National Center for Health Statistics

Edward J. Sondik, Ph.D., Director

Jack R. Anderson, Deputy Director

Jack R. Anderson, Acting Associate Director for

International Statistics

Jennifer H. Madans, Ph.D., Associate Director for Science

Lawrence H. Cox, Ph.D., Associate Director for Research

and Methodology

Diane M. Makuc, Dr.P.H., Acting Associate Director for

Analysis, Epidemiology, and Health Promotion

P. Douglas Williams, Acting Associate Director for Data

Standards, Program Development, and Extramural Programs

Edward L. Hunter, Associate Director for Planning, Budget,

and Legislation

Jennifer H. Madans, Ph.D., Acting Associate Director for

Vital and Health Statistics Systems

Douglas L. Zinn, Acting Associate Director for

Management and Operations

Charles J. Rothwell, Associate Director for Information

Technology and Services

Division of Vital Statistics

James A. Weed, Ph.D., Acting Director

James A. Weed, Ph.D., Acting Chief, Mortality Statistics

Branch
Preface

This handbook contains instructions for physicians on cause-of-death 

certification. It was prepared by the Department of Health and Human 

Services’ Centers for Disease Control and Prevention’s National Center for 

Health Statistics (NCHS). These instructions pertain to the 2003 revision 

of the U.S. Standard Certificate of Death and the 1992 revision of the 

Model State Vital Statistics Act and Regulations. This handbook serves as 

a model that can be adapted by any vital statistics registration area. 

Other handbooks and references on preparing and registering vital records 

are mentioned at the end of the section on Medical Certification of Death 

and are listed in the references. For most of these resources, the State vital 

statistics office or NCHS can provide as many copies as desired. 

For detailed information on completing other items on the death certificate, refer to the Medical Examiners’ and Coroners’ Handbook on Death

Registration and Fetal Death Reporting or the Funeral Directors’ Handbook

on Death Registration and Fetal Death Reporting. 

Keywords: medical certification c death certificate c guidelines c handbook 

iii
Acknowledgments

This publication was prepared by staff from the Division of Vital Statistics 

led by Donna L. Hoyert, Ph.D., and Arialdi M. Minino, M.P.H. Robert N. 

Anderson, Ph.D., also contributed to this effort. Mary Anne Freedman, 

M.A., the Director of the Division of Vital Statistics while this publication 

was being prepared, reviewed and commented on the contents. Expert 

medical review and comments were provided by Randy Hanzlick, M.D.; 

Gregory G. Davis, M.D.; and Lillian R. Blackmon, M.D. Additional medical 

input was provided by Henry Thiede, M.D.; Kenneth C. Schoendorf, M.D.; 

and Sonja Rasmussen, M.D. 

This handbook was edited by Demarius V. Miller, typeset by Jacqueline M. 

Davis, and the graphics produced by Jarmila G. Ogburn of the Publications Branch, Division of Data Services. 

v
Contents

Preface ............................................................. iii

Acknowledgments ................................................... v

Introduction ........................................................ 1

Purpose .......................................................... 1

Importance of Death Registration ................................. 1

U.S. Standard Certificate of Death ................................ 3

Confidentiality of Vital Records .................................... 4

Physician’s Responsibility ......................................... 4

General Instructions for Completing Death Certificates .............. 7

Medical Certification of Death ....................................... 9

Pronouncing Date and Time of Death ............................. 9

Cause of Death ................................................... 9

Changes to Cause of Death....................................... 12

Instructions ..................................................... 12

Part I of the Cause-of-Death Section ............................. 12

Line (a) Immediate Cause ...................................... 13

Lines (b), (c), and (d) Due to (or as a Consequence of) ........... 13

Approximate Interval Between Onset and Death ................ 14

Part II of the Cause-of-Death Section (Other Significant 

Conditions) .................................................... 14

Doubt and Cause of Death ....................................... 15

Other Items for Medical Certification ............................. 15

Completing the Certifier Section ................................. 16

Examples of Cause-of-Death Certification ........................ 17

Common Problems in Death Certification ........................ 31

Additional Resources ............................................ 33

Completing Other Items on the Death Certificate ................... 34

Name of Decedent (Margin) ...................................... 34

Place of Death (Item 14) ......................................... 34

Facility Name (Items 15–17) ..................................... 35

Date Pronounced Dead (Item 24) ................................. 36

Time Pronounced Dead (Item 25) ................................ 37

Pronouncing Physician (Items 26–28) ............................ 37

Date Pronounced Dead (Item 29) ................................. 38

vii
Time Pronounced Dead (Item 30) ................................ 39

Was Medical Examiner or Coroner Contacted? (Item 31) .......... 40

Cause of Death (Item 32) ........................................ 40

Autopsy (Items 33 and 34) ....................................... 41

Tobacco Use Contribute to Death (Item 35) ....................... 42

If Female, Pregnancy Status (Item 36) ............................ 42

Manner of Death (Item 37) ....................................... 42

Accident or Injury (Items 38–44) ................................. 43

Certifier (Items 45–49)............................................ 46

References ....................................................... 49

Appendixes

A. The U.S. Standard Certificate of Death ........................ 52

B. The Vital Statistics Registration System in the United States . . . 54

viii
Introduction

Purpose

This handbook is designed to acquaint physicians, medical students, and 

others with the vital registration system in the United States and to provide instructions for completing and filing death certificates. Emphasis is 

directed toward the certification of medical information, the primary responsibility of the physician, and a critical piece of information on the 

death certificate. 

Importance of death registration

The death certificate is a permanent record of the fact of death, and 

depending on the State of death, may be needed to get a burial permit. 

State law specifies the required time for completing and filing the death 

certificate. 

The death certificate provides important personal information about the 

decedent and about the circumstances and cause of death. This information has many uses related to the settlement of the estate and provides 

family members closure, peace of mind, and documentation of the cause of 

death. 

The death certificate is the source for State and national mortality statistics (figures 1–3) and is used to determine which medical conditions receive research and development funding, to set public health goals, and to 

measure health status at local, State, national, and international levels. 

The Centers for Disease Control and Prevention’s National Center for 

Health Statistics (NCHS) publishes summary mortality data in the National Vital Statistics Report publication ‘‘Deaths: Final data’’ and on the 

Internet at http://www.cdc.gov/nchs (under vital statistics, mortality). 

These mortality data are valuable to physicians indirectly by influencing 

funding that supports medical and health research that may alter clinical 

practice and directly as a research tool. Research topics include identifying 

disease etiology, evaluating diagnostic and therapeutic techniques, 

1
Figure 1. Deaths by age

Figure 2. Deaths by cause

2
Figure 3. Percent of persons born alive in selected years surviving to

specific ages

examining medical or mental health problems that may be found among 

specific groups of people (1), and indicating areas in which medical research can have the greatest impact on reducing mortality. 

Analyses typically focus on a single condition reported on the death certificate, but some analyses do consider all conditions mentioned. Such 

analyses are important in studying certain diseases and conditions and in 

investigating relationships between conditions reported on the same death 

certificate (for example, types of fatal injuries and automobile crashes or 

types of infections and HIV). 

Because statistical data derived from death certificates can be no more 

accurate than the information on the certificate, it is very important that 

all persons concerned with the registration of deaths strive not only for 

complete registration, but also for accuracy and promptness in reporting 

these events. Furthermore, the potential usefulness of detailed specific 

information is greater than more general information. 

U.S. Standard Certificate of Death

The registration of deaths is a State function supported by individual State 

laws and regulations. The original death certificates are filed in the States 

3
and stored in accordance with State practice. Each State has a contract 

with NCHS that allows the Federal Government to use information from 

the State records to produce national vital statistics. The national data 

program is called the National Vital Statistics System (NVSS) (2,3). 

To ensure consistency in the NVSS, NCHS provides leadership and coordination in the development of a standard certificate of death for the States 

to use as a model. The standard certificate is revised periodically to ensure 

that the data collected relate to current and anticipated needs. In the 

revision process, stakeholders review and evaluate each item on the standard certificate for its registration, legal, genealogical, statistical, medical, 

and research value. The associations on the stakeholder panel that recommended the current U.S. Standard Certificate of Death included the American Medical Association, the National Association of Medical Examiners, 

the College of American Pathologists, and the American Hospital Association (2). 

Most State certificates conform closely in content and arrangement to the 

standard. Minor modifications are sometimes necessary to comply with 

State laws or regulations or to meet specific information needs. Having 

similar forms promotes uniformity of data and comparable national statistics. They also allow the comparison of individual State data with national 

data and of individual State data with national data and data from other 

States. Uniformity of death certificates among the States also increases 

their acceptability as legal records. 

Confidentiality of vital records

To encourage appropriate access to vital records, NCHS promotes the 

development of model vital statistics laws concerning confidentiality (4). 

State laws and supporting regulations define which persons have authorized access to vital records. Some States have few restrictions on access 

to death certificates. However, there are restrictions on access to death 

certificates in the majority of States. Legal safeguards to the confidentiality 

of vital records have been strengthened over time in some States. 

Physician’s responsibility

The physician’s principal responsibility in death registration is to complete 

the medical part of the death certificate. In fulfilling the role of the certifier 

(i.e., person completing the medical part of the death certificate), the 

physician performs the final act of care to a patient by providing closure 

with a well-thought-out and complete death certificate that will allow the 

4
family to close the person’s affairs. At the same time, the physician performs a service for the larger community. 

The physician is to: 

+ Be familiar with State and local regulations on medical certifications for 

deaths without medical attendance or involving external causes that 

may require the physician to report the case to a medical examiner or 

coroner. 

+ Complete relevant portions of the death certificate. 

+ Deliver the signed or electronically authenticated death certificate to 

the funeral director promptly so that the funeral director can file it with 

the State or local registrar within the State’s prescribed time period. 

+ Assist the State or local registrar by answering inquiries promptly. 

