The 19?8 Revision

of the U.S.

Standard

Certificates

This report examines the procedures followed

in the 1978 revision of the U.S. Standard

certificates of Live Birth, Death, Fetal Death,

Marriage, and Divorce or Annulment. It

outlines the history and basic principles of the

standard certificates and the major objectives

of this revision; describes the principal

additions, modifications, and deletions of

items; and discusses changes in fetal death

reporting as well as the implementation of the

new certificates and reporting forms.

Documents and Committee Reports

Series 4, No. 23

DHHS Publication No. [PH!3) 83-1460

US Department of Health and Human

Services

Public Health Service

National Center for Health Statistics

Hyattsville, Maryland

February 1983
COPYRIGHT INFORMATION

All material appearing in this report is in the public domain and may be

reproduced or copied without permission; citation as to source,

however, is appreciated.

SUGGESTED CITATION

National Center for Health Statistics, M. L, Dundon, G, A. Gay, and J. L.

George: The 1978 revision of the US. standard certificates. Vita/ and

/-/es/fh Sfafisfics. Series 4-No. 23, DHHS Pub. No, (PHS) 83-1460.

Public Health Service. Washington, US. Government Printing Office,

February 1983.

Libra~ of Congress Cataloging in Publication Data

National Center for Health Statistics (U. S.)

The 1978 revision of the U.S. standard certificates.

(Vital and health statistics. Series 4, Documents and committee

reports; no. 23) (DHHS publication: no. (PHS) 83-1460)

Authors Mary Lou Dundon, George A. Gay, and Jean L. George.

Supt. of Dots. no.: HE 20.62094/23

1. Registers of births, etc.—United States. 1, Dundon, Mary Lou. Il.

Gay, George A. Ill. George, Jean L. IV. Title. V. Series: V1. Series: DHHS

publication; no. (PHS) 83-1460. (DNLM: 1. Birth certificates. 2. Death

certificates. 3. Marriage. 4. Divorce. 5. Records—Standards. W2 A

N148vd No. 23)

HA37.U1693 no. 23 (HA38) 312’.0973s 82-600302

ISBN 0-8406-0268-5 (353.0081’9)
National Center for Health Statistics

MANNING FEINLEIB, M. D., Dr.P. H., Director

ROBERT A. ISRAEL, Deputy Director

JACOB J. FELDMAN, Ph. D., Associate Director for Analysis

and Epidemiology

GAIL F. FISHER, Ph. D., Associate Director for the

Cooperative Health Statistics System

GARRIE J. LOSEE, Associate Director for Data Processing

and Services

ALVAN O. ZARATE, Ph. D., Assistant Director for

International Statistics

E. EARL BRYANT, Associate Director for Interview and

Examination Statistics

ROBERT L. QUAVE, Acting Associate Director for

Management

MONROE G. SIRKEN, Ph. D., Associate Directorfor

Research and Methodology

PETER L. HURLEY, Associate Director for Vital and

Health Care Statistics

ALICE HAYWOOD, Information Officer

Vital and Health Care Statistics Program

PETER L. HURLEY, Associate Director

GLORIA KAPANTAIS, Assistant to the Director for Data

Policy, Planning, and Ana@sis

Division of Vhal Statistics

JOHN E. PATTERSON, Director

ALICE M. HETZEL, Deputy Director

GEORGE A. GAY, ChieJ Registration Methods Branch
Preface

The content and format of this publication follow

closelythose of an earlier publication, “The 1968Revision

of the Standard Certiilcates: by Robert D. Grove, Ph.D.

(Public Health ServicePublication Number 1000-Series4-

Number 8). The authors wish to acknowledge that contribution to the development of this publication.

...

Ill
History ,,, .,,,,,,, . .. . .. .. . .. . .. .. . . .. . .. . .. .. . .. .. . .. . .. .. . .. . .. . . .. . .. . .. . .. . .. .. . .. . .. .. . .. . .. . .. .. . .. .

Major objectives . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Recommendations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

General recommendations forall record forms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Recommendationsfor revision of the U.S. Standard Certificate of Live Birth . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Recommendations for revision of the U.S. Standard Certificate of Death . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Recommendations for revision of the U.S. Standard Certificate of Marriage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Recommendations forrevisionof the U.S. Standard Certificate of Divorce . . . , . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Changes in fetal death reporting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Recommendations forthe U.S. Standard Report of Fetal Death . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Recommendations for the U.S. Standard Report oflnduced Termination of Pregnancy. . . . . . . . . . . . . . . . . . . . . . .

Other items considered but not recommended . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Implementation ofnewcertificates and reporting forms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Appendixes

1. Technical Consultant Panel onthe Revision ofthe U.S. Standard Certificates and Reports . . . . . . . . . . . . . . . . . . .

Il. Summary of responses to questionnaires on revision ofthe U.S. Standard Certificates . . . . . . . . . . . . . . . . . . . . . . .

Ill. Exhibits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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v
The 1978 Revision of

the U.S. Standard

Certificates

by Mary Lou Dundon, George A. Gay, and Jean L. George,

Division of Vital Statistics

History

The vital statistics ofthe United States are collectedand

published through a decentralized, cooperative system.

Responsibilityfor registration of births, deaths,fetal deaths,

marriages, divorces and annulments, and induced terminations of pregnancy is vested in the individual States and

certain independent registration areas. The registration

system comprises 57 registration areas: each State, the

District of Columbia, New York City, Ameriean Samoa,

Guam, Puerto Rico, the Virgin Islands, and the Trust

Territory of the Pacific Islands. The degree of uniformity

necessary for national statistics has been achieved by

periodic issuance of recommended standards from the

responsible national agency and the cooperative adoption

of these standards by the individual registration areas.

These standards take the form of recommended laws and

regulations (Model State Vital Statistics Act and Regulations), definitions (livebirth, fetal death, and so forth), and

reporting forms (U.S. Standard Certiilcates and Report

Forms).

The standard certificateshave been the principal means

for achieving the uniformity in information upon which

national vitalstatistics are based. To date there have been 10

revisions of the Standard Certifkate of Live Birth, 9

revisionsofthe Standard certificate of Death, 6 revisionsof

the Standard Certificate of Fetal Death (formerly StiUbirth), and 3 revisions of the Standard Certificates of

Marriage and Divorce or Annulment.

The firststandard cetilcates for the registration of vital

events were developed in 1900by the U.S. Bureau of the

Census. These certificateswere used for the registration of

live births and deaths. The 1902 Act of Congress that

established the Bureau ofthe Census as a permanent agency

of the Federal Government included a provision giving the

agency statutory authority for the development of registration areas for births and deaths. The Bureau of the Census

undertook to develop a system for the annual collection of

vital statistics that would produce nationally comparable

data. The overall objective was to develop and maintain a

system of registration uniform in such matters as law,

forms, procedures, and statistical methodology. Maintaining such a system meant periodic reviewsof recommended

standards and revisionsto reflectchanging social conditions

and user demands for data.

The Bureau of the Census retained the authority for

producing national vital statistics until 1946, when the

function was transferred to the U.S. Public Health Service.

It is presently assigned to the Division of Vital Statistics of

the National Center for Health Statistics (NCHS). Authority for this activity by the National Center for

Health Statistics is found in the Public Health Service

Act, 42 USC 242k. This law requires that NCHS collect

data annually from vital records of the States and provide assistance to the States in achieving comparability

of data.

Since the production of national vital stafiitics is

dependent upon cooperation between the Federal agency

and the indkidual registration areas, the development ofthe

standard certificates must be a cooperative effort. In the

revision process opinions are solicited from persons involved in preparation, registration, and tabulation of the

records and from consumers of the data to determine

whether changes need to be made and, if so, where. This

revision process is designed to ensure that the standard

certificates meet, as nearly as possible, the uses for which

they are intended not only at the national levelbut also at

the State and local levels.

The standard certificatesare an integral part ofthe Vital

Statistics Cooperative Program. This program is an endeavor of the National Center for Health Statistics to

cooperate with Federal, State, and local agenciesand other

concerned groups and individuals to improve the quality,

timeliness, and utility of health data. The standard certiilcates represent the minimum basic data set necessaryfor

the collection and publication of comparable national,

State, and local vital statistics data.

The U.S. Standard Certificates and Reports are used as

models for the development of State forms for the

registration of vital events. Because of the many uses made

of the State certi.ilcatesand reports, many factors must be

considered and evaluated in deciding what should be

1
included in the recommended standards. Examples of uses

are:

● The records serve as legal and personal identifkation.

This requires information regarding name, age, and

date and place of occurrenc~ signatures; and addresses.

The individual and numerous public agencies—

schools, welfare departments, Passport Office, Social

SecurityAdministration,and VeteransAdministration—

have a direct interest in information used for legal

purposes.

● The records provide the statistical information needed

by State and local government agencies, particularly

health departments, to plan and evaluate their programs. The specific data needed vary considerably

because of the large differences between States in size

and composition of population, local government

organizations, and magnitude of public programs.

● The records provide vital statistics for the entire

country. These statistics are numerous, varied, and in

many casesrelated to major public programs. Statistics

of births, deaths, marriages, and divorcesare frequently

used in public health research and administration to

measure and analyze rates of population growth and

changes in population composition, to study social

problems (for example, broken families and out-ofwedlock births), and to measure actual or potential

consumers for numerous products and services.

Faced with this myriad of uses of vital records, the

National Center for Health Statistics and the vital statistics

office of each State must make choices regarding the

inclusion or exclusion of data elementsfor each revision of

the standard certiilcates.
Major objectives

In January 1971 the Public Health Conference on

Records and Statistics Standing Committee assigned top

priority to the establishment of a committee to consider

content and format revisionsin the Standard Certificatesof

Live Birth, Death, Fetal Death, Marriage, and Divorce or

Annulment that would go into effect in January 1978.It

was noted by the Standing Committee that interest in vital

statistics was growing in both public and private agencies

and that data collection mechanisms were being developed

in such fields as health, medicine, hospital administration,

and social welfare. Becauseof this development, coordination with the vital statisticssystem was needed. Other areas

of concern that required study included safeguards on

conildentiality and the entire matter of automation.

In 1972the Technical Consultant Panel was appointed

and given the tasks of reviewing the 1968revisions of the

standard certificates and of developing drafts of new

standard certit3cates.The Panel was organized into two

groups. The first group was called the “Parent Group” and

was composed entirely of State vital registration and

statistics executives.This group wasto overseethe revision

process and make the final decisions on what recommendations would be made to NCHS regarding the revisions.

In addition to the Parent Group, a series of “Subgroups” were established. These Subgroups were responsible for reviewingspectilc topics and making recommendations to the Parent Group.

Subgroups wereestablished to reviewand make recommendations on the following subjects: The content of the

birth certificate, the death certificate, the marriage certificate, the divorce or annulment certii%ate, and the fetal

death certificate; and the format of all certificates. Members of the Parent Group were assigned to work on

each of the Subgroups. In addition, persons who are

involved with the completion of the documents or who

use the data derived from the documents were assigned

to the Subgroups. The Subgroups included representatives of the American Medical Association, the American

Hospital Association, the National Funeral Directors

Association, and universities, as well as clerks of court

and medical examiners. The rosters of the membership

of the Parent Group and each of the Subgroups are

shown in appendix I.

The charge given to the Panel by the Public Health

Conference on Records and Statistics Standing Committee

was as follows:

To advise and assist the National Center for Health

Statistics in surveying a wide and representative group

of agencies and individuals; carrying out field tests of

items and formats; developing drafts of certMcatesfor

review, and assisting in drafting final certificate forms,

together with procedures and educational materials,for

initiation and use by the registration areas.

Among the topics to be considered were

●

●

●

●

●

in

Study of the form in which records are prepared to

determine whether the information required for the

legal document might be separate or separable from a

document with information required for generalhealth

statistics purposes.

Design and conduct of programs for testing new and

problematical old items on certifhtes to determine

whether they should be included and offered to the

registration areasfor adoption; development oftabulation plans to accompany standard certitlcates for the

guidance of registration areas.

Design of formats and arrangement of items to

facilitate use of mechanical devicesfor completion and

processing of records.

Development of schemesto facilitate systematic use of

followback surveys on samples of the population in

coordination with continuing and complete registration. In plans for followback studies consideration was

to be given to the needs of the States and cities for

information that would require a substantially larger

sampleand to mechanismsor arrangementsfor cooperative ventures that could be expanded for areas interested and willing to cooperate and pay costs.

ldentK1cation of statutory, regulatory, or administrative changes needed to effect the recommendations.

At the first meeting of the Technical Consultant Panel

1972a timetable was discussed. The schedule called for

recommendations regarding revisions of the standard

certificates and reporting forms to be presented to NCHS

3
by the Panel in late 1975, the work of the NCHS to be

completed in 1976, and the new certificates to be implemented in January 1978.

Since the membership of the Panel was limited in size,

the major tool used in soliciting a wide range ofideas was a

questionnaire that wassent to concerned organizations and

individuals throughout the country. The content of each

questionnaire was decided upon by the Panel members in

consultation with NCHS staff.

The questionnaires were designed to obtain information that would aid in the development of the standard

certificates. Therefore, the questionnaires were sent to

persons and organizations having an interest either in the

records or in the data derived from the records. Viewswere

solicited from those involved in the preparation of the

documents, those involved in the tabulation of the data

derived from the documents, and those using the records

for legal purposes or the data for statistical purposes. In an

effort to ensure adequate representation of these persons

and organizations at the national, State, and locallevels,the

mailing list was developed jointly by NCHS and by the

Registrar of Vital Statistics in each State.

Since vital records are State records and the State

Registrar is the official in each State responsible for the

collection and tabulation of vital statistics, he or she is in a

unique position to know those persons or organizations

within the State whose opinions should be sought during

the development of the standard certi.ticates.Therefore,

each State Registrar was asked to provide a mailing listfor

his or her State.

When the request for the mailing list was sent to the

State Registrars, a list of suggested organizations was

included for their consideration. The list included those

organizations that would be most directly concerned with

the preparation of the the vital records or use of the data

collected from the records. It was not intended that the list

be restrictivein any way, and the registrarswereencouraged

to add to or delete from the list as they felt necessary.

The following are the organizations inch.ded in the

suggested list: State Medical Association; State Funeral

Directors Association; State Hospital Associatio~ State

Medical Record Librarians Association; State Coroners or

Medical Examiners Association; State, County, or City

Clerks Associatiorq Local Registrars Association; County

Judges Association State Bar Associatiory State Hospital

Administrators Association Clerks of Court Association;

and State Osteopathic Association. The registrars werealso

encouraged to include researchersin various professions in

their States who would have an interest in vital statistics.

This procedure was designed to ensure that producers

and users of vital statistics data in all parts of the country

would have an opportunity to offer suggestions. It would

also serve as an aid to State Registrars in the promotion of

the new standard certificates when they went into effectin

1978.They would know the reaction ofthe different groups

within their States toward the various certificates, and this

knowledge should enable them to do a better job.

While the State Registrars are in the best position to

provide the mailing list for each State, the staff of the

Division of Vital Statisticsin NCHS isin a similar position

to identify national organizations and persons of national

prominence whose counsel should be sought. The list that

the staff developed included representatives of those involved in the preparation and collection of vital records and

those who use the records and/or the data. Federal agencies

that have an interest in the records or data were also

included.

The mailing list prepared by NCHS included State

Registrars of Vital Statistics; State Health Officers;American Bar Association, American Medical Association; National Funeral Directors Association; American Hospital

Association National Association of County Recorders

and Clerks; national religious organizations; Population

Association of America; American Public Health Association; American Sociological Association, Centers for

DiseaseControu Passport OfXW,Immigration and Naturalization Servicq Social Security Administration; Bureau of

the Census; the Children’s Bureau, and the National

Organization of Women.

The procedure followed in the development of the

mailing list provided as complete coverage as possible of

those who are involved in vital registration and the

development of vital statistics and of those who utilize the

records and resulting statistics. Appendix 11 shows the

number of questionnaires that were sent out by type of

respondent and the number completed and returned to

NCHS.

