–D–
2003 Revisions, Standard Certificates of Death and Live Birth

This appendix reproduces the standard certificates of death and of live birth as of the 2003 round of revisions. Electronic files of the form of the certificates and additional details and instructions are available at http://www.cdc.gov/nchs/vital_certs_rev.htm.



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–D– 2003 Revisions, Standard Certificates of Death and Live Birth This appendix reproduces the standard certificates of death and of live birth as of the 2003 round of revisions. Electronic files of the form of the certificates and additional details and instructions are available at http://www.cdc.gov/nchs/vital_certs_rev.htm. 117

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118 VITAL STATISTICS U.S. STANDARD CERTIFICATE OF DEATH LOCAL FILE NO. STATE FILE NO. 1. DECEDENT’S LEGAL NAME (Include AKA’s if any) (First, Middle, Last) 2. SEX 3. SOCIAL SECURITY NUMBER NAME OF DECEDENT ____________________________________________ 4a. AGE-Last Birthday 4b. UNDER 1 YEAR 4c. UNDER 1 DAY 5. DATE OF BIRTH (Mo/Day/Yr) 6. BIRTHPLACE (City and State or Foreign Country) (Years) Months Days Hours Minutes 7a. RESIDENCE-STATE 7b. COUNTY 7c. CITY OR TOWN 7d. STREET AND NUMBER 7e. APT. NO. 7f. ZIP CODE 7g. INSIDE CITY LIMITS? Yes No 8. EVER IN US ARMED FORCES? 9. MARITAL STATUS AT TIME OF DEATH 10. SURVIVING SPOUSE’S NAME (If wife, give name prior to first marriage) Yes No Married Married, but separated Widowed Divorced Never Married Unknown 11. FATHER’S NAME (First, Middle, Last) 12. MOTHER’S NAME PRIOR TO FIRST MARRIAGE (First, Middle, Last) To Be Completed/ Verified By: FUNERAL DIRECTOR: For use by physician or institution 13a. INFORMANT’S NAME 13b. RELATIONSHIP TO DECEDENT 13c. MAILING ADDRESS (Street and Number, City, State, Zip Code) 14. PLACE OF DEATH (Check only one: see instructions) IF DEATH OCCURRED IN A HOSPITAL: IF DEATH OCCURRED SOMEWHERE OTHER THAN A HOSPITAL: Inpatient Emergency Room/Outpatient Dead on Arrival Hospice facility Nursing home/Long term care facility Decedent’s home Other (Specify): 15. FACILITY NAME (If not institution, give street & number) 16. CITY OR TOWN , STATE, AND ZIP CODE 17. COUNTY OF DEATH 18. METHOD OF DISPOSITION: Burial Cremation 19. PLACE OF DISPOSITION (Name of cemetery, crematory, other place) Donation Entombment Removal from State Other (Specify):_____________________________ 20. LOCATION-CITY, TOWN, AND STATE 21. NAME AND COMPLETE ADDRESS OF FUNERAL FACILITY 22. SIGNATURE OF FUNERAL SERVICE LICENSEE OR OTHER AGENT 23. LICENSE NUMBER (Of Licensee) 24. DATE PRONOUNCED DEAD (Mo/Day/Yr) 25. TIME PRONOUNCED DEAD ITEMS 24-28 MUST BE COMPLETED BY PERSON WHO PRONOUNCES OR CERTIFIES DEATH 26. SIGNATURE OF PERSON PRONOUNCING DEATH (Only when applicable) 27. LICENSE NUMBER 28. DATE SIGNED (Mo/Day/Yr) 29. ACTUAL OR PRESUMED DATE OF DEATH 30. ACTUAL OR PRESUMED TIME OF DEATH 31. WAS MEDICAL EXAMINER OR (Mo/Day/Yr) (Spell Month) CORONER CONTACTED? Yes No Approximate CAUSE OF DEATH (See instructions and examples) interval: 32. PART I. Enter the chain of events--diseases, injuries, or complications--that directly caused the death. DO NOT enter terminal events such as cardiac Onset to death arrest, respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines if necessary. IMMEDIATE CAUSE (Final _____________ disease or condition ---------> a._____________________________________________________________________________________________________________ resulting in death) Due to (or as a consequence of): _____________ Sequentially list conditions, b._____________________________________________________________________________________________________________ if any, leading to the cause Due to (or as a consequence of): listed on line a. Enter the _____________ UNDERLYING CAUSE c._____________________________________________________________________________________________________________ (disease or injury that Due to (or as a consequence of): initiated the events resulting _____________ in death) LAST d._____________________________________________________________________________________________________________ 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. WERE AUTOPSY FINDINGS AVAILABLE TO COMPLETE THE CAUSE OF DEATH? Yes No 35. DID TOBACCO USE CONTRIBUTE 36. IF FEMALE: 37. MANNER OF DEATH MEDICAL CERTIFIER To Be Completed By: TO DEATH? Not pregnant within past year Natural Homicide Yes Probably Pregnant at time of death Accident Pending Investigation Not pregnant, but pregnant within 42 days of death No Unknown Suicide Could not be determined Not pregnant, but pregnant 43 days to 1 year before death Unknown if pregnant within the past year 38. DATE OF INJURY 39. TIME OF INJURY 40. PLACE OF INJURY (e.g., Decedent’s home; construction site; restaurant; wooded area) 41. INJURY AT WORK? (Mo/Day/Yr) (Spell Month) Yes No 42. LOCATION OF INJURY: State: City or Town: Street & Number: Apartment No.: Zip Code: 43. DESCRIBE HOW INJURY OCCURRED: 44. IF TRANSPORTATION INJURY, SPECIFY: Driver/Operator Passenger Pedestrian Other (Specify) 45. CERTIFIER (Check only one): Certifying physician-To the best of my knowledge, death occurred due to the cause(s) and manner stated. Pronouncing & Certifying physician-To the best of my knowledge, death occurred at the time, date, and place, and due to the cause(s) and manner stated. Medical Examiner/Coroner-On the basis of examination, and/or investigation, in my opinion, death occurred at the time, date, and place, and due to the cause(s) and manner stated. Signature of certifier:_____________________________________________________________________________ 46. NAME, ADDRESS, AND ZIP CODE OF PERSON COMPLETING CAUSE OF DEATH (Item 32) 47. TITLE OF CERTIFIER 48. LICENSE NUMBER 49. DATE CERTIFIED (Mo/Day/Yr) 50. FOR REGISTRAR ONLY- DATE FILED (Mo/Day/Yr) 51. DECEDENT’S EDUCATION-Check the box 52. DECEDENT OF HISPANIC ORIGIN? Check the box 53. DECEDENT’S RACE (Check one or more races to indicate what the that best describes the highest degree or level of that best describes whether the decedent is decedent considered himself or herself to be) school completed at the time of death. Spanish/Hispanic/Latino. Check the “No” box if W hite decedent is not Spanish/Hispanic/Latino. 