§500.ILLUSTRATION C. Medical Certificate of Death

DECEDENT’S BIRTH NO.

REGISTRATION DISTRICT NO

State of Illinois

STATE FILE NUMBER

REGISTERED NUMBER

MEDICAL 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 Funeral Director’s, Hospital, or Physician’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 D.O.A OP EMER RM INPATIENT (SPECIFY)

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

6a.

6b.

6c.

DECEASED

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)

7.

8a.

8b.

9.

B..........................

SOCIAL SECURITY NUMBER

USUAL OCCUPATION

KIND OF BUSINESS OR INDUSTRY

EDUCATION (SPECIFY ONLY HIGHEST GRADE COMPLETED)

C..........................

10.

11a.

11b.

Elementary, Secondary (0-12) 12.

College (1-4 or 5 +)

D..........................

RESIDENCE (STREET AND NUMBER)

CITY, TOWN OR ROAD DISTRICT NO.

INSIDE CITY (YES/NO)

COUNTY

E..........................

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)

1..........................

17a.

17b.

17c.

2..........................

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

3..........................

Immediate Cause (Final disease or condition resulting in death)

›

→

..........................

{

..........................

(a)

..........................

CONDITIONS IF ANY WHICH GIVE RISE TO IMMEDIATE CAUSE (a) STATING THE UNDERLYING CAUSE LAST

DUE TO, OR AS A CONSEQUENCE OF

CAUSE

(b)

DUE TO, OR AS A CONSEQUENCE OF

(c)

4..........................

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

AUTOPSY (YES/NO)

WERE AUTOPSY FINDINGS AVAILABLE PRIOR TO

COMPLETION OF CAUSE OF DEATH? (YES/NO)

5..........................

19a.

19b.

N.........................

DATE OF OPERATION, IF ANY

MAJOR FINDINGS OF OPERATION

IF FEMALE WAS THERE A PREGNANCY

IN PAST THREE MONTHS?

P..........................

20a.

20b.

20c.  YES    NO

............................

I (DID) (DID NOT) ATTEND THE DECEASED

(MONTH, DAY, YEAR)

WAS  CORONER  OR  MEDICAL EXAMINER NOTIFIED? (YES/NO)

HOUR OF DEATH

............................

AND LAST SAW HIM/HER ALIVE ON

21a.

21b.

21c.

M

TO THE BEST OF MY KNOWLEDGE, DEATH OCCURRED AT THE TIME, DATE AND PLACE AND DUE TO THE CAUSE(S) STATED

DATE SIGNED

(MONTH, DAY, YEAR)

CERTIFIER

22a.  SIGNATURE  ►

22b.

NAME AND ADDRESS OF CERTIFIER

(TYPE OR PRINT)

ILLINOIS LICENSE NUMBER

22c.

22d.

NAME OF ATTENDING PHYSICIAN IF OTHER THAN CERTIFIER

(TYPE OR PRINT)

NOTE: IF AN INJURY WAS INVOLVED IN THIS DEATH THE CORONER OR MEDICAL EXAMINER MUST BE NOTIFIED.

23.

BURIAL, CREMATION, REMOVAL (SPECIFY)

CEMETERY OR CREMATORY-NAME

LOCATION

CITY OR TOWN

STATE

DATE

(MONTH, DAY, YEAR)

24b.

24a.

24c.

24d.

FUNERAL HOME

NAME

STREET AND NUMBER OR R.F.D.

CITY OR TOWN

STATE

ZIP

DISPOSITION

25a.

FUNERAL DIRECTOR'S SIGNATURE

FUNERAL DIRECTOR'S ILLINOIS LICENSE NUMBER

25b.►

25c.

LOCAL REGISTRAR'S SIGNATURE

DATE FILED BY LOCAL REGISTRAR    (MONTH, DAY, YEAR)

26a.►

26b.

VR200 (Rev 1/89)

Illinois Department of Public Health – Office of Vital Records

(BASED ON 1989 US STANDARD CERTIFICATE)

 

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