The questionnaires asked for opinions regarding the

content of the present standard certificates, proposed

changes, and formatting ofthe cert~lcates.The respondents

were requested to answer some specific questions about

each of the items on the current certifkates and about the

items that were recommended for addition. Space was also

provided for the respondents to indicate any newitemsthey

felt should be added to the certificates.

The questionnaire responses were summarized in a

quantitative manner by the Division of Vital Statistics and

the results provided to the Subgroups. This information

was used in their review of the content and format of the

standard certitlcatesto formulate recommendations to the

Parent Group.

The advice and counsel of persons who must provide

the information called for on the various cetilcates was

sought throughout the review process. The Technical

Consultant Panel and NCHS made every effort to ensure

that the information requested on each of the certikates

wasreasonable and that there was a reasonable expectation

that it could be adequately provided by the respondents.

The advice of all State Registrars of Vital Statistics was

sought during the revision of the standard certificates,The

final documents also were submitted to their national

organization, the American Association for Vital Records

and Public Health Statistics, and to that organization’s

parent organization, the Association of State and Territorial Health Officials,for their endorsement.

4
Recommendations

General recommendations for all

record forms

The following recommendations were made by the

TechnicalConsultant Panel and incorporated into the 1978

revision of the standard reporting forms. For comparison,

an analysis ofthe content of each ofthe standard certificates

by the year it was revised is shown in appendix III.

Formatting relating to all certificates and forms

s

●

●

●

●

The size (7%x 8?$ of the 1968 revision of the U.S.

Standard Cerdtlcatesshould be maintained for the new

revision.

All the forms should have white as their color, with

black type.

Allitemsshould be shown on the front side ofthe form,

and there should be nothing on the reverse side.

The type style used in the present (1968 revision)

certificatesshould be retained for the new revisions.

Considerable discussion centered on whether a multicopy format should be recommended for certain ofthe

standard certflcates. The Panel felt that it should not

recommend this but that a study should be made and a

report published detailing the advantages and disadvantages of multicopy formats with regard to each

certificate.The report should address specifkations for

paper and carbon paper and other points a State

should consider before adopting a multicopy format

for any certitlcate.

Item content relating to all certificates and forms

● Within the items asking for race, the term “Negro”was

deleted and replaced with the term “Black.” This

change was made on all the certiilcates and reporting

forms.

● The Panel considered adding an item to the birth and

death certificatesto collect data on ethnic origin. The

major purpose of this item would be to collect data on

the Hispanic origin population in this country. The

Panel recommended against adding the item to the

standard cert~lcates but did recommend that the five

southwestern States with substantial Hispanic minorities (California, Colorado, New Mexico, Arizona, and

Texas) use the Bureau of the Census list of Hispanic

surnames (this list was used in conjunction with the

1980Census) to develop birth and death statistics for

the Hispanic origin population in their States. Afterthe

recommendations were received from the Panel,

NCHS was asked by organizations interested in Hispanic data to reconsider and add an item to the U.S.

Standard Certificates of Live Birth and Death. Upon

reevaluation, NCHS and the Parent Group of the

Panel decided not to add the item to the standard

certi.ilcatesand developed the following plan to collect

data on the Hispanic origin population:

●

●

●

●

Recommend that the five southwestern States use

the Bureau of the Census list of surnames as

suggested by the Panel.

Work with the five southwestern States and other

States having signiilcant Hispanic origin populations to develop a suitable item for use on birth and

death certitlcates.

Contact all States and apprise them ofthe need for

this data and requestthat theygivestrong consideration to the addition of an item to their certitlcatesto

collectsuch data.

Collect data about this population group on the

NCHS natality and mo~a~ty followback surveys.

. For clarity, the education items were reformatted to

include elementary and high school in one category

rather than two. There was no intent to change the

content of the items. This change was made on all the

certifkates containing the education item.

5
Recommendations for revision of the

U.S. Standard Certificate of Live Birth

See exhibit 1 for final revision

Moditlcations

●

●

●

●

●

●

The certificatewasreformatted by moving the certKlcation statement and registrar information above the

parentage information to make it possible to issue

short-form certifications by photographic means.

The items relating to the certifier were rnodiiied so

that information about the actual attendant can be

obtained.

The pregnancy history items were reformatted and

some changes made. An effort was made to get the

total number of previous pregnancies, including those

that ended in induced abortions. The requirement for

the exact day of pregnancy termination was deleted—

month and year were felt to be sufficient.

The item “Legitimate-Yes or No” was replaced by

the item “Is Mother Married—Yes or No.” Since the

marital status of the mother is the determining factor

for the legitimacy of the child under the laws of almost

all States, the information obtained should be compatible with that collected in the past. Asking the

question about the mother rather than the child

should prove less offensive and thereby result in

higher quality data with more States retaining or

adding the item to their certificates.

The items asking for complications “related to” and

“not related to” pregnancy were modi.tied to clarify

them. It was felt that the previous wording was

confusing and vague and that the changes would

provide better data.

The heading of the conildential portion of the

certificate was changed from “Confidential Information for Medical and Health Use Only” to “Information for Medical and Health Use Only.” Concern was

expressed about the term “confidential” since its

meaning might be interpreted differently by different

people. This difference in interpretation might result

in incomplete or improperly reported information in

this portion of the certificate. The change in heading

adequately indicates how the data are to be used and

that the data should not be included in certitled

copies.

Additions

● The mother’s mailing address was added. It was felt

this item had utility for query and notiilcation

programs and would also aid in obtaining better

quality data in the “usual residence of mother” item.

● The requirement for the signature of the parent or

other informant was added. Requiring the signature

6

rather than just the name should result in better

quality data. A certification statement is included in

this item for the informant to certify that the personal

information on the certiilcate is true to the best of his

or her knowledge and belief.

. Anew item—Apgar score at 1minute and 5minutes—

was added to the certii3cate. Studies have shown this

item to have applicability in the overall study of the

health of the newborn child, and the information

should be readily obtainable.

Deletions

. The item “Inside City Limits” for place of birth was

dropped. It was felt that this item had little utility.

However, the “Inside City Limits” item for place of

residence was retained, since it is a useful item for

Census tract coding and properly assigning events

within a county.

● The item “Birth Injuries” was dropped because it was

so poorly reported as to make it unreliable as a

statistical or medical tool.

Recommendations for revision of the

U.S. Standard Certificate of Death

See exhibit 2 for final revision

The Subgroup recommended that three versions of

the death certificate should be developed as in the past.

The various versions are designed to accommodate those

states that prefer to have a different certiilcate for medical

examiners or coroners than for physicians. Other States

prefer to use the same certificate for both medical

examiners or coroners and physicians. The only difference between the certificates is in the section where the

certifier signs. Otherwise, the content is the same.

The three versions developed were the U.S. Standard

CertKlcate of Death (Physician, Medical Examiner or

Coroner), the U.S. Standard Certificate of Death (Physician), and the U.S. Standard Certiilcate of Death (Medical Examiner or Coroner).

Modifications

● The certflcate was reformatted to place the cause of

death section at the bottom of the certiilcate. There

was considerable discussion regarding whether this

section should or should not be routinely included on

certified copies. By placing the section at the bottom,

those States wishing to exclude it from certified copies

can do so when copies are made.

. The section for the physician’s certiilcation was

modii5ed. The present recommendation of the Model

State Vital Statistics Act is that physicians other than

the attending physician be allowed to sign the medical
certification under certain circumstances. The

changesmade would accommodate that recommendation.

● The item in the accidental death section relating to the

manner of death was mod~led by adding “Pending

Investigation” to the list of possibilities that previously included “Accident, Suicide, Homicide, Undetermined.” This addition should lead to better

reporting in the “Cause of Death” portion of the

certificate. The medical examiners who served on the

Subgroup for the Revision ofthe Standard Certillcate

of Death highly recommended this addition.

. Several changes were made in terminology relating to

the funeral director and the funeral home. The

information desired from the various items was not

changed, however. “Funeral Director” was replaced

with “Funeral Service Licensee or Person Acting as

Such: and “Funeral Home—Name and Address”

wasreplaced with “Name of Facility” and “Address of

Facility.”

Additions

. An item was added to the cetilcate asking “If

Hospital or Institution, Indicate Dead on Arrival,

Outpatient/ Emergency Room, Inpatient.” It was felt

that this information would be beneficial in developing mortality statistics for hospitals. It should also

make hospitals more willing to show the hospital as

the place of death if they can also indicate dead on

arrival.

● The item “Was Decedent Ever in U.S. Armed

Forces?” was returned to the certificate. This item was

deleted from the U.S. Standard Certflcate of Death

in 1968. There were many requests from veterans

groups all over the country to have the item returned

to the certificate, and it was decided that it should be

included in the 1978revision.

● An item was added to the certificate asking whether

the case was referred to the medical examiner or

coroner. Since a physician may, at the request of the

medical examiner or coroner, certify a death that

appears to be a medical examiner or coroner case, it

was considered important to at least know that the

case was reviewed by the medical examiner or

coroner.

Deletions

● The item “Inside City Limits” relating to place of

death was deleted, It was felt that the item had little

utility. However, the “Inside City Limits” item for

place of residence was retained since it is useful in

properly assigning events within a county.

. The items listed below were deleted from the certiiicate. It was felt that each of these served no useful

legal or statistical purpose, and that their deletion

would not affect reporting.

. Whether autopsy findings were considered in

determining cause of death.

● The dates “From” and “To” relating to when the

physician attended the decedent.

. The date the physician last saw the decedent alive.

● Whether the physician viewed the body after

death.

● The date of burial.

Recommendations for revision of the

U.S. Standard Certificate of Marriage

See exhibit 3 for final revision

Modifications

● The heading of the form was changed to read “U.S.

Standard License and Certificate of Marriage.” The

intent was to combine in one form both the license

and the certificate in order to reduce the workload

and number of forms required by the local official

responsible for marriage registration.

● The question asking whether a religious or civil

official performed the ceremony was changed. The

question now asks whether the ceremony was religious or civil. This is the information that was really

desired, and it was felt that this is a better way of

asking the question.

● The heading of the confidential portion of the

certificate was changed from “Conildential Information” to “Information for Statistical Purposes Only.”

The reason for removing the term “Conildential” is

the same as for deleting it from the birth certillcate.

The change in heading adequately indicates how the

data are to be used and makes it possible to exclude

the information from certified copies.

Additions

● The item “Age; for both of the parties to be married,

was added. “Date of Birth” for both parties remains

on the certificate. The addition of “Age” provides an

extra means for verifying whether the parties meet the

age requirements for marriage. The county clerks on

the Subgroup felt this addition would be most

beneficial.

● Including the license within the cert~lcate required

adding certitlcation statements by the applicants and

the person issuing the license. This also necessitated

adding the date the license was subscribed and sworn

to, the signature of the issuing officer, and the title of

the issuing officer. With the addition of the date the

license was subscribed and sworn to, the dates when

7
each party signed were no longer necessary and were

therefore deleted.

. An item requesting the name of the city where the

marriage was performed was added. This more

precisely locates the actual place of marriage.

. The title of the person performing the marriage

ceremony was added. This item provides information helpful in determining whether the person is

authorized to conduct marriage ceremonies under

the laws of a particular State.

Deletions

●

●

●

The item “State: referring to the place where the

marriage was performed, was deleted. Since the

marriage can only be legally performed in the State

where the license is issued, this item was considered

unnecessary.

The “Inside City Limits” items that related to the

residemx of the bride and groom were deleted. It was

felt they served no legal or statistical purpose.

The date of the signing of the certificate was deleted.

The date of the marriage ceremony is requested and

this is the important date.

Recommendations for revision of the

U.S. Standard Certificate of Divorce

See exhibit 4 for final revision

Modifications

●

●

●

●

The heading of the certificate was changed from “U.S.

Standard Certificate of Absolute Divorce or Annulment” to “U.S. Standard Certitlcate of Divorce,

Dissolution of Marriage or Annulment.” The addition of dissolution of marriage reflects a change in

laws and/or terminology in several States.

The item “Local File Numberfl which appeared at the

top ofthe certificate,was changed to “Court Identification (Court file number).” The Court file number is

the local file number. The change in terminology

better reflects what is to be shown.

The item “Living Children—Total Number” was

changed to “Number of Children Ever Born Alive of

This Marriage.” The purpose of the change was to

obtain data to study how the stability of a couple’s

marriage is affected by chddren born of that union.

The item “Living Children Under 18 Years of Age”

was changed to “Children Under 18in This Family.”

The attempt was to ascertain the number of children

directly affected by the divorce. It was felt the change

in wording would produce better, more accurate data

on the subject.

The term “Plaintiff” was replaced by the term “Petitioner” throughout the certificate. This reflects the

changing attitudes and laws in the country, making

divorce proceedings less adversary.

As in the birth and marriage certitlcates, the heading

of the conildential portion of the certificate was

changed from “Cofildential Information” to %formation for Statistical Purposes Only.”

Additions

● No items were added.

Deletions

● The “Inside City Limits” items relating to the residence of the husband and wife were deleted.

● The items “Decree Granted To” and “Legal Grounds

for Decree” were deleted. These items have little, if

any, statistical value, and it was felt they served no

useful purpose on the certi.tlcate.

Changes in fetal death reporting

In January 1973the U.S. Supreme Court ruled that the

restrictive abortion laws of two States were unconstitutional and that performance of an abortion within the first 2

trimesters after conception was a matter between the

woman and her doctor. The net result ofthisruling wasthat

abortion under these criteria became legal in all States. A

few States had liberalized abortion laws prior to the ruling

and had systems requiring the reporting of information

about these events. After this ruling the number of legal

abortions throughout the country increased dramatically,

and a number of other States established reporting systems.

Becauseof the impact of abortion on fertility,the need was

recognizedfor standardized reporting to facilitatecollection

and publication of data from States able to provide the data

desired. The Centers for Disease Control (CDC) had been

collecting abortion data from participating States since

1969because oftheir interest in the surveillanceof abortion

mortality and morbidity. They were, however, collecting

whatever information the States had available and had not

attempted to develop a uniform reporting system.

Because of the NCHS interest in examining abortion

data from a health and demographic point of viewand the

CDC interest in the data as a surveillance tool, it was

decidedthat NCHS should collectdata from States meeting

NCHS standards for completeness and comparability of

data and make them available to CDC for their program,

while CDC would=continue to collect whatever data they

could from the remaining States.

The Technical Cons&ant Panel on the Revision of the

U.S. Standard Certificates,working closelywith the Technical Consultant Panel on the Revision of the Model State

Vital Statistics Act, discussed the data needs related to
induced abortions and made recommendations for the

development of a uniform reporting system in all States.

The definition of fetal death recommended by the

World Health Organization, whichisincluded in the Model

State Vital Statistics Act, includes induced abortion in its

coverage, Induced abortion would be considered a fetal

death under this definition:

Fetal death is death prior to the complete expulsion

or extraction from its mother of a product of human

conception, irrespective of the duration of pregnancy

the death is indicated by the fact that after such

separation, the fetus does not breathe or show any

other evidence of life such as beating of the heart,

pulsation of the umbilical cord, or deftite movement

of the voluntary muscles.

It was considered inappropriate to collect abortion

data on the same form used to collect spontaneous fetal

death information for several reasons. One is that data

needs are different for induced abortion than for spontaneous fetal death. Adding items to the fetal death

form to meet both needs would create serious space

problems. Another reason for separate reporting forms

is that the majority of the States only require reporting

of spontaneous fetal deaths at 20 weeks of gestation

and over.

This excludes most induced abortions since the majority occur at under 20 weeks of gestation. Also, the name

of the patient is needed on forms for spontaneous fetal

deaths but is not necessary on an induced termination

report. This item was excluded from the induced termination report to encourage reporting. For these reasons a

separate form was recommended to the States for collecting information on induced terminations of pregnancy. It

was also recommended that all induced terminations be

reported regardless of length of gestation and regardless

of the present reporting requirements for fetal deaths.

General recommendations on the reporting of fetal

deaths and induced terminations of pregnancy follow.

●

●

●

Spontaneous fetal deaths and induced terminations of

pregnancy (induced abortions) should both be reported

and should be reported on separate forms.

