DCRP Appendix with table of contents

Appendix C Attachments A-I.pdf

Deaths in Custody Reporting Program -- state prison collection

DCRP Appendix with table of contents

OMB: 1121-0249

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Appendix C. Attachment Table of Contents
Attachment A.

2000 Death in Custody Reporting Act (P.L. 106-297)

p. 2-3

Attachment B.

2013 Death in Custody Reporting Act (P.L. 113-242)

p. 4-8

Attachment C.

42 USC 3732

p. 9-13

Attachment D.

42 USC 3739 (g)

p. 14-16

Attachment E.

Prison survey forms NPS-4 and NPS-4A

p. 17-22

Attachment F.

U.S. Standard Death Certificate

p. 23-27

Attachment G.

42 USC 3735

p. 28-29

Attachment H.

Mailing packet

p. 30-35

Attachment I.

Verification call script

p. 36-41

Attachment A. 2000 Deaths in Custody Reporting Act
(P.L. 106-297)

PUBLIC LAW 106–297—OCT. 13, 2000

114 STAT. 1045

Public Law 106–297
106th Congress
An Act
To amend the Violent Crime Control and Law Enforcement Act of 1994 to ensure
that certain information regarding prisoners is reported to the Attorney General.

Oct. 13, 2000
[H.R. 1800]

Be it enacted by the Senate and House of Representatives of
the United States of America in Congress assembled,
SECTION 1. SHORT TITLE.

This Act may be cited as the ‘‘Death in Custody Reporting
Act of 2000’’.

Death in Custody
Reporting Act of
2000.
42 USC 13701
note.

SEC. 2. REPORTING OF INFORMATION.

Section 20104(a) of the Violent Crime Control and Law Enforcement Act of 1994 (42 U.S.C. 13704(a)) is amended—
(1) in paragraph (1)—
(A) by inserting ‘‘(A)’’ after ‘‘(1)’’; and
(B) by redesignating subparagraphs (A) and (B) as
clauses (i) and (ii), respectively;
(2) in paragraph (2), by striking ‘‘(2)’’ and inserting ‘‘(B)’’;
(3) in paragraph (3)—
(A) by striking ‘‘(3)’’ and inserting ‘‘(C)’’;
(B) by redesignating subparagraphs (A) and (B) as
clauses (i) and (ii), respectively; and
(C) by striking the period and inserting ‘‘; and’’; and
(4) by adding at the end the following new paragraph:
‘‘(2) such State has provided assurances that it will follow
guidelines established by the Attorney General in reporting,
on a quarterly basis, information regarding the death of any
person who is in the process of arrest, is en route to be incarcerated, or is incarcerated at a municipal or county jail, State
prison, or other local or State correctional facility (including
any juvenile facility) that, at a minimum, includes—
‘‘(A) the name, gender, race, ethnicity, and age of the
deceased;
‘‘(B) the date, time, and location of death; and
‘‘(C) a brief description of the circumstances surrounding the death.’’.
Approved October 13, 2000.
LEGISLATIVE HISTORY—H.R. 1800:
CONGRESSIONAL RECORD, Vol. 146 (2000):
July 24, considered and passed House.
Oct. 3, considered and passed Senate.

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Attachment B. 2013 Death in Custody Report Act
(P.L. 113-242).

PUBLIC LAW 113–242—DEC. 18, 2014

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DEATH IN CUSTODY REPORTING ACT OF 2013

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PUBL242

128 STAT. 2860

PUBLIC LAW 113–242—DEC. 18, 2014

Public Law 113–242
113th Congress
An Act
Dec. 18, 2014
[H.R. 1447]

Death in Custody
Reporting Act
of 2013.
42 USC 13701
note.
42 USC 13727.

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Waiver authority.

VerDate Mar 15 2010

08:05 Jan 13, 2015

To encourage States to report to the Attorney General certain information regarding
the deaths of individuals in the custody of law enforcement agencies, and for
other purposes.

