State Of Illinois Certificate Of Death Page 2
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244. TITLE OF CERTIFIER
45. DATE CERTIFIED (Month/Day/Year)
46. SIGNATURE OF CERTIFIER
47. DECEDENT'S EDUCATION - Check the
48. DECEDENT OF HISPANIC ORIGIN? - Check the box that best
49. DECEDENT'S RACE - Check one or more races to indicate what the decedent
box that best describes the highest degree or
describes whether the decedent is Spanish/Hispanic/Latino.
considered himself or herself to be.
level of school completed at the time of death.
Check the "No" box if decedent is not Spanish/Hispanic/Latino.
White
Black or African American
8th grade or less
No, not Spanish/Hispanic/Latino
9th - 12 grade; no diploma
American Indian or Alaskan Native
Yes, Mexican, Mexican American, Chicano
High school graduate or GED completed
Yes, Puerto Rican
Some college credit, but no degree
(Name of the enrolled or principle tribe)
Yes, Cuban
Associated degree(e.g. AA, AS)
Yes, other Spanish/Hispanic/Latino
Asian Indian
Chinese
Filipino
Japanese
Korean
Bachelor's degree(e.g. BA, AB, BS)
Master's degree(e.g. MA, MS, MEng, MEd, MSW, MBA)
Vietnamese
Other Asian(Specify)
Specify:
Doctorate(e.g. PhD, EdD) or Professional degree(e.g. MD, DDS, DVM, LLB, JD)
Unknown
Native Hawaiian
Guamanian or Chamorro
Samoan
Other Pacific Islander(Specify)
Other(Specify)
50. DECEDENT'S USUAL OCCUPATION (Indicate type of work done during most of working life. DO NOT USE RETIRED).
51. BUSINESS/INDUSTRY (Enter type of business or industry, NOT COMPANY NAME)
Printed by the Authority of the State of Illinois
P.O. #148109
150M
7/07
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