\>** |        |   |                     |   |   |         |   |        |
| a.       |        |   |                     |   |   |         |   |        |
| [In      |        |   |                     |   |   |         |   |        |
| testinal |        |   |                     |   |   |         |   |        |
| he       |        |   |                     |   |   |         |   |        |
| morrhage |        |   |                     |   |   |         |   |        |
| \_\      |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_]{.un |        |   |                     |   |   |         |   |        |
| derline} |        |   |                     |   |   |         |   |        |
|          |        |   |                     |   |   |         |   |        |
| r        |        |   |                     |   |   |         |   |        |
| esulting |        |   |                     |   |   |         |   |        |
| in       |        |   |                     |   |   |         |   |        |
| death)   |        |   |                     |   |   |         |   |        |
| Due to   |        |   |                     |   |   |         |   |        |
| (or as a |        |   |                     |   |   |         |   |        |
| con      |        |   |                     |   |   |         |   |        |
| sequence |        |   |                     |   |   |         |   |        |
| of):     |        |   |                     |   |   |         |   |        |
|          |        |   |                     |   |   |         |   |        |
| Sequ     |        |   |                     |   |   |         |   |        |
| entially |        |   |                     |   |   |         |   |        |
| list     |        |   |                     |   |   |         |   |        |
| con      |        |   |                     |   |   |         |   |        |
| ditions, |        |   |                     |   |   |         |   |        |
| b.       |        |   |                     |   |   |         |   |        |
| [        |        |   |                     |   |   |         |   |        |
| Ruptured |        |   |                     |   |   |         |   |        |
| i        |        |   |                     |   |   |         |   |        |
| ntestine |        |   |                     |   |   |         |   |        |
| \_\_\_\  |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_]{.un |        |   |                     |   |   |         |   |        |
| derline} |        |   |                     |   |   |         |   |        |
|          |        |   |                     |   |   |         |   |        |
| if any,  |        |   |                     |   |   |         |   |        |
| leading  |        |   |                     |   |   |         |   |        |
| to the   |        |   |                     |   |   |         |   |        |
| cause    |        |   |                     |   |   |         |   |        |
| Due to   |        |   |                     |   |   |         |   |        |
| (or as a |        |   |                     |   |   |         |   |        |
| con      |        |   |                     |   |   |         |   |        |
| sequence |        |   |                     |   |   |         |   |        |
| of):     |        |   |                     |   |   |         |   |        |
|          |        |   |                     |   |   |         |   |        |
| listed   |        |   |                     |   |   |         |   |        |
| on line  |        |   |                     |   |   |         |   |        |
| a. Enter |        |   |                     |   |   |         |   |        |
| the      |        |   |                     |   |   |         |   |        |
|          |        |   |                     |   |   |         |   |        |
| **UN     |        |   |                     |   |   |         |   |        |
| DERLYING |        |   |                     |   |   |         |   |        |
| CAUSE**  |        |   |                     |   |   |         |   |        |
| c.       |        |   |                     |   |   |         |   |        |
| [Non-m   |        |   |                     |   |   |         |   |        |
| edically |        |   |                     |   |   |         |   |        |
| induced  |        |   |                     |   |   |         |   |        |
| abortio  |        |   |                     |   |   |         |   |        |
| n\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_]{.un |        |   |                     |   |   |         |   |        |
| derline} |        |   |                     |   |   |         |   |        |
|          |        |   |                     |   |   |         |   |        |
| (disease |        |   |                     |   |   |         |   |        |
| or       |        |   |                     |   |   |         |   |        |
| injury   |        |   |                     |   |   |         |   |        |
| that Due |        |   |                     |   |   |         |   |        |
| to (or   |        |   |                     |   |   |         |   |        |
| as a     |        |   |                     |   |   |         |   |        |
| con      |        |   |                     |   |   |         |   |        |
| sequence |        |   |                     |   |   |         |   |        |
| of):     |        |   |                     |   |   |         |   |        |
|          |        |   |                     |   |   |         |   |        |
| i        |        |   |                     |   |   |         |   |        |
| nitiated |        |   |                     |   |   |         |   |        |
| the      |        |   |                     |   |   |         |   |        |
| events   |        |   |                     |   |   |         |   |        |
| r        |        |   |                     |   |   |         |   |        |
| esulting |        |   |                     |   |   |         |   |        |
|          |        |   |                     |   |   |         |   |        |
| in       |        |   |                     |   |   |         |   |        |
| death)   |        |   |                     |   |   |         |   |        |
| **LAST** |        |   |                     |   |   |         |   |        |
| d.       |        |   |                     |   |   |         |   |        |
| [\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_]{.un |        |   |                     |   |   |         |   |        |
| derline} |        |   |                     |   |   |         |   |        |
+----------+--------+---+---------------------+---+---+---------+---+--------+
| **PART   |        |   |                     |   | 3 |         |   |        |
| II.**    |        |   |                     |   | 3 |         |   |        |
| Enter    |        |   |                     |   | \ |         |   |        |
| other    |        |   |                     |   | . |         |   |        |
| [sig     |        |   |                     |   | W |         |   |        |
| nificant |        |   |                     |   | A |         |   |        |
| co       |        |   |                     |   | S |         |   |        |
| nditions |        |   |                     |   | A |         |   |        |
| cont     |        |   |                     |   | N |         |   |        |
| ributing |        |   |                     |   | A |         |   |        |
| to       |        |   |                     |   | U |         |   |        |
| de       |        |   |                     |   | T |         |   |        |
| ath]{.un |        |   |                     |   | O |         |   |        |
| derline} |        |   |                     |   | P |         |   |        |
| but not  |        |   |                     |   | S |         |   |        |
| r        |        |   |                     |   | Y |         |   |        |
| esulting |        |   |                     |   | P |         |   |        |
| in the   |        |   |                     |   | E |         |   |        |
| un       |        |   |                     |   | R |         |   |        |
| derlying |        |   |                     |   | F |         |   |        |
| cause    |        |   |                     |   | O |         |   |        |
| given in |        |   |                     |   | R |         |   |        |
| PART I   |        |   |                     |   | M |         |   |        |
|          |        |   |                     |   | E |         |   |        |
|          |        |   |                     |   | D |         |   |        |
|          |        |   |                     |   | ? |         |   |        |
|          |        |   |                     |   |   |         |   |        |
|          |        |   |                     |   |  |         |   |        |
|          |        |   |                     |   | Y |         |   |        |
|          |        |   |                     |   | e |         |   |        |
|          |        |   |                     |   | s |         |   |        |
|          |        |   |                     |   | ■ |         |   |        |
|          |        |   |                     |   | N |         |   |        |
|          |        |   |                     |   | o |         |   |        |
+----------+--------+---+---------------------+---+---+---------+---+--------+
|          |        |   |                     |   | 3 |         |   |        |
|          |        |   |                     |   | 4 |         |   |        |
|          |        |   |                     |   | \ |         |   |        |
|          |        |   |                     |   | . |         |   |        |
|          |        |   |                     |   | W |         |   |        |
|          |        |   |                     |   | E |         |   |        |
|          |        |   |                     |   | R |         |   |        |
|          |        |   |                     |   | E |         |   |        |
|          |        |   |                     |   | A |         |   |        |
|          |        |   |                     |   | U |         |   |        |
|          |        |   |                     |   | T |         |   |        |
|          |        |   |                     |   | O |         |   |        |
|          |        |   |                     |   | P |         |   |        |
|          |        |   |                     |   | S |         |   |        |
|          |        |   |                     |   | Y |         |   |        |
|          |        |   |                     |   | F |         |   |        |
|          |        |   |                     |   | I |         |   |        |
|          |        |   |                     |   | N |         |   |        |
|          |        |   |                     |   | D |         |   |        |
|          |        |   |                     |   | I |         |   |        |
|          |        |   |                     |   | N |         |   |        |
|          |        |   |                     |   | G |         |   |        |
|          |        |   |                     |   | S |         |   |        |
|          |        |   |                     |   | A |         |   |        |
|          |        |   |                     |   | V |         |   |        |
|          |        |   |                     |   | A |         |   |        |
|          |        |   |                     |   | I |         |   |        |
|          |        |   |                     |   | L |         |   |        |
|          |        |   |                     |   | A |         |   |        |
|          |        |   |                     |   | B |         |   |        |
|          |        |   |                     |   | L |         |   |        |
|          |        |   |                     |   | E |         |   |        |
|          |        |   |                     |   | T |         |   |        |
|          |        |   |                     |   | O |         |   |        |
|          |        |   |                     |   |   |         |   |        |
|          |        |   |                     |   | C |         |   |        |
|          |        |   |                     |   | O |         |   |        |
|          |        |   |                     |   | M |         |   |        |
|          |        |   |                     |   | P |         |   |        |
|          |        |   |                     |   | L |         |   |        |
|          |        |   |                     |   | E |         |   |        |
|          |        |   |                     |   | T |         |   |        |
|          |        |   |                     |   | E |         |   |        |
|          |        |   |                     |   | T |         |   |        |
|          |        |   |                     |   | H |         |   |        |
|          |        |   |                     |   | E |         |   |        |
|          |        |   |                     |   | C |         |   |        |
|          |        |   |                     |   | A |         |   |        |
|          |        |   |                     |   | U |         |   |        |
|          |        |   |                     |   | S |         |   |        |
|          |        |   |                     |   | E |         |   |        |
|          |        |   |                     |   | O |         |   |        |
|          |        |   |                     |   | F |         |   |        |
|          |        |   |                     |   | D |         |   |        |
|          |        |   |                     |   | E |         |   |        |
|          |        |   |                     |   | A |         |   |        |
|          |        |   |                     |   | T |         |   |        |
|          |        |   |                     |   | H |         |   |        |
|          |        |   |                     |   | ? |         |   |        |
|          |        |   |                     |   |  |         |   |        |
|          |        |   |                     |   | Y |         |   |        |
|          |        |   |                     |   | e |         |   |        |
|          |        |   |                     |   | s |         |   |        |
|          |        |   |                     |   | ■ |         |   |        |
|          |        |   |                     |   | N |         |   |        |
|          |        |   |                     |   | o |         |   |        |
+----------+--------+---+---------------------+---+---+---------+---+--------+
| 35\. DID |        | 3 |                     | 3 |   |         |   |        |
| TOBACCO  |        | 6 |                     | 7 |   |         |   |        |
| USE      |        | \ |                     | \ |   |         |   |        |
| CO       |        | . |                     | . |   |         |   |        |
| NTRIBUTE |        | I |                     | M |   |         |   |        |
| TO       |        | F |                     | A |   |         |   |        |
| DEATH?   |        | F |                     | N |   |         |   |        |
|          |        | E |                     | N |   |         |   |        |
| Yes  |        | M |                     | E |   |         |   |        |
|       |        | A |                     | R |   |         |   |        |
| Probably |        | L |                     | O |   |         |   |        |
|          |        | E |                     | F |   |         |   |        |
| ■ No     |        | : |                     | D |   |         |   |        |
|        |        |   |                     | E |   |         |   |        |
| Unknown |        |  |                     | A |   |         |   |        |
|          |        |  |                     | T |   |         |   |        |
|          |        |  |                     | H |   |         |   |        |
|          |        | N |                     |   |   |         |   |        |
|          |        | o |                     | ■ |   |         |   |        |
|          |        | t |                     | N |   |         |   |        |
|          |        | p |                     | a |   |         |   |        |
|          |        | r |                     | t |   |         |   |        |
|          |        | e |                     | u |   |         |   |        |
|          |        | g |                     | r |   |         |   |        |
|          |        | n |                     | a |   |         |   |        |
|          |        | a |                     | l |   |         |   |        |
|          |        | n |                     |  |   |         |   |        |
|          |        | t |                     |  |   |         |   |        |
|          |        | w |                     |  |   |         |   |        |
|          |        | i |                     | H |   |         |   |        |
|          |        | t |                     | o |   |         |   |        |
|          |        | h |                     | m |   |         |   |        |
|          |        | i |                     | i |   |         |   |        |
|          |        | n |                     | c |   |         |   |        |
|          |        | p |                     | i |   |         |   |        |
|          |        | a |                     | d |   |         |   |        |
|          |        | s |                     | e |   |         |   |        |
|          |        | t |                     |   |   |         |   |        |
|          |        | y |                     |  |   |         |   |        |
|          |        | e |                     | A |   |         |   |        |
|          |        | a |                     | c |   |         |   |        |
|          |        | r |                     | c |   |         |   |        |
|          |        |   |                     | i |   |         |   |        |
|          |        |  |                     | d |   |         |   |        |
|          |        |  |                     | e |   |         |   |        |
|          |        |  |                     | n |   |         |   |        |
|          |        | P |                     | t |   |         |   |        |
|          |        | r |                     |  |   |         |   |        |
|          |        | e |                     |  |   |         |   |        |
|          |        | g |                     |  |   |         |   |        |
|          |        | n |                     | P |   |         |   |        |
|          |        | a |                     | e |   |         |   |        |
|          |        | n |                     | n |   |         |   |        |
|          |        | t |                     | d |   |         |   |        |
|          |        | a |                     | i |   |         |   |        |
|          |        | t |                     | n |   |         |   |        |
|          |        | t |                     | g |   |         |   |        |
|          |        | i |                     | I |   |         |   |        |
|          |        | m |                     | n |   |         |   |        |
|          |        | e |                     | v |   |         |   |        |
|          |        | o |                     | e |   |         |   |        |
|          |        | f |                     | s |   |         |   |        |
|          |        | d |                     | t |   |         |   |        |
|          |        | e |                     | i |   |         |   |        |
|          |        | a |                     | g |   |         |   |        |
|          |        | t |                     | a |   |         |   |        |
|          |        | h |                     | t |   |         |   |        |
|          |        |   |                     | i |   |         |   |        |
|          |        | ■ |                     | o |   |         |   |        |
|          |        | N |                     | n |   |         |   |        |
|          |        | o |                     |   |   |         |   |        |
|          |        | t |                     |  |   |         |   |        |
|          |        | p |                     |  |   |         |   |        |
|          |        | r |                     |  |   |         |   |        |
|          |        | e |                     | S |   |         |   |        |
|          |        | g |                     | u |   |         |   |        |
|          |        | n |                     | i |   |         |   |        |
|          |        | a |                     | c |   |         |   |        |
|          |        | n |                     | i |   |         |   |        |
|          |        | t |                     | d |   |         |   |        |
|          |        | , |                     | e |   |         |   |        |
|          |        | b |                     |  |   |         |   |        |
|          |        | u |                     |  |   |         |   |        |
|          |        | t |                     |  |   |         |   |        |
|          |        | p |                     | C |   |         |   |        |
|          |        | r |                     | o |   |         |   |        |
|          |        | e |                     | u |   |         |   |        |
|          |        | g |                     | l |   |         |   |        |
|          |        | n |                     | d |   |         |   |        |
|          |        | a |                     | n |   |         |   |        |
|          |        | n |                     | o |   |         |   |        |
|          |        | t |                     | t |   |         |   |        |
|          |        | w |                     | b |   |         |   |        |
|          |        | i |                     | e |   |         |   |        |
|          |        | t |                     | d |   |         |   |        |
|          |        | h |                     | e |   |         |   |        |
|          |        | i |                     | t |   |         |   |        |
|          |        | n |                     | e |   |         |   |        |
|          |        | 4 |                     | r |   |         |   |        |
|          |        | 2 |                     | m |   |         |   |        |
|          |        | d |                     | i |   |         |   |        |
|          |        | a |                     | n |   |         |   |        |
|          |        | y |                     | e |   |         |   |        |
|          |        | s |                     | d |   |         |   |        |
|          |        | o |                     |   |   |         |   |        |
|          |        | f |                     |   |   |         |   |        |
|          |        | d |                     |   |   |         |   |        |
|          |        | e |                     |   |   |         |   |        |
|          |        | a |                     |   |   |         |   |        |
|          |        | t |                     |   |   |         |   |        |
|          |        | h |                     |   |   |         |   |        |
|          |        |   |                     |   |   |         |   |        |
|          |        |  |                     |   |   |         |   |        |
|          |        |  |                     |   |   |         |   |        |
|          |        |  |                     |   |   |         |   |        |
|          |        | N |                     |   |   |         |   |        |
|          |        | o |                     |   |   |         |   |        |
|          |        | t |                     |   |   |         |   |        |
|          |        | p |                     |   |   |         |   |        |
|          |        | r |                     |   |   |         |   |        |
|          |        | e |                     |   |   |         |   |        |
|          |        | g |                     |   |   |         |   |        |
|          |        | n |                     |   |   |         |   |        |
|          |        | a |                     |   |   |         |   |        |
|          |        | n |                     |   |   |         |   |        |
|          |        | t |                     |   |   |         |   |        |
|          |        | , |                     |   |   |         |   |        |
|          |        | b |                     |   |   |         |   |        |
|          |        | u |                     |   |   |         |   |        |
|          |        | t |                     |   |   |         |   |        |
|          |        | p |                     |   |   |         |   |        |
|          |        | r |                     |   |   |         |   |        |
|          |        | e |                     |   |   |         |   |        |
|          |        | g |                     |   |   |         |   |        |
|          |        | n |                     |   |   |         |   |        |
|          |        | a |                     |   |   |         |   |        |
|          |        | n |                     |   |   |         |   |        |
|          |        | t |                     |   |   |         |   |        |
|          |        | 4 |                     |   |   |         |   |        |
|          |        | 3 |                     |   |   |         |   |        |
|          |        | d |                     |   |   |         |   |        |
|          |        | a |                     |   |   |         |   |        |
|          |        | y |                     |   |   |         |   |        |
|          |        | s |                     |   |   |         |   |        |
|          |        | t |                     |   |   |         |   |        |
|          |        | o |                     |   |   |         |   |        |
|          |        | 1 |                     |   |   |         |   |        |
|          |        | y |                     |   |   |         |   |        |
|          |        | e |                     |   |   |         |   |        |
|          |        | a |                     |   |   |         |   |        |
|          |        | r |                     |   |   |         |   |        |
|          |        | b |                     |   |   |         |   |        |
|          |        | e |                     |   |   |         |   |        |
|          |        | f |                     |   |   |         |   |        |
|          |        | o |                     |   |   |         |   |        |
|          |        | r |                     |   |   |         |   |        |
|          |        | e |                     |   |   |         |   |        |
|          |        | d |                     |   |   |         |   |        |
|          |        | e |                     |   |   |         |   |        |
|          |        | a |                     |   |   |         |   |        |
|          |        | t |                     |   |   |         |   |        |
|          |        | h |                     |   |   |         |   |        |
|          |        |   |                     |   |   |         |   |        |
|          |        |  |                     |   |   |         |   |        |
|          |        |  |                     |   |   |         |   |        |
|          |        |  |                     |   |   |         |   |        |
|          |        | U |                     |   |   |         |   |        |
|          |        | n |                     |   |   |         |   |        |
|          |        | k |                     |   |   |         |   |        |
|          |        | n |                     |   |   |         |   |        |
|          |        | o |                     |   |   |         |   |        |
|          |        | w |                     |   |   |         |   |        |
|          |        | n |                     |   |   |         |   |        |
|          |        | i |                     |   |   |         |   |        |
|          |        | f |                     |   |   |         |   |        |
|          |        | p |                     |   |   |         |   |        |
|          |        | r |                     |   |   |         |   |        |
|          |        | e |                     |   |   |         |   |        |
|          |        | g |                     |   |   |         |   |        |
|          |        | n |                     |   |   |         |   |        |
|          |        | a |                     |   |   |         |   |        |
|          |        | n |                     |   |   |         |   |        |
|          |        | t |                     |   |   |         |   |        |
|          |        | w |                     |   |   |         |   |        |
|          |        | i |                     |   |   |         |   |        |
|          |        | t |                     |   |   |         |   |        |
|          |        | h |                     |   |   |         |   |        |
|          |        | i |                     |   |   |         |   |        |
|          |        | n |                     |   |   |         |   |        |
|          |        | t |                     |   |   |         |   |        |
|          |        | h |                     |   |   |         |   |        |
|          |        | e |                     |   |   |         |   |        |
|          |        | p |                     |   |   |         |   |        |
|          |        | a |                     |   |   |         |   |        |
|          |        | s |                     |   |   |         |   |        |
|          |        | t |                     |   |   |         |   |        |
|          |        | y |                     |   |   |         |   |        |
|          |        | e |                     |   |   |         |   |        |
|          |        | a |                     |   |   |         |   |        |
|          |        | r |                     |   |   |         |   |        |
+----------+--------+---+---------------------+---+---+---------+---+--------+
| 38\.     | 39\.   |   | 40\. PLACE OF       |   |   |         | 4 |        |
| DATE OF  | TIME   |   | INJURY (e.g.,       |   |   |         | 1 |        |
| INJURY   | OF     |   | Decedent's home;    |   |   |         | \ |        |
|          | INJURY |   | construction site;  |   |   |         | . |        |
| (Mo      |        |   | restaurant; wooded  |   |   |         | I |        |
| /Day/Yr) | A      |   | area)               |   |   |         | N |        |
| (Spell   | pprox. |   |                     |   |   |         | J |        |
| Month)   | 2320   |   |                     |   |   |         | U |        |
|          |        |   |                     |   |   |         | R |        |
| August   |        |   |                     |   |   |         | Y |        |
| 15, 2003 |        |   |                     |   |   |         | A |        |
|          |        |   |                     |   |   |         | T |        |
|          |        |   |                     |   |   |         | W |        |
|          |        |   |                     |   |   |         | O |        |
|          |        |   |                     |   |   |         | R |        |
|          |        |   |                     |   |   |         | K |        |
|          |        |   |                     |   |   |         | ? |        |
|          |        |   |                     |   |   |         |   |        |
|          |        |   |                     |   |   |         |  |        |
|          |        |   |                     |   |   |         | Y |        |
|          |        |   |                     |   |   |         | e |        |
|          |        |   |                     |   |   |         | s |        |
|          |        |   |                     |   |   |         |  |        |
|          |        |   |                     |   |   |         | N |        |
|          |        |   |                     |   |   |         | o |        |
+----------+--------+---+---------------------+---+---+---------+---+--------+
| 42\.     |        |   |                     |   |   |         |   |        |
| LOCATION |        |   |                     |   |   |         |   |        |
| OF       |        |   |                     |   |   |         |   |        |
| INJURY:  |        |   |                     |   |   |         |   |        |
| State:   |        |   |                     |   |   |         |   |        |
| Missouri |        |   |                     |   |   |         |   |        |
| City or  |        |   |                     |   |   |         |   |        |
| Town:    |        |   |                     |   |   |         |   |        |
| near     |        |   |                     |   |   |         |   |        |
| Al       |        |   |                     |   |   |         |   |        |
| exandria |        |   |                     |   |   |         |   |        |
|          |        |   |                     |   |   |         |   |        |
| Street & |        |   |                     |   |   |         |   |        |
| Number:  |        |   |                     |   |   |         |   |        |
| mile     |        |   |                     |   |   |         |   |        |
| marker   |        |   |                     |   |   |         |   |        |
| 17 on    |        |   |                     |   |   |         |   |        |
| state    |        |   |                     |   |   |         |   |        |
| route    |        |   |                     |   |   |         |   |        |
| 46a      |        |   |                     |   |   |         |   |        |
| A        |        |   |                     |   |   |         |   |        |
| partment |        |   |                     |   |   |         |   |        |
| No.: Zip |        |   |                     |   |   |         |   |        |
| Code:    |        |   |                     |   |   |         |   |        |
+----------+--------+---+---------------------+---+---+---------+---+--------+
| 43\.     |        |   |                     |   |   | 44\. IF |   |        |
| DESCRIBE |        |   |                     |   |   | TRANSPO |   |        |
| HOW      |        |   |                     |   |   | RTATION |   |        |
| INJURY   |        |   |                     |   |   | INJURY, |   |        |
| O        |        |   |                     |   |   | S       |   |        |
| CCURRED: |        |   |                     |   |   | PECIFY: |   |        |
|          |        |   |                     |   |   |         |   |        |
|          |        |   |                     |   |   |        |   |        |
|          |        |   |                     |   |   | D       |   |        |
|          |        |   |                     |   |   | river/O |   |        |
|          |        |   |                     |   |   | perator |   |        |
|          |        |   |                     |   |   |         |   |        |
|          |        |   |                     |   |   | Pa   |   |        |
|          |        |   |                     |   |   | ssenger |   |        |
|          |        |   |                     |   |   |         |   |        |
|          |        |   |                     |   |   | Ped  |   |        |
|          |        |   |                     |   |   | estrian |   |        |
|          |        |   |                     |   |   |         |   |        |
|          |        |   |                     |   |   |        |   |        |
|          |        |   |                     |   |   | Other |   |        |
|          |        |   |                     |   |   | (S      |   |        |
|          |        |   |                     |   |   | pecify) |   |        |
+----------+--------+---+---------------------+---+---+---------+---+--------+

**ITEM 32 -- CAUSE OF DEATH (See example above)**

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.

Take care to make the entry legible. Use a computer printer with high
resolution, typewriter with good black ribbon and clean keys, or print
legibly using permanent **black** ink in completing the CAUSE OF DEATH
Section. **Do** **not** **abbreviate** conditions entered in section.

**[Part I]{.underline} (Chain of events leading directly to death)**

•Only **one** cause should be entered on each line. [Line
(a)]{.underline} **MUST ALWAYS** have an entry. **DO NOT** leave blank.
Additional lines may be added if necessary.

•If the condition on [Line (a)]{.underline} resulted from an underlying
condition, put the underlying condition on [Line (b)]{.underline}, and
so on, until the full sequence is reported. **ALWAYS** enter the
**underlying cause of death** on the [lowest used line]{.underline} in
Part I.

•For each cause indicate the best estimate of the interval between the
presumed onset and the date of death. The terms "unknown" or
"approximately" may be used. General terms, such as minutes, hours, or
days, are acceptable, if necessary. **DO NOT** leave blank.

•The terminal event (for example, cardiac arrest or respiratory arrest)
should not be used. If a mechanism of death seems most appropriate to
you for line (a), then you must always list its cause(s) on the line(s)
below it (for example, cardiac arrest **due to** coronary artery
atherosclerosis *or* cardiac arrest **due to** blunt impact to chest).

• If an organ system failure such as congestive heart failure, hepatic
failure, renal failure, or respiratory failure is listed as a cause of
death, always report its etiology on the line(s) beneath it (for
example, renal failure **due to** Type I diabetes mellitus).

•When indicating neoplasms as a cause of death, include the
following: 1) primary site *or* that the primary site is unknown, 2)
benign or malignant, 3) cell type *or* that the cell type is unknown, 4)
grade of neoplasm, and 5) part or lobe of organ affected. (For example,
a primary well-differentiated squamous cell carcinoma, lung, left upper
lobe.)

•Always report the fatal injury (for example, stab wound of chest), the
trauma (for example, transection of subclavian vein), and impairment of
function (for example, air embolism).

**Part II (Other significant conditions)**

•Enter all diseases or conditions contributing to death that were not
reported in the chain of events in Part I and that did not result in the
**underlying cause of death**.

•If two or more possible sequences resulted in death, or if two
conditions seem to have added together, report in Part I the one that,
in your opinion, most directly caused death. Report in Part II the other
conditions or diseases.

**CHANGES TO CAUSE OF DEATH**

Should additional medical information or autopsy findings become
available that would change the cause of death originally reported, the
original death certificate should be amended by the certifying physician
by **immediately** reporting the revised cause of death to the State
Vital Records Office.

**ITEMS ON WHEN DEATH OCCURRED**

Items 24-25 and 29-31 should always be completed. If the facility uses a
separate pronouncer or other person to indicate that death has taken
place with another person more familiar with the case completing the
remainder of the medical portion of the death certificate, the
pronouncer completes Items 24-28. If a certifier completes Items 24-25
as well as items 29-49, Items 26-28 may be left blank.

**ITEMS 24-25, 29-30 -- DATE AND TIME OF DEATH**

Spell out the name of the month. If the exact date of death is unknown,
enter the **approximate** date. If the date cannot be approximated,
enter the date the body is found and identify as **date found**. Date
pronounced and actual date may be the same. Enter the exact hour and
minutes according to a 24-hour clock; estimates may be provided with
"Approx." placed before the time.

**ITEMS 33-34 - AUTOPSY**

•33 - Enter "Yes" if either a partial or full autopsy was performed.
Otherwise enter "No."

•34 - Enter "Yes" if autopsy findings were available to complete the
cause of death; otherwise enter "No". Leave item blank if no autopsy was
performed.

**ITEM 35 - DID TOBACCO USE CONTRIBUTE TO DEATH?**

Check "yes" if, in your opinion, the use of tobacco contributed to
death. Tobacco use may contribute to deaths due to a wide variety of
diseases; for example, tobacco use contributes to many deaths due to
emphysema or lung cancer and some heart disease and cancers of the head
and neck. Check "no" if, in your clinical judgment, tobacco use did not
contribute to this particular death.

**ITEM 36 - IF FEMALE, WAS DECEDENT PREGNANT AT TIME OF DEATH OR WITHIN
PAST YEAR?**

This information is important in determining pregnancy-related
mortality.

**ITEM 37 - MANNER OF DEATH**

•Always check Manner of Death, which is important: 1) in determining
accurate causes of death; 2) in processing insurance claims; and 3) in
statistical studies of injuries and death.

•Indicate "Pending investigation" if the manner of death cannot be
determined whether due to an accident, suicide, or homicide within the
statutory time limit for filing the death certificate. This should be
changed later to one of the other terms.

•Indicate "Could not be Determined" **ONLY** when it is impossible to
determine the manner of death.

**ITEMS 38-44 - ACCIDENT OR INJURY -- to be filled out in all cases of
deaths due to injury or poisoning.**

•38 - Enter the exact month, day, and year of injury. Spell out the name
of the month. **DO NOT** use a number for the month. (Remember, the date
of injury may differ from the date of death.) Estimates may be provided
with "Approx." placed before the date.

•39 **-** Enter the exact hour and minutes of injury or use your best
estimate. Use a 24-hour clock.

•40 - Enter the general place (such as restaurant, vacant lot, or home)
where the injury occurred. **DO NOT** enter firm or organization names.
(For example, enter "factory", **not** "Standard Manufacturing, Inc." )

•41 - Complete if anything other than natural disease is mentioned in
Part I or Part II of the medical certification, including homicides,
suicides, and accidents. This includes all motor vehicle deaths. The
item **[must]{.underline}** be completed for decedents ages 14 years or
over and may be completed for those less than 14 years of age if
warranted. Enter "Yes" if the injury occurred at work. Otherwise enter
"No". An injury may occur at work regardless of whether the injury
occurred in the course of the decedent's "usual" occupation. Examples of
injury at work and injury not at work follow:

+-----------------------------------+-----------------------------------+
| **Injury at work**                | **Injury [not]{.underline} at     |
|                                   | work**                            |
| Injury while working or in        |                                   |
| vocational training on job        | Injury while engaged in personal  |
| premises                          | recreational activity on job      |
|                                   | premises                          |
| Injury while on break or at lunch |                                   |
| or in parking lot on job premises | Injury while a visitor (not on    |
|                                   | official work business) to job    |
| Injury while working for pay or   | premises                          |
| compensation, including at home   |                                   |
|                                   | Homemaker working at homemaking   |
| Injury while working as a         | activities                        |
| volunteer law enforcement         |                                   |
| official etc.                     | Student in school                 |
|                                   |                                   |
| Injury while traveling on         | Working for self for no profit    |
| business, including to/from       | (mowing yard, repairing own roof, |
| business contacts                 | hobby)                            |
|                                   |                                   |
|                                   | Commuting to or from work         |
+-----------------------------------+-----------------------------------+

•42 - Enter the complete address where the injury occurred including zip
code.

•43 - Enter a brief but specific and clear description of how the injury
occurred. Explain the circumstances or cause of the injury. Specify
**type** **of** **gun** or **type of vehicle** (e.g., car, bulldozer,
train, etc.) when relevant to circumstances. Indicate if more than one
vehicle involved; specify type of vehicle decedent was in.

•44 -Specify role of decedent (e.g. driver, passenger). Driver/operator
and passenger should be designated for modes other than motor vehicles
such as bicycles. Other applies to watercraft, aircraft, animal, or
people attached to outside of vehicles (e.g. surfers).

[Rationale]{.underline}: Motor vehicle accidents are a major cause of
unintentional deaths; details will help determine effectiveness of
current safety features and laws.

**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:]{.underline}**

+-------------+-------------+-------------+-------------+-------------+
| Abscess     | Car         | D           | H           | Pulmonary   |
|             | cinomatosis | isseminated | yponatremia | arrest      |
| Abdominal   |             | intra       |             |             |
| hemorrhage  | Cardiac     | vascular    | Hypotension | Pulmonary   |
|             | arrest      |             |             | edema       |
| Adhesions   |             | c           | Immuno      |             |
|             | Cardiac     | oagulopathy | suppression | Pulmonary   |
| Adult       | dysrhythmia |             |             | embolism    |
| respiratory |             | Dysrhythmia | Increased   |             |
| distress    | Car         |             | intra       | Pulmonary   |
| syndrome    | diomyopathy | End-stage   | cranial     | in          |
|             |             | liver       | pressure    | sufficiency |
| Acute       | Card        | disease     |             |             |
| myocardial  | iopulmonary |             | Intra       | Renal       |
| infarction  | arrest      | End-stage   | cranial     | failure     |
|             |             | renal       | hemorrhage  |             |
| Altered     | Cellulitis  | disease     |             | Respiratory |
| mental      |             |             | M           | arrest      |
| status      | Cerebral    | Epidural    | alnutrition |             |
|             | edema       | hematoma    |             | Seizures    |
| Anemia      |             |             | Metabolic   |             |
|             | Cere        | Exs         | enc         | Sepsis      |
| Anoxia      | brovascular | anguination | ephalopathy |             |
|             | accident    |             |             | Septic      |
| Anoxic      |             | Failure to  | Multi-organ | shock       |
| enc         | Cerebellar  | thrive      | failure     |             |
| ephalopathy | tonsillar   |             |             | Shock       |
|             | herniation  | Fracture    | M           |             |
| Arrhythmia  |             |             | ulti-system | Starvation  |
|             | Chronic     | Gangrene    | organ       |             |
| Ascites     | bedridden   |             | failure     | Subdural    |
|             | state       | Gastr       |             | hematoma    |
| Aspiration  |             | ointestinal | Myocardial  |             |
|             | Cirrhosis   | hemorrhage  | infarction  | S           |
| Atrial      |             |             |             | ubarachnoid |
| f           | C           | Heart       | Necrotizing | hemorrhage  |
| ibrillation | oagulopathy | failure     | soft-tissue |             |
|             |             |             | infection   | Sudden      |
| Bacteremia  | Compression | Hemothorax  |             | death       |
|             | fracture    |             | Old age     |             |
| Bedridden   |             | Hepatic     |             | Throm       |
|             | Congestive  | failure     | Open (or    | bocytopenia |
| Biliary     | heart       |             | closed)     |             |
| obstruction | failure     | Hepatitis   | head injury | Uncal       |
|             |             |             |             | herniation  |
| Bowel       | Convulsions | Hepatorenal | Paralysis   |             |
| obstruction |             | syndrome    |             | Urinary     |
|             | Decubiti    |             | P           | tract       |
| Brain       |             | Hy          | ancytopenia | infection   |
| injury      | Dehydration | perglycemia |             |             |
|             |             |             | Perforated  | Ventricular |
| Brain stem  | Dementia    | H           | gallbladder | f           |
| herniation  | (when not   | yperkalemia |             | ibrillation |
|             |             |             | Peritonitis |             |
| Car         | otherwise   | Hypovolemic |             | Ventricular |
| cinogenesis | specified)  | shock       | Pleural     | tachycardia |
|             |             |             | effusions   |             |
|             | Diarrhea    |             |             | Volume      |
|             |             |             | Pneumonia   | 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    | Epidural    | Hip         | Pulmonary   | Subdural    |
|             | hematoma    | fracture    | emboli      | hematoma    |
| Bolus       |             |             |             |             |
|             | Exs         | H           | Seizure     | Surgery     |
| Choking     | anguination | yperthermia | disorder    |             |
|             |             |             |             | Thermal     |
| Drug or     | Fall        | Hypothermia | Sepsis      | bur         |
| alcohol     |             |             |             | ns/chemical |
| ov          | Fracture    | Open        | S           | burns       |
| erdose/drug |             | reduction   | ubarachnoid |             |
| or          |             | of fracture | hemorrhage  |             |
|             |             |             |             |             |
| alcohol     |             |             |             |             |
| abuse       |             |             |             |             |
+-------------+-------------+-------------+-------------+-------------+

Contact your State vital statistics office for questions related to
writing cause-of-death statements. Additional instructional material on
writing cause-of-death statements including handbooks, summary
instructions, and tutorials are available online at www.thename.org or
www.cdc.gov/nchswww/about/major/dvs/handbk.htm, or by request from NCHS,
Room 7318, 3311 Toledo Road, Hyattsville, Maryland 20782-2003.

Query Letter 10

(External Causes)

*The following sample query letter consists of a lengthy series of
questions even though the attachments have been separated into four. The
questions are designed to address a variety of problems in
certification. We would suggest that specific query letters list only
the questions that are relevant for the specific case. This will improve
the appearance of the query letter.*

(Letterhead)

Dear Doctor \_\_\_\_\_\_\_\_

We are writing this letter to obtain additional information about the
cause of death that you certified for
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_, who died
\_\_\_\_\_\_\_\_\_\_\_\_\_.

Accurate cause-of-death information is essential, not only to the family
of the decedent, but also for medical research, funding, and resource
allocation in our State and at the national level.

In this particular death, we need additional information to properly
classify the death. In order to classify this death properly in our
statistics, would you please supply the information on the attachment?
We want to assure you that the information you provide us is
confidential and will be handled accordingly.

If you have any question, please
contact\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_.
Instructions and an example of a properly completed death certificate
are provided with the attached material.

We appreciate your attention and prompt reply.