Be it enacted by the Senate and House of Representatives of
the United States of America in Congress assembled,
SECTION 1. SHORT TITLE.

This Act may be cited as the ‘‘Death in Custody Reporting
Act of 2013’’.
SEC. 2. STATE INFORMATION REGARDING INDIVIDUALS WHO DIE IN
THE CUSTODY OF LAW ENFORCEMENT.

(a) IN GENERAL.—For each fiscal year after the expiration of
the period specified in subsection (c)(1) in which a State receives
funds for a program referred to in subsection (c)(2), the State
shall report to the Attorney General, on a quarterly basis and
pursuant to guidelines established by the Attorney General,
information regarding the death of any person who is detained,
under arrest, or is in the process of being arrested, is en route
to be incarcerated, or is incarcerated at a municipal or county
jail, State prison, State-run boot camp prison, boot camp prison
that is contracted out by the State, any State or local contract
facility, or other local or State correctional facility (including any
juvenile facility).
(b) INFORMATION REQUIRED.—The report required by this section shall contain information that, at a minimum, includes—
(1) the name, gender, race, ethnicity, and age of the
deceased;
(2) the date, time, and location of death;
(3) the law enforcement agency that detained, arrested,
or was in the process of arresting the deceased; and
(4) a brief description of the circumstances surrounding
the death.
(c) COMPLIANCE AND INELIGIBILITY.—
(1) COMPLIANCE DATE.—Each State shall have not more
than 120 days from the date of enactment of this Act to comply
with subsection (a), except that—
(A) the Attorney General may grant an additional 120
days to a State that is making good faith efforts to comply
with such subsection; and
(B) the Attorney General shall waive the requirements
of subsection (a) if compliance with such subsection by
a State would be unconstitutional under the constitution
of such State.

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PUBLIC LAW 113–242—DEC. 18, 2014

128 STAT. 2861

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(2) INELIGIBILITY FOR FUNDS.—For any fiscal year after
the expiration of the period specified in paragraph (1), a State
that fails to comply with subsection (a), shall, at the discretion
of the Attorney General, be subject to not more than a 10percent reduction of the funds that would otherwise be allocated
for that fiscal year to the State under subpart 1 of part E
of title I of the Omnibus Crime Control and Safe Streets Act
of 1968 (42 U.S.C. 3750 et seq.), whether characterized as
the Edward Byrne Memorial State and Local Law Enforcement
Assistance Programs, the Local Government Law Enforcement
Block Grants Program, the Edward Byrne Memorial Justice
Assistance Grant Program, or otherwise.
(d) REALLOCATION.—Amounts not allocated under a program
referred to in subsection (c)(2) to a State for failure to fully comply
with subsection (a) shall be reallocated under that program to
States that have not failed to comply with such subsection.
(e) DEFINITIONS.—In this section the terms ‘‘boot camp prison’’
and ‘‘State’’ have the meaning given those terms, respectively, in
section 901(a) of the Omnibus Crime Control and Safe Streets
Act of 1968 (42 U.S.C. 3791(a)).
(f) STUDY AND REPORT OF INFORMATION RELATING TO DEATHS
IN CUSTODY.—
(1) STUDY REQUIRED.—The Attorney General shall carry
out a study of the information reported under subsection (b)
and section 3(a) to—
(A) determine means by which such information can
be used to reduce the number of such deaths; and
(B) examine the relationship, if any, between the
number of such deaths and the actions of management
of such jails, prisons, and other specified facilities relating
to such deaths.
(2) REPORT.—Not later than 2 years after the date of the
enactment of this Act, the Attorney General shall prepare and
submit to Congress a report that contains the findings of the
study required by paragraph (1).

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SEC. 3. FEDERAL LAW ENFORCEMENT DEATH IN CUSTODY REPORTING
REQUIREMENT.

