We obtained 14,440 de-identified electronic death records all with multiple-cause-of-death from the Utah Department of Health (UDOH) for the period 1 January 2008 to 31 December 2008. The records included a section describing the disease or condition directly leading to death, and any antecedent causes, co-morbid conditions and other significant contributing conditions. An example of a paper and electronic death certificate are shown in Figures 2 and 3 respectively. All death certificates used in this study have been processed using the Mortality Medical Data System (MMDS) and the record axis codes were received from UDOH. For our study we randomly selected 6,450 (45%) records. All death records included in the study were previously also coded by NCHS into ICD-10, but this information was not used for our coding, it was only used as posteriori to assess to quality of the automatic coding.