Sincerely,

State Registrar/Vital Statistics Cooperative Program

4 Attachments

Query for Accidents Not Involving Transportation

+----------+--------+---+---------------------+---+---+---------+---+--------+
| **CAUSE  |        |   |                     |   |   |         |   | Appro  |
| OF DEATH |        |   |                     |   |   |         |   | ximate |
| (See     |        |   |                     |   |   |         |   | int    |
| inst     |        |   |                     |   |   |         |   | erval: |
| ructions |        |   |                     |   |   |         |   |        |
| and      |        |   |                     |   |   |         |   | Onset  |
| exa      |        |   |                     |   |   |         |   | to     |
| mples)** |        |   |                     |   |   |         |   | death  |
|          |        |   |                     |   |   |         |   |        |
| 32\.     |        |   |                     |   |   |         |   | [\_\   |
| **PART   |        |   |                     |   |   |         |   | _\_\_\ |
| I.**     |        |   |                     |   |   |         |   | _\_\_] |
| Enter    |        |   |                     |   |   |         |   | {.unde |
| the      |        |   |                     |   |   |         |   | rline} |
| [chain   |        |   |                     |   |   |         |   |        |
| of       |        |   |                     |   |   |         |   | [\_\   |
| events]  |        |   |                     |   |   |         |   | _\_\_\ |
| {.underl |        |   |                     |   |   |         |   | _\_\_] |
| ine}\--d |        |   |                     |   |   |         |   | {.unde |
| iseases, |        |   |                     |   |   |         |   | rline} |
| i        |        |   |                     |   |   |         |   |        |
| njuries, |        |   |                     |   |   |         |   | [\_\_\ |
| or       |        |   |                     |   |   |         |   | _\_\_\ |
| comp     |        |   |                     |   |   |         |   | _\_\_] |
| lication |        |   |                     |   |   |         |   | {.unde |
| s\--that |        |   |                     |   |   |         |   | rline} |
| directly |        |   |                     |   |   |         |   |        |
| caused   |        |   |                     |   |   |         |   | [\_\   |
| the      |        |   |                     |   |   |         |   | _\_\_\ |
| death.   |        |   |                     |   |   |         |   | _\_\_] |
| DO NOT   |        |   |                     |   |   |         |   | {.unde |
| enter    |        |   |                     |   |   |         |   | rline} |
| terminal |        |   |                     |   |   |         |   |        |
| events   |        |   |                     |   |   |         |   |        |
| such as  |        |   |                     |   |   |         |   |        |
| cardiac  |        |   |                     |   |   |         |   |        |
|          |        |   |                     |   |   |         |   |        |
| arrest,  |        |   |                     |   |   |         |   |        |
| res      |        |   |                     |   |   |         |   |        |
| piratory |        |   |                     |   |   |         |   |        |
| arrest,  |        |   |                     |   |   |         |   |        |
| or       |        |   |                     |   |   |         |   |        |
| ven      |        |   |                     |   |   |         |   |        |
| tricular |        |   |                     |   |   |         |   |        |
| fibr     |        |   |                     |   |   |         |   |        |
| illation |        |   |                     |   |   |         |   |        |
| without  |        |   |                     |   |   |         |   |        |
| showing  |        |   |                     |   |   |         |   |        |
| the      |        |   |                     |   |   |         |   |        |
| e        |        |   |                     |   |   |         |   |        |
| tiology. |        |   |                     |   |   |         |   |        |
| DO NOT   |        |   |                     |   |   |         |   |        |
| ABB      |        |   |                     |   |   |         |   |        |
| REVIATE. |        |   |                     |   |   |         |   |        |
| Enter    |        |   |                     |   |   |         |   |        |
| only one |        |   |                     |   |   |         |   |        |
| cause on |        |   |                     |   |   |         |   |        |
| a line.  |        |   |                     |   |   |         |   |        |
| Add      |        |   |                     |   |   |         |   |        |
| ad       |        |   |                     |   |   |         |   |        |
| ditional |        |   |                     |   |   |         |   |        |
|          |        |   |                     |   |   |         |   |        |
| lines if |        |   |                     |   |   |         |   |        |
| ne       |        |   |                     |   |   |         |   |        |
| cessary. |        |   |                     |   |   |         |   |        |
|          |        |   |                     |   |   |         |   |        |
| I        |        |   |                     |   |   |         |   |        |
| MMEDIATE |        |   |                     |   |   |         |   |        |
| CAUSE    |        |   |                     |   |   |         |   |        |
| (Final   |        |   |                     |   |   |         |   |        |
|          |        |   |                     |   |   |         |   |        |
| disease  |        |   |                     |   |   |         |   |        |
| or       |        |   |                     |   |   |         |   |        |
| c        |        |   |                     |   |   |         |   |        |
| ondition |        |   |                     |   |   |         |   |        |
| **\-\-\  |        |   |                     |   |   |         |   |        |
| -\-\-\-\ |        |   |                     |   |   |         |   |        |
| -\--\>** |        |   |                     |   |   |         |   |        |
| a.       |        |   |                     |   |   |         |   |        |
| [\_\     |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_]{.un |        |   |                     |   |   |         |   |        |
| derline} |        |   |                     |   |   |         |   |        |
|          |        |   |                     |   |   |         |   |        |
| r        |        |   |                     |   |   |         |   |        |
| esulting |        |   |                     |   |   |         |   |        |
| in       |        |   |                     |   |   |         |   |        |
| death)   |        |   |                     |   |   |         |   |        |
| Due to   |        |   |                     |   |   |         |   |        |
| (or as a |        |   |                     |   |   |         |   |        |
| con      |        |   |                     |   |   |         |   |        |
| sequence |        |   |                     |   |   |         |   |        |
| of):     |        |   |                     |   |   |         |   |        |
|          |        |   |                     |   |   |         |   |        |
| Sequ     |        |   |                     |   |   |         |   |        |
| entially |        |   |                     |   |   |         |   |        |
| list     |        |   |                     |   |   |         |   |        |
| con      |        |   |                     |   |   |         |   |        |
| ditions, |        |   |                     |   |   |         |   |        |
| b.       |        |   |                     |   |   |         |   |        |
| [\_\_    |        |   |                     |   |   |         |   |        |
| \_\_\_\_ |        |   |                     |   |   |         |   |        |
| \_\_\_\_ |        |   |                     |   |   |         |   |        |
| \_\_\_\_ |        |   |                     |   |   |         |   |        |
| \        |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_]{.un |        |   |                     |   |   |         |   |        |
| derline} |        |   |                     |   |   |         |   |        |
|          |        |   |                     |   |   |         |   |        |
| if any,  |        |   |                     |   |   |         |   |        |
| leading  |        |   |                     |   |   |         |   |        |
| to the   |        |   |                     |   |   |         |   |        |
| cause    |        |   |                     |   |   |         |   |        |
| Due to   |        |   |                     |   |   |         |   |        |
| (or as a |        |   |                     |   |   |         |   |        |
| con      |        |   |                     |   |   |         |   |        |
| sequence |        |   |                     |   |   |         |   |        |
| of):     |        |   |                     |   |   |         |   |        |
|          |        |   |                     |   |   |         |   |        |
| listed   |        |   |                     |   |   |         |   |        |
| on line  |        |   |                     |   |   |         |   |        |
| a. Enter |        |   |                     |   |   |         |   |        |
| the      |        |   |                     |   |   |         |   |        |
|          |        |   |                     |   |   |         |   |        |
| **UN     |        |   |                     |   |   |         |   |        |
| DERLYING |        |   |                     |   |   |         |   |        |
| CAUSE**  |        |   |                     |   |   |         |   |        |
| c.       |        |   |                     |   |   |         |   |        |
| [        |        |   |                     |   |   |         |   |        |
| \_\_\_\_ |        |   |                     |   |   |         |   |        |
| \_\_\_\_ |        |   |                     |   |   |         |   |        |
| \_\_\    |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_]{.un |        |   |                     |   |   |         |   |        |
| derline} |        |   |                     |   |   |         |   |        |
|          |        |   |                     |   |   |         |   |        |
| (disease |        |   |                     |   |   |         |   |        |
| or       |        |   |                     |   |   |         |   |        |
| injury   |        |   |                     |   |   |         |   |        |
| that Due |        |   |                     |   |   |         |   |        |
| to (or   |        |   |                     |   |   |         |   |        |
| as a     |        |   |                     |   |   |         |   |        |
| con      |        |   |                     |   |   |         |   |        |
| sequence |        |   |                     |   |   |         |   |        |
| of):     |        |   |                     |   |   |         |   |        |
|          |        |   |                     |   |   |         |   |        |
| i        |        |   |                     |   |   |         |   |        |
| nitiated |        |   |                     |   |   |         |   |        |
| the      |        |   |                     |   |   |         |   |        |
| events   |        |   |                     |   |   |         |   |        |
| r        |        |   |                     |   |   |         |   |        |
| esulting |        |   |                     |   |   |         |   |        |
|          |        |   |                     |   |   |         |   |        |
| in       |        |   |                     |   |   |         |   |        |
| death)   |        |   |                     |   |   |         |   |        |
| **LAST** |        |   |                     |   |   |         |   |        |
| d.       |        |   |                     |   |   |         |   |        |
| [        |        |   |                     |   |   |         |   |        |
| \_\_\_\_ |        |   |                     |   |   |         |   |        |
| \_\_\_\_ |        |   |                     |   |   |         |   |        |
| \_\_\_\_ |        |   |                     |   |   |         |   |        |
| \_\      |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_]{.un |        |   |                     |   |   |         |   |        |
| derline} |        |   |                     |   |   |         |   |        |
+----------+--------+---+---------------------+---+---+---------+---+--------+
| **PART   |        |   |                     |   | 3 |         |   |        |
| II.**    |        |   |                     |   | 3 |         |   |        |
| Enter    |        |   |                     |   | \ |         |   |        |
| other    |        |   |                     |   | . |         |   |        |
| [sig     |        |   |                     |   | W |         |   |        |
| nificant |        |   |                     |   | A |         |   |        |
| co       |        |   |                     |   | S |         |   |        |
| nditions |        |   |                     |   | A |         |   |        |
| cont     |        |   |                     |   | N |         |   |        |
| ributing |        |   |                     |   | A |         |   |        |
| to       |        |   |                     |   | U |         |   |        |
| de       |        |   |                     |   | T |         |   |        |
| ath]{.un |        |   |                     |   | O |         |   |        |
| derline} |        |   |                     |   | P |         |   |        |
| but not  |        |   |                     |   | S |         |   |        |
| r        |        |   |                     |   | Y |         |   |        |
| esulting |        |   |                     |   | P |         |   |        |
| in the   |        |   |                     |   | E |         |   |        |
| un       |        |   |                     |   | R |         |   |        |
| derlying |        |   |                     |   | F |         |   |        |
| cause    |        |   |                     |   | O |         |   |        |
| given in |        |   |                     |   | R |         |   |        |
| PART I   |        |   |                     |   | M |         |   |        |
|          |        |   |                     |   | E |         |   |        |
|          |        |   |                     |   | D |         |   |        |
|          |        |   |                     |   | ? |         |   |        |
|          |        |   |                     |   |   |         |   |        |
|          |        |   |                     |   |  |         |   |        |
|          |        |   |                     |   | Y |         |   |        |
|          |        |   |                     |   | e |         |   |        |
|          |        |   |                     |   | s |         |   |        |
|          |        |   |                     |   |  |         |   |        |
|          |        |   |                     |   |  |         |   |        |
|          |        |   |                     |   |  |         |   |        |
|          |        |   |                     |   | N |         |   |        |
|          |        |   |                     |   | o |         |   |        |
+----------+--------+---+---------------------+---+---+---------+---+--------+
|          |        |   |                     |   | 3 |         |   |        |
|          |        |   |                     |   | 4 |         |   |        |
|          |        |   |                     |   | \ |         |   |        |
|          |        |   |                     |   | . |         |   |        |
|          |        |   |                     |   | W |         |   |        |
|          |        |   |                     |   | E |         |   |        |
|          |        |   |                     |   | R |         |   |        |
|          |        |   |                     |   | E |         |   |        |
|          |        |   |                     |   | A |         |   |        |
|          |        |   |                     |   | U |         |   |        |
|          |        |   |                     |   | T |         |   |        |
|          |        |   |                     |   | O |         |   |        |
|          |        |   |                     |   | P |         |   |        |
|          |        |   |                     |   | S |         |   |        |
|          |        |   |                     |   | Y |         |   |        |
|          |        |   |                     |   | F |         |   |        |
|          |        |   |                     |   | I |         |   |        |
|          |        |   |                     |   | N |         |   |        |
|          |        |   |                     |   | D |         |   |        |
|          |        |   |                     |   | I |         |   |        |
|          |        |   |                     |   | N |         |   |        |
|          |        |   |                     |   | G |         |   |        |
|          |        |   |                     |   | S |         |   |        |
|          |        |   |                     |   | A |         |   |        |
|          |        |   |                     |   | V |         |   |        |
|          |        |   |                     |   | A |         |   |        |
|          |        |   |                     |   | I |         |   |        |
|          |        |   |                     |   | L |         |   |        |
|          |        |   |                     |   | A |         |   |        |
|          |        |   |                     |   | B |         |   |        |
|          |        |   |                     |   | L |         |   |        |
|          |        |   |                     |   | E |         |   |        |
|          |        |   |                     |   | T |         |   |        |
|          |        |   |                     |   | O |         |   |        |
|          |        |   |                     |   |   |         |   |        |
|          |        |   |                     |   | C |         |   |        |
|          |        |   |                     |   | O |         |   |        |
|          |        |   |                     |   | M |         |   |        |
|          |        |   |                     |   | P |         |   |        |
|          |        |   |                     |   | L |         |   |        |
|          |        |   |                     |   | E |         |   |        |
|          |        |   |                     |   | T |         |   |        |
|          |        |   |                     |   | E |         |   |        |
|          |        |   |                     |   | T |         |   |        |
|          |        |   |                     |   | H |         |   |        |
|          |        |   |                     |   | E |         |   |        |
|          |        |   |                     |   | C |         |   |        |
|          |        |   |                     |   | A |         |   |        |
|          |        |   |                     |   | U |         |   |        |
|          |        |   |                     |   | S |         |   |        |
|          |        |   |                     |   | E |         |   |        |
|          |        |   |                     |   | O |         |   |        |
|          |        |   |                     |   | F |         |   |        |
|          |        |   |                     |   | D |         |   |        |
|          |        |   |                     |   | E |         |   |        |
|          |        |   |                     |   | A |         |   |        |
|          |        |   |                     |   | T |         |   |        |
|          |        |   |                     |   | H |         |   |        |
|          |        |   |                     |   | ? |         |   |        |
|          |        |   |                     |   |  |         |   |        |
|          |        |   |                     |   | Y |         |   |        |
|          |        |   |                     |   | e |         |   |        |
|          |        |   |                     |   | s |         |   |        |
|          |        |   |                     |   |  |         |   |        |
|          |        |   |                     |   |  |         |   |        |
|          |        |   |                     |   |  |         |   |        |
|          |        |   |                     |   | N |         |   |        |
|          |        |   |                     |   | o |         |   |        |
+----------+--------+---+---------------------+---+---+---------+---+--------+
| 35\. DID |        | 3 |                     | 3 |   |         |   |        |
| TOBACCO  |        | 6 |                     | 7 |   |         |   |        |
| USE      |        | \ |                     | \ |   |         |   |        |
| CO       |        | . |                     | . |   |         |   |        |
| NTRIBUTE |        | I |                     | M |   |         |   |        |
| TO       |        | F |                     | A |   |         |   |        |
| DEATH?   |        | F |                     | N |   |         |   |        |
|          |        | E |                     | N |   |         |   |        |
| Yes   |        | M |                     | E |   |         |   |        |
|       |        | A |                     | R |   |         |   |        |
| Probably |        | L |                     | O |   |         |   |        |
|          |        | E |                     | F |   |         |   |        |
|  No     |        | : |                     | D |   |         |   |        |
|        |        |   |                     | E |   |         |   |        |
| Unknown |        |  |                     | A |   |         |   |        |
|          |        |  |                     | T |   |         |   |        |
|          |        |  |                     | H |   |         |   |        |
|          |        | N |                     |   |   |         |   |        |
|          |        | o |                     |  |   |         |   |        |
|          |        | t |                     |  |   |         |   |        |
|          |        | p |                     |  |   |         |   |        |
|          |        | r |                     | N |   |         |   |        |
|          |        | e |                     | a |   |         |   |        |
|          |        | g |                     | t |   |         |   |        |
|          |        | n |                     | u |   |         |   |        |
|          |        | a |                     | r |   |         |   |        |
|          |        | n |                     | a |   |         |   |        |
|          |        | t |                     | l |   |         |   |        |
|          |        | w |                     |  |   |         |   |        |
|          |        | i |                     |  |   |         |   |        |
|          |        | t |                     |  |   |         |   |        |
|          |        | h |                     | H |   |         |   |        |
|          |        | i |                     | o |   |         |   |        |
|          |        | n |                     | m |   |         |   |        |
|          |        | p |                     | i |   |         |   |        |
|          |        | a |                     | c |   |         |   |        |
|          |        | s |                     | i |   |         |   |        |
|          |        | t |                     | d |   |         |   |        |
|          |        | y |                     | e |   |         |   |        |
|          |        | e |                     |   |   |         |   |        |
|          |        | a |                     |  |   |         |   |        |
|          |        | r |                     | A |   |         |   |        |
|          |        |   |                     | c |   |         |   |        |
|          |        |  |                     | c |   |         |   |        |
|          |        |  |                     | i |   |         |   |        |
|          |        |  |                     | d |   |         |   |        |
|          |        | P |                     | e |   |         |   |        |
|          |        | r |                     | n |   |         |   |        |
|          |        | e |                     | t |   |         |   |        |
|          |        | g |                     |  |   |         |   |        |
|          |        | n |                     |  |   |         |   |        |
|          |        | a |                     | P |   |         |   |        |
|          |        | n |                     | e |   |         |   |        |
|          |        | t |                     | n |   |         |   |        |
|          |        | a |                     | d |   |         |   |        |
|          |        | t |                     | i |   |         |   |        |
|          |        | t |                     | n |   |         |   |        |
|          |        | i |                     | g |   |         |   |        |
|          |        | m |                     | I |   |         |   |        |
|          |        | e |                     | n |   |         |   |        |
|          |        | o |                     | v |   |         |   |        |
|          |        | f |                     | e |   |         |   |        |
|          |        | d |                     | s |   |         |   |        |
|          |        | e |                     | t |   |         |   |        |
|          |        | a |                     | i |   |         |   |        |
|          |        | t |                     | g |   |         |   |        |
|          |        | h |                     | a |   |         |   |        |
|          |        |   |                     | t |   |         |   |        |
|          |        |  |                     | i |   |         |   |        |
|          |        |  |                     | o |   |         |   |        |
|          |        |  |                     | n |   |         |   |        |
|          |        | N |                     |   |   |         |   |        |
|          |        | o |                     |  |   |         |   |        |
|          |        | t |                     |  |   |         |   |        |
|          |        | p |                     |  |   |         |   |        |
|          |        | r |                     | S |   |         |   |        |
|          |        | e |                     | u |   |         |   |        |
|          |        | g |                     | i |   |         |   |        |
|          |        | n |                     | c |   |         |   |        |
|          |        | a |                     | i |   |         |   |        |
|          |        | n |                     | d |   |         |   |        |
|          |        | t |                     | e |   |         |   |        |
|          |        | , |                     |  |   |         |   |        |
|          |        | b |                     |  |   |         |   |        |
|          |        | u |                     |  |   |         |   |        |
|          |        | t |                     | C |   |         |   |        |
|          |        | p |                     | o |   |         |   |        |
|          |        | r |                     | u |   |         |   |        |
|          |        | e |                     | l |   |         |   |        |
|          |        | g |                     | d |   |         |   |        |
|          |        | n |                     | n |   |         |   |        |
|          |        | a |                     | o |   |         |   |        |
|          |        | n |                     | t |   |         |   |        |
|          |        | t |                     | b |   |         |   |        |
|          |        | w |                     | e |   |         |   |        |
|          |        | i |                     | d |   |         |   |        |
|          |        | t |                     | e |   |         |   |        |
|          |        | h |                     | t |   |         |   |        |
|          |        | i |                     | e |   |         |   |        |
|          |        | n |                     | r |   |         |   |        |
|          |        | 4 |                     | m |   |         |   |        |
|          |        | 2 |                     | i |   |         |   |        |
|          |        | d |                     | n |   |         |   |        |
|          |        | a |                     | e |   |         |   |        |
|          |        | y |                     | d |   |         |   |        |
|          |        | s |                     |   |   |         |   |        |
|          |        | o |                     |   |   |         |   |        |
|          |        | f |                     |   |   |         |   |        |
|          |        | d |                     |   |   |         |   |        |
|          |        | e |                     |   |   |         |   |        |
|          |        | a |                     |   |   |         |   |        |
|          |        | t |                     |   |   |         |   |        |
|          |        | h |                     |   |   |         |   |        |
|          |        |   |                     |   |   |         |   |        |
|          |        |  |                     |   |   |         |   |        |
|          |        |  |                     |   |   |         |   |        |
|          |        |  |                     |   |   |         |   |        |
|          |        | N |                     |   |   |         |   |        |
|          |        | o |                     |   |   |         |   |        |
|          |        | t |                     |   |   |         |   |        |
|          |        | p |                     |   |   |         |   |        |
|          |        | r |                     |   |   |         |   |        |
|          |        | e |                     |   |   |         |   |        |
|          |        | g |                     |   |   |         |   |        |
|          |        | n |                     |   |   |         |   |        |
|          |        | a |                     |   |   |         |   |        |
|          |        | n |                     |   |   |         |   |        |
|          |        | t |                     |   |   |         |   |        |
|          |        | , |                     |   |   |         |   |        |
|          |        | b |                     |   |   |         |   |        |
|          |        | u |                     |   |   |         |   |        |
|          |        | t |                     |   |   |         |   |        |
|          |        | p |                     |   |   |         |   |        |
|          |        | r |                     |   |   |         |   |        |
|          |        | e |                     |   |   |         |   |        |
|          |        | g |                     |   |   |         |   |        |
|          |        | n |                     |   |   |         |   |        |
|          |        | a |                     |   |   |         |   |        |
|          |        | n |                     |   |   |         |   |        |
|          |        | t |                     |   |   |         |   |        |
|          |        | 4 |                     |   |   |         |   |        |
|          |        | 3 |                     |   |   |         |   |        |
|          |        | d |                     |   |   |         |   |        |
|          |        | a |                     |   |   |         |   |        |
|          |        | y |                     |   |   |         |   |        |
|          |        | s |                     |   |   |         |   |        |
|          |        | t |                     |   |   |         |   |        |
|          |        | o |                     |   |   |         |   |        |
|          |        | 1 |                     |   |   |         |   |        |
|          |        | y |                     |   |   |         |   |        |
|          |        | e |                     |   |   |         |   |        |
|          |        | a |                     |   |   |         |   |        |
|          |        | r |                     |   |   |         |   |        |
|          |        | b |                     |   |   |         |   |        |
|          |        | e |                     |   |   |         |   |        |
|          |        | f |                     |   |   |         |   |        |
|          |        | o |                     |   |   |         |   |        |
|          |        | r |                     |   |   |         |   |        |
|          |        | e |                     |   |   |         |   |        |
|          |        | d |                     |   |   |         |   |        |
|          |        | e |                     |   |   |         |   |        |
|          |        | a |                     |   |   |         |   |        |
|          |        | t |                     |   |   |         |   |        |
|          |        | h |                     |   |   |         |   |        |
|          |        |   |                     |   |   |         |   |        |
|          |        |  |                     |   |   |         |   |        |
|          |        |  |                     |   |   |         |   |        |
|          |        |  |                     |   |   |         |   |        |
|          |        | U |                     |   |   |         |   |        |
|          |        | n |                     |   |   |         |   |        |
|          |        | k |                     |   |   |         |   |        |
|          |        | n |                     |   |   |         |   |        |
|          |        | o |                     |   |   |         |   |        |
|          |        | w |                     |   |   |         |   |        |
|          |        | n |                     |   |   |         |   |        |
|          |        | i |                     |   |   |         |   |        |
|          |        | f |                     |   |   |         |   |        |
|          |        | p |                     |   |   |         |   |        |
|          |        | r |                     |   |   |         |   |        |
|          |        | e |                     |   |   |         |   |        |
|          |        | g |                     |   |   |         |   |        |
|          |        | n |                     |   |   |         |   |        |
|          |        | a |                     |   |   |         |   |        |
|          |        | n |                     |   |   |         |   |        |
|          |        | t |                     |   |   |         |   |        |
|          |        | w |                     |   |   |         |   |        |
|          |        | i |                     |   |   |         |   |        |
|          |        | t |                     |   |   |         |   |        |
|          |        | h |                     |   |   |         |   |        |
|          |        | i |                     |   |   |         |   |        |
|          |        | n |                     |   |   |         |   |        |
|          |        | t |                     |   |   |         |   |        |
|          |        | h |                     |   |   |         |   |        |
|          |        | e |                     |   |   |         |   |        |
|          |        | p |                     |   |   |         |   |        |
|          |        | a |                     |   |   |         |   |        |
|          |        | s |                     |   |   |         |   |        |
|          |        | t |                     |   |   |         |   |        |
|          |        | y |                     |   |   |         |   |        |
|          |        | e |                     |   |   |         |   |        |
|          |        | a |                     |   |   |         |   |        |
|          |        | r |                     |   |   |         |   |        |
+----------+--------+---+---------------------+---+---+---------+---+--------+
| 38\.     | 39\.   |   | 40\. PLACE OF       |   |   |         | 4 |        |
| DATE OF  | TIME   |   | INJURY (e.g.,       |   |   |         | 1 |        |
| INJURY   | OF     |   | Decedent's home;    |   |   |         | \ |        |
|          | INJURY |   | construction site;  |   |   |         | . |        |
| (Mo      |        |   | restaurant; wooded  |   |   |         | I |        |
| /Day/Yr) |        |   | area)               |   |   |         | N |        |
| (Spell   |        |   |                     |   |   |         | J |        |
| Month)   |        |   |                     |   |   |         | U |        |
|          |        |   |                     |   |   |         | R |        |
|          |        |   |                     |   |   |         | Y |        |
|          |        |   |                     |   |   |         | A |        |
|          |        |   |                     |   |   |         | T |        |
|          |        |   |                     |   |   |         | W |        |
|          |        |   |                     |   |   |         | O |        |
|          |        |   |                     |   |   |         | R |        |
|          |        |   |                     |   |   |         | K |        |
|          |        |   |                     |   |   |         | ? |        |
|          |        |   |                     |   |   |         |   |        |
|          |        |   |                     |   |   |         |  |        |
|          |        |   |                     |   |   |         |  |        |
|          |        |   |                     |   |   |         |  |        |
|          |        |   |                     |   |   |         |  |        |
|          |        |   |                     |   |   |         |  |        |
|          |        |   |                     |   |   |         |  |        |
|          |        |   |                     |   |   |         |  |        |
|          |        |   |                     |   |   |         |  |        |
|          |        |   |                     |   |   |         |  |        |
|          |        |   |                     |   |   |         | Y |        |
|          |        |   |                     |   |   |         | e |        |
|          |        |   |                     |   |   |         | s |        |
|          |        |   |                     |   |   |         |  |        |
|          |        |   |                     |   |   |         | N |        |
|          |        |   |                     |   |   |         | o |        |
+----------+--------+---+---------------------+---+---+---------+---+--------+
| 42\.     |        |   |                     |   |   |         |   |        |
| LOCATION |        |   |                     |   |   |         |   |        |
| OF       |        |   |                     |   |   |         |   |        |
| INJURY:  |        |   |                     |   |   |         |   |        |
| State:   |        |   |                     |   |   |         |   |        |
| City or  |        |   |                     |   |   |         |   |        |
| Town:    |        |   |                     |   |   |         |   |        |
|          |        |   |                     |   |   |         |   |        |
| Street & |        |   |                     |   |   |         |   |        |
| Number:  |        |   |                     |   |   |         |   |        |
| A        |        |   |                     |   |   |         |   |        |
| partment |        |   |                     |   |   |         |   |        |
| No.: Zip |        |   |                     |   |   |         |   |        |
| Code:    |        |   |                     |   |   |         |   |        |
+----------+--------+---+---------------------+---+---+---------+---+--------+
| 43\.     |        |   |                     |   |   | 44\. IF |   |        |
| DESCRIBE |        |   |                     |   |   | TRANSPO |   |        |
| HOW      |        |   |                     |   |   | RTATION |   |        |
| INJURY   |        |   |                     |   |   | INJURY, |   |        |
| O        |        |   |                     |   |   | S       |   |        |
| CCURRED: |        |   |                     |   |   | PECIFY: |   |        |
|          |        |   |                     |   |   |         |   |        |
|          |        |   |                     |   |   |        |   |        |
|          |        |   |                     |   |   | D       |   |        |
|          |        |   |                     |   |   | river/O |   |        |
|          |        |   |                     |   |   | perator |   |        |
|          |        |   |                     |   |   |         |   |        |
|          |        |   |                     |   |   | Pa   |   |        |
|          |        |   |                     |   |   | ssenger |   |        |
|          |        |   |                     |   |   |         |   |        |
|          |        |   |                     |   |   | Ped  |   |        |
|          |        |   |                     |   |   | estrian |   |        |
|          |        |   |                     |   |   |         |   |        |
|          |        |   |                     |   |   |        |   |        |
|          |        |   |                     |   |   | Other |   |        |
|          |        |   |                     |   |   | (S      |   |        |
|          |        |   |                     |   |   | pecify) |   |        |
+----------+--------+---+---------------------+---+---+---------+---+--------+

1A. Please state if the manner of death was accidental, homicidal,
suicidal, natural, or undetermined.
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_.

If undetermined, was there a pending investigation?
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_.

1B. State what happened to the decedent, describe in detail the external
event that caused the death.

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

1C. State the medical condition(s) that required the treatment (medical,
surgical, medicaments)

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

1D. Describe in detail the treatment (medical, surgical, name of
medicaments) or the exposure (name of chemicals, type of medical
devices, or other applicable external factors)
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

2\. [Fire]{.underline}

A. Origin of fire (blowlamp, candle, match, torch, fireplace
etc.)\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

> B. If fire was caused by explosion, indicate agent (aerosol, gasoline,
> bomb
> etc.)\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

C. Fire located in: Private dwelling\_\_\_ Other building or structure
\_\_\_ Not in building or structure (stationary vehicle, forest
etc)\_\_\_
Other\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

D. Resulted in large uncontrolled fire: Yes\_\_\_ No\_\_\_

E. Fire ignited: Explosive material (specify type) \_\_\_\_\_\_ Clothing
(type) \_\_\_\_\_\_\_\_\_\_\_Other \_\_\_\_\_\_\_\_

> F. Victim: Burned \_\_\_ Incinerated, cremated \_\_\_ Asphyxiated by
> (smoke, flame,
>
> fumes, etc.) \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Other
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

3\. [Fall]{.underline} (state how it happened, e.g. fall
from/on/into/out of [name of structure]{.underline})

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

4\. Describe in detail the external event
(\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ )
that eventually brought about the medical complications which caused the
death.
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_.

5\. Place of occurrence (home, residential institution, public
administrative area, sports area, street and highway, trade and service
areas, industrial and construction area, farm, other -please specify-)
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

[, M.D.]{.underline}

(Signature of Certifying Physician)

Please provide your office
phone:\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
fax:\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

(Please see other side)

Instructions on Medical Certification of Causes of Death

Example of properly completed medical certification

+----------+--------+---+---------------------+---+---+---------+---+--------+
| **CAUSE  |        |   |                     |   |   |         |   | Appro  |
| OF DEATH |        |   |                     |   |   |         |   | ximate |
| (See     |        |   |                     |   |   |         |   | int    |
| inst     |        |   |                     |   |   |         |   | erval: |
| ructions |        |   |                     |   |   |         |   |        |
| and      |        |   |                     |   |   |         |   | Onset  |
| exa      |        |   |                     |   |   |         |   | to     |
| mples)** |        |   |                     |   |   |         |   | death  |
|          |        |   |                     |   |   |         |   |        |
| 32\.     |        |   |                     |   |   |         |   | [1     |
| **PART   |        |   |                     |   |   |         |   | h      |
| I.**     |        |   |                     |   |   |         |   | our\_] |
| Enter    |        |   |                     |   |   |         |   | {.unde |
| the      |        |   |                     |   |   |         |   | rline} |
| [chain   |        |   |                     |   |   |         |   |        |
| of       |        |   |                     |   |   |         |   | [1     |
| events]  |        |   |                     |   |   |         |   | h      |
| {.underl |        |   |                     |   |   |         |   | our\_] |
| ine}\--d |        |   |                     |   |   |         |   | {.unde |
| iseases, |        |   |                     |   |   |         |   | rline} |
| i        |        |   |                     |   |   |         |   |        |
| njuries, |        |   |                     |   |   |         |   | [1     |
| or       |        |   |                     |   |   |         |   | h      |
| comp     |        |   |                     |   |   |         |   | our\_] |
| lication |        |   |                     |   |   |         |   | {.unde |
| s\--that |        |   |                     |   |   |         |   | rline} |
| directly |        |   |                     |   |   |         |   |        |
| caused   |        |   |                     |   |   |         |   | [\_\   |
| the      |        |   |                     |   |   |         |   | _\_\_\ |
| death.   |        |   |                     |   |   |         |   | _\_\_] |
| DO NOT   |        |   |                     |   |   |         |   | {.unde |
| enter    |        |   |                     |   |   |         |   | rline} |
| terminal |        |   |                     |   |   |         |   |        |
| events   |        |   |                     |   |   |         |   |        |
| such as  |        |   |                     |   |   |         |   |        |
| cardiac  |        |   |                     |   |   |         |   |        |
|          |        |   |                     |   |   |         |   |        |
| arrest,  |        |   |                     |   |   |         |   |        |
| res      |        |   |                     |   |   |         |   |        |
| piratory |        |   |                     |   |   |         |   |        |
| arrest,  |        |   |                     |   |   |         |   |        |
| or       |        |   |                     |   |   |         |   |        |
| ven      |        |   |                     |   |   |         |   |        |
| tricular |        |   |                     |   |   |         |   |        |
| fibr     |        |   |                     |   |   |         |   |        |
| illation |        |   |                     |   |   |         |   |        |
| without  |        |   |                     |   |   |         |   |        |
| showing  |        |   |                     |   |   |         |   |        |
| the      |        |   |                     |   |   |         |   |        |
| e        |        |   |                     |   |   |         |   |        |
| tiology. |        |   |                     |   |   |         |   |        |
| DO NOT   |        |   |                     |   |   |         |   |        |
| ABB      |        |   |                     |   |   |         |   |        |
| REVIATE. |        |   |                     |   |   |         |   |        |
| Enter    |        |   |                     |   |   |         |   |        |
| only one |        |   |                     |   |   |         |   |        |
| cause on |        |   |                     |   |   |         |   |        |
| a line.  |        |   |                     |   |   |         |   |        |
| Add      |        |   |                     |   |   |         |   |        |
| ad       |        |   |                     |   |   |         |   |        |
| ditional |        |   |                     |   |   |         |   |        |
|          |        |   |                     |   |   |         |   |        |
| lines if |        |   |                     |   |   |         |   |        |
| ne       |        |   |                     |   |   |         |   |        |
| cessary. |        |   |                     |   |   |         |   |        |
|          |        |   |                     |   |   |         |   |        |
| I        |        |   |                     |   |   |         |   |        |
| MMEDIATE |        |   |                     |   |   |         |   |        |
| CAUSE    |        |   |                     |   |   |         |   |        |
| (Final   |        |   |                     |   |   |         |   |        |
|          |        |   |                     |   |   |         |   |        |
| disease  |        |   |                     |   |   |         |   |        |
| or       |        |   |                     |   |   |         |   |        |
| c        |        |   |                     |   |   |         |   |        |
| ondition |        |   |                     |   |   |         |   |        |
| **\-\-\  |        |   |                     |   |   |         |   |        |
| -\-\-\-\ |        |   |                     |   |   |         |   |        |
| -\--\>** |        |   |                     |   |   |         |   |        |
| a.       |        |   |                     |   |   |         |   |        |
| [        |        |   |                     |   |   |         |   |        |
| Epidural |        |   |                     |   |   |         |   |        |
| he       |        |   |                     |   |   |         |   |        |
| morrhage |        |   |                     |   |   |         |   |        |
| \_\_\_\  |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_]{.un |        |   |                     |   |   |         |   |        |
| derline} |        |   |                     |   |   |         |   |        |
|          |        |   |                     |   |   |         |   |        |
| r        |        |   |                     |   |   |         |   |        |
| esulting |        |   |                     |   |   |         |   |        |
| in       |        |   |                     |   |   |         |   |        |
| death)   |        |   |                     |   |   |         |   |        |
| Due to   |        |   |                     |   |   |         |   |        |
| (or as a |        |   |                     |   |   |         |   |        |
| con      |        |   |                     |   |   |         |   |        |
| sequence |        |   |                     |   |   |         |   |        |
| of):     |        |   |                     |   |   |         |   |        |
|          |        |   |                     |   |   |         |   |        |
| Sequ     |        |   |                     |   |   |         |   |        |
| entially |        |   |                     |   |   |         |   |        |
| list     |        |   |                     |   |   |         |   |        |
| con      |        |   |                     |   |   |         |   |        |
| ditions, |        |   |                     |   |   |         |   |        |
| b.       |        |   |                     |   |   |         |   |        |
| [F       |        |   |                     |   |   |         |   |        |
| ractured |        |   |                     |   |   |         |   |        |
| skull    |        |   |                     |   |   |         |   |        |
| \_\      |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_]{.un |        |   |                     |   |   |         |   |        |
| derline} |        |   |                     |   |   |         |   |        |
|          |        |   |                     |   |   |         |   |        |
| if any,  |        |   |                     |   |   |         |   |        |
| leading  |        |   |                     |   |   |         |   |        |
| to the   |        |   |                     |   |   |         |   |        |
| cause    |        |   |                     |   |   |         |   |        |
| Due to   |        |   |                     |   |   |         |   |        |
| (or as a |        |   |                     |   |   |         |   |        |
| con      |        |   |                     |   |   |         |   |        |
| sequence |        |   |                     |   |   |         |   |        |
| of):     |        |   |                     |   |   |         |   |        |
|          |        |   |                     |   |   |         |   |        |
| listed   |        |   |                     |   |   |         |   |        |
| on line  |        |   |                     |   |   |         |   |        |
| a. Enter |        |   |                     |   |   |         |   |        |
| the      |        |   |                     |   |   |         |   |        |
|          |        |   |                     |   |   |         |   |        |
| **UN     |        |   |                     |   |   |         |   |        |
| DERLYING |        |   |                     |   |   |         |   |        |
| CAUSE**  |        |   |                     |   |   |         |   |        |
| c. [Fall |        |   |                     |   |   |         |   |        |
| on       |        |   |                     |   |   |         |   |        |
| stairway |        |   |                     |   |   |         |   |        |
| \_\_\    |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_]{.un |        |   |                     |   |   |         |   |        |
| derline} |        |   |                     |   |   |         |   |        |
|          |        |   |                     |   |   |         |   |        |
| (disease |        |   |                     |   |   |         |   |        |
| or       |        |   |                     |   |   |         |   |        |
| injury   |        |   |                     |   |   |         |   |        |
| that Due |        |   |                     |   |   |         |   |        |
| to (or   |        |   |                     |   |   |         |   |        |
| as a     |        |   |                     |   |   |         |   |        |
| con      |        |   |                     |   |   |         |   |        |
| sequence |        |   |                     |   |   |         |   |        |
| of):     |        |   |                     |   |   |         |   |        |
|          |        |   |                     |   |   |         |   |        |
| i        |        |   |                     |   |   |         |   |        |
| nitiated |        |   |                     |   |   |         |   |        |
| the      |        |   |                     |   |   |         |   |        |
| events   |        |   |                     |   |   |         |   |        |
| r        |        |   |                     |   |   |         |   |        |
| esulting |        |   |                     |   |   |         |   |        |
|          |        |   |                     |   |   |         |   |        |
| in       |        |   |                     |   |   |         |   |        |
| death)   |        |   |                     |   |   |         |   |        |
| **LAST** |        |   |                     |   |   |         |   |        |
| d.       |        |   |                     |   |   |         |   |        |
| [\_\_    |        |   |                     |   |   |         |   |        |
| \_\_\_\_ |        |   |                     |   |   |         |   |        |
| \_\_\    |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_]{.un |        |   |                     |   |   |         |   |        |
| derline} |        |   |                     |   |   |         |   |        |
+----------+--------+---+---------------------+---+---+---------+---+--------+
| **PART   |        |   |                     |   | 3 |         |   |        |
| II.**    |        |   |                     |   | 3 |         |   |        |
| Enter    |        |   |                     |   | \ |         |   |        |
| other    |        |   |                     |   | . |         |   |        |
| [sig     |        |   |                     |   | W |         |   |        |
| nificant |        |   |                     |   | A |         |   |        |
| co       |        |   |                     |   | S |         |   |        |
| nditions |        |   |                     |   | A |         |   |        |
| cont     |        |   |                     |   | N |         |   |        |
| ributing |        |   |                     |   | A |         |   |        |
| to       |        |   |                     |   | U |         |   |        |
| de       |        |   |                     |   | T |         |   |        |
| ath]{.un |        |   |                     |   | O |         |   |        |
| derline} |        |   |                     |   | P |         |   |        |
| but not  |        |   |                     |   | S |         |   |        |
| r        |        |   |                     |   | Y |         |   |        |
| esulting |        |   |                     |   | P |         |   |        |
| in the   |        |   |                     |   | E |         |   |        |
| un       |        |   |                     |   | R |         |   |        |
| derlying |        |   |                     |   | F |         |   |        |
| cause    |        |   |                     |   | O |         |   |        |
| given in |        |   |                     |   | R |         |   |        |
| PART I   |        |   |                     |   | M |         |   |        |
|          |        |   |                     |   | E |         |   |        |
| Chronic  |        |   |                     |   | D |         |   |        |
| r        |        |   |                     |   | ? |         |   |        |
| heumatic |        |   |                     |   |   |         |   |        |
| endo     |        |   |                     |   |  |         |   |        |
| carditis |        |   |                     |   | Y |         |   |        |
|          |        |   |                     |   | e |         |   |        |
|          |        |   |                     |   | s |         |   |        |
|          |        |   |                     |   | ■ |         |   |        |
|          |        |   |                     |   | N |         |   |        |
|          |        |   |                     |   | o |         |   |        |
+----------+--------+---+---------------------+---+---+---------+---+--------+
|          |        |   |                     |   | 3 |         |   |        |
|          |        |   |                     |   | 4 |         |   |        |
|          |        |   |                     |   | \ |         |   |        |
|          |        |   |                     |   | . |         |   |        |
|          |        |   |                     |   | W |         |   |        |
|          |        |   |                     |   | E |         |   |        |
|          |        |   |                     |   | R |         |   |        |
|          |        |   |                     |   | E |         |   |        |
|          |        |   |                     |   | A |         |   |        |
|          |        |   |                     |   | U |         |   |        |
|          |        |   |                     |   | T |         |   |        |
|          |        |   |                     |   | O |         |   |        |
|          |        |   |                     |   | P |         |   |        |
|          |        |   |                     |   | S |         |   |        |
|          |        |   |                     |   | Y |         |   |        |
|          |        |   |                     |   | F |         |   |        |
|          |        |   |                     |   | I |         |   |        |
|          |        |   |                     |   | N |         |   |        |
|          |        |   |                     |   | D |         |   |        |
|          |        |   |                     |   | I |         |   |        |
|          |        |   |                     |   | N |         |   |        |
|          |        |   |                     |   | G |         |   |        |
|          |        |   |                     |   | S |         |   |        |
|          |        |   |                     |   | A |         |   |        |
|          |        |   |                     |   | V |         |   |        |
|          |        |   |                     |   | A |         |   |        |
|          |        |   |                     |   | I |         |   |        |
|          |        |   |                     |   | L |         |   |        |
|          |        |   |                     |   | A |         |   |        |
|          |        |   |                     |   | B |         |   |        |
|          |        |   |                     |   | L |         |   |        |
|          |        |   |                     |   | E |         |   |        |
|          |        |   |                     |   | T |         |   |        |
|          |        |   |                     |   | O |         |   |        |
|          |        |   |                     |   |   |         |   |        |
|          |        |   |                     |   | C |         |   |        |
|          |        |   |                     |   | O |         |   |        |
|          |        |   |                     |   | M |         |   |        |
|          |        |   |                     |   | P |         |   |        |
|          |        |   |                     |   | L |         |   |        |
|          |        |   |                     |   | E |         |   |        |
|          |        |   |                     |   | T |         |   |        |
|          |        |   |                     |   | E |         |   |        |
|          |        |   |                     |   | T |         |   |        |
|          |        |   |                     |   | H |         |   |        |
|          |        |   |                     |   | E |         |   |        |
|          |        |   |                     |   | C |         |   |        |
|          |        |   |                     |   | A |         |   |        |
|          |        |   |                     |   | U |         |   |        |
|          |        |   |                     |   | S |         |   |        |
|          |        |   |                     |   | E |         |   |        |
|          |        |   |                     |   | O |         |   |        |
|          |        |   |                     |   | F |         |   |        |
|          |        |   |                     |   | D |         |   |        |
|          |        |   |                     |   | E |         |   |        |
|          |        |   |                     |   | A |         |   |        |
|          |        |   |                     |   | T |         |   |        |
|          |        |   |                     |   | H |         |   |        |
|          |        |   |                     |   | ? |         |   |        |
|          |        |   |                     |   |  |         |   |        |
|          |        |   |                     |   | Y |         |   |        |
|          |        |   |                     |   | e |         |   |        |
|          |        |   |                     |   | s |         |   |        |
|          |        |   |                     |   | ■ |         |   |        |
|          |        |   |                     |   | N |         |   |        |
|          |        |   |                     |   | o |         |   |        |
+----------+--------+---+---------------------+---+---+---------+---+--------+
| 35\. DID |        | 3 |                     | 3 |   |         |   |        |
| TOBACCO  |        | 6 |                     | 7 |   |         |   |        |
| USE      |        | \ |                     | \ |   |         |   |        |
| CO       |        | . |                     | . |   |         |   |        |
| NTRIBUTE |        | I |                     | M |   |         |   |        |
| TO       |        | F |                     | A |   |         |   |        |
| DEATH?   |        | F |                     | N |   |         |   |        |
|          |        | E |                     | N |   |         |   |        |
| Yes   |        | M |                     | E |   |         |   |        |
|       |        | A |                     | R |   |         |   |        |
| Probably |        | L |                     | O |   |         |   |        |
|          |        | E |                     | F |   |         |   |        |
| ■ No     |        | : |                     | D |   |         |   |        |
|        |        |   |                     | E |   |         |   |        |
| Unknown |        |  |                     | A |   |         |   |        |
|          |        |  |                     | T |   |         |   |        |
|          |        |  |                     | H |   |         |   |        |
|          |        | N |                     |   |   |         |   |        |
|          |        | o |                     |  |   |         |   |        |
|          |        | t |                     |  |   |         |   |        |
|          |        | p |                     |  |   |         |   |        |
|          |        | r |                     | N |   |         |   |        |
|          |        | e |                     | a |   |         |   |        |
|          |        | g |                     | t |   |         |   |        |
|          |        | n |                     | u |   |         |   |        |
|          |        | a |                     | r |   |         |   |        |
|          |        | n |                     | a |   |         |   |        |
|          |        | t |                     | l |   |         |   |        |
|          |        | w |                     |  |   |         |   |        |
|          |        | i |                     |  |   |         |   |        |
|          |        | t |                     |  |   |         |   |        |
|          |        | h |                     | H |   |         |   |        |
|          |        | i |                     | o |   |         |   |        |
|          |        | n |                     | m |   |         |   |        |
|          |        | p |                     | i |   |         |   |        |
|          |        | a |                     | c |   |         |   |        |
|          |        | s |                     | i |   |         |   |        |
|          |        | t |                     | d |   |         |   |        |
|          |        | y |                     | e |   |         |   |        |
|          |        | e |                     |   |   |         |   |        |
|          |        | a |                     | ■ |   |         |   |        |
|          |        | r |                     | A |   |         |   |        |
|          |        |   |                     | c |   |         |   |        |
|          |        |  |                     | c |   |         |   |        |
|          |        |  |                     | i |   |         |   |        |
|          |        |  |                     | d |   |         |   |        |
|          |        | P |                     | e |   |         |   |        |
|          |        | r |                     | n |   |         |   |        |
|          |        | e |                     | t |   |         |   |        |
|          |        | g |                     |  |   |         |   |        |
|          |        | n |                     |  |   |         |   |        |
|          |        | a |                     |  |   |         |   |        |
|          |        | n |                     | P |   |         |   |        |
|          |        | t |                     | e |   |         |   |        |
|          |        | a |                     | n |   |         |   |        |
|          |        | t |                     | d |   |         |   |        |
|          |        | t |                     | i |   |         |   |        |
|          |        | i |                     | n |   |         |   |        |
|          |        | m |                     | g |   |         |   |        |
|          |        | e |                     | I |   |         |   |        |
|          |        | o |                     | n |   |         |   |        |
|          |        | f |                     | v |   |         |   |        |
|          |        | d |                     | e |   |         |   |        |
|          |        | e |                     | s |   |         |   |        |
|          |        | a |                     | t |   |         |   |        |
|          |        | t |                     | i |   |         |   |        |
|          |        | h |                     | g |   |         |   |        |
|          |        |   |                     | a |   |         |   |        |
|          |        |  |                     | t |   |         |   |        |
|          |        |  |                     | i |   |         |   |        |
|          |        |  |                     | o |   |         |   |        |
|          |        | N |                     | n |   |         |   |        |
|          |        | o |                     |   |   |         |   |        |
|          |        | t |                     |  |   |         |   |        |
|          |        | p |                     |  |   |         |   |        |
|          |        | r |                     |  |   |         |   |        |
|          |        | e |                     | S |   |         |   |        |
|          |        | g |                     | u |   |         |   |        |
|          |        | n |                     | i |   |         |   |        |
|          |        | a |                     | c |   |         |   |        |
|          |        | n |                     | i |   |         |   |        |
|          |        | t |                     | d |   |         |   |        |
|          |        | , |                     | e |   |         |   |        |
|          |        | b |                     |  |   |         |   |        |
|          |        | u |                     |  |   |         |   |        |
|          |        | t |                     |  |   |         |   |        |
|          |        | p |                     | C |   |         |   |        |
|          |        | r |                     | o |   |         |   |        |
|          |        | e |                     | u |   |         |   |        |
|          |        | g |                     | l |   |         |   |        |
|          |        | n |                     | d |   |         |   |        |
|          |        | a |                     | n |   |         |   |        |
|          |        | n |                     | o |   |         |   |        |
|          |        | t |                     | t |   |         |   |        |
|          |        | w |                     | b |   |         |   |        |
|          |        | i |                     | e |   |         |   |        |
|          |        | t |                     | d |   |         |   |        |
|          |        | h |                     | e |   |         |   |        |
|          |        | i |                     | t |   |         |   |        |
|          |        | n |                     | e |   |         |   |        |
|          |        | 4 |                     | r |   |         |   |        |
|          |        | 2 |                     | m |   |         |   |        |
|          |        | d |                     | i |   |         |   |        |
|          |        | a |                     | n |   |         |   |        |
|          |        | y |                     | e |   |         |   |        |
|          |        | s |                     | d |   |         |   |        |
|          |        | o |                     |   |   |         |   |        |
|          |        | f |                     |   |   |         |   |        |
|          |        | d |                     |   |   |         |   |        |
|          |        | e |                     |   |   |         |   |        |
|          |        | a |                     |   |   |         |   |        |
|          |        | t |                     |   |   |         |   |        |
|          |        | h |                     |   |   |         |   |        |
|          |        |   |                     |   |   |         |   |        |
|          |        |  |                     |   |   |         |   |        |
|          |        |  |                     |   |   |         |   |        |
|          |        |  |                     |   |   |         |   |        |
|          |        | N |                     |   |   |         |   |        |
|          |        | o |                     |   |   |         |   |        |
|          |        | t |                     |   |   |         |   |        |
|          |        | p |                     |   |   |         |   |        |
|          |        | r |                     |   |   |         |   |        |
|          |        | e |                     |   |   |         |   |        |
|          |        | g |                     |   |   |         |   |        |
|          |        | n |                     |   |   |         |   |        |
|          |        | a |                     |   |   |         |   |        |
|          |        | n |                     |   |   |         |   |        |
|          |        | t |                     |   |   |         |   |        |
|          |        | , |                     |   |   |         |   |        |
|          |        | b |                     |   |   |         |   |        |
|          |        | u |                     |   |   |         |   |        |
|          |        | t |                     |   |   |         |   |        |
|          |        | p |                     |   |   |         |   |        |
|          |        | r |                     |   |   |         |   |        |
|          |        | e |                     |   |   |         |   |        |
|          |        | g |                     |   |   |         |   |        |
|          |        | n |                     |   |   |         |   |        |
|          |        | a |                     |   |   |         |   |        |
|          |        | n |                     |   |   |         |   |        |
|          |        | t |                     |   |   |         |   |        |
|          |        | 4 |                     |   |   |         |   |        |
|          |        | 3 |                     |   |   |         |   |        |
|          |        | d |                     |   |   |         |   |        |
|          |        | a |                     |   |   |         |   |        |
|          |        | y |                     |   |   |         |   |        |
|          |        | s |                     |   |   |         |   |        |
|          |        | t |                     |   |   |         |   |        |
|          |        | o |                     |   |   |         |   |        |
|          |        | 1 |                     |   |   |         |   |        |
|          |        | y |                     |   |   |         |   |        |
|          |        | e |                     |   |   |         |   |        |
|          |        | a |                     |   |   |         |   |        |
|          |        | r |                     |   |   |         |   |        |
|          |        | b |                     |   |   |         |   |        |
|          |        | e |                     |   |   |         |   |        |
|          |        | f |                     |   |   |         |   |        |
|          |        | o |                     |   |   |         |   |        |
|          |        | r |                     |   |   |         |   |        |
|          |        | e |                     |   |   |         |   |        |
|          |        | d |                     |   |   |         |   |        |
|          |        | e |                     |   |   |         |   |        |
|          |        | a |                     |   |   |         |   |        |
|          |        | t |                     |   |   |         |   |        |
|          |        | h |                     |   |   |         |   |        |
|          |        |   |                     |   |   |         |   |        |
|          |        |  |                     |   |   |         |   |        |
|          |        |  |                     |   |   |         |   |        |
|          |        |  |                     |   |   |         |   |        |
|          |        | U |                     |   |   |         |   |        |
|          |        | n |                     |   |   |         |   |        |
|          |        | k |                     |   |   |         |   |        |
|          |        | n |                     |   |   |         |   |        |
|          |        | o |                     |   |   |         |   |        |
|          |        | w |                     |   |   |         |   |        |
|          |        | n |                     |   |   |         |   |        |
|          |        | i |                     |   |   |         |   |        |
|          |        | f |                     |   |   |         |   |        |
|          |        | p |                     |   |   |         |   |        |
|          |        | r |                     |   |   |         |   |        |
|          |        | e |                     |   |   |         |   |        |
|          |        | g |                     |   |   |         |   |        |
|          |        | n |                     |   |   |         |   |        |
|          |        | a |                     |   |   |         |   |        |
|          |        | n |                     |   |   |         |   |        |
|          |        | t |                     |   |   |         |   |        |
|          |        | w |                     |   |   |         |   |        |
|          |        | i |                     |   |   |         |   |        |
|          |        | t |                     |   |   |         |   |        |
|          |        | h |                     |   |   |         |   |        |
|          |        | i |                     |   |   |         |   |        |
|          |        | n |                     |   |   |         |   |        |
|          |        | t |                     |   |   |         |   |        |
|          |        | h |                     |   |   |         |   |        |
|          |        | e |                     |   |   |         |   |        |
|          |        | p |                     |   |   |         |   |        |
|          |        | a |                     |   |   |         |   |        |
|          |        | s |                     |   |   |         |   |        |
|          |        | t |                     |   |   |         |   |        |
|          |        | y |                     |   |   |         |   |        |
|          |        | e |                     |   |   |         |   |        |
|          |        | a |                     |   |   |         |   |        |
|          |        | r |                     |   |   |         |   |        |
+----------+--------+---+---------------------+---+---+---------+---+--------+
| 38\.     | 39\.   |   | 40\. PLACE OF       |   |   |         | 4 |        |
| DATE OF  | TIME   |   | INJURY (e.g.,       |   |   |         | 1 |        |
| INJURY   | OF     |   | Decedent's home;    |   |   |         | \ |        |
|          | INJURY |   | construction site;  |   |   |         | . |        |
| (Mo      |        |   | restaurant; wooded  |   |   |         | I |        |
| /Day/Yr) | 1500   |   | area)               |   |   |         | N |        |
| (Spell   |        |   |                     |   |   |         | J |        |
| Month)   |        |   | decedent's home     |   |   |         | U |        |
|          |        |   |                     |   |   |         | R |        |
| June 30, |        |   |                     |   |   |         | Y |        |
| 2006     |        |   |                     |   |   |         | A |        |
|          |        |   |                     |   |   |         | T |        |
|          |        |   |                     |   |   |         | W |        |
|          |        |   |                     |   |   |         | O |        |
|          |        |   |                     |   |   |         | R |        |
|          |        |   |                     |   |   |         | K |        |
|          |        |   |                     |   |   |         | ? |        |
|          |        |   |                     |   |   |         |   |        |
|          |        |   |                     |   |   |         |  |        |
|          |        |   |                     |   |   |         |  |        |
|          |        |   |                     |   |   |         |  |        |
|          |        |   |                     |   |   |         |  |        |
|          |        |   |                     |   |   |         |  |        |
|          |        |   |                     |   |   |         |  |        |
|          |        |   |                     |   |   |         |  |        |
|          |        |   |                     |   |   |         | Y |        |
|          |        |   |                     |   |   |         | e |        |
|          |        |   |                     |   |   |         | s |        |
|          |        |   |                     |   |   |         | ■ |        |
|          |        |   |                     |   |   |         | N |        |
|          |        |   |                     |   |   |         | o |        |
+----------+--------+---+---------------------+---+---+---------+---+--------+
| 42\.     |        |   |                     |   |   |         |   |        |
| LOCATION |        |   |                     |   |   |         |   |        |
| OF       |        |   |                     |   |   |         |   |        |
| INJURY:  |        |   |                     |   |   |         |   |        |
| State:   |        |   |                     |   |   |         |   |        |
| North    |        |   |                     |   |   |         |   |        |
| Carolina |        |   |                     |   |   |         |   |        |
| City or  |        |   |                     |   |   |         |   |        |
| Town:    |        |   |                     |   |   |         |   |        |
| Cary     |        |   |                     |   |   |         |   |        |
|          |        |   |                     |   |   |         |   |        |
| Street & |        |   |                     |   |   |         |   |        |
| Number:  |        |   |                     |   |   |         |   |        |
| 1426 May |        |   |                     |   |   |         |   |        |
| Drive    |        |   |                     |   |   |         |   |        |
| A        |        |   |                     |   |   |         |   |        |
| partment |        |   |                     |   |   |         |   |        |
| No.: Zip |        |   |                     |   |   |         |   |        |
| Code:    |        |   |                     |   |   |         |   |        |
| 27       |        |   |                     |   |   |         |   |        |
| 512-0004 |        |   |                     |   |   |         |   |        |
+----------+--------+---+---------------------+---+---+---------+---+--------+
| 43\.     |        |   |                     |   |   | 44\. IF |   |        |
| DESCRIBE |        |   |                     |   |   | TRANSPO |   |        |
| HOW      |        |   |                     |   |   | RTATION |   |        |
| INJURY   |        |   |                     |   |   | INJURY, |   |        |
| O        |        |   |                     |   |   | S       |   |        |
| CCURRED: |        |   |                     |   |   | PECIFY: |   |        |
|          |        |   |                     |   |   |         |   |        |
| Fell     |        |   |                     |   |   |        |   |        |
| down     |        |   |                     |   |   | D       |   |        |
| basement |        |   |                     |   |   | river/O |   |        |
| stairs   |        |   |                     |   |   | perator |   |        |
| onto a   |        |   |                     |   |   |         |   |        |
| cement   |        |   |                     |   |   | Pa   |   |        |
| floor    |        |   |                     |   |   | ssenger |   |        |
|          |        |   |                     |   |   |         |   |        |
|          |        |   |                     |   |   | Ped  |   |        |
|          |        |   |                     |   |   | estrian |   |        |
|          |        |   |                     |   |   |         |   |        |
|          |        |   |                     |   |   |        |   |        |
|          |        |   |                     |   |   | Other |   |        |
|          |        |   |                     |   |   | (S      |   |        |
|          |        |   |                     |   |   | pecify) |   |        |
+----------+--------+---+---------------------+---+---+---------+---+--------+