42 USC 13727a.

(a) IN GENERAL.—For each fiscal year (beginning after the
date that is 120 days after the date of the enactment of this
Act), the head of each Federal law enforcement agency shall submit
to the Attorney General a report (in such form and manner specified
by the Attorney General) that contains information regarding the
death of any person who is—
(1) detained, under arrest, or is in the process of being
arrested by any officer of such Federal law enforcement agency
(or by any State or local law enforcement officer while participating in and for purposes of a Federal law enforcement operation, task force, or any other Federal law enforcement capacity
carried out by such Federal law enforcement agency); or
(2) en route to be incarcerated or detained, or is incarcerated or detained at—
(A) any facility (including any immigration or juvenile
facility) pursuant to a contract with such Federal law
enforcement agency;
(B) any State or local government facility used by
such Federal law enforcement agency; or

Effective date.

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128 STAT. 2862

PUBLIC LAW 113–242—DEC. 18, 2014

(C) any Federal correctional facility or Federal pretrial detention facility located within the United States.
(b) INFORMATION REQUIRED.—Each report required by this section shall include, at a minimum, the information required by
section 2(b).
(c) STUDY AND REPORT.—Information reported under subsection
(a) shall be analyzed and included in the study and report required
by section 2(f).

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Approved December 18, 2014.

LEGISLATIVE HISTORY—H.R. 1447:
HOUSE REPORTS: No. 113–285 (Comm. on the Judiciary).
CONGRESSIONAL RECORD:
Vol. 159 (2013): Dec. 12, considered and passed House.
Vol. 160 (2014): Dec. 10, considered and passed Senate.

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Attachment C. 42 USC § 3732

Attachment D. 42 USC § 3789(g)

Attachment E. Prison Survey forms NPS-4 and NPS-4A

OMB No. 1121-0094 Approval Expires XX/XX/201X

DEATHS IN CUSTODY—2015
ANNUAL SUMMARY OF INMATE DEATHS
IN STATE PRISONS

Form NPS-4

U.S. DEPARTMENT OF JUSTICE
BUREAU OF JUSTICE STATISTICS
AND ACTING AS COLLECTION AGENT:
RTI INTERNATIONAL

FORM COMPLETED BY:
Name

Title

Official
Address

Telephone

City

FAX

State

Zip

E-mail

What deaths should be reported?
INCLUDE deaths of ALL persons…


Confined in your correctional facilities, whether housed
under your jurisdiction or that of another state



Under your jurisdiction but housed in private correctional
facilities, whether located in or out of state



Under your jurisdiction but in special facilities (e.g.,
medical/ treatment/release centers, halfway houses,
police/court lockups, or work farms)



EXCLUDE deaths of ALL persons…


Executed in your state



Confined in local jail facilities, whether located in or out of
state



Under your jurisdiction but housed in a state-operated
correctional facility in another state or in a federal facility



Under probation or parole supervision in your state

In transit to or from your facilities while under your
supervision

During 2015, how many persons died while in the custody of your state correctional facilities?
Number of deaths in 2015
Please fill out the number of deaths that occurred in calendar year 2015 above and submit this form and corresponding NPS-4A forms
to RTI International. You may submit these data in one of these ways:
ONLINE: Complete this form online at: https://bjsdcrp.rti.org
E-MAIL: [email protected]
FAX (TOLL-FREE): (866) 800-9179

MAIL:

RTI International, Attn: Data Capture
Project Number: 0215015.001.100.102.100
5265 Capital Boulevard
Raleigh, NC 27690-1652

For each inmate death, please ensure that you have submitted a STATE PRISON INMATE DEATH REPORT (NPS-4A) form.
IF NO DEATHS OCCURRED, it is still important that you complete this form and return it to RTI International.
If you need assistance, contact Matt Bensen of RTI International toll-free at (800) 344-1387 or send an e-mail to [email protected]

BURDEN STATEMENT
Under the Paperwork Reduction Act, we cannot ask you to respond to a collection of information unless it displays a currently valid OMB control number. The
burden of this collection is estimated to average 5 minutes per response, including reviewing instructions, searching existing data sources, gathering necessary
data, and completing and reviewing this form. Send comments regarding this burden estimate or any aspect of this survey, including suggestions for reducing this
burden, to the Director, Bureau of Justice Statistics, 810 Seventh Street, NW, Washington, DC 20531. Do not send your completed form to this address.

