STATE OF IOWA
IOWA DEPARTMENT OF PUBLIC HEALTH
114-
CERTIFICATE OF DEATH
BIRTH
NUMBER
1. DECEDENT’S
FIRST
MIDDLE
LAST
SUFFIX, if any
FULL NAME
2. SEX
3a. AGE – LAST BIRTHDAY
3b. UNDER 1 YEAR
3c. UNDER 1 DAY
4. DATE OF BIRTH (Month, Day, Year)
5. COUNTY OF DEATH
Months
Days
Hours
Minutes
Years
6. PLACE OF BIRTH (City & State, or Foreign Country)
7. SOCIAL SECURITY NUMBER
8. CITIZEN OF WHAT COUNTRY?
9. EVER IN U.S.
ARMED FORCES?
Yes
No
10a. MARITAL STATUS AT TIME OF DEATH
10b. DECEDENT’S LAST NAME PRIOR TO ANY
11. SURVIVING SPOUSE (Full name prior to any marriage)
MARRIAGE (If ever married)
Married
Married but separated
Widowed
Divorced
Never Married
Unknown
12a. RESIDENCE-STATE
12b. RESIDENCE-COUNTY
12c. RESIDENCE-CITY OR TOWN
12d. RESIDENCE-STREET & NUMBER, ZIP CODE
12e. INSIDE
CITY LIMITS?
Yes
No
13. FATHER’S
FIRST
MIDDLE
LAST
14. MOTHER’S
FIRST
MIDDLE
LAST
NAME
NAME PRIOR
TO ANY MARRIAGE
15a. INFORMANT’S
15b. INFORMANT’S MAILING ADDRESS (Street & Number, City, State, Zip Code)
15c. RELATIONSHIP TO DECEDENT
NAME
16. PLACE OF DEATH (Check only one)
IF DEATH OCCURRED IN A HOSPITAL
IF DEATH OCCURRED SOMEWHERE OTHER THAN A HOSPITAL
Inpatient
ER/Outpatient
Dead on Arrival
Hospice Facility
Nursing Home/Long-Term Care Facility
Decedent’s Home
Other (Specify)_____________________________
17a. FACILITY NAME (If not institution, give street and number)
17b. CITY, TOWN, OR LOCATION & ZIP CODE OF DEATH
17c. INSIDE CITY LIMITS?
Yes
No
DISPOSITION
18. METHOD OF DISPOSITION
19. PLACE OF DISPOSITION (Name of Cemetery, Crematory, or other place)
Burial
Cremation
Donation
Entombment
Removal from State
Other (Specify) _______________________________
20. LOCATION OF DISPOSITION (City or Town & State)
21. NAME AND COMPLETE ADDRESS OF FUNERAL FACILITY
22a. FUNERAL DIRECTOR – Printed Name
22b. FUNERAL DIRECTOR – Signature
23. LICENSE NUMBER
PRONOUNCEMENT, CERTIFICATION AND CAUSE OF DEATH
ITEMS 24 – 28 REQUIRED TO BE COMPLETED BY
24. DATE PRONOUNCED DEAD (Month, Day, Year) (Spell out month)
25. TIME PRONOUNCED DEAD
PERSON WHO PRONOUNCES OR CERTIFIES DEATH
TIME _______________
AM
PM
Military
26. NAME OF PERSON PRONOUNCING DEATH (If different than certifier) (Type or print legibly)
27. TITLE
28. LICENSE NUMBER
31a. MEDICAL EXAMINER
(MD, DO, PA, ARNP, RN, LPN)
CONTACTED?
Yes
No
31b. If Yes, M.E. case number
29. ACTUAL OR PRESUMED DATE OF DEATH
30. ACTUAL OR PRESUMED TIME OF DEATH
(Month, Day, Year) (Spell out month)
TIME _______________
AM
PM
Military
CAUSE OF DEATH (See instructions and examples)
32b. Approximate
32a. 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,
interval between onset
respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines if necessary.
and death
IMMEDIATE CAUSE (Final disease or
a.
condition resulting in death)
Due to (or as a consequence of):
b.
Sequentially list conditions, if any, leading to
Due to (or as a consequence of):
the cause listed on line a. Enter the
c.
UNDERLYING CAUSE (disease or injury that
initiated the events resulting in death) LAST
Due to (or as a consequence of):
d.
Due to (or as a consequence of):
32c. PART II. Enter other significant conditions contributing to death but not resulting in the underlying cause given in PART I.
33. WAS AN AUTOPSY PERFORMED?
Yes
No
34. If yes, WERE AUTOPSY FINDINGS AVAILABLE TO
COMPLETE CAUSE OF DEATH?
Yes
No
35. DID TOBACCO USE
36. IF FEMALE:
37. MANNER OF DEATH
CONTRIBUTE TO DEATH?
Not pregnant within past year
Not pregnant, but pregnant within 42 days of death
Natural
Homicide
Yes
Probably
Pregnant at time of death
Not pregnant, but pregnant 43 days to 1 year before death
Accident
Pending Investigation
No
Unknown
Unknown if pregnant within the past year
Suicide
Could not be Determined
38. DATE OF INJURY (Month, Day, Year) (Spell out month)
40. PLACE OF INJURY (e.g., home, farm, street, roadway, etc.)
41. INJURY AT WORK?
39. TIME OF INJURY
AM
PM
Yes
No
TIME __________
Military
42. LOCATION OF INJURY: (Complete physical address – Street & Number, Apt. #, City or Town, State, Zip Code)
43. IF TRANSPORTATION INJURY, SPECIFY:
Driver/Operator
Passenger
Pedestrian
Other (Specify) _______________________________
44. DESCRIBE HOW INJURY OCCURRED:
45. CERTIFIER
Certifying MD, DO, PA, ARNP – To the best of my knowledge, death occurred at the time, date, and place, and due to the cause(s) and manner stated.
(Check only one)
Medical Examiner (MD, DO) – On the basis of examination and/or investigation, in my opinion, death occurred at the time, date, & place, and due to the cause(s) & manner stated.
Signature ______________________________________________________________ 46. TITLE ____________ 47. DATE CERTIFIED (Month, Day, Year) _________________________________
48. NAME & COMPLETE MAILING ADDRESS OF CERTIFYING PHYSICIAN OR MEDICAL EXAMINER (Type or print legibly)
49. LICENSE NUMBER
50. FOR REGISTRAR ONLY – REGISTRAR SIGNATURE
50a. DATE RECEIVED BY REGISTRAR (Month, Day, Year)