**ITEM 32 -- CAUSE OF DEATH (See example above)**

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.

Take care to make the entry legible. Use a computer printer with high
resolution, typewriter with good black ribbon and clean keys, or print
legibly using permanent **black** ink in completing the CAUSE OF DEATH
Section. **Do** **not** **abbreviate** conditions entered in section.

**[Part I]{.underline} (Chain of events leading directly to death)**

•Only **one** cause should be entered on each line. [Line
(a)]{.underline} **MUST ALWAYS** have an entry. **DO NOT** leave blank.
Additional lines may be added if necessary.

•If the condition on [Line (a)]{.underline} resulted from an underlying
condition, put the underlying condition on [Line (b)]{.underline}, and
so on, until the full sequence is reported. **ALWAYS** enter the
**underlying cause of death** on the [lowest used line]{.underline} in
Part I.

•For each cause indicate the best estimate of the interval between the
presumed onset and the date of death. The terms "unknown" or
"approximately" may be used. General terms, such as minutes, hours, or
days, are acceptable, if necessary. **DO NOT** leave blank.

•The terminal event (for example, cardiac arrest or respiratory arrest)
should not be used. If a mechanism of death seems most appropriate to
you for line (a), then you must always list its cause(s) on the line(s)
below it (for example, cardiac arrest **due to** coronary artery
atherosclerosis *or* cardiac arrest **due to** blunt impact to chest).

• If an organ system failure such as congestive heart failure, hepatic
failure, renal failure, or respiratory failure is listed as a cause of
death, always report its etiology on the line(s) beneath it (for
example, renal failure **due to** Type I diabetes mellitus).

•When indicating neoplasms as a cause of death, include the
following: 1) primary site *or* that the primary site is unknown, 2)
benign or malignant, 3) cell type *or* that the cell type is unknown, 4)
grade of neoplasm, and 5) part or lobe of organ affected. (For example,
a primary well-differentiated squamous cell carcinoma, lung, left upper
lobe.)

•Always report the fatal injury (for example, stab wound of chest), the
trauma (for example, transection of subclavian vein), and impairment of
function (for example, air embolism).

**Part II (Other significant conditions)**

•Enter all diseases or conditions contributing to death that were not
reported in the chain of events in Part I and that did not result in the
**underlying cause of death**.

•If two or more possible sequences resulted in death, or if two
conditions seem to have added together, report in Part I the one that,
in your opinion, most directly caused death. Report in Part II the other
conditions or diseases.

**CHANGES TO CAUSE OF DEATH**

Should additional medical information or autopsy findings become
available that would change the cause of death originally reported, the
original death certificate should be amended by the certifying physician
by **immediately** reporting the revised cause of death to the State
Vital Records Office.

**ITEMS ON WHEN DEATH OCCURRED**

Items 24-25 and 29-31 should always be completed. If the facility uses a
separate pronouncer or other person to indicate that death has taken
place with another person more familiar with the case completing the
remainder of the medical portion of the death certificate, the
pronouncer completes Items 24-28. If a certifier completes Items 24-25
as well as items 29-49, Items 26-28 may be left blank.

**ITEMS 24-25, 29-30 -- DATE AND TIME OF DEATH**

Spell out the name of the month. If the exact date of death is unknown,
enter the **approximate** date. If the date cannot be approximated,
enter the date the body is found and identify as **date found**. Date
pronounced and actual date may be the same. Enter the exact hour and
minutes according to a 24-hour clock; estimates may be provided with
"Approx." placed before the time.

**ITEMS 33-34 - AUTOPSY**

•33 - Enter "Yes" if either a partial or full autopsy was performed.
Otherwise enter "No."

•34 - Enter "Yes" if autopsy findings were available to complete the
cause of death; otherwise enter "No". Leave item blank if no autopsy was
performed.

**ITEM 35 - DID TOBACCO USE CONTRIBUTE TO DEATH?**

Check "yes" if, in your opinion, the use of tobacco contributed to
death. Tobacco use may contribute to deaths due to a wide variety of
diseases; for example, tobacco use contributes to many deaths due to
emphysema or lung cancer and some heart disease and cancers of the head
and neck. Check "no" if, in your clinical judgment, tobacco use did not
contribute to this particular death.

**ITEM 36 - IF FEMALE, WAS DECEDENT PREGNANT AT TIME OF DEATH OR WITHIN
PAST YEAR?**

This information is important in determining pregnancy-related
mortality.

**ITEM 37 - MANNER OF DEATH**

•Always check Manner of Death, which is important: 1) in determining
accurate causes of death; 2) in processing insurance claims; and 3) in
statistical studies of injuries and death.

•Indicate "Pending investigation" if the manner of death cannot be
determined whether due to an accident, suicide, or homicide within the
statutory time limit for filing the death certificate. This should be
changed later to one of the other terms.

•Indicate "Could not be Determined" **ONLY** when it is impossible to
determine the manner of death.

**ITEMS 38-44 - ACCIDENT OR INJURY -- to be filled out in all cases of
deaths due to injury or poisoning.**

•38 - Enter the exact month, day, and year of injury. Spell out the name
of the month. **DO NOT** use a number for the month. (Remember, the date
of injury may differ from the date of death.) Estimates may be provided
with "Approx." placed before the date.

•39 **-** Enter the exact hour and minutes of injury or use your best
estimate. Use a 24-hour clock.

•40 - Enter the general place (such as restaurant, vacant lot, or home)
where the injury occurred. **DO NOT** enter firm or organization names.
(For example, enter "factory", **not** "Standard Manufacturing, Inc." )

•41 - Complete if anything other than natural disease is mentioned in
Part I or Part II of the medical certification, including homicides,
suicides, and accidents. This includes all motor vehicle deaths. The
item **[must]{.underline}** be completed for decedents ages 14 years or
over and may be completed for those less than 14 years of age if
warranted. Enter "Yes" if the injury occurred at work. Otherwise enter
"No". An injury may occur at work regardless of whether the injury
occurred in the course of the decedent's "usual" occupation. Examples of
injury at work and injury not at work follow:

+-----------------------------------+-----------------------------------+
| **Injury at work**                | **Injury [not]{.underline} at     |
|                                   | work**                            |
| Injury while working or in        |                                   |
| vocational training on job        | Injury while engaged in personal  |
| premises                          | recreational activity on job      |
|                                   | premises                          |
| Injury while on break or at lunch |                                   |
| or in parking lot on job premises | Injury while a visitor (not on    |
|                                   | official work business) to job    |
| Injury while working for pay or   | premises                          |
| compensation, including at home   |                                   |
|                                   | Homemaker working at homemaking   |
| Injury while working as a         | activities                        |
| volunteer law enforcement         |                                   |
| official etc.                     | Student in school                 |
|                                   |                                   |
| Injury while traveling on         | Working for self for no profit    |
| business, including to/from       | (mowing yard, repairing own roof, |
| business contacts                 | hobby)                            |
|                                   |                                   |
|                                   | Commuting to or from work         |
+-----------------------------------+-----------------------------------+

•42 - Enter the complete address where the injury occurred including zip
code.

•43 - Enter a brief but specific and clear description of how the injury
occurred. Explain the circumstances or cause of the injury. Specify
**type** **of** **gun** or **type of vehicle** (e.g., car, bulldozer,
train, etc.) when relevant to circumstances. Indicate if more than one
vehicle involved; specify type of vehicle decedent was in.

•44 -Specify role of decedent (e.g. driver, passenger). Driver/operator
and passenger should be designated for modes other than motor vehicles
such as bicycles. Other applies to watercraft, aircraft, animal, or
people attached to outside of vehicles (e.g. surfers).

[Rationale]{.underline}: Motor vehicle accidents are a major cause of
unintentional deaths; details will help determine effectiveness of
current safety features and laws.

**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:]{.underline}**

+-------------+-------------+-------------+-------------+-------------+
| Abscess     | Car         | D           | H           | Pulmonary   |
|             | cinomatosis | isseminated | yponatremia | arrest      |
| Abdominal   |             | intra       |             |             |
| hemorrhage  | Cardiac     | vascular    | Hypotension | Pulmonary   |
|             | arrest      |             |             | edema       |
| Adhesions   |             | c           | Immuno      |             |
|             | Cardiac     | oagulopathy | suppression | Pulmonary   |
| Adult       | dysrhythmia |             |             | embolism    |
| respiratory |             | Dysrhythmia | Increased   |             |
| distress    | Car         |             | intra       | Pulmonary   |
| syndrome    | diomyopathy | End-stage   | cranial     | in          |
|             |             | liver       | pressure    | sufficiency |
| Acute       | Card        | disease     |             |             |
| myocardial  | iopulmonary |             | Intra       | Renal       |
| infarction  | arrest      | End-stage   | cranial     | failure     |
|             |             | renal       | hemorrhage  |             |
| Altered     | Cellulitis  | disease     |             | Respiratory |
| mental      |             |             | M           | arrest      |
| status      | Cerebral    | Epidural    | alnutrition |             |
|             | edema       | hematoma    |             | Seizures    |
| Anemia      |             |             | Metabolic   |             |
|             | Cere        | Exs         | enc         | Sepsis      |
| Anoxia      | brovascular | anguination | ephalopathy |             |
|             | accident    |             |             | Septic      |
| Anoxic      |             | Failure to  | Multi-organ | shock       |
| enc         | Cerebellar  | thrive      | failure     |             |
| ephalopathy | tonsillar   |             |             | Shock       |
|             | herniation  | Fracture    | M           |             |
| Arrhythmia  |             |             | ulti-system | Starvation  |
|             | Chronic     | Gangrene    | organ       |             |
| Ascites     | bedridden   |             | failure     | Subdural    |
|             | state       | Gastr       |             | hematoma    |
| Aspiration  |             | ointestinal | Myocardial  |             |
|             | Cirrhosis   | hemorrhage  | infarction  | S           |
| Atrial      |             |             |             | ubarachnoid |
| f           | C           | Heart       | Necrotizing | hemorrhage  |
| ibrillation | oagulopathy | failure     | soft-tissue |             |
|             |             |             | infection   | Sudden      |
| Bacteremia  | Compression | Hemothorax  |             | death       |
|             | fracture    |             | Old age     |             |
| Bedridden   |             | Hepatic     |             | Throm       |
|             | Congestive  | failure     | Open (or    | bocytopenia |
| Biliary     | heart       |             | closed)     |             |
| obstruction | failure     | Hepatitis   | head injury | Uncal       |
|             |             |             |             | herniation  |
| Bowel       | Convulsions | Hepatorenal | Paralysis   |             |
| obstruction |             | syndrome    |             | Urinary     |
|             | Decubiti    |             | P           | tract       |
| Brain       |             | Hy          | ancytopenia | infection   |
| injury      | Dehydration | perglycemia |             |             |
|             |             |             | Perforated  | Ventricular |
| Brain stem  | Dementia    | H           | gallbladder | f           |
| herniation  | (when not   | yperkalemia |             | ibrillation |
|             |             |             | Peritonitis |             |
| Car         | otherwise   | Hypovolemic |             | Ventricular |
| cinogenesis | specified)  | shock       | Pleural     | tachycardia |
|             |             |             | effusions   |             |
|             | Diarrhea    |             |             | Volume      |
|             |             |             | Pneumonia   | 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    | Epidural    | Hip         | Pulmonary   | Subdural    |
|             | hematoma    | fracture    | emboli      | hematoma    |
| Bolus       |             |             |             |             |
|             | Exs         | H           | Seizure     | Surgery     |
| Choking     | anguination | yperthermia | disorder    |             |
|             |             |             |             | Thermal     |
| Drug or     | Fall        | Hypothermia | Sepsis      | bur         |
| alcohol     |             |             |             | ns/chemical |
| ov          | Fracture    | Open        | S           | burns       |
| erdose/drug |             | reduction   | ubarachnoid |             |
| or          |             | of fracture | hemorrhage  |             |
|             |             |             |             |             |
| alcohol     |             |             |             |             |
| abuse       |             |             |             |             |
+-------------+-------------+-------------+-------------+-------------+

Contact your State vital statistics office for questions related to
writing cause-of-death statements. Additional instructional material on
writing cause-of-death statements including handbooks, summary
instructions, and tutorials are available online at www.thename.org or
www.cdc.gov/nchswww/about/major/dvs/handbk.htm, or by request from NCHS,
Room 7318, 3311 Toledo Road, Hyattsville, Maryland 20782-2003.

Query for Accidents Involving Transportation

+----------+--------+---+---------------------+---+---+---------+---+--------+
| **CAUSE  |        |   |                     |   |   |         |   | Appro  |
| OF DEATH |        |   |                     |   |   |         |   | ximate |
| (See     |        |   |                     |   |   |         |   | int    |
| inst     |        |   |                     |   |   |         |   | erval: |
| ructions |        |   |                     |   |   |         |   |        |
| and      |        |   |                     |   |   |         |   | Onset  |
| exa      |        |   |                     |   |   |         |   | to     |
| mples)** |        |   |                     |   |   |         |   | death  |
|          |        |   |                     |   |   |         |   |        |
| 32\.     |        |   |                     |   |   |         |   | [\     |
| **PART   |        |   |                     |   |   |         |   | _\_\_\ |
| I.**     |        |   |                     |   |   |         |   | _\_\_] |
| Enter    |        |   |                     |   |   |         |   | {.unde |
| the      |        |   |                     |   |   |         |   | rline} |
| [chain   |        |   |                     |   |   |         |   |        |
| of       |        |   |                     |   |   |         |   | [\     |
| events]  |        |   |                     |   |   |         |   | _\_\_\ |
| {.underl |        |   |                     |   |   |         |   | _\_\_] |
| ine}\--d |        |   |                     |   |   |         |   | {.unde |
| iseases, |        |   |                     |   |   |         |   | rline} |
| i        |        |   |                     |   |   |         |   |        |
| njuries, |        |   |                     |   |   |         |   | [\     |
| or       |        |   |                     |   |   |         |   | _\_\_\ |
| comp     |        |   |                     |   |   |         |   | _\_\_] |
| lication |        |   |                     |   |   |         |   | {.unde |
| s\--that |        |   |                     |   |   |         |   | rline} |
| directly |        |   |                     |   |   |         |   |        |
| caused   |        |   |                     |   |   |         |   | [\     |
| the      |        |   |                     |   |   |         |   | _\_\_\ |
| death.   |        |   |                     |   |   |         |   | _\_\_] |
| DO NOT   |        |   |                     |   |   |         |   | {.unde |
| enter    |        |   |                     |   |   |         |   | rline} |
| terminal |        |   |                     |   |   |         |   |        |
| events   |        |   |                     |   |   |         |   |        |
| such as  |        |   |                     |   |   |         |   |        |
| cardiac  |        |   |                     |   |   |         |   |        |
|          |        |   |                     |   |   |         |   |        |
| arrest,  |        |   |                     |   |   |         |   |        |
| res      |        |   |                     |   |   |         |   |        |
| piratory |        |   |                     |   |   |         |   |        |
| arrest,  |        |   |                     |   |   |         |   |        |
| or       |        |   |                     |   |   |         |   |        |
| ven      |        |   |                     |   |   |         |   |        |
| tricular |        |   |                     |   |   |         |   |        |
| fibr     |        |   |                     |   |   |         |   |        |
| illation |        |   |                     |   |   |         |   |        |
| without  |        |   |                     |   |   |         |   |        |
| showing  |        |   |                     |   |   |         |   |        |
| the      |        |   |                     |   |   |         |   |        |
| e        |        |   |                     |   |   |         |   |        |
| tiology. |        |   |                     |   |   |         |   |        |
| DO NOT   |        |   |                     |   |   |         |   |        |
| ABB      |        |   |                     |   |   |         |   |        |
| REVIATE. |        |   |                     |   |   |         |   |        |
| Enter    |        |   |                     |   |   |         |   |        |
| only one |        |   |                     |   |   |         |   |        |
| cause on |        |   |                     |   |   |         |   |        |
| a line.  |        |   |                     |   |   |         |   |        |
| Add      |        |   |                     |   |   |         |   |        |
| ad       |        |   |                     |   |   |         |   |        |
| ditional |        |   |                     |   |   |         |   |        |
|          |        |   |                     |   |   |         |   |        |
| lines if |        |   |                     |   |   |         |   |        |
| ne       |        |   |                     |   |   |         |   |        |
| cessary. |        |   |                     |   |   |         |   |        |
|          |        |   |                     |   |   |         |   |        |
| I        |        |   |                     |   |   |         |   |        |
| MMEDIATE |        |   |                     |   |   |         |   |        |
| CAUSE    |        |   |                     |   |   |         |   |        |
| (Final   |        |   |                     |   |   |         |   |        |
|          |        |   |                     |   |   |         |   |        |
| disease  |        |   |                     |   |   |         |   |        |
| or       |        |   |                     |   |   |         |   |        |
| c        |        |   |                     |   |   |         |   |        |
| ondition |        |   |                     |   |   |         |   |        |
| **\-\-\  |        |   |                     |   |   |         |   |        |
| -\-\-\-\ |        |   |                     |   |   |         |   |        |
| -\--\>** |        |   |                     |   |   |         |   |        |
| a.       |        |   |                     |   |   |         |   |        |
| \_\_\_   |        |   |                     |   |   |         |   |        |
| \_\_\_\_ |        |   |                     |   |   |         |   |        |
| [\_\     |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_]{.un |        |   |                     |   |   |         |   |        |
| derline} |        |   |                     |   |   |         |   |        |
|          |        |   |                     |   |   |         |   |        |
| r        |        |   |                     |   |   |         |   |        |
| esulting |        |   |                     |   |   |         |   |        |
| in       |        |   |                     |   |   |         |   |        |
| death)   |        |   |                     |   |   |         |   |        |
| Due to   |        |   |                     |   |   |         |   |        |
| (or as a |        |   |                     |   |   |         |   |        |
| con      |        |   |                     |   |   |         |   |        |
| sequence |        |   |                     |   |   |         |   |        |
| of):     |        |   |                     |   |   |         |   |        |
|          |        |   |                     |   |   |         |   |        |
| Sequ     |        |   |                     |   |   |         |   |        |
| entially |        |   |                     |   |   |         |   |        |
| list     |        |   |                     |   |   |         |   |        |
| con      |        |   |                     |   |   |         |   |        |
| ditions, |        |   |                     |   |   |         |   |        |
| b.       |        |   |                     |   |   |         |   |        |
| \_\_     |        |   |                     |   |   |         |   |        |
| \_\_\_\_ |        |   |                     |   |   |         |   |        |
| \_\_[\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_]{.un |        |   |                     |   |   |         |   |        |
| derline} |        |   |                     |   |   |         |   |        |
|          |        |   |                     |   |   |         |   |        |
| if any,  |        |   |                     |   |   |         |   |        |
| leading  |        |   |                     |   |   |         |   |        |
| to the   |        |   |                     |   |   |         |   |        |
| cause    |        |   |                     |   |   |         |   |        |
| Due to   |        |   |                     |   |   |         |   |        |
| (or as a |        |   |                     |   |   |         |   |        |
| con      |        |   |                     |   |   |         |   |        |
| sequence |        |   |                     |   |   |         |   |        |
| of):     |        |   |                     |   |   |         |   |        |
|          |        |   |                     |   |   |         |   |        |
| listed   |        |   |                     |   |   |         |   |        |
| on line  |        |   |                     |   |   |         |   |        |
| a. Enter |        |   |                     |   |   |         |   |        |
| the      |        |   |                     |   |   |         |   |        |
|          |        |   |                     |   |   |         |   |        |
| **UN     |        |   |                     |   |   |         |   |        |
| DERLYING |        |   |                     |   |   |         |   |        |
| CAUSE**  |        |   |                     |   |   |         |   |        |
| c.       |        |   |                     |   |   |         |   |        |
| \_       |        |   |                     |   |   |         |   |        |
| \_\_\_\_ |        |   |                     |   |   |         |   |        |
| [\_\_\   |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_]{.un |        |   |                     |   |   |         |   |        |
| derline} |        |   |                     |   |   |         |   |        |
|          |        |   |                     |   |   |         |   |        |
| (disease |        |   |                     |   |   |         |   |        |
| or       |        |   |                     |   |   |         |   |        |
| injury   |        |   |                     |   |   |         |   |        |
| that Due |        |   |                     |   |   |         |   |        |
| to (or   |        |   |                     |   |   |         |   |        |
| as a     |        |   |                     |   |   |         |   |        |
| con      |        |   |                     |   |   |         |   |        |
| sequence |        |   |                     |   |   |         |   |        |
| of):     |        |   |                     |   |   |         |   |        |
|          |        |   |                     |   |   |         |   |        |
| i        |        |   |                     |   |   |         |   |        |
| nitiated |        |   |                     |   |   |         |   |        |
| the      |        |   |                     |   |   |         |   |        |
| events   |        |   |                     |   |   |         |   |        |
| r        |        |   |                     |   |   |         |   |        |
| esulting |        |   |                     |   |   |         |   |        |
|          |        |   |                     |   |   |         |   |        |
| in       |        |   |                     |   |   |         |   |        |
| death)   |        |   |                     |   |   |         |   |        |
| **LAST** |        |   |                     |   |   |         |   |        |
| d.       |        |   |                     |   |   |         |   |        |
| \_\_\_   |        |   |                     |   |   |         |   |        |
| \_\_\_\_ |        |   |                     |   |   |         |   |        |
| [\_\_\   |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_]{.un |        |   |                     |   |   |         |   |        |
| derline} |        |   |                     |   |   |         |   |        |
+----------+--------+---+---------------------+---+---+---------+---+--------+
| **PART   |        |   |                     |   | 3 |         |   |        |
| II.**    |        |   |                     |   | 3 |         |   |        |
| Enter    |        |   |                     |   | \ |         |   |        |
| other    |        |   |                     |   | . |         |   |        |
| [sig     |        |   |                     |   | W |         |   |        |
| nificant |        |   |                     |   | A |         |   |        |
| co       |        |   |                     |   | S |         |   |        |
| nditions |        |   |                     |   | A |         |   |        |
| cont     |        |   |                     |   | N |         |   |        |
| ributing |        |   |                     |   | A |         |   |        |
| to       |        |   |                     |   | U |         |   |        |
| de       |        |   |                     |   | T |         |   |        |
| ath]{.un |        |   |                     |   | O |         |   |        |
| derline} |        |   |                     |   | P |         |   |        |
| but not  |        |   |                     |   | S |         |   |        |
| r        |        |   |                     |   | Y |         |   |        |
| esulting |        |   |                     |   | P |         |   |        |
| in the   |        |   |                     |   | E |         |   |        |
| un       |        |   |                     |   | R |         |   |        |
| derlying |        |   |                     |   | F |         |   |        |
| cause    |        |   |                     |   | O |         |   |        |
| given in |        |   |                     |   | R |         |   |        |
| PART I   |        |   |                     |   | M |         |   |        |
|          |        |   |                     |   | E |         |   |        |
|          |        |   |                     |   | D |         |   |        |
|          |        |   |                     |   | ? |         |   |        |
|          |        |   |                     |   |   |         |   |        |
|          |        |   |                     |   |  |         |   |        |
|          |        |   |                     |   | Y |         |   |        |
|          |        |   |                     |   | e |         |   |        |
|          |        |   |                     |   | s |         |   |        |
|          |        |   |                     |   |  |         |   |        |
|          |        |   |                     |   |  |         |   |        |
|          |        |   |                     |   |  |         |   |        |
|          |        |   |                     |   | N |         |   |        |
|          |        |   |                     |   | o |         |   |        |
+----------+--------+---+---------------------+---+---+---------+---+--------+
|          |        |   |                     |   | 3 |         |   |        |
|          |        |   |                     |   | 4 |         |   |        |
|          |        |   |                     |   | \ |         |   |        |
|          |        |   |                     |   | . |         |   |        |
|          |        |   |                     |   | W |         |   |        |
|          |        |   |                     |   | E |         |   |        |
|          |        |   |                     |   | R |         |   |        |
|          |        |   |                     |   | E |         |   |        |
|          |        |   |                     |   | A |         |   |        |
|          |        |   |                     |   | U |         |   |        |
|          |        |   |                     |   | T |         |   |        |
|          |        |   |                     |   | O |         |   |        |
|          |        |   |                     |   | P |         |   |        |
|          |        |   |                     |   | S |         |   |        |
|          |        |   |                     |   | Y |         |   |        |
|          |        |   |                     |   | F |         |   |        |
|          |        |   |                     |   | I |         |   |        |
|          |        |   |                     |   | N |         |   |        |
|          |        |   |                     |   | D |         |   |        |
|          |        |   |                     |   | I |         |   |        |
|          |        |   |                     |   | N |         |   |        |
|          |        |   |                     |   | G |         |   |        |
|          |        |   |                     |   | S |         |   |        |
|          |        |   |                     |   | A |         |   |        |
|          |        |   |                     |   | V |         |   |        |
|          |        |   |                     |   | A |         |   |        |
|          |        |   |                     |   | I |         |   |        |
|          |        |   |                     |   | L |         |   |        |
|          |        |   |                     |   | A |         |   |        |
|          |        |   |                     |   | B |         |   |        |
|          |        |   |                     |   | L |         |   |        |
|          |        |   |                     |   | E |         |   |        |
|          |        |   |                     |   | T |         |   |        |
|          |        |   |                     |   | O |         |   |        |
|          |        |   |                     |   |   |         |   |        |
|          |        |   |                     |   | C |         |   |        |
|          |        |   |                     |   | O |         |   |        |
|          |        |   |                     |   | M |         |   |        |
|          |        |   |                     |   | P |         |   |        |
|          |        |   |                     |   | L |         |   |        |
|          |        |   |                     |   | E |         |   |        |
|          |        |   |                     |   | T |         |   |        |
|          |        |   |                     |   | E |         |   |        |
|          |        |   |                     |   | T |         |   |        |
|          |        |   |                     |   | H |         |   |        |
|          |        |   |                     |   | E |         |   |        |
|          |        |   |                     |   | C |         |   |        |
|          |        |   |                     |   | A |         |   |        |
|          |        |   |                     |   | U |         |   |        |
|          |        |   |                     |   | S |         |   |        |
|          |        |   |                     |   | E |         |   |        |
|          |        |   |                     |   | O |         |   |        |
|          |        |   |                     |   | F |         |   |        |
|          |        |   |                     |   | D |         |   |        |
|          |        |   |                     |   | E |         |   |        |
|          |        |   |                     |   | A |         |   |        |
|          |        |   |                     |   | T |         |   |        |
|          |        |   |                     |   | H |         |   |        |
|          |        |   |                     |   | ? |         |   |        |
|          |        |   |                     |   |  |         |   |        |
|          |        |   |                     |   | Y |         |   |        |
|          |        |   |                     |   | e |         |   |        |
|          |        |   |                     |   | s |         |   |        |
|          |        |   |                     |   |  |         |   |        |
|          |        |   |                     |   |  |         |   |        |
|          |        |   |                     |   |  |         |   |        |
|          |        |   |                     |   | N |         |   |        |
|          |        |   |                     |   | o |         |   |        |
+----------+--------+---+---------------------+---+---+---------+---+--------+
| 35\. DID |        | 3 |                     | 3 |   |         |   |        |
| TOBACCO  |        | 6 |                     | 7 |   |         |   |        |
| USE      |        | \ |                     | \ |   |         |   |        |
| CO       |        | . |                     | . |   |         |   |        |
| NTRIBUTE |        | I |                     | M |   |         |   |        |
| TO       |        | F |                     | A |   |         |   |        |
| DEATH?   |        | F |                     | N |   |         |   |        |
|          |        | E |                     | N |   |         |   |        |
| Yes  |        | M |                     | E |   |         |   |        |
|       |        | A |                     | R |   |         |   |        |
| Probably |        | L |                     | O |   |         |   |        |
|          |        | E |                     | F |   |         |   |        |
|  No     |        | : |                     | D |   |         |   |        |
|        |        |   |                     | E |   |         |   |        |
| Unknown |        |  |                     | A |   |         |   |        |
|          |        |  |                     | T |   |         |   |        |
|          |        |  |                     | H |   |         |   |        |
|          |        | N |                     |   |   |         |   |        |
|          |        | o |                     |  |   |         |   |        |
|          |        | t |                     |  |   |         |   |        |
|          |        | p |                     |  |   |         |   |        |
|          |        | r |                     | N |   |         |   |        |
|          |        | e |                     | a |   |         |   |        |
|          |        | g |                     | t |   |         |   |        |
|          |        | n |                     | u |   |         |   |        |
|          |        | a |                     | r |   |         |   |        |
|          |        | n |                     | a |   |         |   |        |
|          |        | t |                     | l |   |         |   |        |
|          |        | w |                     |  |   |         |   |        |
|          |        | i |                     |  |   |         |   |        |
|          |        | t |                     |  |   |         |   |        |
|          |        | h |                     | H |   |         |   |        |
|          |        | i |                     | o |   |         |   |        |
|          |        | n |                     | m |   |         |   |        |
|          |        | p |                     | i |   |         |   |        |
|          |        | a |                     | c |   |         |   |        |
|          |        | s |                     | i |   |         |   |        |
|          |        | t |                     | d |   |         |   |        |
|          |        | y |                     | e |   |         |   |        |
|          |        | e |                     |   |   |         |   |        |
|          |        | a |                     |  |   |         |   |        |
|          |        | r |                     | A |   |         |   |        |
|          |        |   |                     | c |   |         |   |        |
|          |        |  |                     | c |   |         |   |        |
|          |        |  |                     | i |   |         |   |        |
|          |        |  |                     | d |   |         |   |        |
|          |        | P |                     | e |   |         |   |        |
|          |        | r |                     | n |   |         |   |        |
|          |        | e |                     | t |   |         |   |        |
|          |        | g |                     |  |   |         |   |        |
|          |        | n |                     |  |   |         |   |        |
|          |        | a |                     |  |   |         |   |        |
|          |        | n |                     | P |   |         |   |        |
|          |        | t |                     | e |   |         |   |        |
|          |        | a |                     | n |   |         |   |        |
|          |        | t |                     | d |   |         |   |        |
|          |        | t |                     | i |   |         |   |        |
|          |        | i |                     | n |   |         |   |        |
|          |        | m |                     | g |   |         |   |        |
|          |        | e |                     | I |   |         |   |        |
|          |        | o |                     | n |   |         |   |        |
|          |        | f |                     | v |   |         |   |        |
|          |        | d |                     | e |   |         |   |        |
|          |        | e |                     | s |   |         |   |        |
|          |        | a |                     | t |   |         |   |        |
|          |        | t |                     | i |   |         |   |        |
|          |        | h |                     | g |   |         |   |        |
|          |        |   |                     | a |   |         |   |        |
|          |        |  |                     | t |   |         |   |        |
|          |        |  |                     | i |   |         |   |        |
|          |        |  |                     | o |   |         |   |        |
|          |        | N |                     | n |   |         |   |        |
|          |        | o |                     |   |   |         |   |        |
|          |        | t |                     |  |   |         |   |        |
|          |        | p |                     |  |   |         |   |        |
|          |        | r |                     |  |   |         |   |        |
|          |        | e |                     | S |   |         |   |        |
|          |        | g |                     | u |   |         |   |        |
|          |        | n |                     | i |   |         |   |        |
|          |        | a |                     | c |   |         |   |        |
|          |        | n |                     | i |   |         |   |        |
|          |        | t |                     | d |   |         |   |        |
|          |        | , |                     | e |   |         |   |        |
|          |        | b |                     |  |   |         |   |        |
|          |        | u |                     |  |   |         |   |        |
|          |        | t |                     |  |   |         |   |        |
|          |        | p |                     | C |   |         |   |        |
|          |        | r |                     | o |   |         |   |        |
|          |        | e |                     | u |   |         |   |        |
|          |        | g |                     | l |   |         |   |        |
|          |        | n |                     | d |   |         |   |        |
|          |        | a |                     | n |   |         |   |        |
|          |        | n |                     | o |   |         |   |        |
|          |        | t |                     | t |   |         |   |        |
|          |        | w |                     | b |   |         |   |        |
|          |        | i |                     | e |   |         |   |        |
|          |        | t |                     | d |   |         |   |        |
|          |        | h |                     | e |   |         |   |        |
|          |        | i |                     | t |   |         |   |        |
|          |        | n |                     | e |   |         |   |        |
|          |        | 4 |                     | r |   |         |   |        |
|          |        | 2 |                     | m |   |         |   |        |
|          |        | d |                     | i |   |         |   |        |
|          |        | a |                     | n |   |         |   |        |
|          |        | y |                     | e |   |         |   |        |
|          |        | s |                     | d |   |         |   |        |
|          |        | o |                     |   |   |         |   |        |
|          |        | f |                     |   |   |         |   |        |
|          |        | d |                     |   |   |         |   |        |
|          |        | e |                     |   |   |         |   |        |
|          |        | a |                     |   |   |         |   |        |
|          |        | t |                     |   |   |         |   |        |
|          |        | h |                     |   |   |         |   |        |
|          |        |   |                     |   |   |         |   |        |
|          |        |  |                     |   |   |         |   |        |
|          |        |  |                     |   |   |         |   |        |
|          |        |  |                     |   |   |         |   |        |
|          |        | N |                     |   |   |         |   |        |
|          |        | o |                     |   |   |         |   |        |
|          |        | t |                     |   |   |         |   |        |
|          |        | p |                     |   |   |         |   |        |
|          |        | r |                     |   |   |         |   |        |
|          |        | e |                     |   |   |         |   |        |
|          |        | g |                     |   |   |         |   |        |
|          |        | n |                     |   |   |         |   |        |
|          |        | a |                     |   |   |         |   |        |
|          |        | n |                     |   |   |         |   |        |
|          |        | t |                     |   |   |         |   |        |
|          |        | , |                     |   |   |         |   |        |
|          |        | b |                     |   |   |         |   |        |
|          |        | u |                     |   |   |         |   |        |
|          |        | t |                     |   |   |         |   |        |
|          |        | p |                     |   |   |         |   |        |
|          |        | r |                     |   |   |         |   |        |
|          |        | e |                     |   |   |         |   |        |
|          |        | g |                     |   |   |         |   |        |
|          |        | n |                     |   |   |         |   |        |
|          |        | a |                     |   |   |         |   |        |
|          |        | n |                     |   |   |         |   |        |
|          |        | t |                     |   |   |         |   |        |
|          |        | 4 |                     |   |   |         |   |        |
|          |        | 3 |                     |   |   |         |   |        |
|          |        | d |                     |   |   |         |   |        |
|          |        | a |                     |   |   |         |   |        |
|          |        | y |                     |   |   |         |   |        |
|          |        | s |                     |   |   |         |   |        |
|          |        | t |                     |   |   |         |   |        |
|          |        | o |                     |   |   |         |   |        |
|          |        | 1 |                     |   |   |         |   |        |
|          |        | y |                     |   |   |         |   |        |
|          |        | e |                     |   |   |         |   |        |
|          |        | a |                     |   |   |         |   |        |
|          |        | r |                     |   |   |         |   |        |
|          |        | b |                     |   |   |         |   |        |
|          |        | e |                     |   |   |         |   |        |
|          |        | f |                     |   |   |         |   |        |
|          |        | o |                     |   |   |         |   |        |
|          |        | r |                     |   |   |         |   |        |
|          |        | e |                     |   |   |         |   |        |
|          |        | d |                     |   |   |         |   |        |
|          |        | e |                     |   |   |         |   |        |
|          |        | a |                     |   |   |         |   |        |
|          |        | t |                     |   |   |         |   |        |
|          |        | h |                     |   |   |         |   |        |
|          |        |   |                     |   |   |         |   |        |
|          |        |  |                     |   |   |         |   |        |
|          |        |  |                     |   |   |         |   |        |
|          |        |  |                     |   |   |         |   |        |
|          |        | U |                     |   |   |         |   |        |
|          |        | n |                     |   |   |         |   |        |
|          |        | k |                     |   |   |         |   |        |
|          |        | n |                     |   |   |         |   |        |
|          |        | o |                     |   |   |         |   |        |
|          |        | w |                     |   |   |         |   |        |
|          |        | n |                     |   |   |         |   |        |
|          |        | i |                     |   |   |         |   |        |
|          |        | f |                     |   |   |         |   |        |
|          |        | p |                     |   |   |         |   |        |
|          |        | r |                     |   |   |         |   |        |
|          |        | e |                     |   |   |         |   |        |
|          |        | g |                     |   |   |         |   |        |
|          |        | n |                     |   |   |         |   |        |
|          |        | a |                     |   |   |         |   |        |
|          |        | n |                     |   |   |         |   |        |
|          |        | t |                     |   |   |         |   |        |
|          |        | w |                     |   |   |         |   |        |
|          |        | i |                     |   |   |         |   |        |
|          |        | t |                     |   |   |         |   |        |
|          |        | h |                     |   |   |         |   |        |
|          |        | i |                     |   |   |         |   |        |
|          |        | n |                     |   |   |         |   |        |
|          |        | t |                     |   |   |         |   |        |
|          |        | h |                     |   |   |         |   |        |
|          |        | e |                     |   |   |         |   |        |
|          |        | p |                     |   |   |         |   |        |
|          |        | a |                     |   |   |         |   |        |
|          |        | s |                     |   |   |         |   |        |
|          |        | t |                     |   |   |         |   |        |
|          |        | y |                     |   |   |         |   |        |
|          |        | e |                     |   |   |         |   |        |
|          |        | a |                     |   |   |         |   |        |
|          |        | r |                     |   |   |         |   |        |
+----------+--------+---+---------------------+---+---+---------+---+--------+
| 38\.     | 39\.   |   | 40\. PLACE OF       |   |   |         | 4 |        |
| DATE OF  | TIME   |   | INJURY (e.g.,       |   |   |         | 1 |        |
| INJURY   | OF     |   | Decedent's home;    |   |   |         | \ |        |
|          | INJURY |   | construction site;  |   |   |         | . |        |
| (Mo      |        |   | restaurant; wooded  |   |   |         | I |        |
| /Day/Yr) | A      |   | area)               |   |   |         | N |        |
| (Spell   | pprox. |   |                     |   |   |         | J |        |
| Month)   | 2320   |   | road side near      |   |   |         | U |        |
|          |        |   | state highway       |   |   |         | R |        |
| August   |        |   |                     |   |   |         | Y |        |
| 15, 2003 |        |   |                     |   |   |         | A |        |
|          |        |   |                     |   |   |         | T |        |
|          |        |   |                     |   |   |         | W |        |
|          |        |   |                     |   |   |         | O |        |
|          |        |   |                     |   |   |         | R |        |
|          |        |   |                     |   |   |         | K |        |
|          |        |   |                     |   |   |         | ? |        |
|          |        |   |                     |   |   |         |   |        |
|          |        |   |                     |   |   |         |  |        |
|          |        |   |                     |   |   |         |  |        |
|          |        |   |                     |   |   |         |  |        |
|          |        |   |                     |   |   |         |  |        |
|          |        |   |                     |   |   |         |  |        |
|          |        |   |                     |   |   |         |  |        |
|          |        |   |                     |   |   |         |  |        |
|          |        |   |                     |   |   |         |  |        |
|          |        |   |                     |   |   |         |  |        |
|          |        |   |                     |   |   |         |  |        |
|          |        |   |                     |   |   |         |  |        |
|          |        |   |                     |   |   |         |  |        |
|          |        |   |                     |   |   |         |  |        |
|          |        |   |                     |   |   |         | Y |        |
|          |        |   |                     |   |   |         | e |        |
|          |        |   |                     |   |   |         | s |        |
|          |        |   |                     |   |   |         |  |        |
|          |        |   |                     |   |   |         | N |        |
|          |        |   |                     |   |   |         | o |        |
+----------+--------+---+---------------------+---+---+---------+---+--------+
| 42\.     |        |   |                     |   |   |         |   |        |
| LOCATION |        |   |                     |   |   |         |   |        |
| OF       |        |   |                     |   |   |         |   |        |
| INJURY:  |        |   |                     |   |   |         |   |        |
| State:   |        |   |                     |   |   |         |   |        |
| City or  |        |   |                     |   |   |         |   |        |
| Town:    |        |   |                     |   |   |         |   |        |
|          |        |   |                     |   |   |         |   |        |
| Street & |        |   |                     |   |   |         |   |        |
| Number:  |        |   |                     |   |   |         |   |        |
| A        |        |   |                     |   |   |         |   |        |
| partment |        |   |                     |   |   |         |   |        |
| No.: Zip |        |   |                     |   |   |         |   |        |
| Code:    |        |   |                     |   |   |         |   |        |
+----------+--------+---+---------------------+---+---+---------+---+--------+
| 43\.     |        |   |                     |   |   | 44\. IF |   |        |
| DESCRIBE |        |   |                     |   |   | TRANSPO |   |        |
| HOW      |        |   |                     |   |   | RTATION |   |        |
| INJURY   |        |   |                     |   |   | INJURY, |   |        |
| O        |        |   |                     |   |   | S       |   |        |
| CCURRED: |        |   |                     |   |   | PECIFY: |   |        |
|          |        |   |                     |   |   |         |   |        |
|          |        |   |                     |   |   |        |   |        |
|          |        |   |                     |   |   | D       |   |        |
|          |        |   |                     |   |   | river/O |   |        |
|          |        |   |                     |   |   | perator |   |        |
|          |        |   |                     |   |   |         |   |        |
|          |        |   |                     |   |   | Pa   |   |        |
|          |        |   |                     |   |   | ssenger |   |        |
|          |        |   |                     |   |   |         |   |        |
|          |        |   |                     |   |   | Ped  |   |        |
|          |        |   |                     |   |   | estrian |   |        |
|          |        |   |                     |   |   |         |   |        |
|          |        |   |                     |   |   |        |   |        |
|          |        |   |                     |   |   | Other |   |        |
|          |        |   |                     |   |   | (S      |   |        |
|          |        |   |                     |   |   | pecify) |   |        |
+----------+--------+---+---------------------+---+---+---------+---+--------+

1A. Please state if the manner of death was accidental, homicidal,
suicidal, natural, or undetermined.
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_.