8th grade or less Black or African American American Indian or Alaska Native 9th - 12th grade; no diploma (Name of the enrolled or principal tribe) _______________ No, not Spanish/Hispanic/Latino Asian Indian High school graduate or GED completed Chinese FUNERAL DIRECTOR Filipino Yes, Mexican, Mexican American, Chicano To Be Completed By: Some college credit, but no degree Japanese Korean Yes, Puerto Rican Associate degree (e.g., AA, AS) Vietnamese Other Asian (Specify)__________________________________________ Yes, Cuban Bachelor’s degree (e.g., BA, AB, BS) Native Hawaiian Guamanian or Chamorro Master’s degree (e.g., MA, MS, MEng, Samoan Yes, other Spanish/Hispanic/Latino MEd, MSW, MBA) Other Pacific Islander (Specify)_________________________________ (Specify) __________________________ Other (Specify)___________________________________________ Doctorate (e.g., PhD, EdD) or Professional degree (e.g., MD, DDS, DVM, LLB, JD) 54. DECEDENT’S USUAL OCCUPATION (Indicate type of work done during most of working life. DO NOT USE RETIRED). 55. KIND OF BUSINESS/INDUSTRY REV. 11/2003

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APPENDIX D 119 MEDICAL CERTIFIER INSTRUCTIONS for selected items on U.S. Standard Certificate of Death (See Physicians’ Handbook or Medical Examiner/Coroner Handbook on Death Registration for instructions on all items) ITEMS ON WHEN DEATH OCCURRED Items 24-25 and 29-31 should always be completed. If the facility uses a separate pronouncer or other person to indicate that death has taken place with another person more familiar with the case completing the remainder of the medical portion of the death certificate, the pronouncer completes Items 24-28. If a certifier completes Items 24-25 as well as items 29-49, Items 26-28 may be left blank. ITEMS 24-25, 29-30 – DATE AND TIME OF DEATH Spell out the name of the month. If the exact date of death is unknown, enter the approximate date. If the date cannot be approximated, enter the date the body is found and identify as date found. Date pronounced and actual date may be the same. Enter the exact hour and minutes according to a 24-hour clock; estimates may be provided with “Approx.” placed before the time. ITEM 32 – CAUSE OF DEATH (See attached examples) Take care to make the entry legible. Use a computer printer with high resolution, typewriter with good black ribbon and clean keys, or print legibly using permanent black ink in completing the CAUSE OF DEATH Section. Do not abbreviate conditions entered in section. Part I (Chain of events leading directly to death) •Only one cause should be entered on each line. Line (a) MUST ALWAYS have an entry. DO NOT leave blank. Additional lines may be added if necessary. •If the condition on Line (a) resulted from an underlying condition, put the underlying condition on Line (b), and so on, until the full sequence is reported. ALWAYS enter the underlying cause of death on the lowest used line in Part I. •For each cause indicate the best estimate of the interval between the presumed onset and the date of death. The terms “unknown” or “approximately” may be used. General terms, such as minutes, hours, or days, are acceptable, if necessary. DO NOT leave blank. •The terminal event (for example, cardiac arrest or respiratory arrest) should not be used. If a mechanism of death seems most appropriate to you for line (a), then you must always list its cause(s) on the line(s) below it (for example, cardiac arrest due to coronary artery atherosclerosis or cardiac arrest due to blunt impact to chest). • If an organ system failure such as congestive heart failure, hepatic failure, renal failure, or respiratory failure is listed as a cause of death, always report its etiology on the line(s) beneath it (for example, renal failure due to Type I diabetes mellitus). •When indicating neoplasms as a cause of death, include the following: 1) primary site or that the primary site is unknown, 2) benign or malignant, 3) cell type or that the cell type is unknown, 4) grade of neoplasm, and 5) part or lobe of organ affected. (For example, a primary well- differentiated squamous cell carcinoma, lung, left upper lobe.) •Always report the fatal injury (for example, stab wound of chest), the trauma (for example, transection of subclavian vein), and impairment of function (for example, air embolism). PART II (Other significant conditions) •Enter all diseases or conditions contributing to death that were not reported in the chain of events in Part I and that did not result in the underlying cause of death. See attached examples. •If two or more possible sequences resulted in death, or if two conditions seem to