Reports of both spontaneous fetal death and induced

termination of pregnancy should be considered legally

required statistical reports rather than legaldocuments

to be retained permanently by the State Health

Departments, The documents serve no legal purpose

and there is no reason why a State should have to

maintain these fdes after the statistical work with the

records is completed,

Only spontaneous fetal deaths at 20 weeks gestation

and over should be reported. Good reporting of fetal

deaths of under 20 weeks gestation has been very

difficult. Since most State laws presently require only

reporting offetal deaths at 20weeksgestation and over,

efforts should be focused at getting better reporting of

these events and not require those under 20 weeks.

. All induced terminations of pregnancy, regardless of

gestation, should be reported. Sincethe vast majority of

these events occur at under 20 weeks gestation, it is

essential to have this group reported.

● There is no need for a “Cotildential” section on either

of the forms since they will not be used for legal

purposes and will both be designated “Cordidential.”

Recommendations for the U.S.

Standard Report of Fetal Death

See exhibit 5 for final revision

Changes made in the U.S. Standard Certificate of

Fetal Death for the collection of data on spontaneous

fetal deaths at 20 weeks gestation and over follow.

Modifications

●

●

●

●

●

The heading was changed to “U.S. Standard Report of

Fetal Death.’ Thisis consistent with the suggestion that

these documents be statistical reports rather than

certifkates to be fded permanently.

The items requesting information about the previous

pregnancies of the mother were changed so that the

information isconsistent with the information obtained

on the birth certifkate.

The item “Legitimate-Yes or No” wasreplaced by the

item “Is Mother Married-Yes or No.” This is consistent with the information obtained on the birth

Certflcate.

The items relating to complications were modified to

clarify them and to make them agree with the birth

certiilcate changes.

No signatures are required on the form, but it does ask

for tfie name and ‘title of the physician or other

attendant and the name of the person completing the

report.

Additions

● An item was added requesting physician’s estimate

of gestation. While the primary means for determining length of gestation will remain the length of

time between the date last normal menses began

and the date of delivery, this new item will provide

data in those cases where the date last normal

menses began is not available or the gestation determined by this method is obviously in error.

Deletions

A number of items were deIeted since they were

unnecessary on a statistical reporting form. These include

name of fetus; “Inside City Limits” relating to place of

delive~, place of birth of both mother and fathe~ whether

autopsy findings were considered in determining cause of

9
death; signature of person certifying cause of fetal death;

date certiilcation was signed; whether the attendant was an

M.D., D.0, Midwife, or other; the mailing address of the

certiileq signature of other authorized officialifthe delivery

was not attended by a physician; whether the fetus was

buried, cremated, or removed; name of cemetery or

crematory location of cemetery or crematory; date of

burial, cremation, or removal; name and address of the

funeral home; signature ofthe funeral directoq signature of

the registrar and date received by local registrar. “Btih

Injuriesto the Fetus” was dropped because it wasso poorly

reported as to make it unreliable as a statistical or medical

tool.

Recommendations for the U.S.

Standard Report of Induced

Termination of Pregnancy

See exhibit 6 for final revision

This new form isto be used for the collection of data

about induced abortions. Since this is a new reporting

form, a brief justification is included here for each item.

1. Place of termination.

la. Facility — Name (If not hospital or clinic,

give address).

lb. City, town, or location of pregnancy

termination.

Ic. County of pregnancy termination. These

items are essential for querying for missing

information. Item 1a provides information

about the types of facilities where induced

terminations are performed. Items lb and Ic

provide information useful in planning for

health facilities and health education

programs.

2. Patient information.

2a. Patient identification. This item is necessary

for querying for missing information.

2b. Age of patient. This item is important in

studying the impact of induced terminations

on fertility rates of different age groups

within the population. It also permits

examination of the risks of complications

by age.

2c. Married? (Yes, No). This item will aid in

determining the impact of induced terminations on the fertility rates of married and

unmarried women. It will also be an aid in

developing family planning programs and

evaluating their effectiveness.

3. Date of pregnancy termination. This information is needed to determine when the pregnancy

termination occurred. It is also used to deter4a-d.

5.

6.

7a-d.

8a-d.

9.

10.

11.

mine the length of gestation (used with date last

normal menses began). Data on length of gestation is important in determining the risks associated with induced terminations. The infcwmation on year of pregnancy is essential in computing annual rates and ratios of induced

terminations.

Residence of patient — State, count v, citl’, tmi’n,

. .

or location, and whether inside cit>~limits. These

items provide data for the analysis of induced

termination by residence of the patient. The residence data are used with the city and county of

termination to provide information on the

amount of movement occurring within a State

or between States to obtain induced terminations of pregnancy. This type of information is

useful in planning the location of health care

facilities.

Race ofpatient. This information is needed to

study the impact of induced terminations on

such factors as the birth rate of the general

population and among unmarried women for

different racial groups.

Education of patient. This item provides information on the socioeconomic status of the

patient for studying the impact of induced termination on the health and fertility of various

socioeconomic groups. This information may

also prove useful in developing educational campaigns dealing with family planning.

Previous pregnancies of patient. This information will provide some insight into the use of

induced termination to limit family size, Siriw

this item also asks for the number of previously

induced terminations, it will provide data on the

characteristics of women who may need alternative methods of family planning.

Type of termination procedures. This information, when viewed with the complications item,

will provide some measure of the risks associated

with the different procedures. When length of

gestation is included, it will provide some indication of the effectiveness and safety oft he various

termination procedures at different gestatiomd

ages.

Complications of pregnancy termination. This

item will provide data regarding the risk of

induced termination.

Date last normal menses began. This item is

used with the date of termination to calculate

the length of gestation. Length of gestation is an

important variable in evaluating the effectiveness and safety of the various termination

procedures.

Ph~wician’sestimate ofgestation. This item provides a check on the length of gestation as calcu10
lated from date of last normal menses. It permits 13. Name ofperson completing report. This is the

the physician to report an estimate when there is primary person who will be queried for missing

doubt as to the accuracy of the length of gesta- information, although the physician will be contion or when date of last normal menses is tatted in some instances.

unavailable or misleading. .

12, Name of attendingplrysician. This item is needed

so that queries can be made to obtain missing or

additional information.

11
Other items considered but not

recommended

Throughout the course of the revision process many

items were suggested for inclusion on the various standard

certiilcates. Most of these suggestions came from the

questionnaires that were sent out. The revision committee

gave consideration to all items that were suggested. However,sincethe certifkates are limited in size,and sinm not all

the items suggestedwere appropriate for this mode of data

collection, not all the suggested items were included.

Examples of new items that were suggested but not

included on the standard certificatesare “Date of Marriage”

on the live birth certifkatq “Imputed Lethality,” “Embalmer’sSignature,” “Percent Blood Alcohol,” “Drug Use,”

“Recent Operation: and “Pregnancy (Recent Past)” on the

death certificate; “Social Security Number? “Information

Related to Children and Court Obligations from Previous

Marriages: and “Religion”on the marriage certificate;and

“Social Security Number; “Religion,” “whether Maiden

Name Was Restored,” “Residence at Time of Separation,”

“Case Numbeq” and “Question Related to Child Custody

and Child Support” on the divorce certiilcate.

While these items all have value, the committee feltthat

they might better be obtained from other sources and that it

should be left to the individual States to determine if such

items should appear on the State certiilcates.

12
Implementation of new

cehificates and reporting forms

As in years past, the schedule for revision of the

standard certillcatescalledfor distribution ofthe newforms

to the States approximately 1year before the revised State

certiilcates would go into use to allow the States time to

draft their own forms, obtain approvals, print, and distribute them. In December 1975the Technical Consultant

Panel made recommendations in a final report to NCHS.

These recommendations were reviewed, and final drafts of

the certificates and reports were developed and forwarded

to the Officeof Management and Budgetfor clearance.The

clearance was received in June 1976 and the approved

forms were printed. The standard certificates and reports

were distributed to the States in December 1976.

Instructional handbooks were prepared for each of the

certificates and reports. Included in the handbooks was

information on how the registration systemoperates and an

item-by-item listing giving the use or purpose of each item

and instructions on how it should be completed. These

handbooks (listed below) were provided to each State for

distribution to the appropriate persons or for use as

guides in the development of State handbooks.

i%spita~ Handbook on %irth Registration and Fetal Death

Reporting

Physicians’ Handbook on Medical Certl~cation: Death,

Birth, Fetal Death

Funeral Directors’ Handbook on Death Registration and

Fetal Death Reporting

Medical Examiners’ and Coroners’ Handbook on Death

Registration and Fetal Death Reporting

Handbook on the Reporting of Induced Termination of

Pregnancy

Handbook on Marriage Registration

Handbook on Divorce Regiwration

Slidepresentations with cassettetapes wereprepared on

how to complete the U.S. Standard Certificateof LiveBirth

and the U.S. Standard Certiilcate of Death. Three separate

presentations were developed on death-one for funeral

directors on how to complete the personal items on the

cm-tiiicateand one each for physicians and medical examiners or coroners on how to complete the medical certification of cause of death.

Two copies of each of the slide presentations were sent

to the the State vital statistics offices. The States were

encouraged to use these materials for training purposes and

in the development of other instructional materials.

In general, most States have been able to. adopt

certflcates containing most of the items on the U.S.

Standard Certificate of Live Birth and Death and the U.S.

Standard Report of Fetal Death. The acceptance of the

standard marriage and divorce forms continues to be a

problem but has improved over previous years. Many

States still do not have a system for reporting induced

terminations of pregnancy therefore, this standard form

has not been widely accepted. Appendix III has tables

showing the number of registration areas that have included each item of the standard certificates and reports

in their reporting forms as of August 1982.

13
Appendixes

Contents

1. Technical Consultant Panel on Revision of the U.S. Standard Certificates and Reports . . . . . . . . . . . . . . . . . . . . . . .

Parent Group . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Subgroup for the Revision of the U.S. Standard Certificate of Live Birth . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Subgroup for the Revision of the U.S. Standard Certificate of Death . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ,.O

Subgroup for the Revision of the U.S. Standard Certificate of Marriage and the U.S. Standard Certificate of

Divorce or Annulment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Subgroup for the Revision of the U.S. Standard Certificate of Fetal Death . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Subgroup for the Revision of the Structural Format of all the Standard Certificates . . . . . . . . . . . . . . . . . . . . . .

National Center for Health Statistics resource personnel for the Parent Group and all Subgroups . . . . . . . . .

15

15

15

16

16

16

17

17

Il. Summary of responses to questionnaires on revision of the U.S. Standard Certificates . . . . . . . . . . . . . . . . . . . . . . . 19

Ill. Exhibits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1. U.S. Standard Certificate of Live Birth . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1a. Content of the U.S. Standard Certificate of Live Birth, by year revised . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1b. Number of registration areas reporting each item on the U.S. Standard Certificate of Live Birth:

August 1982 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

2. U.S. Standard Certificate of Death (Physician) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

2a, U.S. Standard Certificate of Death (Physician, Medical Examiner or Coroner) . . . . . . . . . . . . . . . . . . . . . . .

2b. U.S. Standard Certificate of Death (Medical Examiner or Coroner) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

2c. Content of the U.S. Standard Certificate of Death, by year revised . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

2d. Number of registration areas reporting each item on the U.S. Standard Certificate of Death:

August 1982 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

3. U.S. Standard License and Certificate of Marriage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

3a. Content of the U.S. Standard License and Certificate of Marriage, by year revised . . . . . . . . . . . . . . . . . . . .

3b. Number of registration areas reporting each item on the U.S. Standard License and Certificate of

Marriage: August 1982 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

4. U.S. Standard Certificate of Divorce, Dissolution of Marriage or Annulment . . . . . . . . . . . . . . . . . . . . . . . . .

4a. Content of the U.S. Standard Certificate of Divorce, Dissolution of Marriage or Annulment, by

year revised . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

4b. Number of registration areas reporting each item on the U.S. Standard Certificate of Divorce,

Dissolution of Marriage or Annulment: August 1982 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

5. U.S. Standard Report of Fetal Death . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

5a. Content of the U.S. Standard Report of Fetal Death, by year revised . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

5b. Number of registration areas reporting each item on the U.S. Standard Report of Fetal Death:

August 1982 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .,

6. U.S. Standard Report of Induced Termination of Pregnancy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

6a. Content of the U.S. Standard Report of Induced Termination of Pregnancy, new in 1978 . . . . . . . . . . . . . .

6b. Number of registration areas reporting each item on the U.S. Standard Report of Induced Termination of

Pregnancy; August 1982 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

21

21

22

26

28

29

30

31

36

38

39

41

43

44

46

48

49

53

55

56

58

14
Appendix L Technical

Consultant Panel on Revision

of the U.S. Standard

Certificates and Reports

Parent Group

Robert G. Webster, Chairman

Piedmont, California

(Formerly Chief Deputy Director, California

Department of Public Health)

Russell Booker

Chief, Registration Services

Bureau of Vital Records and Health Statistics

State Department of Health

Richmond, Virginia

William D. Johnson

Director, Division of Public Health Statistics

State Department of Health

Pierre, South Dakota

Frederick L. King

Chief, Section of Administrative Services

State Department of Health

Minneapolis, Minnesota

Robert L. Liljegren

Principal Statistician

Records and Statistics Section

State Department of Health

Denver, Colorado

Vito Logrillo

Director of Health Statistics

State Department of Health

Albany, New York

Marian Martin

State Registrar

State Board of Health

Portland, Oregon

Leo A. Ozier

Assistant Legal Technical Advisor

Illinois Department of Public Health

Sprin@leld, Illinois

James J. Palmersheim, Ph.D.

Project Director, Cooperative Health Information

System

Department of Public Health

Springtleld, Illinois

Myma K. Sen

Associate State Registrar

Research and Statistics Office

Hawaii Department of Health

Honolulu, Hawaii

Roger Smith

Health Program Advisor

Bureau of Vital Statistics Registration

State Department of Public Health

Sacramento, California

Subgroup for the Revision of the U.S.

Standard Certificate of Live Birth

Marian Martin, Chairman I

State Registrar

State Board of Health

Portland, Oregon

William D. Johnson]

Director, Division of Public Health Statistics

State Department of Health

Pierre, South Dakota

Frederick L. Kingl

Chief, Section of Administrative Services

State Department of Health

Minneapolis, Minnesota

1Members of the Parent Group.

15
William W. Jack, M.D. Deane L. Huxtable

Representative of the Maternal and Child Care State Registrar and Director

Committee Bureau of Vital Records

American Medical Association State Department of Health

Grand Rapids, Michigan Richmond, Virginia

R. T. F. Schmidt, M.D.

Director, Department of Obstetrics and Gynecology Subgroup for the Revision of the U.S.

Good Samaritan Hospital Standard Certificate of Marriage and

Cincinnati, Ohio

(Dr. Schmidt replaced Dr. Jack in the Subgroup, the U.S. Standard Certificate of

September 1974) Divorce or Annulment

Reynolds Farley, Ph.D.

Associate Professor, Department of Sociology, and

Associate Director, Population Studies Center

University of Michigan

Ann Arbor, Michigan

Mary E. Converse

Director, Central Clearinghouse for ICDA

American Hospital Association

Chicago, Illinois

Leo A. Ozier, Chairmanl

Assistant Legal Technical Advisor

Illinois Department of Public Health

Springtleld, Illinois

Roger Smith]

Health Program Advisor

Bureau of Vital Statistics Registration

State Department of Public Health

Sacramento, California

Loretta Bowman

Subgroup for the Revision of the U.S. Clerk of Court

Standard Certificate of Death Clark County

Las Vegas, Nevada

Vito Logrillo, Chairmanl

Director of Health Statistics

William G. Sharp

State Department of Health

County Clerk

Los Angeles County

Albany, New York Los Angeles, California

Myrna K. Senl

Associate State Registrar

Research and Statistics Office

Hawaii Department of Health

Honolulu, Hawaii

Howard C. Raether

Executive Secretary

National Funeral Directors Association

Milwaukee, Wisconsin

Charles S. Petty, M.D.

Chief Medical Examiner

Dallas County

Dallas, Texas

George E. Gantner, M.D.

Chief Medical Examiner

Office of Medical Examiner

St. Louis County

Clayton, Missouri

‘MembersoftheParentGroup.

Thomas P. Monahan, Ph.D.

