Certificate Of Death Form

State of Louisiana - Certificate of Death

1A. LAST NAME OF DECEDENT:

1B. FIRST NAME:

1C. MIDDLE NAME:

2A. DATE OF DEATH (Month, Day, Year):

2B. HOUR OF DEATH:

3. SEX:

4. RACE (Specify White, Black, etc.):

5. MARITAL STATUS (Specify Married, Never Married, Widowed, Divorced):

6. SURVIVING SPOUSE (If Wife, give Maiden Name):

7. DATE OF BIRTH (Month, Day, Year):

8A. AGE YEARS:

8B. UNDER 1 YEAR:

8C. UNDER 1 DAY:

9. BIRTHPLACE (City and State, or Foreign Country):

10. USUAL OCCUPATION (Kind of work done during most of working life, NEVER specify retired):

11. KIND OF BUSINESS/INDUSTRY

12. OF HISPANIC ORIGIN?

13. EVER IN U.S. ARMED FORCES?:

YES

14. SOCIAL SECURITY NUMBER

Free Text

15. DECEDENT'S EDUCATION (Specify ONLY HIGHEST grade completed):

ELEMENTARY/SECONDARY (0-12)

COLLEGE (1-4, 5+):

Free Text

16A. PLACE OF DEATH (Check ONLY one, if death in NON-LISTED facility check OTHER and specify on line BELOW.):

HOSPITAL:

INPATIENT

ER / OUTPATIENT

DOA

NON-HOSPITAL:

NURSING HOME

RESIDENCE

OTHER

16B. NAME OF FACILITY (If not in Facility, give street address or location)

16C. PLACE OF DEATH IN CITY LIMITS? (YES or NO)

17A. CITY, TOWN OR LOCATION OF DEATH

17B. PARISH OF DEATH

18A. STREET ADDRESS (If rural, specify rural route number or location):

18B. PARISH OF RESIDENCE

18C. STATE OF RESIDENCE

18D. USUAL RESIDENCE OF DECEDENT (City, town or location):

18E. ZIP CODE

18F. RESIDENCE INSIDE CITY LIMITS? (YES or NO):

19A. FATHER'S LAST NAME

FIRST

MIDDLE

19B. FATHER'S PLACE OF BIRTH:

19C. STATE

20A. MOTHER'S MAIDEN NAME

FIRST

MIDDLE

20B. MOTHER'S PLACE OF BIRTH:

20C. STATE

21A. NAME OF INFORMANT

21B. DATE (Month, Day, Year):

22A. METHOD OF DISPOSITION

BURIAL

CREMATION

REMOVAL

OTHER

22B. DATE THEREOF (Month, Day, Year):

22C. NAME AND LOCATION OF CEMETERY OR CREMATORIUM:

23A. SIGNATURE AND ADDRESS OF FUNERAL DIRECTOR

23B. FACILITY NUMBER:

23C. LICENSE NUMBER

24. ALTERATIONS

New Field:

25C. DATE OF ISSUE

26. SIGNATURE OF LOCAL REGISTRAR

New Field:

28B. TIME OF INJURY

28C. INJURY AT WORK (YES or NO):

28D. DESCRIBE HOW INJURY OCCURRED

28E. PLACE OF INJURY (Specify at home, farm, factory, street, etc.):

28F. LOCATION (Street, Number or Rural Route, City Parish, State)

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29A. I CERTIFY THAT I ATTENDED THE DECEDENT:

Free Text

AND THAT DEATH OCCURRED ON THE DATE AND HOUR STATED ABOVE DUE TO THE CAUSES AND IN THE MANNER SO STATED.

FROM:

TO:

New Field:

29B. SIGNATURE OF PHYSICIAN OR CORONER

29C. DATE (Month, Day, Year):

29D. TYPE OR PRINT NAME AND TITLE OF PHYSICIAN OR CORONER:

29E. ADDRESS OF PHYSICIAN OR CORONER

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30. PART I.

30. 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 OR HEART FAILURE.

Free Text

IMMEDIATE CAUSE (Final disease or condition resulting in death.)

Sequentially list conditions, if any, leading to immediate cause.

Enter UNDERLYING CAUSE (Disease or injury that initiated events resulting in death) LAST

New Field:

Free Text

30. PART II. OTHER SIGNIFICANT CONDITIONS CONTRIBUTING TO DEATH BUT NOT RESULTING IN THE UNDERLYING CAUSE IN PART I.

Tobacco

Other

31. IF DECEASED WAS FEMALE 10-49. WAS SHE PREGNANT IN THE LAST 90 DAYS?

Yes

Unk.

32A. WAS AN AUTOPSY PERFORMED?

Yes

32B. WERE AUTOPSY FINDINGS AVAILABLE PRIOR TO COMPLETION OF CAUSE OF DEATH?:

Yes

Complete Death Form

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