have added together, report in Part I the one that, in your opinion, most directly caused death. Report in Part II the other conditions or diseases. CHANGES TO CAUSE OF DEATH Should additional medical information or autopsy findings become available that would change the cause of death originally reported, the original death certificate should be amended by the certifying physician by immediately reporting the revised cause of death to the State Vital Records Office. ITEMS 33-34 - AUTOPSY •33 - Enter “Yes” if either a partial or full autopsy was performed. Otherwise enter “No.” •34 - Enter “Yes” if autopsy findings were available to complete the cause of death; otherwise enter “No”. Leave item blank if no autopsy was performed. ITEM 35 - DID TOBACCO USE CONTRIBUTE TO DEATH? Check “yes” if, in your opinion, the use of tobacco contributed to death. Tobacco use may contribute to deaths due to a wide variety of diseases; for example, tobacco use contributes to many deaths due to emphysema or lung cancer and some heart disease and cancers of the head and neck. Check “no” if, in your clinical judgment, tobacco use did not contribute to this particular death. ITEM 36 - IF FEMALE, WAS DECEDENT PREGNANT AT TIME OF DEATH OR WITHIN PAST YEAR? This information is important in determining pregnancy-related mortality. ITEM 37 - MANNER OF DEATH •Always check Manner of Death, which is important: 1) in determining accurate causes of death; 2) in processing insurance claims; and 3) in statistical studies of injuries and death. •Indicate “Pending investigation” if the manner of death cannot be determined whether due to an accident, suicide, or homicide within the statutory time limit for filing the death certificate. This should be changed later to one of the other terms. •Indicate “Could not be Determined” ONLY when it is impossible to determine the manner of death. ITEMS 38-44 - ACCIDENT OR INJURY – to be filled out in all cases of deaths due to injury or poisoning. •38 - Enter the exact month, day, and year of injury. Spell out the name of the month. DO NOT use a number for the month. (Remember, the date of injury may differ from the date of death.) Estimates may be provided with “Approx.” placed before the date. •39 - Enter the exact hour and minutes of injury or use your best estimate. Use a 24-hour clock. •40 - Enter the general place (such as restaurant, vacant lot, or home) where the injury occurred. DO NOT enter firm or organization names. (For example, enter “factory”, not “Standard Manufacturing, Inc.” ) •41 - Complete if anything other than natural disease is mentioned in Part I or Part II of the medical certification, including homicides, suicides, and accidents. This includes all motor vehicle deaths. The item must be completed for decedents ages 14 years or over and may be completed for those less than 14 years of age if warranted. Enter “Yes” if the injury occurred at work. Otherwise enter “No”. An injury may occur at work regardless of whether the injury occurred in the course of the decedent’s “usual” occupation. Examples of injury at work and injury not at work follow: Injury at work Injury not at work Injury while working or in vocational training on job premises Injury while engaged in personal recreational activity on job premises Injury while on break or at lunch or in parking lot on job premises Injury while a visitor (not on official work business) to job premises Injury while working for pay or compensation, including at home Homemaker working at homemaking activities Injury while working as a volunteer law enforcement official etc. Student in school Injury while traveling on business, including to/from business contacts Working for self for no profit (mowing yard, repairing own roof, hobby) Commuting to or from work •42 - Enter the complete address where the injury occurred including zip code. •43 - Enter a brief but specific and clear description of how the injury occurred. Explain the circumstances or cause of the injury. Specify type of gun or type of vehicle (e.g., car, bulldozer, train, etc.) when relevant to circumstances. Indicate if more than one vehicle involved; specify type of vehicle decedent was in. •44 -Specify role of decedent (e.g. driver, passenger). Driver/operator and passenger should be designated for modes other than motor vehicles such as bicycles. Other applies to watercraft, aircraft, animal, or people attached to outside of vehicles (e.g. surfers). Rationale: Motor vehicle accidents are a major cause of unintentional deaths; details will help determine effectiveness of current safety features and laws. REFERENCES For more information on how to complete the medical certification section of the death certificate, refer to tutorial at http://www.TheNAME.org and resources including instructions and handbooks available by request from NCHS, Room 7318, 3311 Toledo Road, Hyattsville, Maryland 20782- 2003 or at www.cdc.gov/nchs/about/major/dvs/handbk.htm REV. 11/2003