Professor of Sociology

Villanova University

Villanova, Pennsylvania

Judge Ralph J. Podel

County Court House

Milwaukee, Wisconsin

Subgroup for the Revision of the U.S.

Standard Certificate of Fetal Death

Robert G. Webster, Chairman]

Piedmont, California

(Formerly Chief Deputy Director,

California Department of Public Health

Robert L. Liljegrenl

(Chairman, Format Subgroup)

Principal Statistician

Records and Statistics Section

State Department of Health

Denver,Colorado

16
Vito Logrillo 1

(Chairman, Death Subgroup)

Director of Health Statistics

State Department of Health

Albany, New York

Marian Martint

(Chairman, Birth Subgroup)

State Registrar

State Board of Health

Portland, Oregon

R. T. F. Schmidt, M.D.

Director, Department of Obstetrics and Gynecology

Good Samaritan Hospital

Cincinnati, Ohio

Ralph Franciosi, M.D.

Pediatric Pathologist

Minnesota Children’s Health Center and Hospital

Minneapolis, Minnesota

Jack Smith

Chief, Statistical Services Unit

Family Planning Evaluation

Centers for Disease Control

Atlanta, Georgia

Two meetings of this Subgroup were held, and it was

decided that a separate form should be developed for

induced terminations. This Subgroup developed both the

U.S. Standard Report of Fetal Death and the U.S.

Standard Report of Induced Termination of Pregnancy.

Subgroup for the Revision of the

Structural Format of all the Standard

Certificates

Robert L. LiIjegren, Chairman I

Principal Statistician

Records and Statistics Section

State Department of Health

Denver, Colorado

Russell Bookerl

Chief, Registration Services

Bureau of Vhal Records and Health Statistics

State Department of Health

Richmond, Virginia

James J. Palmersheim, Ph.D. 1

Project Director, Cooperative Health Information

System

Department of Public Health

Springfield, Illinois

Hazel V. Aune

Verona, Wisconsin

(Formerly Chief, National Consulting Service,

National Office of Vital Statistics,

Department of Health, Education, and Welfare,

Washington, D. C.)

Lydia Berving

Methods and Procedures Advisor

Division of Electronic Data Processing

Illinois Department of Public Health

Spnngileld, Illinois

Garland Land

Director, Bureau of Statistical Services

Division of Health

Missouri Department of Public Health and Welfare

Jefferson Chy, Missouri

National Center for Health Statistics

resource personnel for the Parent

Group and all Subgroups

Robert A. Israel

Deputy Director

National Center for Health Statistics

John E. Patterson

Director

Division of Vital Statistics

Mice M. Hetzel

Deputy Director, Division of Vital Statistics

(and Acting Chief, Marriage and Divorce Branch)

Division of Vital Statistics

Marshall C. Evans

Assistant for Program Development and Management

Office of the Associate Director for Data Systems

Phillip R. Beattie

Special Assistant for Program Development and

Management

Office of the Associate Director for Operations

Loren E. Chancellor

Chief, Registration Methods Branch

Division of Vital Statistics

George A. Gay

Public Health Analyst

Registration Methods Branch

Division of Vital Statistics

Robert J. Armstrong

Chief, Mortality Statistics Branch

1Members of the Parent Group. Division of Vital Statistics

17
Robert L. Heuser

Chief, Natality Statistics Branch

Division of Vital Statistics

Marvin Templeton

Chief, Data Control Branch

Division of Vital Statistics

Russell Kuhn

Statistician-Demographer

Registration Methods Branch

Division of Vital Statistics

18
Appendix Il. Summary of

responsesto questionnaireson

revision of the U.S. Standard

Certificates

Birth Death Fetal death

Respondent category Mailed Returned Mailed Returned Mailed Returned

out Number Percent out Number Percent out Number Percent

All respondents, . . . . . . . . . . . . . . . . . . . . . 573 200 201 34

State vital regis~ration and statistics

executives . . . . . . . . . . . . . . . . . . . . . . . . . . 83 49

State haalth officers, . . . . . . . . . . . . . . . . . 59 18

Medical and health services and related

associations . . . . . . . . . . . . . . . . . . . . . . . . 228 62

Coroners or Medical Examiners, funeral

directors, and related associations . . . 5 1

Legal and judicial, and related

associations . . . . . . . . . . . . . . . . . . ,., .,. 25

Researchers (individuals).....,...,.,.. 41 1;

Research and professional organizations

(includes universities) . . . . . . . . . . . . . . . 27 11

Federal agencies . . . . . . . . . . . . . . . . . . . . . 26 7

County and city officials and related

associations ., .,, ,,, . . . . . . . . . . . . . . . . 17 3

Local registrars of vital statistics . . . . . . . 28 14

Other State and local officials . . . . . . . . . 20 11

Other . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12 2

Religious organizations, . . . . . . . . . . . . . . . 2 1

35 676 223 33 584

51 61

20 35

59

31

84

59

52 62 84

18 31 57

27 211 43 20 202 61 30

20 116 43 37 78 19 25

27

40

3 17

18 :: 38

0

15 3:

6 25

8 40

41

27

33

23

11 33 24

6 26 20

3 17 15

14 50 24

9 38 13

2 18 12

1 50 2

1 7

10 42

7 54

2 17

1 50

18

50

55

17

50

18

28

24

11

2

Marriage Divorce

Respondent category Mailed Returned Mailed Returned

out Number Percent out Number Percent

All respondents . . ...!.... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 380 115 30 406 122 30

State vital registration and statistics executives . . . . . . . . . . . . . . . . . . . . . . . . 84 47 56 84 47 56

State heaithofficers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59 17 29 59 17 29

Medical and health services and related associations . . . . . . . . . . . . . . . . . . . 25 1 4 25 0 0

Coroners or Medicai Examiners, funeral directors, and related

associations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0 0 0 0 0 0

Legai, judicial, and related associations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43 4 9 57 4 7

Researchers (individuals) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35 15 43 35 15 - 43

Research and professional organizations (includes universities) . . . . . . . . . 33 6 18 34 6 18

Federal agencies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15 0 0 15 0 0

County and city officials and related associations . . . . . . . . . . . . . . . . . . . . . . 43 12 28 57 22 39

Local registrars ofvital statistics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 3 27 9 1 11

Other State and local officials . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 3 60 5 3 60

Other . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14 4 29 14 4 29

Religious organizations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13 3 23 12 3 25

19
Appendix Ill. Exhibits

Exhibit 1. U.S. Standard Certificate of Live Birth

TYPE Form Approved

OR ~{lNT OMB No. 68R 1900

PEFW:ENT U.S. STANDARD

Foil LOCAL FILE NUMBER CERTIFICATE OF LIVE BIRTH

lNSTRSIJ#ONS

WRTH NUMOER

CHILD-NAME FIRST MIDDLE LAST SEX DATE OF BIRTH (.$1o..9.,. Yr ) HOUR

HANDBOOK

1. -— 2

3a. 3b. M

HOSPITAL-NAME 11/“.1 in hosni(d, ,!w street and “umber)

~.-–. .- —-

CITY, TOWN OR LOCATION OF BIRTH cOUNTY OF SIRTH

k.

I certify that the Staredinformal.. COIYW.IW this child is we 10 the best.1 my know!edgead belkf. DATE SIGNEO (.%1,s..1,.. Yr., NAME ANO TITLE OF ATTENDANT AT 81RTH IF OTHER THAN

CERTIFIER I’r\x or Prlno

@

S1. ,sNn.tum> ➤

I

. . —.— — 5LI. 15C. ____

CERTIFIER-NAME AND TITLE rrw.e w print) MAILING ADDRESS (Wrr.t <,, n + ,, v<, c’,,, or T“,, “. .s,nt.. Am)

~DATE RECEIVED BY REGISTFIAR IWwh. u.,. YWI

6a, (S!m.ture) ➤ 6b,

MOTHER-MAIDEN NAME F, ,7ST MIDDLE LAS, AGE ,,4, ,,”,. STATE OF BIRTH ([r””, ,“ lSA,. t,.nw country,

~,>1fhl’ btrtht

7a.

RESIDENCE-STATE COUNTY

__---fl:::=

CITY, TOWN OR LDCATION STREET AND NUMSER DF REStDENCE

81. 8b. 8c.

MOTHER$ MAILING ADDRESS-l f”onc os.botr. enter Z(P Code .“1,

FATHER-NAME ,, .s., MIDDLE LAST AGE ,.,, ,,”,. STATE OF BIRTH ,1/ “o, ,. lr s A “.”. co”nlry,

(,/ (h,” b,r,h,

10b. 1o:,

I certifythm the personal Information w.vlde d.. this certificate ,scorrect 10 the best of my knowledge and belief.

(Slrn.t.r. of Pam”!.

RELATIOV TO CHILD

DCA7H morn

ONE \ EAR OF

AGC

p:b:ly::h

c.rdf,.a,. for m,,

,hlld

MU LTIPLt NIRTHS

E“,., St.,. P,1.

N“r”h,, for “I.?, (,1

LIVE DIRTHIG)

FCTAL DCATH(S)

INFORMATION FOR MEDICAL ANO HEALTH USE 0NL%

+AU–hOTHER k g,.wh,te BImC RACE-FATHER k % Whom,Black, BIRTH WEIGHT THIS 81RTH-Smsle. Win. lm!et. IF NDT SINGLE BIRTH-Bom

Am,m,o Indian. etc.) Amwmm Indim. ,{. )

IsP..,,,,

IS MOTHER MARRIED,

(s”,.1,, ,

em (s,.<)/,, I,,,,. sccocd. th,rd. ,,, ,SPOcr/”) fswc,fY, .s w .01

,

12 \13.

{COmPlm eachwctmnl

LIVE BIRTHS OTHER TERMINATIONS

(0. not mdud? lhi$ Child] [S00.,.”..., and h,duc,d)

I

I

u

i

18. . 19=.– ——

17s NOWhvmq i 17b. NOWdead Ild. :e~r: 20 i 17e. :,:;,20 DATE LAST NORMAL MENSES MONTH OF PREGNANCY PRE ,,, “,,”,, ,0 ,,mt,,

—-—

PRENATAL VISITS Total “umber , :,.4/4R SCORE

BEGAN (.! fwl,h,D.,. Y,.,,,, NATAL CARE BEGAN For,%. 5 mm.

sec. “d, ,,, (SP,W, )

Wnber_ / Number_ N..ber_ i Nu.be,_ 20. 21a. 21b. 22a. 22b.

COMPLICATIONS OF PREGNANcY ,De,crlb< ,,, u,.,. .... . . ..

“mm ❑ ~ None❑ N... ❑ i None❑ 23,

---------------- -- —--- J- —---— -

)AIE OF LAST LIVE 8!RTH DATE OF LASTOTHERTERM!N CONCURRENT 1LLNESSES OR CBND!TIONS AFFECTING THE PREGNANCY ,Ur’crib, or wrlf, ,“.”..7

,,,,.,h, 1..,, ATION (., ,,,,(..,,,, ,,, d or,. .,,,,..,

,,,,,,,,. ,“,,.,

17C, I171. 124.

:OMPLICA’TIONSOF LA80R ANDIDR DELIVERY (Dcacribc.x writ. ,110..v CONGENITAL MALFORMATIONS OR ANDMALIES OF CHILD (D.,,crobe ., <nrll, IIO”C.I

21
Exhibitla.Contentof theU.S.StandardCertificateof LiveBirth,

by yearrevised

Item 1900191019151918193019391949195619681978

Birthinformation

Nameof child....................

Sex...............,....*.........

Dateof birth....................

Hour...............*.............

Placeof birth:

Nameof hospital...............

Streetandnumber..............

If birthoccurredin hospital

or institution,giveitsname

insteadof streetnumber......

Streetandnumberifnot in

hospital......................

Townshipof,or................

Villageof,or.................

City....................● ......

City,town,or locationof

birth.........................

Insidecitylimits.............

If outsidecityor townlimits,

writerural...................

Countyof birth................

Ward. ● *,. . ● ● ● ● . . . . . , ● ● ● ● ● . ● . . . .

Birthweight.....................

Multiplebirth...................

Birthorderifnot singlebirth..

Apgarscore:

l minute.......................

S minutes......................

Motherinformation

Maidenname......................

Fullname........................

Age● ......● ..● ..........,.● ....● .

Birthplace.......................

Birthplace(Stateor country)....

Birthplace(cityor place).......

.Mother’sstaybeforedelivery:

In hospitalor institution.....

In thiscommunity..............

Residence........................

State..........................

county.........................

x

x

x

x

x

x

x

x

:

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

xxx

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

;

x

x

x

x

x

x

x

x

x

x

x

x

:

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

:

x

x

x

x

x

x

x

x

x

x

i

x

x

x

.

x

x

x

x

x

x

x

x

x

x

x

x

22
Exhibitla.Contentof theU.S.StandardCertificateof LiveBirth,

by yearrevised--Con.

Item 1900191019151918193019391949195619681978

Motherinformation--Con.

City,town,or location........

Streetandnumber..............

Insidecitylimits.............

If rural,givelocation........

Is residenceon a farm?........

Mother’smailingaddress.........

Race..● .0 . . . ● . . . . . . . . . . ..* ● * ● . . . .

Education........................

Legitimate.......................

Ismothermarried?...............

Occupation.......................

Usualoccupation.................

Natureof industry...............

Date(monthandyear)last

engagedin thiswork............

Totaltimespentin thiswork....

Fatherinformation

Name.**..● ● 0.● . ● ● . . . . . ● .0 . . . . . . . ●

Age● ..*.***..● ...................

Birthplace.......................

Birthplace(Stateor country)....

Birthplace(cityor place).......

Race...................● .........

Education........................

Residence........................

Occupation.......................

Usualoccupation.................

Natureof industry...............

Date(monthandyear)last

engagedin thiswork............

Totaltime(years)spentin this

work...............● ● ...........

Pregnancyinformation

Pregnancyhistory:l

Livebirths,now living........

Livebirths,now dead..........

Borndead(stillborn,fetal

death)........................

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

i

x

x

x

x

x

x

x

ii

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

lpriorto 1939 the pregn~cy historyitem includedthe birthbeingregistered.

Beginningwith 1939 the birthbeingregisteredis excluded.

23
Exhibitla.Contentof theU.S.StandardCertificateof LiveBirth,

by yearrevised--Con.

Item 1900191019151918193019391949195619681978

Pregnancyinformation--Con.

Borndeadafter20weeks

pregnancy.....................

Otherterminations(spontaneous

and induced):

Under20weeks...............

Over20 weeks................

Dateof lastlivebirth........

Dateof lastfetaldeath.......

Dateof lastother

termination..................

Whetherbornaliveor stillborn..

Causeof stillbirth..............

Stillbirth--before laboror

duringlabor....................

If stillborn,periodof

gestation.......................

Datelastnormalmensesbegan....

Lengthof pregnancy(completed

weeks) . . . . . . . . ● . . . . . . . . , ● . ● . . . . .

Monthsof pregnancy..............

Prematureor fullterm...........

Monthof pregnancyprenatalcare

began.......*.● .................

Numberof prenatalvisits........

Concurrentillnessesor

conditionsaffectingthe

pregnancy.......................

Complicationsnot relatedto

pregnancy....o..............o...

Complicationsof pregnancy.......

Complicationsrelatedto

pregnancy.......................

Complicationsof laborand/or

delivery........................

Complicationsof labor...........

Congenitalmalformationsor

anomaliesof child..............

Birthinjuriesto child..........

Certificationinformation

Signatureof certifier...........

Typeof attendant................

Datesigned.....................O

x---

x

Xxxx-:: :-

x-----

x-----

x---

ii

xx--

x----

x-----

xx

xx

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x
Exhibitla.Contentof theU.S.StandardCertificateof LiveBirth,

by yearrevised--Con.

Item 1900191019151918193019391949195619681978

Certificationinformation--Con.

D:~en whichgivennamewas

.*****..*.. .........*.**.*

Nameof registraraddinggiven

name............................

Nameandtitleof attendantat

birth if other than certifier. . .

Nameandtitleof certifier......

Nameof certifier................

Mailingaddressof certifier.....

Addressof certifier.............

Signatureof registrar...........