«AGENCY ID»

OMB No. 1121-0094 Approval Expires XX/XX/201X

DEATHS IN CUSTODY—2016
STATE PRISON INMATE
DEATH REPORT

Form NPS-4A
(Addendum)

U.S. DEPARTMENT OF JUSTICE
BUREAU OF JUSTICE STATISTICS
AND ACTING AS COLLECTION AGENT:
RTI INTERNATIONAL

FORM COMPLETED BY:
Name

Title

Official
Address

Telephone

City

FAX

State

Zip

E-mail

Instructions for Completion
If no deaths occurred in 2016:

You will not need to report anything at this time.

At the beginning of 2016, you will be asked to complete a summary form whether or not you had a death occurrence in 2015.
If you had more than one death in 2016:

Make copies of this form for each additional death.

Complete the entire form for each inmate death.

Once your death records are complete, there are several ways to submit a death report:
ONLINE: Complete the report online at: https://bjsdcrp.rti.org

MAIL: RTI International, Attn: Data Capture
Project Number: 0215015.001.100.102.100
5265 Capital Boulevard
Raleigh, NC 27690-1652

E-MAIL: [email protected]
FAX (TOLL-FREE): (866) 800-9179

If you need assistance, call Matt Bensen of RTI International toll-free at (800) 344-1387 or [email protected]

What deaths should be reported?
INCLUDE deaths of ALL persons…






Confined in your correctional facilities, whether housed
under your jurisdiction or that of another state
Under your jurisdiction but housed in private correctional
facilities, whether located in or out of state
Under your jurisdiction but in special facilities (e.g.,
medical/treatment/release centers, halfway houses,
police/court lockups, or work farms)
In transit to or from your facilities while under your
supervision

EXCLUDE deaths of ALL persons…


Executed in your state



Confined in local jail facilities, whether located in or out of
state



Under your jurisdiction but housed in a state-operated
correctional facility in another state or in a federal facility



Under probation or parole supervision in your state



Under your jurisdiction but on AWOL or escape-status at
the time of death

BURDEN STATEMENT
Under the Paperwork Reduction Act, we cannot ask you to respond to a collection of information unless it displays a currently valid OMB control number. The
burden of this collection is estimated to average 30 minutes per each reported death, including reviewing instructions, searching existing data sources, gathering
necessary data, and completing and reviewing this form. Send comments regarding this burden estimate or any aspect of this survey, including suggestions for
reducing this burden, to the Director, Bureau of Justice Statistics, 810 Seventh Street, NW, Washington, DC 20531. Do not send your completed form to this
address.

«AGENCY ID»

STATE PRISON INMATE DEATH REPORT
1.

What was the inmate’s name?

LAST

FIRST

On what date was the inmate admitted to one of
your correctional facilities?

MI
MONTH

DAY

YEAR

On what date did the inmate die?
2
MONTH

DAY

For what offense(s) was the inmate being held?
a.

YEAR

b.
3.

What was the name and location of the
correctional facility involved?

c.
d.

Facility Name:

Facility City:

Facility State:
10. Since admission, did the inmate ever stay
overnight in a mental health facility?

What was the inmate’s date of birth?

