DECEDENT |
1. DECEDENT’S LEGAL NAME (First, Middle, Last, Suffix) |
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2. SEX |
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3. DATE OF DEATH (Month, Day, Year) |
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4. TIME OF DEATH |
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5a. AGE-Last |
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5b. UNDER 1 YEAR |
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5c. UNDER 1 DAY |
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6. DATE OF BIRTH |
(Month, Day, Year) |
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7. BIRTHPLACE (City and State or Foreign |
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(Approx.) |
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Birthday (Years) |
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Country) |
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Months |
Days |
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Hours |
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Minutes |
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TYPE/PRINT |
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8a. PLACE |
OF DEATH |
(Check only one) |
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IN |
IF DEATH OCCURRED IN A HOSPITAL |
IF DEATH OCCURRED SOMEWHERE OTHER THAN A HOSPITAL |
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PERMANENT |
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Other (Specify) _________________ |
BLACK INK |
Inpatient |
ER/Outpatient |
DOA |
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Hospice facility |
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Nursing home/Long term care facility Decedent’s home |
Other residence |
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________________________________________________ NAMEOF DECEDENT (For use by Physician or Institution) i(F |
8b. FACILITY NAME (If not institution, give |
street and number) |
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8c. CITY OR TOWN |
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8d. COUNTY OF DEATH |
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9. MARITAL STATUS |
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10. SURVIVING |
SPOUSE (If wife, give |
11a. DECEDENT’S USUAL |
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11b. KIND OF BUSINESS/INDUSTRY |
Married |
Married, but separated |
Widowed |
name prior to first marriage) |
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OCCUPATION |
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Divorced |
Never married |
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Unknown |
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12. SOCIAL SECURITY NUMBER |
13a. RESIDENCE-STATE OR FOREIGN COUNTRY |
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13b. COUNTY |
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13c. CITY OR TOWN |
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13d. STREET AND NUMBER |
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13e. INSIDE CITY LIMITS |
13f. ZIP CODE |
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14. WAS DECEDENT EVER IN US ARMED |
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Yes |
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No |
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FORCES? |
Yes |
No |
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15. DECEDENT’S EDUCATION (Check the box that |
16. DECEDENT OF |
HISPANIC ORIGIN? (Check the |
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17. DECEDENT’S RACE (Check |
one or more races to indicate what the |
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best describes the highest degree or level of |
box that best describes whether the decedent is |
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decedent |
considered himself or herself to be) |
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school completed at the time of death) |
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Spanish/Hispanic/Latino. Check the “No” box if |
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White |
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Vietnamese |
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8th grade or less |
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decedent is not Spanish/Hispanic/Latino) |
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Black or African American |
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Other Asian (Specify) |
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9th – 12th grade; no diploma |
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No, not Spanish/Hispanic/Latino |
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American Indian or Alaska Native |
____________________ |
High school graduate or GED completed |
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Yes, Mexican, Mexican American, Chicano |
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(Name of the enrolled or principal |
Native Hawaiian |
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Some college credit, but no degree |
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Yes, Puerto Rican |
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tribe) ___________________ |
Guamanian or Chamorro |
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Associate degree (e.g., AA, AS) |
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Yes, Cuban |
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Asian Indian |
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Samoan |
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Bachelor’s degree (e.g., BA, AB, BS) |
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Yes, other Spanish/Hispanic/Latino (Specify) |
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Chinese |
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Other Pacific Islander (Specify) |
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Master’s degree (e.g.,MA,MS,MEng,MEd,MSW,MBA) |
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___________________________ |
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Filipino |
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____________________ |
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Other (Specify) |
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Doctorate (e.g., PhD, EdD) or Professional degree |
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Japanese |
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____________________ |
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(e.g., MD, DDS, DVM, LLB, JD) |
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Unknown |
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Korean |
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Unknown |
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Unknown |
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PARENTS |
18. FATHER’S NAME (First, Middle, Last) |
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19. MOTHER’S |
NAME PRIOR TO FIRST MARRIAGE (First, Middle, Last) |
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20a. INFORMANT’S NAME |
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20b. RELATIONSHIP TO |
DECEDENT |
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20c. MAILING ADDRESS (Street and Number, City, State, Zip Code) |
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DISPOSITION |
21a. METHOD OF DISPOSITION |
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Burial |
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Cremation |
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21b. PLACE OF DISPOSITION (Name of |
cemetery, |