Registrar........................

Datereceivedby registrar.......

Datereceivedby local

registrar.......................

Datefiled.......................

Signatureof parentor other

informant.......................

Informant........................

Relationto child................

x

x

x

x

x

x

x

i

x

x

x

x

i

x

x

x

x

i

x

x

x

x

i

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

NOTE: X Itemincludedon standardcertificate.

- Itemnot includedon standardcertificate.

25
Exhibit lb. Number of registration areas reporting each item on the

U.S.StandardCertificateof LiveBirth:August1982

Item Item United Outlying

number Statesl areas2

1

2

3a

3b

4a

4b

4C

5a

5b

SC

Sd

z

6b

:

7C

8a

8b

&

8e

9

10a

10b

10C

lla

llb

12

13

14

15a

15b

16

17a

17b

17C

17d

17e

Child--name.........● ..........● *...........● ● ● .

Sex....0....● .....*...............0.............

Dateof birth......● ....*● .........● ............

Hourof birth● ● ....● . . . . . ● ● . . ● . . . . . . . . . . . . . . . ● ● .

Hospital--name(orstreetaddressif birthnot

in hospital)...................................

City,town,or locationof birth................

Countyof birth....0...... ........ . . . . . . . . . ● ..0

Certifier--signature ............................

Datesignedby certifier.......................

Nameandtitleof attendantat birthif other

thancertifier....*....● . ...*... .* ..*..*. . . . . . .

Certifier--nameandtitle.......................

Certifier--mailing address......................

Registrar--signature ....*....................*..

Registrar--datareceived........................

Mother--maidenname.............................

Mother--age....*..................,.*...........

Stateof birth...*....● ● . . . . . . . ● o . . . ● . . . . ● . . . .

Residence--State ● .*....*... .................*

Residence--county .....*................*......

Residence--city,town,or location............

Residence--street andnumber..................

Residence--inside citylimits.................

Mother’smailingaddress........................

Father--name....................................

Father--age...*....● .........● ● ...● ....● . . . ● ● . . .

Father--Stateof birth.*.......................●

Informant--signature ............................

Informant--relationto child....................

Race--mother................................*...

Race--father......*...............● .............

Birthweight● ...● ● ..● ● ...0..........● .......0...

Birth--single,twin,triplet....................

If not singlebirth,bornfirst,second.........

Ismothermarried?.................● .............

Livebirthsof thismother--nowliving..........

Livebirthsof thismother--nowdead............

Dateof lastlivebirth.........................

Otherterminationsof thismother--

under20weeks...0.0..... .....0.... 0....00. ● . .

Otherterminationsof thismother--

over20weeks.............● ....*.....*....,...

See footnotesat endof exhibit.

52

52

52

52

52

52

51

52

51

52

52

51

50

52

52

52

52

52

z;

49

52

48

52

52

52

50

43

52

52

52

52

52

42

52

52

51

52

52

5

5
Exhibitlb. Numberof registrationareasreportingeach itemon the”

U.S. StandardCertificateof LiveBirth:August1982--Con.

Item Item

United Outlying

number Statesl areas2

17f

18

19

20

21a

21b

22a

22b

23

24

25

26

--

--

Dateof lastothertermination..................

Education--mother ..............................●

Education--father ..............● ................

Datelastmenstrualperiodbegan................

Monthprenatalcarebegan......................

Prenatalvisits--totalnumber...................

Apgarscore--lminute...........................

Apgarscore--5minutes..........................

Complicationsof pregnancy......................

Concurrentillnessesor conditionsaffecting

pregnancy.......**.....● .........● .............

Complicationsof laborand/ordelivery..........

Congenitalmalformations........................

Hispanicorigin--motherand father3.............

Ethnicorigin--motherandfather3...............

u

49

50

52

51

47

47

51

51

;:

9

15

3

3

3

3

3

3

2

:

4

4

4

0

0

150 states, J)istrict of Colwbia,and New York Ci.ty.

z~er-jcm Smoa, G-, Puerto Rico, virgin Islands, and TrustTerritoryof the

PacificIslands.

3Noton standardcertificate.

27
Exhibit 2. U.S. Standard Certificate of Death (Physician)

[phySiCian Form Approved

U.S. STANDARD OMB No. 68X 1901

LOCAL FILE NUMBER CERTIFICATE OF DEATH

TYPE

OR ;filNT

STATE FILE NUMBER

DECEOENT-NAME F!RST M100LE LAST SEX DATE OF DEATH (MO. D., ) P,

.

PER~&AEMT

FOR

lNSTRU~T1014S

14AHOBOOK

J

IF DEATH

OCCURRED IN

INSTITUTION.

SEE HAND800X

REGARDtNG

COMPLETION 0P

RESIDENCE ITEMS

1. 2. 3.

RACE-(e,n., Wtit,. Blink. Aw,lc,n AGE-;;;,lrth5w UNDER 1 YEAR I UNDER 1 DAY

1mllan, ●tc.) ,Sp.c,,,,

DATE OF BIRTH (Mm. D.,. Yr.) COUNTY OF DEATH

M05. ) DAYS HOURS ! MINS.

4. 5a. 5b.

I

5C. ! 6. 7a.

CITY, TOWN OR LOCATION OF DEATH HOSPITAL OR OTHER lNSTITUTlON-Nme flrnot In .+lhw. zi.e #trr.t and numbrrJ IF HOSP OR INST. Ird,t,,, 00A.

1!4.

OPIEmar. Rm.. I.!mimu mp...vi.

le. 7;

STATE OF BIRTH (Jfnot r. U.S.A.. CITIZEN OF WHAT COUNTRY MARRIED. NEvER MARRIED, SURVIVING SPOUSE (1/ w{f,, ,1”. m.Mm name] WAS DECEDENT EVER IN u S

nom, country) WIDOWED. DIVORCED fSlxClf?l

8.

ARMeO F0RcE57

9. 10. 11.

~~f, Y,, “, No,

SDCIAL SECURITY NUMSER USUAL OCCUPATION (Clr+ kind .X mark done d“ri”, most of KIND OF SUSINESSOR INDUSTRY

wmki”z fife, ewn N retired)

13. 14a. 14b.

RESIDENCE-STATE COUNTY CITY, TOWN OR LOCATION STREET AND NUMSER

l===

FATHER-NAME FIRST MOTHER-MAIDEN NAME FIRST M,ODLE LAsr

INFORMANT-NAME fmx or Prf.u MAILING ADORESS STREET OR R.F.O. NO. CITV OR TOWN STATE :,,,

18b.

BuRIAL, CREMATIDN. REMOVAL. OTHER lSP*CVY1 CEMETERY OR CREMATORY-NAME LOCATION CITY OR TOWN S,nre

& 19b. 19C.

PUN E_4AL SERVICE LICENSEE Or Pmon Actlw As Such NAME OF FACILITY

(St,n.t”m)

ADDRESS OF FACILITY

20C.

To the Lwstof my knowlcdw, dwth occu,,ed ●t the tire,, date ,& Plem srd d.. [0 the DATE SIGNED (Ma, D.,. Yr,) HOUR OF DEATH

cn.wls) stattd.

21b. 21C. PA

NAME OF ATTENDING PHYSICIAN IF OTHER THAN CERTIFIER (T,P, c.r PrlntJ

NAME AND ADDRESS OF CERTIFIER flyP, .a, ~{m,,

DATE RECEIVED 8Y REGISTRAR (MD,, Day. YF.)

CO~FD~~~NS 22b.

WHICH GAVE IMMEDIATE CAUSE [ENTER ONLY ONE CAUSE PE8 LINE FOR I*), lb). AND (.).1 , Interval b+tw*.n ..=! .0.! 8N.th

J

RISETO IMMEDIATE cAUSE STATING THE UNDERLYING CAUSELAST

PART

1

[ M I

DUE TO, DR AS A cONSEQUENCE OF,

P

lnt*wd btwmtn o.w ●miX4G

{

lb)

i

DuE TO. OR AS A cONSEQUENCE OF: 1“,.,.,1 Imtw,.. ““W; 4*; ,1..,,,

I

[cl

I

PART OTHER SIGNIFICANT CONDITIONS-CmdNlons contributiw to death b.: ..1 re!mcd 1. .x.= SIW. in PART 1 I*I AUTOPSY (Sbwdfy )’.’ WAS CASE REFERRED TO ME IXCA1

n

or No) EXAMINER DR CDRONER

(sPcdt? Y,, “r N<>)

24. 25.

ACC( DENT @PrdfY Y.. or No) DATE OF INJURY (Mo.. DOY. Y..) HOUR DF INJURY DESCRIBE HOW INJURY DCCURRED

.-

2ss. Z&. 26C. M 2W.

INJURY AT WORK (Specify Y,, PLACE OF lNJURY-At home, farm. alma. Nctoly. .Ifim buildiq, LDCATION

..-—

STREET OR R.F. D. NO. CITY OR TOWN — \, All

0, N.] m. (sPeclfY)

l-1-lvy~8.3

28
Exhibit 2a. U.S. Standard Certificate of Death (Physician, Medical Examiner or Coroner)

(PHYSICIAN, MEDICAL EXAMINER OR CORONER) APr3roVed

U.S. STANDARD 0N2L No. 68R 1901

LOCfiL FILE NUMBER CERTIFICATE OF DEATH

TYPE

STATE F,LE NuMBER

OR PRINT

DECEDENT-NAME F,RST MIDDLE .4S1 SEX OAT E 0 F DEATH ,.%1. D.,, Y,,,

IN

PER~@ENT

FOR

lNSTR#:TIONS

HANDBOOK

,, 12EATH

QCCUi?R~O IN

,NSTITLITION,

:EE HANDBOOK

RCOARDING

COMPLETION of

RESIDENCE ITCMS J

1. 2. 3.

RACE -[e,Q,,White,81 sk.American AGE-can 8,”hday uNDER 1 YEAR I

UNDER 1 DAY

Ind,m. etc.) ,S,,dfy,

DATE OF 81RTH f%!., nav. t’r I COUNTY DF OEATH

o’..., !40S. 1 DAYS HOURS ; MINS.

4 5a. 5b. i 5C. I

6, la.

CITY. TOWN OR LOCATIDN OF DEATH HOSPITAL 08 DTHER INSTITUTION.Name ,If ,,,,t t,, ,.,th,.r d,,. ,tv,. t .nd ,,,,mber) IF HOSP OR IN?.T I“d,mte DOA,

OP/Emer Rm., Inpatmm LS’DeCtfYJ

7b. 7C. 7d.

STATE OF BIRTH (Iln.atfn us A., CITIZEN OF WHAT COUNTRY MARRIED. NEveR MARRIED. SURVIVING SPOUSE ,1/ m,(, .,,,. .,,.o,d,-. ..”,..,

nmll. .O.n(ry, WIDOWED. DIVORCED ,S,m, f,,

WAS OECEDENT EVER IN u S

ARMED FORCES?

8, 9. 10. 11

~2:lf > Y?, or.\.,

SDCIAL SECURITY NUMBER

..— —.. . .

USUAL OCCUPATION ((7,.,. !,md ,,( I,,,,,, ,,,,.,. ,,,,,,., .,,,,,, ,,, <IND OF BUSINESS DR INDuSTRY

tit,,):,,,, 1,1!.,.,,.” ,( r! ,,r?!,, I

13, 14a,

RESIDENCE-STATE COUNTY CITY. TOWN OR LOCATION

15s. 15b. 15., ~15d

-:’R-N’ME ““s’ “s’

158,

MIODLE

I:’HER‘A”’’’’””’’’’”;

‘,14;, M,DOLE LAST

INFORMANT-NAME (T,I,V o, w.,, MAILING ADDRESS S,” SF, (,” !, ! ,, .,,, .. . r., ,,. ,“WN STATE ZIP

18b.

BURIAL, CREMATION, REMOVAL, OTHER (.smwfY) .rJ,,AT, rJN C,TV OR TOWN STATE

19a.

FuNERAL SERVICE LICENSEE 0, PersonActing A, Such

--—- .—

NAME OF FACILITY

(Swmlurr,

21a, To the best of my knowledge, death occurred at the wne. date md place and due to the 223 0“ (he bass 1,-ex.,m,nat,o? ,,-(! “c ,n.es,,qalm”. ,“ m“ 0!3,”,0” death occurred at the ,,m,,

Ca”$eld stated d.,. and p!,,. and !I ,. ,“ m. cm-ml,) ,,ated

:=

u

a:

,s,.”., !,., ..II D,,,.) F

F: -:

~50 ,~!tyyr, ,,?,8 b

OATE SIGNED ,,11.. IMY, Yr , :$ > HOUR DF DEATH :ac DA KS IGNED II,, 1,, . $. ‘“ ““ HOUR OF DEATH

=x .

~~6

E(” Z

21b. 21C. M :!: 22b,

:?

22C.

NAME OF ATTENDING PHYSICIAN IF OTHER THAN CERTIFIER (’,,,%,. ,,,1,,,,,,, a -“ ,RONOIJ,,CED “EA,, ,,,, ,,r. , - PSONOU?JCEO OEAD ,,,,,,,.,

:Z

~::

H 21d

z

22d ON

. ..l?&L___ :

NAME AND AtJDRESS OF CERTIFIER (PHVs[CIAN. MEDICAL EXAMINER OR cOflONERi , T%p. ,Jrrm. t,

.——

CON

,,

U!

AN”

TIONS ➤ 124b

WHICHC.AVL IMMEDIATE CAUSE [ENTER OWL Y ONE CAUSE PER LINE FOR L+ W. AND (C). I

R,5C 70

, [.wwI h.x.%ee. onset and death

thlf.4L01&7E PART

CA”S[ I

IN

STATtNCi THE DUE TO. OR .4S A CDNSEOUENCE DF

– .—..—-~

LINDIRLYi NG

,CA!JSE L.-.37

1“,.w31 b+,ween 0“,,, and death

‘ {

(b)

.—— -- .—— —______

== CON5EOU5NCE OF

—– - . . ..~

1“,,,”,1 b,,we” o“%, wd death

q

\

(d i

.,

1. PART OTHER SIGN IF IcANT CONDITIONS-COMItOOn5 ,..t, )b.t,.g m death b.t not ,e!ated t. ~ue ~gven,0 PART I .. . ‘ AUTO??, .,p”,.,,, >., WAS CASE REFERRED TO MEDICAL

II , ,,. EXAMINER OR CORONGR

!

c.jwc,,, , ,., ,,, ,,,,

I 2; I 27.

ACC ,SUICIDE, HOM . UNDET . DATC OF INJURY ,11,, Da,. ! t , HOUH OF~URY

OR PENDING INVEST ,s,>.., [,,

DESCRIBE HCIW 3iN,URY ‘3,:CU=QE3

28a, 2Sb 2SC, M 28d.

INJURY AT \VORK ,W CU, Ye. PLACE DF INJURY- A, home, farm. wee,. 1..,0,”. “If,m bu,ld, n,, LOCATION 3. *E.., . . . .. !. ?4,. C!TV OR TO.VN

HRA-162-1

,>, .%, etc !s,w..,f,,

sTArE

Rev. 1178 28e. 28f. 28g.

29
Exhibit 2b. U.S. Standard Certificate of Death (Medical Examiner or Coroner)

TYPE

OR ~FJINT

PERA4A:ENT

FOR

Irmmluplorns

I4AS401OOK

IF DEATH

OCCURRED IN

lNST1 TUTION.

SEE HAND@OOK

REGARDING

COMPLETION OF

RES[OENCE ITEMS

[MEDICAL EXAMINER OR CORONER) Form Approved

U.S: STANDARD OME No. 68R 1901

LOCAL FILE NuMBER CERTIFICATE OF DEATH STATE FILE NUMBER

/LTECEDENT-NAME FIRST MIDDLE LAST SEX DATE OF DEATH (till. U*V. Y* 1

1. z. 3.

RACE -(e. W.WhlN, Bl@ck,Amwk* AGE-:;::,Iirlhday

_—. —

UNDER 1 YEAR

Ir,dhn$ ●..) (sprcl/y]

I UNDER 1 DAY DATE OF BIRTH f.wo., DOY. Yr.} COUNTY OF DEATH

Mos. DAVS HOURS ; MINS.