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120 VITAL STATISTICS Cause-of-death – Background, Examples, and Common Problems Accurate cause of death information is important •to the public health community in evaluating and improving the health of all citizens, and •often to the family, now and in the future, and to the person settling the decedent’s estate. The cause-of-death section consists of two parts. Part I is for reporting a chain of events leading directly to death, with the immediate cause of death (the final disease, injury, or complication directly causing death) on line a and the underlying cause of death (the disease or injury that initiated the chain of events that led directly and inevitably to death) on the lowest used line. Part II is for reporting all other significant diseases, conditions, or injuries that contributed to death but which did not result in the underlying cause of death given in Part I. The cause-of-death information should be YOUR best medical OPINION. A condition can be listed as “probable” even if it has not been definitively diagnosed. Examples of properly completed medical certifications Approximate interval: CAUSE OF DEATH (See instructions and examples) Onset to death 32. 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, respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines if necessary. IMMEDIATE CAUSE (Final Minutes Rupture of myocardium __________________________________________________________________________________ disease or condition ---------> a. resulting in death) Due to (or as a consequence of): 6 days Acute myocardial infarction_______________________________________________________________________________ Sequentially list conditions, b. if any, leading to the cause Due to (or as a consequence of): listed on line a. Enter the 5 years Coronary artery thrombosis_______________________________________________________________________________ UNDERLYING CAUSE c. (disease or injury that Due to (or as a consequence of): initiated the events resulting 7 years Atherosclerotic coronary artery disease__________________________________________________________________ in death) LAST d. 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 Diabetes, Chronic obstructive pulmonary disease, smoking 34. WERE AUTOPSY FINDINGS AVAILABLE TO COMPLETE THE CAUSE OF DEATH? Yes No 35. DID TOBACCO USE CONTRIBUTE TO DEATH? 36. IF FEMALE: 37. MANNER OF DEATH Not pregnant within past year Yes Probably Natural Homicide Pregnant at time of death Not pregnant, but pregnant within 42 days of death Accident Pending Investigation No Unknown Suicide Could not be determined Not pregnant, but pregnant 43 days to 1 year before death Unknown if pregnant within the past year Approximate interval: CAUSE OF DEATH (See instructions and examples) Onset to death 32. 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, respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines if necessary. IMMEDIATE CAUSE (Final 2 Days Aspiration pneumonia_______________________________________________________________ disease or condition ---------> a. resulting in death) Due to (or as a consequence of): 7 weeks Complications of coma___________________________________________________________________________________ Sequentially list conditions, b. if any, leading to the cause Due to (or as a consequence of): listed on line a. Enter the 7 weeks Blunt force injuries________________________________________________________________________________________ UNDERLYING CAUSE c. (disease or injury that Due to (or as a consequence of): initiated the events resulting Motor vehicle accident____________________________________________________________________________________ in death) LAST d. 7 weeks 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. WERE AUTOPSY FINDINGS AVAILABLE TO COMPLETE THE CAUSE OF DEATH? Yes No 35. DID TOBACCO USE CONTRIBUTE TO DEATH? 36. IF FEMALE: 37. MANNER OF DEATH Not pregnant within past year Yes Probably Natural Homicide Pregnant at time of death Accident Pending Investigation Not pregnant, but pregnant within 42 days of death No Unknown Suicide Could not be determined Not pregnant, but pregnant 43 days to 1 year before death Unknown if pregnant within the past year 38. DATE OF INJURY 39. TIME OF INJURY 40. PLACE OF INJURY (e.g., Decedent’s home; construction site; restaurant; wooded area) 41. INJURY AT WORK? (Mo/Day/Yr) (Spell Month) Approx. 2320 road side near state highway Yes No August 15, 2003 42. LOCATION OF INJURY: State: Missouri City or Town: near Alexandria Street & Number: mile marker 17 on state route 46a Apartment No.: Zip Code: 43. DESCRIBE HOW INJURY OCCURRED: 44. IF TRANSPORTATION INJURY, SPECIFY: Driver/Operator Decedent driver of van, ran off road into tree Passenger Pedestrian Other (Specify) Common problems in death certification The elderly decedent should have a clear and distinct etiological sequence for cause of death, if possible. Terms such as senescence, infirmity, old age, and advanced age have little value for public health or medical research. Age is recorded elsewhere on the certificate. When a number of conditions resulted in death, the physician should choose the single sequence that, in his or her opinion, best describes the process leading to death, and place any other pertinent conditions in Part II. If after careful consideration the physician cannot determine a sequence that ends in death, then the medical examiner or coroner should be consulted about conducting an investigation or providing assistance in completing the cause of death. The infant decedent should have a clear and distinct etiological sequence for cause of death, if possible. “Prematurity” should not be entered without explaining the etiology of prematurity. Maternal conditions may have initiated or affected the sequence that resulted in infant death, and such maternal causes should be reported in addition to the infant causes on the infant’s death certificate (e.g., Hyaline membrane disease due to prematurity, 28 weeks due to placental abruption due to blunt trauma to mother’s abdomen). When SIDS is suspected, a complete investigation should be conducted, typically by a medical examiner or coroner. If the infant is under 1 year of age, no cause of death is determined after scene investigation, clinical history is reviewed, and a complete autopsy is performed, then the death can be reported as Sudden Infant Death Syndrome. When processes such as the following are reported, additional information about the etiology should be reported: Abscess Carcinomatosis Disseminated intra vascular Hyponatremia Pulmonary arrest Abdominal hemorrhage Cardiac arrest coagulopathy Hypotension Pulmonary edema Adhesions Cardiac dysrhythmia Dysrhythmia Immunosuppression Pulmonary embolism Adult respiratory distress syndrome Cardiomyopathy End-stage liver disease Increased intra cranial pressure Pulmonary insufficiency Acute myocardial infarction Cardiopulmonary arrest End-stage renal disease Intra cranial hemorrhage Renal failure Altered mental status Cellulitis Epidural hematoma Malnutrition Respiratory arrest Anemia Cerebral edema Exsanguination Metabolic encephalopathy Seizures Anoxia Cerebrovascular accident Failure to thrive Multi-organ failure Sepsis Anoxic encephalopathy Cerebellar tonsillar herniation Fracture Multi-system organ failure Septic shock Arrhythmia Chronic bedridden state Gangrene Myocardial infarction Shock Ascites Cirrhosis Gastrointestinal hemorrhage Necrotizing soft-tissue infection Starvation Aspiration Coagulopathy Heart failure Old age Subdural hematoma Atrial fibrillation Compression fracture Hemothorax Open (or closed) head injury Subarachnoid hemorrhage Bacteremia Congestive heart failure Hepatic failure Paralysis Sudden death Bedridden Convulsions Hepatitis Pancytopenia Thrombocytopenia Biliary obstruction Decubiti Hepatorenal syndrome Perforated gallbladder Uncal herniation Bowel obstruction Dehydration Hyperglycemia Peritonitis Urinary tract infection Brain injury Dementia (when not Hyperkalemia Pleural effusions Ventricular fibrillation Brain stem herniation otherwise specified) Hypovolemic shock Pneumonia Ventricular tachycardia Carcinogenesis Diarrhea Volume depletion If the certifier is unable to determine the etiology of a process such as those shown above, the process must be qualified as being of an unknown, undetermined, probable, presumed, or unspecified etiology so it is clear that a distinct etiology was not inadvertently or carelessly omitted. The following conditions and types of death might seem to be specific or natural but when the medical history is examined further may be found to be complications of an injury or poisoning (possibly occurring long ago). Such cases should be reported to the medical examiner/coroner. Asphyxia Epidural hematoma Hip fracture Pulmonary emboli Subdural hematoma Bolus Exsanguination Hyperthermia Seizure disorder Surgery Choking Fall Hypothermia Sepsis Thermal burns/chemical burns Drug or alcohol overdose/drug or Fracture Open reduction of fracture Subarachnoid hemorrhage alcohol abuse REV. 11/2003

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APPENDIX D 121 FUNERAL DIRECTOR INSTRUCTIONS for selected items on U.S. Standard Certificate of Death (For additional information concerning all items on certificate see Funeral Directors’ Handbook on Death Registration) ITEM 1. DECEDENT’S LEGAL NAME Include any other names used by decedent, if substantially different from the legal name, after the abbreviation AKA (also known as) e.g. Samuel Langhorne Clemens AKA Mark Twain, but not Jonathon Doe AKA John Doe ITEM 5. DATE OF BIRTH Enter the full name of the month (January, February, March etc.) Do not use a number or abbreviation to designate the month. ITEM 7A-G. RESIDENCE OF DECEDENT (information divided into seven categories) Residence of decedent is the place where the decedent actually resided. The place of residence is not necessarily the same as “home state” or “legal residence”. Never enter a temporary residence such as one used during a visit, business trip, or vacation. Place of residence during a tour of military duty or during attendance at college is considered permanent and should be entered as the place of residence. If the decedent had been living in a facility where an individual usually resides for a long period of time, such as a group home, mental institution, nursing home, penitentiary, or hospital for the chronically ill, report the location of that facility in item 7. If the decedent was an infant who never resided at home, the place of residence is that of the parent(s) or legal guardian. Never use an acute care hospital’s location as the place of residence for any infant. If Canadian residence, please specify Province instead of State. ITEM 10. SURVIVING SPOUSE’S NAME If the decedent was married at the time of death, enter the full name of the surviving spouse. If the surviving spouse is the wife, enter her name prior to first marriage. This item is used in establishing proper insurance settlements and other survivor benefits. ITEM 12. MOTHER’S NAME PRIOR TO FIRST MARRIAGE Enter the name used prior to first marriage, commonly known as the maiden name. This name is useful because it remains constant throughout life. ITEM 14. PLACE OF DEATH The place where death is pronounced should be considered the place where death occurred. If the place of death is unknown but the body