Handbook on Death Registration

Introduction

Registration Requirements

Responsibilities of the Funeral Director or Person Acting as Such

Death Certificate Cover Letter

Instructions for Completing a Death Certificate

Amending the Certificate of Death

Authorizations

1. Instructions for Completing the Application for the Disinterment Permit
2. Instructions for Completing the Disinterment Consent Forms

Delayed Registration of Death

Item-By-Item - Demographic

• 1. Legal Name of Deceased (Include AKAs If Any) (first, middle, last)
• 2. Date of Death
• 3. Sex
• 4. Date of Birth:
• 5. Age
• 6. Birthplace (City & State or Foreign Country):
• 7. Social Security Number:
• 8. Marital Status:
• 9. Surviving Spouse (If Wife, Give Name Prior to First Marriage)
• 10. Residence
• 11. Father's Name
• 12. Mother's Maiden Name
• 13. Place of Death (Check Only One)
• 14. County of Death
• 15. City or Town, Zip (If Outside City Limits, Give Precinct No.)
• 16. Facility Name (if not institution, give street address)
• 17. Informant's Name & Relationship To Deceased
• 18. Mailing Address of Informant (Street and Number, City, State, and Zip Code)
• 19. Method of Disposition
• 20. Signature of Funeral Director or Person Acting as Such
• 21. Unknown, Section, Block, Lot, Space
• 22. Place of Disposition (Name of Cemetery, Crematory, or Other Place)
• 23. Location (City/Town, and State)
• 24. Name of Funeral Facility
• 25. Complete Address of Funeral Facility (Street and Number, City, State, Zip Code)

Item-By-Item - Medical

• 26. Certifier
• 27. Signature of Certifier
• 28. Date Signed (Month Day Year)
• 29. License Number
• 30. Time of Death (Actual or Presumed)
• 31. Printed Name, Address of Certifier (Street and Number, City, State, Zip Code)
• 32. Title of Certifier
• 33. Cause of Death - Part 1 and Part 2
• 34. Was An Autopsy Performed?
• 35. Were Autopsy Findings Available to Completion of Cause of Death?
• 36. Manner of Death
• 37. Did Tobacco Use Contribute to Death?
• 38. If Female
• 39. If Transportation Injury, Specify
• Injury Details, items 40a through 40f
  1. Date of Injury (Mo/Day/Yr)
  2. Time of Injury
  3. Injury at Work
  4. Place of Injury (e.g. Decedent's Home, Construction Site, Restaurant, Wooded Area)
  5. Location (Street and Number or Rural Route, City or Town, State)
  6. County of Injury
• 41. Describe How Injury Occurred
• Local Registrar information 42a-42c
  1. Registrar File Number
  2. Date Received by Local Registrar
  3. Registrar
• 43. Decedent's Education
• 44. Decedent of Hispanic Origin?
• 45. Decedent's Race
• 46. Ever in U.S. Armed Forces?
• 47. Ever a Peace Officer in This State?
• 48. Decedent's Usual Occupation
• 49. Type of Business/Industry