~ 51. 5b. ‘ 5C. I 6. la.

CITY, TDWN OR LOCATION OF DEATH HOSpITAL OR OTHER INSTITUTION-N- (lfnOt {. dthec. ZIw StM M ..171w

-—

IF H(ISP OR ltJST Ind,’ul” tIOA,

OP/Enmr. Rm. I.P.SWII1 ,v-.,I?J

n!. k 7d.

STATE OF 81RTH (I(wlin US.A. CITIZEN OF WHAT COUNTRY MARRIED, NEVER MARRIED,

..—

SURVIVING SPOUSE Nf w{(<. tit,, maid,” name) WAS DECEDENT EVEH IN US

“cm, ,,7”” fry) WIDDWED, DIVORCED (SP,d/Y) ARMED FORCES>

8. 9. 10. 11.

fp/, v,. !,?.Vm

SGCIAL SECURITY NUMSER USUAL OCCUPATION (c!., hind ofuorh done duri”l mm, .( KIND OF BUSINESS OR 1NDUSTR%

IVO,M.E u!., *w” ff rr:imd)

13. 14*. 14b.

RESIOENCE-STATE COUNTY CITY. TG+YN OR LOCATION 3TREETANDNUMBER INSIDE CITV LIMITS

,,prc,,, Y..,,, ,V,J,

FATHER-NAME F8RST M,ODLE LAST MOTHER-MAIDEN NAME FIRST ?.!,00LE LAST

INFDRMANT-NAME (TYII, .a, Pdno MAILING ADDRE23 STREET OR R.F.0. No. CITY OR TOWN 57ATC 21P

I.w.

BURIAL. CREMATION, ITEMoVAL, OTHER ,SPCNI,) CEMETERY OR CREMATORY-NAME LOCATION CITV OR TOWN STATC

198. 19b. 19C.

FuNERAL sERvtcE tICENSEE 0, personActing AS such NAME DF FACILITY ADDRESS OF FACILITY

I (s{,”.l ”-)

20b. 20C.

On the b-is of .xaminmio. .ndlor i.vmiimio.. 1. my opfni.and@athocwred .t the Nm.. DATE SIGNED (MO.. h,. Y,.)

, d,,. and IN= ●d d., to the mm(s) ,t,ted.

HOUR OF DEATH

21b. M 21C. M

PRONOUNCED DEAD 1.WO.,D.?. Yr.J pRONOUNCED DEAD w<,.,,

21d. ON 21e. AT M

NAME ANO ADDRESS OF CERTIFIER lTYX or Print)

DATE t7ECEl VE0 BY’ REGISTRAR (M.,, Do, Y,,

22b.

CO~FOj~l:NS

IMMEDIATE CAU3E [ENTER OML Y ONE CAUSE PER LINE FOR (d, lb), ANO /.).1 lnmv.1 W**. mm ●l dwh

m,.. .,-,

!

...- .-

1W:;:TE

STATINO THE

UNDERLYING

CAUSE LAST

~1

1

,,1.

.

I M I

DUE TO. OR AS A CONSEQUENCE DF:

{

Inwvd imltwm O.WI WJ death

I

(b)

I

LYuETO, OR AS A CONSECIUENCE OF: 1“1,,”,8 t+lw,” O“Mt SIW daalh

I

(d I

PART OTHER SIGNIFICANT CDNDITIONS-COrWit ionsCOnlribulirq to d,,th but ml ,,l,ud to mum givm i“ PART I (,)

n

AUTOPSY ,sP@/y Ye’ “v V.,

I ’24.

ACC.. SUICIDE. HDM,, UNDET.. DATE OF INJURY (M.,, D.w. Yr.) HDUR OF INJURY

OR PENDING INVEST, (Sn,cif,)

DESCRIBE HOW INJURY OCCURRED

25a. 2Sb. 25c. M 25d.

INJURY AT WORK WMY Y.. PLACE OF INJURY-A, honw. farm. ,!,”t, Iwmrv. office bulldim, LGCATION STREET OR R.F, O. NO.

etc. (S.n,dr,)

C,’W OR 10wN 5TATC

HRA-162.2

Rev. lf78

30
Exhibit 2c. Content of theU.S. Standard Certificate of Death,

by year revised

Item 1900 1910 1918 1930 1939 1949 1956 1968 1978

Decedent information

Name. . . . . . . . . ● . . ● ● ● . ● ● . . . . ..* . . . . . .

Sex . ● . . . . . . . . . . . . . . . . . . . . . ..* . ● ● . . .

Race . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Ag;;ars

. . . . . . . ● ., . . ● . . . . . . . . ● *. . . . .

Months . . . . . . . . . . ...***.. . . . . . . . . .

Days. . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Hours . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Minutes ● ● . . . . . . . . . . . . . . . . . . . . . . . .

Date of birth . . . . . . . . . . . . . . . . . . . . . .

Birthplace:

State or country . . . . . . . . . . . . . . . . .

City, town, or county . . . . . . . . . . . .

City or town . . . . . . . . . . . . . . . . . . . . .

Citizen of what country . . . . . . . . . . . .

How long inU.S., if of foreign

birth . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Marital status . . . . . . . . . . . . . . . . . . . . .

Surviving spouse (if wife,

give maiden name) . . . . . . . . . . . . . . . . .

Name of husband or wife.... . . . . . . . .

Age of husband or wife, if alive . . .

Was decedent ever inU.S. armed

forces? . . . . . . . . . . . . . . . . . . . . . . . . . . . .

If yes, give war or dates of

.

service . . . . . . . . . . . . . . . . . . . . . . . . .

If veteran, name war . . . . . . . . . . . . .

Social security number . . . . . . . . . . . . .

Occupation . . . . . . . . . . . . . . . . . . . . . . . . .

Usual occupation . . . . . . . . . . . . . . . . . . .

Name of employer . . . . . . . . . . . . . . . . . . .

Business or industry . . . . . . . . . . . . . . .

Date deceased last worked at this

occupation . . . . . . . . . . . . . . . . . . . . . . . .

Total time (years) spent in this

occupation . . . . . . . . . . . . . . . . . . . . . . . .

Residence:

Former or usual residence . . . . . . . . .

State . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Length of residence in the State

(years, months, and days) . . . . . . . .

county ● ● . ● . . ● ● . . . . . ● . . . . . . . . . . . . . .

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

ii

x

x

x

x

x

x

x

x

x

x

x

x

x

i

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

i

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

i

x

x

x

x

i

x

x

x

31

a
Exhibit2c.Contentof theU.S.StandardCertificateof Death,

by yearrevised--Con.

Item 190019101918193019391949195619681978

Decedentinformation--Con.

City,town,or location...........

Ifnonresident,givecityor

townandState.................

Ward..............................

Streetandnumber.................

Insidecitylimits................

Is residenceon a farm?...........

Fathers’sname......................

Birthplaceof father:

Stateor country..................

Cityor town......................

City,town,or county.............

Mother’smaidenname................

Birthplaceof mother:

Stateor country..................

Cityor town......................

City,town,or county..........o..

Placeof deathinformation

county...● ● ● ......● .........● .*● ● ● .●

City,town,or location.............

Insidecitylimits..................

Townshipof,or.....................

Villageof,or......................

Cityof.............................

Ward...............................●

Streetand number..................

Nameof hospitalor other

institution........................

If hospitalor institutionindicate

whetherdeadon arrival,outpatient/

emergencyroomor inpatient........

If deathoccurredin a hospitalor

institution,giveitsnameinstead

of streetandnumber.............

Ifnot in hospitalor institution

givestreetaddressor location...

Lengthof stayin hospital..........

Lengthof stayin thiscommunity....

Lengthof staywheredeath

occurred...........................

Lengthof residencein theState....

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

:

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

ii

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

:

x

x

x

x

i

x

x

x

x

x

x

x

x

x

x

ii

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

32
Exhibit 2c. Content of the U.S. Standard Certificate of Death, 

by year revised--Con. 

Item 1900 1910 1918 1930 1939 1949 1956 1968 1978 

Medical certification 

Cause of death ...................... 

Duration .......................... 

Date of onset ..................... 

Immediate cause of death ............ 

Interval between onset and death . . 

Due to , ............................. 

Interval between onset and death . . 

Due to , ............................. 

Interval between onset and death . . 

Contributory cause .................. 

Duration .......................... 

Date of onset ..................... 

Other significant conditions ........ 

Duration .......................... 

Interval between onset and death . . 

Was autopsy performed? .............. 

Were autopsy findings considered in 

determining cause of death? ....... 

What test confirmed diagnosis? ...... 

Major findings of autopsy ........... 

Did an operation precede death? ..... 

Date of operation ................. 

Name of operation ................. 

Major findings of operations ...... 

Where was disease contracted if not 

place of death? .................... 

For deaths from external causes: 

Accident, suicide, homicide, 

undetermined, or pending 

investigation .................... 

Accident, suicide, homicide, or 

undetermined ..................... 

Accident, suicide, or homicide .... 

Date of injury .................... 

Hour of injury .................... 

How injury occurred ............... 

Injury at work .................... 

Place of injury ................... 

Location of injury ................ 

Means of injury ................... 

Manner of injury .................. 

Nature of injury .................. 

z 

X 

X 

X 

X 

X 

X 

X 

X 

X 

X 

X 

X 

X 

X 

I 

X 

X 

x 

X 

X 

X 

X 

X 

X 

X 

X 

I 

X 

X 

X 

X 

X 

X 

X 

X 

f 

X 

X 

X 

X 

X 

x 

X 

X 

x - 

x x x x x x - - 

x x x x x x 

x x x x 

x x x x 

x x x x x 

x” :: x” :: f x” 

x - - - - 

x - - - - - 

x - - - - - 

33 
Exhibit 2c. Content of the U.S. Standard Certificate of Death, 

by year revised--Con. 

Item 1900 1910 1918 1930 1939 1949 1956 1968 1978 

Medical certification--Con. 

Was disease or injury related to 

occupation? ...................... 

If so, specify .................. 

Certifier: 

Signature and title of certifier . . 

Separate medical examiner or 

coroner certification ............ 

Date signed ....................... 

Date of death ..................... 

Hour of death ..................... 

Date pronounced dead .............. 

Hour pronounced dead .............. 

Name of attending physician, if 

other than certifier ............. 

Name of certifier ................. 

Address of certifier .............. 

Dates physician attended 

decedent ......................... 

Date last seen alive .............. 

Whether physician viewed body 

after death ...................... 

Was case referred to medical 

examiner or coroner .............. 

Disposition information 

Burial, cremation, or removal ....... 

Date of burial ...................... 

Place of burial or removal .......... 

Place of burial, cremation, 

or removal ......................... 

Name of cemetery or crematory ....... 

Locat ion .......................... 

Signature of funeral director ....... 

Signature of funeral service 

licensee or person acting as such . . 

Name of funeral director 

(or person acting as such) ......... 

Address ........................... 

Name of facility (funeral home) ..... 

Address of facility (funeral 

home) ............................ 

X 

f 

X 

X 

f 

X 

X 

X 

X 

X 

X 

X 

X 

X 

:: 

X 

X 

X 

X 

X 

x” 

X 

X 

x” 

X 

X 

X 

X 

X 

X 

X 

X 

X 

X 

X 

X 

X 

:: 

X 

X 

x” 

X 

X 

X 

X 

X 

X 

f 

X 

X 

z 

X 

X 

X 

X 

X 

X 

X 

X 

X 

X 

X 

x” 

X 

X 

X 

X 

:: 

X 

:: 

X 

X 

X 

X 

X 

X 

z 

X 

X 

X 

X 

x” 

X 

X 

X 

X 

:: 

X 

I 

ii 

X 

X 

X 

X 

X 

X 

X 

X 

34 
Exhibit 2c. Content of the U.S. Standard Certificate of Death, 

by year revised--Con. 

1900 1910 1918 1930 1939 1949 1956 1968 1978 

Other information 

Informant ‘s signature. . . . . . . . . . . . . . . - - - - X - - - - 

Informant’s name. . . . . . . . . . . . . . . . . . . . X X X X - X X X X 

Address . . . . . . . . . . . . . . . . . . . . . . . . . . . x x x x x - x x 

Registrar’s signature............... - - x x :: x x 

Registrar . . . . . . . . . . . . . . . . . . . . . . . . . . . xXxX----- 

Date received by local registrar.. . . - - - - X X X X - 

Date received by registrar.. . . . . . . . . - - - - - - - - X 

Date filed . . . . . . . . . . . . . . . . . . . . . . . . . . x x x x - - - - - 

NOTE: X Item included on standard certificate. 

- Item not included on standard certificate. 

35 
Exhibit 2d. Number of registration areas reporting each item on the 

U.S. Standard Certificate of Death: August 1982 

Item 

number Item United 

States1 

Cut lying 

areas2 

1 

: 

4 

zt 

SC 

6 

7a 

7b 

7c 

7d 

i 

10 

11 

12 

13 

14a 

14b 

15a 

15b 

15c 

15d 

15e 

i”7 

18a 

18b 

19a 

19b 

19c 

20a 

20b 

2oc 

21a 

21b 

21c 

21d 

Decedent--name .................................. 

Sex ............................................. 

Date of death ................................... 

Race ............................................ 

Age--last birthday .............................. 

Age if under 1 year ............................. 

Age if under 1 day .............................. 

Date of birth ................................... 

County of death ................................. 

City, town, or location of death ................ 

Hospital or other Institution of death--if 

neither, give street address ................... 

For institutional death indicate whether dead 

on arrival, outpatient/emergency room, 

inpatient ...................................... 

State of birth .................................. 

Citizen of what country ......................... 

Married, never married, widowed, divorced ....... 

Surviving spouse--name .......................... 

Was decedent ever in Armed Forces? .............. 

Social security number .......................... 

Usual occupation ................................ 

Kind of business or industry .................... 

Residence--State ................................ 

Residence--county ............................... 

Residence--city ................................. 

Residence--street and number .................... 

Residence--inside city limits ................... 

Father--name .................................... 

Mother--maiden name ............................. 

Informant - -name ................................. 

Informant--mailing address ...................... 

Method of disposition ........................... 

Name of cemetery ................................ 

Location of cemetery--city and State ............ 

Funeral service licensee--signature ............. 

Name of facility ................................ 

Address of facility ............................. 

Certifier--signature and title ................. 

Date signed by certifier ........................ 

Hour of death ................................... 

Name of attending physician if other than 

certifier ...................................... 

5: 

52 

52 

:i 

52 

52 

51 

52 

52 

42 

52 

50 

52 

51 

45 

52 

:I 

52 

51 

52 

52 

51 

52 

52 

:; 

52 

52 

;; 

46 

47 

52 

;i 

29 

See footnotes at end of exhibit. 

36 
Exhibit 2d. Number of registration areas reporting each item on the 

U.S. Standard Certificate of Death: August 1982--Con. 

Item 

number Item United 

States1 

Out lying 

areas2 

22a 

22b 

22c 

22d 

22e 

23 

24a 

24b 

25 

28a 

28b 

28c 

28d 

28e 

28f 

28g 

-- 

-- 

Medical examiner or coroner--signature and 

title .......................................... 

Date signed ..................................... 

Hour of death ................................... 

Date pronounced dead ............................ 

Hour pronounced dead ............................ 

Certifier--name and address ..................... 

Registrar--signature ............................ 

Date received by registrar ...................... 

Cause of death .................................. 

Interval between onset of condition and death ... 

Other significant conditions contributing 

to death ....................................... 

Was autopsy performed? .......................... 

Was case referred to medical examiner or 

coroner 3 ........................................ 

Accident, suicide, homicide, undetermined, or 

pending investigation .......................... 

Date of injury .................................. 

Hour of injury .................................. 

Describe how injury occurred.: .................. 

Was injury at work? .............................. 

Place of injury (home, factory) ................. 

Location of injury--street, city, State ......... 

Was the decedent of hispanic origin?3 ........... 

Ethnic origin of decedent3 ...................... 

49 

48 

kc! 

