DD Form 2064

CUI (when filled in)
OMB No. 0720-COFD
Expires YYYYMMDD

CERTIFICATE OF DEATH

The public reporting burden for this collection of information is estimated to average less than 1 hour 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. Send comments regarding this burden estimate or any other aspect of this collection of
information, including suggestions for reducing the burden, to the Department of Defense, Washington Headquarters Services, at [email protected].
Respondents should be aware that notwithstanding any other provision of law, no person shall be subject to any penalty for failing to comply with a collection of information if it does not display a
currently valid OMB control number.

DEMOGRAPHICS
2. SEX

1. NAME OF DECEDENT (Last, First, Middle)

3. RACE AND ETHNICITY (Select All That Apply)
AMERICAN INDIAN OR ALASKA
NATIVE

ASIAN

BLACK OR AFRICAN AMERICAN

HISPANIC OR LATINO

MIDDLE EASTERN OR NORTH
AFRICAN

NATIVE HAWAIIAN OR PACIFIC
ISLANDER

WHITE
4. SOCIAL SECURITY NO.

5. DATE OF BIRTH

6. AGE

7. BIRTHPLACE (City, State/Country)

9. COUNTY

8. DECEDENT'S RESIDENTIAL ADDRESS (Street Number and Name, APT., City, State, Zip Code)

SINGLE OR NEVER MARRIED

MARRIED

DIVORCED

SEPARATED

11. HIGHEST EDUCATION LEVEL

WIDOWED

10. MARITAL STATUS:
UNKNOWN
12. NAME OF PRIMARY NEXT-OF-KIN

13. RELATIONSHIP TO DECEDENT

14. MAILING ADDRESS OF PRIMARY NEXT-OF-KIN

15. NAME OF DECEDENT'S FATHER

16. MAIDEN NAME OF DECEDENT'S MOTHER

17. SERVED IN ARMED FORCES?

NEEDS DD67
YES

NO

If "YES," enter branch of
service:

CAUSE OF DEATH

19. TIME OF DEATH

18. DATE OF DEATH

20. LOCATION OF DEATH

21. PART 1. IMMEDIATE CAUSE OF DEATH

21c. DUE TO:

21d. INTERVAL

21e. DUE TO:

21f. INTERVAL

HOMICIDE

SUICIDE

NATURAL

UNDETERMINED

21. PART 2. OTHER SIGNIFICANT CONDITIONS

ACCIDENT

23. AUTOPSY
PERFORMED?

22. MANNER OF DEATH:
24. HOW INJURY OCCURRED

26. TRANSPORTATION DEATH?
YES

NO

29. TOBACCO CONTRIBUTE TO DEATH?
YES

21b. INTERVAL

PENDING

YES
NO

25. DATE/TIME/LOCATION INJURY OCCURED (If involved in death)

27. WORK RELATED DEATH?
YES
30: IF FEMALE:

NO

NO

28. DISASTER RELATED DEATH? (Describe event)
YES

NO

PREGNANT AT TIME OF AUTOPSY

PREGNANT WITHIN LAST YEAR

PREGNANT WITHIN LAST 42 DAYS

NOT PREGNANT

UNKNOWN

CERTIFYING OFFICIAL OR MEDICAL EXAMINER
I CERTIFY TO THE BEST OF MY KNOWLEDGE, DEATH OCCURRED AT THE TIME, DATE, PLACE, AND DUE TO THE CAUSE(S) AND MANNER AS STATED.
31. NAME AND TITLE/DEGREE OF CERTIFYING OFFICIAL OR MEDICAL EXAMINER

32. STATE LICENSED AND NO.

33. SIGNATURE OF CERTIFYING OFFICIAL OR MEDICAL EXAMINER

34. DATE

35. ADDRESS OF CERTIFYING OFFICIAL OR MEDICAL EXAMINER

DD FORM 2064, 20240730 DRAFT

CUI (when filled in)

