Completing the Medical Information Section

These instructions pertain to the 2004 Revision {Form VS-154(1-04)} and 2009 Revision {Form VS-154(7-08)} of the State of Oklahoma Certificate of Death.  The physician completes Items 25 through 49.

• For all items on the death certificate, "unknown" is an entry option.  However, please understand that this should be the exception and not the common practice!  Every attempt should be made to obtain the information requested for record submission. 
• If an item does not apply to a particular situation, you can leave it blank.  Otherwise, all required items must be completed.  If there are required items left blank on the certificate, it will be rejected in accordance with Oklahoma Administrative Code 310:105-1-2(1).
• Make entries legible.  Use a computer printer with high resolution, a typewriter with good black ribbon and clean keys, or print legibly using permanent black ink. 
• Avoid abbreviations whenever possible.  If you must use an abbreviation, please use a standard abbreviation.  (ex., US Postal Service abbreviations for addresses)  DO NOT abbreviate conditions entered in the Cause of Death section.
• Do not make alterations or erasures.
• Contact the Vital Records Division if you have any questions or concerns.

Item 25.  Place of Death

If the decedent was pronounced dead in a hospital, check the box indicating the decedent's status at the hospital:  Inpatient, Emergency room/Outpatient or Dead on Arrival.  Hospitals are licensed institutions providing patients diagnostic and therapeutic services by a medical staff.

If the decedent was pronounced dead somewhere else, check the box indicating whether pronouncement occurred at a hospice facility, nursing home/long-term care facility, decedent's home, or other location.

Hospice facility refers to a licensed institution providing hospice care (e.g., palliative and supportive care for the dying), not to hospice care that might be provided in a number of different settings, including a patient's home. 

If death was pronounced at a licensed long-term care facility, check the box that indicates nursing home/long term care facility.  A long-term care facility is not a hospital, but provides patient care beyond custodial care (e.g., nursing home, skilled nursing facility, long-term care facilities, convalescent care facility, extended care facility, intermediate care facility, residential care facility, congregate care facility). 

If death was pronounced in the decedent's home, check the box that indicates decedent's home.  A decedent's home includes independent living units including private homes, apartments, bungalows, and cottages. 

If death was pronounced at a licensed ambulatory/surgical center, orphanage, prison ward, public building, birthing center, facilities offering housing and custodial care, but not patient care (e.g., board and care home, group home, custodial care facility, foster home), check "Other (specify)."  If "Other(specify)" is checked, specify where death was legally pronounced, such as a prison ward, physician's office, the highway where a traffic accident occurred, a vessel at sea, orphanage, group home, or at work.

Item 26.  Facility Name

If the death occurred in a hospital, enter the full name of the hospital.

If death occurred en route to or on arrival at a hospital, enter the full name of the hospital.  Deaths that occur in an ambulance or emergency squad vehicle en route to a hospital fall in this category.

If the death occurred in another type of institution such as a nursing home, enter the name of the institution where the decedent died.

If the death occurred at home, enter the house number and street name.

If the death occurred at some place other than those described above, enter the number and street of the place or building where the decedent died.

If the death occurred on a moving conveyance, enter the name of the "moving conveyance.  For example, if death occurred at sea, enter the name of the vessel (ex, S.S. Olive Seas), or if death occurred in flight, enter the flight designation (ex, Eastern Airlines Flight 296). 

Item 27.  City or Town, State and ZIP Code of Location of Death

Enter the name of the city, town, village, or location, State, and ZIP Code where death occurred.

Item 28.  County of Death

Enter the name of the county of the institution or address given in Item 26 where death occurred. 

Item 29.  Date of Death

Enter the exact month, day, and four-digit year that the decedent was pronounced dead.

Item 30.  Time of Death

Enter the exact time the decedent was pronounced dead.  If the exact time of death is unknown, the person who pronounces the body dead should approximate the time.  "Approx" should be placed before the time. 

Item 31.  Was Medical Examiner Contacted?

Enter "Yes" if the medical examiner was contacted in reference to this case, whether the medical examiner accepted the case as their jurisdiction or not.  Otherwise, enter "No."  Do not leave this item blank. 

