CERTIFICATE OF DEATH (INQUEST REPORT OF FATAL)

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					                                                                    CERTIFICATE OF DEATH
                                                                 (INQUEST REPORT OF FATAL)
NAME OF DECEASED                                    (a) FIRST                  (b) MIDDLE           (c) LAST          SEX          DATE OF BIRTH
                                                                                                                                      MO     DAY       YEAR

DATE OF DEATH                                 MO              DAY                   YEAR             TIME OF DEATH



                                                                                            PLACE OF DEATH
HOSPITAL: INPATIENT                              ER/OUTPATIENT                DOA     OTHER:      NURSING HOME       RESIDENCE OTHER (SPECIFY)
PLACE OF DEATH                                                                                                        NAME OF HOSPITAL OR INSTITUTION



                   PART 1. ENTER THE DISEASES, INJURIES OR COMPLICATIONS THAT CAUSED THE DEATH. DO NOT ENTER                                     Approximate
                           THE MODE OF DYINGSUCH AS CARDIAC OR RESPIRATORY ARREST, SHOCK, OR HEART FAILURE.                                      Interval Between
                           LIST ONLY ONE CAUSE ON EACH LINE.                                                                                     Onset and Death
                   IMMEDIATE CAUSE (Final disease                        a.
                   or condition resulting in death)
                                                                                           DUE TO (OR AS A LIKELY CONSEQUENCE OF)
                   Sequentially list conditions, if any,                 b.
                   leading to immediate cause. Enter

                                                                {                          DUE TO (OR AS A LIKELY CONSEQUENCE OF)
CAUSE OF DEATH




                   UNDERLYING CAUSE (disease
                   or injury that initiated events                       c.
                   resulting in death) LAST                   DUE TO (OR AS A LIKELY CONSEQUENCE OF)
                                                     d.
                   PART 2. OTHER SIGNIFICANT CONDITIONS CONTRIBUTING TO DEATH BUT      AUTOPSY?                                      AUTOPSY FINDINGS AVAILABLE
                           NOT RESULTING IN THE UNDERLYING CAUSE GIVEN IN PART 1                                                     PRIOR TO COMPLETION OF
                               (i.e., substance abuse, diabetes, etc.)                                                               CAUSE OF DEATH?
                                                                                                                        YES   NO               YES NO
                   AUTOPSY FINDINGS




MANNER OF DEATH                                            DATE OF INJURY             TIME OF INJURY       INJURY AT WORK     PLACE OF INJURY AT HOME, FARM,
                                                                                                                              STREET, FACTORY, OFFICE, ETC. [SPECIFY]
                 NATURAL                                                                                       YES     NO
                 ACCIDENT
                                                           LOCATION (STREET AND NUMBER, CITY OR TOWN)
                 SUICIDE
                 HOMICIDE
                 PENDING INVESTIGATION                     DESCRIBE HOW INJURY OCCURRED

                 COULD NOT BE DETERMINED

CERTIFIER




SIGNATURE OF CERTIFIER                                                                                                               DATE SIGNED
                                                                                                                                        MO     DAY         YEAR