Controlled by: OUSD(P&R)
CUI Category: PRVCY
Distribution/Dissemination Control: FEDCON
POC: [email protected]

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CUI (when filled in)
Decedent's Name:

DISPOSITION OF REMAINS
36. NAME OF MORTICIAN

37. GRADE (Military or DoD)

39. SIGNATURE

40. DATE

38. LICENSE NO. AND STATE

41. INSTALLATION OR ADDRESS

42. NAME AND LOCATION OF CEMETERY/CREMATORY

44. NAME OF FUNERAL DIRECTOR

43. BURIAL OR CREMATION?

45. NAME OF FUNERAL FACILITY

46. DATE OF DISPOSITION

VITAL STATISTICS REGISTRATION
47. REGISTRAR

48. FILE NO.

49. DATE

50. REGISTRAR ADDRESS

NEEDS DD67

DD FORM 2064, 20240730 DRAFT

CUI (when filled in)

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CUI (when filled in)
INSTRUCTIONS
BLOCK 1: Enter the name of the decedent by Last Name, First Name, Middle
Name. Middle name initial is acceptable.
BLOCK 2: The decedent’s gender/sex, as appropriate.
BLOCK 3: Options listed on the fillable PDF are listed as: American Indian or
Alaska Native, Asian, Black or African American, Hispanic or
Latino, Middle Eastern or North African, Native Hawaiian or Pacific
Islander, White.
BLOCK 4: Use the decedent’s full Social Security Number.
BLOCK 5: Enter the date as MM-DD-YYYY. MM is the two digit month. DD is
the two digit day. YYYY is the four digit year.
BLOCK 6: Enter the decedent’s age, at the date of death.
BLOCK 7: Birthplace is the location by city and state, if born in the United
States. If born outside of the United States, enter the city and
country.
BLOCK 8: Enter the decedent’s most current residential address, city, state or
country, and zip code as of the date of death.
BLOCK 9: Enter the county in which the decedent’s address falls in.
BLOCK 10: Check the box which most accurately represents the decedent’s
known marital status. Choose one of the available options.
BLOCK 11: Enter the decedent’s highest academic level completed (EG High
school, undergraduate, professional degree, or a specific grade
level).
BLOCK 12: Enter the name of the decedent’s closest living relative by: First
Name, Middle Name and Last Name. Middle Name initial is
acceptable.
BLOCK 13: The relation the next-of-kin to the decedent. Examples: Mother,
Father, Sister, Brother, Grandfather, Grandmother, Daughter, Son,
etc.
BLOCK 14: Enter the next-of-kin’s most current mailing address, city, state or
country, and zip code.
BLOCK 15: Enter the name of the decedent’s father by: First Name, Middle
Name, Last Name. Middle name initial is acceptable.
BLOCK 16: Enter the name of the decedent’s mother by: First Name, Middle
Name, Last Name (Maiden Name). Middle name initial is
acceptable.
BLOCK 17: Was the decedent a service member as of date of death? If
“YES”, what branch of service? Options listed on the fillable PDF
are listed as: Air Force, Army, Marine Corps, Navy, Coast Guard,
and Space Force.
BLOCK 18: Date the decedent was declared dead. Enter the date as MM-DDYYYY. MM is the two digit month. DD is the two digit day. YYYY
is the four digit year.
BLOCK 19: Time the decedent was declared dead. Enter the time as a 24Hour Clock/Military time.
BLOCK 20: Enter location as city and state if decedent died in the United
States. If death occurred outside of the United States, enter the
location as city and country. Include
BLOCK 21a. PART 1: Enter the final disease or condition resulting in death.
BLOCK 21c and 21e: If the condition on PART 1 resulted from an underlying
condition, put the underlying condition in BLOCK 21a, and so on,
until the full sequence is reported.
BLOCKS 21b,d,f: Enter a time interval from onset of disease process to death
(EG: minutes, hours, months, years).
BLOCK 21 PART 2: Enter all diseases or conditions contributing to death that
were not reported in BLOCKS 21a, 21c, or 21e, and that did not
result in the underlying cause of death.
BLOCK 22: 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
BLOCK 23: Check “YES” if either a partial or full autopsy was performed.
Otherwise, check “NO.”
BLOCK 24: Enter a brief description on how any injuries, resulting in death,
occurred.
BLOCK 25: Enter the time as a 24-Hour Clock/Military time. Enter the date as
MM-DD-YYYY. Enter the location by city and state, if injury
occurred in the United States. If occurred outside of the United
States, enter the city and country.
BLOCK 26: Check “YES” if death occurred as a: passenger, driver, pilot, or
crewmember of a vehicle mishap. Otherwise, check “NO.”