+ Deliver a supplemental report of cause of death to the State vital 

statistics office when autopsy findings or further investigation reveals 

the cause of death to be different from what was originally reported. 

In some States, hospitals and other institutions are authorized to initiate 

the preparation of the death certificate when the death occurred in that 

hospital or institution. In such cases, the attending physician will usually 

complete the cause-of-death section and sign the certificate at the hospital 

or other institution. Jurisdictions with electronic registration systems may 

have other ways to authenticate the certification than by using a signature 

on paper. In a few States, when the attending physician (physician in 

charge of the patient’s care for the condition that resulted in death) is not 

available at the time of death to certify the cause of death, another physician on duty at the hospital or other institution may pronounce the decedent legally dead; and, with the permission of the attending physician, the 

‘‘pronouncing physician’’ may authorize release of the body to the funeral 

director. In such cases, the attending physician will certify the cause of 

death at a later time. 

In all cases, the attending physician is responsible for certifying the cause 

of death. In most cases, he or she will both pronounce death and certify 

the cause of death. Only in the instances when the attending physician is 

unavailable to certify the cause of death at the time of death, and State law 

provides for a pronouncing physician, will a different physician pronounce 

death. 

If completed properly, the cause of death will communicate the same 

essential information (11) that a case history would. For example, the 

following cause-of-death statement is complete: 

5
I a) Septic shock 

b) Infected decubitus ulcers 

c) Complications of cerebral infarction 

d) Cerebral artery atherosclerosis 

II Insulin-dependent diabetes mellitus 

If not completed properly, information may be missing from the cause-ofdeath section, so someone reading the cause of death would not know why 

the condition on the lowest used line developed. For example: 

I a) Pneumonia 

b) Malnutrition 

c) 

II 

This example does not explain what caused malnutrition. A variety of 

different circumstances could cause malnutrition, so the statement is 

incomplete and ambiguous. 

In some cases, the physician will be contacted to verify information reported on a death certificate or to provide additional information to clarify 

what was meant. The original cause-of-death statement may not be wrong 

from a clinical standpoint, but may not include sufficient information for 

assigning codes for statistical purposes. Following guidelines in this handbook should minimize the frequency with which a physician will need to 

spend additional time answering follow-up questions about a patient’s 

cause of death. 

6
General Instructions for Completing Death

Certificates

Death certificates are permanent legal records from which official copies 

are made. It is essential that the certificate be prepared accurately. Funeral directors are responsible for completing most of the information on 

the death certificate with the assistance of an informant who is usually a 

family member. 

Completing a death certificate involves the following guidelines: 

+ Use the current form designated by the State. 

+ Complete each item, following the specific instructions for that item. 

+ 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. 

+ Do not use abbreviations except those recommended in the specific 

item instructions. 

+ Verify with the informant the spelling of names, especially those that 

have different spellings for the same sound (Smith or Smyth, Gail or 

Gayle, Wolf or Wolfe, and so forth). 

+ Refer problems not covered in these instructions to the State office of 

vital statistics or to the local registrar. 

+ Obtain all signatures; rubber stamps or other facsimile signatures are 

not acceptable. If jurisdiction provides, authenticate electronically. 

+ Do not make alterations or erasures. 

+ File the original certificate or report with the registrar. Reproductions 

or duplicates are not acceptable. 

Most States require that the death certificate be completed and filed within 

a specified time period. Physicians are expected to use medical training, 

knowledge of medicine, available medical history, symptoms, diagnostic 

tests, and autopsy results, if available, to determine the cause of death. 

Generally, it is possible to file a certificate with the cause of death listed as 

pending or pending further study. This is especially useful when additional 

7
investigation such as autopsy results are expected, but it obligates the 

attending physician to update the original information after the additional 

information becomes available. 

8
Medical Certification of Death

The physician’s primary responsibility in death registration is pronouncing the death and, when he or she is the attending physician, reporting 

cause of death. The medical part of the certificate includes: 

+ Date and time pronounced dead 

+ Date and time of death 

+ Question on whether the case was referred to the medical examiner or 

coroner 

+ Cause-of-death section including cause of death, manner of death, 

tobacco use, and females’ pregnancy status items 

+ Injury items for cases involving injuries 

+ Certifier section with signatures 

In most cases, a physician will both pronounce death and certify or report 

the cause of death. A different physician will pronounce death only when 

the attending physician is unavailable to certify the cause of death at the 

time of death and if State law provides for this option. If an inquiry is 

required by a State Post-Mortem Examinations Act, a medical examiner or 

coroner is responsible for determining cause of death (4). 

Pronouncing date and time of death

Items 24 and 25 must be completed by the person who pronounces death. 

This may be the pronouncing physician, pronouncing/certifying physician, or the medical examiner or coroner. For cases involving a pronouncing physician different from the certifying physician, the pronouncing 

physician must also complete items 26–28. 

Cause of death

This section must be completed by either the attending physician, the 

medical examiner, or the coroner. The cause-of-death section, a facsimile 

of which is shown below, follows guidelines recommended by the World 

Health Organization. An important feature is the reported underlying cause 

9
of death determined by the certifying physician and defined as (a) the 

disease or injury that initiated the train of morbid events leading directly 

to death, or (b) the circumstances of the accident or violence that produced 

the fatal injury. In addition to the underlying cause of death, this section 

provides for reporting the entire sequence of events leading to death as 

well as other conditions significantly contributing to death (5). 

The cause-of-death section is designed to elicit the opinion of the medical 

certifier. Causes of death on the death certificate represent a medical 

opinion that might vary among individual physicians. A properly completed cause-of-death section provides an etiologic explanation of the order, type, and association of events resulting in death. The initial condition 

that starts the etiologic sequence is specific if it does not leave any doubt 

as to why it developed. For example, sepsis is not specific because a 

number of different conditions may have resulted in sepsis, whereas human immunodeficiency virus syndrome is specific. 

In certifying the cause of death, any disease, abnormality, injury, or poisoning, if believed to have adversely affected the decedent, should be 

reported. If the use of alcohol and/or other substance, a smoking history, 

a recent pregnancy, injury, or surgery was believed to have contributed to 

death, then this condition should be reported. The conditions present at 

the time of death may be completely unrelated, arising independently of 

each other; they may be causally related to each other, that is, one condition may lead to another which in turn leads to a third condition; and so 

forth. Death may also result from the combined effect of two or more 

conditions. 

10
As can be seen, the cause-of-death section consists of two parts. The first 

part is for reporting the sequence of events leading to death, proceeding 

backwards from the final disease or condition resulting in death. So each 

condition in Part I should cause the condition above it. 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. Other significant conditions that contributed to the death, but did not lead to the underlying cause, are reported in 

Part II. 

In addition, there are questions relating to autopsy, manner of death (for 

example, accident), and injury. The cause of death should include information provided by the pathologist if an autopsy or other type of postmortem examination is done. For deaths that have microscopic examinations 

pending at the time the certificate is filed, the additional information 

should be reported as soon as it is available. If the physician has any 

questions about the procedure for doing this, he or she should contact his 

or her State registrar. 

For statistical and research purposes, it is important that the causes of 

death and, in particular, the underlying cause of death be reported as 

specifically and as precisely as possible. Careful reporting results in statistics for both underlying and multiple causes of death (i.e., all conditions 

mentioned on a death certificate) reflecting the best medical opinion. 

Every cause-of-death statement is coded and tabulated in the statistical 

offices according to the latest revision of the International Classification of

Diseases (5). When there is a problem with the reported cause of death 

(e.g., when a causal sequence is reported in reverse order), the rules 

provide a consistent way to select the most likely underlying cause. However, it is better when rules designed to compensate for poor reporting are 

not invoked so that the rules are confirming the physician’s statement 

rather than imposing assumptions about what the physician meant. 

Statistically, mortality research focuses on the underlying cause of death 

because public health interventions seek to break the sequence of causally 

related medical conditions as early as possible. However, all cause information reported on death certificates is important and is analyzed. 

In the sections that follow, detailed instructions on how to complete Parts 

I and II are given. A number of examples of properly completed certificates 

with case histories are provided in this section to illustrate how the cause 

of death should be reported. Some common problems are also discussed 

later in this section. 

11
Changes to cause of death

Should additional medical information or autopsy findings become available that would change the cause or causes of death originally reported, 

the certifying physician should amend the original death certificate by 

immediately reporting the revised cause of death to the State vital records 

office or local registrar. 

Instructions

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 the physician’s best medical OPINION. Report each disease, abnormality, injury, or poisoning that 

the physician believes adversely affected the decedent. A condition can be 

listed as ‘‘probable’’ if it has not been definitively diagnosed. 

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.) 

For each fatal injury (for example, stab wound of chest), always report the 

trauma (for example, transection of subclavian vein), and impairment of 

function (for example, air embolism) that contributed to death. 

Part I of the cause-of-death section

Only one cause is to be entered on each line of Part I. Additional lines 

should be added between the printed lines when necessary. For each 

cause, indicate in the space provided the approximate interval between the 

date of onset (not necessarily the date of diagnosis) and the date of death. 

12
For clarity, do not use parenthetical statements and abbreviations when 

reporting the cause of death. The underlying cause of death should be 

entered on the LOWEST LINE USED IN PART I. The underlying cause of 

death is the disease or injury that started the sequence of events leading 

directly to death or the circumstances of the accident or violence that 

produced the fatal injury. In the case of a violent death, the form of 

external violence or accident is antecedent to an injury entered, although 

the two events may be almost simultaneous. 

Line (a) immediate cause

In Part I, the immediate cause of death is reported on line (a). This is the 

final disease, injury, or complication directly causing the death. An immediate cause of death must always be reported on line (a). It can be the sole 

entry in the cause-of-death section if that condition is the only condition 

causing the death. 

