§500.ILLUSTRATION E. Corrected Cause of Death Certification

For Original  Record
STATE OF ILLINOIS
CORRECTED CAUSE OF DEATH CERTIFICATION
Concerning the death record of:
who died at			in the County of		, Illinois, on the		day of		, 19
I HEREBY CERTIFY that the death certificate for the person named above should be corrected as follows, to reflect post mortem and/or other findings which were not available when the cause of death was initially certified on the certificate of death:

 

18.	DEATH WAS CAUSED BY:						[ENTER ONLY ONE CAUSE PER LINE FOR (a), (b), AND (c)			APPROXIMATE INTERVAL BETWEEN ONSET AND DEATH
PART I		IMMEDIATE CAUSE
CONDITIONS IF ANY			{	(a)
WHICH GIVE RISE TO				DUE TO OR AS A CONSEQUENCE OF:
IMMEDIATE CAUSE (a)				(b)
STATING THE UNDERLYING				DUE TO OR AS A CONSEQUENCE OF:
CAUSE LAST.				(c)
PART II. OTHER SIGNIFICANT CONDITIONS: CONDITIONS CONTRIBUTING TO DEATH BUT NOT RELATED TO CAUSE GIVEN IN PART 1(a)									AUTOPSY (Yes/No) 19a.		IF YES,  WERE FINDINGS CONSIDERED IN DETERMINING  CAUSE OF DEATH 19b.
DATE OF OPERATION IF ANY					MAJOR FINDINGS OF OPERATION
20a.					20b.

 

Signature

, M.D.,

Date

(Attending Physician or Pathologist)

Address

Accepted for filing on the

day of

, 19

.  By

Title

VR-400.2 (10/70r)

OFFICE OF VITAL RECORDS

-

ILLINOIS DEPARTMENT OF PUBLIC HEALTH

-

SPRINGFIELD 62706

 

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