If undetermined, was there a pending investigation?
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_.

1B. State what happened to the decedent, describe in detail the external
event that caused the death.

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

2\. Describe in detail the external event
(\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ )
that eventually brought about the medical complications which caused the
death.
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_.

3\. Place of occurrence (home, residential institution, public
administrative area, sports area, street and highway, trade and service
areas, industrial and construction area, farm, other -please specify-)
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

4A. Type of vehicle, e.g. automobile, motorcycle, 3-wheeled motor
vehicle for on road use, van, pick-up truck, heavy transport vehicle,
bus, vehicle mainly used on industrial premises within buildings (e.g.,
forklift), vehicle mainly used in agriculture (e.g., tractor, combine),
construction vehicle (e.g., bulldozer), all-terrain vehicle or other
vehicle designed for off-road use, bicycle, train, streetcar, animal,
powered fishing boat, water-skis, helicopter, private airplane
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

4B. Location at time of accident. On highway \_\_\_ Off highway\_\_\_
Stationary (parked car)\_\_\_ Railway yard, track, railroad\_\_\_ In
flight, midair\_\_\_ At airport, on runway\_\_\_ In water\_\_\_
Other\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

4C. Collision: Yes\_\_\_ No\_\_\_.

If Yes, collision with what type of vehicle
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ and location at time of collision
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

4D.1) Involving vehicle: Loss of control \_\_\_ Sinking \_\_\_
Explosion, fire\_\_\_ Object thrown on\_\_ Excessive heat\_\_\_

Other
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

2\) What happened to decedent? Fell\_\_\_ Injured while boarding
\_\_\_Inhaled smoke \_\_\_Fell from vehicle\_\_\_

Run over by\_\_\_ Hit by moving part\_\_\_ Crushed\_\_\_ Thrown
from\_\_\_ Other \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

3\) Status of decedent: (check a. or b.)

a\. If IN or ON vehicle:

> Driver\_\_\_ Passenger\_\_\_ Occupant\_\_\_ Rider\_\_\_ Crew of
> vehicle\_\_\_ Other \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

b\. If NOT in or on vehicle:

> Pedestrian\_\_\_ Outside of vehicle\_\_\_ Water skier\_\_\_
> Swimmer\_\_\_ Person on ground injured in air transport accident\_\_
> Airline ground crew \_\_\_ Dock worker\_\_\_
> Other\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

4\) If decedent was occupant of vehicle, please specify type of vehicle
\_\_\_\_\_\_\_\_\_\_\_\_\_\_

[, M.D.]{.underline}

(Signature of Certifying Physician)

Please provide your office
phone:\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
fax:\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

(Please see other side)

Instructions on Medical Certification of Causes of Death

Example of properly completed medical certification

+----------+--------+---+---------------------+---+---+---------+---+--------+
| **CAUSE  |        |   |                     |   |   |         |   | Appro  |
| OF DEATH |        |   |                     |   |   |         |   | ximate |
| (See     |        |   |                     |   |   |         |   | int    |
| inst     |        |   |                     |   |   |         |   | erval: |
| ructions |        |   |                     |   |   |         |   |        |
| and      |        |   |                     |   |   |         |   | Onset  |
| exa      |        |   |                     |   |   |         |   | to     |
| mples)** |        |   |                     |   |   |         |   | death  |
|          |        |   |                     |   |   |         |   |        |
| 32\.     |        |   |                     |   |   |         |   | [2     |
| **PART   |        |   |                     |   |   |         |   | Days]  |
| I.**     |        |   |                     |   |   |         |   | {.unde |
| Enter    |        |   |                     |   |   |         |   | rline} |
| the      |        |   |                     |   |   |         |   |        |
| [chain   |        |   |                     |   |   |         |   | [7     |
| of       |        |   |                     |   |   |         |   | weeks] |
| events]  |        |   |                     |   |   |         |   | {.unde |
| {.underl |        |   |                     |   |   |         |   | rline} |
| ine}\--d |        |   |                     |   |   |         |   |        |
| iseases, |        |   |                     |   |   |         |   | [7     |
| i        |        |   |                     |   |   |         |   | weeks] |
| njuries, |        |   |                     |   |   |         |   | {.unde |
| or       |        |   |                     |   |   |         |   | rline} |
| comp     |        |   |                     |   |   |         |   |        |
| lication |        |   |                     |   |   |         |   | [7     |
| s\--that |        |   |                     |   |   |         |   | weeks] |
| directly |        |   |                     |   |   |         |   | {.unde |
| caused   |        |   |                     |   |   |         |   | rline} |
| the      |        |   |                     |   |   |         |   |        |
| death.   |        |   |                     |   |   |         |   |        |
| DO NOT   |        |   |                     |   |   |         |   |        |
| enter    |        |   |                     |   |   |         |   |        |
| terminal |        |   |                     |   |   |         |   |        |
| events   |        |   |                     |   |   |         |   |        |
| such as  |        |   |                     |   |   |         |   |        |
| cardiac  |        |   |                     |   |   |         |   |        |
|          |        |   |                     |   |   |         |   |        |
| arrest,  |        |   |                     |   |   |         |   |        |
| res      |        |   |                     |   |   |         |   |        |
| piratory |        |   |                     |   |   |         |   |        |
| arrest,  |        |   |                     |   |   |         |   |        |
| or       |        |   |                     |   |   |         |   |        |
| ven      |        |   |                     |   |   |         |   |        |
| tricular |        |   |                     |   |   |         |   |        |
| fibr     |        |   |                     |   |   |         |   |        |
| illation |        |   |                     |   |   |         |   |        |
| without  |        |   |                     |   |   |         |   |        |
| showing  |        |   |                     |   |   |         |   |        |
| the      |        |   |                     |   |   |         |   |        |
| e        |        |   |                     |   |   |         |   |        |
| tiology. |        |   |                     |   |   |         |   |        |
| DO NOT   |        |   |                     |   |   |         |   |        |
| ABB      |        |   |                     |   |   |         |   |        |
| REVIATE. |        |   |                     |   |   |         |   |        |
| Enter    |        |   |                     |   |   |         |   |        |
| only one |        |   |                     |   |   |         |   |        |
| cause on |        |   |                     |   |   |         |   |        |
| a line.  |        |   |                     |   |   |         |   |        |
| Add      |        |   |                     |   |   |         |   |        |
| ad       |        |   |                     |   |   |         |   |        |
| ditional |        |   |                     |   |   |         |   |        |
|          |        |   |                     |   |   |         |   |        |
| lines if |        |   |                     |   |   |         |   |        |
| ne       |        |   |                     |   |   |         |   |        |
| cessary. |        |   |                     |   |   |         |   |        |
|          |        |   |                     |   |   |         |   |        |
| I        |        |   |                     |   |   |         |   |        |
| MMEDIATE |        |   |                     |   |   |         |   |        |
| CAUSE    |        |   |                     |   |   |         |   |        |
| (Final   |        |   |                     |   |   |         |   |        |
|          |        |   |                     |   |   |         |   |        |
| disease  |        |   |                     |   |   |         |   |        |
| or       |        |   |                     |   |   |         |   |        |
| c        |        |   |                     |   |   |         |   |        |
| ondition |        |   |                     |   |   |         |   |        |
| **\-\-\  |        |   |                     |   |   |         |   |        |
| -\-\-\-\ |        |   |                     |   |   |         |   |        |
| -\--\>** |        |   |                     |   |   |         |   |        |
| a.       |        |   |                     |   |   |         |   |        |
| [As      |        |   |                     |   |   |         |   |        |
| piration |        |   |                     |   |   |         |   |        |
| pneu     |        |   |                     |   |   |         |   |        |
| monia\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_]{.un |        |   |                     |   |   |         |   |        |
| derline} |        |   |                     |   |   |         |   |        |
|          |        |   |                     |   |   |         |   |        |
| r        |        |   |                     |   |   |         |   |        |
| esulting |        |   |                     |   |   |         |   |        |
| in       |        |   |                     |   |   |         |   |        |
| death)   |        |   |                     |   |   |         |   |        |
| Due to   |        |   |                     |   |   |         |   |        |
| (or as a |        |   |                     |   |   |         |   |        |
| con      |        |   |                     |   |   |         |   |        |
| sequence |        |   |                     |   |   |         |   |        |
| of):     |        |   |                     |   |   |         |   |        |
|          |        |   |                     |   |   |         |   |        |
| Sequ     |        |   |                     |   |   |         |   |        |
| entially |        |   |                     |   |   |         |   |        |
| list     |        |   |                     |   |   |         |   |        |
| con      |        |   |                     |   |   |         |   |        |
| ditions, |        |   |                     |   |   |         |   |        |
| b.       |        |   |                     |   |   |         |   |        |
| [Compl   |        |   |                     |   |   |         |   |        |
| ications |        |   |                     |   |   |         |   |        |
| of       |        |   |                     |   |   |         |   |        |
| coma\_\  |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_]{.un |        |   |                     |   |   |         |   |        |
| derline} |        |   |                     |   |   |         |   |        |
|          |        |   |                     |   |   |         |   |        |
| if any,  |        |   |                     |   |   |         |   |        |
| leading  |        |   |                     |   |   |         |   |        |
| to the   |        |   |                     |   |   |         |   |        |
| cause    |        |   |                     |   |   |         |   |        |
| Due to   |        |   |                     |   |   |         |   |        |
| (or as a |        |   |                     |   |   |         |   |        |
| con      |        |   |                     |   |   |         |   |        |
| sequence |        |   |                     |   |   |         |   |        |
| of):     |        |   |                     |   |   |         |   |        |
|          |        |   |                     |   |   |         |   |        |
| listed   |        |   |                     |   |   |         |   |        |
| on line  |        |   |                     |   |   |         |   |        |
| a. Enter |        |   |                     |   |   |         |   |        |
| the      |        |   |                     |   |   |         |   |        |
|          |        |   |                     |   |   |         |   |        |
| **UN     |        |   |                     |   |   |         |   |        |
| DERLYING |        |   |                     |   |   |         |   |        |
| CAUSE**  |        |   |                     |   |   |         |   |        |
| c.       |        |   |                     |   |   |         |   |        |
| [Blunt   |        |   |                     |   |   |         |   |        |
| force    |        |   |                     |   |   |         |   |        |
| injur    |        |   |                     |   |   |         |   |        |
| ies\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_]{.un |        |   |                     |   |   |         |   |        |
| derline} |        |   |                     |   |   |         |   |        |
|          |        |   |                     |   |   |         |   |        |
| (disease |        |   |                     |   |   |         |   |        |
| or       |        |   |                     |   |   |         |   |        |
| injury   |        |   |                     |   |   |         |   |        |
| that Due |        |   |                     |   |   |         |   |        |
| to (or   |        |   |                     |   |   |         |   |        |
| as a     |        |   |                     |   |   |         |   |        |
| con      |        |   |                     |   |   |         |   |        |
| sequence |        |   |                     |   |   |         |   |        |
| of):     |        |   |                     |   |   |         |   |        |
|          |        |   |                     |   |   |         |   |        |
| i        |        |   |                     |   |   |         |   |        |
| nitiated |        |   |                     |   |   |         |   |        |
| the      |        |   |                     |   |   |         |   |        |
| events   |        |   |                     |   |   |         |   |        |
| r        |        |   |                     |   |   |         |   |        |
| esulting |        |   |                     |   |   |         |   |        |
|          |        |   |                     |   |   |         |   |        |
| in       |        |   |                     |   |   |         |   |        |
| death)   |        |   |                     |   |   |         |   |        |
| **LAST** |        |   |                     |   |   |         |   |        |
| d.       |        |   |                     |   |   |         |   |        |
| [Motor   |        |   |                     |   |   |         |   |        |
| vehicle  |        |   |                     |   |   |         |   |        |
| accid    |        |   |                     |   |   |         |   |        |
| ent\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_]{.un |        |   |                     |   |   |         |   |        |
| derline} |        |   |                     |   |   |         |   |        |
+----------+--------+---+---------------------+---+---+---------+---+--------+
| **PART   |        |   |                     |   | 3 |         |   |        |
| II.**    |        |   |                     |   | 3 |         |   |        |
| Enter    |        |   |                     |   | \ |         |   |        |
| other    |        |   |                     |   | . |         |   |        |
| [sig     |        |   |                     |   | W |         |   |        |
| nificant |        |   |                     |   | A |         |   |        |
| co       |        |   |                     |   | S |         |   |        |
| nditions |        |   |                     |   | A |         |   |        |
| cont     |        |   |                     |   | N |         |   |        |
| ributing |        |   |                     |   | A |         |   |        |
| to       |        |   |                     |   | U |         |   |        |
| de       |        |   |                     |   | T |         |   |        |
| ath]{.un |        |   |                     |   | O |         |   |        |
| derline} |        |   |                     |   | P |         |   |        |
| but not  |        |   |                     |   | S |         |   |        |
| r        |        |   |                     |   | Y |         |   |        |
| esulting |        |   |                     |   | P |         |   |        |
| in the   |        |   |                     |   | E |         |   |        |
| un       |        |   |                     |   | R |         |   |        |
| derlying |        |   |                     |   | F |         |   |        |
| cause    |        |   |                     |   | O |         |   |        |
| given in |        |   |                     |   | R |         |   |        |
| PART I   |        |   |                     |   | M |         |   |        |
|          |        |   |                     |   | E |         |   |        |
|          |        |   |                     |   | D |         |   |        |
|          |        |   |                     |   | ? |         |   |        |
|          |        |   |                     |   |   |         |   |        |
|          |        |   |                     |   |  |         |   |        |
|          |        |   |                     |   | Y |         |   |        |
|          |        |   |                     |   | e |         |   |        |
|          |        |   |                     |   | s |         |   |        |
|          |        |   |                     |   |  |         |   |        |
|          |        |   |                     |   |  |         |   |        |
|          |        |   |                     |   |  |         |   |        |
|          |        |   |                     |   | N |         |   |        |
|          |        |   |                     |   | o |         |   |        |
+----------+--------+---+---------------------+---+---+---------+---+--------+
|          |        |   |                     |   | 3 |         |   |        |
|          |        |   |                     |   | 4 |         |   |        |
|          |        |   |                     |   | \ |         |   |        |
|          |        |   |                     |   | . |         |   |        |
|          |        |   |                     |   | W |         |   |        |
|          |        |   |                     |   | E |         |   |        |
|          |        |   |                     |   | R |         |   |        |
|          |        |   |                     |   | E |         |   |        |
|          |        |   |                     |   | A |         |   |        |
|          |        |   |                     |   | U |         |   |        |
|          |        |   |                     |   | T |         |   |        |
|          |        |   |                     |   | O |         |   |        |
|          |        |   |                     |   | P |         |   |        |
|          |        |   |                     |   | S |         |   |        |
|          |        |   |                     |   | Y |         |   |        |
|          |        |   |                     |   | F |         |   |        |
|          |        |   |                     |   | I |         |   |        |
|          |        |   |                     |   | N |         |   |        |
|          |        |   |                     |   | D |         |   |        |
|          |        |   |                     |   | I |         |   |        |
|          |        |   |                     |   | N |         |   |        |
|          |        |   |                     |   | G |         |   |        |
|          |        |   |                     |   | S |         |   |        |
|          |        |   |                     |   | A |         |   |        |
|          |        |   |                     |   | V |         |   |        |
|          |        |   |                     |   | A |         |   |        |
|          |        |   |                     |   | I |         |   |        |
|          |        |   |                     |   | L |         |   |        |
|          |        |   |                     |   | A |         |   |        |
|          |        |   |                     |   | B |         |   |        |
|          |        |   |                     |   | L |         |   |        |
|          |        |   |                     |   | E |         |   |        |
|          |        |   |                     |   | T |         |   |        |
|          |        |   |                     |   | O |         |   |        |
|          |        |   |                     |   |   |         |   |        |
|          |        |   |                     |   | C |         |   |        |
|          |        |   |                     |   | O |         |   |        |
|          |        |   |                     |   | M |         |   |        |
|          |        |   |                     |   | P |         |   |        |
|          |        |   |                     |   | L |         |   |        |
|          |        |   |                     |   | E |         |   |        |
|          |        |   |                     |   | T |         |   |        |
|          |        |   |                     |   | E |         |   |        |
|          |        |   |                     |   | T |         |   |        |
|          |        |   |                     |   | H |         |   |        |
|          |        |   |                     |   | E |         |   |        |
|          |        |   |                     |   | C |         |   |        |
|          |        |   |                     |   | A |         |   |        |
|          |        |   |                     |   | U |         |   |        |
|          |        |   |                     |   | S |         |   |        |
|          |        |   |                     |   | E |         |   |        |
|          |        |   |                     |   | O |         |   |        |
|          |        |   |                     |   | F |         |   |        |
|          |        |   |                     |   | D |         |   |        |
|          |        |   |                     |   | E |         |   |        |
|          |        |   |                     |   | A |         |   |        |
|          |        |   |                     |   | T |         |   |        |
|          |        |   |                     |   | H |         |   |        |
|          |        |   |                     |   | ? |         |   |        |
|          |        |   |                     |   |  |         |   |        |
|          |        |   |                     |   | Y |         |   |        |
|          |        |   |                     |   | e |         |   |        |
|          |        |   |                     |   | s |         |   |        |
|          |        |   |                     |   |  |         |   |        |
|          |        |   |                     |   |  |         |   |        |
|          |        |   |                     |   |  |         |   |        |
|          |        |   |                     |   | N |         |   |        |
|          |        |   |                     |   | o |         |   |        |
+----------+--------+---+---------------------+---+---+---------+---+--------+
| 35\. DID |        | 3 |                     | 3 |   |         |   |        |
| TOBACCO  |        | 6 |                     | 7 |   |         |   |        |
| USE      |        | \ |                     | \ |   |         |   |        |
| CO       |        | . |                     | . |   |         |   |        |
| NTRIBUTE |        | I |                     | M |   |         |   |        |
| TO       |        | F |                     | A |   |         |   |        |
| DEATH?   |        | F |                     | N |   |         |   |        |
|          |        | E |                     | N |   |         |   |        |
| Yes   |        | M |                     | E |   |         |   |        |
|       |        | A |                     | R |   |         |   |        |
| Probably |        | L |                     | O |   |         |   |        |
|          |        | E |                     | F |   |         |   |        |
|  No     |        | : |                     | D |   |         |   |        |
|        |        |   |                     | E |   |         |   |        |
| Unknown |        |  |                     | A |   |         |   |        |
|          |        |  |                     | T |   |         |   |        |
|          |        | N |                     | H |   |         |   |        |
|          |        | o |                     |   |   |         |   |        |
|          |        | t |                     |  |   |         |   |        |
|          |        | p |                     |  |   |         |   |        |
|          |        | r |                     |  |   |         |   |        |
|          |        | e |                     | N |   |         |   |        |
|          |        | g |                     | a |   |         |   |        |
|          |        | n |                     | t |   |         |   |        |
|          |        | a |                     | u |   |         |   |        |
|          |        | n |                     | r |   |         |   |        |
|          |        | t |                     | a |   |         |   |        |
|          |        | w |                     | l |   |         |   |        |
|          |        | i |                     |  |   |         |   |        |
|          |        | t |                     |  |   |         |   |        |
|          |        | h |                     |  |   |         |   |        |
|          |        | i |                     | H |   |         |   |        |
|          |        | n |                     | o |   |         |   |        |
|          |        | p |                     | m |   |         |   |        |
|          |        | a |                     | i |   |         |   |        |
|          |        | s |                     | c |   |         |   |        |
|          |        | t |                     | i |   |         |   |        |
|          |        | y |                     | d |   |         |   |        |
|          |        | e |                     | e |   |         |   |        |
|          |        | a |                     |   |   |         |   |        |
|          |        | r |                     |  |   |         |   |        |
|          |        |   |                     | A |   |         |   |        |
|          |        |  |                     | c |   |         |   |        |
|          |        |  |                     | c |   |         |   |        |
|          |        | P |                     | i |   |         |   |        |
|          |        | r |                     | d |   |         |   |        |
|          |        | e |                     | e |   |         |   |        |
|          |        | g |                     | n |   |         |   |        |
|          |        | n |                     | t |   |         |   |        |
|          |        | a |                     |  |   |         |   |        |
|          |        | n |                     |  |   |         |   |        |
|          |        | t |                     | P |   |         |   |        |
|          |        | a |                     | e |   |         |   |        |
|          |        | t |                     | n |   |         |   |        |
|          |        | t |                     | d |   |         |   |        |
|          |        | i |                     | i |   |         |   |        |
|          |        | m |                     | n |   |         |   |        |
|          |        | e |                     | g |   |         |   |        |
|          |        | o |                     | I |   |         |   |        |
|          |        | f |                     | n |   |         |   |        |
|          |        | d |                     | v |   |         |   |        |
|          |        | e |                     | e |   |         |   |        |
|          |        | a |                     | s |   |         |   |        |
|          |        | t |                     | t |   |         |   |        |
|          |        | h |                     | i |   |         |   |        |
|          |        |   |                     | g |   |         |   |        |
|          |        |  |                     | a |   |         |   |        |
|          |        |  |                     | t |   |         |   |        |
|          |        | N |                     | i |   |         |   |        |
|          |        | o |                     | o |   |         |   |        |
|          |        | t |                     | n |   |         |   |        |
|          |        | p |                     |   |   |         |   |        |
|          |        | r |                     |  |   |         |   |        |
|          |        | e |                     |  |   |         |   |        |
|          |        | g |                     |  |   |         |   |        |
|          |        | n |                     | S |   |         |   |        |
|          |        | a |                     | u |   |         |   |        |
|          |        | n |                     | i |   |         |   |        |
|          |        | t |                     | c |   |         |   |        |
|          |        | , |                     | i |   |         |   |        |
|          |        | b |                     | d |   |         |   |        |
|          |        | u |                     | e |   |         |   |        |
|          |        | t |                     |  |   |         |   |        |
|          |        | p |                     |  |   |         |   |        |
|          |        | r |                     |  |   |         |   |        |
|          |        | e |                     | C |   |         |   |        |
|          |        | g |                     | o |   |         |   |        |
|          |        | n |                     | u |   |         |   |        |
|          |        | a |                     | l |   |         |   |        |
|          |        | n |                     | d |   |         |   |        |
|          |        | t |                     | n |   |         |   |        |
|          |        | w |                     | o |   |         |   |        |
|          |        | i |                     | t |   |         |   |        |
|          |        | t |                     | b |   |         |   |        |
|          |        | h |                     | e |   |         |   |        |
|          |        | i |                     | d |   |         |   |        |
|          |        | n |                     | e |   |         |   |        |
|          |        | 4 |                     | t |   |         |   |        |
|          |        | 2 |                     | e |   |         |   |        |
|          |        | d |                     | r |   |         |   |        |
|          |        | a |                     | m |   |         |   |        |
|          |        | y |                     | i |   |         |   |        |
|          |        | s |                     | n |   |         |   |        |
|          |        | o |                     | e |   |         |   |        |
|          |        | f |                     | d |   |         |   |        |
|          |        | d |                     |   |   |         |   |        |
|          |        | e |                     |   |   |         |   |        |
|          |        | a |                     |   |   |         |   |        |
|          |        | t |                     |   |   |         |   |        |
|          |        | h |                     |   |   |         |   |        |
|          |        |   |                     |   |   |         |   |        |
|          |        |  |                     |   |   |         |   |        |
|          |        |  |                     |   |   |         |   |        |
|          |        | N |                     |   |   |         |   |        |
|          |        | o |                     |   |   |         |   |        |
|          |        | t |                     |   |   |         |   |        |
|          |        | p |                     |   |   |         |   |        |
|          |        | r |                     |   |   |         |   |        |
|          |        | e |                     |   |   |         |   |        |
|          |        | g |                     |   |   |         |   |        |
|          |        | n |                     |   |   |         |   |        |
|          |        | a |                     |   |   |         |   |        |
|          |        | n |                     |   |   |         |   |        |
|          |        | t |                     |   |   |         |   |        |
|          |        | , |                     |   |   |         |   |        |
|          |        | b |                     |   |   |         |   |        |
|          |        | u |                     |   |   |         |   |        |
|          |        | t |                     |   |   |         |   |        |
|          |        | p |                     |   |   |         |   |        |
|          |        | r |                     |   |   |         |   |        |
|          |        | e |                     |   |   |         |   |        |
|          |        | g |                     |   |   |         |   |        |
|          |        | n |                     |   |   |         |   |        |
|          |        | a |                     |   |   |         |   |        |
|          |        | n |                     |   |   |         |   |        |
|          |        | t |                     |   |   |         |   |        |
|          |        | 4 |                     |   |   |         |   |        |
|          |        | 3 |                     |   |   |         |   |        |
|          |        | d |                     |   |   |         |   |        |
|          |        | a |                     |   |   |         |   |        |
|          |        | y |                     |   |   |         |   |        |
|          |        | s |                     |   |   |         |   |        |
|          |        | t |                     |   |   |         |   |        |
|          |        | o |                     |   |   |         |   |        |
|          |        | 1 |                     |   |   |         |   |        |
|          |        | y |                     |   |   |         |   |        |
|          |        | e |                     |   |   |         |   |        |
|          |        | a |                     |   |   |         |   |        |
|          |        | r |                     |   |   |         |   |        |
|          |        | b |                     |   |   |         |   |        |
|          |        | e |                     |   |   |         |   |        |
|          |        | f |                     |   |   |         |   |        |
|          |        | o |                     |   |   |         |   |        |
|          |        | r |                     |   |   |         |   |        |
|          |        | e |                     |   |   |         |   |        |
|          |        | d |                     |   |   |         |   |        |
|          |        | e |                     |   |   |         |   |        |
|          |        | a |                     |   |   |         |   |        |
|          |        | t |                     |   |   |         |   |        |
|          |        | h |                     |   |   |         |   |        |
|          |        |   |                     |   |   |         |   |        |
|          |        |  |                     |   |   |         |   |        |
|          |        |  |                     |   |   |         |   |        |
|          |        | U |                     |   |   |         |   |        |
|          |        | n |                     |   |   |         |   |        |
|          |        | k |                     |   |   |         |   |        |
|          |        | n |                     |   |   |         |   |        |
|          |        | o |                     |   |   |         |   |        |
|          |        | w |                     |   |   |         |   |        |
|          |        | n |                     |   |   |         |   |        |
|          |        | i |                     |   |   |         |   |        |
|          |        | f |                     |   |   |         |   |        |
|          |        | p |                     |   |   |         |   |        |
|          |        | r |                     |   |   |         |   |        |
|          |        | e |                     |   |   |         |   |        |
|          |        | g |                     |   |   |         |   |        |
|          |        | n |                     |   |   |         |   |        |
|          |        | a |                     |   |   |         |   |        |
|          |        | n |                     |   |   |         |   |        |
|          |        | t |                     |   |   |         |   |        |
|          |        | w |                     |   |   |         |   |        |
|          |        | i |                     |   |   |         |   |        |
|          |        | t |                     |   |   |         |   |        |
|          |        | h |                     |   |   |         |   |        |
|          |        | i |                     |   |   |         |   |        |
|          |        | n |                     |   |   |         |   |        |
|          |        | t |                     |   |   |         |   |        |
|          |        | h |                     |   |   |         |   |        |
|          |        | e |                     |   |   |         |   |        |
|          |        | p |                     |   |   |         |   |        |
|          |        | a |                     |   |   |         |   |        |
|          |        | s |                     |   |   |         |   |        |
|          |        | t |                     |   |   |         |   |        |
|          |        | y |                     |   |   |         |   |        |
|          |        | e |                     |   |   |         |   |        |
|          |        | a |                     |   |   |         |   |        |
|          |        | r |                     |   |   |         |   |        |
+----------+--------+---+---------------------+---+---+---------+---+--------+
| 38\.     | 39\.   |   | 40\. PLACE OF       |   |   |         | 4 |        |
| DATE OF  | TIME   |   | INJURY (e.g.,       |   |   |         | 1 |        |
| INJURY   | OF     |   | Decedent's home;    |   |   |         | \ |        |
|          | INJURY |   | construction site;  |   |   |         | . |        |
| (Mo      |        |   | restaurant; wooded  |   |   |         | I |        |
| /Day/Yr) | A      |   | area)               |   |   |         | N |        |
| (Spell   | pprox. |   |                     |   |   |         | J |        |
| Month)   | 2320   |   | road side near      |   |   |         | U |        |
|          |        |   | state highway       |   |   |         | R |        |
| August   |        |   |                     |   |   |         | Y |        |
| 15, 2005 |        |   |                     |   |   |         | A |        |
|          |        |   |                     |   |   |         | T |        |
|          |        |   |                     |   |   |         | W |        |
|          |        |   |                     |   |   |         | O |        |
|          |        |   |                     |   |   |         | R |        |
|          |        |   |                     |   |   |         | K |        |
|          |        |   |                     |   |   |         | ? |        |
|          |        |   |                     |   |   |         |   |        |
|          |        |   |                     |   |   |         |  |        |
|          |        |   |                     |   |   |         |  |        |
|          |        |   |                     |   |   |         |  |        |
|          |        |   |                     |   |   |         |  |        |
|          |        |   |                     |   |   |         |  |        |
|          |        |   |                     |   |   |         |  |        |
|          |        |   |                     |   |   |         |  |        |
|          |        |   |                     |   |   |         |  |        |
|          |        |   |                     |   |   |         |  |        |
|          |        |   |                     |   |   |         |  |        |
|          |        |   |                     |   |   |         |  |        |
|          |        |   |                     |   |   |         |  |        |
|          |        |   |                     |   |   |         |  |        |
|          |        |   |                     |   |   |         | Y |        |
|          |        |   |                     |   |   |         | e |        |
|          |        |   |                     |   |   |         | s |        |
|          |        |   |                     |   |   |         |  |        |
|          |        |   |                     |   |   |         | N |        |
|          |        |   |                     |   |   |         | o |        |
+----------+--------+---+---------------------+---+---+---------+---+--------+
| 42\.     |        |   |                     |   |   |         |   |        |
| LOCATION |        |   |                     |   |   |         |   |        |
| OF       |        |   |                     |   |   |         |   |        |
| INJURY:  |        |   |                     |   |   |         |   |        |
| State:   |        |   |                     |   |   |         |   |        |
| Missouri |        |   |                     |   |   |         |   |        |
| City or  |        |   |                     |   |   |         |   |        |
| Town:    |        |   |                     |   |   |         |   |        |
| near     |        |   |                     |   |   |         |   |        |
| Al       |        |   |                     |   |   |         |   |        |
| exandria |        |   |                     |   |   |         |   |        |
|          |        |   |                     |   |   |         |   |        |
| Street & |        |   |                     |   |   |         |   |        |
| Number:  |        |   |                     |   |   |         |   |        |
| mile     |        |   |                     |   |   |         |   |        |
| marker   |        |   |                     |   |   |         |   |        |
| 17 on    |        |   |                     |   |   |         |   |        |
| state    |        |   |                     |   |   |         |   |        |
| route    |        |   |                     |   |   |         |   |        |
| 46a      |        |   |                     |   |   |         |   |        |
| A        |        |   |                     |   |   |         |   |        |
| partment |        |   |                     |   |   |         |   |        |
| No.: Zip |        |   |                     |   |   |         |   |        |
| Code:    |        |   |                     |   |   |         |   |        |
+----------+--------+---+---------------------+---+---+---------+---+--------+
| 43\.     |        |   |                     |   |   | 44\. IF |   |        |
| DESCRIBE |        |   |                     |   |   | TRANSPO |   |        |
| HOW      |        |   |                     |   |   | RTATION |   |        |
| INJURY   |        |   |                     |   |   | INJURY, |   |        |
| O        |        |   |                     |   |   | S       |   |        |
| CCURRED: |        |   |                     |   |   | PECIFY: |   |        |
|          |        |   |                     |   |   |         |   |        |
| Decedent |        |   |                     |   |   |        |   |        |
| driver   |        |   |                     |   |   | D       |   |        |
| of van,  |        |   |                     |   |   | river/O |   |        |
| ran off  |        |   |                     |   |   | perator |   |        |
| road     |        |   |                     |   |   |         |   |        |
| into     |        |   |                     |   |   | Pa   |   |        |
| tree     |        |   |                     |   |   | ssenger |   |        |
|          |        |   |                     |   |   |         |   |        |
|          |        |   |                     |   |   | Ped  |   |        |
|          |        |   |                     |   |   | estrian |   |        |
|          |        |   |                     |   |   |         |   |        |
|          |        |   |                     |   |   |        |   |        |
|          |        |   |                     |   |   | Other |   |        |
|          |        |   |                     |   |   | (S      |   |        |
|          |        |   |                     |   |   | pecify) |   |        |
+----------+--------+---+---------------------+---+---+---------+---+--------+

**ITEM 32 -- CAUSE OF DEATH (See example above)**

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.

Take care to make the entry legible. Use a computer printer with high
resolution, typewriter with good black ribbon and clean keys, or print
legibly using permanent **black** ink in completing the CAUSE OF DEATH
Section. **Do** **not** **abbreviate** conditions entered in section.

**[Part I]{.underline} (Chain of events leading directly to death)**

•Only **one** cause should be entered on each line. [Line
(a)]{.underline} **MUST ALWAYS** have an entry. **DO NOT** leave blank.
Additional lines may be added if necessary.

•If the condition on [Line (a)]{.underline} resulted from an underlying
condition, put the underlying condition on [Line (b)]{.underline}, and
so on, until the full sequence is reported. **ALWAYS** enter the
**underlying cause of death** on the [lowest used line]{.underline} in
Part I.

•For each cause indicate the best estimate of the interval between the
presumed onset and the date of death. The terms "unknown" or
"approximately" may be used. General terms, such as minutes, hours, or
days, are acceptable, if necessary. **DO NOT** leave blank.

•The terminal event (for example, cardiac arrest or respiratory arrest)
should not be used. If a mechanism of death seems most appropriate to
you for line (a), then you must always list its cause(s) on the line(s)
below it (for example, cardiac arrest **due to** coronary artery
atherosclerosis *or* cardiac arrest **due to** blunt impact to chest).

• If an organ system failure such as congestive heart failure, hepatic
failure, renal failure, or respiratory failure is listed as a cause of
death, always report its etiology on the line(s) beneath it (for
example, renal failure **due to** Type I diabetes mellitus).

•When indicating neoplasms as a cause of death, include the
following: 1) primary site *or* that the primary site is unknown, 2)
benign or malignant, 3) cell type *or* that the cell type is unknown, 4)
grade of neoplasm, and 5) part or lobe of organ affected. (For example,
a primary well-differentiated squamous cell carcinoma, lung, left upper
lobe.)

•Always report the fatal injury (for example, stab wound of chest), the
trauma (for example, transection of subclavian vein), and impairment of
function (for example, air embolism).

**Part II (Other significant conditions)**

•Enter all diseases or conditions contributing to death that were not
reported in the chain of events in Part I and that did not result in the
**underlying cause of death**.

•If two or more possible sequences resulted in death, or if two
conditions seem to have added together, report in Part I the one that,
in your opinion, most directly caused death. Report in Part II the other
conditions or diseases.

**CHANGES TO CAUSE OF DEATH**

Should additional medical information or autopsy findings become
available that would change the cause of death originally reported, the
original death certificate should be amended by the certifying physician
by **immediately** reporting the revised cause of death to the State
Vital Records Office.

**ITEMS ON WHEN DEATH OCCURRED**

Items 24-25 and 29-31 should always be completed. If the facility uses a
separate pronouncer or other person to indicate that death has taken
place with another person more familiar with the case completing the
remainder of the medical portion of the death certificate, the
pronouncer completes Items 24-28. If a certifier completes Items 24-25
as well as items 29-49, Items 26-28 may be left blank.

**ITEMS 24-25, 29-30 -- DATE AND TIME OF DEATH**

Spell out the name of the month. If the exact date of death is unknown,
enter the **approximate** date. If the date cannot be approximated,
enter the date the body is found and identify as **date found**. Date
pronounced and actual date may be the same. Enter the exact hour and
minutes according to a 24-hour clock; estimates may be provided with
"Approx." placed before the time.

**ITEMS 33-34 - AUTOPSY**

•33 - Enter "Yes" if either a partial or full autopsy was performed.
Otherwise enter "No."

•34 - Enter "Yes" if autopsy findings were available to complete the
cause of death; otherwise enter "No". Leave item blank if no autopsy was
performed.

**ITEM 35 - DID TOBACCO USE CONTRIBUTE TO DEATH?**

Check "yes" if, in your opinion, the use of tobacco contributed to
death. Tobacco use may contribute to deaths due to a wide variety of
diseases; for example, tobacco use contributes to many deaths due to
emphysema or lung cancer and some heart disease and cancers of the head
and neck. Check "no" if, in your clinical judgment, tobacco use did not
contribute to this particular death.

**ITEM 36 - IF FEMALE, WAS DECEDENT PREGNANT AT TIME OF DEATH OR WITHIN
PAST YEAR?**

This information is important in determining pregnancy-related
mortality.

**ITEM 37 - MANNER OF DEATH**

•Always check Manner of Death, which is important: 1) in determining
accurate causes of death; 2) in processing insurance claims; and 3) in
statistical studies of injuries and death.

•Indicate "Pending investigation" if the manner of death cannot be
determined whether due to an accident, suicide, or homicide within the
statutory time limit for filing the death certificate. This should be
changed later to one of the other terms.

•Indicate "Could not be Determined" **ONLY** when it is impossible to
determine the manner of death.

**ITEMS 38-44 - ACCIDENT OR INJURY -- to be filled out in all cases of
deaths due to injury or poisoning.**

•38 - Enter the exact month, day, and year of injury. Spell out the name
of the month. **DO NOT** use a number for the month. (Remember, the date
of injury may differ from the date of death.) Estimates may be provided
with "Approx." placed before the date.

•39 **-** Enter the exact hour and minutes of injury or use your best
estimate. Use a 24-hour clock.

•40 - Enter the general place (such as restaurant, vacant lot, or home)
where the injury occurred. **DO NOT** enter firm or organization names.
(For example, enter "factory", **not** "Standard Manufacturing, Inc." )

•41 - Complete if anything other than natural disease is mentioned in
Part I or Part II of the medical certification, including homicides,
suicides, and accidents. This includes all motor vehicle deaths. The
item **[must]{.underline}** be completed for decedents ages 14 years or
over and may be completed for those less than 14 years of age if
warranted. Enter "Yes" if the injury occurred at work. Otherwise enter
"No". An injury may occur at work regardless of whether the injury
occurred in the course of the decedent's "usual" occupation. Examples of
injury at work and injury not at work follow:

+-----------------------------------+-----------------------------------+
| **Injury at work**                | **Injury [not]{.underline} at     |
|                                   | work**                            |
| Injury while working or in        |                                   |
| vocational training on job        | Injury while engaged in personal  |
| premises                          | recreational activity on job      |
|                                   | premises                          |
| Injury while on break or at lunch |                                   |
| or in parking lot on job premises | Injury while a visitor (not on    |
|                                   | official work business) to job    |
| Injury while working for pay or   | premises                          |
| compensation, including at home   |                                   |
|                                   | Homemaker working at homemaking   |
| Injury while working as a         | activities                        |
| volunteer law enforcement         |                                   |
| official etc.                     | Student in school                 |
|                                   |                                   |
| Injury while traveling on         | Working for self for no profit    |
| business, including to/from       | (mowing yard, repairing own roof, |
| business contacts                 | hobby)                            |
|                                   |                                   |
|                                   | Commuting to or from work         |
+-----------------------------------+-----------------------------------+

•42 - Enter the complete address where the injury occurred including zip
code.

•43 - Enter a brief but specific and clear description of how the injury
occurred. Explain the circumstances or cause of the injury. Specify
**type** **of** **gun** or **type of vehicle** (e.g., car, bulldozer,
train, etc.) when relevant to circumstances. Indicate if more than one
vehicle involved; specify type of vehicle decedent was in.

•44 -Specify role of decedent (e.g. driver, passenger). Driver/operator
and passenger should be designated for modes other than motor vehicles
such as bicycles. Other applies to watercraft, aircraft, animal, or
people attached to outside of vehicles (e.g. surfers).

[Rationale]{.underline}: Motor vehicle accidents are a major cause of
unintentional deaths; details will help determine effectiveness of
current safety features and laws.

**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:]{.underline}**

+-------------+-------------+-------------+-------------+-------------+
| Abscess     | Car         | D           | H           | Pulmonary   |
|             | cinomatosis | isseminated | yponatremia | arrest      |
| Abdominal   |             | intra       |             |             |
| hemorrhage  | Cardiac     | vascular    | Hypotension | Pulmonary   |
|             | arrest      |             |             | edema       |
| Adhesions   |             | c           | Immuno      |             |
|             | Cardiac     | oagulopathy | suppression | Pulmonary   |
| Adult       | dysrhythmia |             |             | embolism    |
| respiratory |             | Dysrhythmia | Increased   |             |
| distress    | Car         |             | intra       | Pulmonary   |
| syndrome    | diomyopathy | End-stage   | cranial     | in          |
|             |             | liver       | pressure    | sufficiency |
| Acute       | Card        | disease     |             |             |
| myocardial  | iopulmonary |             | Intra       | Renal       |
| infarction  | arrest      | End-stage   | cranial     | failure     |
|             |             | renal       | hemorrhage  |             |
| Altered     | Cellulitis  | disease     |             | Respiratory |
| mental      |             |             | M           | arrest      |
| status      | Cerebral    | Epidural    | alnutrition |             |
|             | edema       | hematoma    |             | Seizures    |
| Anemia      |             |             | Metabolic   |             |
|             | Cere        | Exs         | enc         | Sepsis      |
| Anoxia      | brovascular | anguination | ephalopathy |             |
|             | accident    |             |             | Septic      |
| Anoxic      |             | Failure to  | Multi-organ | shock       |
| enc         | Cerebellar  | thrive      | failure     |             |
| ephalopathy | tonsillar   |             |             | Shock       |
|             | herniation  | Fracture    | M           |             |
| Arrhythmia  |             |             | ulti-system | Starvation  |
|             | Chronic     | Gangrene    | organ       |             |
| Ascites     | bedridden   |             | failure     | Subdural    |
|             | state       | Gastr       |             | hematoma    |
| Aspiration  |             | ointestinal | Myocardial  |             |
|             | Cirrhosis   | hemorrhage  | infarction  | S           |
| Atrial      |             |             |             | ubarachnoid |
| f           | C           | Heart       | Necrotizing | hemorrhage  |
| ibrillation | oagulopathy | failure     | soft-tissue |             |
|             |             |             | infection   | Sudden      |
| Bacteremia  | Compression | Hemothorax  |             | death       |
|             | fracture    |             | Old age     |             |
| Bedridden   |             | Hepatic     |             | Throm       |
|             | Congestive  | failure     | Open (or    | bocytopenia |
| Biliary     | heart       |             | closed)     |             |
| obstruction | failure     | Hepatitis   | head injury | Uncal       |
|             |             |             |             | herniation  |
| Bowel       | Convulsions | Hepatorenal | Paralysis   |             |
| obstruction |             | syndrome    |             | Urinary     |
|             | Decubiti    |             | P           | tract       |
| Brain       |             | Hy          | ancytopenia | infection   |
| injury      | Dehydration | perglycemia |             |             |
|             |             |             | Perforated  | Ventricular |
| Brain stem  | Dementia    | H           | gallbladder | f           |
| herniation  | (when not   | yperkalemia |             | ibrillation |
|             |             |             | Peritonitis |             |
| Car         | otherwise   | Hypovolemic |             | Ventricular |
| cinogenesis | specified)  | shock       | Pleural     | tachycardia |
|             |             |             | effusions   |             |
|             | Diarrhea    |             |             | Volume      |
|             |             |             | Pneumonia   | 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    | Epidural    | Hip         | Pulmonary   | Subdural    |
|             | hematoma    | fracture    | emboli      | hematoma    |
| Bolus       |             |             |             |             |
|             | Exs         | H           | Seizure     | Surgery     |
| Choking     | anguination | yperthermia | disorder    |             |
|             |             |             |             | Thermal     |
| Drug or     | Fall        | Hypothermia | Sepsis      | bur         |
| alcohol     |             |             |             | ns/chemical |
| ov          | Fracture    | Open        | S           | burns       |
| erdose/drug |             | reduction   | ubarachnoid |             |
| or          |             | of fracture | hemorrhage  |             |
|             |             |             |             |             |
| alcohol     |             |             |             |             |
| abuse       |             |             |             |             |
+-------------+-------------+-------------+-------------+-------------+

Contact your State vital statistics office for questions related to
writing cause-of-death statements. Additional instructional material on
writing cause-of-death statements including handbooks, summary
instructions, and tutorials are available online at www.thename.org or
www.cdc.gov/nchswww/about/major/dvs/handbk.htm, or by request from NCHS,
Room 7318, 3311 Toledo Road, Hyattsville, Maryland 20782-2003.

