| ADMINISTRATIVE DATA |
|---|
| 1. FIRST NAMES |
2. LAST NAME |
3. SEX |
| 4. DATE OF BIRTH |
5. PLACE OF RESIDENCE |
6. OCCUPATION |
7. NATIONALITY |
| 8. NATIONAL IDENTITY NUMBER/PASSPORT NUMBER |
9. DATE OF DEATH |
10. TIME OF DEATH |
11. PLACE OF DEATH (Check one only)
HOSPITAL☐ Inpatient ☐ ER/Outpatient ☐ DOA |
OTHER
☐ Institution☐ Residence☐ Other (Specify) |
12. FACILITY NAME |
| FRAME A |
| 13. PART I.Enter condition, disease or injury that caused death. Do not enter mode of dying, such as cardiac or respiratory arrest, shock or heart failure. List only one cause on each line. The condition thought to be the underlying cause of death should appear last. |
Approximate time interval between onset and death ______________________________________________________________ |
1(a) Final disease or condition leading to death (immediate cause of death)
1(b) Other disease or condition if any leading to
a1(c) Other disease or condition if any leading to b
1(d) Other disease or condition if any leading to c |
a. ________________
b. ________________
c. ________________
d. ________________ |
| 14. PART II. Other significant conditions leading to death but not resulting in the underlying cause given in Part I____________________________________________________________________________________________________ |
15. WAS AN AUTOPSY PERFORMED?☐ Yes ☐ No |
| 16. WERE AUTOPSY FINDINGS USED IN COMPLETING THIS CERTFICATE? ☐ Yes ☐ No |
| FRAME B |
|---|
| 17a. WAS SURGERY PERFORMED DURING LAST 4 WEEKS?☐ Yes ☐ No ☐ Unknown |
17b. IF YES SPECIFY DATE OF SURGERY |
17c. IF YES SPECIFY REASON FOR SURGERY (Disease or condition) |
18. MANNER OF DEATH
☐ Natural
☐ Accident
☐ Suicide
☐ Homicide
☐ Pending investigation
☐ Could not be determined |
19a. DATE OF INJURY |
19b. TIME OF INJURY |
19c. INJURY AT WORK?☐ Yes ☐ No |
| |
19d. DESCRIBE HOW INJURY OCCURRED |
| 19e. PLACE OF INJURY - at home, farm, street, factory, office building, construction site etc. |
| 19f. LOCATION OF INJURY (geographical location) |
20a. IF FEMALE:
☐ Not pregnant, but pregnant within 42 days of death
☐ Not pregnant within past year
☐ Pregnant at time of death
☐ Not pregnant, but pregnant 43 days to 1 year before death
☐ Unknown If pregnant within the past year |
21. IF FOETAL OR INFANT DEATH:
21a. Multiple pregnancy☐ Yes ☐ No☐ Unknown
21b. Stillborn☐ Yes ☐ No☐ Unknown
21c. If death within 24 hours specify number of hours survived: |
21d. BIRTH WEIGHT IN GRAMMES: |
| 21e. AGE OF MOTHER IN YEARS: |
20b. DID THE PREGNANCY CONTRIBUTE TO THE DEATH?
☐ Yes ☐ No☐ Unknown |
21f. IF DEATH WAS PERINATAL, PLEASE STATE CONDITIONS OF MOTHER THAT AFFECTED THE FOETUS OR NEWBORN: |
| 22. NAME OF CERTIFYING PHYSICIAN |
23. To the best of my knowledge, death occurred at the time, date and place and due to the cause(s) and manner stated. |
| 24. STAMP/REGISTRATION NUMBER |
25a. NAME AND TITLE
25b. SIGNATURE
25c. DATE |