MONTH

DAY

Yes
No
Don’t Know

YEAR

11. Where did the inmate die?
5.

What was the inmate’s sex?
Male
Female

Was the inmate of Hispanic, Latino, or Spanish
origin?
Yes
No

In a general housing unit in the facility or in a
general housing unit on prison grounds
In a segregation unit
In a special medical unit/infirmary within your
facility
In a special mental health services unit within
your facility
In a medical center outside your facility
In a mental health center outside your facility
While in transit
Elsewhere
Please Specify:

In addition, what was the inmate’s race? Please
select one or more of the following racial
categories:
White
Black or African American
American Indian or Alaska Native
Asian
Native Hawaiian or Pacific Islander
Some other race
Please Specify:

«AGENCY ID»

12. Are the results of a medical examiner’s or coroner’s evaluation (such as an autopsy, postmortem exam, or
review of medical records) available to establish an official cause of death?
YES
CONTINUE TO Q13
Evaluation complete—results are pending
SKIP REMAINING QUESTIONS AND SUBMIT THIS FORM—YOU WILL BE CONTACTED AT A
LATER TIME FOR THE CAUSE OF DEATH
No evaluation is planned
13. What was the cause of death?

CONTINUE TO Q13

*** Please SPECIFY cause of death—it is critical information***

Illness—Exclude AIDS-related deaths [Specify]
Acquired Immune Deficiency Syndrome (AIDS)
Accidental alcohol/drug intoxication [Describe]
Accidental injury to self [Describe]
Accidental injury by other (e.g., vehicular accidents
during transport) [Describe]
Suicide (e.g., hanging, knife/cutting instrument,
intentional drug overdose) [Describe]
Homicide [Describe]
Other cause(s) [Specify]

14. Where did the incident (e.g., accident, suicide, or homicide) causing the death take place?
NOT APPLICABLE—Cause of death was illness, intoxication, or AIDS-related
In the prison facility or on the prison grounds
In the inmate’s cell/room
In a temporary holding area/lockup
In a common area within the facility (e.g., yard, library, cafeteria)
In a special medical unit/infirmary
[PLEASE
In a special mental health services unit
SPECIFY]
In a segregation unit
On death row, special unit awaiting capital punishment
Elsewhere within the prison facility
Please Specify:

Outside the prison facility (e.g., while on work release or on work detail)
Elsewhere
Please Specify:

15. When did the incident (e.g., accident, suicide, or homicide) causing the death occur?
NOT APPLICABLE—Cause of death was illness, intoxication, or AIDS-related
Morning (6 am to Noon)
Afternoon (Noon to 6 pm)
Evening (6 pm to Midnight)
Overnight (Midnight to 6 am)
«AGENCY ID»

16. Excluding emergency care provided at the time of death, did the inmate receive any of the following medical
services for the medical condition that caused his/her death after admission to your correctional facilities?
NOT APPLICABLE—Cause of death was accidental injury, intoxication, suicide, or homicide

a.
b.
c.
d.
e.
f.

YES
NO
DON’T KNOW
Evaluated by physician/medical staff ..........................  ...............................
PLEASE PROVIDE A
Diagnostic tests (e.g., X-rays, MRI) ............................  ...............................
RESPONSE FOR
Medications .................................................................  ...............................
EACH ITEM (a–f)
Treatment/care other than medications ......................  ...............................
Surgery ........................................................................  ...............................
Confinement in special medical unit ...........................  ...............................

17. Was the cause of death the result of a pre-existing medical condition or did the inmate develop the condition
after admission? (If multiple conditions caused the death and any of the conditions were pre-existing, mark
“Pre-existing medical condition.”)
NOT APPLICABLE—Cause of death was accidental injury, intoxication, suicide, or homicide
Pre-existing medical condition
Deceased developed condition after admission
Could not be determined

Please add any additional notes regarding this death here:

«AGENCY ID»

Attachment F. U.S. Standard Death Certificate

U.S. STANDARD CERTIFICATE OF DEATH

4a. AGE-Last Birthday
(Years)

4b. UNDER 1 YEAR

4c. UNDER 1 DAY

Months

Hours

Days

7a. RESIDENCE-STATE

2. SEX

5. DATE OF BIRTH (Mo/Day/Yr) 6. BIRTHPLACE (City and State or Foreign Country)

7b. COUNTY

7c. CITY OR TOWN
7e. APT. NO.