Item 32.  Was an Autopsy Performed? 

Enter "Yes" if a partial or complete autopsy was performed.  Otherwise enter "No."

Item 33.  Were Autopsy Findings Available to Complete the Cause of Death?

Enter "Yes" if the autopsy findings were available at the time that cause of death was determined.  Otherwise enter "No."  Leave this item blank if no autopsy was performed. 

Item 34.  Cause of Death - Part I

Follow the instructions printed on the certificate.

The cause of death means the disease, abnormality, injury, or poisoning that caused the death, not the mechanism of death, such as cardiac or respiratory arrest, shock, or heart failure.

The immediate cause of death (final disease or condition resulting in death) is reported on line (a).  Antecedent conditions, if any, that gave rise to the cause are reported on lines (b), (c), and (d).  The underlying cause (disease or injury that initiated events resulting in death) should be reported on the last line used in Part I.  No entry is necessary on lines (b), (c), and (d) if the immediate cause of death on line (a) describes completely the sequence of events.  ONLY ONE CAUSE SHOULD BE ENTERED ON A LINE.

When indicating neoplasms as a cause of death, include the following: 1) primary site, or that the primary site is unknown, 2) benign or malignant, 3) cell type, or that the cell type is unknown, 4) grade of neoplasm, and 5) part or lobe of organ affected. (For example, a primary well-differentiated squamous cell carcinoma, lung, left upper lobe.)

When indicating neoplasms as a cause of death, include the following:

1. Primary site – this is the most important information to report on a cancer death.  If the primary site is unknown, use a statement such as “primary site unknown.”  If the cancer spreads (metastasizes) to other sites, report the other sites also.  Be sure to identify which site was primary and which site(s) were secondary.  The term “metastatic” preceding a neoplasm of a site does not identify whether that was the primary or secondary site.  Another way to report primary/secondary sites is to use terms such as “to” and “from.”
2. Benign or malignant – terms such as “tumor,” “mass,” “growth,” or “neoplasm” do not identify the behavior of the neoplasm.  If the behavior of the neoplasm is unknown, use a statement such as “tumor of the brain, unknown behavior.”  We do not assume a neoplasm was malignant just because it was fatal; benign tumors can cause fatal complications.  Ways to show the neoplasm was malignant include using terms such as “malignant” and “cancer,” or specifying that there were metastases.  Sometimes the cell type identifies whether the tumor was malignant or benign.
3. Cell type – if the cell type is known, specify it on the certificate.  Examples of cell types include carcinoma, histiocytoma, adenocarcinoma, mesothelioma, lymphoma, etc. 
4. Grade of neoplasm – well-differentiated, moderately-differentiated, poorly-differentiated.
5. Part or lobe of organ affected – specific location of the primary site.

Space is provided to the right of the lines for recording the interval between the presumed onset of the condition (not the diagnosis of the condition) and the date of death.  This should be entered for all condition in Part I.  These intervals usually are established by the physician on the basis of available information.  In some cases the interval will have to be estimated (“approximately” may be used).  General terms, such as “minutes,” “hours,” or “days” are acceptable if necessary.  If the time of onset is entirely unknown, enter “unknown.”  Do not leave item blank. 

Item 35.  Cause of Death - Part II

Follow the instructions printed on the certificate.

All other important diseases or conditions that were present at the time of death and that may have contribute to the death, but did not lead to the underlying cause of death listed in Part I, or were not reported in the chain of events in Part I, should be recorded in this section. 

Common Problems in Death Certification

Often several acceptable ways of writing a cause-of-death statement exist.  Optimally, a certifier will be able to provide a simple description of the process leading to death that is etiologically clear and be confident that this is the correct sequence of causes.  However, realistically, description of the process is sometimes difficult because the certifier is not certain.