46 

52 

50 

50 

52 

52 

52 

52 

34 

52 

51 

51 

51 

51 

51 

51 

9 

14 

5 

5 

1 

i 

3 

4 

5 

5 

4 

i 

--- --- ---4- 

150 States, District of Columbia, and New York City. 

2American Samoa, Guam, Puerto Rico, Virgin Islands, and Trust Territory 

of the Pacific Islands. 

3Not on standard certificate. 

37 
Exhibit 3. U.S. Standard License and Certificate of Marriage 

vs. STANDARD 

LlCDNSE NUMBER LICENSE AND CERTIFICATE OF MARRIAGE 

SlDENCE -STREET AND NUMBER 

Form Approved 

OMB No.68Ft1903 

HRA-164 I I 

Rev. I/78 25. 26. 271. !27b. 28. I 

38 
Exhibit 3a. Content of the U.S. Standard License and Certificate of Marriage, 

by year revised 

1956 1968 1978 

Groom information 

Name .................................................. 

Age ................................................... 

Date of birth ......................................... 

Race .................................................. 

Education ............................................. 

Usual residence: 

State ............................................... 

county .............................................. 

City, town, or location ............................. 

Street and number ................................... 

Inside city limits .................................. 

Birthplace (State or foreign country) ................. 

Mar ital status : 

Number of this marriage ............................. 

Number of previous marriages ........................ 

Previous marital status ............................. 

How last marriage ended ............................. 

Date last marriage ended ............................ 

Father--name .......................................... 

Birthplace (State or foreign country) ............... 

Mother--maiden name ................................... 

Birthplace (State or foreign country) ............... 

Occupation ............................................ 

Business or industry .................................. 

Bride information 

Name .................................................. 

Maiden name if different .............................. 

Age ................................................... 

Date of birth ......................................... 

Race .................................................. 

Education ............................................. 

Usual residence: 

State ............................................... 

county .............................................. 

City, town, or location ............................. 

Street and number ................................... 

Inside city limits .................................. 

Birthplace (State or foreign country) ................. 

Marital status: 

Number of this marriage ............................. 

Number of previous marriages ........................ 

X 

f 

: 

X 

X 

x 

X 

X 

X 

X 

X 

X 

X 

X 

X 

f 

X 

X 

X 

T 

X 

:: 

X 

:: 

X 

X 

X 

I 

X 

X 

X 

X 

X 

X 

X 

X 

x 

X 

X 

X 

X 

39 
Exhibit 3a. Content of the U.S. Standard License and Certificate of Marriage, 

by year revised--Con. 

Item 1956 1968 1978 

Bride information--Con. 

Previous marital status ............................. 

How last marriage ended ............................. 

Date last marriage ended ............................ 

Father--name .......................................... 

Birthplace (State or foreign country) ............... 

Mother--maiden name ................................... 

Birthplace (State or foreign country) ............... 

Occupation ............................................ 

Business or industry .................................. 

License information 

Signatures of applicants .............................. 

Date signed ........................................... 

Groom's signature ..................................... 

Bride's signature ..................................... 

Date license was subscribed and sworn to .............. 

Signature of issuing officer .......................... 

Title of issuing officer .............................. 

Ceremony information 

Date of marriage ...................................... 

Place of marriage: 

State ............................................... 

county .............................................. 

City ................................................ 

Person performing ceremony: 

Title ............................................... 

Signature ........................................... 

Religious or civil .................................. 

Date signed ........................................... 

Type of ceremony--religious or civil .................. 

Witnesses to ceremony--signatures ..................... 

Other information 

Signature of local official making return to 

State health department ............................. 

Date received by local official ....................... 

Date of recording ..................................... 

X 

x - 

x - 

:: 

X 

X 

X 

X X 

x - 

X X 

X 

X 

X 

x” - 

x - 

X 

X X 

X x .x 

X X 

x - - 

NOTE: X Item included on standard certificate. 

- Item not included on standard certificate. 

40 
-- - 

Exhibit 3b. Number of registration areas reporting each item on the 

U.S. Standard License and Certificate of Marriage: August 1982 

Item 

number Item United 

States1 

Out lying 

areas2 

1 

:a 

:: 

3d 

4 

ia 

6b 

;: 

8a 

8b 

lia 

lob 

1oc 

10d 

11 

12 

13a 

13b 

14a 

14b 

15 

Ea 

17b 

17c 

18a 

18b 

18c 

18d 

18e 

18f 

19a 

19b 

20a 

20b 

Groom- -name ....................................... 

Age ............................................. 

Residence--street and number .................... 

Residence--city, town, or location .............. 

Residence--county ............................... 

Residence--State ................................ 

Birthplace ...................................... 

Date of birth ................................... 

Father--name .................................... 

Father--birthplace .............................. 

Mother--maiden name ............................. 

Mother --birthplace .............................. 

Bride--name ....................................... 

Maiden name ..................................... 

Age ............................................. 

Residence--street and number .................... 

Residence--city, town, or location ............... 

Residence--county ............................... 

Residence--State ................................ 

Birthplace ...................................... 

Date of birth ................................... 

Father--name .................................... 

Father--birthplace .............................. 

Mother--maiden name ............................. 

Mother--birthplace .............................. 

Groom--signature .................................. 

Bride--signature .................................. 

License--date issued .............................. 

License--signature of issuing officer ............. 

License--title of issuing officer ................. 

Ceremony--date .................................... 

Ceremony--city .................................... 

Ceremony--county .................................. 

Signature of person performing ceremony ........... 

Title of person performing ceremony ............... 

Type of ceremony . ..) .............................. 

Signature of witness to ceremony .................. 

Signature of.witness to ceremony .................. 

Local official--signature ......................... 

Date received by local official ................... 

4 

: 

3 

2 

1 

i 

4 

: 

f 

2 

fi 

4 

1 

3 

: 

I 

2 

3 

2 

1 

: 

1 

3 

i 

3 

z 

3 

See footnotes at end of exhibit. 

41 
Exhibit 3b. Number of registration areas reporting each item on the 

U.S. Standard License and Certificate of Marriage: August 1982--Con. 

Item 

number Item United States1 

Gut lying 

areas2 

21 

22 

23a 

23b 

24 

25 

26 

27a 

27b 

28 

Groom--race ...................................... 

Number of this marriage ........................ zz 

Last marriage ended by divorce, 

dissolution or annulment ...................... 39 

Last marriage--date ended ...................... 24 

Education ...................................... 18 

Bride--race ...................................... 34 

Number of this marriage ........................ 39 

Last marriage ended by divorce, 

dissolu’;ion, or annulment ..................... 39 

Last marriage--date ended ...................... 

Dducat ion ...................................... f;: 

2 

2 

2 

150 States, District of Columbia, and New York City. 

2American Samoa, Guam, Puerto Rico, Virgin Islands, and Trust Territory 

of the Pacific Islands. 

42 
Exhibit 4. U.S. Standard Certificate of Divorce, Dissolution of Marriage or Annulment 

Form Approved 

TYPE U.S. STANDARD OMBNo.68R1904 

OR FUINT 

PERM?NENT 

CERTIFICATE OF DIVORCE, COURT IOENTlFlCATlON 

INK ,cour, 1110 ““rnbl,~ DISSOLUTION OF MARRIAGE OR ANNULMENT STATE FlLE NUMBER 

FOR 

INSTRUCTIONS HUSBAND-NAME FIRST MlDDLE LAST 

HRA-165 

Rsv.1/78 

43 
Exhibit 4a. Content of the U.S. Standard Certificate of Divorce, Dissolution 

of Marriage or Annulment, by year revised 

1956 1968 1978 

Husband information 

Name .................................................. 

Date of birth ......................................... 

Race .................................................. 

Education ............................................. 

Usual residence: 

State ............................................... 

county .............................................. 

City, town, or location ............................. 

Street and number ................................... 

Inside city limits .................................. 

Birthplace (State or foreign country) ................. 

Mar ital status : 

Number of this marriage ............................. 

If previously married, how many ended by 

death? divorce? ..................................... 

Occupation ............................................ 

Business or industry .................................. 

Wife information 

Name .................................................. 

Date of birth ......................................... 

Race .................................................. 

Education ............................................. 

Usual residence: 

State ............................................... 

county .............................................. 

City, town, or location ............................. 

Street and nmber ................................... 

Inside city limits .................................. 

Birthplace (State or foreign country) ................. 

Marital status: 

If previously married, how many ended by 

death? divorce? ................................... 

Occupation ............................................ 

Business or industry .................................. 

X 

X 

X 

:: 

X 

X 

X 

X 

X 

X 

:: 

ft 

X 

X 

X 

X 

X 

x” 

X 

X 

X 

X 

X 

X 

X 

x” 

X 

X 

X 

X 

X 

X 

44 
Exhibit 4a. Content of the U.S. Standard Certificate of Divorce, Dissolution 

of Marriage or Annulment, by year revised--Con. 

Item 1956 1968 1978 

Decree information 

Date marriage was dissolved ........................... 

Type of decree--divorce, dissolution, or annulment .... 

Date of entry ......................................... 

County of decree ...................................... 

Title of court ........................................ 

Title of court official ............................... 

Signature of certifying court official ................ 

Party to whom decree granted .......................... 

Legal grounds for decree .............................. 

Petitioner ............................................ 

Plaintiff ............................................. 

Attorney for petitioner ............................... 

Address ............................................. 

Attorney for plaintiff ................................ 

Address ............................................. 

Other information 

Place of this marriage: 

State or foreign country . . . . . . . . . . . . . . . . . . . . . . . . . . . . 

county . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 

City . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 

Date of this marriage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 

Date couple separated . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 

Number of children ever born alive of this marriage... 

Living children in this family........................ 

Children under 18 in this family...................... 

--.--- --- 

X X 

X 

X z 

X X 

X X 

X X 

X X 

x - 

x - 

X 

x - 

X 

X 

x - 

x - 

X X 

X X 

X X 

X 

X 3t 

-- 

NOTE: X Item included on standard certificate. 

- Item not included on standard certificate. 

45 
Exhibit 4b. Number of registration areas reporting each item on the U.S. 

Standard Certificate of Divorce, Dissolution of Marriage or Annulment: 

August 1982 

Item 

number Item United 

States1 

Outlying 

areas2 

1 

2a 

2b 

;: 

: 

2 

ii 

6c 

6d 

; 

9a 

9b 

ii: 

10 

lla 

llb 

12 

13a 

13b 

14a 

14b 

14c 

14d 

14e 

14f 

21” 

16 

17a 

17b 

18 

Husband--name ..................................... 

Residence--street address ....................... 

Residence--city, town, or location .............. 

Residence--county ............................... 

Residence--State ................................ 

Birthplace ...................................... 

Date of birth ................................... 

Wife--name ........................................ 

Maiden name ..................................... 

Residence--street address ....................... 

Residence--city, town, or location .............. 

Residence--county ............................... 

Residence--State ................................ 

Birthplace ...................................... 

Date of birth ................................... 

Place of this marriage--city ...................... 

county .......................................... 

State ........................................... 

Date of this marriage ............................. 

Date couple separated ............................. 

Number of children born alive of this marriage .... 

Number of children under 18 years in family ....... 

Who is petitioner? ................................. 

Name of attorney for petitioner ................... 

Address of attorney ............................... 

Date of dissolution ............................... 

Type of decree granted ............................ 

Date of entry of judgment ......................... 

County of decree .................................. 

Title of court .................................... 

Signature of certifying official .................. 

Title of official ................................. 

Husband--race ..................................... 

Number of this marriage ......................... 

How many ended by death? ........................ 

How many ended by divorce, dissolution, 

or annulment? ................................... 

Education ....................................... 

43 

26 

:: 

35 

30 

33 

35 

34 

26 

;: 

z; 

33 

25 ;!: 

40 

22 

25 

36 

38 

26 

2 

41 

31 

if 

33 ii-i 

31 

21 

f : 2 

2 

See footnotes at end of exhibit. 

46 
Exhibit 4b. Number of registration areas reporting each item on the U.S. 

Standard Certificate of Divorce, Dissolution of Marriage or Annulment: 

August 1982--Con. 

Item 

number Item United 

States1 

Outlying 

areas2 

19 Wife--race ........................................ 30 

20 Number of,this marriage ......................... 31 ; 

21a How many ended by death? ........................ 21 2 

21b How many ended by divorce, dissolution, 

or annulment? ................................... 21 

22 Education ....................................... 21 ; 

150 States and District of Columbia. 

2American Samoa, Guam, Puerto Rico, Virgin Islands, and Trust Territory 

of the Pacific Islands. 

. t 

, 

47 
Exhibit 5. U.S. Standard Report of Fetal Death 

HRA-163 

Rev.1/78 

48 
Exhibit 5a. Content of the U.S. Standard Report of Fetal Death, 

by year revised 

Item 1930 1939 1949 1956 1968 1978 

Fetal death information 

Name of fetus ................................... 

Sex of fetus .................................... 

Date of delivery ................................ 

Hour of delivery ................................ 

Place of delivery: 

Name of hospital .............................. 

State ......................................... 

If birth occurred in hospital or institution, 

give its name instead of street number ...... 

Street and number if not in hospital .......... 

Township ...................................... 

Village ....................................... 

City .......................................... 

City, town, or location of delivery ........... 

Inside city limits ............................ 

If outside city or town limits, write rural ... 

County of delivery ............................ 

Ward .......................................... 

Weight of fetus ................................. 

Multiple delivery ............................... 

Order if not single delivery .................... 

Mother information 

Maiden name .................................... 

Age ............................................ 

Birthplace (State or country) .................. 

Birthplace (city or place) ..................... 

Length of stay in hospital or institution 

before delivery ............................... 

Residence ...................................... 

State ........................................ 

county ....................................... 

City, town, or location ...................... 

Street and number ............................ 

Inside city limits ........................... 

If rural, give location ...................... 

Is residence on a farm? ...................... 

Mother’s mailing address ....................... 

Race ........................................... 

Education ...................................... 

X 

X 

X 

X 

X 

X 

X 

X 

X 

X 

X 

X 

X 

X 

X 

X 

X 

X 

x 

z 

X 

X 

X 

X 

X 

X 

X 

X 

X 

X 

X 

X 

X 

X 

X 

X 

X 

f 

:: 

X 

X 

X 

X 

X 

X 

X 

X 

X 

X 

X 

X 

X 

X 

X 

X 

X 

x 

% 

X 

X 

X 

X 

X 

X 

X 

f 

X 

X 

X 

X 

f 

X 

f 

X 

x 

X 

X 

X 

X 

X 

X 

X 

X 

X 

X 

:: 

X 

X 

X 

f 

X 

z 

x 

X 

x 

X 

X 

X 

X 

X 

x 

X 

x” 

X 

X 

X 

X 

X 

z 

x 

X 

49 
Exhibit 5a. Content of the U.S. Standard Report of Fetal Death, 

by year revised--Con. 

1930 1939 1949 1956 1968 1978 

Mother information--Con. 

Legit imate ...................................... 

Is mother married? ............................... 

Occupation ...................................... 

Usual occupation ................................ 

Kind of business or industry .................... 

Date (month and year) last engaged in this 

work ........................................... 

Total time (years) spent in this work ........... 

Father information 

Name ............................................ 

&e ............................................. 

Birthplace (State or country) ................... 

Birthplace (city or place) ...................... 

Race ............................................ 

Education ....................................... 

Residence ....................................... 

Occupation ...................................... 

Usual occupation ................................ 

Kind of business or industry .................... 

Date (month and year) last engaged in this 

work ........................................... 

Total time (years) spent in this work ........... 

Pregnancy information 

Pregnancy history1 

Live births, now living ....................... 

Live births, now dead ......................... 

Born dead (stillborn, fetal death) ............ 

Born dead after 20 weeks pregnancy ............ 

Other terminations (spontaneous and induced): 

Under 20 weeks .............................. 

Over 20 weeks ............................... 

Date of last live birth ....................... 

Date of last fetal death ...................... 

Date of last other termination ................ 

Whether born alive or stillborn ................. 

Month of pregnancy prenatal care began .......... 

Number of prenatal visits ....................... 

X 

X 

X 

X 

X 

X 

X 

X 

X 

X 

X 

X 

X 

X 

X 

f 

X 

X 

X 

x 

X 

X 

X 

X 

X 

X 

X 

X 

:: 

X 

X X 

X 

X 

X 

X 

X 

f 

:: 

X 

X 

X 

X 

1Prior to 1939 the pregnancy history item included the event being registered. 