BLOCK 27: Check “YES” if death occurred while at work, or in relation to work
duties and responsibilities. Otherwise, check “NO.”
BLOCK 28: Check “YES” if death occurred as a result of a major disaster.
Examples of disaster includes, but is not limited to: tornado,
hurricane, flooding, tsunami, plague, etc. Following the “YES”
answer, enter the event that has occurred. Otherwise, check
“NO”, and leave description field blank.
BLOCK 29: Check “YES” if tobacco use is a contribution to the immediate
cause of death. Otherwise, check “NO.” If death cannot be
determined as a contributor, check “UNKNOWN.”
BLOCK 30: *ONLY APPLICABLE TO FEMALE DECEDENTS. Check the box
which most accurately represents the decedent’s known
pregnancy status.
**BLOCKS 31-35 ARE TO BE FILLED OUT BY THE CERTIFYING OFFICAL
OR MEDICAL EXAMINER ONLY.
BLOCK 31: Enter by First Name, Middle Initial, Last Name, followed by title or
degree.
BLOCK 32: Enter licensing state’s abbreviation followed by license number.
BLOCK 33: Utilize a digital signature, or a handwritten signature as
applicable.
BLOCK 34: Enter the date the certifying official or medical examiner signed
the form. Enter date as MM-DD-YYYY.
BLOCK 35: Enter the duty mailing address of the certifying official or medical
examiner. Address should include the city, state or country, and
zip code.
**BLOCKS 36-41 ARE TO BE FILLED OUT BY THE MORTICIAN ONLY
BLOCK 36: Enter by First Name, Middle Initial, Last Name
BLOCK 37: *ONLY APPLICABLE TO MILITARY OR GS EMPLOYEES. Enter
as single or double letter descriptor followed by two digit, numeric
grade (ex. E-06, O-05, GS-12).
BLOCK 38: Enter licensing state’s abbreviation followed by license number.
BLOCK 39: Utilize a digital signature, or a handwritten signature as
applicable.
BLOCK 40: Enter the date the mortician signed the form. Enter date as MMDD-YYYY.
BLOCK 41: Enter the duty mailing address of the mortician. Address should
include the city, state or country, and zip code.
BLOCK 42: Enter the name of the cemetery/crematory, followed by the
address.
BLOCK 43: Check the appropriate box applicable to the disposition of the
decedent.
BLOCK 44: Enter the name of the funeral director by First Name, Middle
Initial, Last Name.
BLOCK 45: Enter the name of the funeral facility handling the decedent.
BLOCK 46: Enter the date of the decedent’s disposition as MM-DD-YYYY.

NEEDS DD67

DD FORM 2064, 20240730 DRAFT

**BLOCKS 47-50 ARE TO BE FILLED OUT BY THE STATE OR LOCAL
VITAL STATISTICS, AS APPLICABLE BY STATE LAWS.
BLOCK 47: Enter the name of the state or local registrar handling the death
certificate of decedent.
BLOCK 48: Enter the file or registration number for the death certificate.
BLOCK 49: Enter date the file or registration number was assigned.
BLOCK 50: Enter the address of the registrar.

CUI (when filled in)

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