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21c. LOCATION - City or Town and State |
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Donation |
Entombment |
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Removal from State |
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crematory, other place) |
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Other (Specify) _________________________ |
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22a. SIGNATURE OF FUNERAL DIRECTOR |
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22b. LICENSE NUMBER |
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22c. SIGNATURE OF EMBALMER |
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22d. LICENSE NUMBER |
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23a. NAME AND ADDRESS OF FUNERAL HOME |
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23b. LICENSE |
NUMBER OF FUNERAL HOME |
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REGISTRAR |
24. REGISTRAR’S SIGNATURE |
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25. DATE FILED (Month, Day, Year) |
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26. CERTIFIER (Check only one): |
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CERTIFIER |
26a. PHYSICIAN -To the best of my knowledge, death occurred at the date and place, and due to the cause(s) and manner stated. |
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PHYSICIAN |
26b. MEDICAL EXAMINER - On the basis of examination, and/or investigation, in my opinion, death occurred at the date, and place, and due to the cause(s) and manner stated. |
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OR |
27a. SIGNATURE OF CERTIFIER |
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27b. LICENSE NUMBER |
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27c. DATE SIGNED (Month, Day, Year) |
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MEDICAL |
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EXAMINER |
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EXECUTING |
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27d. NAME AND ADDRESS |
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CAUSE OF |
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DEATH MUST |
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COMPLETE |
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AND SIGN |
28. PART I. Enter the chain of events (diseases, injuries, or complications) that directly caused the death. DO NOT enter terminal events such as cardiac arrest, |
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Approximate interval: |
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WITHIN 48 |
respiratory arrest, or ventricular fibrillation without showing the etiology. Enter only one cause on a line. |
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Onset to death |
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HOURS. |
IMMEDIATE CAUSE |
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a. __________________________________________________________________________ |
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__________________ |
MEDICAL |
(Final disease or condition |
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resulting in death) |
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Due to (or as a consequence of) |
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CERTIFICATION |
Sequentially list conditions, |
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b. __________________________________________________________________________ |
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__________________ |
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if any, leading to the cause |
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Due to (or as a consequence of): |
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listed on line a. Enter the |
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__________________ |
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c. |
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UNDERLYING CAUSE |
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(disease or injury that |
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Due to (or as a consequence of): |
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__________________ |
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initiated the events resulting |
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d. |
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MEDICAL |
in death) LAST |
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CERTIFICATION |
PART II. Other significant conditions contributing to death but not resulting in the underlying cause given in PART I. |
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29a. WAS AN AUTOPSY |
PERFORMED? |
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Yes |
No |
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________________________________________________________________________________ |
29b. WERE AUTOPSY FINDINGS AVAILABLE TO |
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COMPLETE THE CAUSE OF DEATH? |
Yes |
No |
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30. MANNER OF DEATH |
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31. DID TOBACCO USE |
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32. IF FEMALE: |
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Natural |
Homicide |
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CONTRIBUTE TO DEATH? |
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Not pregnant within past year |
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Not pregnant, but pregnant 43 days to |
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Yes |
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Probably |
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Pregnant at time of death |
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1 year before death |
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Accident |
Pending Investigation |
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Unknown if pregnant within the past year |
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No |
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Unknown |
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Not pregnant, but pregnant within 42 days of death |
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Suicide |
Could not be determined |
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33. IF TRANSPORTATION |
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34a. DATE OF INJURY |
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34b. TIME OF |
34c. INJURY AT WORK? |
34d. PLACE OF INJURY –at home, farm, street, factory, office, building, etc. |
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INJURY, SPECIFY: |
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(Month, Day, Year) |
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INJURY |
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Yes |
No |
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(Specify) |
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Driver/Operator |
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Passenger |
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34e. |
DESCRIBE HOW INJURY OCCURRED |
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34f. LOCATION OF INJURY (Street and Number, City or Town, State) |
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Pedestrian |
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Other (Specify) ____________ |
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PH-1659 (Rev. 10/2011) |
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RDA 1399 |