Dr Andrew describes the history of the death certificate, the correct way for it to be completed and why it matters.
A death certificate is an official document issued by the government, which declares cause and manner of death, location of death, time of death and some other personal information about the deceased.
There are several reasons why you may need to obtain a death certificate. Most often it is to serve as proof of death for legal purposes. These reasons may include accessing pension benefits, claiming life insurance, settling estates, getting married (if a widow or widower needs to prove that their previous partner has passed), or arranging for a funeral.
Government officials may need the death certificate to review the cause of death during investigations to determine if foul-play occurred.
Public health officials use death certificates to compile data on various statistics, including leading causes of death. Public health policies depend heavily on the mortality data from death certificates because they are the only source of information about the causes of death and illnesses preceding death.
A Brief History – key dates in the history of this important document
- 1538 – Registry of christenings, marriages and burials by a clergy
- 1632 – Practice codified in the colonies
- 1639 – Massachusetts shifts burden to government
- 1836 – English government establishes central registry for deaths by cause
- 1844 – Massachusetts follows suit
- 1872 – American Public Health Association (APHA) is formed
- 1893 – International Statistical Institute proposes a classification system for causes of death
- 1899 – APHA recommends revision of classification every decade; ICD-1 in 1900
- 1910 – Manner of death required on death certificate if not natural
- 1915 – First “modern” Medical Examiner system established in New York City
- 1918 – Check box added to standard death certificate
- Natural
- Accident
- Suicide
- Homicide
- Undetermined
- 1926 – English Coroners Amendment Act
Reportable Deaths
Reportable deaths are a special category of death required to be reported to the authorities and investigated. Note that not all reportable deaths are “suspicious” in the legal sense, yet the public health implications of such deaths require more in-depth investigation.
There are many categories of “Reportable” Deaths. Most jurisdictions in the United States have some variation of the following list codified in law
- Death resulting from a criminal act, regardless of time interval between incident and death
- Suicide, regardless of time interval between incident and death
- Death resulting from accidental injury, regardless of time interval between incident and death
- Deaths associated with fire or explosion
- Deaths associated with firearms or other mortal weapons
- Death in associated with any public or private conveyance
- Illegal abortion or complications thereof
- Death due to poison, illicit drug use or overdose
- Exposure to toxic agent during course of employment
- Deaths resulting from agents which constitute a public health or environmental hazard
- Sudden, unexpected death of a person under 60 in apparent good health
- Death unattended by a practicing physician
- Death in legal custody
- Deaths associated with diagnostic or therapeutic procedures, including intra- and perioperative deaths
- Death in which a body is to be cremated
- Deaths occurring less than 24 hours after admission to health care facility, save for those known to be terminally ill from natural disease and death is imminent and expected
- Death of a child under 18 save for criteria above
- Death of a child from any cause when death occurs in day care, foster care or child is in custody of or being investigated by DCYF
- Fetal death resulting from trauma after 20 weeks or 350 gm
- Death known to have been improperly certified
- Death of any unidentified person regardless of cause or manner
- Discovered buried remains, known or thought to be human
- Decomposed and skeletonized remains
- Suspicious or unusual circumstances surrounding a presumed natural death
- Death of a prominent or controversial person
Completing the Standard Death Certificate
Death certificates are governed by state statutes. is legally permitted to Variations exist in who is legally permitted to complete a death certificate and how they should be filled out. Usually the attending physician is responsible for completing the certificate, however, depending on the circumstances and local statute, it may be completed by a nurse practitioner. The medical examiner will certify cause and manner of death in the reportable cases in which he or she assumes jurisdiction. It is important for many reasons that the certificate be completed accurately.
For example, life insurance companies will use the information on the death certificate to determine whether the deceased’s beneficiaries qualify for double indemnity death benefits in the instance of accidental deaths.
Therefore, the practical considerations require that the cause of death be provided with etiological specificity. Cause of death may be defined as the disease, injury, or combination thereof that initiates an ultimately lethal train of events, and, without which, death would not have occurred.
Here are some examples that are not acceptable as a cause of death – because all lack etiological specificity, i.e. all are due to what is the actual underlying or proximal cause of death.
- Pneumonia
- Congestive Heart Failure
- Cardiomyopathy
- Atrial Fibrillation
- Cerebrovascular Accident
- Dementia
- Renal Failure
- Failure to Thrive
- Aspiration Pneumonia
- Gangrene of Feet
- Sepsis
- Sepsis due to Pneumonia
- Immune Compromised State
- Cardiac Disease
- Stroke
- Cirrhosis
Here are acceptable examples
- Klebsiella Pneumonia
- Renal Failure due to Diabetes
- Dementia due to Alzheimer’s Disease
- Coronary Artery Disease
- Cerebrovascular Accident due to Atherosclerotic Cardiovascular Disease
- Viral Syndrome
- Aging or Old Age (if they are old)
- Abdominal Aortic Aneurysm
- Ischemic Heart Disease
- Myocardial Infarction
- Chronic Obstructive Pulmonary Disease
A simple rule of thumb would be that if one can still legitimately ask, “Due to what,” of a cause of death, the certificate is not yet complete.
If as is often the case there may be more than one injury and/or disease process competing for the designation of proximate cause of death. In the final analysis the certifier must opine as to what the proximate cause is and relegate any competing cause to “Part 2” of the certificate (see below). Several things need to be considered, for example the following are unacceptable since they appear to “put the cart before the horse”:
- Lung Cancer due to Pneumonia
- Bladder cancer due to Urosepsis
Additionally, the cause of death must make sense. For example, if it is claimed that condition A is due to condition B, there must be a medical explanation. The following are not acceptable since they do not follow this rule:
- Coronary Artery Disease due to Bladder Cancer
- Bladder Cancer due to Coronary Artery Disease
The placement of conditions leading to death is important. The proximate or underlying cause (the injury/disease that actually caused death) should be listed in Part 1 of the death certificate and any conditions contributing to, but not actually causing death, even though they may be etiologically specific are relegated to Part 2. For example:
- Part 1. Coronary Artery Disease Part 2. Bladder Cancer
- Part 1. Bladder Cancer Part 2. Coronary Artery Disease
In the clinical judgement of the certifier of the first example, the decedent died of heart disease, aggravated by bladder cancer. In the judgement of the certifier in the second example the opposite was true. Both certificates are acceptable.
In Summary
In addition to the need to properly identify and catalogue the cause of all deaths for public health and safety purposes, the death certificate is an extremely important document for a host of other reasons including Social Security benefits, disposition of estate (bank accounts, stocks and bonds, property etc.), life insurance policies, veteran’s benefits, union benefits, outstanding loans and funeral planning.
The accurate completion and recording of the certificate of death is an essential governmental and public health function.
