Form Sfn 58647 - Funeral Directors Worksheet For Completing A Facts Of Death Record Page 3
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4SFN 58647 (10-2013)
Page 3
Instructions for Funeral Director’s Worksheet
ITEM 1 - DECEDENT'S LEGAL NAME
Include any other names used by decedent. If substantially different from the legal name, after the abbreviation AKA (also known as) e.g.
Samuel Langhorne Clemens AKA Mark Twain, but not Jonathon Doe AKA John Doe.
ITEM 5 - DATE OF BIRTH
Enter the full name of the month (January, February, March etc.) Do not use a number or abbreviation to designate the month. Use the full
Century.
ITEM 10 - RESIDENCE OF DECEDENT (Information divided into seven categories)
Residence of decedent is the place where the decedent actually resided. The place of residence is not necessarily the same as “home state”
or “legal residence”. Never enter a temporary address such as one used during a visit, business trip, or vacation. Place of residence during a
tour of military duty or during attendance at college is considered permanent and should be entered as the place of residence. If the
decedent had been living in a facility where an individual usually resides for a long period of time, such as a group home, mental institution,
nursing home, assisted living center, penitentiary, or hospital for the chronically ill, report the location of that facility in item 14. If the decedent
was an infant who never resided at home, the place of residence is that of the parent(s) or legal guardian. Never use an acute care hospital’s
location as the place of residence for any infant. If Canadian residence, please specify province instead of State.
ITEM 13 - SURVIVING SPOUSE'S NAME
If the decedent was married at the time of death, enter the full name of the surviving spouse. If the surviving Spouse is the wife, enter her
name prior to first marriage. This item is used in establishing proper insurance settlements and other survivor benefits.
ITEM 15 - MOTHER'S NAME PRIOR TO FIRST MARRIAGE
Enter the name used prior to first marriage, commonly known as maiden name. This name is useful because it remains constant throughout
life.
ITEM 23 - DECEDENT'S EDUCATION
From the Funeral Director’s Worksheet, indicate the Highest. Information in this section will not appear on the certified copy of the
death certificate. This information is used to study the relationship between mortality and education, (which roughly corresponds
with socioeconomic status). This information is valuable in medical studies of causes of death and in programs to prevent illness
and death.
ITEM 24 - DECEDENT'S HISPANIC ORIGIN
Check “No” or check the “Yes” box that best corresponds with the decedent’s ethnic Spanish identity as given by the informant. Note that
“Hispanic” is not a race and item 22 must also be completed. Do not leave this item blank. With respect to this item, “Hispanic” refers to
people whose origins are from Spain, Mexico, or the Spanish-speaking Caribbean Islands or countries of Central or South America. Origin
includes ancestry, nationality and lineage. There is no set rule about how many generations are to be taken into account in determining
Hispanic origin; it may be based on the country or origin or a parent, grandparent, or some far removed ancestor. Although the prompts
include the major Hispanic groups, other groups may be specified under “other”. “Other” may be used for decedents of multiple Hispanic
origin (e.g. Mexican-Puerto Rican). Information in this section will not appear on the certified copy of the death certificate. This
information is needed to identify health problems in a large minority population in the United States. Identifying health problems
will make it possible to target public health resources to this important segment of our population.
ITEM 25 - DECEDENT'S RACE
Enter the race of the decedent as state by the informant. Hispanic is not a race; information on Hispanic ethnicity is collected separately in
item 52. American Indian and Alaska Native refer only to those native to North American and does not include Asian Indian. Please specify
the name of enrolled or principal tribe (e.g. Sioux, Cheyenne, etc) for American Indian or Alaska Native. For Asians check Asian Indian,
Chines, Filipino, Japanese, Korean, Vietnamese, or specify other Asian group. For Pacific Islanders check Guamanian or Chamarro,
Samoan, or specify other Pacific Island Group. If the decent was of mixed race, enter each race (e.g. Samoan – Chinese – Filipino or White,
American Indian). Information in this section will not appear on the certified copy of the death certificate. Race is essential for
identifying specific mortality patterns and leading causes of death among different racial groups. It is also used to determine if
specific health programs are needed in particular areas to make population estimates.
ITEM 27 and 28 - OCCUPATION AND INDUSTRY
Questions concerning occupation and industry must be completed for all decedents 14 years of age or older. This information is useful in
studying deaths related to jobs and in identifying any new risks. For example, the link between lung disease and lung cancer and asbestos
exposure in jobs such as shipbuilding or construction was mad possible by this sort of information on death certificates. Information in this
section will not appear on the certified copy of the death certificate.
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