The immediate cause does not mean the mechanism of death or terminal 

event (for example, cardiac arrest or respiratory arrest). The mechanism of 

death (for example, cardiac or respiratory arrest) should not be reported as 

the immediate cause of death as it is a statement not specifically related to 

the disease process, and it merely attests to the fact of death. Therefore, 

the mechanism of death provides no additional information on the cause 

of death. 

Lines (b), (c), and (d) due to (or as a consequence of)

On line (b) report the disease, injury, or complication, if any, that gave rise 

to the immediate cause of death reported on line (a). If this in turn resulted 

from a further condition, record that condition on line (c). If this in turn 

resulted from a further condition, record that condition on line (d). For as 

many conditions as are involved, write the full sequence, one condition per 

line, with the most recent condition at the top, and the underlying cause of 

death reported on the lowest line used in Part I. If more than four lines are 

needed, add additional lines (writing ‘‘due to’’ between conditions on the 

same line is the same as drawing an additional line) rather than using 

space in Part II to continue the sequence. The following certification is an 

example in which an additional line was necessary. 

13
The words ‘‘due to (or as a consequence of),’’ which are printed between the 

lines of Part I, apply not only in sequences with an etiological or pathological basis and usually a chronological time ordering, but also to sequences 

in which an antecedent condition is believed to have prepared the way for 

a subsequent cause by damage to tissues or impairment of function. 

If the immediate cause of death arose as a complication of or from an error 

or accident in surgery or other medical procedure or treatment, it is 

important to report what condition was being treated, what medical procedure was performed, what the complication or error was, and what the 

result of the complication or error was. 

Approximate interval between onset and death

Space is provided to the right of lines (a), (b), (c), and (d) for recording the 

interval between the presumed onset of the condition (not the diagnosis of 

the condition) and the date of death. This should be entered for all conditions in Part I. These intervals usually are established by the physician on 

the basis of available information. In some cases the interval will have to 

be estimated. The terms ‘‘unknown’’ or ‘‘approximately’’ may be used. 

General terms, such as minutes, hours, or days, are acceptable, if necessary. If the time of onset is entirely unknown, state that the interval is 

‘‘Unknown.’’ Do not leave these items blank. 

This information is useful in coding certain diseases and also provides a 

useful check on the accuracy of the reported sequence of conditions. 

Part II of the cause-of-death section (other significant conditions)

All other important diseases or conditions that were present at the time of 

death and that may have contributed to the death, but did not lead to the 

14
underlying cause of death listed in Part I or were not reported in the chain 

of events in Part I, should be recorded on these lines. (More than one 

condition can be reported per line in Part II.) 

Multiple conditions and sequences of conditions resulting in death are 

common, particularly among the elderly. When there are two or more 

possible sequences resulting in death, or if two conditions seem to have 

added together, choose and report in Part I the sequence thought to have 

had the greatest impact. Other conditions or conditions from the other 

sequence(s) should be reported in Part II. For example, in the case of a 

diabetic male with chronic ischemic heart disease who dies from pneumonia, his certifying physician must choose the sequence of conditions that 

had the greatest impact and report this sequence in Part I. One possible 

sequence that the certifier might report would be pneumonia due to diabetes mellitus in Part I with chronic ischemic heart disease reported in 

Part II. Another possibility would be pneumonia due to the chronic ischemic heart disease entered in Part I with diabetes mellitus reported in 

Part II. Or the certifier might consider the pneumonia to be due to the 

ischemic heart disease that was due to the diabetes mellitus and report 

this entire sequence in Part I. Because these three different possibilities 

would be coded very differently, it is important for the certifying physician 

to decide which sequence most accurately describes the conditions causing death. 

Doubt and cause of death

In cases of doubt, it may be necessary to use qualifying phrases in either 

Part I or Part II to reflect uncertainty as to which conditions led to death. In 

cases where the certifier is unable to establish a cause of death based 

upon reasonable medical certainty, he or she should enter ‘‘Unknown’’ in 

the cause-of-death section. However, this should be shown only after all 

efforts have been made to determine the cause of death. An autopsy 

should be performed, if possible. 

Other items for medical certification

The remaining items that require the physician’s certification relate to 

autopsy, manner of death, injury, female decedent’s pregnancy status, if 

tobacco use contributed to death, and whether the case was referred to the 

medical examiner or coroner. 

The physician should indicate whether an autopsy was performed and 

whether the findings were available to complete the cause of death. If 

additional medical information or autopsy findings are received after the 

15
physician has certified the cause of death and he or she determines the

cause to be different from what was originally entered on the death certificate, the original certificate should be amended by filing a supplemental

report of cause of death with the State registrar. Information on the proper

form to use and procedure to follow can be obtained from the State registrar.

In most cases the manner of death will be checked ‘‘Natural.’’ In those

cases when an accident, suicide, or homicide has occurred, the medical

examiner or coroner must be notified. If the medical examiner or coroner

does not assume jurisdiction, the physician should check the appropriate

manner of death and describe the injury and accident.

Completing the certifier section

Physicians can play different roles in medical certification. A pronouncing

physician is a physician who determines that the decedent is legally dead,

but was not in charge of the patient’s care for the illness or condition that

resulted in death. The attending physician is responsible for completing

the cause-of-death section (item 32). If a pronouncing physician is involved, the attending physician plays the role of a certifying physician. If no

pronouncing physician is involved, the attending physician plays the role

of both the pronouncing and certifying physician. The medical examiner or

coroner investigates certain types of deaths according to State law and

complete the cause of death for these cases.

The following chart specifies the items to be completed by each type of

medical certifier.

MEDICAL CERTIFICATION

Medical certifier Complete items

Pronouncing physician 24–31

Certifying physician 32–37, 45–49 (sometimes 38–44)

Pronouncing and certifying physician 24, 25, 29–37, and 45–49

(sometimes 38–44)

Medical examiner or coroner 24, 25, 29, 30, and 32–49

The attending physician is usually in a better position than any other

individual to make a judgment as to which of the conditions led directly to

death and to state the antecedent conditions, if any, that gave rise to this

cause.

16
Because the items completed by the pronouncing or pronouncing and 

certifying physician, and medical examiner or coroner differ, separate 

statements are provided that specify to what information each physician is 

attesting. This agreement is denoted when each physician signs the completed statement, adding his or her degree or title and license number. 

Certain jurisdictions may provide for electronic authentication instead of a 

signature on the paper document. The date of certification and mailing 

address of the physician should also be provided. 

Examples of cause-of-death certification

Case history no. 1

Shortly after dinner on the day prior to admission to the hospital, this 

48-year-old male developed a cramping, epigastric pain, which radiated to 

his back, followed by nausea and vomiting. The pain was not relieved by 

positional changes or antacids. The pain persisted, and 24 hours after its 

onset, the patient sought medical attention. He had a 10-year history of 

excessive alcohol consumption and a 2-year history of frequent episodes of 

similar epigastric pain. The patient denied diarrhea, constipation, hematemesis, or melena. The patient was admitted to the hospital with a diagnosis of an acute exacerbation of chronic pancreatitis. Radiological findings 

included a duodenal ileus and pancreatic calcification. Serum amylase 

was 4,032 units per liter. The day after admission, the patient seemed to 

improve. However, that evening he became disoriented, restless, and hypotensive. Despite intravenous fluids and vasopressors, the patient remained hypotensive and died. Autopsy findings revealed many areas of 

fibrosis in the pancreas with the remaining areas showing multiple foci of 

acute inflammation and necrosis. 

17
Notes on death certification:

Duodenal ileus and pancreatic calcification are nonspecific processes and

neither could be listed as an underlying cause of death.

Case history no. 2

A 68-year-old male was admitted to the hospital with progressive right 

lower quadrant pain of several weeks’ duration. The patient had lost approximately 40 pounds, with progressive weakness and malaise. On physical examination, the patient had an enlarged liver span that was four 

finger breadths below the right costal margin. Rectal examination was 

normal and stool was negative for occult blood. Routine laboratory studies 

were within normal limits. A chest x ray and barium enema were negative. 

His EKG showed a right bundle branch block. CT scan showed numerous 

masses within both lobes of the liver. A needle biopsy of the liver was 

diagnostic of moderately differentiated hepatocellular carcinoma, and the 

patient was started on chemotherapy. Three months after the diagnosis, 

the patient developed sharp diminution of liver function as well as a deep 

venous thrombosis of his left thigh, and he was admitted to the hospital. 

On his third day, the patient developed a pulmonary embolism and died 30 

minutes later. 

18
Case history no. 3

This 75-year-old male was admitted to the hospital complaining of severe 

chest pain. He had a 10-year history of arteriosclerotic heart disease with 

EKG findings of myocardial ischemia and several episodes of congestive 

heart failure controlled by digitalis preparations and diuretics. Five months 

before this admission, the patient was found to be anemic, with an hematocrit of 17, and to have occult blood in the stool. A barium enema revealed 

a large polypoid mass in the cecum diagnosed as carcinoma by biopsy. 

Because of the patient’s cardiac status, he was not considered to be a 

surgical candidate. Instead, he was treated with a 5-week course of radiation therapy and periodic packed red cell transfusions. He completed this 

course 3 months before this hospital admission. On this admission the 

EKG was diagnostic of an acute anterior wall myocardial infarction. He 

expired 2 days later. 

19
Notes on death certification:

Acute myocardial infarction, listed in Part I line (a) as the immediate cause

of death, is a direct consequence of arteriosclerotic heart disease, the underlying cause listed in Part I line (b).

Carcinoma of cecum is listed in Part II because it caused anemia and

weakened the patient, but it did not cause arteriosclerotic heart disease.

Congestive heart failure is listed in Part II because it also weakened the

patient. Although it was caused by the arteriosclerotic heart disease, it was

not part of the causal sequence leading to the acute myocardial infarction.