8. EVER IN US ARMED FORCES?
□ Yes □ No

STATE FILE NO.
3. SOCIAL SECURITY NUMBER

Minutes

7d. STREET AND NUMBER

To Be Completed/ Verified By:
FUNERAL DIRECTOR:

NAME OF DECEDENT ____________________________________________
For use by physician or institution

LOCAL FILE NO.
1. DECEDENT’S LEGAL NAME (Include AKA’s if any) (First, Middle, Last)

7f. ZIP CODE

9. MARITAL STATUS AT TIME OF DEATH
□ Married □ Married, but separated □ Widowed
□ Divorced □ Never Married □ Unknown

7g. INSIDE CITY LIMITS?

□ Yes □

10. SURVIVING SPOUSE’S NAME (If wife, give name prior to first marriage)

11. FATHER’S NAME (First, Middle, Last)

12. MOTHER’S NAME PRIOR TO FIRST MARRIAGE (First, Middle, Last)

13a. INFORMANT’S NAME

13c. MAILING ADDRESS (Street and Number, City, State, Zip Code)

13b. RELATIONSHIP TO DECEDENT

14. PLACE OF DEATH (Check only one: see instructions)
IF DEATH OCCURRED IN A HOSPITAL:
□ Inpatient □ Emergency Room/Outpatient □ Dead on Arrival
15. FACILITY NAME (If not institution, give street & number)
18. METHOD OF DISPOSITION: □ Burial □ Cremation
□ Donation □ Entombment □ Removal from State
□ Other (Specify):_____________________________
20. LOCATION-CITY, TOWN, AND STATE

IF DEATH OCCURRED SOMEWHERE OTHER THAN A HOSPITAL:

□ Hospice facility □ Nursing home/Long term care facility □ Decedent’s home □ Other (Specify):
16. CITY OR TOWN , STATE, AND ZIP CODE

17. COUNTY OF DEATH

19. PLACE OF DISPOSITION (Name of cemetery, crematory, other place)

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)

ITEMS 24-28 MUST BE COMPLETED BY PERSON
WHO PRONOUNCES OR CERTIFIES DEATH

26. SIGNATURE OF PERSON PRONOUNCING DEATH (Only when applicable)
29. ACTUAL OR PRESUMED DATE OF DEATH
(Mo/Day/Yr) (Spell Month)

25. TIME PRONOUNCED DEAD

27. LICENSE NUMBER

30. ACTUAL OR PRESUMED TIME OF DEATH

28. DATE SIGNED (Mo/Day/Yr)
31. WAS MEDICAL EXAMINER OR
CORONER CONTACTED? □ Yes

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
disease or condition --------->
resulting in death)
Sequentially list conditions,
if any, leading to the cause
listed on line a. Enter the
UNDERLYING CAUSE
(disease or injury that
initiated the events resulting
in death) LAST

□ No

Approximate
interval:
Onset to death

CAUSE OF DEATH (See instructions and examples)

a._____________________________________________________________________________________________________________
Due to (or as a consequence of):

_____________

b._____________________________________________________________________________________________________________
Due to (or as a consequence of):

_____________

c._____________________________________________________________________________________________________________
Due to (or as a consequence of):

_____________

d._____________________________________________________________________________________________________________

_____________

To Be Completed By:
MEDICAL CERTIFIER

PART II. Enter other significant conditions contributing to death but not resulting in the underlying cause given in PART I

35.

DID TOBACCO USE CONTRIBUTE
TO DEATH?

