§500.ILLUSTRATION B. Medical Examiner's – Coroner's Certificate of Death

PERMANENT CERTIFICATE

REGISTRATION DISTRICT NO.

STATE OF ILLINOIS

STATE FILE NUMBER

MEDICAL EXAMINER'S – CORONER'S

TEMPORARY CERTIFICATE

REGISTERED NUMBER

CERTIFICATE OF DEATH

Type, or Print in

DECEASED - NAME

FIRST

MIDDLE

LAST

SEX

DATE OF DEATH

(MONTH DAY YEAR)

PERMANENT INK

1.

2.

3.

See Coroner's or Funeral Director's Handbook for INSTRUCTIONS

COUNTY OF DEATH

AGE-LAST BIRTHDAY (YRS)

UNDER 1 YEAR

UNDER 1 DAY

DATE OF BIRTH (MONTH, DAY, YEAR)

MOS

DAYS

HOURS

MIN

4.

5a.

5b.

5c.

5d.

CITY, TOWN, TWP, OR ROAD DISTRICT NUMBER

HOSPITAL OR OTHER INSTUTITION – NAME (IF NOT IN EITHER GIVE STREET AND NUMBER)

IF HOSPITAL OR INST INDICATE DOA OP EMER RM INPATIENT (SPECIFY)

A.........................

6a.

6b.

6c.

BIRTHPLACE (CITY AND STATE OR FOREIGN COUNTRY)

MARRIED, NEVER MARRIED WIDOWED, DIVORCED (SPECIFY)

NAME OF SURVIVING SPOUSE  (MAIDEN NAME IF WIFE)

WAS DECEASED EVER IN US  ARMED FORCES? (YES/NO)

DECEASED

7.

8a.

8b.

9.

B.........................   C.........................   D.........................   E.........................

SOCIAL SECURITY NUMBER

USUAL OCCUPATION

KIND OF BUSINESS OR INDUSTRY

EDUCATION (SPECIFY ONLY HIGHEST GRADE COMPLETED)

10.

11a.

11b.

Elementary, Secondary (0-12)

College (1-4 or 5 +)

12.

RESIDENCE (STREET AND NUMBER)

CITY, TOWN OR ROAD DISTRICT NO.

INSIDE CITY (YES/NO)

COUNTY

13a.

13b.

13c.

13d.

PRINTED BY THE AUTHORITY OF THE STATE OF ILLINOIS

STATE

ZIP CODE

RACE (WHITE, BLACK, AMERICAN INDIAN, etc.) (SPECIFY)

OF HISPANIC ORIGIN? (SPECIFY NO OR YES – IF YES, SPECIFY CUBAN, MEXICAN, PUERTO RICAN, etc.)

13e.

13f.

14a.

14b.

NO

YES

SPECIFY:

PARENTS

FATHER - NAME

FIRST

MIDDLE

LAST

MOTHER - NAME

FIRST

MIDDLE

LAST

15.

16.

INFORMANT'S NAME  (TYPE OR PRINT)

RELATIONSHIP

MAILING ADDRESS  (STREET AND NO. OR R.F.D., CITY OR TOWN, STATE, ZIP)

17a.

17b.

17c.

1.......................... 2.......................... 3.......................... 4.......................... 5..........................

18. PART I Enter the diseases, injuries or complications that caused the death. Do not enter the mode of dying, such as cardiac or respiratory arrest, shock or heart failure. List only one cause on each line.

APPROXIMATE INTERVAL BETWEEN ONSET AND DEATH

Immediate Cause (Final disease or condition resulting in death)

{

(a)

CONDITIONS IF ANY WHICH GIVE RISE TO IMMEDIATE CAUSE (a) STATING THE UNDER-LYING CAUSE LAST.

DUE TO, OR AS A CONSEQUENCE OF

(b)

DUE TO, OR AS A CONSEQUENCE OF

CAUSE

(c)

N........................ P........................ ........................... ............................ H,G.................... RIF...................... UNK....................

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

ATUOPSY (YES/NO)

WERE AUTOPSY FINDINGS AVAILABLE PRIOR TO COMPLETION OF CAUSE OF DEATH? (YES/NO)

19a.

19b.

NATURAL, ACCIDENT, HOMICIDE, SUICIDE, UNDETERMINED, (SPECIFY)

DATE OF INJURY (MONTH  DAY  YEAR)

HOUR

HOW INJURY OCCURRED (ENTER NATURE OF INJURY MENTIONED IN PART I OR PART II, ITEM 18)

20a.

20b.

20c.

M.

20d.

INJURY AT WORK (YES/NO)

PLACE OF INJURY (AT HOME, FARM, STREET FACTORY, OFFICE BUILDING, ETC.) (SPECIFY)

LOCATION (CITY, VIL. OR  TOWN OR TWP. OR  RD. DIST. NO ., COUTY, STATE)

IF FEMALE WAS THERE A PREGNANCY IN PAST THREE MONTHS?

20e.

20f.

20g.

20h.   YES    NO

I CERTIFY THAT IN MY OPINION BASED UPON MY INVESTIGATION AND/OR THE INQUISITION. THIS DEATH OCCURRED ON THE DATE, AT THE PLACE AND DUE TO THE CAUSE(S) STATED, AND THAT………………....

THE DECEDENT WAS PRONOUNCED DEAD ON

AT

MONTH

DAY

YEAR

21a.

21b.

21c.

M.

CORONER'S-MEDICAL EXAMINER'S SIGNATURE

DATE SIGNED

(MONTH, DAY, YEAR)

CERTIFIER

22a.►

22b.

CORONER'S PHYSICIAN'S SIGNATURE

DATE SIGNED

(MONTH, DAY, YEAR)

23a.►

23b.

BURIAL, CREMATION, REMOVAL (SPECIFY)

CEMETERY OR CREMATORY-NAME

LOCATION

CITY OR TOWN

STATE

DATE

(MONTH, DAY, YEAR)

24a.

24b.

24c.

24d.

FUNERAL HOME

NAME

STREET AND NUMBER OF RFD

CITY OR TOWN

STATE

ZIP

DISPOSITION

25a.

FUNERAL DIRECTOR'S SIGNATURE

FUNERAL DIRECTOR'S ILLINOS LICENSE NUMBER

25b.►

25c.

LOCAL REGISTRAR'S SIGNATURE

DATE FILED BY LOCAL REGISTRAR

(MONTH, DAY, YEAR)

26a.►

26b.

VR202 (Rev 1/89)

Illinois Department of Public Health – Office of Vital Records

(BASED ON 1988 US STANDARD CERTIFICATE)

 

(Source:  Added at 15 Ill. Reg. 11706, effective August 1, 1991)