Case history no. 4

A 68-year-old female was admitted to the ICU with dyspnea and moderate 

retrosternal pain of 5-hours duration, which did not respond to nitroglycerin. There was a past history of obesity, noninsulin-dependent diabetes 

mellitus, hypertension, and episodes of nonexertional chest pain, diagnosed as angina pectoris, for 8 years. Over the first 72 hours, she developed a significant elevation of the MB isoenzyme of creatine phosphokinase, 

confirming an acute myocardial infarction. A Type II second-degree AV 

block developed, and a temporary pacemaker was put in place. She subsequently developed dyspnea with fluid retention and cardiomegaly on 

chest radiograph. She improved with diuretics. On the seventh hospital 

day, during ambulation, she suddenly developed chest pain and increased 

dyspnea. An acute pulmonary embolism was suspected and intravenous 

heparin was started. The diagnosis of pulmonary embolism was confirmed 

by a ventilation/perfusion scan as well as arterial blood gas measurements. One hour later, she became unresponsive and resuscitation efforts 

were unsuccessful. 

20
Notes on death certification:

In this case, noninsulin-dependent diabetes mellitus, obesity, hypertension,

and congestive heart failure would all be considered factors that contributed

to the death. However, they would not be in the direct causal sequence of

Part I, so they would be placed in Part II.

Case history no. 5

A 78-year-old female with a temperature of 102.6° F was admitted to the 

hospital from a nursing home. She first became a resident of the nursing 

home 2 years earlier following a cerebrovascular accident, which left her 

with a residual left hemiparesis. Over the next year, she became increasingly dependent on others to help with her activities of daily living, eventually requiring an in-dwelling bladder catheter 6 months before the current 

admission. For the 3 days prior to admission, she was noted to have lost 

her appetite and to have become increasingly withdrawn. 

On admission to the hospital her leukocyte count was 19,700, she had 

pyuria, and gram-negative rods were seen on a gram stain of urine. 

Ampicillin and gentamicin were administered intravenously. On the third 

hospital day, admission blood cultures turned positive for Pseudomonas

aeruginosa, which was resistant to ampicillin and gentamicin. Antibiotic 

therapy was changed to ticarcillin clavulanate, to which the organism was 

sensitive. Despite the antibiotics and intravenous fluid support, the patient’s fever persisted. On the fourth hospital day, she became hypotensive 

and died. 

This case illustrates that additional lines may be added to Part I. 

21
Case history no. 6

A 34-year-old male was admitted to the hospital with severe shortness of 

breath. He had a 9-month history of unintentional weight loss, night 

sweats, and diarrhea. The patient had no history of any medical condition 

that would cause immunodeficiency. An Elisa test and confirmatory Western Blot test for human immunodeficiency virus (HIV) were positive. 

T-lymphocyte tests indicated a low T helper -suppressor ratio. A lung 

biopsy was positive for pneumocystis carinii pneumonia (PCP), indicating 

a diagnosis of acquired immunodeficiency syndrome (AIDS). 

The patient’s pneumonia responded to pentamidine therapy, and the patient was discharged. The patient had two additional admissions for PCP. 

Seventeen months after the patient was first discovered to be HIV positive, 

he again developed PCP but did not respond to therapy. He died 2 weeks 

later. 

22
Notes on death certification:

By definition, AIDS is due to HIV infection; even though it may seem redundant to specify HIV infection in the causal sequence death, it is desirable to

do so. HIV infection and AIDS are not synonymous, and there is a variable

clinical course between the time of HIV infection and onset of AIDS.

Case history no. 7

A 75-year-old male had a 10-year history of chronic bronchitis associated 

with smoking two packs of cigarettes a day for more than 40 years. When 

seen by his physician approximately 2 years prior to his terminal episode, 

he had moderately reduced FEV1 and FVC with no response to bronchodilators. During his last year, he required corticosteroids to prevent wheezing and coughing at night; however, he was unable to reduce his smoking 

to less than one pack of cigarettes per day. When seen 3 months prior to 

his terminal episode, he had significantly reduced FEV1 and FVC with no 

response to bronchodilators. He awoke one evening complaining to his 

wife about coughing and worsening shortness of breath. He was taken to 

the emergency room where he was found to have an acute exacerbation of 

obstructive airway disease. He was admitted to the hospital. At the patient’s request, no mechanical ventilation was employed, and he died 12 

hours later in respiratory arrest. 

23
Notes on death certification:

In this case, respiratory arrest is considered a mechanism of death, and it

would not be listed as the Immediate Cause of Death.

Case history no. 8

A 75-year-old female had a 15-year history of noninsulin-dependent diabetes mellitus, a 13-year history of mild hypertension treated with thiazide 

diuretics, and an uncomplicated myocardial infarction 6 years prior to the 

present illness. She was found disoriented in her apartment and brought 

to the hospital. On admission she was noted to be unresponsive, without 

focal neurologic signs, and severely dehydrated with a blood pressure of 

90/60. Initial laboratory tests disclosed severe hyperglycemia, hyperosmolarity, azotemia, and mild ketosis without acidosis. A diagnosis of hyperosmolar nonketotic coma was made. 

The patient was vigorously treated with fluids, electrolytes, insulin, and 

broad-spectrum antibiotics, although no source for infection was documented. Within 72 hours, the patient’s hyperosmolar, hyperglycemic state 

was resolved. However, she remained anuric with progressive azotemia. 

Attempts at renal dialysis were unsuccessful, and the patient died on the 

8th hospital day in severe renal failure. 

24
Notes on death certification:

In this case, hypertension and a previous myocardial infarction would both

be considered factors that contributed to the death. However, they would

not be in the direct causal sequence of Part I, so they would be placed in

Part II.

Case history no. 9

This 53-year-old male was admitted to the hospital following 2 days of 

intermittent midepigastric and left-sided chest pain. The pain radiated to 

his left arm and was accompanied by nausea and vomiting. He gave a 

history that included 2 years of occasional chest discomfort, a near syncopal episode 6 months prior, hypertension, a 30-year history of one-packper-day cigarette smoking, congenital blindness, and insulin-dependent 

diabetes mellitus. He was noted to be markedly obese and to have severe 

hypercholesterolemia. 

At the time of admission, his enzyme studies were normal, but the EKG 

suggested myocardial ischemia. Two days later, he experienced an episode 

of severe chest pain that did not respond to nitroglycerin and was accompanied by ST-segment elevation. A cardiac catheterization demonstrated 

severe multivessel coronary artery stenosis. He underwent quadruple coronary artery bypass surgery. Shortly, after being taken off the cardiopulmonary bypass machine, he went into cardiac arrest. As resuscitation was 

being attempted by open cardiac massage, a rupture developed in his left 

ventricular wall that resulted in rapid exsanguination and death. 

25
Notes on death certification:

In this case, insulin-dependent diabetes mellitus, cigarette smoking, hypertension, and hypercholesterolemia would all be considered factors that

contributed to the death. However, they would not be in the direct causal

sequence of Part I, so they would be placed in Part II. The surgery probably

played a role in death but did not cause the coronary artery disease, so it is

also listed in Part II.

Case history no. 10

A 1,480-gram male infant was born at 32-weeks gestation to a 20-year-old 

primiparous woman. Newborn screening found elevated levels of immunoreactive trypsinogen in the blood. The infant developed respiratory distress syndrome and required mechanical ventilation for 7 days. Despite 

receiving adequate calories for growth, the infant gained weight poorly and 

had persistent diarrhea. Steatorrhea was confirmed upon microscopic 

examination. Results from a sweat chloride test given on the 21st day after 

birth were negative, but the patient had an elevated sweat chloride concentration of 85 millimoles per liter when the test was repeated at 35 days 

of age. On the 37th day after birth, the infant became lethargic and was 

noted to be edematous. Escherichia coli was cultured from the infant’s 

cerebral spinal fluid, total serum proteins were reported to be low, and 

clotting studies were prolonged. The infant died at 45 days of age despite 

appropriate life-saving efforts. Gross autopsy confirmed the clinical impression of cystic fibrosis. 

26
Notes on death certification:

In this case, prematurity, malabsorption, respiratory distress syndrome,

and failure to thrive would all be considered factors that contributed to the

death. However, they would not be in the direct causal sequence of Part I, so

they would be placed in Part II.

Case history no. 11

A 30-year-old, gravida-six, para-five, with a history of gestational hypertension, reported to the emergency room at 36 weeks gestation with complaints of abdominal cramping and light vaginal bleeding during the past 

12 hours. At time of first assessment, fetal heart tones were detected. The 

uterus was tense, irritable, and tender. The mother was hypotensive with 

tachycardia. A presumptive diagnosis of abruptio placenta was made, and 

an emergency cesarean section was performed under general anesthesia. 

The baby was stillborn. The mother continued to bleed from her uterus 

and phlebotomy sites and went into profound shock secondary to disseminated intravascular coagulation. Despite administration of blood and clotting factors, intravascular pressure could not be maintained, and the mother 

died on the operating table. Maternal autopsy confirmed the clinical 

diagnosis. 

A death certificate would be completed for the mother and a fetal death 

report for the fetus. The cause of fetal death is reported using a different 

format. Please refer to the Medical Examiners’ and Coroners’ Handbook on

Death Registration and Fetal Death Reporting for further information. 

27
Maternal death certificate: 

Notes on death certification:

In this case, gestational hypertension would be considered a factor that

contributed to the death. However, it would not be in the direct causal

sequence of Part I, so it would be placed in Part II.

28
Fetal death report: 

Case history no. 12

A 92-year-old male was found dead in bed. He had no significant 

medical history. Autopsy disclosed minimal coronary disease and generalized atrophic changes commonly associated with aging. No specific cause 

of death was identified. Toxicology was negative. 

29
Note: In some cases, no overwhelming cause presents itself. It is acceptable

to indicate that a thorough investigation was performed; however, no cause

could be determined.

