State Of Iowa Iowa Department Of Public Health Certificate Of Death (Page 4 of 4) in pdf

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

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

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

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 _______________

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

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 _______________

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

condition resulting in death) 

Due to (or as a consequence of):

Sequentially list conditions, if any, leading to

Due to (or as a consequence of):

the cause listed on line a. Enter the

UNDERLYING CAUSE (disease or injury that

initiated the events resulting in death) LAST

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

34. If yes, WERE AUTOPSY FINDINGS AVAILABLE TO



COMPLETE CAUSE OF DEATH?

Yes

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



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



Yes

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)