Suicide Query

+----------+--------+---+---------------------+---+---+---------+---+--------+
| **CAUSE  |        |   |                     |   |   |         |   | Appro  |
| OF DEATH |        |   |                     |   |   |         |   | ximate |
| (See     |        |   |                     |   |   |         |   | int    |
| inst     |        |   |                     |   |   |         |   | erval: |
| ructions |        |   |                     |   |   |         |   |        |
| and      |        |   |                     |   |   |         |   | Onset  |
| exa      |        |   |                     |   |   |         |   | to     |
| mples)** |        |   |                     |   |   |         |   | death  |
|          |        |   |                     |   |   |         |   |        |
| 32\.     |        |   |                     |   |   |         |   | [2     |
| **PART   |        |   |                     |   |   |         |   | Days]  |
| I.**     |        |   |                     |   |   |         |   | {.unde |
| Enter    |        |   |                     |   |   |         |   | rline} |
| the      |        |   |                     |   |   |         |   |        |
| [chain   |        |   |                     |   |   |         |   | [7     |
| of       |        |   |                     |   |   |         |   | weeks] |
| events]  |        |   |                     |   |   |         |   | {.unde |
| {.underl |        |   |                     |   |   |         |   | rline} |
| ine}\--d |        |   |                     |   |   |         |   |        |
| iseases, |        |   |                     |   |   |         |   | [7     |
| i        |        |   |                     |   |   |         |   | weeks] |
| njuries, |        |   |                     |   |   |         |   | {.unde |
| or       |        |   |                     |   |   |         |   | rline} |
| comp     |        |   |                     |   |   |         |   |        |
| lication |        |   |                     |   |   |         |   | [7     |
| s\--that |        |   |                     |   |   |         |   | weeks] |
| directly |        |   |                     |   |   |         |   | {.unde |
| caused   |        |   |                     |   |   |         |   | rline} |
| the      |        |   |                     |   |   |         |   |        |
| death.   |        |   |                     |   |   |         |   |        |
| DO NOT   |        |   |                     |   |   |         |   |        |
| enter    |        |   |                     |   |   |         |   |        |
| terminal |        |   |                     |   |   |         |   |        |
| events   |        |   |                     |   |   |         |   |        |
| such as  |        |   |                     |   |   |         |   |        |
| cardiac  |        |   |                     |   |   |         |   |        |
|          |        |   |                     |   |   |         |   |        |
| arrest,  |        |   |                     |   |   |         |   |        |
| res      |        |   |                     |   |   |         |   |        |
| piratory |        |   |                     |   |   |         |   |        |
| arrest,  |        |   |                     |   |   |         |   |        |
| or       |        |   |                     |   |   |         |   |        |
| ven      |        |   |                     |   |   |         |   |        |
| tricular |        |   |                     |   |   |         |   |        |
| fibr     |        |   |                     |   |   |         |   |        |
| illation |        |   |                     |   |   |         |   |        |
| without  |        |   |                     |   |   |         |   |        |
| showing  |        |   |                     |   |   |         |   |        |
| the      |        |   |                     |   |   |         |   |        |
| e        |        |   |                     |   |   |         |   |        |
| tiology. |        |   |                     |   |   |         |   |        |
| DO NOT   |        |   |                     |   |   |         |   |        |
| ABB      |        |   |                     |   |   |         |   |        |
| REVIATE. |        |   |                     |   |   |         |   |        |
| Enter    |        |   |                     |   |   |         |   |        |
| only one |        |   |                     |   |   |         |   |        |
| cause on |        |   |                     |   |   |         |   |        |
| a line.  |        |   |                     |   |   |         |   |        |
| Add      |        |   |                     |   |   |         |   |        |
| ad       |        |   |                     |   |   |         |   |        |
| ditional |        |   |                     |   |   |         |   |        |
|          |        |   |                     |   |   |         |   |        |
| lines if |        |   |                     |   |   |         |   |        |
| ne       |        |   |                     |   |   |         |   |        |
| cessary. |        |   |                     |   |   |         |   |        |
|          |        |   |                     |   |   |         |   |        |
| I        |        |   |                     |   |   |         |   |        |
| MMEDIATE |        |   |                     |   |   |         |   |        |
| CAUSE    |        |   |                     |   |   |         |   |        |
| (Final   |        |   |                     |   |   |         |   |        |
|          |        |   |                     |   |   |         |   |        |
| disease  |        |   |                     |   |   |         |   |        |
| or       |        |   |                     |   |   |         |   |        |
| c        |        |   |                     |   |   |         |   |        |
| ondition |        |   |                     |   |   |         |   |        |
| **\-\-\  |        |   |                     |   |   |         |   |        |
| -\-\-\-\ |        |   |                     |   |   |         |   |        |
| -\--\>** |        |   |                     |   |   |         |   |        |
| a.       |        |   |                     |   |   |         |   |        |
| [\_\_    |        |   |                     |   |   |         |   |        |
| \_\_\_\_ |        |   |                     |   |   |         |   |        |
| \_\_\_\_ |        |   |                     |   |   |         |   |        |
| \_\_\_\_ |        |   |                     |   |   |         |   |        |
| \_\      |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_]{.un |        |   |                     |   |   |         |   |        |
| derline} |        |   |                     |   |   |         |   |        |
|          |        |   |                     |   |   |         |   |        |
| r        |        |   |                     |   |   |         |   |        |
| esulting |        |   |                     |   |   |         |   |        |
| in       |        |   |                     |   |   |         |   |        |
| death)   |        |   |                     |   |   |         |   |        |
| Due to   |        |   |                     |   |   |         |   |        |
| (or as a |        |   |                     |   |   |         |   |        |
| con      |        |   |                     |   |   |         |   |        |
| sequence |        |   |                     |   |   |         |   |        |
| of):     |        |   |                     |   |   |         |   |        |
|          |        |   |                     |   |   |         |   |        |
| Sequ     |        |   |                     |   |   |         |   |        |
| entially |        |   |                     |   |   |         |   |        |
| list     |        |   |                     |   |   |         |   |        |
| con      |        |   |                     |   |   |         |   |        |
| ditions, |        |   |                     |   |   |         |   |        |
| b.       |        |   |                     |   |   |         |   |        |
| [\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_]{.un |        |   |                     |   |   |         |   |        |
| derline} |        |   |                     |   |   |         |   |        |
|          |        |   |                     |   |   |         |   |        |
| if any,  |        |   |                     |   |   |         |   |        |
| leading  |        |   |                     |   |   |         |   |        |
| to the   |        |   |                     |   |   |         |   |        |
| cause    |        |   |                     |   |   |         |   |        |
| Due to   |        |   |                     |   |   |         |   |        |
| (or as a |        |   |                     |   |   |         |   |        |
| con      |        |   |                     |   |   |         |   |        |
| sequence |        |   |                     |   |   |         |   |        |
| of):     |        |   |                     |   |   |         |   |        |
|          |        |   |                     |   |   |         |   |        |
| listed   |        |   |                     |   |   |         |   |        |
| on line  |        |   |                     |   |   |         |   |        |
| a. Enter |        |   |                     |   |   |         |   |        |
| the      |        |   |                     |   |   |         |   |        |
|          |        |   |                     |   |   |         |   |        |
| **UN     |        |   |                     |   |   |         |   |        |
| DERLYING |        |   |                     |   |   |         |   |        |
| CAUSE**  |        |   |                     |   |   |         |   |        |
| c.       |        |   |                     |   |   |         |   |        |
| [\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_]{.un |        |   |                     |   |   |         |   |        |
| derline} |        |   |                     |   |   |         |   |        |
|          |        |   |                     |   |   |         |   |        |
| (disease |        |   |                     |   |   |         |   |        |
| or       |        |   |                     |   |   |         |   |        |
| injury   |        |   |                     |   |   |         |   |        |
| that Due |        |   |                     |   |   |         |   |        |
| to (or   |        |   |                     |   |   |         |   |        |
| as a     |        |   |                     |   |   |         |   |        |
| con      |        |   |                     |   |   |         |   |        |
| sequence |        |   |                     |   |   |         |   |        |
| of):     |        |   |                     |   |   |         |   |        |
|          |        |   |                     |   |   |         |   |        |
| i        |        |   |                     |   |   |         |   |        |
| nitiated |        |   |                     |   |   |         |   |        |
| the      |        |   |                     |   |   |         |   |        |
| events   |        |   |                     |   |   |         |   |        |
| r        |        |   |                     |   |   |         |   |        |
| esulting |        |   |                     |   |   |         |   |        |
|          |        |   |                     |   |   |         |   |        |
| in       |        |   |                     |   |   |         |   |        |
| death)   |        |   |                     |   |   |         |   |        |
| **LAST** |        |   |                     |   |   |         |   |        |
| d.       |        |   |                     |   |   |         |   |        |
| [\_\_\   |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_]{.un |        |   |                     |   |   |         |   |        |
| derline} |        |   |                     |   |   |         |   |        |
+----------+--------+---+---------------------+---+---+---------+---+--------+
| **PART   |        |   |                     |   | 3 |         |   |        |
| II.**    |        |   |                     |   | 3 |         |   |        |
| Enter    |        |   |                     |   | \ |         |   |        |
| other    |        |   |                     |   | . |         |   |        |
| [sig     |        |   |                     |   | W |         |   |        |
| nificant |        |   |                     |   | A |         |   |        |
| co       |        |   |                     |   | S |         |   |        |
| nditions |        |   |                     |   | A |         |   |        |
| cont     |        |   |                     |   | N |         |   |        |
| ributing |        |   |                     |   | A |         |   |        |
| to       |        |   |                     |   | U |         |   |        |
| de       |        |   |                     |   | T |         |   |        |
| ath]{.un |        |   |                     |   | O |         |   |        |
| derline} |        |   |                     |   | P |         |   |        |
| but not  |        |   |                     |   | S |         |   |        |
| r        |        |   |                     |   | Y |         |   |        |
| esulting |        |   |                     |   | P |         |   |        |
| in the   |        |   |                     |   | E |         |   |        |
| un       |        |   |                     |   | R |         |   |        |
| derlying |        |   |                     |   | F |         |   |        |
| cause    |        |   |                     |   | O |         |   |        |
| given in |        |   |                     |   | R |         |   |        |
| PART I   |        |   |                     |   | M |         |   |        |
|          |        |   |                     |   | E |         |   |        |
|          |        |   |                     |   | D |         |   |        |
|          |        |   |                     |   | ? |         |   |        |
|          |        |   |                     |   |   |         |   |        |
|          |        |   |                     |   |  |         |   |        |
|          |        |   |                     |   | Y |         |   |        |
|          |        |   |                     |   | e |         |   |        |
|          |        |   |                     |   | s |         |   |        |
|          |        |   |                     |   |  |         |   |        |
|          |        |   |                     |   |  |         |   |        |
|          |        |   |                     |   |  |         |   |        |
|          |        |   |                     |   | N |         |   |        |
|          |        |   |                     |   | o |         |   |        |
+----------+--------+---+---------------------+---+---+---------+---+--------+
|          |        |   |                     |   | 3 |         |   |        |
|          |        |   |                     |   | 4 |         |   |        |
|          |        |   |                     |   | \ |         |   |        |
|          |        |   |                     |   | . |         |   |        |
|          |        |   |                     |   | W |         |   |        |
|          |        |   |                     |   | E |         |   |        |
|          |        |   |                     |   | R |         |   |        |
|          |        |   |                     |   | E |         |   |        |
|          |        |   |                     |   | A |         |   |        |
|          |        |   |                     |   | U |         |   |        |
|          |        |   |                     |   | T |         |   |        |
|          |        |   |                     |   | O |         |   |        |
|          |        |   |                     |   | P |         |   |        |
|          |        |   |                     |   | S |         |   |        |
|          |        |   |                     |   | Y |         |   |        |
|          |        |   |                     |   | F |         |   |        |
|          |        |   |                     |   | I |         |   |        |
|          |        |   |                     |   | N |         |   |        |
|          |        |   |                     |   | D |         |   |        |
|          |        |   |                     |   | I |         |   |        |
|          |        |   |                     |   | N |         |   |        |
|          |        |   |                     |   | G |         |   |        |
|          |        |   |                     |   | S |         |   |        |
|          |        |   |                     |   | A |         |   |        |
|          |        |   |                     |   | V |         |   |        |
|          |        |   |                     |   | A |         |   |        |
|          |        |   |                     |   | I |         |   |        |
|          |        |   |                     |   | L |         |   |        |
|          |        |   |                     |   | A |         |   |        |
|          |        |   |                     |   | B |         |   |        |
|          |        |   |                     |   | L |         |   |        |
|          |        |   |                     |   | E |         |   |        |
|          |        |   |                     |   | T |         |   |        |
|          |        |   |                     |   | O |         |   |        |
|          |        |   |                     |   |   |         |   |        |
|          |        |   |                     |   | C |         |   |        |
|          |        |   |                     |   | O |         |   |        |
|          |        |   |                     |   | M |         |   |        |
|          |        |   |                     |   | P |         |   |        |
|          |        |   |                     |   | L |         |   |        |
|          |        |   |                     |   | E |         |   |        |
|          |        |   |                     |   | T |         |   |        |
|          |        |   |                     |   | E |         |   |        |
|          |        |   |                     |   | T |         |   |        |
|          |        |   |                     |   | H |         |   |        |
|          |        |   |                     |   | E |         |   |        |
|          |        |   |                     |   | C |         |   |        |
|          |        |   |                     |   | A |         |   |        |
|          |        |   |                     |   | U |         |   |        |
|          |        |   |                     |   | S |         |   |        |
|          |        |   |                     |   | E |         |   |        |
|          |        |   |                     |   | O |         |   |        |
|          |        |   |                     |   | F |         |   |        |
|          |        |   |                     |   | D |         |   |        |
|          |        |   |                     |   | E |         |   |        |
|          |        |   |                     |   | A |         |   |        |
|          |        |   |                     |   | T |         |   |        |
|          |        |   |                     |   | H |         |   |        |
|          |        |   |                     |   | ? |         |   |        |
|          |        |   |                     |   |  |         |   |        |
|          |        |   |                     |   | Y |         |   |        |
|          |        |   |                     |   | e |         |   |        |
|          |        |   |                     |   | s |         |   |        |
|          |        |   |                     |   |  |         |   |        |
|          |        |   |                     |   |  |         |   |        |
|          |        |   |                     |   |  |         |   |        |
|          |        |   |                     |   | N |         |   |        |
|          |        |   |                     |   | o |         |   |        |
+----------+--------+---+---------------------+---+---+---------+---+--------+
| 35\. DID |        | 3 |                     | 3 |   |         |   |        |
| TOBACCO  |        | 6 |                     | 7 |   |         |   |        |
| USE      |        | \ |                     | \ |   |         |   |        |
| CO       |        | . |                     | . |   |         |   |        |
| NTRIBUTE |        | I |                     | M |   |         |   |        |
| TO       |        | F |                     | A |   |         |   |        |
| DEATH?   |        | F |                     | N |   |         |   |        |
|          |        | E |                     | N |   |         |   |        |
| Yes   |        | M |                     | E |   |         |   |        |
|       |        | A |                     | R |   |         |   |        |
| Probably |        | L |                     | O |   |         |   |        |
|          |        | E |                     | F |   |         |   |        |
|  No     |        | : |                     | D |   |         |   |        |
|        |        |   |                     | E |   |         |   |        |
| Unknown |        |  |                     | A |   |         |   |        |
|          |        |  |                     | T |   |         |   |        |
|          |        | N |                     | H |   |         |   |        |
|          |        | o |                     |   |   |         |   |        |
|          |        | t |                     |  |   |         |   |        |
|          |        | p |                     |  |   |         |   |        |
|          |        | r |                     | N |   |         |   |        |
|          |        | e |                     | a |   |         |   |        |
|          |        | g |                     | t |   |         |   |        |
|          |        | n |                     | u |   |         |   |        |
|          |        | a |                     | r |   |         |   |        |
|          |        | n |                     | a |   |         |   |        |
|          |        | t |                     | l |   |         |   |        |
|          |        | w |                     |  |   |         |   |        |
|          |        | i |                     |  |   |         |   |        |
|          |        | t |                     | H |   |         |   |        |
|          |        | h |                     | o |   |         |   |        |
|          |        | i |                     | m |   |         |   |        |
|          |        | n |                     | i |   |         |   |        |
|          |        | p |                     | c |   |         |   |        |
|          |        | a |                     | i |   |         |   |        |
|          |        | s |                     | d |   |         |   |        |
|          |        | t |                     | e |   |         |   |        |
|          |        | y |                     |   |   |         |   |        |
|          |        | e |                     |  |   |         |   |        |
|          |        | a |                     | A |   |         |   |        |
|          |        | r |                     | c |   |         |   |        |
|          |        |   |                     | c |   |         |   |        |
|          |        |  |                     | i |   |         |   |        |
|          |        |  |                     | d |   |         |   |        |
|          |        | P |                     | e |   |         |   |        |
|          |        | r |                     | n |   |         |   |        |
|          |        | e |                     | t |   |         |   |        |
|          |        | g |                     |  |   |         |   |        |
|          |        | n |                     |  |   |         |   |        |
|          |        | a |                     | P |   |         |   |        |
|          |        | n |                     | e |   |         |   |        |
|          |        | t |                     | n |   |         |   |        |
|          |        | a |                     | d |   |         |   |        |
|          |        | t |                     | i |   |         |   |        |
|          |        | t |                     | n |   |         |   |        |
|          |        | i |                     | g |   |         |   |        |
|          |        | m |                     | I |   |         |   |        |
|          |        | e |                     | n |   |         |   |        |
|          |        | o |                     | v |   |         |   |        |
|          |        | f |                     | e |   |         |   |        |
|          |        | d |                     | s |   |         |   |        |
|          |        | e |                     | t |   |         |   |        |
|          |        | a |                     | i |   |         |   |        |
|          |        | t |                     | g |   |         |   |        |
|          |        | h |                     | a |   |         |   |        |
|          |        |   |                     | t |   |         |   |        |
|          |        |  |                     | i |   |         |   |        |
|          |        |  |                     | o |   |         |   |        |
|          |        | N |                     | n |   |         |   |        |
|          |        | o |                     |   |   |         |   |        |
|          |        | t |                     |  |   |         |   |        |
|          |        | p |                     |  |   |         |   |        |
|          |        | r |                     | S |   |         |   |        |
|          |        | e |                     | u |   |         |   |        |
|          |        | g |                     | i |   |         |   |        |
|          |        | n |                     | c |   |         |   |        |
|          |        | a |                     | i |   |         |   |        |
|          |        | n |                     | d |   |         |   |        |
|          |        | t |                     | e |   |         |   |        |
|          |        | , |                     |  |   |         |   |        |
|          |        | b |                     |  |   |         |   |        |
|          |        | u |                     | C |   |         |   |        |
|          |        | t |                     | o |   |         |   |        |
|          |        | p |                     | u |   |         |   |        |
|          |        | r |                     | l |   |         |   |        |
|          |        | e |                     | d |   |         |   |        |
|          |        | g |                     | n |   |         |   |        |
|          |        | n |                     | o |   |         |   |        |
|          |        | a |                     | t |   |         |   |        |
|          |        | n |                     | b |   |         |   |        |
|          |        | t |                     | e |   |         |   |        |
|          |        | w |                     | d |   |         |   |        |
|          |        | i |                     | e |   |         |   |        |
|          |        | t |                     | t |   |         |   |        |
|          |        | h |                     | e |   |         |   |        |
|          |        | i |                     | r |   |         |   |        |
|          |        | n |                     | m |   |         |   |        |
|          |        | 4 |                     | i |   |         |   |        |
|          |        | 2 |                     | n |   |         |   |        |
|          |        | d |                     | e |   |         |   |        |
|          |        | a |                     | d |   |         |   |        |
|          |        | y |                     |   |   |         |   |        |
|          |        | s |                     |   |   |         |   |        |
|          |        | o |                     |   |   |         |   |        |
|          |        | f |                     |   |   |         |   |        |
|          |        | d |                     |   |   |         |   |        |
|          |        | e |                     |   |   |         |   |        |
|          |        | a |                     |   |   |         |   |        |
|          |        | t |                     |   |   |         |   |        |
|          |        | h |                     |   |   |         |   |        |
|          |        |   |                     |   |   |         |   |        |
|          |        |  |                     |   |   |         |   |        |
|          |        |  |                     |   |   |         |   |        |
|          |        | N |                     |   |   |         |   |        |
|          |        | o |                     |   |   |         |   |        |
|          |        | t |                     |   |   |         |   |        |
|          |        | p |                     |   |   |         |   |        |
|          |        | r |                     |   |   |         |   |        |
|          |        | e |                     |   |   |         |   |        |
|          |        | g |                     |   |   |         |   |        |
|          |        | n |                     |   |   |         |   |        |
|          |        | a |                     |   |   |         |   |        |
|          |        | n |                     |   |   |         |   |        |
|          |        | t |                     |   |   |         |   |        |
|          |        | , |                     |   |   |         |   |        |
|          |        | b |                     |   |   |         |   |        |
|          |        | u |                     |   |   |         |   |        |
|          |        | t |                     |   |   |         |   |        |
|          |        | p |                     |   |   |         |   |        |
|          |        | r |                     |   |   |         |   |        |
|          |        | e |                     |   |   |         |   |        |
|          |        | g |                     |   |   |         |   |        |
|          |        | n |                     |   |   |         |   |        |
|          |        | a |                     |   |   |         |   |        |
|          |        | n |                     |   |   |         |   |        |
|          |        | t |                     |   |   |         |   |        |
|          |        | 4 |                     |   |   |         |   |        |
|          |        | 3 |                     |   |   |         |   |        |
|          |        | d |                     |   |   |         |   |        |
|          |        | a |                     |   |   |         |   |        |
|          |        | y |                     |   |   |         |   |        |
|          |        | s |                     |   |   |         |   |        |
|          |        | t |                     |   |   |         |   |        |
|          |        | o |                     |   |   |         |   |        |
|          |        | 1 |                     |   |   |         |   |        |
|          |        | y |                     |   |   |         |   |        |
|          |        | e |                     |   |   |         |   |        |
|          |        | a |                     |   |   |         |   |        |
|          |        | r |                     |   |   |         |   |        |
|          |        | b |                     |   |   |         |   |        |
|          |        | e |                     |   |   |         |   |        |
|          |        | f |                     |   |   |         |   |        |
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|          |        | r |                     |   |   |         |   |        |
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|          |        | d |                     |   |   |         |   |        |
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|          |        | h |                     |   |   |         |   |        |
|          |        |   |                     |   |   |         |   |        |
|          |        |  |                     |   |   |         |   |        |
|          |        |  |                     |   |   |         |   |        |
|          |        | U |                     |   |   |         |   |        |
|          |        | n |                     |   |   |         |   |        |
|          |        | k |                     |   |   |         |   |        |
|          |        | n |                     |   |   |         |   |        |
|          |        | o |                     |   |   |         |   |        |
|          |        | w |                     |   |   |         |   |        |
|          |        | n |                     |   |   |         |   |        |
|          |        | i |                     |   |   |         |   |        |
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|          |        | n |                     |   |   |         |   |        |
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|          |        | h |                     |   |   |         |   |        |
|          |        | i |                     |   |   |         |   |        |
|          |        | n |                     |   |   |         |   |        |
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|          |        | y |                     |   |   |         |   |        |
|          |        | e |                     |   |   |         |   |        |
|          |        | a |                     |   |   |         |   |        |
|          |        | r |                     |   |   |         |   |        |
+----------+--------+---+---------------------+---+---+---------+---+--------+
| 38\.     | 39\.   |   | 40\. PLACE OF       |   |   |         | 4 |        |
| DATE OF  | TIME   |   | INJURY (e.g.,       |   |   |         | 1 |        |
| INJURY   | OF     |   | Decedent's home;    |   |   |         | \ |        |
|          | INJURY |   | construction site;  |   |   |         | . |        |
| (Mo      |        |   | restaurant; wooded  |   |   |         | I |        |
| /Day/Yr) |        |   | area)               |   |   |         | N |        |
| (Spell   |        |   |                     |   |   |         | J |        |
| Month)   |        |   |                     |   |   |         | U |        |
|          |        |   |                     |   |   |         | R |        |
|          |        |   |                     |   |   |         | Y |        |
|          |        |   |                     |   |   |         | A |        |
|          |        |   |                     |   |   |         | T |        |
|          |        |   |                     |   |   |         | W |        |
|          |        |   |                     |   |   |         | O |        |
|          |        |   |                     |   |   |         | R |        |
|          |        |   |                     |   |   |         | K |        |
|          |        |   |                     |   |   |         | ? |        |
|          |        |   |                     |   |   |         |   |        |
|          |        |   |                     |   |   |         |  |        |
|          |        |   |                     |   |   |         |  |        |
|          |        |   |                     |   |   |         |  |        |
|          |        |   |                     |   |   |         |  |        |
|          |        |   |                     |   |   |         |  |        |
|          |        |   |                     |   |   |         |  |        |
|          |        |   |                     |   |   |         |  |        |
|          |        |   |                     |   |   |         |  |        |
|          |        |   |                     |   |   |         |  |        |
|          |        |   |                     |   |   |         |  |        |
|          |        |   |                     |   |   |         | Y |        |
|          |        |   |                     |   |   |         | e |        |
|          |        |   |                     |   |   |         | s |        |
|          |        |   |                     |   |   |         |  |        |
|          |        |   |                     |   |   |         | N |        |
|          |        |   |                     |   |   |         | o |        |
+----------+--------+---+---------------------+---+---+---------+---+--------+
| 42\.     |        |   |                     |   |   |         |   |        |
| LOCATION |        |   |                     |   |   |         |   |        |
| OF       |        |   |                     |   |   |         |   |        |
| INJURY:  |        |   |                     |   |   |         |   |        |
| State:   |        |   |                     |   |   |         |   |        |
| Missouri |        |   |                     |   |   |         |   |        |
| City or  |        |   |                     |   |   |         |   |        |
| Town:    |        |   |                     |   |   |         |   |        |
|          |        |   |                     |   |   |         |   |        |
| Street & |        |   |                     |   |   |         |   |        |
| Number:  |        |   |                     |   |   |         |   |        |
| mile     |        |   |                     |   |   |         |   |        |
| marker   |        |   |                     |   |   |         |   |        |
| 17 on    |        |   |                     |   |   |         |   |        |
| state    |        |   |                     |   |   |         |   |        |
| route    |        |   |                     |   |   |         |   |        |
| 46a      |        |   |                     |   |   |         |   |        |
| A        |        |   |                     |   |   |         |   |        |
| partment |        |   |                     |   |   |         |   |        |
| No.: Zip |        |   |                     |   |   |         |   |        |
| Code:    |        |   |                     |   |   |         |   |        |
+----------+--------+---+---------------------+---+---+---------+---+--------+
| 43\.     |        |   |                     |   |   | 44\. IF |   |        |
| DESCRIBE |        |   |                     |   |   | TRANSPO |   |        |
| HOW      |        |   |                     |   |   | RTATION |   |        |
| INJURY   |        |   |                     |   |   | INJURY, |   |        |
| O        |        |   |                     |   |   | S       |   |        |
| CCURRED: |        |   |                     |   |   | PECIFY: |   |        |
|          |        |   |                     |   |   |         |   |        |
|          |        |   |                     |   |   |        |   |        |
|          |        |   |                     |   |   | D       |   |        |
|          |        |   |                     |   |   | river/O |   |        |
|          |        |   |                     |   |   | perator |   |        |
|          |        |   |                     |   |   |         |   |        |
|          |        |   |                     |   |   | Pa   |   |        |
|          |        |   |                     |   |   | ssenger |   |        |
|          |        |   |                     |   |   |         |   |        |
|          |        |   |                     |   |   | Ped  |   |        |
|          |        |   |                     |   |   | estrian |   |        |
|          |        |   |                     |   |   |         |   |        |
|          |        |   |                     |   |   |        |   |        |
|          |        |   |                     |   |   | Other |   |        |
|          |        |   |                     |   |   | (S      |   |        |
|          |        |   |                     |   |   | pecify) |   |        |
+----------+--------+---+---------------------+---+---+---------+---+--------+

1A. Please state if the manner of death was accidental, homicidal,
suicidal, natural, or undetermined.
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_.

If undetermined, was there a pending investigation?
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_.

1B. State what happened to the decedent, describe in detail the external
event that caused the death.

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

2\. How did the decedent commit suicide? (If applicable, state type of
weapon, poison, medication etc.)

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

3\. Describe in detail the external event
(\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ )
that eventually brought about the medical complications which caused the
death.
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_.

4\. Place of occurrence (home, residential institution, public
administrative area, sports area, street and highway, trade and service
areas, industrial and construction area, farm, other -please specify-)
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

[, M.D.]{.underline}

(Signature of Certifying Physician)

Please provide your office
phone:\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
fax:\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

(Please see other side)

Instructions on Medical Certification of Causes of Death

Example of properly completed medical certification

+----------+--------+---+---------------------+---+---+---------+---+--------+
| **CAUSE  |        |   |                     |   |   |         |   | Appro  |
| OF DEATH |        |   |                     |   |   |         |   | ximate |
| (See     |        |   |                     |   |   |         |   | int    |
| inst     |        |   |                     |   |   |         |   | erval: |
| ructions |        |   |                     |   |   |         |   |        |
| and      |        |   |                     |   |   |         |   | Onset  |
| exa      |        |   |                     |   |   |         |   | to     |
| mples)** |        |   |                     |   |   |         |   | death  |
|          |        |   |                     |   |   |         |   |        |
| 32\.     |        |   |                     |   |   |         |   | [2     |
| **PART   |        |   |                     |   |   |         |   | Days]  |
| I.**     |        |   |                     |   |   |         |   | {.unde |
| Enter    |        |   |                     |   |   |         |   | rline} |
| the      |        |   |                     |   |   |         |   |        |
| [chain   |        |   |                     |   |   |         |   | [7     |
| of       |        |   |                     |   |   |         |   | weeks] |
| events]  |        |   |                     |   |   |         |   | {.unde |
| {.underl |        |   |                     |   |   |         |   | rline} |
| ine}\--d |        |   |                     |   |   |         |   |        |
| iseases, |        |   |                     |   |   |         |   | [\_\   |
| i        |        |   |                     |   |   |         |   | _\_\_\ |
| njuries, |        |   |                     |   |   |         |   | _\_\_] |
| or       |        |   |                     |   |   |         |   | {.unde |
| comp     |        |   |                     |   |   |         |   | rline} |
| lication |        |   |                     |   |   |         |   |        |
| s\--that |        |   |                     |   |   |         |   | [\_\   |
| directly |        |   |                     |   |   |         |   | _\_\_\ |
| caused   |        |   |                     |   |   |         |   | _\_\_] |
| the      |        |   |                     |   |   |         |   | {.unde |
| death.   |        |   |                     |   |   |         |   | rline} |
| DO NOT   |        |   |                     |   |   |         |   |        |
| enter    |        |   |                     |   |   |         |   |        |
| terminal |        |   |                     |   |   |         |   |        |
| events   |        |   |                     |   |   |         |   |        |
| such as  |        |   |                     |   |   |         |   |        |
| cardiac  |        |   |                     |   |   |         |   |        |
|          |        |   |                     |   |   |         |   |        |
| arrest,  |        |   |                     |   |   |         |   |        |
| res      |        |   |                     |   |   |         |   |        |
| piratory |        |   |                     |   |   |         |   |        |
| arrest,  |        |   |                     |   |   |         |   |        |
| or       |        |   |                     |   |   |         |   |        |
| ven      |        |   |                     |   |   |         |   |        |
| tricular |        |   |                     |   |   |         |   |        |
| fibr     |        |   |                     |   |   |         |   |        |
| illation |        |   |                     |   |   |         |   |        |
| without  |        |   |                     |   |   |         |   |        |
| showing  |        |   |                     |   |   |         |   |        |
| the      |        |   |                     |   |   |         |   |        |
| e        |        |   |                     |   |   |         |   |        |
| tiology. |        |   |                     |   |   |         |   |        |
| DO NOT   |        |   |                     |   |   |         |   |        |
| ABB      |        |   |                     |   |   |         |   |        |
| REVIATE. |        |   |                     |   |   |         |   |        |
| Enter    |        |   |                     |   |   |         |   |        |
| only one |        |   |                     |   |   |         |   |        |
| cause on |        |   |                     |   |   |         |   |        |
| a line.  |        |   |                     |   |   |         |   |        |
| Add      |        |   |                     |   |   |         |   |        |
| ad       |        |   |                     |   |   |         |   |        |
| ditional |        |   |                     |   |   |         |   |        |
|          |        |   |                     |   |   |         |   |        |
| lines if |        |   |                     |   |   |         |   |        |
| ne       |        |   |                     |   |   |         |   |        |
| cessary. |        |   |                     |   |   |         |   |        |
|          |        |   |                     |   |   |         |   |        |
| I        |        |   |                     |   |   |         |   |        |
| MMEDIATE |        |   |                     |   |   |         |   |        |
| CAUSE    |        |   |                     |   |   |         |   |        |
| (Final   |        |   |                     |   |   |         |   |        |
|          |        |   |                     |   |   |         |   |        |
| disease  |        |   |                     |   |   |         |   |        |
| or       |        |   |                     |   |   |         |   |        |
| c        |        |   |                     |   |   |         |   |        |
| ondition |        |   |                     |   |   |         |   |        |
| **\-\-\  |        |   |                     |   |   |         |   |        |
| -\-\-\-\ |        |   |                     |   |   |         |   |        |
| -\--\>** |        |   |                     |   |   |         |   |        |
| a.       |        |   |                     |   |   |         |   |        |
| [Pen     |        |   |                     |   |   |         |   |        |
| etration |        |   |                     |   |   |         |   |        |
| brain    |        |   |                     |   |   |         |   |        |
| in       |        |   |                     |   |   |         |   |        |
| jury\_\_ |        |   |                     |   |   |         |   |        |
| \_\_\_\_ |        |   |                     |   |   |         |   |        |
| \_\_\_\  |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_]{.un |        |   |                     |   |   |         |   |        |
| derline} |        |   |                     |   |   |         |   |        |
|          |        |   |                     |   |   |         |   |        |
| r        |        |   |                     |   |   |         |   |        |
| esulting |        |   |                     |   |   |         |   |        |
| in       |        |   |                     |   |   |         |   |        |
| death)   |        |   |                     |   |   |         |   |        |
| Due to   |        |   |                     |   |   |         |   |        |
| (or as a |        |   |                     |   |   |         |   |        |
| con      |        |   |                     |   |   |         |   |        |
| sequence |        |   |                     |   |   |         |   |        |
| of):     |        |   |                     |   |   |         |   |        |
|          |        |   |                     |   |   |         |   |        |
| Sequ     |        |   |                     |   |   |         |   |        |
| entially |        |   |                     |   |   |         |   |        |
| list     |        |   |                     |   |   |         |   |        |
| con      |        |   |                     |   |   |         |   |        |
| ditions, |        |   |                     |   |   |         |   |        |
| b.       |        |   |                     |   |   |         |   |        |
| [Gunshot |        |   |                     |   |   |         |   |        |
| wound to |        |   |                     |   |   |         |   |        |
| h        |        |   |                     |   |   |         |   |        |
| ead\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_]{.un |        |   |                     |   |   |         |   |        |
| derline} |        |   |                     |   |   |         |   |        |
|          |        |   |                     |   |   |         |   |        |
| if any,  |        |   |                     |   |   |         |   |        |
| leading  |        |   |                     |   |   |         |   |        |
| to the   |        |   |                     |   |   |         |   |        |
| cause    |        |   |                     |   |   |         |   |        |
| Due to   |        |   |                     |   |   |         |   |        |
| (or as a |        |   |                     |   |   |         |   |        |
| con      |        |   |                     |   |   |         |   |        |
| sequence |        |   |                     |   |   |         |   |        |
| of):     |        |   |                     |   |   |         |   |        |
|          |        |   |                     |   |   |         |   |        |
| listed   |        |   |                     |   |   |         |   |        |
| on line  |        |   |                     |   |   |         |   |        |
| a. Enter |        |   |                     |   |   |         |   |        |
| the      |        |   |                     |   |   |         |   |        |
|          |        |   |                     |   |   |         |   |        |
| **UN     |        |   |                     |   |   |         |   |        |
| DERLYING |        |   |                     |   |   |         |   |        |
| CAUSE**  |        |   |                     |   |   |         |   |        |
| c.       |        |   |                     |   |   |         |   |        |
| [\_\_\   |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_]{.un |        |   |                     |   |   |         |   |        |
| derline} |        |   |                     |   |   |         |   |        |
|          |        |   |                     |   |   |         |   |        |
| (disease |        |   |                     |   |   |         |   |        |
| or       |        |   |                     |   |   |         |   |        |
| injury   |        |   |                     |   |   |         |   |        |
| that Due |        |   |                     |   |   |         |   |        |
| to (or   |        |   |                     |   |   |         |   |        |
| as a     |        |   |                     |   |   |         |   |        |
| con      |        |   |                     |   |   |         |   |        |
| sequence |        |   |                     |   |   |         |   |        |
| of):     |        |   |                     |   |   |         |   |        |
|          |        |   |                     |   |   |         |   |        |
| i        |        |   |                     |   |   |         |   |        |
| nitiated |        |   |                     |   |   |         |   |        |
| the      |        |   |                     |   |   |         |   |        |
| events   |        |   |                     |   |   |         |   |        |
| r        |        |   |                     |   |   |         |   |        |
| esulting |        |   |                     |   |   |         |   |        |
|          |        |   |                     |   |   |         |   |        |
| in       |        |   |                     |   |   |         |   |        |
| death)   |        |   |                     |   |   |         |   |        |
| **LAST** |        |   |                     |   |   |         |   |        |
| d.       |        |   |                     |   |   |         |   |        |
| [\_\     |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_]{.un |        |   |                     |   |   |         |   |        |
| derline} |        |   |                     |   |   |         |   |        |
+----------+--------+---+---------------------+---+---+---------+---+--------+
| **PART   |        |   |                     |   | 3 |         |   |        |
| II.**    |        |   |                     |   | 3 |         |   |        |
| Enter    |        |   |                     |   | \ |         |   |        |
| other    |        |   |                     |   | . |         |   |        |
| [sig     |        |   |                     |   | W |         |   |        |
| nificant |        |   |                     |   | A |         |   |        |
| co       |        |   |                     |   | S |         |   |        |
| nditions |        |   |                     |   | A |         |   |        |
| cont     |        |   |                     |   | N |         |   |        |
| ributing |        |   |                     |   | A |         |   |        |
| to       |        |   |                     |   | U |         |   |        |
| de       |        |   |                     |   | T |         |   |        |
| ath]{.un |        |   |                     |   | O |         |   |        |
| derline} |        |   |                     |   | P |         |   |        |
| but not  |        |   |                     |   | S |         |   |        |
| r        |        |   |                     |   | Y |         |   |        |
| esulting |        |   |                     |   | P |         |   |        |
| in the   |        |   |                     |   | E |         |   |        |
| un       |        |   |                     |   | R |         |   |        |
| derlying |        |   |                     |   | F |         |   |        |
| cause    |        |   |                     |   | O |         |   |        |
| given in |        |   |                     |   | R |         |   |        |
| PART I   |        |   |                     |   | M |         |   |        |
|          |        |   |                     |   | E |         |   |        |
|          |        |   |                     |   | D |         |   |        |
|          |        |   |                     |   | ? |         |   |        |
|          |        |   |                     |   |   |         |   |        |
|          |        |   |                     |   | ■ |         |   |        |
|          |        |   |                     |   | Y |         |   |        |
|          |        |   |                     |   | e |         |   |        |
|          |        |   |                     |   | s |         |   |        |
|          |        |   |                     |   |  |         |   |        |
|          |        |   |                     |   |  |         |   |        |
|          |        |   |                     |   | N |         |   |        |
|          |        |   |                     |   | o |         |   |        |
+----------+--------+---+---------------------+---+---+---------+---+--------+
|          |        |   |                     |   | 3 |         |   |        |
|          |        |   |                     |   | 4 |         |   |        |
|          |        |   |                     |   | \ |         |   |        |
|          |        |   |                     |   | . |         |   |        |
|          |        |   |                     |   | W |         |   |        |
|          |        |   |                     |   | E |         |   |        |
|          |        |   |                     |   | R |         |   |        |
|          |        |   |                     |   | E |         |   |        |
|          |        |   |                     |   | A |         |   |        |
|          |        |   |                     |   | U |         |   |        |
|          |        |   |                     |   | T |         |   |        |
|          |        |   |                     |   | O |         |   |        |
|          |        |   |                     |   | P |         |   |        |
|          |        |   |                     |   | S |         |   |        |
|          |        |   |                     |   | Y |         |   |        |
|          |        |   |                     |   | F |         |   |        |
|          |        |   |                     |   | I |         |   |        |
|          |        |   |                     |   | N |         |   |        |
|          |        |   |                     |   | D |         |   |        |
|          |        |   |                     |   | I |         |   |        |
|          |        |   |                     |   | N |         |   |        |
|          |        |   |                     |   | G |         |   |        |
|          |        |   |                     |   | S |         |   |        |
|          |        |   |                     |   | A |         |   |        |
|          |        |   |                     |   | V |         |   |        |
|          |        |   |                     |   | A |         |   |        |
|          |        |   |                     |   | I |         |   |        |
|          |        |   |                     |   | L |         |   |        |
|          |        |   |                     |   | A |         |   |        |
|          |        |   |                     |   | B |         |   |        |
|          |        |   |                     |   | L |         |   |        |
|          |        |   |                     |   | E |         |   |        |
|          |        |   |                     |   | T |         |   |        |
|          |        |   |                     |   | O |         |   |        |
|          |        |   |                     |   |   |         |   |        |
|          |        |   |                     |   | C |         |   |        |
|          |        |   |                     |   | O |         |   |        |
|          |        |   |                     |   | M |         |   |        |
|          |        |   |                     |   | P |         |   |        |
|          |        |   |                     |   | L |         |   |        |
|          |        |   |                     |   | E |         |   |        |
|          |        |   |                     |   | T |         |   |        |
|          |        |   |                     |   | E |         |   |        |
|          |        |   |                     |   | T |         |   |        |
|          |        |   |                     |   | H |         |   |        |
|          |        |   |                     |   | E |         |   |        |
|          |        |   |                     |   | C |         |   |        |
|          |        |   |                     |   | A |         |   |        |
|          |        |   |                     |   | U |         |   |        |
|          |        |   |                     |   | S |         |   |        |
|          |        |   |                     |   | E |         |   |        |
|          |        |   |                     |   | O |         |   |        |
|          |        |   |                     |   | F |         |   |        |
|          |        |   |                     |   | D |         |   |        |
|          |        |   |                     |   | E |         |   |        |
|          |        |   |                     |   | A |         |   |        |
|          |        |   |                     |   | T |         |   |        |
|          |        |   |                     |   | H |         |   |        |
|          |        |   |                     |   | ? |         |   |        |
|          |        |   |                     |   | ■ |         |   |        |
|          |        |   |                     |   | Y |         |   |        |
|          |        |   |                     |   | e |         |   |        |
|          |        |   |                     |   | s |         |   |        |
|          |        |   |                     |   |  |         |   |        |
|          |        |   |                     |   |  |         |   |        |
|          |        |   |                     |   | N |         |   |        |
|          |        |   |                     |   | o |         |   |        |
+----------+--------+---+---------------------+---+---+---------+---+--------+
| 35\. DID |        | 3 |                     | 3 |   |         |   |        |
| TOBACCO  |        | 6 |                     | 7 |   |         |   |        |
| USE      |        | \ |                     | \ |   |         |   |        |
| CO       |        | . |                     | . |   |         |   |        |
| NTRIBUTE |        | I |                     | M |   |         |   |        |
| TO       |        | F |                     | A |   |         |   |        |
| DEATH?   |        | F |                     | N |   |         |   |        |
|          |        | E |                     | N |   |         |   |        |
| Yes   |        | M |                     | E |   |         |   |        |
|       |        | A |                     | R |   |         |   |        |
| Probably |        | L |                     | O |   |         |   |        |
|          |        | E |                     | F |   |         |   |        |
| ■ No     |        | : |                     | D |   |         |   |        |
|        |        |   |                     | E |   |         |   |        |
| Unknown |        |  |                     | A |   |         |   |        |
|          |        |  |                     | T |   |         |   |        |
|          |        | N |                     | H |   |         |   |        |
|          |        | o |                     |   |   |         |   |        |
|          |        | t |                     |  |   |         |   |        |
|          |        | p |                     |  |   |         |   |        |
|          |        | r |                     |  |   |         |   |        |
|          |        | e |                     | N |   |         |   |        |
|          |        | g |                     | a |   |         |   |        |
|          |        | n |                     | t |   |         |   |        |
|          |        | a |                     | u |   |         |   |        |
|          |        | n |                     | r |   |         |   |        |
|          |        | t |                     | a |   |         |   |        |
|          |        | w |                     | l |   |         |   |        |
|          |        | i |                     |  |   |         |   |        |
|          |        | t |                     |  |   |         |   |        |
|          |        | h |                     | H |   |         |   |        |
|          |        | i |                     | o |   |         |   |        |
|          |        | n |                     | m |   |         |   |        |
|          |        | p |                     | i |   |         |   |        |
|          |        | a |                     | c |   |         |   |        |
|          |        | s |                     | i |   |         |   |        |
|          |        | t |                     | d |   |         |   |        |
|          |        | y |                     | e |   |         |   |        |
|          |        | e |                     |   |   |         |   |        |
|          |        | a |                     |  |   |         |   |        |
|          |        | r |                     | A |   |         |   |        |
|          |        |   |                     | c |   |         |   |        |
|          |        |  |                     | c |   |         |   |        |
|          |        |  |                     | i |   |         |   |        |
|          |        | P |                     | d |   |         |   |        |
|          |        | r |                     | e |   |         |   |        |
|          |        | e |                     | n |   |         |   |        |
|          |        | g |                     | t |   |         |   |        |
|          |        | n |                     |  |   |         |   |        |
|          |        | a |                     |  |   |         |   |        |
|          |        | n |                     | P |   |         |   |        |
|          |        | t |                     | e |   |         |   |        |
|          |        | a |                     | n |   |         |   |        |
|          |        | t |                     | d |   |         |   |        |
|          |        | t |                     | i |   |         |   |        |
|          |        | i |                     | n |   |         |   |        |
|          |        | m |                     | g |   |         |   |        |
|          |        | e |                     | I |   |         |   |        |
|          |        | o |                     | n |   |         |   |        |
|          |        | f |                     | v |   |         |   |        |
|          |        | d |                     | e |   |         |   |        |
|          |        | e |                     | s |   |         |   |        |
|          |        | a |                     | t |   |         |   |        |
|          |        | t |                     | i |   |         |   |        |
|          |        | h |                     | g |   |         |   |        |
|          |        |   |                     | a |   |         |   |        |
|          |        |  |                     | t |   |         |   |        |
|          |        |  |                     | i |   |         |   |        |
|          |        | N |                     | o |   |         |   |        |
|          |        | o |                     | n |   |         |   |        |
|          |        | t |                     |   |   |         |   |        |
|          |        | p |                     | ■ |   |         |   |        |
|          |        | r |                     | S |   |         |   |        |
|          |        | e |                     | u |   |         |   |        |
|          |        | g |                     | i |   |         |   |        |
|          |        | n |                     | c |   |         |   |        |
|          |        | a |                     | i |   |         |   |        |
|          |        | n |                     | d |   |         |   |        |
|          |        | t |                     | e |   |         |   |        |
|          |        | , |                     |  |   |         |   |        |
|          |        | b |                     |  |   |         |   |        |
|          |        | u |                     | C |   |         |   |        |
|          |        | t |                     | o |   |         |   |        |
|          |        | p |                     | u |   |         |   |        |
|          |        | r |                     | l |   |         |   |        |
|          |        | e |                     | d |   |         |   |        |
|          |        | g |                     | n |   |         |   |        |
|          |        | n |                     | o |   |         |   |        |
|          |        | a |                     | t |   |         |   |        |
|          |        | n |                     | b |   |         |   |        |
|          |        | t |                     | e |   |         |   |        |
|          |        | w |                     | d |   |         |   |        |
|          |        | i |                     | e |   |         |   |        |
|          |        | t |                     | t |   |         |   |        |
|          |        | h |                     | e |   |         |   |        |
|          |        | i |                     | r |   |         |   |        |
|          |        | n |                     | m |   |         |   |        |
|          |        | 4 |                     | i |   |         |   |        |
|          |        | 2 |                     | n |   |         |   |        |
|          |        | d |                     | e |   |         |   |        |
|          |        | a |                     | d |   |         |   |        |
|          |        | y |                     |   |   |         |   |        |
|          |        | s |                     |   |   |         |   |        |
|          |        | o |                     |   |   |         |   |        |
|          |        | f |                     |   |   |         |   |        |
|          |        | d |                     |   |   |         |   |        |
|          |        | e |                     |   |   |         |   |        |
|          |        | a |                     |   |   |         |   |        |
|          |        | t |                     |   |   |         |   |        |
|          |        | h |                     |   |   |         |   |        |
|          |        |   |                     |   |   |         |   |        |
|          |        |  |                     |   |   |         |   |        |
|          |        |  |                     |   |   |         |   |        |
|          |        | N |                     |   |   |         |   |        |
|          |        | o |                     |   |   |         |   |        |
|          |        | t |                     |   |   |         |   |        |
|          |        | p |                     |   |   |         |   |        |
|          |        | r |                     |   |   |         |   |        |
|          |        | e |                     |   |   |         |   |        |
|          |        | g |                     |   |   |         |   |        |
|          |        | n |                     |   |   |         |   |        |
|          |        | a |                     |   |   |         |   |        |
|          |        | n |                     |   |   |         |   |        |
|          |        | t |                     |   |   |         |   |        |
|          |        | , |                     |   |   |         |   |        |
|          |        | b |                     |   |   |         |   |        |
|          |        | u |                     |   |   |         |   |        |
|          |        | t |                     |   |   |         |   |        |
|          |        | p |                     |   |   |         |   |        |
|          |        | r |                     |   |   |         |   |        |
|          |        | e |                     |   |   |         |   |        |
|          |        | g |                     |   |   |         |   |        |
|          |        | n |                     |   |   |         |   |        |
|          |        | a |                     |   |   |         |   |        |
|          |        | n |                     |   |   |         |   |        |
|          |        | t |                     |   |   |         |   |        |
|          |        | 4 |                     |   |   |         |   |        |
|          |        | 3 |                     |   |   |         |   |        |
|          |        | d |                     |   |   |         |   |        |
|          |        | a |                     |   |   |         |   |        |
|          |        | y |                     |   |   |         |   |        |
|          |        | s |                     |   |   |         |   |        |
|          |        | t |                     |   |   |         |   |        |
|          |        | o |                     |   |   |         |   |        |
|          |        | 1 |                     |   |   |         |   |        |
|          |        | y |                     |   |   |         |   |        |
|          |        | e |                     |   |   |         |   |        |
|          |        | a |                     |   |   |         |   |        |
|          |        | r |                     |   |   |         |   |        |
|          |        | b |                     |   |   |         |   |        |
|          |        | e |                     |   |   |         |   |        |
|          |        | f |                     |   |   |         |   |        |
|          |        | o |                     |   |   |         |   |        |
|          |        | r |                     |   |   |         |   |        |
|          |        | e |                     |   |   |         |   |        |
|          |        | d |                     |   |   |         |   |        |
|          |        | e |                     |   |   |         |   |        |
|          |        | a |                     |   |   |         |   |        |
|          |        | t |                     |   |   |         |   |        |
|          |        | h |                     |   |   |         |   |        |
|          |        |   |                     |   |   |         |   |        |
|          |        |  |                     |   |   |         |   |        |
|          |        |  |                     |   |   |         |   |        |
|          |        | U |                     |   |   |         |   |        |
|          |        | n |                     |   |   |         |   |        |
|          |        | k |                     |   |   |         |   |        |
|          |        | n |                     |   |   |         |   |        |
|          |        | o |                     |   |   |         |   |        |
|          |        | w |                     |   |   |         |   |        |
|          |        | n |                     |   |   |         |   |        |
|          |        | i |                     |   |   |         |   |        |
|          |        | f |                     |   |   |         |   |        |
|          |        | p |                     |   |   |         |   |        |
|          |        | r |                     |   |   |         |   |        |
|          |        | e |                     |   |   |         |   |        |
|          |        | g |                     |   |   |         |   |        |
|          |        | n |                     |   |   |         |   |        |
|          |        | a |                     |   |   |         |   |        |
|          |        | n |                     |   |   |         |   |        |
|          |        | t |                     |   |   |         |   |        |
|          |        | w |                     |   |   |         |   |        |
|          |        | i |                     |   |   |         |   |        |
|          |        | t |                     |   |   |         |   |        |
|          |        | h |                     |   |   |         |   |        |
|          |        | i |                     |   |   |         |   |        |
|          |        | n |                     |   |   |         |   |        |
|          |        | t |                     |   |   |         |   |        |
|          |        | h |                     |   |   |         |   |        |
|          |        | e |                     |   |   |         |   |        |
|          |        | p |                     |   |   |         |   |        |
|          |        | a |                     |   |   |         |   |        |
|          |        | s |                     |   |   |         |   |        |
|          |        | t |                     |   |   |         |   |        |
|          |        | y |                     |   |   |         |   |        |
|          |        | e |                     |   |   |         |   |        |
|          |        | a |                     |   |   |         |   |        |
|          |        | r |                     |   |   |         |   |        |
+----------+--------+---+---------------------+---+---+---------+---+--------+
| 38\.     | 39\.   |   | 40\. PLACE OF       |   |   |         | 4 |        |
| DATE OF  | TIME   |   | INJURY (e.g.,       |   |   |         | 1 |        |
| INJURY   | OF     |   | Decedent's home;    |   |   |         | \ |        |
|          | INJURY |   | construction site;  |   |   |         | . |        |
| (Mo      |        |   | restaurant; wooded  |   |   |         | I |        |
| /Day/Yr) | 2100   |   | area)               |   |   |         | N |        |
| (Spell   |        |   |                     |   |   |         | J |        |
| Month)   |        |   | decedent's home     |   |   |         | U |        |
|          |        |   |                     |   |   |         | R |        |
| May 10,  |        |   |                     |   |   |         | Y |        |
| 2005     |        |   |                     |   |   |         | A |        |
|          |        |   |                     |   |   |         | T |        |
|          |        |   |                     |   |   |         | W |        |
|          |        |   |                     |   |   |         | O |        |
|          |        |   |                     |   |   |         | R |        |
|          |        |   |                     |   |   |         | K |        |
|          |        |   |                     |   |   |         | ? |        |
|          |        |   |                     |   |   |         |   |        |
|          |        |   |                     |   |   |         |  |        |
|          |        |   |                     |   |   |         |  |        |
|          |        |   |                     |   |   |         |  |        |
|          |        |   |                     |   |   |         |  |        |
|          |        |   |                     |   |   |         |  |        |
|          |        |   |                     |   |   |         |  |        |
|          |        |   |                     |   |   |         |  |        |
|          |        |   |                     |   |   |         |  |        |
|          |        |   |                     |   |   |         |  |        |
|          |        |   |                     |   |   |         |  |        |
|          |        |   |                     |   |   |         |  |        |
|          |        |   |                     |   |   |         |  |        |
|          |        |   |                     |   |   |         | Y |        |
|          |        |   |                     |   |   |         | e |        |
|          |        |   |                     |   |   |         | s |        |
|          |        |   |                     |   |   |         | ■ |        |
|          |        |   |                     |   |   |         | N |        |
|          |        |   |                     |   |   |         | o |        |
+----------+--------+---+---------------------+---+---+---------+---+--------+
| 42\.     |        |   |                     |   |   |         |   |        |
| LOCATION |        |   |                     |   |   |         |   |        |
| OF       |        |   |                     |   |   |         |   |        |
| INJURY:  |        |   |                     |   |   |         |   |        |
| State:   |        |   |                     |   |   |         |   |        |
| Alabama  |        |   |                     |   |   |         |   |        |
| City or  |        |   |                     |   |   |         |   |        |
| Town:    |        |   |                     |   |   |         |   |        |
| near     |        |   |                     |   |   |         |   |        |
| Al       |        |   |                     |   |   |         |   |        |
| exandria |        |   |                     |   |   |         |   |        |
|          |        |   |                     |   |   |         |   |        |
| Street & |        |   |                     |   |   |         |   |        |
| Number:  |        |   |                     |   |   |         |   |        |
| 3129     |        |   |                     |   |   |         |   |        |
| Discus   |        |   |                     |   |   |         |   |        |
| Avenue   |        |   |                     |   |   |         |   |        |
| A        |        |   |                     |   |   |         |   |        |
| partment |        |   |                     |   |   |         |   |        |
| No.: Zip |        |   |                     |   |   |         |   |        |
| Code:    |        |   |                     |   |   |         |   |        |
| 36       |        |   |                     |   |   |         |   |        |
| 102-8888 |        |   |                     |   |   |         |   |        |
+----------+--------+---+---------------------+---+---+---------+---+--------+
| 43\.     |        |   |                     |   |   | 44\. IF |   |        |
| DESCRIBE |        |   |                     |   |   | TRANSPO |   |        |
| HOW      |        |   |                     |   |   | RTATION |   |        |
| INJURY   |        |   |                     |   |   | INJURY, |   |        |
| O        |        |   |                     |   |   | S       |   |        |
| CCURRED: |        |   |                     |   |   | PECIFY: |   |        |
|          |        |   |                     |   |   |         |   |        |
| Cleaning |        |   |                     |   |   |        |   |        |
| gun but  |        |   |                     |   |   | D       |   |        |
| had      |        |   |                     |   |   | river/O |   |        |
| contact  |        |   |                     |   |   | perator |   |        |
| wound to |        |   |                     |   |   |         |   |        |
| right    |        |   |                     |   |   | Pa   |   |        |
| temple   |        |   |                     |   |   | ssenger |   |        |
|          |        |   |                     |   |   |         |   |        |
|          |        |   |                     |   |   | Ped  |   |        |
|          |        |   |                     |   |   | estrian |   |        |
|          |        |   |                     |   |   |         |   |        |
|          |        |   |                     |   |   |        |   |        |
|          |        |   |                     |   |   | Other |   |        |
|          |        |   |                     |   |   | (S      |   |        |
|          |        |   |                     |   |   | pecify) |   |        |
+----------+--------+---+---------------------+---+---+---------+---+--------+