Case history no. 13

A 102-year-old female was brought to the hospital because her word 

combinations were not comprehensible. However, at admission, her sentences were lucid. She was placed on blood anticoagulants. She had a 

history of arthritis, hypertension, blocked arteries, coronary thrombosis 

(25 years before), stroke (10 years before), periodic TIAs (8-year period), 

and congestive heart failure (hospitalized 6 years before). On the fourth 

day in the hospital, a colonoscopy indicated internal bleeding, so the 

anticoagulant was discontinued. She was released from the hospital after 

7 days. After discharge, language and motor skills were impaired although 

functioning was better earlier in the day; moreover, her leg coloration 

started changing. After a week at home, the woman was re-admitted to the 

hospital following a spell of vomiting. Vascular imaging indicated that 

circulation was blocked at the groin, there was no improvement in language, ability to eat and keep food down deteriorated, and heart rate 

periodically was arrythmic with periods of third-degree heart block. After a 

week of hospitalization, she was sent home under hospice care and died 2 

days later. Her attending physician completed the death certificate. 

30
Common problems in death certification

Often several acceptable ways of writing a cause-of-death statement exist. 

Optimally, a certifier will be able to provide a simple description of the 

process leading to death that is etiologically clear and be confident that 

this is the correct sequence of causes. However, realistically, description of 

the process is sometimes difficult because the certifier is not certain. 

In this case, the certifier should think through the causes about which 

he/she is confident and what possible etiologies could have resulted in 

these conditions. The certifier should select the causes that are suspected 

to have been involved and use words such as ‘‘probable’’ or ‘‘presumed’’ to 

indicate that the description provided is not completely certain. If the 

initiating condition reported on the death certificate could have arisen 

from a pre-existing condition, but the certifier cannot determine the etiology, he/she should state that the etiology is unknown, undetermined, or 

unspecified, so it is clear that the certifier did not have enough information 

to provide even a qualified etiology. Reporting a cause of death as unknown should be a last resort. 

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. 

‘‘Multiple system failure’’ could be included in Part II, but the systems need 

to be specified to ensure that the information is captured. If after careful 

31
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 Sudden Infant Death Syndrome (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, review of clinical history, and a complete 

autopsy. The death then can be reported as SIDS. Refer to the Medical

Examiners’ and Coroners’ Handbook on Death Registration and Fetal Death

Reporting for more information. 

Most certifiers will find themselves, at some point, in the circumstance in 

which they are unable to provide a simple description of the process of

death. In this situation, the certifier should try to provide a clear sequence, qualify the causes about which he/she is uncertain, and be able 

to explain the certification chosen. 

When processes such as the following are reported, additional information about the etiology should be reported:

Abscess

Abdominal hemorrhage

Adhesions

Adult respiratory distress

syndrome

Acute myocardial infarction

Altered mental status Anemia

Anoxia Anoxic encephalopathy

Arrhythmia

Ascites

Aspiration

Atrial fibrillation

Bacteremia

Bedridden

Biliary obstruction

Bowel obstruction

Brain injury

Brain stem herniation

Carcinogenesis

Carcinomatosis

Cardiac arrest

Cardiac dysrhythmia

Cardiomyopathy

Cardiopulmonary arrest Cellulitis

Cerebral edema

32

Cerebrovascular accident Hemothorax Peritonitis

Cerebellar tonsillar herniation Hepatic failure Pleural effusions

Chronic bedridden state Hepatitis Pneumonia

Cirrhosis Hepatorenal syndrome Pulmonary arrest

Coagulopathy

Compression fracture

Congestive heart failure Convulsions

Hyperglycemia

Hyperkalemia

Hypovolemic shock Hyponatremia

Pulmonary edema Pulmonary embolism

Pulmonary insufficiency Renal failure

Decubiti Hypotension Respiratory arrest

Dehydration

Dementia (when not

otherwise specified)

Diarrhea

Immunosuppression

Increased intra cranial

pressure

Intra cranial hemorrhage

Seizures

Sepsis

Septic shock

Shock

Disseminated intra vascular Malnutrition Starvation

coagulopathy

Dysrhythmia

End-stage liver disease

End-stage renal disease

Epidural hematoma

Exsanguination

Failure to thrive

Metabolic encephalopathy

Multiorgan failure

Multisystem organ failure

Myocardial infarction Necrotizing soft-tissue infection

Old age

Subdural hematoma

Subarachnoid

hemorrhage

Sudden death Thrombocytopenia

Uncal herniation Urinary tract infection

Fracture Open (or closed) head Ventricular fibrillation

Gangrene

Gastrointestinal

injury

Pancytopenia

Ventricular tachycardia

Volume depletion

hemorrhage

Heart failure

Paralysis

Perforated gallbladder
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. However, when the medical history is examined further it may be 

found to be complications of an injury or poisoning (possibly occurring 

long ago). Such cases should be reported to the medical examiner or 

coroner. 

Asphyxia

Bolus

Choking

Drug or alcohol overdose/drug or alcohol abuse

Epidural hematoma

Exsanguination

Fall

Fracture

Hip fracture

Hyperthermia

Hypothermia

Open reduction of fracture

Pulmonary emboli

Seizure disorder

Sepsis

Subarachnoid hemorrhage Subdural hematoma

Surgery

Thermal burns/chemical burns

Additional resources

In addition to the series of handbooks, additional resources include manuals, guidelines, and Web sites (7–15). Resources on completing death certificates should be kept with or near blank death certificates for easy 

reference. Additional copies of government-produced resources are available from the State vital statistics offices, the National Center for Health 

Statistics, and the Internet at http://www.cdc.gov/nchs (under vital statistics, mortality, writing cause-of-death statements). 

33
Completing Other Items on the Death Certificate

These instructions pertain to the 2003 revision of the

U.S. Standard Certificate of Death.

NAME OF DECEDENT: For use by physician or institution

The left-hand margin of the certificate contains a line where the physician 

or hospital can write in the name of the decedent. This allows the hospital 

to assist in completing the death certificate before the body is removed by 

the funeral director. However, because the funeral director is responsible 

for completion of the personal information about the decedent and because the hospital frequently does not have the complete legal name of the 

decedent, the hospital or physician should enter the name they have for 

the decedent in this item. The funeral director will then enter the full legal 

name in item 1. 

14. PLACE OF DEATH (Check only one; see instructions)

Check the type of place where the decedent was pronounced dead. 

Hospital deaths

If the decedent was pronounced dead in a hospital, check the box indicating the decedent’s status at the hospital: Inpatient, Emergency Room/ 

Outpatient (ER) or Dead on Arrival (DOA). Hospitals are licensed institutions 

providing patients diagnostic and therapeutic services by a medical staff. 

Nonhospital deaths

If the decedent was pronounced dead somewhere else, check the box 

indicating whether pronouncement occurred at a Hospice facility, Nursing 

home/Long-term care facility, Decedent’s home, or other location. 

Hospice facility refers to a licensed institution providing hospice care (e.g., 

palliative and supportive care for the dying), not to hospice care that might 

be provided in a number of different settings, including a patient’s home. 

34
If death was pronounced at a licensed long-term care facility, check the 

box that indicates Nursing home/Long term care facility. A long-term care 

facility is not a hospital, but provides patient care beyond custodial care 

(e.g., nursing home, skilled nursing facility, long-term care facilities, convalescent care facility, extended care facility, intermediate care facility, 

residential care facility, congregate care facility). 

If death was pronounced in the decedent’s home, check the box that 

indicates decedent’s home. A decedent’s home includes independent living 

units including private homes, apartments, bungalows, and cottages. 

If death was pronounced at a licensed ambulatory/surgical center, orphanage, prison ward, public building, birthing center, facilities offering housing and custodial care, but not patient care (e.g., board and care home, 

group home, custodial care facility, foster home), check ‘‘Other (Specify).’’ 

If ‘‘Other (Specify)’’ is checked, specify where death was legally pronounced, such as a prison ward, physician’s office, the highway where a 

traffic accident occurred, a vessel, orphanage, group home, or at work. 

If the place of death is unknown, but the body is found in a State, enter the 

place where the body is found as the place of death. 

15. FACILITY NAME (If not an institution, give street and number)

Institution deaths

If the death occurred in a hospital, enter the full name of the hospital. 

If death occurred en route to or on arrival at a hospital, enter the full name 

of the hospital. Deaths that occur in an ambulance or emergency squad 

vehicle en route to a hospital fall in this category. 

If the death occurred in another type of institution such as a nursing 

home, enter the name of the institution where the decedent died. 

Noninstitution deaths

If the death occurred at home, enter the house number and street name. 

If the death occurred at some place other than those described above, 

enter the number and street name of the place or building (if at a building) 

where the decedent died. 

If the death occurred on a moving conveyance, enter the name of the 

vessel, for example, S.S. Olive Seas (at sea) or ‘‘Eastern Airlines Flight 296 

(in flight).’’ 

35
16. CITY OR TOWN, STATE, AND ZIP CODE

Enter the name of the city, town, village, or location, State, and zip code 

where death occurred. 

17. COUNTY OF DEATH

Enter the name of the county of the institution or address given in item 15 

where death occurred. If the death occurred on a moving conveyance in 

the United States and the body is first removed from the conveyance in 

this State, complete a death certificate and enter as the place of death the 

address where the body was first removed from the conveyance. 

If the death occurred on a moving conveyance in international waters, 

international airspace, or in a foreign country or its airspace, and the body 

is first removed from the conveyance in this State, register the death in 

this State, but enter the actual place of death insofar as can be determined. 

These items are used to identify the place of death to determine who has

jurisdiction for deaths that legally require investigation by a medical examiner or coroner. These items are also used for research and statistics comparing hospital and nonhospital deaths. Valuable information is also provided

for health planning and the utilization of health facilities.