is found in your State, the certificate of death should be completed and filed in accordance with the laws of your State. Enter the place where the body is found as the place of death. ITEM 51. DECEDENT’S EDUCATION (Check appropriate box on death certificate) Check the box that corresponds to the highest level of education that the decedent completed. Information in this section will not appear on the certified copy of the death certificate. This information is used to study the relationship between mortality and education (which roughly corresponds with socioeconomic status). This information is valuable in medical studies of causes of death and in programs to prevent illness and death. ITEM 52. WAS DECEDENT OF HISPANIC ORIGIN? (Check “No” or appropriate “Yes” box) Check “No” or check the “Yes” box that best corresponds with the decedent’s ethnic Spanish identity as given by the informant. Note that “Hispanic” is not a race and item 53 must also be completed. Do not leave this item blank. With respect to this item, “Hispanic” refers to people whose origins are from Spain, Mexico, or the Spanish-speaking Caribbean Islands or countries of Central or South America. Origin includes ancestry, nationality, and lineage. There is no set rule about how many generations are to be taken into account in determining Hispanic origin; it may be based on the country of origin of a parent, grandparent, or some far-removed ancestor. Although the prompts include the major Hispanic groups, other groups may be specified under “other”. “Other” may also be used for decedents of multiple Hispanic origin (e.g. Mexican-Puerto Rican). Information in this section will not appear on the certified copy of the death certificate. This information is needed to identify health problems in a large minority population in the United States. Identifying health problems will make it possible to target public health resources to this important segment of our population. ITEM 53. RACE (Check appropriate box or boxes on death certificate) Enter the race of the decedent as stated by the informant. Hispanic is not a race; information on Hispanic ethnicity is collected separately in item 52. American Indian and Alaska Native refer only to those native to North and South America (including Central America) and does not include Asian Indian. Please specify the name of enrolled or principal tribe (e.g., Navajo, Cheyenne, etc.) for the American Indian or Alaska Native. For Asians check Asian Indian, Chinese, Filipino, Japanese, Korean, Vietnamese, or specify other Asian group; for Pacific Islanders check Guamanian or Chamorro, Samoan, or specify other Pacific Island group. If the decedent was of mixed race, enter each race (e.g., Samoan- Chinese-Filipino or White, American Indian). Information in this section will not appear on the certified copy of the death certificate. Race is essential for identifying specific mortality patterns and leading causes of death among different racial groups. It is also used to determine if specific health programs are needed in particular areas and to make population estimates. ITEMS 54 AND 55. OCCUPATION AND INDUSTRY Questions concerning occupation and industry must be completed for all decedents 14 years of age or older. This information is useful in studying deaths related to jobs and in identifying any new risks. For example, the link between lung disease and lung cancer and asbestos exposure in jobs such as shipbuilding or construction was made possible by this sort of information on death certificates. Information in this section will not appear on the certified copy of the death certificate. ITEM 54. DECEDENT’S USUAL OCCUPATION Enter the usual occupation of the decedent. This is not necessarily the last occupation of the decedent. Never enter “retired”. Give kind of work decedent did during most of his or her working life, such as claim adjuster, farmhand, coal miner, janitor, store manager, college professor, or civil engineer. If the decedent was a homemaker at the time of death but had worked outside the household during his or her working life, enter that occupation. If the decedent was a homemaker during most of his or her working life, and never worked outside the household, enter “homemaker”. Enter “student” if the decedent was a student at the time of death and was never regularly employed or employed full time during his or her working life. Information in this section will not appear on the certified copy of the death certificate. ITEM 55. KIND OF BUSINESS/INDUSTRY Kind of business to which occupation in item 54 is related, such as insurance, farming, coal mining, hardware store, retail clothing, university, or government. DO NOT enter firm or organization names. If decedent was a homemaker as indicated in item 54, then enter either “own home” or “someone else’s home” as appropriate. If decedent was a student as indicated in item 54, then enter type of school, such as high school or college, in item 55. Information in this section will not appear on the certified copy of the death certificate. NOTE: This recommended standard death certificate is the result of an extensive evaluation process. Information on the process and resulting recommendations as well as plans for future activities is available on the Internet at: http://www.cdc.gov/nchs/vital_certs_rev.htm. REV. 11/2003