In this case, the certifier should think through the causes about which he/she is confident and what possible etiologies could have resulted in these conditions.  The certifier should select the causes that are suspected to have been involved and use words such as "probable" or "presumed" to indicate that the description provided is not completely certain.  If the initiating condition reported on the death certificate could have arisen from a pre-existing condition, but the certifier cannot determine the etiology, he/she should state that the etiology is unknown, undetermined, or unspecified, so it is clear that the certifier did not have enough information to provide even a qualified etiology.  Reporting a cause of death as unknown should be a last resort.  

The elderly decedent should have a clear and distinct etiological sequence for cause of death, if possible.  Terms such as senescence, infirmity, old age, and advanced age have little value for public health or medical research.  Age is recorded elsewhere on the certificate.  When a number of conditions resulted in death, the physician should choose the single sequence that, in his/her opinion, best describes the process leading to death, and place any other pertinent conditions in Part II.  "Multiple system failure" could be included in Part II, but the systems need to be specified to ensure that the information is captured.  If after careful consideration, the physician cannot determine a sequence that ends in death, then the medical examiner should be consulted about conducting an investigation or providing assistance in completing the cause of death. 

The infant decedent should have a clear and distinct etiological sequence for cause of death, if possible.  "Prematurity" should not be entered without explaining the etiology of prematurity.  Maternal conditions may have initiated or affected the sequence that resulted in infant death, and such maternal causes should be reported in addition to the infant causes on the infant's death certificate (e.g., hyaline membrane disease due to prematurity, 28 weeks due to placental abruption due to blunt trauma to mother's abdomen). 

When Sudden Infant Death Syndrome (SIDS) is suspected, a complete investigation is to be conducted by the medical examiner.

Most certifiers will find themselves, at some point, in the circumstance in which they are unable to provide a simple description of the process of death.  In this situation, the certifier should try to provide a clear sequence, qualify the causes about which he/she is uncertain, and be able to explain the certification chosen. 

When processes such as the following are reported, additional information about the etiology should be reported:

If the certifier is unable to determine the etiology of a process such as those shown above, the process must be qualified as being of an unknown, undetermined, probable, presumed, or unspecified etiology so it is clear that a distinct etiology was not inadvertently or carelessly omitted. 

The following conditions and types of death might seem to be specific or natural.  However, when the medical history is examined further it may be found to be complications of an injury or poisoning (possibly occurring long ago).  Such cases must be reported to the medical examiner.

Item 36.  Manner of Death

Complete this item for all deaths.  Check the box corresponding to the manner of death.  Deaths not due to external causes should be identified as "Natural."  Usually, these are the only types of deaths a physician will certify. 

All deaths due to external causes must be referred to the medical examiner.  If the manner of death checked in Item 36 was anything other than natural, Items 39 through 45 must also be completed. 

Item 37.  If Female

If the decedent is a female, check the appropriate box in Item 37.  If the decedent is a male, leave the item blank.  If the female is either older than 75 years of age or younger than 5 years of age, check the "Not pregnant within past year" box. 

Item 38.  Did Tobacco Use Contribute to Death?

Check "Yes" if, in the physician's opinion, any use of tobacco or tobacco exposure contributed to death.  For example, tobacco use may contribute to deaths due to emphysema or lung cancer.  Tobacco use also may contribute to some heart disease and cancers of the head and neck.  Tobacco use should also be reported in deaths due to fires started by smoking.  Check "Yes," if in the physician's clinical judgment, tobacco use contributed to this particular death.  Check "No,' if, in the physician's opinion, the use of tobacco did not contribute to death. 

Items 39 through 45.  Accident or Injury - To be filled out in all cases of deaths due to injury or poisoning.

Complete these items in cases where injury caused or contributed to the death.  All deaths resulting from injury must be reported to the medical examiner who will certify the cause of death.  Therefore, the medical examiner will be the one to complete Items 39 through 45. 

Item 39.  Date of Injury

Enter the exact month, day, and year that the injury occurred.  The date of injury may not necessarily be the same as the date of death.  Estimates may be provided with "Approx" placed before the date.

Item 40.  Time of Injury

Enter the exact time when the injury occurred, according to local time.  If the exact time of death is unknown, the time should be approximated by the person who certifies the death.  "Approx" should be placed before the time.  The date of injury may differ from the date of death. 