□

Yes □ Probably

□

33. WAS AN AUTOPSY PERFORMED?
□ Yes □ No
34. WERE AUTOPSY FINDINGS AVAILABLE TO
COMPLETE THE CAUSE OF DEATH? □ Yes □ No
37. MANNER OF DEATH

36. IF FEMALE:
□ Not pregnant within past year

□ Natural

□ Pregnant at time of death

□ Accident □ Pending Investigation

□ Not pregnant, but pregnant within 42 days of death

Unknown

□ Homicide

□ 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)
(Mo/Day/Yr) (Spell Month)
42. LOCATION OF INJURY:

State:

41. INJURY AT WORK?
□ Yes □ No

City or Town:

Street & Number:
43. DESCRIBE HOW INJURY OCCURRED:

Apartment No.:

Zip Code:
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

To Be Completed By:
FUNERAL DIRECTOR

51. DECEDENT’S EDUCATION-Check the box
that best describes the highest degree or level of
school completed at the time of death.

49. DATE CERTIFIED (Mo/Day/Yr)

50. FOR REGISTRAR ONLY- DATE FILED (Mo/Day/Yr)

52. DECEDENT OF HISPANIC ORIGIN? Check the box
that best describes whether the decedent is
Spanish/Hispanic/Latino. Check the “No” box if
decedent is not Spanish/Hispanic/Latino.

53. 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

□
□
□
□
□
□
□
□
□
□
□
□

□

8th grade or less

□

9th - 12th grade; no diploma

□

High school graduate or GED completed

□

Some college credit, but no degree

□

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,
MEd, MSW, MBA)

□

Yes, other Spanish/Hispanic/Latino
(Specify) __________________________

□

Doctorate (e.g., PhD, EdD) or
Professional degree (e.g., MD, DDS,
DVM, LLB, JD)

□
□
□

White
Black or African American
American Indian or Alaska Native
(Name of the enrolled or principal tribe) _______________
Asian Indian
Chinese
Filipino
Japanese
Korean
Vietnamese
Other Asian (Specify)__________________________________________
Native Hawaiian
Guamanian or Chamorro
Samoan
Other Pacific Islander (Specify)_________________________________
Other (Specify)___________________________________________

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

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 welldifferentiated 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 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.
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 207822003 or at www.cdc.gov/nchs/about/major/dvs/handbk.htm

REV. 11/2003

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
CAUSE OF DEATH (See instructions and examples)
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
disease or condition --------->
resulting in death)
Sequentially list conditions,
if any, leading to the cause
listed on line a. Enter the
UNDERLYING CAUSE
(disease or injury that
initiated the events resulting
in death) LAST

Rupture of myocardium __________________________________________________________________________________

Acute myocardial infarction_______________________________________________________________________________

Coronary artery thrombosis_______________________________________________________________________________

Yes

Probably
Unknown

Atherosclerotic coronary artery disease__________________________________________________________________

36. 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. Enter the
UNDERLYING CAUSE
(disease or injury that
initiated the events resulting
in death) LAST

Aspiration pneumonia_______________________________________________________________

Complications of coma___________________________________________________________________________________

■ No

Blunt force injuries________________________________________________________________________________________

Motor vehicle accident____________________________________________________________________________________

Unknown

7 weeks

39. TIME OF INJURY

7 weeks

33. WAS AN AUTOPSY PERFORMED?
■ Yes
No
34. WERE AUTOPSY FINDINGS AVAILABLE TO
COMPLETE THE CAUSE OF DEATH? ■ Yes No
37. MANNER OF DEATH

36. IF FEMALE:
Not pregnant within past year
Natural
Homicide
Pregnant at time of death
■ Accident
Pending Investigation
Not pregnant, but pregnant within 42 days of death
Suicide
Could not be determined
Not pregnant, but pregnant 43 days to 1 year before death
Unknown if pregnant within the past year
40. PLACE OF INJURY (e.g., Decedent’s home; construction site; restaurant; wooded area)
41. INJURY AT WORK?

Approx. 2320

road side near state highway

Yes ■ No

August 15, 2003
42. LOCATION OF INJURY:

7 weeks