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122 VITAL STATISTICS U.S. STANDARD CERTIFICATE OF LIVE BIRTH LOCAL FILE NO. BIRTH NUMBER: 4. DATE OF BIRTH (Mo/Day/Yr) 2. TIME OF BIRTH 3. SEX 1. CHILD’S NAME (First, Middle, Last, Suffix) CHILD (24 hr) 5. FACILITY NAME (If not institution, give street and number) 6. CITY, TOWN, OR LOCATION OF BIRTH 7. COUNTY OF BIRTH 8a. MOTHER’S CURRENT LEGAL NAME (First, Middle, Last, Suffix) 8b. DATE OF BIRTH (Mo/Day/Yr) MOTHER 8c. MOTHER’S NAME PRIOR TO FIRST MARRIAGE (First, Middle, Last, Suffix) 8d. BIRTHPLACE (State, Territory, or Foreign Country) 9a. RESIDENCE OF MOTHER-STATE 9b. COUNTY 9c. CITY, TOWN, OR LOCATION 9g. INSIDE CITY 9d. STREET AND NUMBER 9e. APT. NO. 9f. ZIP CODE LIMITS? Yes No 10a. FATHER’S CURRENT LEGAL NAME (First, Middle, Last, Suffix) 10b. DATE OF BIRTH (Mo/Day/Yr) 10c. BIRTHPLACE (State, Territory, or Foreign Country) FATHER 11. CERTIFIER’S NAME: _______________________________________________ 12. DATE CERTIFIED 13. DATE FILED BY REGISTRAR CERTIFIER ______/ ______ / __________ ______/ ______ / __________ TITLE: MD DO HOSPITAL ADMIN. CNM/CM OTHER MIDWIFE MM DD YYYY MM DD YYYY OTHER (Specify)_____________________________ INFORMATION FOR ADMINISTRATIVE USE 9 Same as residence, or: MOTHER 14. MOTHER’S MAILING ADDRESS: State: City, Town, or Location: Street & Number: Apartment No.: Zip Code: 16. SOCIAL SECURITY NUMBER REQUESTED 17. FACILITY ID. (NPI) 15. MOTHER MARRIED? (At birth, conception, or any time between) Yes No FOR CHILD? Yes No IF NO, HAS PATERNITY ACKNOWLEDGEMENT BEEN SIGNED IN THE HOSPITAL? Yes No 18. MOTHER’S SOCIAL SECURITY NUMBER: 19. FATHER’S SOCIAL SECURITY NUMBER: INFORMATION FOR MEDICAL AND HEALTH PURPOSES ONLY 20. MOTHER’S EDUCATION (Check the 21. MOTHER OF HISPANIC ORIGIN? (Check 22. MOTHER’S RACE (Check one or more races to indicate MOTHER box that best describes the highest the box that best describes whether the what the mother considers herself to be) degree or level of school completed at mother is Spanish/Hispanic/Latina. Check the W hite the time of delivery) “No” box if mother is not Spanish/Hispanic/Latina) Black or African American American Indian or Alaska Native No, not Spanish/Hispanic/Latina 8th grade or less (Name of the enrolled or principal tribe)________________ Yes, Mexican, Mexican American, Chicana Asian Indian 9th - 12th grade, no diploma Chinese Yes, Puerto Rican High school graduate or GED Filipino completed Yes, Cuban Japanese Korean Some college credit but no degree Yes, other Spanish/Hispanic/Latina Vietnamese Associate degree (e.g., AA, AS) Other Asian (Specify)______________________________ (Specify)_____________________________ Native Hawaiian Bachelor’s degree (e.g., BA, AB, BS) Guamanian or Chamorro Master’s degree (e.g., MA, MS, Samoan MEng, MEd, MSW, MBA) Other Pacific Islander (Specify)______________________ Doctorate (e.g., PhD, EdD) or Other (Specify)___________________________________ Professional degree (e.g., MD, DDS, DVM, LLB, JD) 23. FATHER’S EDUCATION (Check the 24. FATHER OF HISPANIC ORIGIN? (Check 25. FATHER’S RACE (Check one or more races to indicate FATHER box that best describes the highest the box that best describes whether the what the father considers himself to be) degree or level of school completed at father is Spanish/Hispanic/Latino. Check the the time of delivery) “No” box if father is not Spanish/Hispanic/Latino) W hite Black or African American No, not Spanish/Hispanic/Latino _________________________ 8th grade or less American Indian or Alaska Native Yes, Mexican, Mexican American, Chicano (Name of the enrolled or principal tribe)________________ 9th - 12th grade, no diploma Asian Indian Mother’s Medical Record Yes, Puerto Rican High school graduate or GED Chinese completed Yes, Cuban Filipino Japanese Some college credit but no degree Yes, other Spanish/Hispanic/Latino ________________ Korean Associate degree (e.g., AA, AS) (Specify)_____________________________ Vietnamese Mother’s Name Other Asian (Specify)______________________________ Bachelor’s degree (e.g., BA, AB, BS) Native Hawaiian Master’s degree (e.g., MA, MS, Guamanian or Chamorro MEng, MEd, MSW, MBA) Samoan Doctorate (e.g., PhD, EdD) or Other Pacific Islander (Specify)______________________ Professional degree (e.g., MD, DDS, Other (Specify)___________________________________ No. DVM, LLB, JD) 26. PLACE WHERE BIRTH OCCURRED (Check one) 27. ATTENDANT’S NAME, TITLE, AND NPI 28. MOTHER TRANSFERRED FOR MATERNAL MEDICAL OR FETAL INDICATIONS FOR Hospital NAME: _______________________ NPI:_______ DELIVERY? Yes No Freestanding birthing center IF YES, ENTER NAME OF FACILITY MOTHER Home Birth: Planned to deliver at home? 9 Yes 9 No TITLE: MD DO CNM/CM OTHER MIDWIFE TRANSFERRED FROM: Clinic/Doctor’s office OTHER (Specify)___________________ _______________________________________ Other (Specify)_______________________ REV. 11/2003

