CDC 43.5 122 CMRS-City Health Officers or Vital Statistics Regist

Form Approved
OMB No. 0920-0004

122 CMRS - City health officers or vital statistics registrars, Weekly Mortality Report
City:

City Code:

Age

Total Deaths Including
Pneumonia and Influenza

Date of Report:

Pneumonia

Influenza

Under 28 days
28 days to 1 Year
1 - 14
15 - 24
25 - 44
45 - 64
65 - 74
75 - 84
85 and over
Unknown
TOTAL
THE NUMBER OF DEATHS is the number of certificate received by your office during the reporting period, regardless of date of death. The count includes
all certificates of deaths occurring in your city regardless of the residence of the deceased. It does not include fetal deaths (stillbirths).

Public reporting burden of this collection of information is estimated to average 12 minutes per response, including the time for reviewing instructions, searching 
existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or 
sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding 
this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Information Collection 
Review Office, 1600 Clifton Road NE, MS D‐74, Atlanta, Georgia 30333; ATTN: PRA (0920‐0004).

U.S. DEPARTMENT OF HEALTH & HUMAN SERVICES