Item 41.  Place of Injury

Enter the general type of place (such as restaurant, vacant lot, baseball field, construction site, office building, or decedent's home) where the injury occurred.  DO NOT enter firm or organization names.

Item 42.  Describe How Injury Occurred

Enter, in narrative form, a brief but specific and clear description of how the injury occurred.  Explain the circumstances or cause of the injury, such as "fell off ladder while painting house," "driver of car ran off roadway," or "passenger in car in car-truck collision."  Specify type of gun (e.g., handgun, hunting rifle) or type of vehicle (e.g., car, bulldozer, train, etc.) when relevant to circumstances.  Indicate if more than one vehicle was involved; specify type of vehicle decedent was in.  For motor vehicle accidents, indicate whether the decedent was a driver, passenger, or pedestrian. 

If known, indicate what activity the decedent was engaged in when the injury occurred (e.g., playing a sport, working for income, hanging out at a bar). 

Item 43.  Injury at Work?

Enter "Yes" if the injury occurred at work.  Otherwise enter "No."  An injury may occur at work regardless of whether the injury occurred in the course of the decedent's "usual" occupation.

Examples of injury at work and injury not at work follow:

These guidelines were developed jointly by:  The National Association for Public Health Statistics and Information Systems (NAPHSIS), the National Institute of Occupational Safety and Health (NIOSH), the National Center for Health Statistics (NCHS), and the National Center for Environmental Health and Injury Control (NCEHIC).  For questions contact the Oklahoma State Department of Health Vital Records Division.

Item 44.  Location of Injury

Enter the complete address where the injury took place, including ZIP Code.  Fill in as many of the items as is known. 

Item 45.  If Transportation Injury, Specify:

Specify role of decedent (e.g., driver, passenger) in the transportation accident.  "Driver/Operator" and "Passenger" should be designated for modes other than motor vehicles such as bicycles.  "Other" applies to watercraft, aircraft, animal, or people attached to outside of vehicles (e.g., "surfers") but are not bona fide passengers or drivers. 

Item 46.  Certifier

According to State Law, 63 OS 1-317(c), "The medical certification shall be completed and signed . . . by the physician in charge of the patient's care for the illness or condition which resulted in death . . ." The medical certifier fitting this legal definition will check the first box, "Physician in charge of the patient's care."

According to State Law, 63 OS 1-317(d), "In the event that the physician in charge of the patient's care for the illness or condition which resulted in death is not in attendance at the time of death, the medical certification shall be completed and signed . . . by the physician in attendance at the time of death." The medical certifier fitting this legal definition will check the second box, "Physician in attendance at time of death only." 

In both paragraphs (c) and (d) referred to above, there is a clause reading "except when inquiry as to the cause of death is required by Section 938 of this title."  This refers to cases where investigation is required by the medical examiner.  When the medical examiner claims jurisdiction of the case, he/she will check the third box, "Medical Examiner." 

The physician who certifies to the cause of death in Items 34 and 35 signs the certificate in permanent black ink.  The degree or title of the physician should also be indicated.  Rubber stamps or facsimile signatures are not permitted. 

Item 47.  Name, Address and ZIP Code of Person Completing Cause of Death

Type or print the full name and address of the person whose signature appears in Item 46. 

Item 48.  License Number

Enter the State license number of the physician who signs the certificate in Item 46.

Item 49.  Date Death Certified

Enter the exact month, day, and year that the certifier signed the certificate.

Return the Original Certificate to the Funeral Director

The funeral director will review the certificate for completeness and accuracy.

If there is a problem with the Medical Information portion of the certificate, the funeral director is urged to bring it to the physician's attention.  The funeral director is required to file an accurate certificate.  Please cooperate with the funeral director in this effort.

If the funeral director finds a problem in the Personal Information portion of the certificate, they may have to make a new certificate.  This means they will have to ask you to repeat your efforts.  The funeral director is required to file an accurate certificate.  Please cooperate with the funeral director in this effort.

Upon final completion, the funeral director will turn the certificate in to the State Registrar. 

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