Items on when death occurred

Items 24 and 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. In all other cases, the certifier completes Items 24, 

25, 29–37, and 45–49, and Items 26–28 are left blank. 

24. DATE PRONOUNCED DEAD (Month, Day, and Year)

Enter the exact month, day, and four-digit year that the decedent was 

pronounced dead. Complete this item even when it is the same as Item 29, 

the actual or presumed date. 

Enter the full name of the month—January, February, March, etc. Do not 

use a number or abbreviation to designate the month. 

This is used to identify the date the decedent was legally pronounced dead.

This information is very helpful in those cases where a body of a person

who has been dead for some time is found and the death is pronounced by

a medical examiner or coroner.

36
25. TIME PRONOUNCED DEAD

Enter the exact time (hour and minute using a 24-hour clock) the decedent

was pronounced dead according to local time. If daylight saving time is the

official prevailing time where death occurs, it should be used to record the

time of death. Be sure to indicate the time using a 24-hour clock.

A death that occurs at 2400 or 0000 midnight belongs to the start of the

new day. One minute after 12 midnight is entered as 0001 of the new day.

If the exact time of death is unknown, the time should be approximated by

the person who pronounces the body dead. ‘‘Approx’’ should be placed

before the time.

26–28 PRONOUNCING PHYSICIAN ONLY

Items 26–28 are to be completed only when the physician responsible for

completing the medical certification of cause of death is not available at

the time of death to certify the cause of death and when State law provides

for a pronouncing physician. In this situation, a pronouncing physician is

the person who determines that the decedent is legally dead, but who was

not in charge of the patient’s care for the illness or condition that resulted

24-hour clock 12-hour clock

0000 (medical facilities);

2400 (military facilities)

12 midnight

0100 1:00 a.m.

0200 2:00 a.m.

0300 3:00 a.m.

0400 4:00 a.m.

0500 5:00 a.m.

0600 6:00 a.m.

0700 7:00 a.m.

0800 8:00 a.m.

0900 9:00 a.m.

1000 10:00 a.m

1100 11:00 a.m.

1200 12 noon

1300 1:00 p.m.

1400 2:00 p.m.

1500 3:00 p.m.

1600 4:00 p.m.

1700 5:00 p.m.

1800 6:00 p.m.

1900 7:00 p.m.

2000 8:00 p.m.

2100 9:00 p.m.

2200 10:00 p.m.

2300 11:00 p.m

37
in death. This hospital physician certifies to the fact and time of death 

(Items 24 and 25) and signs and dates the death certificate (Items 26–28) 

so the body can be released to the funeral director when the attending 

physician is not available. The attending physician is still responsible for 

completing the cause-of-death section (Item 32). See Part II of this handbook for a more detailed discussion of the completion of Item 32. 

COMPLETE ITEMS 26–28 ONLY WHEN CERTIFYING PHYSICIAN IS NOT 

AVAILABLE AT TIME OF DEATH CERTIFY CAUSE OF DEATH 

26. SIGNATURE OF PERSON PRONOUNCING DEATH (Only when

applicable)

Obtain the signature and the degree or title of the physician who pronounces death in ink. This physician certifies to the time, date, and place 

of death only. Rubber stamps or facsimile signatures are not permitted on 

paper certificates. Jurisdictions with electronic death certificates may have 

other ways to authenticate the certification than by using a signature. 

27. LICENSE NUMBER (Only when applicable)

Enter the State license number of the physician who pronounces death.

28. DATE SIGNED (Month, Day, and Year) (Only when applicable)

Enter the exact month, day, and year that the pronouncing physician 

signs the certificate. Do not use a number to designate the month. 

IF THE ATTENDING PHYSICIAN IS AVAILABLE TO CERTIFY THE FACT OF 

DEATH, ITEMS 26–28 SHOULD NOT BE COMPLETED; IF AVAILABLE, 

THE ATTENDING PHYSICIAN SHOULD COMPLETE ITEMS 24, 25, 29–37, 

AND 45–49 AS BOTH PRONOUNCING AND CERTIFYING PHYSICIAN. 

This information is useful for the quality control program indicating that the

medical certification was provided by the attending physician.

Items 24 and 25 must be completed by the person who pronounces death— 

the pronouncing physician, pronouncing/certifying physician, or medical 

examiner or coroner. 

29. ACTUAL OR PRESUMED DATE OF DEATH (Month, Day, and Year)

Enter the exact month, day, and year that death occurred. 

Enter the full name of the month—January, February, March, etc. Do not 

use a number or abbreviation to designate the month. 

38
Pay particular attention to the entry of month, day, and year when the

death occurs around midnight or December 31. Consider a death at midnight to have occurred at the beginning of the next day rather than the end

of the previous day. For example, the date for a death that occurs at 11:59

p.m. or 2359 on December 31 should be recorded as December 31 while

those occurring the next minute 0000 should be recorded as January 1.

If the exact date of death is unknown, it should be approximated by the

person completing the medical certification. ‘‘Approx’’ should be placed

before the date. If date cannot be determined by approximating, the date

found should be entered and identified as such.

This item is used in conjunction with the hour of death to establish the exact

time of death of the decedent. Epidemiologists also use date of death in

conjunction with the cause-of-death section for research on intervals between injuries, onset of conditions, and death.

30. ACTUAL OR PRESUMED TIME OF DEATH

Enter the exact time (hour and minute using a 24-hour clock) of death

according to local time. If daylight saving time is the official prevailing time

where death occurs, it should be used to record the time of death. Be sure

to indicate the time using a 24-hour clock.

24-hour clock 12-hour clock

0000 (medical facilities);

2400 (military facilities)

12 midnight

0100 1:00 a.m.

0200 2:00 a.m.

0300 3:00 a.m.

0400 4:00 a.m.

0500 5:00 a.m.

0600 6:00 a.m.

0700 7:00 a.m.

0800 8:00 a.m.

0900 9:00 a.m.

1000 10:00 a.m

1100 11:00 a.m.

1200 12 noon

1300 1:00 p.m.

1400 2:00 p.m.

1500 3:00 p.m.

1600 4:00 p.m.

1700 5:00 p.m.

1800 6:00 p.m.

1900 7:00 p.m.

2000 8:00 p.m.

2100 9:00 p.m.

2200 10:00 p.m.

2300 11:00 p.m

39
A death that occurs at 2400 or 0000 midnight belongs to the start of the 

new day. One minute after 12 midnight is entered as 0001 of the new day. 

If the exact time of death is unknown, the time should be approximated by 

the person who certifies the death. ‘‘Approx’’ should be placed before the 

time. 

This item establishes the exact time of death, which is important in inheritance cases when there is a question of who died first. This is often important in the case of multiple deaths in the same family.

31. WAS MEDICAL EXAMINER OR CORONER CONTACTED?

Enter ‘‘Yes’’ if the medical examiner or coroner was contacted in reference 

to this case. Otherwise enter ‘‘No.’’ Do not leave this item blank. 

In cases of accident, suicide, or homicide, the medical examiner or coroner 

must be notified. 

This item records whether the medical examiner or coroner was informed

when the circumstances require such action. In such cases, the physician

must ensure that this is done.

32. CAUSE OF DEATH

Detailed instructions for this item, together with case records, are contained in the section on Medical Certification of Death in this handbook. 

These items are to be completed by the attending physician or medical 

examiner or coroner certifying or reporting his or her opinion on the cause 

of death. 

Part I. Enter the chain of events—diseases, injuries, or complications—that directly caused the death. DO NOT enter terminal events such as cardiac arrest,

respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT

ABBREVIATE. Enter only one cause on a line. Add additional lines if necessary.

The cause of death means the disease, abnormality, injury, or poisoning 

that caused the death, not the mechanism of death, such as cardiac or 

respiratory arrest, shock, or heart failure. 

40
In Part I, the immediate cause of death (final disease or condition resulting 

in death) is reported on line (a). Antecedent conditions, if any, that gave 

rise to the cause are reported on lines (b), (c), and (d). The underlying 

cause (disease or injury that initiated events resulting in death) should be 

reported on the last line used in Part I. No entry is necessary on lines (b), 

(c), and (d) if the immediate cause of death on line (a) describes completely 

the sequence of events. ONLY ONE CAUSE SHOULD BE ENTERED ON A 

LINE. 

Provide the best estimate of the interval between the onset of each condition and death. Do not leave the space for the interval blank; if unknown, 

so specify. 

Part II. Enter other significant conditions contributing to death but not resulting in

the underlying cause given in Part I.

In Part II, enter other important diseases or conditions that contributed to 

death but did not result in the underlying cause of death given in Part I. 

Cause of death is the most important statistical research item on the death

certificate. It provides medical information that serves as a basis for describing trends in human health and mortality and for analyzing the conditions

leading to death. Mortality statistics provide a basis for epidemiological

studies that focus on leading causes of death by age, race, or sex (for

example, HIV, heart disease, and cancer). They also provide a basis for

research in disease etiology and evaluation of diagnostic techniques, which

in turn lead to improvements in patient care.

All conditions reported are important and are analyzed. For example, analyses may examine associations between conditions reported on the same

death certificates such as types of conditions reported in combination with

hepatitis.

33. WAS AN AUTOPSY PERFORMED?

Enter ‘‘Yes’’ if a partial or complete autopsy was performed. Otherwise 

enter ‘‘No.’’ 

An autopsy is important in giving additional insight into the conditions that

lead to death. This additional information is particularly important in arriving at the immediate and underlying causes when the cause is not immediately clear.

41
34. WERE AUTOPSY FINDINGS AVAILABLE TO COMPLETE THE CAUSE

OF DEATH?

Enter ‘‘Yes’’ if the autopsy findings were available at the time that cause of 

death was determined. Otherwise enter ‘‘No.’’ Leave this item blank if no 

autopsy was performed. 