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APPENDIX D 123 29a. DATE OF FIRST PRENATAL CARE VISIT 29b. DATE OF LAST PRENATAL CARE VISIT 30. TOTAL NUMBER OF PRENATAL VISITS FOR THIS PREGNANCY MOTHER ______ /________/ __________ ______ /________/ __________ No Prenatal Care MM DD YYYY _________________________ (If none, enter A0".) MM DD YYYY 31. MOTHER’S HEIGHT 32. MOTHER’S PREPREGNANCY WEIGHT 33. MOTHER’S WEIGHT AT DELIVERY 34. DID MOTHER GET WIC FOOD FOR HERSELF _______ (feet/inches) _________ (pounds) _________ (pounds) DURING THIS PREGNANCY? Yes No 35. NUMBER OF PREVIOUS 36. NUMBER OF OTHER 37. CIGARETTE SMOKING BEFORE AND DURING PREGNANCY 38. PRINCIPAL SOURCE OF LIVE BIRTHS (Do not include PREGNANCY OUTCOMES For each time period, enter either the number of cigarettes or the PAYMENT FOR THIS this child) (spontaneous or induced number of packs of cigarettes smoked. IF NONE, ENTER A0". DELIVERY losses or ectopic pregnancies) Average number of cigarettes or packs of cigarettes smoked per day. Private Insurance 35a. Now Living 35b. Now Dead 36a. Other Outcomes # of cigarettes # of packs Medicaid Three Months Before Pregnancy _________ OR ________ Number _____ Number _____ Number _____ Self-pay First Three Months of Pregnancy _________ OR ________ Other Second Three Months of Pregnancy _________ OR ________ None None None (Specify) _______________ Third Trimester of Pregnancy _________ OR ________ 35c. DATE OF LAST LIVE BIRTH 36b. DATE OF LAST OTHER 39. DATE LAST NORMAL MENSES BEGAN 40. MOTHER’S MEDICAL RECORD NUMBER _______/________ PREGNANCY OUTCOME ______ /________/ __________ MM YYYY _______/________ MM DD YYYY MM YYYY 41. RISK FACTORS IN THIS PREGNANCY 43. OBSTETRIC PROCEDURES (Check all that apply) 46. METHOD OF DELIVERY MEDICAL (Check all that apply) AND Diabetes A. Was delivery with forceps attempted but Cervical cerclage unsuccessful? Prepregnancy (Diagnosis prior to this pregnancy) Tocolysis HEALTH Yes No Gestational (Diagnosis in this pregnancy) External cephalic version: INFORMATION B. Was delivery with vacuum extraction attempted Hypertension Successful but unsuccessful? Prepregnancy (Chronic) Failed Yes No Gestational (PIH, preeclampsia) None of the above Eclampsia C. Fetal presentation at birth Cephalic Previous preterm birth 44. ONSET OF LABOR (Check all that apply) Breech Other Other previous poor pregnancy outcome (Includes Premature Rupture of the Membranes (prolonged, ∃12 hrs.) perinatal death, small-for-gestational age/intrauterine D. Final route and method of delivery (Check one) growth restricted birth) Precipitous Labor (<3 hrs.) Vaginal/Spontaneous Vaginal/Forceps Pregnancy resulted from infertility treatment-If yes, Prolonged Labor (∃ 20 hrs.) Vaginal/Vacuum check all that apply: Fertility-enhancing drugs, Artificial insemination or Cesarean None of the above Intrauterine insemination If cesarean, was a trial of labor attempted? Assisted reproductive technology (e.g., in vitro Yes 45. CHARACTERISTICS OF LABOR AND DELIVERY fertilization (IVF), gamete intrafallopian No (Check all that apply) transfer (GIFT)) 47. MATERNAL MORBIDITY (Check all that apply) Induction of labor (Complications associated with labor and Mother had a previous cesarean delivery Augmentation of labor delivery) If yes, how many __________ Non-vertex presentation Maternal transfusion Steroids (glucocorticoids) for fetal lung maturation Third or fourth degree perineal laceration None of the above received by the mother prior to delivery Ruptured uterus 42. INFECTIONS PRESENT AND/OR TREATED Antibiotics received by the mother during labor Unplanned hysterectomy DURING THIS PREGNANCY (Check all that apply) Clinical chorioamnionitis diagnosed during labor or Admission to intensive care unit maternal temperature >38°C (100.4°F) Gonorrhea Unplanned operating room procedure Moderate/heavy meconium staining of the amniotic fluid Syphilis following delivery Fetal intolerance of labor such that one or more of the None of the above Chlamydia following actions was taken: in-utero resuscitative Hepatitis B measures, further fetal assessment, or operative delivery Hepatitis C Epidural or spinal anesthesia during labor None of the above None of the above NEWBORN INFORMATION 48. NEWBORN MEDICAL RECORD NUMBER 54. ABNORMAL CONDITIONS OF THE NEWBORN 55. CONGENITAL ANOMALIES OF THE NEWBORN N EWBORN (Check all that apply) (Check all that apply) Anencephaly 49. BIRTHWEIGHT (grams preferred, specify unit) Assisted ventilation required immediately Meningomyelocele/Spina bifida following delivery ______________________ Cyanotic congenital heart disease 9 grams 9 lb/oz Congenital diaphragmatic hernia Assisted ventilation required for more than Omphalocele six hours 50. OBSTETRIC ESTIMATE OF GESTATION: Gastroschisis Limb reduction defect (excluding congenital NICU admission _________________ (completed weeks) amputation and dwarfing syndromes) Cleft Lip with or without Cleft Palate Newborn given surfactant replacement Cleft Palate alone therapy 51. APGAR SCORE: Down Syndrome Score at 5 minutes:________________________ No. ____________________ Antibiotics received by the newborn for Karyotype confirmed If 5 minute score is less than 6, suspected neonatal sepsis Karyotype pending Mother’s Medical Record Score at 10 minutes: _______________________ Suspected chromosomal disorder Seizure or serious neurologic dysfunction Karyotype confirmed Karyotype pending 52. PLURALITY - Single, Twin, Triplet, etc. ________________ Significant birth injury (skeletal fracture(s), peripheral Hypospadias nerve injury, and/or soft tissue/solid organ hemorrhage (Specify)________________________ None of the anomalies listed above which requires intervention) Mother’s Name 53. IF NOT SINGLE BIRTH - Born First, Second, Third, etc. (Specify) ________________ 9 None of the above 57. IS INFANT LIVING AT TIME OF REPORT? 58. IS THE INFANT BEING 56. WAS INFANT TRANSFERRED WITHIN 24 HOURS OF DELIVERY? 9 Yes 9 No BREASTFED AT DISCHARGE? IF YES, NAME OF FACILITY INFANT TRANSFERRED Yes No Infant transferred, status unknown TO:______________________________________________________ Yes No

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