**ITEM 32 -- CAUSE OF DEATH (See example above)**

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.

Take care to make the entry legible. Use a computer printer with high
resolution, typewriter with good black ribbon and clean keys, or print
legibly using permanent **black** ink in completing the CAUSE OF DEATH
Section. **Do** **not** **abbreviate** conditions entered in section.

**[Part I]{.underline} (Chain of events leading directly to death)**

•Only **one** cause should be entered on each line. [Line
(a)]{.underline} **MUST ALWAYS** have an entry. **DO NOT** leave blank.
Additional lines may be added if necessary.

•If the condition on [Line (a)]{.underline} resulted from an underlying
condition, put the underlying condition on [Line (b)]{.underline}, and
so on, until the full sequence is reported. **ALWAYS** enter the
**underlying cause of death** on the [lowest used line]{.underline} in
Part I.

•For each cause indicate the best estimate of the interval between the
presumed onset and the date of death. The terms "unknown" or
"approximately" may be used. General terms, such as minutes, hours, or
days, are acceptable, if necessary. **DO NOT** leave blank.

•The terminal event (for example, cardiac arrest or respiratory arrest)
should not be used. If a mechanism of death seems most appropriate to
you for line (a), then you must always list its cause(s) on the line(s)
below it (for example, cardiac arrest **due to** coronary artery
atherosclerosis *or* cardiac arrest **due to** blunt impact to chest).

• If an organ system failure such as congestive heart failure, hepatic
failure, renal failure, or respiratory failure is listed as a cause of
death, always report its etiology on the line(s) beneath it (for
example, renal failure **due to** Type I diabetes mellitus).

•When indicating neoplasms as a cause of death, include the
following: 1) primary site *or* that the primary site is unknown, 2)
benign or malignant, 3) cell type *or* that the cell type is unknown, 4)
grade of neoplasm, and 5) part or lobe of organ affected. (For example,
a primary well-differentiated squamous cell carcinoma, lung, left upper
lobe.)

•Always report the fatal injury (for example, stab wound of chest), the
trauma (for example, transection of subclavian vein), and impairment of
function (for example, air embolism).

**Part II (Other significant conditions)**

•Enter all diseases or conditions contributing to death that were not
reported in the chain of events in Part I and that did not result in the
**underlying cause of death**.

•If two or more possible sequences resulted in death, or if two
conditions seem to have added together, report in Part I the one that,
in your opinion, most directly caused death. Report in Part II the other
conditions or diseases.

**CHANGES TO CAUSE OF DEATH**

Should additional medical information or autopsy findings become
available that would change the cause of death originally reported, the
original death certificate should be amended by the certifying physician
by **immediately** reporting the revised cause of death to the State
Vital Records Office.

**ITEMS ON WHEN DEATH OCCURRED**

Items 24-25 and 29-31 should always be completed. If the facility uses a
separate pronouncer or other person to indicate that death has taken
place with another person more familiar with the case completing the
remainder of the medical portion of the death certificate, the
pronouncer completes Items 24-28. If a certifier completes Items 24-25
as well as items 29-49, Items 26-28 may be left blank.

**ITEMS 24-25, 29-30 -- DATE AND TIME OF DEATH**

Spell out the name of the month. If the exact date of death is unknown,
enter the **approximate** date. If the date cannot be approximated,
enter the date the body is found and identify as **date found**. Date
pronounced and actual date may be the same. Enter the exact hour and
minutes according to a 24-hour clock; estimates may be provided with
"Approx." placed before the time.

**ITEMS 33-34 - AUTOPSY**

•33 - Enter "Yes" if either a partial or full autopsy was performed.
Otherwise enter "No."

•34 - Enter "Yes" if autopsy findings were available to complete the
cause of death; otherwise enter "No". Leave item blank if no autopsy was
performed.

**ITEM 35 - DID TOBACCO USE CONTRIBUTE TO DEATH?**

Check "yes" if, in your opinion, the use of tobacco contributed to
death. Tobacco use may contribute to deaths due to a wide variety of
diseases; for example, tobacco use contributes to many deaths due to
emphysema or lung cancer and some heart disease and cancers of the head
and neck. Check "no" if, in your clinical judgment, tobacco use did not
contribute to this particular death.

**ITEM 36 - IF FEMALE, WAS DECEDENT PREGNANT AT TIME OF DEATH OR WITHIN
PAST YEAR?**

This information is important in determining pregnancy-related
mortality.

**ITEM 37 - MANNER OF DEATH**

•Always check Manner of Death, which is important: 1) in determining
accurate causes of death; 2) in processing insurance claims; and 3) in
statistical studies of injuries and death.

•Indicate "Pending investigation" if the manner of death cannot be
determined whether due to an accident, suicide, or homicide within the
statutory time limit for filing the death certificate. This should be
changed later to one of the other terms.

•Indicate "Could not be Determined" **ONLY** when it is impossible to
determine the manner of death.

**ITEMS 38-44 - ACCIDENT OR INJURY -- to be filled out in all cases of
deaths due to injury or poisoning.**

•38 - Enter the exact month, day, and year of injury. Spell out the name
of the month. **DO NOT** use a number for the month. (Remember, the date
of injury may differ from the date of death.) Estimates may be provided
with "Approx." placed before the date.

•39 **-** Enter the exact hour and minutes of injury or use your best
estimate. Use a 24-hour clock.

•40 - Enter the general place (such as restaurant, vacant lot, or home)
where the injury occurred. **DO NOT** enter firm or organization names.
(For example, enter "factory", **not** "Standard Manufacturing, Inc." )

•41 - Complete if anything other than natural disease is mentioned in
Part I or Part II of the medical certification, including homicides,
suicides, and accidents. This includes all motor vehicle deaths. The
item **[must]{.underline}** be completed for decedents ages 14 years or
over and may be completed for those less than 14 years of age if
warranted. Enter "Yes" if the injury occurred at work. Otherwise enter
"No". An injury may occur at work regardless of whether the injury
occurred in the course of the decedent's "usual" occupation. Examples of
injury at work and injury not at work follow:

+-----------------------------------+-----------------------------------+
| **Injury at work**                | **Injury [not]{.underline} at     |
|                                   | work**                            |
| Injury while working or in        |                                   |
| vocational training on job        | Injury while engaged in personal  |
| premises                          | recreational activity on job      |
|                                   | premises                          |
| Injury while on break or at lunch |                                   |
| or in parking lot on job premises | Injury while a visitor (not on    |
|                                   | official work business) to job    |
| Injury while working for pay or   | premises                          |
| compensation, including at home   |                                   |
|                                   | Homemaker working at homemaking   |
| Injury while working as a         | activities                        |
| volunteer law enforcement         |                                   |
| official etc.                     | Student in school                 |
|                                   |                                   |
| Injury while traveling on         | Working for self for no profit    |
| business, including to/from       | (mowing yard, repairing own roof, |
| business contacts                 | hobby)                            |
|                                   |                                   |
|                                   | Commuting to or from work         |
+-----------------------------------+-----------------------------------+

•42 - Enter the complete address where the injury occurred including zip
code.

•43 - Enter a brief but specific and clear description of how the injury
occurred. Explain the circumstances or cause of the injury. Specify
**type** **of** **gun** or **type of vehicle** (e.g., car, bulldozer,
train, etc.) when relevant to circumstances. Indicate if more than one
vehicle involved; specify type of vehicle decedent was in.

•44 -Specify role of decedent (e.g. driver, passenger). Driver/operator
and passenger should be designated for modes other than motor vehicles
such as bicycles. Other applies to watercraft, aircraft, animal, or
people attached to outside of vehicles (e.g. surfers).

[Rationale]{.underline}: Motor vehicle accidents are a major cause of
unintentional deaths; details will help determine effectiveness of
current safety features and laws.

**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:]{.underline}**

+-------------+-------------+-------------+-------------+-------------+
| Abscess     | Car         | D           | H           | Pulmonary   |
|             | cinomatosis | isseminated | yponatremia | arrest      |
| Abdominal   |             | intra       |             |             |
| hemorrhage  | Cardiac     | vascular    | Hypotension | Pulmonary   |
|             | arrest      |             |             | edema       |
| Adhesions   |             | c           | Immuno      |             |
|             | Cardiac     | oagulopathy | suppression | Pulmonary   |
| Adult       | dysrhythmia |             |             | embolism    |
| respiratory |             | Dysrhythmia | Increased   |             |
| distress    | Car         |             | intra       | Pulmonary   |
| syndrome    | diomyopathy | End-stage   | cranial     | in          |
|             |             | liver       | pressure    | sufficiency |
| Acute       | Card        | disease     |             |             |
| myocardial  | iopulmonary |             | Intra       | Renal       |
| infarction  | arrest      | End-stage   | cranial     | failure     |
|             |             | renal       | hemorrhage  |             |
| Altered     | Cellulitis  | disease     |             | Respiratory |
| mental      |             |             | M           | arrest      |
| status      | Cerebral    | Epidural    | alnutrition |             |
|             | edema       | hematoma    |             | Seizures    |
| Anemia      |             |             | Metabolic   |             |
|             | Cere        | Exs         | enc         | Sepsis      |
| Anoxia      | brovascular | anguination | ephalopathy |             |
|             | accident    |             |             | Septic      |
| Anoxic      |             | Failure to  | Multi-organ | shock       |
| enc         | Cerebellar  | thrive      | failure     |             |
| ephalopathy | tonsillar   |             |             | Shock       |
|             | herniation  | Fracture    | M           |             |
| Arrhythmia  |             |             | ulti-system | Starvation  |
|             | Chronic     | Gangrene    | organ       |             |
| Ascites     | bedridden   |             | failure     | Subdural    |
|             | state       | Gastr       |             | hematoma    |
| Aspiration  |             | ointestinal | Myocardial  |             |
|             | Cirrhosis   | hemorrhage  | infarction  | S           |
| Atrial      |             |             |             | ubarachnoid |
| f           | C           | Heart       | Necrotizing | hemorrhage  |
| ibrillation | oagulopathy | failure     | soft-tissue |             |
|             |             |             | infection   | Sudden      |
| Bacteremia  | Compression | Hemothorax  |             | death       |
|             | fracture    |             | Old age     |             |
| Bedridden   |             | Hepatic     |             | Throm       |
|             | Congestive  | failure     | Open (or    | bocytopenia |
| Biliary     | heart       |             | closed)     |             |
| obstruction | failure     | Hepatitis   | head injury | Uncal       |
|             |             |             |             | herniation  |
| Bowel       | Convulsions | Hepatorenal | Paralysis   |             |
| obstruction |             | syndrome    |             | Urinary     |
|             | Decubiti    |             | P           | tract       |
| Brain       |             | Hy          | ancytopenia | infection   |
| injury      | Dehydration | perglycemia |             |             |
|             |             |             | Perforated  | Ventricular |
| Brain stem  | Dementia    | H           | gallbladder | f           |
| herniation  | (when not   | yperkalemia |             | ibrillation |
|             |             |             | Peritonitis |             |
| Car         | otherwise   | Hypovolemic |             | Ventricular |
| cinogenesis | specified)  | shock       | Pleural     | tachycardia |
|             |             |             | effusions   |             |
|             | Diarrhea    |             |             | Volume      |
|             |             |             | Pneumonia   | 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    | Epidural    | Hip         | Pulmonary   | Subdural    |
|             | hematoma    | fracture    | emboli      | hematoma    |
| Bolus       |             |             |             |             |
|             | Exs         | H           | Seizure     | Surgery     |
| Choking     | anguination | yperthermia | disorder    |             |
|             |             |             |             | Thermal     |
| Drug or     | Fall        | Hypothermia | Sepsis      | bur         |
| alcohol     |             |             |             | ns/chemical |
| ov          | Fracture    | Open        | S           | burns       |
| erdose/drug |             | reduction   | ubarachnoid |             |
| or          |             | of fracture | hemorrhage  |             |
|             |             |             |             |             |
| alcohol     |             |             |             |             |
| abuse       |             |             |             |             |
+-------------+-------------+-------------+-------------+-------------+

Contact your State vital statistics office for questions related to
writing cause-of-death statements. Additional instructional material on
writing cause-of-death statements including handbooks, summary
instructions, and tutorials are available online at www.thename.org or
www.cdc.gov/nchswww/about/major/dvs/handbk.htm, or by request from NCHS,
Room 7318, 3311 Toledo Road, Hyattsville, Maryland 20782-2003.

Homicide Query

+----------+--------+---+---------------------+---+---+---------+---+--------+
| **CAUSE  |        |   |                     |   |   |         |   | Appro  |
| OF DEATH |        |   |                     |   |   |         |   | ximate |
| (See     |        |   |                     |   |   |         |   | int    |
| inst     |        |   |                     |   |   |         |   | erval: |
| ructions |        |   |                     |   |   |         |   |        |
| and      |        |   |                     |   |   |         |   | Onset  |
| exa      |        |   |                     |   |   |         |   | to     |
| mples)** |        |   |                     |   |   |         |   | death  |
|          |        |   |                     |   |   |         |   |        |
| 32\.     |        |   |                     |   |   |         |   | [\     |
| **PART   |        |   |                     |   |   |         |   | _\_\_\ |
| I.**     |        |   |                     |   |   |         |   | _\_\_] |
| Enter    |        |   |                     |   |   |         |   | {.unde |
| the      |        |   |                     |   |   |         |   | rline} |
| [chain   |        |   |                     |   |   |         |   |        |
| of       |        |   |                     |   |   |         |   | [\     |
| events]  |        |   |                     |   |   |         |   | _\_\_\ |
| {.underl |        |   |                     |   |   |         |   | _\_\_] |
| ine}\--d |        |   |                     |   |   |         |   | {.unde |
| iseases, |        |   |                     |   |   |         |   | rline} |
| i        |        |   |                     |   |   |         |   |        |
| njuries, |        |   |                     |   |   |         |   | [\     |
| or       |        |   |                     |   |   |         |   | _\_\_\ |
| comp     |        |   |                     |   |   |         |   | _\_\_] |
| lication |        |   |                     |   |   |         |   | {.unde |
| s\--that |        |   |                     |   |   |         |   | rline} |
| directly |        |   |                     |   |   |         |   |        |
| caused   |        |   |                     |   |   |         |   | [\     |
| the      |        |   |                     |   |   |         |   | _\_\_\ |
| death.   |        |   |                     |   |   |         |   | _\_\_] |
| DO NOT   |        |   |                     |   |   |         |   | {.unde |
| enter    |        |   |                     |   |   |         |   | rline} |
| terminal |        |   |                     |   |   |         |   |        |
| events   |        |   |                     |   |   |         |   |        |
| such as  |        |   |                     |   |   |         |   |        |
| cardiac  |        |   |                     |   |   |         |   |        |
|          |        |   |                     |   |   |         |   |        |
| arrest,  |        |   |                     |   |   |         |   |        |
| res      |        |   |                     |   |   |         |   |        |
| piratory |        |   |                     |   |   |         |   |        |
| arrest,  |        |   |                     |   |   |         |   |        |
| or       |        |   |                     |   |   |         |   |        |
| ven      |        |   |                     |   |   |         |   |        |
| tricular |        |   |                     |   |   |         |   |        |
| fibr     |        |   |                     |   |   |         |   |        |
| illation |        |   |                     |   |   |         |   |        |
| without  |        |   |                     |   |   |         |   |        |
| showing  |        |   |                     |   |   |         |   |        |
| the      |        |   |                     |   |   |         |   |        |
| e        |        |   |                     |   |   |         |   |        |
| tiology. |        |   |                     |   |   |         |   |        |
| DO NOT   |        |   |                     |   |   |         |   |        |
| ABB      |        |   |                     |   |   |         |   |        |
| REVIATE. |        |   |                     |   |   |         |   |        |
| Enter    |        |   |                     |   |   |         |   |        |
| only one |        |   |                     |   |   |         |   |        |
| cause on |        |   |                     |   |   |         |   |        |
| a line.  |        |   |                     |   |   |         |   |        |
| Add      |        |   |                     |   |   |         |   |        |
| ad       |        |   |                     |   |   |         |   |        |
| ditional |        |   |                     |   |   |         |   |        |
|          |        |   |                     |   |   |         |   |        |
| lines if |        |   |                     |   |   |         |   |        |
| ne       |        |   |                     |   |   |         |   |        |
| cessary. |        |   |                     |   |   |         |   |        |
|          |        |   |                     |   |   |         |   |        |
| I        |        |   |                     |   |   |         |   |        |
| MMEDIATE |        |   |                     |   |   |         |   |        |
| CAUSE    |        |   |                     |   |   |         |   |        |
| (Final   |        |   |                     |   |   |         |   |        |
|          |        |   |                     |   |   |         |   |        |
| disease  |        |   |                     |   |   |         |   |        |
| or       |        |   |                     |   |   |         |   |        |
| c        |        |   |                     |   |   |         |   |        |
| ondition |        |   |                     |   |   |         |   |        |
| **\-\-\  |        |   |                     |   |   |         |   |        |
| -\-\-\-\ |        |   |                     |   |   |         |   |        |
| -\--\>** |        |   |                     |   |   |         |   |        |
| a.       |        |   |                     |   |   |         |   |        |
| \_\_\_   |        |   |                     |   |   |         |   |        |
| \_\_\_\_ |        |   |                     |   |   |         |   |        |
| \_\_\_\_ |        |   |                     |   |   |         |   |        |
| [\_\_\   |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_]{.un |        |   |                     |   |   |         |   |        |
| derline} |        |   |                     |   |   |         |   |        |
|          |        |   |                     |   |   |         |   |        |
| r        |        |   |                     |   |   |         |   |        |
| esulting |        |   |                     |   |   |         |   |        |
| in       |        |   |                     |   |   |         |   |        |
| death)   |        |   |                     |   |   |         |   |        |
| Due to   |        |   |                     |   |   |         |   |        |
| (or as a |        |   |                     |   |   |         |   |        |
| con      |        |   |                     |   |   |         |   |        |
| sequence |        |   |                     |   |   |         |   |        |
| of):     |        |   |                     |   |   |         |   |        |
|          |        |   |                     |   |   |         |   |        |
| Sequ     |        |   |                     |   |   |         |   |        |
| entially |        |   |                     |   |   |         |   |        |
| list     |        |   |                     |   |   |         |   |        |
| con      |        |   |                     |   |   |         |   |        |
| ditions, |        |   |                     |   |   |         |   |        |
| b.       |        |   |                     |   |   |         |   |        |
| [\_\_\   |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_]{.un |        |   |                     |   |   |         |   |        |
| derline} |        |   |                     |   |   |         |   |        |
|          |        |   |                     |   |   |         |   |        |
| if any,  |        |   |                     |   |   |         |   |        |
| leading  |        |   |                     |   |   |         |   |        |
| to the   |        |   |                     |   |   |         |   |        |
| cause    |        |   |                     |   |   |         |   |        |
| Due to   |        |   |                     |   |   |         |   |        |
| (or as a |        |   |                     |   |   |         |   |        |
| con      |        |   |                     |   |   |         |   |        |
| sequence |        |   |                     |   |   |         |   |        |
| of):     |        |   |                     |   |   |         |   |        |
|          |        |   |                     |   |   |         |   |        |
| listed   |        |   |                     |   |   |         |   |        |
| on line  |        |   |                     |   |   |         |   |        |
| a. Enter |        |   |                     |   |   |         |   |        |
| the      |        |   |                     |   |   |         |   |        |
|          |        |   |                     |   |   |         |   |        |
| **UN     |        |   |                     |   |   |         |   |        |
| DERLYING |        |   |                     |   |   |         |   |        |
| CAUSE**  |        |   |                     |   |   |         |   |        |
| c.       |        |   |                     |   |   |         |   |        |
| [\_\_\   |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_]{.un |        |   |                     |   |   |         |   |        |
| derline} |        |   |                     |   |   |         |   |        |
|          |        |   |                     |   |   |         |   |        |
| (disease |        |   |                     |   |   |         |   |        |
| or       |        |   |                     |   |   |         |   |        |
| injury   |        |   |                     |   |   |         |   |        |
| that Due |        |   |                     |   |   |         |   |        |
| to (or   |        |   |                     |   |   |         |   |        |
| as a     |        |   |                     |   |   |         |   |        |
| con      |        |   |                     |   |   |         |   |        |
| sequence |        |   |                     |   |   |         |   |        |
| of):     |        |   |                     |   |   |         |   |        |
|          |        |   |                     |   |   |         |   |        |
| i        |        |   |                     |   |   |         |   |        |
| nitiated |        |   |                     |   |   |         |   |        |
| the      |        |   |                     |   |   |         |   |        |
| events   |        |   |                     |   |   |         |   |        |
| r        |        |   |                     |   |   |         |   |        |
| esulting |        |   |                     |   |   |         |   |        |
|          |        |   |                     |   |   |         |   |        |
| in       |        |   |                     |   |   |         |   |        |
| death)   |        |   |                     |   |   |         |   |        |
| **LAST** |        |   |                     |   |   |         |   |        |
| d.       |        |   |                     |   |   |         |   |        |
| [\_\     |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_]{.un |        |   |                     |   |   |         |   |        |
| derline} |        |   |                     |   |   |         |   |        |
+----------+--------+---+---------------------+---+---+---------+---+--------+
| **PART   |        |   |                     |   | 3 |         |   |        |
| II.**    |        |   |                     |   | 3 |         |   |        |
| Enter    |        |   |                     |   | \ |         |   |        |
| other    |        |   |                     |   | . |         |   |        |
| [sig     |        |   |                     |   | W |         |   |        |
| nificant |        |   |                     |   | A |         |   |        |
| co       |        |   |                     |   | S |         |   |        |
| nditions |        |   |                     |   | A |         |   |        |
| cont     |        |   |                     |   | N |         |   |        |
| ributing |        |   |                     |   | A |         |   |        |
| to       |        |   |                     |   | U |         |   |        |
| de       |        |   |                     |   | T |         |   |        |
| ath]{.un |        |   |                     |   | O |         |   |        |
| derline} |        |   |                     |   | P |         |   |        |
| but not  |        |   |                     |   | S |         |   |        |
| r        |        |   |                     |   | Y |         |   |        |
| esulting |        |   |                     |   | P |         |   |        |
| in the   |        |   |                     |   | E |         |   |        |
| un       |        |   |                     |   | R |         |   |        |
| derlying |        |   |                     |   | F |         |   |        |
| cause    |        |   |                     |   | O |         |   |        |
| given in |        |   |                     |   | R |         |   |        |
| PART I   |        |   |                     |   | M |         |   |        |
|          |        |   |                     |   | E |         |   |        |
|          |        |   |                     |   | D |         |   |        |
|          |        |   |                     |   | ? |         |   |        |
|          |        |   |                     |   |   |         |   |        |
|          |        |   |                     |   |  |         |   |        |
|          |        |   |                     |   | Y |         |   |        |
|          |        |   |                     |   | e |         |   |        |
|          |        |   |                     |   | s |         |   |        |
|          |        |   |                     |   |  |         |   |        |
|          |        |   |                     |   |  |         |   |        |
|          |        |   |                     |   |  |         |   |        |
|          |        |   |                     |   | N |         |   |        |
|          |        |   |                     |   | o |         |   |        |
+----------+--------+---+---------------------+---+---+---------+---+--------+
|          |        |   |                     |   | 3 |         |   |        |
|          |        |   |                     |   | 4 |         |   |        |
|          |        |   |                     |   | \ |         |   |        |
|          |        |   |                     |   | . |         |   |        |
|          |        |   |                     |   | W |         |   |        |
|          |        |   |                     |   | E |         |   |        |
|          |        |   |                     |   | R |         |   |        |
|          |        |   |                     |   | E |         |   |        |
|          |        |   |                     |   | A |         |   |        |
|          |        |   |                     |   | U |         |   |        |
|          |        |   |                     |   | T |         |   |        |
|          |        |   |                     |   | O |         |   |        |
|          |        |   |                     |   | P |         |   |        |
|          |        |   |                     |   | S |         |   |        |
|          |        |   |                     |   | Y |         |   |        |
|          |        |   |                     |   | F |         |   |        |
|          |        |   |                     |   | I |         |   |        |
|          |        |   |                     |   | N |         |   |        |
|          |        |   |                     |   | D |         |   |        |
|          |        |   |                     |   | I |         |   |        |
|          |        |   |                     |   | N |         |   |        |
|          |        |   |                     |   | G |         |   |        |
|          |        |   |                     |   | S |         |   |        |
|          |        |   |                     |   | A |         |   |        |
|          |        |   |                     |   | V |         |   |        |
|          |        |   |                     |   | A |         |   |        |
|          |        |   |                     |   | I |         |   |        |
|          |        |   |                     |   | L |         |   |        |
|          |        |   |                     |   | A |         |   |        |
|          |        |   |                     |   | B |         |   |        |
|          |        |   |                     |   | L |         |   |        |
|          |        |   |                     |   | E |         |   |        |
|          |        |   |                     |   | T |         |   |        |
|          |        |   |                     |   | O |         |   |        |
|          |        |   |                     |   |   |         |   |        |
|          |        |   |                     |   | C |         |   |        |
|          |        |   |                     |   | O |         |   |        |
|          |        |   |                     |   | M |         |   |        |
|          |        |   |                     |   | P |         |   |        |
|          |        |   |                     |   | L |         |   |        |
|          |        |   |                     |   | E |         |   |        |
|          |        |   |                     |   | T |         |   |        |
|          |        |   |                     |   | E |         |   |        |
|          |        |   |                     |   | T |         |   |        |
|          |        |   |                     |   | H |         |   |        |
|          |        |   |                     |   | E |         |   |        |
|          |        |   |                     |   | C |         |   |        |
|          |        |   |                     |   | A |         |   |        |
|          |        |   |                     |   | U |         |   |        |
|          |        |   |                     |   | S |         |   |        |
|          |        |   |                     |   | E |         |   |        |
|          |        |   |                     |   | O |         |   |        |
|          |        |   |                     |   | F |         |   |        |
|          |        |   |                     |   | D |         |   |        |
|          |        |   |                     |   | E |         |   |        |
|          |        |   |                     |   | A |         |   |        |
|          |        |   |                     |   | T |         |   |        |
|          |        |   |                     |   | H |         |   |        |
|          |        |   |                     |   | ? |         |   |        |
|          |        |   |                     |   |  |         |   |        |
|          |        |   |                     |   | Y |         |   |        |
|          |        |   |                     |   | e |         |   |        |
|          |        |   |                     |   | s |         |   |        |
|          |        |   |                     |   |  |         |   |        |
|          |        |   |                     |   |  |         |   |        |
|          |        |   |                     |   |  |         |   |        |
|          |        |   |                     |   | N |         |   |        |
|          |        |   |                     |   | o |         |   |        |
+----------+--------+---+---------------------+---+---+---------+---+--------+
| 35\. DID |        | 3 |                     | 3 |   |         |   |        |
| TOBACCO  |        | 6 |                     | 7 |   |         |   |        |
| USE      |        | \ |                     | \ |   |         |   |        |
| CO       |        | . |                     | . |   |         |   |        |
| NTRIBUTE |        | I |                     | M |   |         |   |        |
| TO       |        | F |                     | A |   |         |   |        |
| DEATH?   |        | F |                     | N |   |         |   |        |
|          |        | E |                     | N |   |         |   |        |
| Yes   |        | M |                     | E |   |         |   |        |
|       |        | A |                     | R |   |         |   |        |
| Probably |        | L |                     | O |   |         |   |        |
|          |        | E |                     | F |   |         |   |        |
|  No     |        | : |                     | D |   |         |   |        |
|        |        |   |                     | E |   |         |   |        |
| Unknown |        |  |                     | A |   |         |   |        |
|          |        |  |                     | T |   |         |   |        |
|          |        | N |                     | H |   |         |   |        |
|          |        | o |                     |   |   |         |   |        |
|          |        | t |                     |  |   |         |   |        |
|          |        | p |                     |  |   |         |   |        |
|          |        | r |                     | N |   |         |   |        |
|          |        | e |                     | a |   |         |   |        |
|          |        | g |                     | t |   |         |   |        |
|          |        | n |                     | u |   |         |   |        |
|          |        | a |                     | r |   |         |   |        |
|          |        | n |                     | a |   |         |   |        |
|          |        | t |                     | l |   |         |   |        |
|          |        | w |                     |  |   |         |   |        |
|          |        | i |                     |  |   |         |   |        |
|          |        | t |                     | H |   |         |   |        |
|          |        | h |                     | o |   |         |   |        |
|          |        | i |                     | m |   |         |   |        |
|          |        | n |                     | i |   |         |   |        |
|          |        | p |                     | c |   |         |   |        |
|          |        | a |                     | i |   |         |   |        |
|          |        | s |                     | d |   |         |   |        |
|          |        | t |                     | e |   |         |   |        |
|          |        | y |                     |   |   |         |   |        |
|          |        | e |                     |  |   |         |   |        |
|          |        | a |                     | A |   |         |   |        |
|          |        | r |                     | c |   |         |   |        |
|          |        |   |                     | c |   |         |   |        |
|          |        |  |                     | i |   |         |   |        |
|          |        |  |                     | d |   |         |   |        |
|          |        | P |                     | e |   |         |   |        |
|          |        | r |                     | n |   |         |   |        |
|          |        | e |                     | t |   |         |   |        |
|          |        | g |                     |  |   |         |   |        |
|          |        | n |                     |  |   |         |   |        |
|          |        | a |                     | P |   |         |   |        |
|          |        | n |                     | e |   |         |   |        |
|          |        | t |                     | n |   |         |   |        |
|          |        | a |                     | d |   |         |   |        |
|          |        | t |                     | i |   |         |   |        |
|          |        | t |                     | n |   |         |   |        |
|          |        | i |                     | g |   |         |   |        |
|          |        | m |                     | I |   |         |   |        |
|          |        | e |                     | n |   |         |   |        |
|          |        | o |                     | v |   |         |   |        |
|          |        | f |                     | e |   |         |   |        |
|          |        | d |                     | s |   |         |   |        |
|          |        | e |                     | t |   |         |   |        |
|          |        | a |                     | i |   |         |   |        |
|          |        | t |                     | g |   |         |   |        |
|          |        | h |                     | a |   |         |   |        |
|          |        |   |                     | t |   |         |   |        |
|          |        |  |                     | i |   |         |   |        |
|          |        |  |                     | o |   |         |   |        |
|          |        | N |                     | n |   |         |   |        |
|          |        | o |                     |   |   |         |   |        |
|          |        | t |                     |  |   |         |   |        |
|          |        | p |                     |  |   |         |   |        |
|          |        | r |                     | S |   |         |   |        |
|          |        | e |                     | u |   |         |   |        |
|          |        | g |                     | i |   |         |   |        |
|          |        | n |                     | c |   |         |   |        |
|          |        | a |                     | i |   |         |   |        |
|          |        | n |                     | d |   |         |   |        |
|          |        | t |                     | e |   |         |   |        |
|          |        | , |                     |  |   |         |   |        |
|          |        | b |                     |  |   |         |   |        |
|          |        | u |                     | C |   |         |   |        |
|          |        | t |                     | o |   |         |   |        |
|          |        | p |                     | u |   |         |   |        |
|          |        | r |                     | l |   |         |   |        |
|          |        | e |                     | d |   |         |   |        |
|          |        | g |                     | n |   |         |   |        |
|          |        | n |                     | o |   |         |   |        |
|          |        | a |                     | t |   |         |   |        |
|          |        | n |                     | b |   |         |   |        |
|          |        | t |                     | e |   |         |   |        |
|          |        | w |                     | d |   |         |   |        |
|          |        | i |                     | e |   |         |   |        |
|          |        | t |                     | t |   |         |   |        |
|          |        | h |                     | e |   |         |   |        |
|          |        | i |                     | r |   |         |   |        |
|          |        | n |                     | m |   |         |   |        |
|          |        | 4 |                     | i |   |         |   |        |
|          |        | 2 |                     | n |   |         |   |        |
|          |        | d |                     | e |   |         |   |        |
|          |        | a |                     | d |   |         |   |        |
|          |        | y |                     |   |   |         |   |        |
|          |        | s |                     |   |   |         |   |        |
|          |        | o |                     |   |   |         |   |        |
|          |        | f |                     |   |   |         |   |        |
|          |        | d |                     |   |   |         |   |        |
|          |        | e |                     |   |   |         |   |        |
|          |        | a |                     |   |   |         |   |        |
|          |        | t |                     |   |   |         |   |        |
|          |        | h |                     |   |   |         |   |        |
|          |        |   |                     |   |   |         |   |        |
|          |        |  |                     |   |   |         |   |        |
|          |        |  |                     |   |   |         |   |        |
|          |        | N |                     |   |   |         |   |        |
|          |        | o |                     |   |   |         |   |        |
|          |        | t |                     |   |   |         |   |        |
|          |        | p |                     |   |   |         |   |        |
|          |        | r |                     |   |   |         |   |        |
|          |        | e |                     |   |   |         |   |        |
|          |        | g |                     |   |   |         |   |        |
|          |        | n |                     |   |   |         |   |        |
|          |        | a |                     |   |   |         |   |        |
|          |        | n |                     |   |   |         |   |        |
|          |        | t |                     |   |   |         |   |        |
|          |        | , |                     |   |   |         |   |        |
|          |        | b |                     |   |   |         |   |        |
|          |        | u |                     |   |   |         |   |        |
|          |        | t |                     |   |   |         |   |        |
|          |        | p |                     |   |   |         |   |        |
|          |        | r |                     |   |   |         |   |        |
|          |        | e |                     |   |   |         |   |        |
|          |        | g |                     |   |   |         |   |        |
|          |        | n |                     |   |   |         |   |        |
|          |        | a |                     |   |   |         |   |        |
|          |        | n |                     |   |   |         |   |        |
|          |        | t |                     |   |   |         |   |        |
|          |        | 4 |                     |   |   |         |   |        |
|          |        | 3 |                     |   |   |         |   |        |
|          |        | d |                     |   |   |         |   |        |
|          |        | a |                     |   |   |         |   |        |
|          |        | y |                     |   |   |         |   |        |
|          |        | s |                     |   |   |         |   |        |
|          |        | t |                     |   |   |         |   |        |
|          |        | o |                     |   |   |         |   |        |
|          |        | 1 |                     |   |   |         |   |        |
|          |        | y |                     |   |   |         |   |        |
|          |        | e |                     |   |   |         |   |        |
|          |        | a |                     |   |   |         |   |        |
|          |        | r |                     |   |   |         |   |        |
|          |        | b |                     |   |   |         |   |        |
|          |        | e |                     |   |   |         |   |        |
|          |        | f |                     |   |   |         |   |        |
|          |        | o |                     |   |   |         |   |        |
|          |        | r |                     |   |   |         |   |        |
|          |        | e |                     |   |   |         |   |        |
|          |        | d |                     |   |   |         |   |        |
|          |        | e |                     |   |   |         |   |        |
|          |        | a |                     |   |   |         |   |        |
|          |        | t |                     |   |   |         |   |        |
|          |        | h |                     |   |   |         |   |        |
|          |        |   |                     |   |   |         |   |        |
|          |        |  |                     |   |   |         |   |        |
|          |        |  |                     |   |   |         |   |        |
|          |        | U |                     |   |   |         |   |        |
|          |        | n |                     |   |   |         |   |        |
|          |        | k |                     |   |   |         |   |        |
|          |        | n |                     |   |   |         |   |        |
|          |        | o |                     |   |   |         |   |        |
|          |        | w |                     |   |   |         |   |        |
|          |        | n |                     |   |   |         |   |        |
|          |        | i |                     |   |   |         |   |        |
|          |        | f |                     |   |   |         |   |        |
|          |        | p |                     |   |   |         |   |        |
|          |        | r |                     |   |   |         |   |        |
|          |        | e |                     |   |   |         |   |        |
|          |        | g |                     |   |   |         |   |        |
|          |        | n |                     |   |   |         |   |        |
|          |        | a |                     |   |   |         |   |        |
|          |        | n |                     |   |   |         |   |        |
|          |        | t |                     |   |   |         |   |        |
|          |        | w |                     |   |   |         |   |        |
|          |        | i |                     |   |   |         |   |        |
|          |        | t |                     |   |   |         |   |        |
|          |        | h |                     |   |   |         |   |        |
|          |        | i |                     |   |   |         |   |        |
|          |        | n |                     |   |   |         |   |        |
|          |        | t |                     |   |   |         |   |        |
|          |        | h |                     |   |   |         |   |        |
|          |        | e |                     |   |   |         |   |        |
|          |        | p |                     |   |   |         |   |        |
|          |        | a |                     |   |   |         |   |        |
|          |        | s |                     |   |   |         |   |        |
|          |        | t |                     |   |   |         |   |        |
|          |        | y |                     |   |   |         |   |        |
|          |        | e |                     |   |   |         |   |        |
|          |        | a |                     |   |   |         |   |        |
|          |        | r |                     |   |   |         |   |        |
+----------+--------+---+---------------------+---+---+---------+---+--------+
| 38\.     | 39\.   |   | 40\. PLACE OF       |   |   |         | 4 |        |
| DATE OF  | TIME   |   | INJURY (e.g.,       |   |   |         | 1 |        |
| INJURY   | OF     |   | Decedent's home;    |   |   |         | \ |        |
|          | INJURY |   | construction site;  |   |   |         | . |        |
| (Mo      |        |   | restaurant; wooded  |   |   |         | I |        |
| /Day/Yr) |        |   | area)               |   |   |         | N |        |
| (Spell   |        |   |                     |   |   |         | J |        |
| Month)   |        |   |                     |   |   |         | U |        |
|          |        |   |                     |   |   |         | R |        |
|          |        |   |                     |   |   |         | Y |        |
|          |        |   |                     |   |   |         | A |        |
|          |        |   |                     |   |   |         | T |        |
|          |        |   |                     |   |   |         | W |        |
|          |        |   |                     |   |   |         | O |        |
|          |        |   |                     |   |   |         | R |        |
|          |        |   |                     |   |   |         | K |        |
|          |        |   |                     |   |   |         | ? |        |
|          |        |   |                     |   |   |         |   |        |
|          |        |   |                     |   |   |         |  |        |
|          |        |   |                     |   |   |         |  |        |
|          |        |   |                     |   |   |         |  |        |
|          |        |   |                     |   |   |         |  |        |
|          |        |   |                     |   |   |         |  |        |
|          |        |   |                     |   |   |         |  |        |
|          |        |   |                     |   |   |         |  |        |
|          |        |   |                     |   |   |         |  |        |
|          |        |   |                     |   |   |         | Y |        |
|          |        |   |                     |   |   |         | e |        |
|          |        |   |                     |   |   |         | s |        |
|          |        |   |                     |   |   |         |  |        |
|          |        |   |                     |   |   |         | N |        |
|          |        |   |                     |   |   |         | o |        |
+----------+--------+---+---------------------+---+---+---------+---+--------+
| 42\.     |        |   |                     |   |   |         |   |        |
| LOCATION |        |   |                     |   |   |         |   |        |
| OF       |        |   |                     |   |   |         |   |        |
| INJURY:  |        |   |                     |   |   |         |   |        |
| State:   |        |   |                     |   |   |         |   |        |
| City or  |        |   |                     |   |   |         |   |        |
| Town:    |        |   |                     |   |   |         |   |        |
|          |        |   |                     |   |   |         |   |        |
| Street & |        |   |                     |   |   |         |   |        |
| Number:  |        |   |                     |   |   |         |   |        |
| A        |        |   |                     |   |   |         |   |        |
| partment |        |   |                     |   |   |         |   |        |
| No.: Zip |        |   |                     |   |   |         |   |        |
| Code:    |        |   |                     |   |   |         |   |        |
+----------+--------+---+---------------------+---+---+---------+---+--------+
| 43\.     |        |   |                     |   |   | 44\. IF |   |        |
| DESCRIBE |        |   |                     |   |   | TRANSPO |   |        |
| HOW      |        |   |                     |   |   | RTATION |   |        |
| INJURY   |        |   |                     |   |   | INJURY, |   |        |
| O        |        |   |                     |   |   | S       |   |        |
| CCURRED: |        |   |                     |   |   | PECIFY: |   |        |
|          |        |   |                     |   |   |         |   |        |
|          |        |   |                     |   |   |        |   |        |
|          |        |   |                     |   |   | D       |   |        |
|          |        |   |                     |   |   | river/O |   |        |
|          |        |   |                     |   |   | perator |   |        |
|          |        |   |                     |   |   |         |   |        |
|          |        |   |                     |   |   | Pa   |   |        |
|          |        |   |                     |   |   | ssenger |   |        |
|          |        |   |                     |   |   |         |   |        |
|          |        |   |                     |   |   | Ped  |   |        |
|          |        |   |                     |   |   | estrian |   |        |
|          |        |   |                     |   |   |         |   |        |
|          |        |   |                     |   |   |        |   |        |
|          |        |   |                     |   |   | Other |   |        |
|          |        |   |                     |   |   | (S      |   |        |
|          |        |   |                     |   |   | pecify) |   |        |
+----------+--------+---+---------------------+---+---+---------+---+--------+

