Modern Death Certificate Sample



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IF FEMALE: □ Not pregnant within past year □ Yes □ Probably □ Pregnant at time of death □ No □ Unknown □ Not pregnant, but pregnant within 42 days of death □ Natural □ Homicide □ Accident □ Pending Investigation □ Suicide □ Could not be determined □ Not pregnant, but pregnant 43 days to 1 year before death □ Unknown if pregnant within the past year 38.. DECEDENT’S RACE (Check one or more races to indicate what the decedent considered himself or herself to be) □ No, not Spanish/Hispanic/Latino □ □ □ □ □ □ □ □ □ □ □ □ □ Yes, Mexican, Mexican American, Chicano □ Associate degree (e.g., AA, AS) □ Yes, Puerto Rican □ Bachelor’s degree (e.g., BA, AB, BS) □ Yes, Cuban □ Master’s degree (e.g., MA, MS, MEng, □ Yes, other Spanish/Hispanic/Latino MEd, MSW, MBA) □ Doctorate (e.g., PhD, EdD) or 50.. Examples of injury at work and injury not at work follow: Injury at work Injury not at work Injury while engaged in personal recreational activity on job premises Injury while working or in vocational training on job premises Injury while a visitor (not on official work business) to job premises Injury while on break or at lunch or in parking lot on job premises Homemaker working at homemaking activities Injury while working for pay or compensation, including at home Student in school Injury while working as a volunteer law enforcement official etc.. IF FEMALE: ■ Not pregnant within past year Pregnant at time of death Not pregnant, but pregnant within 42 days of death Not pregnant, but pregnant 43 days to 1 year before death Unknown if pregnant within the past year ■ Natural Accident Suicide Homicide Pending Investigation Could not be determined CAUSE OF DEATH (See instructions and examples) Sequentially list conditions, if any, leading to the cause listed on line a.. When processes such as the following are reported, additional information about the etiology should be reported: Abscess Carcinomatosis Disseminated intra vascular Abdominal hemorrhage Cardiac arrest coagulopathy Adhes




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