This information assists in determining whether, for the 9 percent of cases

for which an autopsy is done, the information was available to assist in

determining the cause of death. Knowing whether the autopsy results were

available for determining the cause of death gives insight into the quality of

the cause-of-death data.

35. DID TOBACCO USE CONTRIBUTE TO DEATH?

Check ‘‘Yes’’ if, in the physician’s opinion, any use of tobacco or tobacco 

exposure contributed to death. For example, tobacco use may contribute 

to deaths due to emphysema or lung cancer. Tobacco use also may contribute to some heart disease and cancers of the head and neck. Tobacco 

use should also be reported in deaths due to fires started by smoking. 

Check ‘‘Yes,’’ if in the physician’s clinical judgment, tobacco use contributed to this particular death. Check ‘‘No,’’ if, in the physician’s opinion, the 

use of tobacco did not contribute to death. 

36. IF FEMALE, WAS DECEDENT PREGNANT AT TIME OF DEATH OR

WITHIN PAST YEAR?

If the decedent is a female, check the appropriate box in Item 36. If the 

decedent is a male, leave the item blank. If the female is either too old or 

too young to be fecund, check the ‘‘Not pregnant within the past year’’ box. 

This information is important in determining the scale of mortality amongst this

population and will be of assistance with maternal mortality review programs.

37. MANNER OF DEATH

42
Complete this item for all deaths. Check the box corresponding to the 

manner of death. Deaths not due to external causes should be identified 

as ‘‘Natural.’’ Usually, these are the only types of deaths a physician will 

certify. 

Indicate ‘‘Pending investigation’’ if the manner of death cannot be determined to be accident, homicide, or suicide 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. 

In cases of accidental death, this information is used to justify the payment

of double indemnity on life insurance policies. It is also used to obtain a

more accurate determination of cause of death.

All deaths due to external causes must be referred to the medical examiner 

or coroner. If the manner of death checked in Item 37 was anything other 

than natural, Items 38–44 must be completed. If a situation ever arises 

where the physician must complete the cause, manner, and circumstances (Items 32, 37, and 38–44) of death in an accidental case, please 

refer to the Medical Examiners’ and Coroners’ Handbook on Death Registration and Fetal Death Reporting. Case histories with properly completed 

death certificates are also included in that handbook. 

The National Association of Medical Examiners have put together a guide 

on how manner of death may be determined (6). In certain cases, there is 

a conflict between the manner of death preferred by the medical examiner 

community and the disease classification. As a result, it is important to 

specify the circumstances involved so that both communities are able to 

make use of the information. 

38–44 ACCIDENT OR INJURY—To be filled out in all cases of

deaths due to injury or poisoning

Complete these items in cases where injury caused or contributed to the 

death. All deaths resulting from injury must be reported to a medical 

examiner or coroner, who will usually certify to the cause of death. However, there may be instances in which a medical examiner or coroner will 

not assume jurisdiction and the attending physician will certify to an 

accidental death. In these cases when the manner of death is anything 

other than natural, the attending physician is to complete Items 38–44. 

43
38. DATE OF INJURY (Month, Day, and Year)

Enter the exact month, day, and year that the injury occurred. Enter the

full name of the month—January, February, March, etc. Do not use a

number or abbreviation to designate the month.

The date of injury may not necessarily be the same as the date of death.

Estimates may be provided with ‘‘Approx’’ placed before the date.

39. TIME OF INJURY

Enter the exact time (hour and minute using a 24-hour clock) when the

injury occurred, according to local time. If daylight saving time is the

official prevailing time where death occurs, it should be used to record the

time of death. Be sure to indicate the time using a 24-hour clock.

If the exact time of death is unknown, the time should be approximated by

the person who certifies the death. ‘‘Approx’’ should be placed before the

time.

The date of injury may differ from the date of death.

24-hour clock 12-hour clock

0000 (medical facilities);

2400 (military facilities)

12 midnight

0100 1:00 a.m.

0200 2:00 a.m.

0300 3:00 a.m.

0400 4:00 a.m.

0500 5:00 a.m.

0600 6:00 a.m.

0700 7:00 a.m.

0800 8:00 a.m.

0900 9:00 a.m.

1000 10:00 a.m

1100 11:00 a.m.

1200 12 noon

1300 1:00 p.m.

1400 2:00 p.m.

1500 3:00 p.m.

1600 4:00 p.m.

1700 5:00 p.m.

1800 6:00 p.m.

1900 7:00 p.m.

2000 8:00 p.m.

2100 9:00 p.m.

2200 10:00 p.m.

2300 11:00 p.m

44
40. PLACE OF INJURY (e.g., Decedent’s home, construction site,

restaurant, wooded area)

Enter the general type of place (such as restaurant, vacant lot, baseball 

field, construction site, office building, or decedent’s home) where the 

injury occurred. DO NOT enter firm or organization names. (For example, 

enter ‘‘factory,’’ not ‘‘Standard Manufacturing, Inc.’’) 

41. INJURY AT WORK?

Complete if anything other than natural disease is mentioned in Part I or 

Part II of the medical certification (Item 32), including homicides, suicides, 

and accidents or if anything other than ‘‘Natural’’ is checked for manner of 

death (Item 37). This includes all motor vehicle deaths. The item must 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 while working or in vocational training on 

job premises 

Injury while on break or at lunch or in parking 

lot on job premises Injury while working for pay or compensation, 

including at home 

Injury while working as a volunteer law enforcement 

official etc. 

Injury while traveling on business, including to or from business contacts 

Injury not at work Injury while engaged in personal recreational activity on 

job premises 

Injury while a visitor (not on official work business) to job 

premises Homemaker working at homemaking activities 

Student in school Working for self for no profit (mowing yard, repairing own 

roof, hobby) 

Commuting to or from work 

These guidelines were developed jointly by: The National Association for Public Health Statistics and 

Information Systems (NAPHSIS), the National Institute of Occupational Safety and Health (NIOSH), 

the National Center for Health Statistics (NCHS), and the National Center for Environmental Health and Injury Control (NCEHIC). For questions contact the State vital statistics office. 

42. LOCATION OF INJURY (Street and Number, City or Town, State,

Apartment No., ZIP Code)

Enter the complete address where the injury took place, including ZIP 

code. Fill in as many of the items as is known. 

43. DESCRIBE HOW INJURY OCCURRED

Enter, in narrative form, a brief but specific and clear description of how 

the injury occurred. Explain the circumstances or cause of the injury, 

45
such as ‘‘fell off ladder while painting house,’’ ‘‘driver of car ran off roadway,’’ or ‘‘passenger in car in car -truck collision.’’ Specify type of gun (e.g., 

handgun, hunting rifle) or type of vehicle (e.g., car, bulldozer, train, etc.) 

when relevant to circumstances. Indicate if more than one vehicle was 

involved; specify type of vehicle decedent was in. For motor vehicle accidents, indicate whether the decedent was a driver, passenger, or pedestrian. 

If known, indicate what activity the decedent was engaged in when the 

injury occurred (e.g., playing a sport, working for income, hanging out at a 

bar). 

In cases of accidental death, Items 38–43 are used in justifying the payment of double indemnity on life insurance policies. They are also needed

for a more accurate determination of causes of death. Information from

these items forms the basis of statistical studies of occupational injuries.

44. IF TRANSPORTATION INJURY, SPECIFY:

Specify role of decedent (e.g., driver, passenger) in the transportation accident. ‘‘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’’) 

but are not bonafide passengers or drivers. 

Details will help assign deaths to categories that may be used to assess

trends and effectiveness of safety programs.

45–49 CERTIFIER

45. CERTIFIER (Check only one)

The Certifying physician is the person who determines the cause of death 

(Item 32). This box should be checked only in those cases when the person 

46
who is completing the medical certification of cause of death is not the 

person who pronounced death (Items 24 and 25). The certifying physician 

is responsible for completing Items 32–49. 

The Pronouncing & Certifying physician box should be checked when the 

same person is responsible for completing Items 24 through 49, that is, 

when the same physician has both pronounced death and certified to the 

cause of death. If this box is checked, Items 26–28 should be left blank. 

The Medical Examiner/Coroner box should be checked when investigation 

is required by the Post Mortem Examination Act and the cause of death is 

completed by a medical examiner or coroner. The medical examiner or 

coroner is then responsible for completing Items 24–46. 

If the attending physician is available to certify the fact of death, Items 

26–28 should not be completed; the attending physician should then 

complete Items 24, 25, 29–37, and 45–49 as both pronouncing and certifying physician. 

The two-physician certifier concept allows a hospital physician to certify to

only the fact and time of death so the body can be released to the funeral

director. The attending physician should complete the cause-of-death section. This certification method should result in improved data on cause of

death because the physician having the most knowledge about the case

completes the cause-of-death section.

Signature of certifier

The physician who certifies to the cause of death in Item 32 signs the 

certificate in permanent black ink. Jurisdictions with an electronic death 

certificate may allow electronic authentication. The degree or title of the 

physician should also be indicated. Rubber stamps or facsimile signatures 

are not permitted. 

46. NAME, ADDRESS, AND ZIP CODE OF PERSON COMPLETING CAUSE

OF DEATH (ITEM 32)

Type or print the full name and address of the person whose signature or 

authentication appears in Item 45. 

This information is used by the State office of vital statistics for querying the

certifier when a question about cause of death arises.

48. LICENSE NUMBER

Enter the State license number of the physician who signs or authenticates the certificate in Item 45. 

47
This number assists in State quality control programs when it is necessary

to contact the certifier for additional information concerning the death.

49. DATE CERTIFIED (Month, Day, and Year)

Enter the exact month, day, and year that the certifier signed the certificate. 

Enter the full name of the month—January, February, March, etc. Do not 

use a number or an abbreviation to designate the month. 

These items are of legal value in attesting that the medical certification was

completed and signed within the time limit required by statute.