1A. Please state if the manner of death was accidental, homicidal,
suicidal, natural, or undetermined.
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_.

If undetermined, was there a pending investigation?
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_.

1B. State what happened to the decedent, describe in detail the external
event that caused the death.

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

2\. How was the decedent assaulted? (If applicable, state type of
weapon, poison, medication etc.)

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

3\. Describe in detail the external event
(\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ )
that eventually brought about the medical complications which caused the
death.
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_.

4\. Place of occurrence (home, residential institution, public
administrative area, sports area, street and highway, trade and service
areas, industrial and construction area, farm, other -please specify-)
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

[, M.D.]{.underline}

(Signature of Certifying Physician)

Please provide your office
phone:\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
fax:\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

(Please see other side)

Instructions on Medical Certification of Causes of Death

Example of properly completed medical certification

+----------+--------+---+---------------------+---+---+---------+---+--------+
| **CAUSE  |        |   |                     |   |   |         |   | Appro  |
| OF DEATH |        |   |                     |   |   |         |   | ximate |
| (See     |        |   |                     |   |   |         |   | int    |
| inst     |        |   |                     |   |   |         |   | erval: |
| ructions |        |   |                     |   |   |         |   |        |
| and      |        |   |                     |   |   |         |   | Onset  |
| exa      |        |   |                     |   |   |         |   | to     |
| mples)** |        |   |                     |   |   |         |   | death  |
|          |        |   |                     |   |   |         |   |        |
| 32\.     |        |   |                     |   |   |         |   | [15    |
| **PART   |        |   |                     |   |   |         |   | hours] |
| I.**     |        |   |                     |   |   |         |   | {.unde |
| Enter    |        |   |                     |   |   |         |   | rline} |
| the      |        |   |                     |   |   |         |   |        |
| [chain   |        |   |                     |   |   |         |   | [15    |
| of       |        |   |                     |   |   |         |   | hours] |
| events]  |        |   |                     |   |   |         |   | {.unde |
| {.underl |        |   |                     |   |   |         |   | rline} |
| ine}\--d |        |   |                     |   |   |         |   |        |
| iseases, |        |   |                     |   |   |         |   | [\_\   |
| i        |        |   |                     |   |   |         |   | _\_\_\ |
| njuries, |        |   |                     |   |   |         |   | _\_\_] |
| or       |        |   |                     |   |   |         |   | {.unde |
| comp     |        |   |                     |   |   |         |   | rline} |
| lication |        |   |                     |   |   |         |   |        |
| s\--that |        |   |                     |   |   |         |   | [\_\   |
| directly |        |   |                     |   |   |         |   | _\_\_\ |
| caused   |        |   |                     |   |   |         |   | _\_\_] |
| the      |        |   |                     |   |   |         |   | {.unde |
| death.   |        |   |                     |   |   |         |   | rline} |
| DO NOT   |        |   |                     |   |   |         |   |        |
| enter    |        |   |                     |   |   |         |   |        |
| terminal |        |   |                     |   |   |         |   |        |
| events   |        |   |                     |   |   |         |   |        |
| such as  |        |   |                     |   |   |         |   |        |
| cardiac  |        |   |                     |   |   |         |   |        |
|          |        |   |                     |   |   |         |   |        |
| arrest,  |        |   |                     |   |   |         |   |        |
| res      |        |   |                     |   |   |         |   |        |
| piratory |        |   |                     |   |   |         |   |        |
| arrest,  |        |   |                     |   |   |         |   |        |
| or       |        |   |                     |   |   |         |   |        |
| ven      |        |   |                     |   |   |         |   |        |
| tricular |        |   |                     |   |   |         |   |        |
| fibr     |        |   |                     |   |   |         |   |        |
| illation |        |   |                     |   |   |         |   |        |
| without  |        |   |                     |   |   |         |   |        |
| showing  |        |   |                     |   |   |         |   |        |
| the      |        |   |                     |   |   |         |   |        |
| e        |        |   |                     |   |   |         |   |        |
| tiology. |        |   |                     |   |   |         |   |        |
| DO NOT   |        |   |                     |   |   |         |   |        |
| ABB      |        |   |                     |   |   |         |   |        |
| REVIATE. |        |   |                     |   |   |         |   |        |
| Enter    |        |   |                     |   |   |         |   |        |
| only one |        |   |                     |   |   |         |   |        |
| cause on |        |   |                     |   |   |         |   |        |
| a line.  |        |   |                     |   |   |         |   |        |
| Add      |        |   |                     |   |   |         |   |        |
| ad       |        |   |                     |   |   |         |   |        |
| ditional |        |   |                     |   |   |         |   |        |
|          |        |   |                     |   |   |         |   |        |
| lines if |        |   |                     |   |   |         |   |        |
| ne       |        |   |                     |   |   |         |   |        |
| cessary. |        |   |                     |   |   |         |   |        |
|          |        |   |                     |   |   |         |   |        |
| I        |        |   |                     |   |   |         |   |        |
| MMEDIATE |        |   |                     |   |   |         |   |        |
| CAUSE    |        |   |                     |   |   |         |   |        |
| (Final   |        |   |                     |   |   |         |   |        |
|          |        |   |                     |   |   |         |   |        |
| disease  |        |   |                     |   |   |         |   |        |
| or       |        |   |                     |   |   |         |   |        |
| c        |        |   |                     |   |   |         |   |        |
| ondition |        |   |                     |   |   |         |   |        |
| **\-\-\  |        |   |                     |   |   |         |   |        |
| -\-\-\-\ |        |   |                     |   |   |         |   |        |
| -\--\>** |        |   |                     |   |   |         |   |        |
| a.       |        |   |                     |   |   |         |   |        |
| [Intra   |        |   |                     |   |   |         |   |        |
| thoracic |        |   |                     |   |   |         |   |        |
| hem      |        |   |                     |   |   |         |   |        |
| orrhage\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_]{.un |        |   |                     |   |   |         |   |        |
| derline} |        |   |                     |   |   |         |   |        |
|          |        |   |                     |   |   |         |   |        |
| r        |        |   |                     |   |   |         |   |        |
| esulting |        |   |                     |   |   |         |   |        |
| in       |        |   |                     |   |   |         |   |        |
| death)   |        |   |                     |   |   |         |   |        |
| Due to   |        |   |                     |   |   |         |   |        |
| (or as a |        |   |                     |   |   |         |   |        |
| con      |        |   |                     |   |   |         |   |        |
| sequence |        |   |                     |   |   |         |   |        |
| of):     |        |   |                     |   |   |         |   |        |
|          |        |   |                     |   |   |         |   |        |
| Sequ     |        |   |                     |   |   |         |   |        |
| entially |        |   |                     |   |   |         |   |        |
| list     |        |   |                     |   |   |         |   |        |
| con      |        |   |                     |   |   |         |   |        |
| ditions, |        |   |                     |   |   |         |   |        |
| b. [Stab |        |   |                     |   |   |         |   |        |
| wound of |        |   |                     |   |   |         |   |        |
| lung     |        |   |                     |   |   |         |   |        |
| \_\      |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_]{.un |        |   |                     |   |   |         |   |        |
| derline} |        |   |                     |   |   |         |   |        |
|          |        |   |                     |   |   |         |   |        |
| if any,  |        |   |                     |   |   |         |   |        |
| leading  |        |   |                     |   |   |         |   |        |
| to the   |        |   |                     |   |   |         |   |        |
| cause    |        |   |                     |   |   |         |   |        |
| Due to   |        |   |                     |   |   |         |   |        |
| (or as a |        |   |                     |   |   |         |   |        |
| con      |        |   |                     |   |   |         |   |        |
| sequence |        |   |                     |   |   |         |   |        |
| of):     |        |   |                     |   |   |         |   |        |
|          |        |   |                     |   |   |         |   |        |
| listed   |        |   |                     |   |   |         |   |        |
| on line  |        |   |                     |   |   |         |   |        |
| a. Enter |        |   |                     |   |   |         |   |        |
| the      |        |   |                     |   |   |         |   |        |
|          |        |   |                     |   |   |         |   |        |
| **UN     |        |   |                     |   |   |         |   |        |
| DERLYING |        |   |                     |   |   |         |   |        |
| CAUSE**  |        |   |                     |   |   |         |   |        |
| c.       |        |   |                     |   |   |         |   |        |
| [\_\_\   |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_]{.un |        |   |                     |   |   |         |   |        |
| derline} |        |   |                     |   |   |         |   |        |
|          |        |   |                     |   |   |         |   |        |
| (disease |        |   |                     |   |   |         |   |        |
| or       |        |   |                     |   |   |         |   |        |
| injury   |        |   |                     |   |   |         |   |        |
| that Due |        |   |                     |   |   |         |   |        |
| to (or   |        |   |                     |   |   |         |   |        |
| as a     |        |   |                     |   |   |         |   |        |
| con      |        |   |                     |   |   |         |   |        |
| sequence |        |   |                     |   |   |         |   |        |
| of):     |        |   |                     |   |   |         |   |        |
|          |        |   |                     |   |   |         |   |        |
| i        |        |   |                     |   |   |         |   |        |
| nitiated |        |   |                     |   |   |         |   |        |
| the      |        |   |                     |   |   |         |   |        |
| events   |        |   |                     |   |   |         |   |        |
| r        |        |   |                     |   |   |         |   |        |
| esulting |        |   |                     |   |   |         |   |        |
|          |        |   |                     |   |   |         |   |        |
| in       |        |   |                     |   |   |         |   |        |
| death)   |        |   |                     |   |   |         |   |        |
| **LAST** |        |   |                     |   |   |         |   |        |
| d.       |        |   |                     |   |   |         |   |        |
| [\_\_    |        |   |                     |   |   |         |   |        |
| \_\_\_\_ |        |   |                     |   |   |         |   |        |
| \_\_\    |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_\_\_\ |        |   |                     |   |   |         |   |        |
| _\_]{.un |        |   |                     |   |   |         |   |        |
| derline} |        |   |                     |   |   |         |   |        |
+----------+--------+---+---------------------+---+---+---------+---+--------+
| **PART   |        |   |                     |   | 3 |         |   |        |
| II.**    |        |   |                     |   | 3 |         |   |        |
| Enter    |        |   |                     |   | \ |         |   |        |
| other    |        |   |                     |   | . |         |   |        |
| [sig     |        |   |                     |   | W |         |   |        |
| nificant |        |   |                     |   | A |         |   |        |
| co       |        |   |                     |   | S |         |   |        |
| nditions |        |   |                     |   | A |         |   |        |
| cont     |        |   |                     |   | N |         |   |        |
| ributing |        |   |                     |   | A |         |   |        |
| to       |        |   |                     |   | U |         |   |        |
| de       |        |   |                     |   | T |         |   |        |
| ath]{.un |        |   |                     |   | O |         |   |        |
| derline} |        |   |                     |   | P |         |   |        |
| but not  |        |   |                     |   | S |         |   |        |
| r        |        |   |                     |   | Y |         |   |        |
| esulting |        |   |                     |   | P |         |   |        |
| in the   |        |   |                     |   | E |         |   |        |
| un       |        |   |                     |   | R |         |   |        |
| derlying |        |   |                     |   | F |         |   |        |
| cause    |        |   |                     |   | O |         |   |        |
| given in |        |   |                     |   | R |         |   |        |
| PART I   |        |   |                     |   | M |         |   |        |
|          |        |   |                     |   | E |         |   |        |
| Several  |        |   |                     |   | D |         |   |        |
| stab     |        |   |                     |   | ? |         |   |        |
| wounds   |        |   |                     |   |   |         |   |        |
| of       |        |   |                     |   | ■ |         |   |        |
| abdomen  |        |   |                     |   | Y |         |   |        |
| and      |        |   |                     |   | e |         |   |        |
| ext      |        |   |                     |   | s |         |   |        |
| remities |        |   |                     |   |  |         |   |        |
|          |        |   |                     |   |  |         |   |        |
|          |        |   |                     |   | N |         |   |        |
|          |        |   |                     |   | o |         |   |        |
+----------+--------+---+---------------------+---+---+---------+---+--------+
|          |        |   |                     |   | 3 |         |   |        |
|          |        |   |                     |   | 4 |         |   |        |
|          |        |   |                     |   | \ |         |   |        |
|          |        |   |                     |   | . |         |   |        |
|          |        |   |                     |   | W |         |   |        |
|          |        |   |                     |   | E |         |   |        |
|          |        |   |                     |   | R |         |   |        |
|          |        |   |                     |   | E |         |   |        |
|          |        |   |                     |   | A |         |   |        |
|          |        |   |                     |   | U |         |   |        |
|          |        |   |                     |   | T |         |   |        |
|          |        |   |                     |   | O |         |   |        |
|          |        |   |                     |   | P |         |   |        |
|          |        |   |                     |   | S |         |   |        |
|          |        |   |                     |   | Y |         |   |        |
|          |        |   |                     |   | F |         |   |        |
|          |        |   |                     |   | I |         |   |        |
|          |        |   |                     |   | N |         |   |        |
|          |        |   |                     |   | D |         |   |        |
|          |        |   |                     |   | I |         |   |        |
|          |        |   |                     |   | N |         |   |        |
|          |        |   |                     |   | G |         |   |        |
|          |        |   |                     |   | S |         |   |        |
|          |        |   |                     |   | A |         |   |        |
|          |        |   |                     |   | V |         |   |        |
|          |        |   |                     |   | A |         |   |        |
|          |        |   |                     |   | I |         |   |        |
|          |        |   |                     |   | L |         |   |        |
|          |        |   |                     |   | A |         |   |        |
|          |        |   |                     |   | B |         |   |        |
|          |        |   |                     |   | L |         |   |        |
|          |        |   |                     |   | E |         |   |        |
|          |        |   |                     |   | T |         |   |        |
|          |        |   |                     |   | O |         |   |        |
|          |        |   |                     |   |   |         |   |        |
|          |        |   |                     |   | C |         |   |        |
|          |        |   |                     |   | O |         |   |        |
|          |        |   |                     |   | M |         |   |        |
|          |        |   |                     |   | P |         |   |        |
|          |        |   |                     |   | L |         |   |        |
|          |        |   |                     |   | E |         |   |        |
|          |        |   |                     |   | T |         |   |        |
|          |        |   |                     |   | E |         |   |        |
|          |        |   |                     |   | T |         |   |        |
|          |        |   |                     |   | H |         |   |        |
|          |        |   |                     |   | E |         |   |        |
|          |        |   |                     |   | C |         |   |        |
|          |        |   |                     |   | A |         |   |        |
|          |        |   |                     |   | U |         |   |        |
|          |        |   |                     |   | S |         |   |        |
|          |        |   |                     |   | E |         |   |        |
|          |        |   |                     |   | O |         |   |        |
|          |        |   |                     |   | F |         |   |        |
|          |        |   |                     |   | D |         |   |        |
|          |        |   |                     |   | E |         |   |        |
|          |        |   |                     |   | A |         |   |        |
|          |        |   |                     |   | T |         |   |        |
|          |        |   |                     |   | H |         |   |        |
|          |        |   |                     |   | ? |         |   |        |
|          |        |   |                     |   | ■ |         |   |        |
|          |        |   |                     |   | Y |         |   |        |
|          |        |   |                     |   | e |         |   |        |
|          |        |   |                     |   | s |         |   |        |
|          |        |   |                     |   |  |         |   |        |
|          |        |   |                     |   |  |         |   |        |
|          |        |   |                     |   | N |         |   |        |
|          |        |   |                     |   | o |         |   |        |
+----------+--------+---+---------------------+---+---+---------+---+--------+
| 35\. DID |        | 3 |                     | 3 |   |         |   |        |
| TOBACCO  |        | 6 |                     | 7 |   |         |   |        |
| USE      |        | \ |                     | \ |   |         |   |        |
| CO       |        | . |                     | . |   |         |   |        |
| NTRIBUTE |        | I |                     | M |   |         |   |        |
| TO       |        | F |                     | A |   |         |   |        |
| DEATH?   |        | F |                     | N |   |         |   |        |
|          |        | E |                     | N |   |         |   |        |
| Yes    |        | M |                     | E |   |         |   |        |
|        |        | A |                     | R |   |         |   |        |
| Probably |        | L |                     | O |   |         |   |        |
|          |        | E |                     | F |   |         |   |        |
| ■ No     |        | : |                     | D |   |         |   |        |
|         |        |   |                     | E |   |         |   |        |
| Unknown |        |  |                     | A |   |         |   |        |
|          |        |  |                     | T |   |         |   |        |
|          |        | N |                     | H |   |         |   |        |
|          |        | o |                     |   |   |         |   |        |
|          |        | t |                     |  |   |         |   |        |
|          |        | p |                     |  |   |         |   |        |
|          |        | r |                     | N |   |         |   |        |
|          |        | e |                     | a |   |         |   |        |
|          |        | g |                     | t |   |         |   |        |
|          |        | n |                     | u |   |         |   |        |
|          |        | a |                     | r |   |         |   |        |
|          |        | n |                     | a |   |         |   |        |
|          |        | t |                     | l |   |         |   |        |
|          |        | w |                     | ■ |   |         |   |        |
|          |        | i |                     | H |   |         |   |        |
|          |        | t |                     | o |   |         |   |        |
|          |        | h |                     | m |   |         |   |        |
|          |        | i |                     | i |   |         |   |        |
|          |        | n |                     | c |   |         |   |        |
|          |        | p |                     | i |   |         |   |        |
|          |        | a |                     | d |   |         |   |        |
|          |        | s |                     | e |   |         |   |        |
|          |        | t |                     |   |   |         |   |        |
|          |        | y |                     |  |   |         |   |        |
|          |        | e |                     | A |   |         |   |        |
|          |        | a |                     | c |   |         |   |        |
|          |        | r |                     | c |   |         |   |        |
|          |        |   |                     | i |   |         |   |        |
|          |        |  |                     | d |   |         |   |        |
|          |        |  |                     | e |   |         |   |        |
|          |        | P |                     | n |   |         |   |        |
|          |        | r |                     | t |   |         |   |        |
|          |        | e |                     |  |   |         |   |        |
|          |        | g |                     |  |   |         |   |        |
|          |        | n |                     |  |   |         |   |        |
|          |        | a |                     | P |   |         |   |        |
|          |        | n |                     | e |   |         |   |        |
|          |        | t |                     | n |   |         |   |        |
|          |        | a |                     | d |   |         |   |        |
|          |        | t |                     | i |   |         |   |        |
|          |        | t |                     | n |   |         |   |        |
|          |        | i |                     | g |   |         |   |        |
|          |        | m |                     | I |   |         |   |        |
|          |        | e |                     | n |   |         |   |        |
|          |        | o |                     | v |   |         |   |        |
|          |        | f |                     | e |   |         |   |        |
|          |        | d |                     | s |   |         |   |        |
|          |        | e |                     | t |   |         |   |        |
|          |        | a |                     | i |   |         |   |        |
|          |        | t |                     | g |   |         |   |        |
|          |        | h |                     | a |   |         |   |        |
|          |        |   |                     | t |   |         |   |        |
|          |        |  |                     | i |   |         |   |        |
|          |        |  |                     | o |   |         |   |        |
|          |        | N |                     | n |   |         |   |        |
|          |        | o |                     |   |   |         |   |        |
|          |        | t |                     |  |   |         |   |        |
|          |        | p |                     |  |   |         |   |        |
|          |        | r |                     | S |   |         |   |        |
|          |        | e |                     | u |   |         |   |        |
|          |        | g |                     | i |   |         |   |        |
|          |        | n |                     | c |   |         |   |        |
|          |        | a |                     | i |   |         |   |        |
|          |        | n |                     | d |   |         |   |        |
|          |        | t |                     | e |   |         |   |        |
|          |        | , |                     |  |   |         |   |        |
|          |        | b |                     |  |   |         |   |        |
|          |        | u |                     |  |   |         |   |        |
|          |        | t |                     | C |   |         |   |        |
|          |        | p |                     | o |   |         |   |        |
|          |        | r |                     | u |   |         |   |        |
|          |        | e |                     | l |   |         |   |        |
|          |        | g |                     | d |   |         |   |        |
|          |        | n |                     | n |   |         |   |        |
|          |        | a |                     | o |   |         |   |        |
|          |        | n |                     | t |   |         |   |        |
|          |        | t |                     | b |   |         |   |        |
|          |        | w |                     | e |   |         |   |        |
|          |        | i |                     | d |   |         |   |        |
|          |        | t |                     | e |   |         |   |        |
|          |        | h |                     | t |   |         |   |        |
|          |        | i |                     | e |   |         |   |        |
|          |        | n |                     | r |   |         |   |        |
|          |        | 4 |                     | m |   |         |   |        |
|          |        | 2 |                     | i |   |         |   |        |
|          |        | d |                     | n |   |         |   |        |
|          |        | a |                     | e |   |         |   |        |
|          |        | y |                     | d |   |         |   |        |
|          |        | s |                     |   |   |         |   |        |
|          |        | o |                     |   |   |         |   |        |
|          |        | f |                     |   |   |         |   |        |
|          |        | d |                     |   |   |         |   |        |
|          |        | e |                     |   |   |         |   |        |
|          |        | a |                     |   |   |         |   |        |
|          |        | t |                     |   |   |         |   |        |
|          |        | h |                     |   |   |         |   |        |
|          |        |   |                     |   |   |         |   |        |
|          |        |  |                     |   |   |         |   |        |
|          |        |  |                     |   |   |         |   |        |
|          |        | N |                     |   |   |         |   |        |
|          |        | o |                     |   |   |         |   |        |
|          |        | t |                     |   |   |         |   |        |
|          |        | p |                     |   |   |         |   |        |
|          |        | r |                     |   |   |         |   |        |
|          |        | e |                     |   |   |         |   |        |
|          |        | g |                     |   |   |         |   |        |
|          |        | n |                     |   |   |         |   |        |
|          |        | a |                     |   |   |         |   |        |
|          |        | n |                     |   |   |         |   |        |
|          |        | t |                     |   |   |         |   |        |
|          |        | , |                     |   |   |         |   |        |
|          |        | b |                     |   |   |         |   |        |
|          |        | u |                     |   |   |         |   |        |
|          |        | t |                     |   |   |         |   |        |
|          |        | p |                     |   |   |         |   |        |
|          |        | r |                     |   |   |         |   |        |
|          |        | e |                     |   |   |         |   |        |
|          |        | g |                     |   |   |         |   |        |
|          |        | n |                     |   |   |         |   |        |
|          |        | a |                     |   |   |         |   |        |
|          |        | n |                     |   |   |         |   |        |
|          |        | t |                     |   |   |         |   |        |
|          |        | 4 |                     |   |   |         |   |        |
|          |        | 3 |                     |   |   |         |   |        |
|          |        | d |                     |   |   |         |   |        |
|          |        | a |                     |   |   |         |   |        |
|          |        | y |                     |   |   |         |   |        |
|          |        | s |                     |   |   |         |   |        |
|          |        | t |                     |   |   |         |   |        |
|          |        | o |                     |   |   |         |   |        |
|          |        | 1 |                     |   |   |         |   |        |
|          |        | y |                     |   |   |         |   |        |
|          |        | e |                     |   |   |         |   |        |
|          |        | a |                     |   |   |         |   |        |
|          |        | r |                     |   |   |         |   |        |
|          |        | b |                     |   |   |         |   |        |
|          |        | e |                     |   |   |         |   |        |
|          |        | f |                     |   |   |         |   |        |
|          |        | o |                     |   |   |         |   |        |
|          |        | r |                     |   |   |         |   |        |
|          |        | e |                     |   |   |         |   |        |
|          |        | d |                     |   |   |         |   |        |
|          |        | e |                     |   |   |         |   |        |
|          |        | a |                     |   |   |         |   |        |
|          |        | t |                     |   |   |         |   |        |
|          |        | h |                     |   |   |         |   |        |
|          |        |   |                     |   |   |         |   |        |
|          |        |  |                     |   |   |         |   |        |
|          |        |  |                     |   |   |         |   |        |
|          |        | U |                     |   |   |         |   |        |
|          |        | n |                     |   |   |         |   |        |
|          |        | k |                     |   |   |         |   |        |
|          |        | n |                     |   |   |         |   |        |
|          |        | o |                     |   |   |         |   |        |
|          |        | w |                     |   |   |         |   |        |
|          |        | n |                     |   |   |         |   |        |
|          |        | i |                     |   |   |         |   |        |
|          |        | f |                     |   |   |         |   |        |
|          |        | p |                     |   |   |         |   |        |
|          |        | r |                     |   |   |         |   |        |
|          |        | e |                     |   |   |         |   |        |
|          |        | g |                     |   |   |         |   |        |
|          |        | n |                     |   |   |         |   |        |
|          |        | a |                     |   |   |         |   |        |
|          |        | n |                     |   |   |         |   |        |
|          |        | t |                     |   |   |         |   |        |
|          |        | w |                     |   |   |         |   |        |
|          |        | i |                     |   |   |         |   |        |
|          |        | t |                     |   |   |         |   |        |
|          |        | h |                     |   |   |         |   |        |
|          |        | i |                     |   |   |         |   |        |
|          |        | n |                     |   |   |         |   |        |
|          |        | t |                     |   |   |         |   |        |
|          |        | h |                     |   |   |         |   |        |
|          |        | e |                     |   |   |         |   |        |
|          |        | p |                     |   |   |         |   |        |
|          |        | a |                     |   |   |         |   |        |
|          |        | s |                     |   |   |         |   |        |
|          |        | t |                     |   |   |         |   |        |
|          |        | y |                     |   |   |         |   |        |
|          |        | e |                     |   |   |         |   |        |
|          |        | a |                     |   |   |         |   |        |
|          |        | r |                     |   |   |         |   |        |
+----------+--------+---+---------------------+---+---+---------+---+--------+
| 38\.     | 39\.   |   | 40\. PLACE OF       |   |   |         | 4 |        |
| DATE OF  | TIME   |   | INJURY (e.g.,       |   |   |         | 1 |        |
| INJURY   | OF     |   | Decedent's home;    |   |   |         | \ |        |
|          | INJURY |   | construction site;  |   |   |         | . |        |
| (Mo      |        |   | restaurant; wooded  |   |   |         | I |        |
| /Day/Yr) | 0330   |   | area)               |   |   |         | N |        |
| (Spell   |        |   |                     |   |   |         | J |        |
| Month)   |        |   | Alley               |   |   |         | U |        |
|          |        |   |                     |   |   |         | R |        |
| August   |        |   |                     |   |   |         | Y |        |
| 23, 2006 |        |   |                     |   |   |         | A |        |
|          |        |   |                     |   |   |         | T |        |
|          |        |   |                     |   |   |         | W |        |
|          |        |   |                     |   |   |         | O |        |
|          |        |   |                     |   |   |         | R |        |
|          |        |   |                     |   |   |         | K |        |
|          |        |   |                     |   |   |         | ? |        |
|          |        |   |                     |   |   |         |   |        |
|          |        |   |                     |   |   |         |  |        |
|          |        |   |                     |   |   |         |  |        |
|          |        |   |                     |   |   |         |  |        |
|          |        |   |                     |   |   |         |  |        |
|          |        |   |                     |   |   |         |  |        |
|          |        |   |                     |   |   |         |  |        |
|          |        |   |                     |   |   |         |  |        |
|          |        |   |                     |   |   |         |  |        |
|          |        |   |                     |   |   |         |  |        |
|          |        |   |                     |   |   |         |  |        |
|          |        |   |                     |   |   |         | Y |        |
|          |        |   |                     |   |   |         | e |        |
|          |        |   |                     |   |   |         | s |        |
|          |        |   |                     |   |   |         | ■ |        |
|          |        |   |                     |   |   |         | N |        |
|          |        |   |                     |   |   |         | o |        |
+----------+--------+---+---------------------+---+---+---------+---+--------+
| 42\.     |        |   |                     |   |   |         |   |        |
| LOCATION |        |   |                     |   |   |         |   |        |
| OF       |        |   |                     |   |   |         |   |        |
| INJURY:  |        |   |                     |   |   |         |   |        |
| State:   |        |   |                     |   |   |         |   |        |
| Maryland |        |   |                     |   |   |         |   |        |
| City or  |        |   |                     |   |   |         |   |        |
| Town:    |        |   |                     |   |   |         |   |        |
| David    |        |   |                     |   |   |         |   |        |
| sonville |        |   |                     |   |   |         |   |        |
|          |        |   |                     |   |   |         |   |        |
| Street & |        |   |                     |   |   |         |   |        |
| Number:  |        |   |                     |   |   |         |   |        |
| alley    |        |   |                     |   |   |         |   |        |
| between  |        |   |                     |   |   |         |   |        |
| 331 &    |        |   |                     |   |   |         |   |        |
| 333      |        |   |                     |   |   |         |   |        |
| Smith    |        |   |                     |   |   |         |   |        |
| Street   |        |   |                     |   |   |         |   |        |
| A        |        |   |                     |   |   |         |   |        |
| partment |        |   |                     |   |   |         |   |        |
| No.: Zip |        |   |                     |   |   |         |   |        |
| Code:    |        |   |                     |   |   |         |   |        |
| 21       |        |   |                     |   |   |         |   |        |
| 035-3330 |        |   |                     |   |   |         |   |        |
+----------+--------+---+---------------------+---+---+---------+---+--------+
| 43\.     |        |   |                     |   |   | 44\. IF |   |        |
| DESCRIBE |        |   |                     |   |   | TRANSPO |   |        |
| HOW      |        |   |                     |   |   | RTATION |   |        |
| INJURY   |        |   |                     |   |   | INJURY, |   |        |
| O        |        |   |                     |   |   | S       |   |        |
| CCURRED: |        |   |                     |   |   | PECIFY: |   |        |
|          |        |   |                     |   |   |         |   |        |
| Stabbed  |        |   |                     |   |   |        |   |        |
| by a     |        |   |                     |   |   | D       |   |        |
| sharp    |        |   |                     |   |   | river/O |   |        |
| in       |        |   |                     |   |   | perator |   |        |
| strument |        |   |                     |   |   |         |   |        |
|          |        |   |                     |   |   | Pa   |   |        |
|          |        |   |                     |   |   | ssenger |   |        |
|          |        |   |                     |   |   |         |   |        |
|          |        |   |                     |   |   | Ped  |   |        |
|          |        |   |                     |   |   | estrian |   |        |
|          |        |   |                     |   |   |         |   |        |
|          |        |   |                     |   |   |        |   |        |
|          |        |   |                     |   |   | Other |   |        |
|          |        |   |                     |   |   | (S      |   |        |
|          |        |   |                     |   |   | pecify) |   |        |
+----------+--------+---+---------------------+---+---+---------+---+--------+

**ITEM 32 -- CAUSE OF DEATH (See example above)**

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.

Take care to make the entry legible. Use a computer printer with high
resolution, typewriter with good black ribbon and clean keys, or print
legibly using permanent **black** ink in completing the CAUSE OF DEATH
Section. **Do** **not** **abbreviate** conditions entered in section.

**[Part I]{.underline} (Chain of events leading directly to death)**

•Only **one** cause should be entered on each line. [Line
(a)]{.underline} **MUST ALWAYS** have an entry. **DO NOT** leave blank.
Additional lines may be added if necessary.

•If the condition on [Line (a)]{.underline} resulted from an underlying
condition, put the underlying condition on [Line (b)]{.underline}, and
so on, until the full sequence is reported. **ALWAYS** enter the
**underlying cause of death** on the [lowest used line]{.underline} in
Part I.

•For each cause indicate the best estimate of the interval between the
presumed onset and the date of death. The terms "unknown" or
"approximately" may be used. General terms, such as minutes, hours, or
days, are acceptable, if necessary. **DO NOT** leave blank.

•The terminal event (for example, cardiac arrest or respiratory arrest)
should not be used. If a mechanism of death seems most appropriate to
you for line (a), then you must always list its cause(s) on the line(s)
below it (for example, cardiac arrest **due to** coronary artery
atherosclerosis *or* cardiac arrest **due to** blunt impact to chest).

• If an organ system failure such as congestive heart failure, hepatic
failure, renal failure, or respiratory failure is listed as a cause of
death, always report its etiology on the line(s) beneath it (for
example, renal failure **due to** Type I diabetes mellitus).

•When indicating neoplasms as a cause of death, include the
following: 1) primary site *or* that the primary site is unknown, 2)
benign or malignant, 3) cell type *or* that the cell type is unknown, 4)
grade of neoplasm, and 5) part or lobe of organ affected. (For example,
a primary well-differentiated squamous cell carcinoma, lung, left upper
lobe.)

•Always report the fatal injury (for example, stab wound of chest), the
trauma (for example, transection of subclavian vein), and impairment of
function (for example, air embolism).

**Part II (Other significant conditions)**

•Enter all diseases or conditions contributing to death that were not
reported in the chain of events in Part I and that did not result in the
**underlying cause of death**.

•If two or more possible sequences resulted in death, or if two
conditions seem to have added together, report in Part I the one that,
in your opinion, most directly caused death. Report in Part II the other
conditions or diseases.

**CHANGES TO CAUSE OF DEATH**

Should additional medical information or autopsy findings become
available that would change the cause of death originally reported, the
original death certificate should be amended by the certifying physician
by **immediately** reporting the revised cause of death to the State
Vital Records Office.

**ITEMS ON WHEN DEATH OCCURRED**

Items 24-25 and 29-31 should always be completed. If the facility uses a
separate pronouncer or other person to indicate that death has taken
place with another person more familiar with the case completing the
remainder of the medical portion of the death certificate, the
pronouncer completes Items 24-28. If a certifier completes Items 24-25
as well as items 29-49, Items 26-28 may be left blank.

**ITEMS 24-25, 29-30 -- DATE AND TIME OF DEATH**

Spell out the name of the month. If the exact date of death is unknown,
enter the **approximate** date. If the date cannot be approximated,
enter the date the body is found and identify as **date found**. Date
pronounced and actual date may be the same. Enter the exact hour and
minutes according to a 24-hour clock; estimates may be provided with
"Approx." placed before the time.

**ITEMS 33-34 - AUTOPSY**

•33 - Enter "Yes" if either a partial or full autopsy was performed.
Otherwise enter "No."

•34 - Enter "Yes" if autopsy findings were available to complete the
cause of death; otherwise enter "No". Leave item blank if no autopsy was
performed.

**ITEM 35 - DID TOBACCO USE CONTRIBUTE TO DEATH?**

Check "yes" if, in your opinion, the use of tobacco contributed to
death. Tobacco use may contribute to deaths due to a wide variety of
diseases; for example, tobacco use contributes to many deaths due to
emphysema or lung cancer and some heart disease and cancers of the head
and neck. Check "no" if, in your clinical judgment, tobacco use did not
contribute to this particular death.

**ITEM 36 - IF FEMALE, WAS DECEDENT PREGNANT AT TIME OF DEATH OR WITHIN
PAST YEAR?**

This information is important in determining pregnancy-related
mortality.

**ITEM 37 - MANNER OF DEATH**

•Always check Manner of Death, which is important: 1) in determining
accurate causes of death; 2) in processing insurance claims; and 3) in
statistical studies of injuries and death.

•Indicate "Pending investigation" if the manner of death cannot be
determined whether due to an accident, suicide, or homicide within the
statutory time limit for filing the death certificate. This should be
changed later to one of the other terms.

•Indicate "Could not be Determined" **ONLY** when it is impossible to
determine the manner of death.

**ITEMS 38-44 - ACCIDENT OR INJURY -- to be filled out in all cases of
deaths due to injury or poisoning.**

•38 - Enter the exact month, day, and year of injury. Spell out the name
of the month. **DO NOT** use a number for the month. (Remember, the date
of injury may differ from the date of death.) Estimates may be provided
with "Approx." placed before the date.

•39 **-** Enter the exact hour and minutes of injury or use your best
estimate. Use a 24-hour clock.