Beginning with 1939 the event being regisw excluded. 

50 
Exhibit 5a. Content of the U.S. Standard Report of Fetal Death, 

by year revised--Con. 

Item 1930 1939 1949 1956 1968 1978 

Pregnancy information--Con. 

Physician’s estimate of gestation ............... 

If stillborn, period of gestation ............... 

Length of pregnancy (completed weeks) ........... 

Date last normal menses began ................... 

Months of pregnancy ............................. 

Premature or full term .......................... 

Concurrent illnesses or conditions affecting 

the pregnancy ................................. 

Complications not related to pregnancy .......... 

Complications of pregnancy ...................... 

Complications related to pregnancy .............. 

Complications of pregnancy and labor ............ 

Complications of labor and/or delivery .......... 

Complications of labor .......................... 

Was labor induced? ............................... 

Congenital malformations or anomalies of fetus . . 

Was there an operation for delivery? ............ 

State all operations, if any .................... 

Did the child die before operation? ............. 

During operation? .............................. 

Birth injuries to fetus ......................... 

Medical certification information 

Cause of stillbirth ............................. 

Fetal causes .................................. 

Maternal causes ............................... 

Cause of fetal death: 

Immediate cause ............................... 

Whether fetal or maternal ................... 

Due to ........................................ 

Whether fetal or maternal ................... 

Due to ........................................ 

Whether fetal or maternal ................... 

Other significant conditions of fetus or 

mother ......................................... 

When fetus died: 

Before labor .................................. 

During labor or delivery ...................... 

During labor .................................. 

Unknown ....................................... 

Was autopsy performed? ............................ 

X 

X 

X 

X 

X 

X 

X 

:: 

X 

X 

X 

x 

X 

X 

X 

X 

X 

X 

x 

X 

X 

X 

x 

X 

X 

X 

X 

X 

X 

X 

X 

X 

x 

X 

X 

X 

X 

X 

X 

X 

X 

X 

X 

X 

:: 

X 

x 

X 

X 

X 

X 

X 

X 

X 

X 

X 

X 

X 

X 

X 

:: 

51 
Exhibit 5a. Content of the U.S. Standard Report of Fetal Death, 

by year revised--Con. 

Item 1930 1939 1949 1956 1968 1978 

Medical certification information--Con. 

Were autopsy findings considered? ............... 

Signature of certifier .......................... 

Date signed ................................... 

Title of certifier .............................. 

Address of certifier .......................... 

Signature of attendant .......................... 

Date signed ................................... 

Title of attendant .............................. 

Address of attendant .......................... 

Name of physician or attendant...........,., ... 

Signature of authorized official if not 

attended by physician .......................... 

Statement of local registrar or coroner if 

physician not present .......................... 

Signature ..................................... 

Title ......................................... 

Disposition information 

Burial, cremation, or removal ................... 

Date of burial .................................. 

Place of burial or cremation .................... 

Name of cemetery or crematory ................... 

Locat ion ...................................... 

Signature of funeral director ................... 

Name of funeral director ........................ 

Address ....................................... 

Name of funeral home ............................ 

Address ....................................... 

Other information 

Name of person completing report ................ 

Title ......................................... 

Informant ....................................... 

Address ....................................... 

Signature of registrar .......................... 

Date received by local registrar ................ 

Date filed with local registrar ................. 

Date given name added ........................... 

Signature of registrar ........................ 

X 

X 

X 

X 

X 

X 

X 

:: 

X 

:: 

X 

X 

I 

X 

X 

X 

X 

x” 

X 

X 

X 

X 

X 

X 

X 

x” 

X 

X 

X 

X 

X 

X 

X 

x” 

X 

X 

X 

X 

X 

NOTE: X Item included on standard certificate. 

- Item not include on standard certificate. 

52 
-.- - 

Exhibit 5b. Number of registration areas reporting each item on the 

U.S. Standard Report of Fetal Death: August 1982 

Item 

number Item United 

States1 

:; 

lc 

;: 

: 

2 

6a 

6b 

6c 

6d 

6e 

8’ 

9 

10 

lla 

llb 

llc 

lld 

lle 

llf 

12a 

12b 

13a 

13b 

14a 

14b 

14c 

14d 

15 

16 

17 

Hospital--name .................................... 

City, town, or location of delivery ............... 

County of delivery ................................ 

Date of delivery .................................. 

Hour of delivery .................................. 

Sex of fetus ...................................... 

Weight of fetus ................................... 

Mother--maiden name ............................... 

Age of mother ................................... 

Residence--State ................................ 

Residence--county ............................... 

Residence--city ................................. 

Residence--street and number .................... 

Residence--inside city limits ................... 

Race .............................................. 

Education ......................................... 

Date last menstrual period began .................. 

Is mother married? ................................. 

Live births of this mother--now living ............ 

Live births of this mother--now dead .............. 

Date of last live birth ........................... 

Other terminations of this mother-- 

under 20 weeks ................................... 

Other terminations of this mother-- 

over 20 weeks .................................... 

Date of last other termination .................... 

Month prenatal care began ......................... 

Prenatal visits--total number ..................... 

Birth--single, twin, triplet ..................... 

If not single birth--born first, second ........... 

Father--name ...................................... 

Age of father ................................... 

Race of father .................................. 

Education of father ............................. 

Cause of fetal death .............................. 

Interval between onset of condition and death ..... 

Other significant conditions contributing 

to death ......................................... 

Whether death occurred before labor or during 

labor or delivery ................................ 

Physician’s estimate of length of gestation ....... 

52 

52 

47 

ii 

52 

52 

50 

52 

i; 

52 

48 

51 

i; 

47 

29 

52 

52 

46 

51 

51 

45 

50 

47 

52 

52 

50 

52 

iz 

52 

49 

52 4 

5 

4 

3 

z 

5 

4 

5 

5 

5 

3 

i 

2 

2 

2 

5 

5 

4 

; 

2 

2 

5 

i 

4 

3 

2 

4 

3 

3 

4 

See footnotes at end of exhibit. 

53 
Exhibit 5b. Number of registration areas reporting each item on the 

U.S. Standard Report of Fetal Death: August 1982--Con. 

Item 

number Item United 

States1 

Outlying 

areas2 

;i 

20 

21 

2; 

24 

-- 

-- 

Was autopsy performed? ............................ 

Complications of pregnancy ........................ ii i 

Complications of labor and/or delivery ............ 44 3 

Concurrent illnesses or conditions affecting 

pregnancy ........................................ 

ti 

3 

Congenital malformations .......................... 

Name of physician or attendant .................... 50 : 

Person completing report--name and title .......... 14 

Hispanic origin--mother and father3 ............... 4 ti 

Ethnic origin--mother and father3 ................. 8 1 

150 States, District of Columbia, and New York City. 

2America-n Samoa, Guam, Puerto Rico, Virgin Islands, and Trust Territory 

of the Pacific Islands. 

3Not on standard certificate. 
Exhibit 6. U.S. Standard Report of Induced Termination of Pregnancy 

". s. STANDARD 

Form Approved 

OMBNo. 66R1901 

REPORT OF INDUCED TERMINATION OF PREGNANCY s,fi,EwLENw+wE,a 

r 

I 

5.---- 6. 14. Non. Cl ! 7b.N 

61. PROCED”RE TH*T TYPE OF TERMINATION PROCEDURES Sb. ADWTIONAL PROCEDURES USED 

TERMlNATEDPREGNANCY FOR THIS TERMINATION. IF ANY 

,C,,ECK “SLY ONE, ICHECK A“ THAT APPLY, 

q .-- ---------- -‘-- SUCTlONC”RETTAGE---------------- cl 

!-J -------------- &xiARPC”RETTAGE ---------------- cl 

r-J-- __-__ ---- ~NTRA-“TE”INESILINEINSTILL*TION----------- cl 

q -.-- ----- INTRI-“TERINEPROST~GL*NOIN lNsr,Ll,ATlON ---- ----- 0 

q --------------- ~YST~~~T~MY----------- ----- ---- 0 

f-J ----------------- ““sT6RsCTOMY ----------------- /-J 

0 ----------OTHER ,sp..prclf>, ---------- El 

-- 

l-IRA-166 

RW. 1178 

55 
Exhibit 6a. Contents of the U.S. Standard Report of Induced Termination 

of Pregnancy, new ‘in 1978 

Item 1978 

Place of induced termination 

Facility--name .................................................... 

Address (if not hospital or clinic) ............................... 

City, town, or location ........................................... 

county ............................................................ 

Induced termination information 

Date of pregnancy termination ..................................... 

Previous pregnancies: 

Live births--now living ......................................... 

Live births--now dead ........................................... 

Other terminations--spontaneous ................................. 

Other terminations--induced ..................................... 

Date last normal menses began ................................... 

Physician’s estimate of gestation ............................... 

Complications of pregnancy termination: 

None ............................................................ 

Hemorrhage ...................................................... 

Infection ....................................................... 

Uterine perforation ............................................. 

Cervical laceration ............................................. 

Retained products ............................................... 

Other (specify) ................................................. 

Type of termination procedures: 

Procedure that terminated pregnancy ............................. 

Additional procedures used ...................................... 

Suction curettage ............................................. 

Sharp curettage ............................................... 

Intra-uterine saline instillation ............................. 

Intra-uterine prostaglandin instillation ...................... 

Hysterotomy ................................................... 

Hysterectomy .................................................. 

Other (specify) ............................................... 

Patient information 

Patient identification ............................................ 

&e ............................................................... 

Marital status .................................................... 

:: 

X 

X 

X 

:: 

X 

X 

x” 

X 

X 

X 

X 

X 

X 

X 

I 

X 

I 

X 

:: 

X 

X 

X 

X 

56 
Exhibit 6a. Contents of the U.S. Standard Report of Induced Termination 

of Pregnancy, new in 1978--Con. 

Patient information--Con. 

Residence: 

State ........................................................... X 

City, town, or location ......................................... X 

Inside city limits .............................................. 

Race .............................................................. :: 

Education ......................................................... X 

Other information 

Name of attending physician . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . X 

Name of person completing report . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . X 

Note: X Item included on standard certificate. 

57 
Exhibit 6b. Number of registration areas reporting each item on the 

U.S. Standard Report of Induced Termination of Pregnancy: 

August 1982 

Item 

number Item United 

States1 

Out lying 

areas2 

ii 

lc 

2a 

2b 

2c 

3 

4a 

4b 

4c 

4d 

ii 

7a 

7b 

7c 

7d 

8a 

8b 

9 

;: 

12 

13 

-- 

-- 

Facility- -name ................................... 

City, town, or location of facility .............. 

County of pregnancy termination .................. 

Patient identification ........................... 

Age of patient ................................... 

Is patient married? .............................. 

Date of pregnancy termination .................... 

Residence--State ................................. 

Residence--county ................................ 

Residence--city, town, or location ............... 

Residence--inside city limits .................... 

Race of patient .................................. 

Education of patient ............................. 

Live births of patient--now living ............... 

Live births of patient--now dead ................. 

Other terminations of patient--spontaneous ....... 

Other terminations of patient--induced ........... 

Procedure that terminated pregnancy .............. 

Additional procedures used ....................... 

Complications of pregnancy termination ........... 

Date last normal menses began .................... 

Physician’s estimate of gestation ................ 

Name of attending physician ...................... 

Name of person completin 

Hispanic or igin- -patient s 

report ................. 

........................ 

Ethnic origin--patient3 .......................... 

36 

36 

30 

26 

i: 

35 

33 

30 

;i 

32 

26 

29 

27 

zi 

35 

24 

32 

:; 

29 

20 

i 

ii 

0 

0 

0 

0 

0 

0 

i 

0 

0 

0 

0 

0 

ii 

0 

0 

ii 

0 

0 

0 

ii 

---d--P--- .- --.- 

150 States, District of Columbia, and New York City. 

2American Samoa, Guam, Puerto Rico, Virgin Islands, and Trust Territory 

of the Pacific Islands. 

3Not on standard certificate. 

t “. S. c,O”ERNMENT PRINTING OFFICE : 1%~ 381-161/105 
Vital and Health Statistics series descriptions 

SERIES 1. 

SERIES 2. 

SERIES 3. 

SERIES 4. 

Programs and Collection Procedures.-Reports describing 

the general programs of the National Center for Health 

Statistics and its offices and divisions and the data collection methods used. They also include definitions and 

other material necessary for understanding the data. 

Data Evaluation and Methods Research.-Studies of new 

statistical methodology including experimental tests of 

new survey methods, studies of vital statistics collection 

methods, new analytical techniques, objective evaluations 

of reliability of collected data, and contributions to statistical theory. 

Analytical and Epidemiological Studies.-Reports presenting analytical or interpretive studies based on vital 

and health statistics, carrying the analysis further than the 

expository types of reports in the other series. 

Documents and Committee Reports.-Final reports of 

major committees concerned with vital and health statistics and documents such as recommended model vital 

registration laws and revised birth and death certificates. 

SERIES 10. Data from the National Health Interview Survey.-Statistics on illness, accidental injuries, disability, use of hospital, medical, dental, and other services, and other 

health-related topics, all based on data collected in the 

continuing national household interview survey. 

SERIES 11. Data From the National Health Examination Survey and 

the National Health and Nutrition Examination Survey.- 

Data from direct examination, testing, and measurement 

of national samples of the civilian noninstitutionalized 

population provide the basis for (1) estimates of the 

medically defined prevalence of specific diseases in the 

United States and the distributions of the population with 

respect to physical, physiological, and psychological 

characteristics and (2) analysis of relationships among the 

various measurements without reference to an explicit 

finite universe of persons. 

SERIES 

SERIES 

2. Data From the Institutionalized Population Surveys.-Discontinued in 1975. Reports from these surveys are included in Series 13. 

3. Data on Health Resources Utilization.-Statistics on the 

utilization of health manpower and facilities providing 

long-term care, ambulatory care, hospital care, and family 

planning services. 

SERIES 14. Data on Health Resources: Manpower and Facilities.- 

Statistics on the numbers, geographic distribution, and 

characteristics of health resources including physicians, 

dentists, nurses, other health occupations, hospitals, 

nursing homes, and outpatient facilities. 

SERIES 15. Data From Special Surveys.-Statistics on health and 

health-related topics collected in special surveys that are 

not a part of the continuing data systems of the National 

Center for Health Statistics. 

SERIES 20. Data on Mortality.-Various statistics on mortality other 

than as included in regular annual or monthly reports. 

Special analyses by cause of death, age, and other demographic variables; geographic and time series analyses; and 

statistics on characteristics of deaths not available from 

the vital records based on sample surveys of those records. 

SERIES 21. Data on Natality, Marriage, and Divorce.-Various statistics on natality, marriage, and divorce other than as 

included in regular annual or monthly reports. Special 

analyses by demographic variables; geographic and time 

series analyses; studies of fertility; and statistics on 

characteristics of births not available from the vital 

records based on sample surveys of those records. 

SERIES 22. Data From the National Mortality and Natality Surveys.- 

Discontinued in 1975. Reports from these sample surveys 

based on vital records are included in Series 20 and 21, 

respectively. 

SERIES 23. Data From the National Survey of Family Growth.- 

Statistics on fertility, family formation and dissolution, 

family planning, and related maternal and infant health 

topics derived from a periodic survey of a nationwide 

probability sample of ever-married women 1544 years of 

age. 

For a list of titles of reports published in these series, write to: 

Scientific and Technical Information Branch 

National Center for Health Statistics 

Public Health Service 

Hyattsville, Md. 20782 
U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES 

Public Health Service 

National Center for Health Statistics 

3766 East.West Highway 

Hyattsville, Maryland 20782 

OFFICIAL BUSINESS 

PENALTY FOR PRIVATE USE, $369 

POSTAGE AND FEES PAID 

U.S. DEPARTMENT OF HHS 

HHS 398 

THIRD CLASS 

DHHS Publication No. (PHS) 83-1460, Series 4, No. 23 

For listings of publications in the VITAL AND HEALTH STATISTICS series, call 301s436-NCHS