48
References

1.Pates RD, Scully KW, Einbinder JS, et al. Adding value to clinical data by 

linkage to a public death registry. Medinfo 2001. London. 2001. 

2.National Center for Health Statistics. Report of the panel to evaluate the U.S. 

standard certificates. Hyattsville, Maryland. 2000. (Addenda, 2001). 

3.Hetzel AM. History and organization of the vital statistics system. National 

Center for Health Statistics. Hyattsville, Maryland. 1997. 

4.National Center for Health Statistics. Model State vital statistics act and 

regulations: 1992 revision. Hyattsville, Maryland: Public Health Service. 1995. 

5.World Health Organization. International statistical classification of diseases 

and related health problems, tenth revision. Geneva: World Health Organization. 1992. 

6.Hanzlick R, Hunsaker III JH, Davis G J. A guide for manner of death classification. NAME. 2002. Accessed at http://www.thename.org/Library/Manner_ 

of_deathv1.pdf on 4/16/2002. 

7.National Center for Health Statistics. Instructions for completing the causeof-death section of the death certificate. Hyattsville, Maryland: National Center for Health Statistics. Accessed at http://www.cdc.gov/nchs/about/major/ 

dvs/handbk.htm on 4/16/2002. 

8.National Center for Health Statistics. Instructions for completing the causeof-death section of the death certificate for injury and poisoning. Hyattsville, 

Maryland: National Center for Health Statistics. Accessed at http://www.cdc. 

gov/nchs/about/major/dvs/handbk.htm on 4/16/2002. 

9.National Center for Health Statistics. Possible solutions to common problems 

in death certification. Hyattsville, Maryland: National Center for Health Statistics. Accessed at http://www.cdc.gov/nchs/about/major/dvs/handbk.htm on 

4/16/2002. 

10.Hanzlick R. Writing cause-of-death statements. St. Louis, MO: National Association of Medical Examiners. Accessed at http://www.thename.org/ 

CauseDeath/COD_main_page.htm on 5/7/2002. 

11.Hanzlick R (Ed). The medical cause-of-death manual. Northfield, Illinois: College of American Pathologists. 

12.Hanzlick R (Ed). Cause-of-death statements and certification of natural and 

unnatural deaths. Northfield, Illinois: College of American Pathologists. 1997. 

13.Texas Department of Health. Online CME medical certification of cause and 

manual of death. Accessed at http://www.tdh.state.tx.us/phpep/cme/cme_dc/ 

default.html on 4/20/2002. 

49
14. National Center for Health Statistics. Cause-of-death module. Hyattsville, Maryland: National Center for Health Statistics. Accessed at http://www.cdc.gov/ 

nchs/data/dvs/edc6.pdf on 4/20/2002. 

15.National Center for Health Statistics. Mortality Web page. Hyattsville, Maryland: National Center for Health Statistics. Accessed at http://www.cdc.gov/ 

nchs/about/major/dvs/mortdata.htm on 4/20/2002. 

50
Appendixes

A. The U.S. Standard Certificate of Death ........................ 52

B. The Vital Statistics Registration System in the United States . . . 54

51
Appendix A

U.S. Standard Certificate of Death

52
53
Appendix B

The Vital Statistics Registration System in the United States

The registration of births, deaths, fetal deaths, and other vital events1 in 

the United States is a State and local function. The civil laws of every State 

provide for a continuous, permanent, and compulsory vital registration 

system. Each system depends to a very great extent upon the conscientious efforts of the physicians, hospital personnel, funeral directors, coroners, and medical examiners in preparing or certifying information needed 

to complete the original records. For a graphic presentation of the registration system, see the accompanying chart, ‘‘The Vital Statistics Registration System in the United States.’’ 

Most States are divided geographically into local registration districts or 

units to facilitate the collection of vital records. A district may be a township, village, town, city, county, or other geographic area or a combination 

of two or more of these areas. In some States, however, the law provides 

that records of birth, death, and/or fetal death be sent directly from the 

reporting source (hospital, physician, or funeral director) to the State vital 

statistics office. In this system, functions normally performed by a local 

registration official are assumed by the staff of the State office. 

In States with a local registrar system, the local registrar collects the 

records of events occurring in his or her area and transmits them to the 

State vital statistics office. The local registrar is required to see that a 

complete certificate is filed for each event occurring in that district. In 

many States, this official also has the duty of issuing burial-transit permits to authorize the disposition of dead human bodies. In many States, 

this official is also required to keep a file of all events occurring within his 

or her district and, if authorized by State law and subject to the restrictions on issuance of copies as specified by the law, may be permitted to 

issue copies of these records. 

1

Vital events are defined as live births, deaths, fetal deaths, marriages, divorces, and induced terminations of

pregnancy, together with any change in civil status that may occur during an individual’s lifetime.

54
The State vital statistics office inspects each record for promptness of 

filing, completeness, and accuracy of information; queries for missing or 

inconsistent information; numbers the records; prepares indexes; processes the records; and stores the documents for permanent reference and 

safekeeping. Statistical information from the records is tabulated for use 

by State and local health departments, other governmental agencies, and 

various private and voluntary organizations. The data are used to evaluate 

health problems and to plan programs and services for the public. An 

important function of the State office is to issue certified copies of the 

certificates to individuals in need of such records and to verify the facts of 

birth and death for agencies requiring legal evidence of such facts. 

The Centers for Disease Control and Prevention’s National Center for 

Health Statistics (NCHS) is vested with the authority for administering the 

vital statistics functions at the national level (3). Electronic data files 

derived from individual records registered in the State offices or, in a few 

cases, copies of the individual records themselves, are transmitted to 

NCHS. From these data, monthly, annual, and special statistical reports 

are prepared for the United States as a whole and for the component 

parts—cities, counties, States, and regions—by various characteristics 

such as sex, race, and cause of death. These statistics are essential in the 

fields of social welfare, public health, and demography. They are also used 

for various administrative purposes, in both business and government. 

NCHS serves as a focal point, exercising leadership in establishing uniform practices through model laws, standard certificate forms, handbooks, and other instructional materials for the continued improvement of 

the vital statistics system in the United States. 

55
56

The Vital Statistics Registration System in the United States

Responsible

Person or Birth Death Fetal

Agency Certificate Certificate Death Report

Hospital authority 1. Completes entire certificate using When death occurs in hospital, may 1. Completes entire report using patient

mother and facility worksheets. initiate preparation of certificate: and facility worksheets.

2. Files certificate with local office Completes information on name, date, 2. Obtains cause of fetal death from

or State office per State law. and place of death; obtains certification of physician.

cause of death from physician; and gives 3. Obtains authorization for final

certificate to funeral director. disposition of fetus.

NOTE: If the attending physician is

unavailable to certify to the cause of

4. Files report with local office or State

office per State law.

death, some States allow a hospital

physician to certify to only the fact and

time of death. With legal pronouncement

of the death and permission of the

attending physician, the body can then

be released to the funeral director. The

attending physician still must complete

the cause-of-death section prior to final

disposition of the body.

Funeral director 1. Obtains personal facts about decedent If fetus is to be buried, the funeral director

and completes certificate. is responsible for obtaining authorization

2. Obtains certification of cause of death for final disposition.

from attending physician or medical

examiner or coroner. NOTE: In some States, the funeral

3. Obtains authorization for final disposition director, or person acting as such, is

per State law. responsible for all duties shown above

4. Files certificate with local office or State under hospital authority. ⇓ 

office per State law.

Physician or other For in-hospital birth, verifies accuracy Completes certification of cause of death Provides cause of fetal death and

professional attendant of medical information and signs and signs certificate. information not available from the medical

certificate. For out-of-hospital birth, records.

duties are same as those for hospital

authority, shown above.
Local office** (may be local

registrar or city or county

health department)

1. Verifies completeness and

accuracy of certificate and queries

incomplete or inconsistent certificates.

2. If authorized by State law, makes

copy or index for local use.

3. Sends certificates to State registrar.

1. Verifies completeness and accuracy of

certificate and queries incomplete or

inconsistent certificates.

2. If authorized by State law, makes copy

or index for local use.

3. If authorized by State law, issues

authorization for final disposition on receipt

of completed certificate.

4. Sends certificates to State registrar.

If State law requires routing of fetal death

reports through local office, the local office

performs the same functions as shown for

the birth and death certificate.

City and county health

departments

1. Use data derived from these records in allocating medical and nursing services.

2. Follow up on infectious diseases.

3. Plan programs.

4. Measure effectiveness of services.

5. Conduct research studies.

State registrar, office of vital

statistics

1. Queries incomplete or inconsistent information.

2. Maintains files for permanent reference and is the source of certified copies.

3. Develops vital statistics for use in planning, evaluating, and administering State and local health activities and for research

studies.

4. Compiles health-related statistics for State and civil divisions of State for use of the health department and other agencies

and groups interested in the fields of medical science, public health, demography, and social welfare.

5. Sends data for all events filed to the National Center for Health Statistics.

Centers for Disease Control

and Prevention, National

Center for Health Statistics

1. Evaluates quality of State vital statistics data and works with States to assure quality.

2. Compiles national statistical data file and runs edits to fully process data.

3. Prepares and publishes national statistics of births, deaths, and fetal deaths; constructs the official U.S. life tables and related

actuarial tables.

4. Conducts health and social research studies based on vital records and on sampling surveys linked to records.

5. Conducts research and methodological studies in vital statistics methods, including the technical, administrative, and legal

aspects of vital records registration and administration.

6. Maintains a continuing technical assistance program to improve the quality and usefulness of vital statistics.

7. Provides leadership and coordination in the development of standard certificates and report and model laws.

** Some States do not have local vital registration offices. In these States, the certificates or reports are transmitted directly to the State office of vital

statistics.

57
DHHS Publication No. (PHS) 2003-1108

03-0002 (4/2003)