•40 - Enter the general place (such as restaurant, vacant lot, or home)
where the injury occurred. **DO NOT** enter firm or organization names.
(For example, enter "factory", **not** "Standard Manufacturing, Inc." )

•41 - Complete if anything other than natural disease is mentioned in
Part I or Part II of the medical certification, including homicides,
suicides, and accidents. This includes all motor vehicle deaths. The
item **[must]{.underline}** be completed for decedents ages 14 years or
over and may be completed for those less than 14 years of age if
warranted. Enter "Yes" if the injury occurred at work. Otherwise enter
"No". An injury may occur at work regardless of whether the injury
occurred in the course of the decedent's "usual" occupation. Examples of
injury at work and injury not at work follow:

+-----------------------------------+-----------------------------------+
| **Injury at work**                | **Injury [not]{.underline} at     |
|                                   | work**                            |
| Injury while working or in        |                                   |
| vocational training on job        | Injury while engaged in personal  |
| premises                          | recreational activity on job      |
|                                   | premises                          |
| Injury while on break or at lunch |                                   |
| or in parking lot on job premises | Injury while a visitor (not on    |
|                                   | official work business) to job    |
| Injury while working for pay or   | premises                          |
| compensation, including at home   |                                   |
|                                   | Homemaker working at homemaking   |
| Injury while working as a         | activities                        |
| volunteer law enforcement         |                                   |
| official etc.                     | Student in school                 |
|                                   |                                   |
| Injury while traveling on         | Working for self for no profit    |
| business, including to/from       | (mowing yard, repairing own roof, |
| business contacts                 | hobby)                            |
|                                   |                                   |
|                                   | Commuting to or from work         |
+-----------------------------------+-----------------------------------+

•42 - Enter the complete address where the injury occurred including zip
code.

•43 - Enter a brief but specific and clear description of how the injury
occurred. Explain the circumstances or cause of the injury. Specify
**type** **of** **gun** or **type of vehicle** (e.g., car, bulldozer,
train, etc.) when relevant to circumstances. Indicate if more than one
vehicle involved; specify type of vehicle decedent was in.

•44 -Specify role of decedent (e.g. driver, passenger). Driver/operator
and passenger should be designated for modes other than motor vehicles
such as bicycles. Other applies to watercraft, aircraft, animal, or
people attached to outside of vehicles (e.g. surfers).

[Rationale]{.underline}: Motor vehicle accidents are a major cause of
unintentional deaths; details will help determine effectiveness of
current safety features and laws.

**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:]{.underline}**

+-------------+-------------+-------------+-------------+-------------+
| Abscess     | Car         | D           | H           | Pulmonary   |
|             | cinomatosis | isseminated | yponatremia | arrest      |
| Abdominal   |             | intra       |             |             |
| hemorrhage  | Cardiac     | vascular    | Hypotension | Pulmonary   |
|             | arrest      |             |             | edema       |
| Adhesions   |             | c           | Immuno      |             |
|             | Cardiac     | oagulopathy | suppression | Pulmonary   |
| Adult       | dysrhythmia |             |             | embolism    |
| respiratory |             | Dysrhythmia | Increased   |             |
| distress    | Car         |             | intra       | Pulmonary   |
| syndrome    | diomyopathy | End-stage   | cranial     | in          |
|             |             | liver       | pressure    | sufficiency |
| Acute       | Card        | disease     |             |             |
| myocardial  | iopulmonary |             | Intra       | Renal       |
| infarction  | arrest      | End-stage   | cranial     | failure     |
|             |             | renal       | hemorrhage  |             |
| Altered     | Cellulitis  | disease     |             | Respiratory |
| mental      |             |             | M           | arrest      |
| status      | Cerebral    | Epidural    | alnutrition |             |
|             | edema       | hematoma    |             | Seizures    |
| Anemia      |             |             | Metabolic   |             |
|             | Cere        | Exs         | enc         | Sepsis      |
| Anoxia      | brovascular | anguination | ephalopathy |             |
|             | accident    |             |             | Septic      |
| Anoxic      |             | Failure to  | Multi-organ | shock       |
| enc         | Cerebellar  | thrive      | failure     |             |
| ephalopathy | tonsillar   |             |             | Shock       |
|             | herniation  | Fracture    | M           |             |
| Arrhythmia  |             |             | ulti-system | Starvation  |
|             | Chronic     | Gangrene    | organ       |             |
| Ascites     | bedridden   |             | failure     | Subdural    |
|             | state       | Gastr       |             | hematoma    |
| Aspiration  |             | ointestinal | Myocardial  |             |
|             | Cirrhosis   | hemorrhage  | infarction  | S           |
| Atrial      |             |             |             | ubarachnoid |
| f           | C           | Heart       | Necrotizing | hemorrhage  |
| ibrillation | oagulopathy | failure     | soft-tissue |             |
|             |             |             | infection   | Sudden      |
| Bacteremia  | Compression | Hemothorax  |             | death       |
|             | fracture    |             | Old age     |             |
| Bedridden   |             | Hepatic     |             | Throm       |
|             | Congestive  | failure     | Open (or    | bocytopenia |
| Biliary     | heart       |             | closed)     |             |
| obstruction | failure     | Hepatitis   | head injury | Uncal       |
|             |             |             |             | herniation  |
| Bowel       | Convulsions | Hepatorenal | Paralysis   |             |
| obstruction |             | syndrome    |             | Urinary     |
|             | Decubiti    |             | P           | tract       |
| Brain       |             | Hy          | ancytopenia | infection   |
| injury      | Dehydration | perglycemia |             |             |
|             |             |             | Perforated  | Ventricular |
| Brain stem  | Dementia    | H           | gallbladder | f           |
| herniation  | (when not   | yperkalemia |             | ibrillation |
|             |             |             | Peritonitis |             |
| Car         | otherwise   | Hypovolemic |             | Ventricular |
| cinogenesis | specified)  | shock       | Pleural     | tachycardia |
|             |             |             | effusions   |             |
|             | Diarrhea    |             |             | Volume      |
|             |             |             | Pneumonia   | 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    | Epidural    | Hip         | Pulmonary   | Subdural    |
|             | hematoma    | fracture    | emboli      | hematoma    |
| Bolus       |             |             |             |             |
|             | Exs         | H           | Seizure     | Surgery     |
| Choking     | anguination | yperthermia | disorder    |             |
|             |             |             |             | Thermal     |
| Drug or     | Fall        | Hypothermia | Sepsis      | bur         |
| alcohol     |             |             |             | ns/chemical |
| ov          | Fracture    | Open        | S           | burns       |
| erdose/drug |             | reduction   | ubarachnoid |             |
| or          |             | of fracture | hemorrhage  |             |
|             |             |             |             |             |
| alcohol     |             |             |             |             |
| abuse       |             |             |             |             |
+-------------+-------------+-------------+-------------+-------------+

Contact your State vital statistics office for questions related to
writing cause-of-death statements. Additional instructional material on
writing cause-of-death statements including handbooks, summary
instructions, and tutorials are available online at www.thename.org or
www.cdc.gov/nchswww/about/major/dvs/handbk.htm, or by request from NCHS,
Room 7318, 3311 Toledo Road, Hyattsville, Maryland 20782-2003.

Query Letter 11

(Format)

(Letterhead)

Dear Doctor \_\_\_\_\_\_\_\_\_

We are writing this letter to obtain additional information about the
cause of death that you certified for
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_, who died
\_\_\_\_\_\_\_\_\_\_\_\_\_.

Accurate cause-of-death information is essential, not only to the family
of the decedent, but also for medical research, funding, and resource
allocation in our State and at the national level.

In this particular death, we would appreciate your review of the
reported sequence of conditions for completeness and logic. In order to
classify this death properly in our statistics, would you please supply
the information on the attachment? We want to assure you that the
information you provide us is confidential and will be handled
accordingly.

If you have any question or would like to know more about various
methods for certifying a cause-of-death statement, please contact
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_.
Instructions and an example of a properly completed death certificate
are provided with the attached material.

We appreciate your attention and prompt reply.

Sincerely,

State Registrar/Vital Statistics Cooperative Program

Attachment

Format Query

+-------------------+----------------------+---+------------+-------+
| **CAUSE OF DEATH  |                      |   |            | A     |
| (See instructions |                      |   |            | pprox |
| and examples)**   |                      |   |            | imate |
|                   |                      |   |            | inte  |
| 32\. **PART I.**  |                      |   |            | rval: |
| Enter the [chain  |                      |   |            |       |
| of                |                      |   |            | Onset |
| events]{.under    |                      |   |            | to    |
| line}\--diseases, |                      |   |            | death |
| injuries, or      |                      |   |            |       |
| com               |                      |   |            | \_\   |
| plications\--that |                      |   |            | _\_\_ |
| directly caused   |                      |   |            | [\_\_ |
| the death. DO NOT |                      |   |            | \_\_\ |
| enter terminal    |                      |   |            | _\_\_ |
| events such as    |                      |   |            | \_]{. |
| cardiac           |                      |   |            | under |
|                   |                      |   |            | line} |
| arrest,           |                      |   |            |       |
| respiratory       |                      |   |            | \_\   |
| arrest, or        |                      |   |            | _\_\_ |
| ventricular       |                      |   |            | [\_\_ |
| fibrillation      |                      |   |            | \_\_\ |
| without showing   |                      |   |            | _\_\_ |
| the etiology. DO  |                      |   |            | \_]{. |
| NOT ABBREVIATE.   |                      |   |            | under |
| Enter only one    |                      |   |            | line} |
| cause on a line.  |                      |   |            |       |
| Add additional    |                      |   |            | \_\   |
|                   |                      |   |            | _\_\_ |
| lines if          |                      |   |            | [\_   |
| necessary.        |                      |   |            | \_\_\ |
|                   |                      |   |            | _\_\_ |
| IMMEDIATE CAUSE   |                      |   |            | \_]{. |
| (Final            |                      |   |            | under |
|                   |                      |   |            | line} |
| disease or        |                      |   |            |       |
| condition         |                      |   |            | \_\   |
| **\-\-            |                      |   |            | _\_\_ |
| \-\-\-\-\-\--\>** |                      |   |            | [\_\_ |
| a.                |                      |   |            | \_\_\ |
| \_\_\_\_\_\_\_\_  |                      |   |            | _\_\_ |
| [\_\_\_\_\_ \_\_  |                      |   |            | \_]{. |
| \_\_              |                      |   |            | under |
| \_\_\_\_\_\_\_\_\ |                      |   |            | line} |
| _\_\_\_\_\_\_\_\_ |                      |   |            |       |
| \_\_\_\_\_\_\_\_\ |                      |   |            |       |
| _\_\_\_\_\_\_\_\_ |                      |   |            |       |
| \_\_\_\_\_\_\_\_\ |                      |   |            |       |
| _\_\_\_\_\_\_\_\_ |                      |   |            |       |
| \_\_\_\_\_\_\_\_\ |                      |   |            |       |
| _\_\_\_\_\_\_\_\_ |                      |   |            |       |
| \_\_\_\_\_\_\_\_\ |                      |   |            |       |
| _\_\_\_\_\_\_\_\_ |                      |   |            |       |
| \_\_]{.underline} |                      |   |            |       |
|                   |                      |   |            |       |
| resulting in      |                      |   |            |       |
| death) Due to (or |                      |   |            |       |
| as a consequence  |                      |   |            |       |
| of):              |                      |   |            |       |
|                   |                      |   |            |       |
| Sequentially list |                      |   |            |       |
| conditions, b.    |                      |   |            |       |
| \_\_\_\           |                      |   |            |       |
| _\_\_\_\_\_\_\_\_ |                      |   |            |       |
| [\_\_\_\_\_       |                      |   |            |       |
| \_\_\_\_\_\_\     |                      |   |            |       |
| _\_\_\_\_\_\_\_\_ |                      |   |            |       |
| \_\_\_\_\_\_\_\_\ |                      |   |            |       |
| _\_\_\_\_\_\_\_\_ |                      |   |            |       |
| \_\_\_\_\_\_\_\_\ |                      |   |            |       |
| _\_\_\_\_\_\_\_\_ |                      |   |            |       |
| \_\_\_\_\_\_\_\_\ |                      |   |            |       |
| _\_\_\_\_\_\_\_\_ |                      |   |            |       |
| \_\_\_\_\_\_\_\_\ |                      |   |            |       |
| _\_\_\_\_\_\_\_\_ |                      |   |            |       |
| \_\_]{.underline} |                      |   |            |       |
|                   |                      |   |            |       |
| if any, leading   |                      |   |            |       |
| to the cause Due  |                      |   |            |       |
| to (or as a       |                      |   |            |       |
| consequence of):  |                      |   |            |       |
|                   |                      |   |            |       |
| listed on line a. |                      |   |            |       |
| Enter the         |                      |   |            |       |
|                   |                      |   |            |       |
| **UNDERLYING      |                      |   |            |       |
| CAUSE** c.        |                      |   |            |       |
| \_\_\_\           |                      |   |            |       |
| _\_\_\_\_\_\_\_\_ |                      |   |            |       |
| [\_\_\_\_\_       |                      |   |            |       |
| \_\_              |                      |   |            |       |
| \_\_\_\_\_\_\_\_\ |                      |   |            |       |
| _\_\_\_\_\_\_\_\_ |                      |   |            |       |
| \_\_\_\_\_\_\_\_\ |                      |   |            |       |
| _\_\_\_\_\_\_\_\_ |                      |   |            |       |
| \_\_\_\_\_\_\_\_\ |                      |   |            |       |
| _\_\_\_\_\_\_\_\_ |                      |   |            |       |
| \_\_\_\_\_\_\_\_\ |                      |   |            |       |
| _\_\_\_\_\_\_\_\_ |                      |   |            |       |
| \_\_\_\_\_\_\_\_\ |                      |   |            |       |
| _\_\_\_\_\_\_\_\_ |                      |   |            |       |
| \_\_]{.underline} |                      |   |            |       |
|                   |                      |   |            |       |
| (disease or       |                      |   |            |       |
| injury that Due   |                      |   |            |       |
| to (or as a       |                      |   |            |       |
| consequence of):  |                      |   |            |       |
|                   |                      |   |            |       |
| initiated the     |                      |   |            |       |
| events resulting  |                      |   |            |       |
|                   |                      |   |            |       |
| in death)         |                      |   |            |       |
| **LAST** d.       |                      |   |            |       |
| \_\               |                      |   |            |       |
| _\_\_\_\_\_\_\_\_ |                      |   |            |       |
| [\_\_\_\_\_       |                      |   |            |       |
| \                 |                      |   |            |       |
| _\_\_\_\_\_\_\_\_ |                      |   |            |       |
| \_\_\_\_\_\_\_\_\ |                      |   |            |       |
| _\_\_\_\_\_\_\_\_ |                      |   |            |       |
| \_\_\_\_\_\_\_\_\ |                      |   |            |       |
| _\_\_\_\_\_\_\_\_ |                      |   |            |       |
| \_\_\_\_\_\_\_\_\ |                      |   |            |       |
| _\_\_\_\_\_\_\_\_ |                      |   |            |       |
| \_\_\_\_\_\_\_\_\ |                      |   |            |       |
| _\_\_\_\_\_\_\_\_ |                      |   |            |       |
| \_\_]{.underline} |                      |   |            |       |
+-------------------+----------------------+---+------------+-------+
| **PART II.**      |                      |   | 33\. WAS   |       |
| Enter other       |                      |   | AN AUTOPSY |       |
| [significant      |                      |   | PERFORMED? |       |
| conditions        |                      |   |            |       |
| contributing to   |                      |   |  Yes  No |       |
| d                 |                      |   |            |       |
| eath]{.underline} |                      |   |            |       |
| 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  | 36\. IF FEMALE:      | 3 |            |       |
| USE CONTRIBUTE TO |                      | 7 |            |       |
| DEATH?            |  Not pregnant       | \ |            |       |
|                   | within past year     | . |            |       |
|  Yes  Probably  |                      | M |            |       |
|                   |  Pregnant at time   | A |            |       |
|  No  Unknown    | of death             | N |            |       |
|                   |                      | N |            |       |
|                   |  Not pregnant, but  | E |            |       |
|                   | pregnant within 42   | R |            |       |
|                   | days of death        | O |            |       |
|                   |                      | F |            |       |
|                   |  Not pregnant, but  | D |            |       |
|                   | pregnant 43 days to  | E |            |       |
|                   | 1 year before death  | A |            |       |
|                   |                      | T |            |       |
|                   |  Unknown if         | H |            |       |
|                   | pregnant within the  |   |            |       |
|                   | past year            |  |            |       |
|                   |                      | N |            |       |
|                   |                      | a |            |       |
|                   |                      | t |            |       |
|                   |                      | u |            |       |
|                   |                      | r |            |       |
|                   |                      | a |            |       |
|                   |                      | l |            |       |
|                   |                      |  |            |       |
|                   |                      | H |            |       |
|                   |                      | o |            |       |
|                   |                      | m |            |       |
|                   |                      | i |            |       |
|                   |                      | c |            |       |
|                   |                      | i |            |       |
|                   |                      | d |            |       |
|                   |                      | e |            |       |
|                   |                      |   |            |       |
|                   |                      |  |            |       |
|                   |                      | A |            |       |
|                   |                      | c |            |       |
|                   |                      | c |            |       |
|                   |                      | i |            |       |
|                   |                      | d |            |       |
|                   |                      | e |            |       |
|                   |                      | n |            |       |
|                   |                      | t |            |       |
|                   |                      |  |            |       |
|                   |                      | P |            |       |
|                   |                      | e |            |       |
|                   |                      | n |            |       |
|                   |                      | d |            |       |
|                   |                      | i |            |       |
|                   |                      | n |            |       |
|                   |                      | g |            |       |
|                   |                      | I |            |       |
|                   |                      | n |            |       |
|                   |                      | v |            |       |
|                   |                      | e |            |       |
|                   |                      | s |            |       |
|                   |                      | t |            |       |
|                   |                      | i |            |       |
|                   |                      | g |            |       |
|                   |                      | a |            |       |
|                   |                      | t |            |       |
|                   |                      | i |            |       |
|                   |                      | o |            |       |
|                   |                      | n |            |       |
|                   |                      |   |            |       |
|                   |                      |  |            |       |
|                   |                      | S |            |       |
|                   |                      | u |            |       |
|                   |                      | i |            |       |
|                   |                      | c |            |       |
|                   |                      | i |            |       |
|                   |                      | d |            |       |
|                   |                      | e |            |       |
|                   |                      |  |            |       |
|                   |                      | C |            |       |
|                   |                      | o |            |       |
|                   |                      | u |            |       |
|                   |                      | l |            |       |
|                   |                      | d |            |       |
|                   |                      | n |            |       |
|                   |                      | o |            |       |
|                   |                      | t |            |       |
|                   |                      | b |            |       |
|                   |                      | e |            |       |
|                   |                      | d |            |       |
|                   |                      | e |            |       |
|                   |                      | t |            |       |
|                   |                      | e |            |       |
|                   |                      | r |            |       |
|                   |                      | m |            |       |
|                   |                      | i |            |       |
|                   |                      | n |            |       |
|                   |                      | e |            |       |
|                   |                      | d |            |       |
+-------------------+----------------------+---+------------+-------+

1\. Is the reported sequence of conditions correct (i.e., condition on
line a results from condition on line b)? Yes\_\_\_ No\_\_\_

If not, please indicate the correct order with the most recent condition
on the top line and the condition starting the sequence on

the lowest line:

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

2\. Is the duration for condition\_\_\_\_\_\_\_\_ correct? Yes\_\_\_
No\_\_\_\_

If not, the duration should be \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_.

[, M.D.]{.underline}

(Signature of Certifying Physician)

Please provide your office
phone:\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
fax:\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

(Please see other side)

Instructions on Medical Certification of Causes of Death

[Example of properly completed medical certification]{.underline}

+-------------------+----------------------+---+-------------+--------+
| **CAUSE OF DEATH  |                      |   |             | Appro  |
| (See instructions |                      |   |             | ximate |
| and examples)**   |                      |   |             | int    |
|                   |                      |   |             | erval: |
| 32\. **PART I.**  |                      |   |             |        |
| Enter the [chain  |                      |   |             | Onset  |
| of                |                      |   |             | to     |
| events]{.under    |                      |   |             | death  |
| line}\--diseases, |                      |   |             |        |
| injuries, or      |                      |   |             | [Mi    |
| com               |                      |   |             | nutes] |
| plications\--that |                      |   |             | {.unde |
| directly caused   |                      |   |             | rline} |
| the death. DO NOT |                      |   |             |        |
| enter terminal    |                      |   |             | [6     |
| events such as    |                      |   |             | days]  |
| cardiac           |                      |   |             | {.unde |
|                   |                      |   |             | rline} |
| arrest,           |                      |   |             |        |
| respiratory       |                      |   |             | [5     |
| arrest, or        |                      |   |             | years] |
| ventricular       |                      |   |             | {.unde |
| fibrillation      |                      |   |             | rline} |
| without showing   |                      |   |             |        |
| the etiology. DO  |                      |   |             | [7     |
| NOT ABBREVIATE.   |                      |   |             | years] |
| Enter only one    |                      |   |             | {.unde |
| cause on a line.  |                      |   |             | rline} |
| Add additional    |                      |   |             |        |
|                   |                      |   |             |        |
| lines if          |                      |   |             |        |
| necessary.        |                      |   |             |        |
|                   |                      |   |             |        |
| IMMEDIATE CAUSE   |                      |   |             |        |
| (Final            |                      |   |             |        |
|                   |                      |   |             |        |
| disease or        |                      |   |             |        |
| condition         |                      |   |             |        |
| **\-\-            |                      |   |             |        |
| \-\-\-\-\-\--\>** |                      |   |             |        |
| a. [Rupture of    |                      |   |             |        |
| myocardium        |                      |   |             |        |
| \_\_\_\           |                      |   |             |        |
| _\_\_\_\_\_\_\_\_ |                      |   |             |        |
| \_\_\_\_\_\_\_\_\ |                      |   |             |        |
| _\_\_\_\_\_\_\_\_ |                      |   |             |        |
| \_\_\_\_\_\_\_\_\ |                      |   |             |        |
| _\_\_\_\_\_\_\_\_ |                      |   |             |        |
| \_\_\_\_\_\_\_\_\ |                      |   |             |        |
| _\_\_\_\_\_\_\_\_ |                      |   |             |        |
| \_\_\_\_\_\_\_\_\ |                      |   |             |        |
| _\_\_\_\_\_\_\_\_ |                      |   |             |        |
| \_\_]{.underline} |                      |   |             |        |
|                   |                      |   |             |        |
| resulting in      |                      |   |             |        |
| death) Due to (or |                      |   |             |        |
| as a consequence  |                      |   |             |        |
| of):              |                      |   |             |        |
|                   |                      |   |             |        |
| Sequentially list |                      |   |             |        |
| conditions, b.    |                      |   |             |        |
| [Acute myocardial |                      |   |             |        |
| infarction\       |                      |   |             |        |
| _\_\_\_\_\_\_\_\_ |                      |   |             |        |
| \_\_\_\_\_\_\_\_\ |                      |   |             |        |
| _\_\_\_\_\_\_\_\_ |                      |   |             |        |
| \_\_\_\_\_\_\_\_\ |                      |   |             |        |
| _\_\_\_\_\_\_\_\_ |                      |   |             |        |
| \_\_\_\_\_\_\_\_\ |                      |   |             |        |
| _\_\_\_\_\_\_\_\_ |                      |   |             |        |
| \_\_\_\_\_\_\_\_\ |                      |   |             |        |
| _\_\_\_\_\_\_\_\_ |                      |   |             |        |
| \_\_]{.underline} |                      |   |             |        |
|                   |                      |   |             |        |
| 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\       |                      |   |             |        |
| _\_\_\_\_\_\_\_\_ |                      |   |             |        |
| \_\_\_\_\_\_\_\_\ |                      |   |             |        |
| _\_\_\_\_\_\_\_\_ |                      |   |             |        |
| \_\_\_\_\_\_\_\_\ |                      |   |             |        |
| _\_\_\_\_\_\_\_\_ |                      |   |             |        |
| \_\_\_\_\_\_\_\_\ |                      |   |             |        |
| _\_\_\_\_\_\_\_\_ |                      |   |             |        |
| \_\_\_\_\_\_\_\_\ |                      |   |             |        |
| _\_\_\_\_\_\_\_\_ |                      |   |             |        |
| \_\_]{.underline} |                      |   |             |        |
|                   |                      |   |             |        |
| (disease or       |                      |   |             |        |
| injury that Due   |                      |   |             |        |
| to (or as a       |                      |   |             |        |
| consequence of):  |                      |   |             |        |
|                   |                      |   |             |        |
| initiated the     |                      |   |             |        |
| events resulting  |                      |   |             |        |
|                   |                      |   |             |        |
| in death)         |                      |   |             |        |
| **LAST** d.       |                      |   |             |        |
| [Atherosclerotic  |                      |   |             |        |
| coronary artery   |                      |   |             |        |
| disease\_\_\_\_\  |                      |   |             |        |
| _\_\_\_\_\_\_\_\_ |                      |   |             |        |
| \_\_\_\_\_\_\_\_\ |                      |   |             |        |
| _\_\_\_\_\_\_\_\_ |                      |   |             |        |
| \_\_\_\_\_\_\_\_\ |                      |   |             |        |
| _\_\_\_\_\_\_\_\_ |                      |   |             |        |
| \_\_\_\_\_\_\_\_\ |                      |   |             |        |
| _\_\_\_\_\_\_\_\_ |                      |   |             |        |
| \_\_]{.underline} |                      |   |             |        |
+-------------------+----------------------+---+-------------+--------+
| **PART II.**      |                      |   | 33\. WAS AN |        |
| Enter other       |                      |   | AUTOPSY     |        |
| [significant      |                      |   | PERFORMED?  |        |
| conditions        |                      |   |             |        |
| contributing to   |                      |   |  Yes ■ No  |        |
| d                 |                      |   |             |        |
| eath]{.underline} |                      |   |             |        |
| 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  | 36\. IF FEMALE:      | 3 |             |        |
| USE CONTRIBUTE TO |                      | 7 |             |        |
| DEATH?            | ■ Not pregnant       | \ |             |        |
|                   | within past year     | . |             |        |
| ■ Yes Probably  |                      | M |             |        |
|                   | Pregnant at time   | A |             |        |
| No Unknown    | of death             | N |             |        |
|                   |                      | N |             |        |
|                   | Not pregnant, but  | E |             |        |
|                   | pregnant within 42   | R |             |        |
|                   | days of death        | O |             |        |
|                   |                      | F |             |        |
|                   | Not pregnant, but  | D |             |        |
|                   | pregnant 43 days to  | E |             |        |
|                   | 1 year before death  | A |             |        |
|                   |                      | T |             |        |
|                   | Unknown if         | H |             |        |
|                   | pregnant within the  |   |             |        |
|                   | past year            | ■ |             |        |
|                   |                      | N |             |        |
|                   |                      | a |             |        |
|                   |                      | t |             |        |
|                   |                      | u |             |        |
|                   |                      | r |             |        |
|                   |                      | a |             |        |
|                   |                      | l |             |        |
|                   |                      |  |             |        |
|                   |                      |  |             |        |
|                   |                      | H |             |        |
|                   |                      | o |             |        |
|                   |                      | m |             |        |
|                   |                      | i |             |        |
|                   |                      | c |             |        |
|                   |                      | i |             |        |
|                   |                      | d |             |        |
|                   |                      | e |             |        |
|                   |                      |   |             |        |
|                   |                      |  |             |        |
|                   |                      |  |             |        |
|                   |                      | A |             |        |
|                   |                      | c |             |        |
|                   |                      | c |             |        |
|                   |                      | i |             |        |
|                   |                      | d |             |        |
|                   |                      | e |             |        |
|                   |                      | n |             |        |
|                   |                      | t |             |        |
|                   |                      |  |             |        |
|                   |                      |  |             |        |
|                   |                      | P |             |        |
|                   |                      | e |             |        |
|                   |                      | n |             |        |
|                   |                      | d |             |        |
|                   |                      | i |             |        |
|                   |                      | n |             |        |
|                   |                      | g |             |        |
|                   |                      | I |             |        |
|                   |                      | n |             |        |
|                   |                      | v |             |        |
|                   |                      | e |             |        |
|                   |                      | s |             |        |
|                   |                      | t |             |        |
|                   |                      | i |             |        |
|                   |                      | g |             |        |
|                   |                      | a |             |        |
|                   |                      | t |             |        |
|                   |                      | i |             |        |
|                   |                      | o |             |        |
|                   |                      | n |             |        |
|                   |                      |   |             |        |
|                   |                      |  |             |        |
|                   |                      |  |             |        |
|                   |                      | S |             |        |
|                   |                      | u |             |        |
|                   |                      | i |             |        |
|                   |                      | c |             |        |
|                   |                      | i |             |        |
|                   |                      | d |             |        |
|                   |                      | e |             |        |
|                   |                      |  |             |        |
|                   |                      |  |             |        |
|                   |                      | C |             |        |
|                   |                      | o |             |        |
|                   |                      | u |             |        |
|                   |                      | l |             |        |
|                   |                      | d |             |        |
|                   |                      | n |             |        |
|                   |                      | o |             |        |
|                   |                      | t |             |        |
|                   |                      | b |             |        |
|                   |                      | e |             |        |
|                   |                      | d |             |        |
|                   |                      | e |             |        |
|                   |                      | t |             |        |
|                   |                      | e |             |        |
|                   |                      | r |             |        |
|                   |                      | m |             |        |
|                   |                      | i |             |        |
|                   |                      | n |             |        |
|                   |                      | e |             |        |
|                   |                      | d |             |        |
+-------------------+----------------------+---+-------------+--------+

**ITEM 32 -- CAUSE OF DEATH (See example above)**

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.

Take care to make the entry legible. Use a computer printer with high
resolution, typewriter with good black ribbon and clean keys, or print
legibly using permanent **black** ink in completing the CAUSE OF DEATH
Section. **Do** **not** **abbreviate** conditions entered in section.

**[Part I]{.underline} (Chain of events leading directly to death)**

•Only **one** cause should be entered on each line. [Line
(a)]{.underline} **MUST ALWAYS** have an entry. **DO NOT** leave blank.
Additional lines may be added if necessary.

•If the condition on [Line (a)]{.underline} resulted from an underlying
condition, put the underlying condition on [Line (b)]{.underline}, and
so on, until the full sequence is reported. **ALWAYS** enter the
**underlying cause of death** on the [lowest used line]{.underline} in
Part I.

•For each cause indicate the best estimate of the interval between the
presumed onset and the date of death. The terms "unknown" or
"approximately" may be used. General terms, such as minutes, hours, or
days, are acceptable, if necessary. **DO NOT** leave blank.

•The terminal event (for example, cardiac arrest or respiratory arrest)
should not be used. If a mechanism of death seems most appropriate to
you for line (a), then you must always list its cause(s) on the line(s)
below it (for example, cardiac arrest **due to** coronary artery
atherosclerosis *or* cardiac arrest **due to** blunt impact to chest).

• If an organ system failure such as congestive heart failure, hepatic
failure, renal failure, or respiratory failure is listed as a cause of
death, always report its etiology on the line(s) beneath it (for
example, renal failure **due to** Type I diabetes mellitus).

•When indicating neoplasms as a cause of death, include the
following: 1) primary site *or* that the primary site is unknown, 2)
benign or malignant, 3) cell type *or* that the cell type is unknown, 4)
grade of neoplasm, and 5) part or lobe of organ affected. (For example,
a primary well-differentiated squamous cell carcinoma, lung, left upper
lobe.)

•Always report the fatal injury (for example, stab wound of chest), the
trauma (for example, transection of subclavian vein), and impairment of
function (for example, air embolism).

**Part II (Other significant conditions)**

•Enter all diseases or conditions contributing to death that were not
reported in the chain of events in Part I and that did not result in the
**underlying cause of death**.

•If two or more possible sequences resulted in death, or if two
conditions seem to have added together, report in Part I the one that,
in your opinion, most directly caused death. Report in Part II the other
conditions or diseases.

**CHANGES TO CAUSE OF DEATH**

Should additional medical information or autopsy findings become
available that would change the cause of death originally reported, the
original death certificate should be amended by the certifying physician
by **immediately** reporting the revised cause of death to the State
Vital Records Office.

**ITEMS ON WHEN DEATH OCCURRED**

Items 24-25 and 29-31 should always be completed. If the facility uses a
separate pronouncer or other person to indicate that death has taken
place with another person more familiar with the case completing the
remainder of the medical portion of the death certificate, the
pronouncer completes Items 24-28. If a certifier completes Items 24-25
as well as items 29-49, Items 26-28 may be left blank.

**ITEMS 24-25, 29-30 -- DATE AND TIME OF DEATH**

Spell out the name of the month. If the exact date of death is unknown,
enter the **approximate** date. If the date cannot be approximated,
enter the date the body is found and identify as **date found**. Date
pronounced and actual date may be the same. Enter the exact hour and
minutes according to a 24-hour clock; estimates may be provided with
"Approx." placed before the time.

**ITEMS 33-34 - AUTOPSY**

•33 - Enter "Yes" if either a partial or full autopsy was performed.
Otherwise enter "No."

•34 - Enter "Yes" if autopsy findings were available to complete the
cause of death; otherwise enter "No". Leave item blank if no autopsy was
performed.

**ITEM 35 - DID TOBACCO USE CONTRIBUTE TO DEATH?**

Check "yes" if, in your opinion, the use of tobacco contributed to
death. Tobacco use may contribute to deaths due to a wide variety of
diseases; for example, tobacco use contributes to many deaths due to
emphysema or lung cancer and some heart disease and cancers of the head
and neck. Check "no" if, in your clinical judgment, tobacco use did not
contribute to this particular death.

**ITEM 36 - IF FEMALE, WAS DECEDENT PREGNANT AT TIME OF DEATH OR WITHIN
PAST YEAR?**

This information is important in determining pregnancy-related
mortality.

**ITEM 37 - MANNER OF DEATH**

•Always check Manner of Death, which is important: 1) in determining
accurate causes of death; 2) in processing insurance claims; and 3) in
statistical studies of injuries and death.

•Indicate "Pending investigation" if the manner of death cannot be
determined whether due to an accident, suicide, or homicide within the
statutory time limit for filing the death certificate. This should be
changed later to one of the other terms.

•Indicate "Could not be Determined" **ONLY** when it is impossible to
determine the manner of death.

**ITEMS 38-44 - ACCIDENT OR INJURY -- to be filled out in all cases of
deaths due to injury or poisoning.**

•38 - Enter the exact month, day, and year of injury. Spell out the name
of the month. **DO NOT** use a number for the month. (Remember, the date
of injury may differ from the date of death.) Estimates may be provided
with "Approx." placed before the date.

•39 **-** Enter the exact hour and minutes of injury or use your best
estimate. Use a 24-hour clock.

•40 - Enter the general place (such as restaurant, vacant lot, or home)
where the injury occurred. **DO NOT** enter firm or organization names.
(For example, enter "factory", **not** "Standard Manufacturing, Inc." )

•41 - Complete if anything other than natural disease is mentioned in
Part I or Part II of the medical certification, including homicides,
suicides, and accidents. This includes all motor vehicle deaths. The
item **[must]{.underline}** be completed for decedents ages 14 years or
over and may be completed for those less than 14 years of age if
warranted. Enter "Yes" if the injury occurred at work. Otherwise enter
"No". An injury may occur at work regardless of whether the injury
occurred in the course of the decedent's "usual" occupation. Examples of
injury at work and injury not at work follow:

+-----------------------------------+-----------------------------------+
| **Injury at work**                | **Injury [not]{.underline} at     |
|                                   | work**                            |
| Injury while working or in        |                                   |
| vocational training on job        | Injury while engaged in personal  |
| premises                          | recreational activity on job      |
|                                   | premises                          |
| Injury while on break or at lunch |                                   |
| or in parking lot on job premises | Injury while a visitor (not on    |
|                                   | official work business) to job    |
| Injury while working for pay or   | premises                          |
| compensation, including at home   |                                   |
|                                   | Homemaker working at homemaking   |
| Injury while working as a         | activities                        |
| volunteer law enforcement         |                                   |
| official etc.                     | Student in school                 |
|                                   |                                   |
| Injury while traveling on         | Working for self for no profit    |
| business, including to/from       | (mowing yard, repairing own roof, |
| business contacts                 | hobby)                            |
|                                   |                                   |
|                                   | Commuting to or from work         |
+-----------------------------------+-----------------------------------+

•42 - Enter the complete address where the injury occurred including zip
code.

•43 - Enter a brief but specific and clear description of how the injury
occurred. Explain the circumstances or cause of the injury. Specify
**type** **of** **gun** or **type of vehicle** (e.g., car, bulldozer,
train, etc.) when relevant to circumstances. Indicate if more than one
vehicle involved; specify type of vehicle decedent was in.

•44 -Specify role of decedent (e.g. driver, passenger). Driver/operator
and passenger should be designated for modes other than motor vehicles
such as bicycles. Other applies to watercraft, aircraft, animal, or
people attached to outside of vehicles (e.g. surfers).

[Rationale]{.underline}: Motor vehicle accidents are a major cause of
unintentional deaths; details will help determine effectiveness of
current safety features and laws.

**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:]{.underline}**

+-------------+-------------+-------------+-------------+-------------+
| Abscess     | Car         | D           | H           | Pulmonary   |
|             | cinomatosis | isseminated | yponatremia | arrest      |
| Abdominal   |             | intra       |             |             |
| hemorrhage  | Cardiac     | vascular    | Hypotension | Pulmonary   |
|             | arrest      |             |             | edema       |
| Adhesions   |             | c           | Immuno      |             |
|             | Cardiac     | oagulopathy | suppression | Pulmonary   |
| Adult       | dysrhythmia |             |             | embolism    |
| respiratory |             | Dysrhythmia | Increased   |             |
| distress    | Car         |             | intra       | Pulmonary   |
| syndrome    | diomyopathy | End-stage   | cranial     | in          |
|             |             | liver       | pressure    | sufficiency |
| Acute       | Card        | disease     |             |             |
| myocardial  | iopulmonary |             | Intra       | Renal       |
| infarction  | arrest      | End-stage   | cranial     | failure     |
|             |             | renal       | hemorrhage  |             |
| Altered     | Cellulitis  | disease     |             | Respiratory |
| mental      |             |             | M           | arrest      |
| status      | Cerebral    | Epidural    | alnutrition |             |
|             | edema       | hematoma    |             | Seizures    |
| Anemia      |             |             | Metabolic   |             |
|             | Cere        | Exs         | enc         | Sepsis      |
| Anoxia      | brovascular | anguination | ephalopathy |             |
|             | accident    |             |             | Septic      |
| Anoxic      |             | Failure to  | Multi-organ | shock       |
| enc         | Cerebellar  | thrive      | failure     |             |
| ephalopathy | tonsillar   |             |             | Shock       |
|             | herniation  | Fracture    | M           |             |
| Arrhythmia  |             |             | ulti-system | Starvation  |
|             | Chronic     | Gangrene    | organ       |             |
| Ascites     | bedridden   |             | failure     | Subdural    |
|             | state       | Gastr       |             | hematoma    |
| Aspiration  |             | ointestinal | Myocardial  |             |
|             | Cirrhosis   | hemorrhage  | infarction  | S           |
| Atrial      |             |             |             | ubarachnoid |
| f           | C           | Heart       | Necrotizing | hemorrhage  |
| ibrillation | oagulopathy | failure     | soft-tissue |             |
|             |             |             | infection   | Sudden      |
| Bacteremia  | Compression | Hemothorax  |             | death       |
|             | fracture    |             | Old age     |             |
| Bedridden   |             | Hepatic     |             | Throm       |
|             | Congestive  | failure     | Open (or    | bocytopenia |
| Biliary     | heart       |             | closed)     |             |
| obstruction | failure     | Hepatitis   | head injury | Uncal       |
|             |             |             |             | herniation  |
| Bowel       | Convulsions | Hepatorenal | Paralysis   |             |
| obstruction |             | syndrome    |             | Urinary     |
|             | Decubiti    |             | P           | tract       |
| Brain       |             | Hy          | ancytopenia | infection   |
| injury      | Dehydration | perglycemia |             |             |
|             |             |             | Perforated  | Ventricular |
| Brain stem  | Dementia    | H           | gallbladder | f           |
| herniation  | (when not   | yperkalemia |             | ibrillation |
|             |             |             | Peritonitis |             |
| Car         | otherwise   | Hypovolemic |             | Ventricular |
| cinogenesis | specified)  | shock       | Pleural     | tachycardia |
|             |             |             | effusions   |             |
|             | Diarrhea    |             |             | Volume      |
|             |             |             | Pneumonia   | 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    | Epidural    | Hip         | Pulmonary   | Subdural    |
|             | hematoma    | fracture    | emboli      | hematoma    |
| Bolus       |             |             |             |             |
|             | Exs         | H           | Seizure     | Surgery     |
| Choking     | anguination | yperthermia | disorder    |             |
|             |             |             |             | Thermal     |
| Drug or     | Fall        | Hypothermia | Sepsis      | bur         |
| alcohol     |             |             |             | ns/chemical |
| ov          | Fracture    | Open        | S           | burns       |
| erdose/drug |             | reduction   | ubarachnoid |             |
| or          |             | of fracture | hemorrhage  |             |
|             |             |             |             |             |
| alcohol     |             |             |             |             |
| abuse       |             |             |             |             |
+-------------+-------------+-------------+-------------+-------------+

Contact your State vital statistics office for questions related to
writing cause-of-death statements. Additional instructional material on
writing cause-of-death statements including handbooks, summary
instructions, and tutorials are available online at www.thename.org or
www.cdc.gov/nchswww/about/major/dvs/handbk.htm, or by request from NCHS,
Room 7318, 3311 Toledo Road, Hyattsville, Maryland 20782-2003.

ICD‑10

[code]{.underline} [Cause]{.underline}

A00 Cholera

A01 Typhoid and paratyphoid fevers

A05.1 Botulism (including infant and wound botulism)

A07.0‑.2,.8‑.9 Other protozoal intestinal diseases (excluding
coccidiosis)

A20 Plague

A21 Tularemia

A22 Anthrax

A23 Brucellosis

A24.0 Glanders

A24.1‑.4 Melioidosis

A25 Rat‑bite fever

A27 Leptospirosis

A30 Leprosy \[Hansen\'s disease\]

A33 Tetanus neonatorum

A34 Obstetrical tetanus

A35 Other tetanus (Tetanus)

A36 Diphtheria

A37 Whooping cough

A44 Bartonellosis

A49.1 Streptococcus pneumoniae - less than 5 years of age

A65 Nonvenereal syphilis

A66 Yaws

A67 Pinta \[carate\]

A68 Relapsing fever

A69 Other spirochaetal infection

A70 Chlamydia psittaci infection (ornithosis)

A75 Typhus fever

A75.1‑.9 Other typhus fever

A77.1 Spotted fever due to Rickettsia conorii (Boutonneuse fever)

A77.2 Spotted fever due to Rickettsia siberica (North Asian tick fever)

A77.3 Spotted fever due to Rickettsia australis (Queensland tick typhus)

A77.8 Other spotted fevers (Other tick‑borne rickettsioses)

A77.9 Spotted fever, unspecified (unspecified tick‑borne rickettsioses)

A78 Q fever

A79 Other rickettsioses

A80 Acute poliomyelitis

A81 Atypical virus infections of central nervous system

A82 Rabies

A84 Tick‑borne viral encephalitis

A85.2 Arthropod‑borne viral encephalitis, unspecified (Viral
encephalitis

transmitted by other and unspecified arthropods)

A90 Dengue fever \[classical dengue\]

A91 Dengue hemorrhagic fever

A92 Other mosquito‑borne viral fevers

A93 Other arthropod‑borne viral fevers, not elsewhere classified

(including Oropouche fever, sandfly fever, Colorado tick fever

and other specified fevers)

ICD‑10

[code]{.underline} [Cause]{.underline}

A94 Unspecified arthropod‑borne viral fever

A95 Yellow fever

A96 Arenaviral hemorrhagic fever

A98‑A99 Other and unspecified viral hemorrhagic fevers (including

Crimean‑Congo, Omsk, Kyasanur Forest, Ebola virus, Hanta virus)

B01 Varicella \[chickenpox\]

B03 Smallpox

B04 Monkeypox

B05 Measles

B06 Rubella \[German measles\]

B08.0 Other orthopoxvirus infections (including cowpox and paravaccinia)

B15 Acute hepatitis A -- less than 20 years of age

B16 Acute hepatitis B -- less than 20 years of age

B26 Mumps

B33.0 Epidemic myalgia (epidemic pleurodynia)

B50‑B54 Malaria

B55 Leishmaniasis

B56 African trypanosomiasis

B57 Chagas\' disease (including American trypanosomiasis)

B65 Schistosomiasis \[bilharziasis\]

B66 Other fluke infections (including other trematode infections)

B67 Echinococcosis

B68 Taeniasis

B69 Cysticercosis

B70 Diphyllobothriasis and sparganosis

B71 Other cestode infections

B72 Dracunculiasis (Dracontiasis)

B73 Onchocerciasis

B74 Filariasis (Filarial infection)

P35.0 Congenital rubella syndrome

W88‑W91 Exposure to radiation

Y36.5 War operation involving nuclear weapons

Causing adverse effects in therapeutic use:

Y58 Bacterial vaccines

Y59.0 Viral vaccines

Y59.1 Rickettsial vaccines

Y59.2 Protozoal vaccines

Y59.3 Immunoglobulin

  ------------------- ---------------------------------------------------
  ICD-10 code         Abbreviated title

  A07.2               Cryptosporidiosis

  A07.3               Isosporiasis

  A16.2-A19           Tuberculosis

  A31                 Nontuberculous mycobacteriosis

  A42                 Actinomycosis

  A43                 Nocardidosis

  A812                Progressive multifocal leukoencephalopathy

  B00                 Herpes simplex

  B25                 Cytomegalovirus

  B37                 Candidiasis

  B38                 Coccidioidomycosis

  B39                 Histoplasmosis

  B44                 Aspergillosis

  B45                 Cryptococcosis

  B58                 Toxoplasmosis

  B59                 Pneumocystosis

  C46                 Kaposi\'s sarcoma

  C83, C85            Non-Hodgkin\'s Lymphoma

  G049                Encephalitis, myelitis, and encephalomyelitis,
                      unspecified

  G934                Encephalopathy, unspecified

  G959                Disease of spinal cord, unspecified

  R64                 Cachexia
  ------------------- ---------------------------------------------------